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12-13
Quality Report
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Contents
Part 1................................................................................................4
Quality Statement
About Us
Types of Services We Deliver
Our Vision
Our Strategic Goals
12-13
Part 2..............................................................................................10
2.1 Statement of Assurance from the Board............................10
Working with our Commissioners
2.2 Review of Clinical Priorities 2012/13..................................11
Safeguarding
Real Time Patient Feedback (Meridian)
Electronic Records
Patient Outcome Measures
Clinical Risk Assessment Tools
NICE Guidance (National Institute for Health and Carel Excellence)
2.3 Priorities for 2013/14...........................................................18
2.4 How We Review Our Services.............................................22
Participation in Clinical Audits
Commissioning for Quality and Innovation (CQUINs)
Participation in Clinical Research
Care Quality Commission (CQC)
Health and Safety
Patient Incidents
Information Governance and Toolkit
Information on Data Quality
P.L.A.C.E (Patient Led Assessments of the Care Environment)
Quality Indicators
Part 3...............................................................................................42
3.1 Our Performance..................................................................42
Key National Priorities
3.2 Patient Experience...............................................................56
3.3 Our Workforce......................................................................64
3.4 Improving Services...............................................................69
Annex 1...........................................................................................76
Comments from our Commissioners and Other Key Stakeholders
Annex 2...........................................................................................81
Comments from our Governors
Annex 3...........................................................................................82
Statement of Directors’ responsibility in respect of the Quality
Report.
Annex
4.........................................................................................83
Independent Auditors’ Assurance Report to the Governors’
Assembly of Humber NHS Foundation Trust on the Quality Report
Humber NHS Foundation Trust | Quality Report 2012/13 | 3
Part 1
Quality Statement
I am delighted to be able to present the Humber NHS Foundation
Trust (HFT) Quality Account for 2012/13.
The document provides an opportunity to inform
you of the quality of service we have provided
in 2012/13 and how we intend to improve the
quality of our services in 2013/14 and beyond.
Our mission at the Trust is to improve the health
and wellbeing of the communities we serve and
as such we are committed to providing the very
best care we can to the people who access our
services. The information in this report describes
the changes that have been made in services
across the Trust in terms of quality improvement
and the enhancement of safety.
• improving the management of wound care in
line with best practice and providing better
value for money with improved patient
outcomes
Some of our key achievements during this year
have been:
• forensic services have introduced the shared
pathway model, improving the recreational
and educational opportunities that are
available to all patients within the forensic
service.
• improving the collection of real time feedback
from service users and carers in a number of
services to help us to measure patient and
carer experience
• improving the quality of patient care planning
and ensuring that the patient’s wishes are
translated into their care plan
• the introduction of the Recovery Star model
to support patients on their pathway to
recovery
• improving the management and prevention
of falls, pressure ulcers and other physical
conditions across services for older people
• continuing to improve the quality of care and
support for patients who are on the end of
life pathway and in doing so, providing better
support to their carers
• improving the effectiveness of discharging
from community hospitals
• widening the availability of services to
support the awareness and diagnosis of
dementia
4 | Quality Report 2012/13 | Humber NHS Foundation Trust
• moving towards a more community-focused
approach to the management of children
with mental health and emotional wellbeing
conditions
• strengthening the use of the care programme
approach to support people with mental
health needs in the community
In addition to this we have had to face the
challenge that the public sector is facing, in
continuing to improve the quality and
effectiveness of services at a time when resources
are increasingly scarce, and where innovation and
improvement are absolutely vital in supporting
service transformation and quality improvement.
We have also seen the opening of the new East
Riding Community Hospital at Beverley and the
new build and refurbishment of the learning
disability unit at Townend Court, both of which
are state-of-the-art buildings and demonstrate
our ongoing commitment to improving patient
care on a continuing basis.
Mental health services have continued to move
towards an approach where payment by results
will replace the current contractual arrangements.
This will ensure that patient care is increasingly
delivered based on best practice and where clear
clinical outcomes are expected.
Our inpatient services continue to see
improvement in the environmental audits, which
reflects the level of investment that has gone into
improving privacy, dignity, cleanliness and the
choice and quality of food available to patients in
all of our inpatient units. The Board has also had
a clear focus on improving the health and
wellbeing of the staff who work for the Trust. A
programme of events has taken place throughout
the year to support the important issue of
improving the health and wellbeing of those who
provide services to patients and support to carers.
This quality report represents our achievements
for 2012/13 and, following extensive consultation
with internal and external stakeholders, sets out
our priorities for improvement for 2013/14 and
beyond.
Throughout this report there are elements of the
content which we are asked to include both by
the Department of Health and Monitor (the
independent regulator for NHS Foundation
Trusts). Whilst I appreciate that this may mean
the document is less easy to read in places, we
have included a glossary at the end of the
document to help explain the terminology that
some of you may not be familiar with.
In selecting the priorities for the coming years,
we have engaged and consulted with patients,
carers, staff, the public, our members, Trust Board
and Governors.
We are also committed to addressing key
recommendations and lessons learned from the
Francis Report regarding the systemic failings
found at Mid Staffordshire Hospitals Trust.
We will continue to take every opportunity to
learn lessons from the work and the progress that
we have already made. The targets that
commissioners set for commissioning for quality
and innovation (CQUIN) will be used to continue
to stretch the performance and improve standards
of care across the Trust in services that are
provided to all of our commissioners and the
patients that they support.
Critical to our success will be to continue to
maintain a strong focus on the health and wellbeing
of the staff employed by the Trust and the
volunteers that support them. Our staff survey
results continue to demonstrate that staff feel
positive about the work that they are doing and the
services that they are able to provide to patients.
We continue to work hard to ensure that we have
a highly skilled and confident workforce, able to
deliver care with compassion, in environments
that are the best we are able to provide.
The information contained in this document has
been subject to robust internal review and external
verification by stakeholders and our external
auditors. Therefore, to the best of my knowledge
these accounts are a true and accurate reflection
of the quality of care we deliver to the patients and
communities that we serve.
On behalf of the Board, I would wish to reaffirm
our commitment to improving the services that
we provide to the communities that we serve on
an ongoing basis, and ensuring that safety and
quality sit at the heart of everything that we do.
David Snowdon
Chief Executive, Humber NHS Foundation Trust
Humber NHS Foundation Trust | Quality Report 2012/13 | 5
About Us
• We employ just under 3,000 staff in mental
health, community, learning disability and
addictions services
• End-of-life, palliative care and wound care are
vital areas of our work, carried out by highlytrained and qualified clinicians
• Our staff surveys tell us that they find
working at Humber rewarding and enjoyable
• We provide secure services for people from
across Yorkshire and the Humber, using
innovative treatments and activities to
enhance the physical and mental wellbeing of
our forensic patients
• Our specialist clinicians are nationallyrecognised experts involved in high-level
research
• As a Foundation Trust, we are constantly reinvesting back into healthcare and improving
the environments in which our patients are
treated, including purpose-built inpatient
facilities for learning disability and forensic
patients
• Our integrated teams work together to make
sure that people are treated in the place
that’s best for them, including intensive home
treatment and early discharge with excellent
support
6 | Quality Report 2012/13 | Humber NHS Foundation Trust
• For the past three years we have had the
highest level of performance in Yorkshire and
the Humber in mental health inpatient
services, according to patient surveys. All our
working age adult inpatient units are now
AIMS (Accreditation for In-patient Mental
Health Services) accredited.
Types of Service We Deliver
Humber NHS Foundation Trust provides a
comprehensive range of mental health, community
services, learning disability and addictions services
to people living in Hull and the East Riding of
Yorkshire, a population of approximately 600,000.
We also provide forensic services to patients from
the wider Yorkshire and Humber area and we
employ just under 3,000 staff.
We offer a comprehensive portfolio of services,
many of which can be accessed through the
Single Point of Access (a fast track to treatment,
help and support).
• falls prevention
• nutrition and dietetics
• forensic services for mental
health, learning disability
patients and personality
disorder patients, including
some from outside our area
• out of hours and
unscheduled care
• bladder and bowel specialist
care
• health services within prisons
• physiotherapy
• podiatry
• child and adolescent mental
health services (CAMHS)
• health trainers
• health visiting
• psychiatric liaison
• Huntington’s disease team
• psychological interventions
• inpatient and community
mental health for working
age adults
• psychotherapy
These include:
• A&E liaison for working age
adults and older people
• addictions, including
inpatient alcohol detox
• children’s services
• chronic fatigue
• counselling
• diabetes services
• community nursing
• East Riding Community
hospitals situated in Beverley,
Withernsea and Bridlington
providing inpatient medical
beds and Hornsea and
Driffield providing outpatient
services
• inpatient and community
mental health for older
people
• intermediate care
• learning disability community
and inpatient services
• long-term conditions
• Macmillan nurses
• palliative care
• perinatal mental health
• school nursing
• self-harm
• stroke services
• therapy services
(Physiotherapy, Speech and
Language)
• tissue viability
• traumatic stress
• unscheduled care
This list is not exhaustive. For more information and for referral pathways,
go to www.humber.nhs.uk/services.htm
To contact the Single Point of Access, phone 01482 617560
or email singlepointofaccess@humber.nhs.uk
Humber NHS Foundation Trust | Quality Report 2012/13 | 7
Our Vision
To improve the health and wellbeing of the
communities we serve.
8 | Quality Report 2012/13 | Humber NHS Foundation Trust
Our Strategic Goals
The Trust has 9 Strategic Goals which form the direction and aspirations of the organisation
and underpin our vision.
These are listed below.­
1. Provide services that are safe, person centred, delivered in appropriate environments
and sensitive to the needs of the individual.
2. Retain the confidence of patients, carers and commissioners by upholding the
principles of the NHS.
3. Be an excellent employer maximising the skills and talents of our valued workforce.
4. Ensure a firm financial foundation underpins the delivery of our vision.
5. To work in partnership with other organisations and local authorities to develop
seamless service provision.
6. Through the use of evidence based practice, provide high quality services to establish
a reputation for exceptional standards of care.
7. Use our positive reputation to develop new services and expand existing ones.
8. Provide and develop services that are efficient, cost effective and responsive to the
needs of the people who use them.
9. Work with members to achieve our vision.
Goal number two outlines our commitment to uphold the principles and values of the NHS. We do
this in the following ways:
Value
Impact
Compassion
We will make sure we take the time to listen and understand
Respect and dignity
We will ensure people are treated as individuals, in environments where
their dignity is maintained
Commitment to the quality
of care
By getting the basics right we will maintain and improve the quality of
care
Improving lives
We will strive to deliver continuous quality improvement, improving
people’s health and wellbeing. We will promote activities that make a
positive impact on the 'work life balance' of our staff
Working together for patients
We will work with partners across organisational boundaries to improve
user and carer experience
Everyone counts
We will maintain clear focus on people as well as services
Humber NHS Foundation Trust | Quality Report 2012/13 | 9
Part 2
2.1 Statement of Assurance from the Board working with our Commissioners
Humber NHS Foundation Trust held a number
of contracts for the services delivered by the Trust
and for services delivered for the Trust by other
providers.
During 2012/13 Humber Foundation Trust
provided 100 and sub-contracted 50 relevant
health services.
The most significant contracts agreed were
as follows:
Commissioners
• NHS East Riding of Yorkshire
• NHS Hull
• NHS North Yorkshire and York
• Specialist Commissioning Group
• Hull City Council
• East Riding of Yorkshire Council
The Trust has reviewed all the data available to
them on the quality of care in all of these relevant
health services through quality key performance
indicators. The data is shared with commissioners
and has not impeded any of the Trust’s objectives.
The income generated by the relevant health
services reviewed in 2012/13 represents 94%
of the total income generated from the provision
of relevant health services by Humber NHS
Foundation Trust from 2012/13.
10 | Quality Report 2012/13 | Humber NHS Foundation Trust
Partnership Section
Humber NHS Foundation Trust values partnership
working with other statutory and non-statutory
organisations. We have partnership arrangements
in place with Barchester Healthcare and Closer
Healthcare. These organisations support Humber
Foundation Trust in the delivery of good quality
services to the populations it serves. We also have
a good track record of working in partnership
with our commissioners to ensure the delivery of
services. We ensure there is regular and
constructive dialogue with our commissioners
about key strategic issues and we then work with
commissioners either through managed change
exercises or tendering opportunities to deliver the
services they require.
2.2 Review of Clinical Priorities 2012/13
Our clinical priorities were set through a rigorous process of
consultation with Trust staff and stakeholders. These priorities fall
under the three domains of patient safety, clinical effectiveness
and patient experience.
A summary of the progress is outlined as
follows:
Domain 1 - Patient Safety
Safeguarding Children
and Adults
Description of Priority
Humber NHS Foundation Trust shares
a commitment to safeguard and promote the
welfare of children and adults. The Trust
recognises its responsibility to prevent the abuse
of children and adults who are at risk. All
employees have a duty of care to safeguard those
in their care.
Safeguarding is a fundamental part of patient
safety and wellbeing and an expected outcome
of the NHS. Healthcare professionals have a key
role in safeguarding, firstly in the identification
of abuse, harm and neglect and secondly
responding appropriately to it. Safeguarding is
integral to complying with legislation, regulations
and delivering effective safe care.
The rules on how we keep children and adults
safe have changed. The priority for 2012 was to
make sure that all staff knew what the changes
were and how important safeguarding is.
Aim/Goal
Summary of Progress
Safeguarding children and adults training is
mandatory for all staff and is undertaken every
three years.
The attendance rate for Safeguarding training is
69% for Children’s and 79.7% for Adults which
is a 29.7% improvement on the previous year.
Safeguarding training is delivered by the Trust’s
Safeguarding team and training department with
additional access to East Riding and Hull
Safeguarding Children and Adult Board courses.
Bespoke training is also delivered Trust-wide
to teams and services. Assurances are given to
the Hull and East Riding Safeguarding Boards and
NHS Yorkshire and the Humber Commissioners
(this includes compliance rates for training).
Throughout the last year, the Safeguarding team
has produced a range of resource materials to
help support staff with any safeguarding queries
they may have. These resources include diary
inserts, credit card-sized information handouts,
decision making pathway posters and patient and
carers’ information leaflets.
Members of the Safeguarding team go out to
meet with staff on a regular basis to provide
updates and run feedback sessions.
This priority has been achieved and high levels of
Safeguarding practice are embedded throughout
the Trust.
To ensure that safeguarding is embedded within
the organisation through training, staff briefings
and lessons learned/feedback sessions.
Humber NHS Foundation Trust | Quality Report 2012/13 | 11
Electronic Records
Implementation of Lorenzo
The Trust has two strategic systems which
together provide its electronic patient record. The services they both support are:
Description of Priority
• Mental Health, Learning Disabilities, Child and Adolescent Mental Health Services,
Addictions and Forensic Services - Lorenzo • East Riding Adult’s Community Services,
East Riding Children’s Community Service,
Hull and East Riding Therapies and Child
Health Surveillance - SystmOne.
Currently, the systems are separate and staff
need to access each one depending on the care
pathway of the patient. Both systems are at
different stages of implementation and usage. Lorenzo is a new system which provides mental
health act functionality and SystmOne is a mature
system which has been used for over a decade
in community services. The systems complement
each other very well, but require an ability to link
records to provide the complete electronic patient
record for the Trust. This is to help the provision in
integrated care for mental health and community
patient using the electronic record, currently there
is some duplication so the Trust can support its
contractual and statutory reporting requirements.
Computer Sciences Corporation’s (CSC)
development pathway for both of these systems
includes the ability to click between the patient
information held in each system. Once this is
in place the current duplication can be removed
to provide a single electronic patient record
at the Trust.
12 | Quality Report 2012/13 | Humber NHS Foundation Trust
The Trust introduced a new electronic record
system, Lorenzo, during 2012/13 within some of
its services. This will standardise and improve how
records are kept.
Aim/Goal
To develop an electronic record system which will
enable all practitioners to standardise and
improve the quality of record keeping and enable
the sharing of clinical records between services
and teams. Lorenzo will also capture performance
data which helps support our understanding of
the quality of services we deliver.
Summary of Progress
The Trust completed the successful implementation
of the Lorenzo system on time and within budget
at the end of May 2012. The Trust was involved
in the development of this new function to
support mental health trusts and is the first to
implement the new system nationally.
Since then there has been a great deal of work
looking at how services and teams can make
better use of and benefit from the functions
already available as well as looking at what else
Lorenzo can provide.
Lorenzo is a modular system and the Trust
is currently implementing the Day Care module
which will further support services in the recording
of individual and group contacts. The Trust was
the first to use this when it went live in
February 2013.
Over the next few months the Trust will
complete its evaluation of the Care Plans and
Prescribing modules which will allow for further
enhancements in the development of electronic
records. Other modules that will be reviewed
include ‘Requests and Results’ and ‘Advanced
Bed Management.’
Work also continues to develop letters in Lorenzo
as well as assessment and other electronic forms
and documents. This will help us to move from
manually hand writing to typing information
between systems and will also cut down on
printing and scanning.
The project team is also looking at opportunities
for expanding and standardising the use of Alerts
and Messaging, Waiting Lists (known as Access
Plans in Lorenzo) and Clinical Notes.
Standardisation of SystmOne
Description of Priority
SystmOne is an electronic recordkeeping system
currently in use across some of our services
(Community Services, Therapies, Children and
Young Peoples Services).
Aim/Goal
Our aim is to ensure that this system is used to its
full potential so that records are standardised and
improved.
Summary of Progress
During 2012/13 we introduced team level
performance reporting across Community Services
using the data captured by staff in SystmOne. This is giving teams better evidence to make
decisions about how to work efficiently. It also
helps us to meet our targets because staff on the
ground know how well their team is doing.
Performance reporting is also helping to improve
data quality by highlighting areas where there are
gaps. For example, we have improved the capture
of the ‘Time of Contact’ to over 99%; this has
given us a better understanding of evening
and overnight activity in our neighbourhood care
teams.
In October, we replaced our old data systems in
the minor injuries units with SystmOne. This has
significantly improved data quality and our ability
to report on activity.
The SystmOne units used by health visitors were
reconfigured at the start of December 2012
to increase the scope of the data we are able to
capture. This will allow us to report in greater
detail against our achievement of the goals within
the Healthy Child Programme.
In addition to the improvements above, the Trust
has started a project to map the current data
fields in SystmOne to the new National
Community Information Data Set (CIDS). This will
enable us to meet the reporting requirements well
in advance of the national deadline in 2014. We are pleased with the progress made in the
implementation of SystmOne towards our goal,
however work will need to continue throughout
2013/14.
Humber NHS Foundation Trust | Quality Report 2012/13 | 13
Domain 2 - Clinical
Effectiveness
NICE Guidance
Clinical Risk Assessment
The National Institute for Health and Care
Excellence (NICE) issues evidence- based guidelines
and standards, which are nationally driven and
accepted, supporting the government’s priorities
and objectives. NICE guidance helps health and
social care professionals deliver the best possible
care based on the best available evidence.
Description of Priority
Clinical Risk Assessment is used to record what
a clinician sees as levels of risk in relation to a
patient. We identified the need to ensure clinical
risk assessments are carried out using the most
appropriate tools and the findings are acted upon
in a timely manner, balancing the patient’s wishes
with clinical need.
Aim/Goal
Our aim was to develop and provide a directory
of appropriate and approved clinical risk
assessment tools.
Description of Priority
Between April 2012 and March 2013, 11 Clinical
Guidelines, 6 Public Health Guidelines and 1
Medical Technology Guideline applicable to the
patients we care for were published by NICE.
Aim/Goal
To show the use of clinical risk assessment tools
through examples from service areas.
To ensure that appropriate and applicable NICE
guidance and standards are disseminated,
considered, monitored and used to inform best
practice by our clinicians.
Summary of Progress
Summary of Progress
The Trust has now developed pages on the
Intranet that list the core assessment tools which
have been approved and are appropriate for use
across mental health, learning disabilities and
community services. The main risk assessment
tool used across mental health services is the
Galatean Risk Screening Tool (GRiST) which has
undergone audit during 2012 and actions are
being formulated to improve the use of this
assessment tool. Work is also being undertaken
to improve the standards of the patient’s falls
assessment tool across the Trust.
Procedures and processes have been established
within the Trust to manage and monitor the
implementation of all appropriate guidance.
All applicable guidance is disseminated to all our
clinicians to inform them of best practice.
Key clinicians respond on behalf of our clinical
networks, who consider its impact on their
services and take action to implement guidance
where required, recording the outcomes and
monitoring progress on a Trust wide web-based
assurance system.
14 | Quality Report 2012/13 | Humber NHS Foundation Trust
Of the 18 pieces of NICE guidance applicable
to our service this year, all underwent a review
to determine our level of compliance with them
and what further works were needed to be
undertaken to reach full compliance within each
service delivery area. It is not a requirement for immediate
compliance, and a three year time frame is
deemed reasonable to work towards full
compliance, with other factors being taken into
consideration such as:
• Are we commissioned for the service? If not
-work with the Commissioners to determine
the parameters.
• Are we the principal service delivery area? If
not -work on Protocols for working together
with other agencies. We have systems, processes, targets and meetings
in place to report to the Commissioners of
compliance, shortfalls, and areas of quality
delivery of care.
NICE guidance is used, in part, to help inform our
packages of care for all patients.
Domain 3 - Patient Experience
Real Time Patient Feedback
(Meridian)
Description of Priority
During 2012, a priority within our organisation
was to make it easier for patients to tell us
what they think about their care and treatment.
This is essential information to help us improve
our services according to what truly concerns our
service users.
Meridian data collection software allows for
patient and carer satisfaction data to be collected
via touch screen computer kiosks in Trust premises
or by the use of handheld/tablet devices. The
Meridian system captures the data in ‘real time’
so that feedback can be instant. Any actions that
need to be taken by the staff can be implemented
quickly and patients and carers can see the
improvements sooner.
‘Real time’ patient feedback
Humber NHS Foundation Trust | Quality Report 2012/13 | 15
Aim/Goal
Our aim was to develop a programme of
capturing real time patient and carer experience
across the Trust. The Trust introduced a system for
collecting patient and carer feedback called
Meridian.
Summary of Progress
Meridian was rolled out within the community
and inpatient areas across adult mental health
services and older people’s mental health services.
A system of “You Said, We Did” posters has been
established, identifying changes that occurred as
a direct result of patient feedback.
Over the last year, patients’ and carers’ experience
has been gathered from a large number of service
areas. This has been organised through a range
of data collection methods including paper based
questionnaires, Meridian questionnaires, patient
stories and comment cards. ‘You said, We did’
feedback is now used in all inpatient units.
All the targets for the rollout of Meridian in
2012/13 were achieved and further work to roll
out this system of patient feedback is planned in
2013/14.
For more information on Meridian and the
outcomes of patient feedback, please see section
on Patient Experience Surveys, page 26.
16 | Quality Report 2012/13 | Humber NHS Foundation Trust
Measuring Patient Experience
and Clinical Outcomes
The priorities of Measuring Clinical Outcomes
and Measuring Patient Outcomes fall under both
Clinical Effectiveness and Patient Experience
domains.
The methods and means by which this priority has
been implemented is described as follows.
Description of Priority
The Trust has prioritised the development of tools
which measure the outcome of patient care and
treatment. These tools measure the difference we
make to people’s lives and the quality of services
provided. They are usually in the form of
questionnaires. Outcome measures are important
from a range of perspectives; the people who
are using services, the clinicians who are providing
the care and the commissioners who will want
to know that the services they commission are
delivering the best possible care and achieving
real improvements in the wellbeing of people
who are using services. There are different types
of measures, some of which measure patient
reported outcomes and some measure clinical
outcomes. These are summarised as follows;
Patient Reported Outcome Measures
(PROMs) – These are tools that help us all to
understand if the interventions we are providing
make a difference to people’s lives from their
perspective. Work has been ongoing in this area
for a while, with a person seconded to the Care
Pathways and Packages Project (CPPP) who is
working with the Department of Health to
identify a PROM. We held workshops to gain an
understanding of the different tools in use across
services and it was agreed that the ‘Recovery Star’
should be the outcome of choice. Its aim is to ask,
“Have we helped you to manage your health and
life more effectively, manage your daily affairs and
look after yourself?”
Patient Reported Experience Measures
(PREMs) – There has been no universally agreed
way to assess and report patient experience,
however, consideration is being given to the use
of the Care Quality Commission (CQC) survey as
part of the Payment By Results.
Our Trust has introduced a real time patient
feedback system (Meridian) for use in community
and inpatient services. It is important that staff
and teams know whether service users have had
a good experience whilst using our services, if we
listened to people, if people’s views were taken
into account, whether they understood their care
plan, if service users have regular reviews of their
care, and if they have trust and confidence in us.
There is a range of questions that we would like
to ask to make sure that we get it right.
Clinically Reported Outcome Measures
(CROMs) –
These are tools that are used by clinical staff,
reviewing a range of risks and needs at point
of assessment. These tools will be used again at
reviews to help people with their journey of
recovery and following discharge from services.
Outcome measures help us to understand if we
are doing the right thing, working with a person’s
individual needs and helping them to manage
their own lives more effectively. It is therefore
essential that the measures we use address the
needs of people we are seeing.
Aim/Goal
Our aim throughout 2012 was to identify
appropriate measures for use within our clinical
networks.
Clinical networks have existed within the Trust for
around seven years but during 2012 they have
been developed further and increased to 21,
covering all the major clinical services provided
across the organisation.
The clinical networks have been charged with
developing patient outcome measures specific to
their network.
Summary of Progress
We have introduced PREMs into our services,
asking people about their experience with our
services.
We use CROMs within services at points of
assessment, review and discharge to monitor
progress.
We plan to introduce PROMs, asking people
about what difference they believe we have made
to their lives.
We are pleased with the progress made towards
our goal for 2012/13 as we have identified
appropriate measures for use within our clinical
networks. Work will continue throughout
2013/14 to embed these patient outcome
measures.
Humber NHS Foundation Trust | Quality Report 2012/13 | 17
2.3 Priorities for 2013/14
How we selected our priorities
The development and delivery of the Trust’s
clinical priorities have been aligned to the Trust’s
Clinical Networks.
During 2012, the Clinical Networks underwent
a radical restructure. There are now 22 networks
covering the services provided by Humber NHS
Foundation Trust.
The main function of the Clinical Networks is
to set the clinical direction for their group of
patients, supporting and informing the service’s
clinical governance objectives and actions. The
Clinical Networks also provide a balance to the
operational management structure of the Trust,
acting as the clinical governance lead and
conscience.
The networks are
• Bladder and Bowel
• Offender Health
• RPIT (Recovery/Psychological
Intervention)/ Personality Disorder/Liaison
(meet as one group)
• Forensics
• Occupational Health
• Older People (mental health)
• Psychological Wellbeing –not yet
established
• Stroke
• Respiratory
• RST (Recovery and Support Teams)
• CAMHS (Child and Adolescent Mental
Health Service)
• Unscheduled Care
• Diabetes
• Musculoskeletal Therapy (MSK)
• Cardiac
• Learning Disability
• Tissue Viability
• Children’s and Young People’s services
• Crisis and Acute Mental Health
• Drugs and Alcohol
• Palliative Care (Macmillan)
• Falls
18 | Quality Report 2012/13 | Humber NHS Foundation Trust
The clinical objectives from each network were mapped against national and local priorities
as identified in the table below.
Priority
Patient Safety
Clinical Effectiveness
Patient
Experience
Improving the
diagnosis, care
and treatment
for people
with dementia
A
B
C
1.Standardise and
implement Falls
Assessment Tool across
East Riding Falls Service.
(Falls)
1.Implement care cluster packages which meet
Payment By Results requirements (Recovery/
Psychological Intervention)
2.Implementation of
e-GRIST (risk
assessment). (RPIT)
3.Develop dementia and early detection assessment
and diagnosis pathway (Older People)
1.Roll out of real
time patient
experience
survey Meridian (Older
People)
3.Audit of Essence of
Care Standards
(pressure ulcers,
nutrition, record
keeping). (Older People)
Improving the
care treatment
for people
with long
term and
chronic health
conditions.
2.Develop clinical pathway for memory assessment
(Older People)
4.Implementation of care packages PLUS (OIder
People)
5.Develop rapid referral care pathway (slow to heal
wounds, negative pressure therapy).(Tissue
Viability)
D
E
F
1.Implementation of
CAHMS Physical Health
Assessment process.
(CAMHS)
1.Implementation of tool for outcome measures
screening. (CAMHS)
1.Implementation
of CAMHS
participation
framework
(user/carer
satisfaction)
(CAMHS)
2.Regular and ongoing
audit of SystmOne
measuring compliance
with National
Standards. (Children
and Young Peoples
Network)
2.Develop clinical pathways. (Cardiac)
3.Development of clinical outcome measures.
(Children and Young Peoples Network)
4.Implementation of my shared pathway (Forensics)
5.Implementation of Mentalisation based therapy
(RPIT)
6.Development of clinical outcomes measures
(MSK)
7.Agree clinical pathway for MSK patients in Hull
and East Riding (MSK)
8.Rapid referral care pathway (slow to heal wounds,
negative pressure therapy). (Tissue Viability)
Improving the
care for
people
approaching
the end of life
Improving the
alternatives to
admission
through care
and treatment
for people
with
unplanned
care needs.
2.Capture real
time service
user experience
(Children’s)
3.Develop the
“Your
Wellbeing”
intranet site
(Occupational
Health)
G
H
I
1.Advanced care planning
to be reviewed for end
of life care
management. (Palliative
Care)
1.Develop end of life dementia pathway (Palliative
Care)
1.Review of
patient
information
leaflets
(Palliative Care)
J
K
L
1.Develop systems to
enable unscheduled
care clinicians to access
SystmOne summary
care records at point of
access, to improve
safety and inform the
clinician’s decision
making process.
(Unscheduled Care)
1.Development of single teams in Neighbourhood
Care and Older People’s Mental Health.
1.Carer project
(Crisis and
Acute Mental
Health)
2.Review Out of Hours service for easier access to
end of life care. (Palliative Care)
3.Ensure that the needs of carers are appropriately
assessed through a carer’s assessment (carers’ diaries
to be developed and piloted). (Palliative Care)
2.Outcome performance measures (Unscheduled
Care)
2.Patient
satisfaction
survey
(Unscheduled
Care)
Humber NHS Foundation Trust | Quality Report 2012/13 | 19
Voting for 2013/14 Priorities
An event was held for external stakeholders,
Governors, staff and patient group
representatives. During the event, presentations
of the proposed priorities were delivered.
Following group discussion those present were
then asked to vote for their preferred priorities.
A list of the 12 priorities was developed, with
a second vote to establish the top three.
The 12 identified priorities to be taken forward
next year are:
• Audit of essence of care standards
and actions in older people’s mental
health services
• Dementia detection and diagnosis
pathway in older people’s mental
health services
• Development of single neighbourhood
care and older people’s mental health
service teams
• Roll out of Meridian real time patient
satisfaction survey in older people’s
services
• Audits of SystmOne electronic patient
records system, compliance with
national standards
• Develop cardiac care clinical pathways
• Implementation of framework for user
and carer satisfaction in child and
adolescent mental health service.
• Advanced care planning within end of
life care
• Develop end of life dementia care
pathway
• Review of patient information leaflets
in palliative care
• Develop systems to enable
unscheduled care clinicians to access
SystmOne summary care records at
point of access, to improve safety and
inform the clinician’s decision making
process
• Carers’ project within crisis and acute
mental health services.
Measuring and Monitoring Clinical Priorities
Clinical network leads will be asked to develop
systems of monitoring and recording progress
of these priorities throughout the year, these will
be developed via action plans. Progress on these
actions will be reported and monitored through
the Clinical Effectiveness and Compliance
Committee (CECC) which feeds into the
Governance Committee.
20 | Quality Report 2012/13 | Humber NHS Foundation Trust
Minutes of these meetings will be shared with
Stakeholders and progress will be reported.
Progress will also be reported within future
Quality Account reports.
The Trust’s response to the Francis report
on Mid Staffordshire Hospital
Following the publication of the report into the
systemic issues at Mid Staffordshire Hospitals Trust
by Robert Francis, QC, the Trust Board has
undertaken an initial review of the full report
and recommendations (taken alongside the initial
Government Response and the work of the NHS
Commissioning Board Chief Nurse). The Trust has
mapped its existing practice against the
recommendations and identified those areas of
potential priority for the Trust. We have also
identified those recommendations where the
Trust response will depend on the national NHS
and Government responses and any subsequent
changes.
From this has come some initial work lead by the
Chief Executive, Medical Director and Director
of Nursing aimed at engaging with the Trust staff
through a series of ‘Listening events’ held around
the Trust. The aim is to gain our employees’ views
on the most important issues for us to prioritise
our attention and efforts on changing. These
views are being brought together to form an
initial set of ‘Francis’ Priorities for the Trust to plan
our actions and changes against.
Humber NHS Foundation Trust | Quality Report 2012/13 | 21
2.4 How We Review Our Services
Participation in Clinical Audits
During 2012/13, 4 national clinical audits and
1 national confidential enquiry covered relevant
health services that Humber NHS Foundation Trust
provides. During 2012/13 Humber NHS
Foundation Trust participated in 3 of the 4 (80%)
of National Clinical Audits eligible to participate
and 1 National Confidential Enquiry (100%) of
the national clinical audits and national
confidential enquiries it is eligible to participate in.
• The reports of 24 local clinical audits were
reviewed by the provider in 2012/13 and
Humber NHS Foundation Trust took the
following actions to improve the quality of
healthcare provided:
• Development of defensible documentation
training which is now mandatory for all
staff
• Development and delivery of a formal
nutritional training package for clinical staff
The national clinical audits and national
confidential enquiries that Humber NHS
Foundation Trust participated in and for which
data collection was completed in 2012/13 are
listed below alongside the number of cases
submitted to each audit as a percentage of the
number of registered cases required by the terms
of that audit or enquiry.
• The ‘Malnutrition Universal Screening Tool’
(MUST) is now used on admission to all
inpatient areas
The reports of 6 national clinical audits were
reviewed by the provider in 2012/13 and Humber
NHS Foundation Trust took the following actions
to improve the quality of healthcare provided:
• Screening for venous thromboembolism
is now a standard measure on admission to
acute mental health inpatient units
• To cascade the results of the national
Prescribing Observatory for Mental Health
(UK) (POMH-UK) Clinical Audits through
the Drugs and Therapeutics Committee
highlighting the high standard of
performance concluded by the audits and
ensuring that these standards are maintained
and a continuation of commitment to the
POMH programme.
22 | Quality Report 2012/13 | Humber NHS Foundation Trust
• Screening and care planning for patients
at risk of developing pressure ulcers is now
a standard measure of older people’s
mental health inpatient units
• Completion of pre-admission Challenging
Behavioural Scale measurements and use
of an ‘ABC’ behavioural chart has been
introduced to older people mental health
units.
In addition action plans are in place for all the
remaining completed local clinical audits and
progress is being monitored by the Clinical Audit
Department.
The national clinical audits and national confidential enquiries that Humber NHS Foundation Trust was
eligible to participate in during 2012/13 are as follows:
Clinical Audits – Eligible to
participate in
Audits
Participated in
Sponsoring
Body
Cases
Submitted
Data
Completed
Prescribing Observatory for Mental
Health (UK) (POMH-UK) – Screening
for metabolic side effects of
antipsychotic drugs
Yes
National Audit
sponsored by
POMH-UK
33 cases
submitted
100% for the
Trust
Yes
Prescribing Observatory for Mental
Health (UK) (POMH-UK) –
Prescribing of antipsychotics for
people with dementia
Yes
National Audit
sponsored by
POMH-UK
75 cases
submitted
100% for the
Trust
Yes
Prescribing Observatory for Mental
Health (UK) (POMH-UK) –
Prescribing for people with
personality
disorder
Yes
National Audit
sponsored by
POMH-UK
28 cases
submitted
100% for the
Trust
Yes
National Audit of Psychological
Therapies
Yes
National Audit
sponsored by
Healthcare
Quality
Improvement
Partnership
(HQIP)
Trust did not
take part
No
Prescribing Observatory for Mental
Health (UK) (POMH-UK) –
Prescribing Antipsychotics for
Children and Adolescents
100% for the Trust
Yes
National Audit
sponsored by
POMH-UK
31 cases
submitted
Ongoing
The National Audit of Psychological
Therapies for Anxiety and
Depression
No ( due to restructure of the
audit team)
• all audit reports reviewed to identify issues
highlighted in reports that apply across
services
• identified lead practitioners to manage
change and improvement in line with action
plans
• monitored progress with action plans from
a central database of actions
• reported quarterly to the Clinical Effectiveness
and Compliance Committee and the
Governance Committee on progress at all
stages of the clinical audit process.
Humber NHS Foundation Trust | Quality Report 2012/13 | 23
National Confidential Enquiries
The Trust participated in the National Confidential
enquiry into the prevention of suicide and
homicide of people with mental illness.
Actions to take forward are:
• to consider adopting the Prevention
of Suicide tool kit as an annual audit tool
• to develop a local policy for the prevention
of suicide.
Actions Taken Following Defensible
Documentation Audit
In September 2010, a serious incident (SI)
identified that record keeping across the
professions was of concern. One of the key
actions of the SI was to develop a training
programme to meet this need. A group of staff
met from nursing, information governance and
training to develop the course. A pilot training
day took place on 8th June 2011 and feedback
from the course was very positive, informing the
development of the defensible documentation
course, which is now mandatory for all clinical
staff. As of December 2012, 33% of staff have
attended the course, which is very impressive.
An improvement in recordkeeping in patients’
notes has been noted in recent feedback from SIs.
A questionnaire has been developed to gain
an understanding of the learning from the course,
what was most useful/least useful, what staff
and their profession/team have done differently
since the course and what the organisation could
do to support them. Learning from this has
influenced the on-going development of the
course and led to the following:
• development of the essential elements
of defensible documentation for paper and
electronic notes. These have now been
printed onto A4 card for all staff to use as an
aide memoire
24 | Quality Report 2012/13 | Humber NHS Foundation Trust
• recordkeeping audit tools developed for
paper and electronic notes based upon the
standards
• communication via the Weekly Global
newsletter to all staff as a reminder of the
standards and learning from the audits.
Changes and Improvements to Practice
Following Audit
The National Prescribing Observatory for Mental
Health audits evidence that the Trust prescribing
practices are of an exceptionally high level when
benchmarked against other NHS Trusts.
Audits in some areas such as safeguarding, record
keeping, nutritional standards for inpatient units
and physical health screening in mental health
have led to the development of additional
training for staff and the following are just three
examples of direct change to front line services:
• Health visitors now screen all post natal
mothers mental health state. • Antenatal patients are now offered a visit for
a health needs assessment with advice and
information being given on breast feeding.
• Mental health patients admitted to adult and
older people’s inpatient units are now
screened for venous thromboembolism.
Commissioning for Quality and Innovation (CQUINs)
CQUIN is an annual scheme where commissioners
and providers agree on which areas need more
focus for improvement and payments are made
for evidencing those improvements. The scheme
is refreshed every 12 months and each scheme
may be different from preceding years.
This year’s scheme is worth around £2.6 million.
Mental health and community services areas are
collecting information from patients and carers,
along with a staff survey for clinicians in mental
health as part of this year’s CQUIN payment
framework.
CQUIN update for 2012/13
A proportion of Humber NHS Foundation Trust’s
income in 2012/13 was conditional upon
achieving quality improvement and innovation
goals agreed between the Trust and our
commissioning organisations and any person or
body we entered into a contract, agreement or
arrangement with for the provision of NHS
services, through the CQUIN payment framework. Further details of the agreed goals for 2012/13
and for the following 12 month period are
available online at http://www.humber.nhs.uk/
about-our-trust/CQUIN-scheme-2013-14.htm
The table below shows the money available to the
Trust from the CQUIN schemes.
Commissioner
NHS Hull
NHS East Riding
NHS Barnsley
Total
12-13 CQUIN
Available
Total
12-13 CQUIN
Achieved
908,000
800,000
(108,000)
47,006
88%
1,422,000
1,246,000
(176,000)
114,854
88%
335,000
319,000
(16,000)
9,382
95%
2,665,000
2,365,000
(300,000)
171,242
89%
Commissioning for Quality and Innovation
(CQUIN) 2013/14
During 2013/14, Humber NHS Foundation Trust
will be working towards CQUINs which have been
agreed with its commissioners, along with the
continuation of the national CQUIN called
‘National Safety Thermometer’. 2012-13
Shortfall
2011-12
Shortfall
% Earned
Over the last three years the Trust has agreed
a number of indicators with local
commissioners. The indicators have been
developed with a key focus on the local priorities
that the Trust and the commissioners feel need
to be addressed.
Humber NHS Foundation Trust | Quality Report 2012/13 | 25
Patient Experience Surveys in Mental Health and Community
Hospital Patient and Carer Experience. (Also part of the Trust
Commissioning for Quality and Innovation scheme)
Description of Priority
These two indicators were some of the main
priorities for the organisation as feedback from
people who use, or care for someone who uses
our services, is a valuable way for the Trust to
understand how the service has been received
and find out what people feel. This is used to help
identify ways to improve services in the future.
Patient feedback helps the Trust to provide care
that is more personal to the individual, improve
the overall service and help plan new service
developments.
Aims/goals
Our goals In 2012/13, was to roll out the
Meridian Patient feedback system across the Trust
using patient feedback to inform service and care
improvements in a timely manner.
Summary of progress
17 service areas have used Meridian-based
questionnaires.
It has continued to be used in a range of services,
including the adult and older people’s mental
health services, but it has also been implemented
in other service areas for the first time. These
services include:
• Community hospitals (re discharge planning)
• Neuropsychology patient satisfaction survey
• Pulmonary rehabilitation patient satisfaction
questionnaire.
Paper questionnaires with Freepost envelopes
26 | Quality Report 2012/13 | Humber NHS Foundation Trust
have been used to collect patient experience from
service users and carers who don’t attend Trust
bases. The information has been put into the
Meridian system on behalf of the patient or carer.
This, however, is less ‘real time’ because of the
delay in postage and inputting.
To overcome this, iPads with 3G network
connection have been introduced in the following
teams:
• Out of Hours and Unscheduled Care
• Hull Adult Wheelchair Services therapies for
handover process and assessment
• Hull Integrated Paediatric Services Therapies
• Community Hospitals.
This year we have been able to build a library of
devices that will be used for one-off or short
episodes of gathering feedback. This allowed the
health visitor team in the East Riding of Yorkshire
and the Hull GP team to use an iPad for an audit
that needed to be completed in one day.
East Riding wound care services have gathered
feedback across a short period of time from
patients in clinic settings. To assist the staff,
trained volunteers met with the patients after
their appointments. This allowed the clinicians to
carry on with their work and the patients to
answer the questions freely and in confidence.
It also has the additional benefit of being
accessible to people with poor literacy skills or IT
skills and people whose first language is not
English.
Areas of improvement gained through ‘real time’ feedback
from patients
A number of areas have seen significant improvement during
2012/13 due to the quality of the feedback received. Patients ‘feeling safe’ in adult inpatient units
Patients reported an improvement in feeling
safe during their stay in adult inpatient units
during 2012/13. Only 65% of patients
reported feeling safe during 2011/12 but
results have improved to 95% during
2012/13 (100% for Older Inpatient Units).
Staff now routinely offer advice to patients
about what to expect during their stay, such
as hearing noise on the ward at night, and
what to do if they feel scared or unsafe.
Staff continue to encourage patients to seek
reassurance and a number of options are
available to help patients adapt during their
stay in the inpatient units.
Improving food to meet dietary needs
Patients reported an improvement in the variety
of food available during their stay on the units
which met their dietary needs. Dietary needs may
be cultural, religious or health-related (i.e.
diabetes). Initial results of 81% in June 2012 have
risen to 94% in December 2012. This has been
achieved by consultation with patients and
feedback to the catering staff resulting in
improved menus on the units over the year.
Activities during the week for inpatients
Patient engagement in activities has been
shown to reduce challenging behaviour and
maintain a calm atmosphere on inpatient
units. 74% of patients reported that they
had a good range of activities to choose
from during June 2012. Inpatient staff have
worked with patients to improve the range
of activities available which resulted in 92%
satisfaction in December 2012.
Waiting time for appointment
94% of people reported that the waiting time for
their first appointment was acceptable; this is an
increase in satisfaction from 88% reported earlier
in the year. This has been achieved by explaining
the current expected waiting time in the first
appointment letter, improving the capacity
in some of the assessment teams and working to
reduce the number of DNAs (Did Not Attend),
which ensures appointments are kept.
Receiving helpful information before
appointment
We have listened to feedback from patients
about the type of information they would
like to receive before their first appointment.
The information pack accompanying first
appointment letters has now been improved
resulting in 95% satisfaction compared with
75% earlier in the year.
Humber NHS Foundation Trust considers that
this data is as described for the following
reasons, it has had an annual audit and it is
managed through monthly monitoring and
reporting.
The Trust has taken the following actions to
improve this percentage and so the quality
of its service by, Implementing real time
feedback through Meridian to identify issues
and address them immediately and regular
action planning to address any areas of
dissatisfaction.
Humber NHS Foundation Trust | Quality Report 2012/13 | 27
Mental Health and Community Services CQUINs for 2013/14
No.
Indicator Name
Indicator Description
1
Health Improvement
Planning in Mental
Health
Patients admitted to 3 adult mental health inpatient units * will receive
physical health screening and may be referred to additional services in
other organisations. Support may include areas such as smoking cessation
and weight management.
2
Patient Experience in
Mental Health
Use of ‘real time’ data to capture patient experience to evaluate care
delivery and make improvements where necessary.
3
Carer Support and
Experience in Mental
Health
Engagement with those in a caring role to identify key areas of
improvement and offer of a Carer assessment in partnership with the
Local Authorities.
4
Dementia Care
Planning in Mental
Health
Those patients with challenging behaviour who are admitted to our Older
Inpatient wards will be offered a specialist assessment and their care plan
will be tailored to improve and enhance the patients experience with
other agencies providing care and treatment.
5
Community Hospital
Patient and Carer
Experience
Use of ‘real time’ data to capture patient experience to evaluate care
delivery and make improvements where necessary.
6
Community Hospital
Staff Experience and
Competency
Feedback from staff and metrics around competency and capability of
staff working in community hospitals.
7
Improving Delayed
Healing of Venous Leg
Ulcers
Improve the healing time for those patients presenting with non-complex
venous leg ulcers.
8
Community Hospital
Dementia Screening
Improve the detection of dementia through screening and risk assessment
for those admitted to community hospitals.
9
Quality Dashboard
A range of indicators will be reported every quarter to commissioners in
areas such as clinical quality of care, workforce, clinical safety and
effectiveness of care. It will also include all quality aspects from the
2013/14 Contracts.
10
National Safety
Thermometer
The 2nd year of collecting information around pressure ulcers, catheter
and urinary tract infections, falls and venous thromboembolism in
community hospitals, older people mental health and Learning Disability
teams and neighbourhood care teams. The Trust will aim to reduce the
number of reported instances over the year.
11
Therapy Services
Satisfaction with Podiatry and Falls service
(* Westlands, Newbridges, Hawthorne Court) Other CQUINs may be developed for 2013/14 following the publication of this report.
28 | Quality Report 2012/13 | Humber NHS Foundation Trust
Participation in Clinical
Research
The number of patients receiving relevant health
services provided or sub contracted by Humber
NHS Foundation Trust in 2012/13 that were
recruited during that period to participate in
research approved by a research ethics committee
was 1243. 508 patients were recruited to
National Institute of Health Research Portfolio
Studies (NIHR) and 752 were recruited to local
studies.
Care Quality Commission
The Care Quality Commission (CQC) are the
regulators of quality standards within all NHS
Trusts. They monitor our standard of care through
inspections, patient feedback and other external
sources of information gathered. The Care Quality
Commission publish which Trusts are compliant
with all the essential standards of care they
monitor and which organisations have
‘conditions’ against their services which require
improvements to be made.
Humber Foundation Trust is required to register
with the Care Quality Commission, and its current
registration status is ‘registered without
conditions’. The Care Quality Commission has not
taken enforcement action against Humber
Foundation Trust during 2012/13.
A thematic inspection on joint working between
adult and children’s services, where parents have
mental health difficulties and/or substance misuse
problems, was undertaken in October 2012.
The Trust has undergone three unannounced
inspection visits. An unannounced inspection was
undertaken at Her Majesty’s Prison Wolds in April
2012, when our in-reach mental health service to
the prison was inspected.
Other registered locations inspected were Maister
Lodge, Newbridges and St Andrew’s. The
assessment covered several CQC quality standards
and the subsequent report gave assurance of
compliance in all areas.
A responsive visit (a visit undertaken due to
concerns raised) was carried out at Derwent ward
within the Humber Centre in December 2012,
this resulted in the requirement to take actions to
support full compliance of one CQC Outcome in
relation to Safety and Suitability of Premises.
Humber NHS Foundation Trust has taken the
following actions to address the requirements
reported by the Care Quality Commission:
• The removal of ligature points in relation to
taps, night lights, and windows
• Review of the process of monitoring actions
following ligature audits.
Humber NHS Foundation Trust has made the
following progress by 31st March 2013:
• All works are finished regarding ligature
points to taps and night lights and a works
schedule in place for the replacement of
windows between May 2013 and July 2013.
A revised procedure has been developed
following the review of the process of
monitoring actions following ligature audits.
• Humber NHS Foundation Trust continues to
have annual inspections by the CQC in
relation to the Mental Capacity Act within all
its inpatient areas; these may be announced
or unannounced visits. Following these visits,
action plans are developed where required.
The Trust continues to monitor all the
standards outlined by the Care Quality
Commission in all of its registered locations.
Humber NHS Foundation Trust | Quality Report 2012/13 | 29
Health and Safety
The Trust has a robust risk assessment and audit
programme in place to enable it to effectively
manage its Health and Safety risks. During the
reporting period, Humber NHS Foundation Trust
received no enforcement or routine visits from
the Health and Safety Executive.
Patient Incidents
Humber NHS Foundation Trust has systems and
processes in place to monitor and manage risk
throughout the organisation. One major element
is the reporting of adverse incidents to patients
and staff. The system ensures incidents are
reported and investigated. Trends and themes are
analysed to support wider learning and actions.
The degree of harm to patients is categorised and
reported via this system.
Examples of Lessons Learned from Incidents
• A weekly professionals’ meeting called the
‘Recovery Planning Meeting’ has been
introduced within working age adult
mental health teams. These meetings are
multi disciplinary and focus on the patient’s
care and their goals. A plan is formulated
around helping the patient reach their
goals with the outcome that the patient
receives a better level of service which is
more recovery focused.
• Reflective practice groups have been
established within working age adult
in-patient units. Staff are given the
opportunity to reflect and review patients
holistically, to help in understanding
behaviours and to contribute to the
recovery focused approach.
All incidents that have resulted in severe patient
harm or death and meet set criteria are reported
externally and investigated as Serious Incidents.
23 Serious Incidents have been reported within
this reporting period, 20 of which resulted in
patient harm or death
• One of the Trust’s mental health teams
have asked RETHINK (a national mental
health organisation established by carers)
to work with them to help improve
engagement and understanding of carers’
needs.
Of the 20 incidents reported as causing severe
harm or death, 15 were in relation to patients
who committed suicide whilst receiving mental
health services, 1 was related to patient seizures,
2 were in relation to grade 4 pressure ulcers, 1
related to a fall and 1 was in relation to relevant
information not being provided. • The Nurse Consultant from the
Safeguarding Team delivered dedicated
training sessions, which included best
interest/safeguarding issues to support
a team within older peoples services to
establish robust procedures (including out
of hours) in relation to the implementation
of the Department of Health’s best interest
documentation. As a result, the team has
changed the format of their multi
disciplinary team meeting to ensure these
issues are reviewed weekly and have
changed the format of the care plan that
it uses.
30 | Quality Report 2012/13 | Humber NHS Foundation Trust
Information Governance (IG) and Toolkit
Information Governance refers to the way in
which organisations process or handle
information in a secure and confidential manner.
It covers personal information relating to our
service users and employees and corporate
information, for example finance and accounting
records.
Information Governance provides a framework in
which Humber NHS Foundation Trust is able to
deal consistently with, and adhere to, the
regulations, codes of practice and law on how
information is handled, for example the Data
Protection Act 1998, the Freedom of Information
Act 2000 and the Confidentiality NHS Code of
Practice.
The way in which the Trust measures its
performance is via the Information Governance
Toolkit. The Information Governance Toolkit is a
performance tool produced by the Department of
Health which draws together the legal rules and
guidance referred to above, as a set of
requirements.
In the current version (Version 10) there are 45
requirements relevant to this Trust. Each
requirement has an attainment level from level 0
(no compliance) to level 3 (full compliance). Trusts
must score a minimum of level 2 or above in all
requirements to achieve an overall rating of
Satisfactory. If any one of the 45 requirements is
assessed at level 0 or 1, the Trust will be rated
Unsatisfactory.
The Trust’s audited submission for version 10 of
the Information Governance Toolkit is as follows:
Level 0
No requirements rated at this level
Level 1
No requirements rated at this level
Level 2
10 requirements rated at this level
Level 3
34 requirements rated at this level
Not relevant
1 requirement assessed as not relevant
Therefore Humber NHS Foundation Trust has
been assessed as Satisfactory on its information
governance compliance. The toolkit has rated the
overall compliance at 92% and is rated Green.
Key areas of development in the year 2012/2013
have been:
Clinical Record Keeping
In September 2010, a Serious Incident (SI)
investigation identified that record keeping across
the professions was of concern. This led to the
development of the Defensible Documentation
training course which is now mandatory for all
clinical staff.
The course gives advice and information to
practitioners to help them improve their individual
standards of record keeping. This benefits
patients and helps the Trust to defend potential
claims for clinical negligence.
Humber NHS Foundation Trust | Quality Report 2012/13 | 31
To date 974 staff has attended the course, and
feedback has been positive. To support staff, a
number of standards have been developed as the
‘essential elements of defensible documentation’
for use with both paper and electronic records.
These have now been printed onto A4 card for all
staff to use as an aide memoire, as suggested by
staff who attended the course.
A regular programme of clinical records audit has
also been implemented to provide further
assurance of demonstrable improvement.
Corporate Records Management
Work continues to strengthen progress made in
the previous year to establish a systematic
programme for the management of the Trust’s
non-clinical corporate records.
Information Asset Owners have been identified in
each corporate and service area and work is
undergoing to enable them to register their
information assets on the Trust’s Information
Asset Register. The Information Asset Register is
being used as the basis for IT disaster recovery
plans.
32 | Quality Report 2012/13 | Humber NHS Foundation Trust
Information Commissioner Monetary
Penalties
The Information Governance Committee now
reviews all monetary penalties issued by the
Information Commissioner. This involves a review
of the Trust’s own internal safeguards in order to
provide assurance that the Trust is not vulnerable
to similar serious untoward events.
Information Governance Training
Annual basic information governance training
remains mandated in line with the NHS Operating
Framework, ‘Informatics Planning 2010/11’. Staff
are encouraged to access training through the
National Learning Management System (NLMS),
an online training programme used by the Trust.
In addition, the Information Governance
Department holds monthly face-to-face training
sessions and IG is covered at staff Induction.
Appropriate Access to Records
A privacy officer within the IG department will be
responsible for monitoring the viewing activity of
users of trust systems holding patient information
via an alerts system.
Data completeness: identifiers
The NHS has a duty to collect the following information as a minimum data requirement to enable
trusts to perform their duties effectively. Patient identifiable data completeness metrics (from Mental
Health Minimum Data Set) should consist of:
Humber Foundation Trust Q4 data
NHS Number
99.6%
Date of Birth
100%
Postcode (normal residence)
99.2%
Current Gender
100%
Registered General Medical Practice Organisation Code
98.8%
Commissioner Organisation Code
99.8%
For Quarter 3 of 2012/13, the Trust achieved 99.6% against the overall national target of 99%.
Actual position at the end of Quarter 4 was again 99.6%.
Data completeness: outcomes
a.Include the patients valid NHS number was:
Accommodation and employment information is
collected for those patients who are on the Care
Programme Approach (CPA). This information
helps monitor the patient’s progress in gaining
and maintaining settled accommodation and/or
employment, both of which contribute to quality
of life and patient recovery.
• (99.9%) for admitted patient care and;
For Quarter 3 of 2012/13, the Trust achieved
83.3% against a national target of 50%.
Information on Data Quality
Humber NHS Foundation Trust submitted records
during 2012/13 to the Secondary User Service for
inclusion in the Hospital Episodes Statistics which
are included in the latest published data. The
percentage of records in the published data
which:
• (99.8%) for out-patient care
b.Include the patients valid General Practitioner
Registration Code are:
• (100%) for admitted patient care and;
• (100%) for out-patient care
Clinical Coding
The Trust was not subject to the Payment by
Results clinical coding audit during the reporting
period by the audit commission.
Humber NHS Foundation Trust | Quality Report 2012/13 | 33
P.L.A.C.E. Patient Led
Assessments of the Care
Environment (formally PEAT)
As of April 2012, the PEAT (Patient Environment
Action Teams) underwent review. This programme
has now been replaced with PLACE (Patient Led
Assessments of the Care Environment) which
is due to commence on 2 April 2013.
Although those who were familiar with the PEAT
process will see many similarities with the revised
process, there are also a number of significant
changes.
Changes
Patient/Public Involvement
In accordance with the Prime Minister’s
commitment to give patients a real voice in
assessing the quality of healthcare, including the
environment for care, at least 50% of those
involved in undertaking assessments must meet
the definition of a ‘patient’:
‘Anyone whose relationship with the hospital is as
a user rather than a provider of services’
Members of Trust’s Councils of Governors or
members of Trusts are eligible to act as ‘patient
representatives’ within their own Trust since their
primary role is to represent the interests of
patients/the public. However, it is good practice
that patient assessors are not drawn solely from
this group.
Local publication of results and action plans
Each PLACE visit will generate a score in the four
separate domains of:
• cleanliness
• food
• privacy and dignity
• general maintenance/décor
The results must be published locally, with an
accompanying action plan that sets out how the
organisation expects to improve their services
before the next assessment.
Date of Assessment(s)
Trusts and other participating organisations will
no longer decide the date(s) on which to
undertake assessment. Rather, the Health and
Social Care Information Centre (HSCIC) will give
Trusts and other organisations six weeks’ notice
of the date on which assessments at any
particular hospital/unit should be undertaken.
Organisations will be free to select the day(s) of
the week on which to organise their assessments.
Assessments will be scheduled evenly across a 12
week assessment period.
34 | Quality Report 2012/13 | Humber NHS Foundation Trust
Quality Indicators
From 2012/13 all Trusts are required to report against a core set of indicators.­The following data
provides the required information. Further information regarding these indicators can be found in Part
Three of this report.
Seven Day Follow Ups
7 Day Follow Ups - 2012/13
102
100
%
98
96
94
92
Apr
May
2010/11
Jun
2011/12
Jul
Aug
2012/13
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
The table below benchmarks our achievements against the national average.
Indicator
Percentage of patients on
Care Programme
Approach who were
followed up within 7
days after discharge from
psychiatric in-patient care
during the reporting
period
NHS Outcomes
Framework Domain
1.Preventing People
from dying
prematurely
2.Enhancing quality of
life for people with
long-term conditions
Health & Social Care Information Centre
performance data (2012-13)
Q1
Q2
Q3
Q4
99.2
99.3
98.7
99.3
National
average
98
97
98
National best
score
100
100
100
Awaiting
Data
Availability
from the IC
National worst
score
95
90
93
Humber NHS
Foundation
Trust
Humber NHS Foundation Trust | Quality Report 2012/13 | 35
The Trust considers that this data is as
described for the following reasons:
1. This indicator is a national target and is
closely monitored and audited. The data is
recorded and reported from the Trust’s
patient administration system (Lorenzo) and
is governed by standard national definitions.
2. It is reported to the Trust Board as part of the
Level 1 performance report and monthly to
services managers and their teams as part of
Level 2 and 3 performance reports.
3. It is also reported externally to our
commissioners on a monthly basis and to
Monitor on a quarterly basis.
The Trust has taken the following actions to
improve this % and so the quality of its
service by:
1. Following an intensive external audit during
Q1 and subsequent internal audits, the Trust
now reports on patients who are discharged
out of area for their continuing community
care. During 2012/13 there were seven
patients who were transferred to other NHS
Trust community mental health teams, all of
whom were followed up.
2. We also monitor patients discharged from
out of area hospitals and transferred to the
care of one of the Humber community
treatment teams
3. Ensuring teams are reminded of patients
discharges
4. Discussions within performance meetings
with unit managers and team leaders
5. Being aware of the current Monitor and
Department of Health requirements within
the Compliance Framework
36 | Quality Report 2012/13 | Humber NHS Foundation Trust
Emergency Re-Admissions
Emergency Re-admissions
102
3.39
3.23
3.39
3.00
%
2.00
1.00
0.00
0.00
Apr
0.00
May
Jun
Jul
0.00
0.00
0.00
0.00
0.00
0.00
Aug
Sep
Oct
Nov
Dec
Jan
The Trust considers that this data is as
described for the following reasons
1. Patients who have be transferred from
another bed either within the Trust or from
another Trust are not included
0.00
Feb
Mar
2. It does not include patient who have been
recalled under a Community Treatment Order
(CTO)
3. It is monitored on a weekly basis
The Trust has not had to take any actions to
improve the % but will maintain its
goodpractice and quality of service.
Humber NHS Foundation Trust | Quality Report 2012/13 | 37
Patient Safety Incidents
This year is the first time that this indicator has
been required to be included within the Quality
Report alongside comparative data provided,
where possible, from the Health and Social Care
Information Centre. The National Reporting and
Learning Service (NRLS) was established in 2003.
The system enables patient safety incident reports
to be submitted to a national database on a
voluntary basis designed to promote learning. It is
mandatory for NHS trusts in England to report all
serious patient safety incidents to the Care
Quality Commission as part of the Care Quality
Commission registration process. To avoid
duplication of reporting, all incidents resulting in
death or severe harm should be reported to the
NRLS who then report them to the Care Quality
Commission. Although it is not mandatory, it is
common practice for NHS Trusts to reports patient
safety incidents under the NRLS’s voluntary
arrangements.
As there is not a nationally established and
regulated approach to reporting and categorising
patient safety incidents, different Trusts may
choose to apply different approaches
and guidance to reporting, categorisation and
validation of patient safety incidents. The
approach taken to determine the classification of
each incident, such as those ‘resulting in severe
harm or death’, will often rely on clinical
judgement. This judgement may, acceptably,
differ between professionals. In addition, the
classification of the impact of an incident may be
subject to a potentially lengthy investigation
which may result in the classification being
changed. This change may not be reported
externally and the data held by a trust may not be
the same as that held by the NRLS. Therefore, it
may be difficult to explain the differences
between the data reported by the Trusts as this
may not be comparable. Total
Incidents
2012/13
Total
Incidents
2011/12
No Causing
Severe
Harm or
Death
2012/13
April – June
691
492
5 (0.72%)
2
5
2
July - September
743
608
2 (0.27%)
6
3
7
October - December
662
657
8 (1.21%)
6
10
6
January - March
693
712
4 (0.72%)
8
2
9
2789
2469
19
22
20
24
TOTAL
No Causing
Severe
Harm or
Death
2011/2
Serious
Incidents
Reported
Externally
2012/13
Serious
Incidents
Reported
Externally
2011/12
During the reporting period, Humber NHS
Foundation Trust had 2,789 patient incidents
reported. Of these, 20 resulted in severe harm or
death, which equates to 0.72%.
1. To allow us to compare our figures with the
national reported figures compiled by the
NHS Commissioning Board Special Health
Authority.
The National Patient Safety Agency (NPSA) reports
nationally on all incidents relating to patient
safety. Within these figures, the national median
rate for incident reporting is 23.8 per 1000 bed
days. Humber Foundation Trust’s reporting rate is
22.6 incidents per 1000 bed days. This puts the
Trust in the middle range for incident reporting.
2. To pick up any trends that would alert us to
areas of concern.
The Trust considers that this data is as
described for the following reasons:
38 | Quality Report 2012/13 | Humber NHS Foundation Trust
The Trust intends to take the following
actions to improve this percentage and so,
the quality of its services by:
1. Ensuring full investigations are carried out
resulting in recommendations for actions.
Ensuring these actions are monitored and
their impact assessed and by sharing lessons
learned across the Trust.
Gate-Keeping
All Gate-Keeping - 2012/13
100
98
%
96
94
92
Apr
May
Gate-Kept (%)
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
The table below benchmarks the Trust’s achievements against the national average:
Indicator
The percentage of
admissions to acute
wards for which the Crisis
Resolution Home
Treatment Team acted as
a gatekeeper during the
reporting period
NHS Outcomes
Framework Domain
2.Enhancing quality of life
for people with long term conditions
Health & Social Care Information Centre
performance data (2012-13)
Q1
Q2
Q3
Q4
Humber NHS
Foundation
Trust
99
100
100
100
National
average
98
98
98
National best
score
100
100
100
Awaiting
Data
Availability
from the IC
National worst
score
83
84
91
The Trust considers that this data is as described for the following reasons:
1. All gate-keeping is now electronic and is
recorded on the Trust’s patient administration
system (Lorenzo) and is adopted across both
Hull and East Riding. Although only patients
aged 16-65 are reported to Monitor and the
Trust Board (graphs and figures above), by
way of good practice this process continues
to be in place for patients aged 66 and over.
2. Gate-keeping is monitored weekly to ensure
consistency and accuracy of data recording
remains across the Trust and is governed by
standard national definitions.
The Trust has not had to take any actions to
improve the % but will maintain its good
practice and quality of service.
Humber NHS Foundation Trust | Quality Report 2012/13 | 39
The National Patient Survey
In 2012 the questionnaire was sent to 850 of our
service users. There was a 32% return rate, which
was the same as the national average.
In the region Humber scores the highest overall.
It is ranked first in ‘medications’ and second in
the region for ‘crisis care’. The Trust is comparable
to others in the region on the other domains.
Survey of people who use community mental health services 2012
Humber NHS Foundation Trust
Section Scores
S1. Health and Social Care Workers
0
1
2
3
4
5
6
7
8
9
10
Same
This trust
S2. Medications
0
1
2
3
4
5
6
7
8
9
10
Same
Best performing
trusts
S3. Talking Therapies
0
1
2
3
4
5
6
7
8
9
10
Same
S4. Care Co-ordinator
0
1
2
3
4
5
6
7
8
9
10
Same
S5. Care Plan
0
1
2
3
4
5
6
7
8
9
10
S6. Care Review
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
S7. Crisis Care
S8. Day to Day Living
S9. Overall
The table above identifies where Humber
Foundation Trust compares with the highest and
lowest scoring Trusts for the reporting period and
provides us with a national average range.
The Trust considers that this data is as
described for the following reasons
The response rate for the Trust in the 2012
National Patient Survey was 32% which is the
same response rate as the national average. The
demographic characteristics for this Trust was also
generally in line with the national picture and
therefore we can conclude that the results in this
survey are reliable.
The Trust has taken the following actions to
improve this % and so the quality of its service:
1. Implementation of the Recovery Star as an
assessment and care planning tool which will
help to identify and support people who are
requiring help on benefits, housing and
finding work.
40 | Quality Report 2012/13 | Humber NHS Foundation Trust
About the same
Same
Worst performing
trusts
This trust’s results
are not shown if there
were fewer than 30
respondents.
Same
Same
Same
Same
2. Ensure that enough information and support
is given to families and carers through the
development of a corporate template for
inpatient welcome packs given on admission
to units.
3. A Self Administration of Medication pilot is
being implemented to increase
independence and decisions on medications.
4. Ensure that all service users are provided with
the name and contact details of their care
co-ordinator / lead professional and how
they can be contacted.
5. Continue action to ensure that all service
users are offered a hard copy of their care
plan and understand the contents.
6. All care co-ordinators to ensure that all service
users have access to out-of-hours support
telephone number.
Staff Who Would Recommend the Trust as a provider of care
to family/friends
Trust result
2012
KF24. Staff
3.58
Trust result
2011
3.60
Worst result
Nationally
- Mental
Health Trusts
3.06
Median result
Nationally
- Mental
Health Trusts
Best result
Nationally
- Mental
Health Trusts
3.54
4.06
Ref; Trust Staff Survey 2012
The Trust considers that this data is as
described for the following reasons:
This data is extracted directly from the report of our
2012 staff survey undertaken by an independent
contractor using the nationally specified criteria. It is
calculated from three questions in the survey
(Questions 12a, 12c and 12d) and expressed as a
score between 1 (worst) and 5 (best).
The Trust has taken the following actions to
improve this score and so the quality of its
service:
The Trust continues to undertake to consult and
involve staff in service improvement and service
development wherever possible. As the vast majority
of our staff are part of our local communities and
therefore they and their families are also part of our
patient population we endeavour to ensure that
staff operate on the principle of whether the service
they provide they would consider good enough for
themselves or their family.
As part of the Trust actions following the
publication of the second Robert Francis QC
report into Mid Staff Hospital Trust, the Chief
Executive supported by Directors, senior managers
and non exec directors has undertaken an
extensive Trust wide “listening exercise” to
engage staff at all levels and across all services in
conversation about the quality of service delivery,
the issues and challenges for staff and linked to
the Francis report what the trust might prioritise
to change and thereby better enable staff to offer
the best possible service.
This is in additional to the already established
Director Visibility Programme where senior
managers take time to listen to staff’s experience
and view and, where necessary, take
management action.
In addition, the Trust continues its PEAT/PLACE
assessments and actions in which support staff in
improving patient environments. The Trust staff
health and well-being group has a programme of
work that includes stress audits, health promotion
and other elements of the staff engagement star.
The Trust has developed and delivers leadership
and management development programmes
which include day lead by occupational health
staff health and well-being and psychology
support in delivering emotional resilience.
The Trust has signed up to the public health
responsibility deal pledges and related
improvement framework. The Trust priorities
from the staff survey are in respect of improving
effective team working and managing
& reducing stress at work.
The actions taken as a result of this are expected
to provide an increased focus on the absolute
priority of quality of services for staff and thereby
influence and improve their perception of their
services and the acceptability of such services to
friends and family.
Humber NHS Foundation Trust | Quality Report 2012/13 | 41
Part Three
3.1 Our Performance
Key National Priorities
The priorities for the NHS are set out by the
Department of Health in the NHS Framework
each year. In order to measure whether these
priorities are being achieved the framework sets
out a range of performance indicators and targets
which the Trust uses to measure and demonstrate
its achievements. At the start of 2012/13 the
Trust identified which of the national priorities
were key to this Trust, some of which are
described below.
Some indicators we have included this year have
changed from those reported in the 2011/12
report. This is due to the necessity to comply
with requirements to provide information on set
indicators, i.e. Patient Safety, Clinical Effectiveness
and Patient Experience.
How We Monitor Performance
Our internal reporting is split into three levels:
Level 1:
Monthly and quarterly performance reports to the
Trust Board. It is also considered by the
Performance and Assurance Group (PAG) which is
chaired by the Director of Strategy and
Performance.
Level 2:
Monthly Dashboard reports to the Hull and East
Riding Business Units.
Level 3:
Monthly performance reports to teams
42 | Quality Report 2012/13 | Humber NHS Foundation Trust
We also report externally to our commissioners via:
Contract Activity Report (CAR)
Completed monthly by the information
management team jointly with the performance
team
Integrated Performance Measures Return
(IPMR)
Completed quarterly by the information
management team jointly with the performance
team
This system ensures that we can:
• monitor critical clinical processes and activities
using measures of clinical and corporate
performance that trigger alerts when
potential problems arise
• analyse the root cause of problems by
exploring relevant and timely information
from different angles and at various levels of
detail
• manage people and processes to improve
decisions, be more effective, enhance
performance and steer the organisation in
the right direction.
Meetings are held regularly at commissioner,
Board, service and team levels. Internal and
external auditing ensures our methods of
calculation and delivery meet the national and
local guidelines.
Domain 1 - Patient Safety
Seven-day follow-up
Description of Priority
The National Suicide Prevention Strategy for
England recognises that anyone being discharged
from inpatient care under the Care Programme
Approach (CPA) should be contacted by a mental
health professional within seven days of their
discharge. The Trust has set a local performance
standard that all patients should be seen face to
face. However, telephone contact is acceptable
under exceptional circumstances where face to
face is not possible.
Aim/Goal
The aim of this priority is to ensure everyone
discharged from a mental health inpatient unit
and who is considered by the clinical team to
require continuing care and treatment managed
within the Trust’s CPA, is followed up within seven
days within the criteria set by Monitor. As a
National Key Performance Indicator, our goal is to
achieve the 95% target of all patients followed
up within seven days of discharge
For any other instances which fall outside these
categories, then advice and support is sought
from the Department of Health. These include
patients transferred to private providers and to
other NHS Trusts for community-based treatment.
Throughout the year the Trust has not only
achieved the 95% target but consistently
remained above 97% performance. The sevenday follow-up process continues to be developed
and improved and the robust methods of
monitoring ensure continued success in achieving
this target. Previous yearly averages were 98.67%
in 2009/10, 99.33% in 2010/11, 99.18% in
2011/12 and 99.12% in 12/13.
Summary of Progress
At the end of 2012/13, five incidents occurred
when patients were unable to be contacted
within the seven days. During this time the Trust
achieved a performance rate of 99.12%. The
0.88% of patients that were not seen were
reported as adverse incidents and fully
investigated. This includes patients who chose not
to engage with services following their discharge.
National exceptions to this are:
• People who die within seven days of
discharge
• Where legal precedence has forced the
removal of a patient from the country
• Patients discharged or transferred to other
NHS hospitals for psychiatric treatment
Humber NHS Foundation Trust | Quality Report 2012/13 | 43
Immunisation Rate for Human
Papillomavirus (HPV)
Description of Priority
Immunisation against Human Papillomavirus
(HPV) highlights an area of national and
international concern to end the transmission of
preventable life-threatening infectious diseases.
Vaccines prevent infectious disease and can
dramatically reduce disease and complications in
early childhood, as well as mortality rates.
The vaccination for HPV is delivered in three
doses. The 90% target relates to the uptake of
the complete course of vaccination, measured as
the total number of 12 to 13 year old girls in East
Riding of Yorkshire schools who have received all
three doses. The programme of vaccinations is
delivered by the Trust’s School Nurses, supported
by our Health Visitors because of the scale of the
programme. Delivery of the doses has to be
spread out over a six month period to work
properly, and this has to be fitted in around the
academic school year.
This is a Tier 2 Vital Signs Monitoring indicator
with a locally agreed target, that >90% of girls
aged 12-13 have completed a full course
(3 doses) of immunisation against HPV.
Summary of progress
Due to the difference between the financial year
we are describing in this report (April 2012 to
March 2013) and the academic year that dictates
the delivery timings of the vaccination doses
(September 2012 to July 2013), we are not able
to report the completed vaccination cycle for
2012/13, as vaccination for Dose 3 will continue
into July. So far in 2012/13 the Trust has
delivered Doses one and two to 94.2% of 12 to
13 year old girls in East Riding of Yorkshire
schools. The Trust has also started the delivery of
Dose three and has vaccinated 29.3% of girls at
the end of March 2013, which is ahead of the
plan and higher than the same time last year.
We are therefore confident of achieving the 90%
target by the end of the academic year.
Between September 2011 and July 2012 the Trust
delivered all three doses of HPV immunisation to
92.3% of girls aged 12-13 in East Riding Schools.
Uptake is reported via the Health Protection
Agency (HPA) website. The HPA issues a report
each autumn on the national uptake in the
previous academic year.
Percentage of 11-12 year old girls given doses
(note scale starts at 85%)
Aim/Goal
Coverage of HPV vaccination programme
97
95
93
94.9
93.6
93.5
92.3
91
Target (50%)
89
87
85
2011/12
Dose 1
44 | Quality Report 2012/13 | Humber NHS Foundation Trust
94.2
Dose 1 & 2
2012/13
Dose 1,2 &3
Target
The Trust considers that this data is as
described for the following reasons:
The Trust sets its own targets of 95% for Dose 1
and 93% for Doses 1 and 2, to ensure that there
is sufficient coverage of girls receiving the first
two doses to achievement least 90% coverage for
receiving all three doses.
The immunisation programme is recorded against
the record of each child individually, from a
master list of all eligible children. We are
therefore able to accurately identify the overall
percentage coverage. The Trust monitors the
delivery of each dose to ensure there is enough
scope in the delivery of doses one and two to be
able to achieve 90% for all three doses, allowing
for some drop out between each dose, as shown
by the 2011/12 figures below:
Percentage of girls receiving vaccination
The Trust has taken the following actions to
improve this % and so the quality of its
service:
During 2012/13 the storage and distribution of
childhood vaccines has been restructured to
ensure that it meets national standards of best
practice. The programme was commenced as
early as possible in September 2013 (the start of
the school year) to give as much time as possible
to identify any girls missed in the first rollout and
vaccinate them during catch-up sessions.
2011/12
2012/13
Dose 1
93.6%
94.9%
Doses 1 and 2
93.5%
94.2
Doses 1, 2 and 3
92.3%
Dose 3 runs to July 2013
Emergency Re-admissions
Summary of Progress
Description of Priority
Not all patients who are re-admitted within 28
days are classified as an emergency. Some
patients are recalled as part of their treatment.
Patients may also be discharged earlier as part of
the home treatment and care plan with a view to
them being re-admitted if the patient and care
co-ordinator feel it is more beneficial to their
overall recovery. They will also be gate-kept by an
Crisis Resolution Team or Intensive Home Care
Team (See gate-keeping)
Helping people to recover from episodes of ill
health.
Aim/Goal
To monitor all patients aged 15 years and above
who have been readmitted within 28 days of
discharge. Although the national target is to be
confirmed, the Trust has levied their own internal
target of 10% or less.
The percentage target is worked out by dividing
the number of re-admissions by the number of
discharges.
At Year End there were a total of 738 admissions.
Of which only six patients were admitted as an
emergency (0.81%). The highest monthly figure
was two readmissions from 59 discharges (3.39%).
Humber NHS Foundation Trust | Quality Report 2012/13 | 45
Clostridium (C.) difficile
Description of Priority
Summary of Progress
This indicator measures the number of C.Difficile
cases where a Foundation Trust has a centrally set
objective.
Trust reported a Year End position of 3 cases of
C.Difficile. All 3 cases were attributable to the
Trust Community Hospital setting. The data is
governed by standard national definitions.
Aim/Goal
The target on this National Key Performance
Indicator is currently not to exceed 4 cases (2 in
Hull & 2 East Riding). It is the aim of the Trust to
achieve this target each year.
Year
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
End
Hull
0
0
0
0
0
0
0
0
0
0
0
0
0
East Riding
0
0
0
0
0
0
0
2
0
1
0
0
3
Trustwide
0
0
0
0
0
0
0
2
0
1
0
0
3
Methicillin-resistant Staphylococcus aureus (MRSA)
Description of Priority
Summary of Progress
This indicator measures the number of MRSA
cases where a Foundation Trust has a centrally set
objective.
Trust reported a Year End position of 0 cases of
MRSA. The data is governed by standard national
definitions.
Aim/Goal
The target on this National Key Performance
Indicator is currently to be no cases of MRSA. It is
the aim of the Trust to achieve this target each year.
Domain 2 - Clinical
Year
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
End
Hull
0
0
0
0
0
0
0
0
0
0
0
0
0
East Riding
0
0
0
0
0
0
0
0
0
0
0
0
0
Trustwide
0
0
0
0
0
0
0
0
0
0
0
0
0
46 | Quality Report 2012/13 | Humber NHS Foundation Trust
Effectiveness
Gate-keeping
Delayed Discharges
Description of Priority
Description of Priority
A mental health inpatient admission is said to
have been gate-kept if the service user has been
assessed by a crisis and home treatment team
(CRHT) within 48 hours prior to their admission
and if they were involved in the decision-making
process which resulted in the admission.
This indicator measures the impact of communitybased care in facilitating timely discharge from
hospital and the mechanisms in place. People
should receive the right care, in the right place,
at the right time.
Aim/Goal
Every referral for admission is individually assessed
to ensure the most appropriate method of care is
provided across both Hull and East Riding. Only
when a patient’s care and treatment cannot be
best met in their own home, is an admission
made.
Summary of Progress
At Year End there were a total of 354 admissions.
The Trust reported that 100% of all admissions to
its acute inpatient units had been gate-kept. This
is above the national target of 95%.
Aim/Goal
The target on this National Key Performance
Indicator is currently below 7.5%. This figure
compares the number of days delayed with the
number of occupied bed days for mental health
and community hospitals. It is the aim of the Trust
to achieve this target.
Summary of Progress
The Trust reported a Year End percentage of
4.16% delays which is 3.34% below the measure
and deemed very good. The number of occupied
bed days is reported through the Trust’s patient
administration system (Lorenzo) and the
community services clinical reporting system
(SystmOne). The number of patients affected and
the number of days that they were delayed by are
reported via weekly unit submissions. The data is
governed by standard national definitions.
Previously the Trust only reported patients whose
delay was attributable to the NHS (either in whole
or part). However, following new Monitor
guidelines, all delayed discharges including those
attributable to social care are now included.
The first quarter of 2012/13 was an unusual one
due to two contributing factors: the closure
of the existing patient administration system (iPM)
and the development of the new administration
system (Lorenzo). However, as robust monitoring
systems continued to be in place for this indicator,
the disruption was kept to a minimum.
Humber NHS Foundation Trust | Quality Report 2012/13 | 47
Delayed Discharge Figures 2012-13
8.00
Axis Title (%)
7.00
6.00
5.00
4.00
3.00
2.00
1.00
0.00
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
2012-13
7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50% 7.50%
Target
5.32% 5.64% 4.08% 4.53% 5.58% 4.58% 3.31% 4.37% 3.34% 3.29% 2.51% 3.02%
The Trust considers that this data is as
described for the following reasons:
1. The chart shows a combined figure for both
Mental Health services and East Riding
Community Hospitals
2. Both the Care Quality Commission and
Monitor measure delayed discharges for
patients whose transfer of care was delayed
due to factors which were the responsibility
of the NHS. The national target for this
indicator is set at equal to or less than 7.5%
The Trust has taken the following actions to
improve this % and so the quality of its
service by:
1. The units having a good working knowledge
of what placements are available and have
been proactive in ensuring all systems and
processes are followed by attending panel
meetings and sharing information. They
liaise regularly with residential homes to give
support and advice and ensure patients
settle in well. Although the overall number
of delayed discharges so far in 2012/13 has
fallen, there continues to be a higher than
average number of delays within older
people’s services. These are primarily due to
housing needs and applications for funding
48 | Quality Report 2012/13 | Humber NHS Foundation Trust
2. Units continue to address these issues by
ensuring that individual patients are regularly
discussed in multi-disciplinary team meetings
and appropriate measures are in place
3. Timely discharge is most difficult for patients
with challenging needs due to availability of
appropriate placements. We therefore
continue to work together with private
providers, the voluntary sector, families and
carers to maintain a high quality of care and
ensure patient needs are met
4. Ensuring recommendations following audit
are adhered to
5. Communicating internally with teams to
ensure consistency and awareness of policy
6. Liaising with families, carers and housing
providers
The external audit of the quality accounts has
identified a weakness in the way the information
relating to this indicator is recorded within patient
notes. The auditors have provided us with a
number of recommendations to improve the way
we record the information required to measure
this indicator. During 2013/14 we will continue to
improve the process and implement the
recommendations raised.
Early Intervention
Description of Priority
Summary of Progress
Referrals come from a variety of sources including
education, child care, child and adolescent mental
health services (CAMHS), family, GP and self. A
number of referrals come through the Single
Point of Access service. Assessments and
treatment are carried out within this service.
There has been a significant reduction in the
number of referrals coming through from East
Riding over the year and a drop in referrals from
Hull in the last quarter. The team are working
hard with local GPs and the local authority/
education to identify strategies to promote the
service. The East Riding caseload is now being
managed more effectively which should also
increase capacity for further new referrals.
Aim/Goal
Meeting commitment to serve new psychosis
cases for ages 14-35.
The Year End target of 83 new cases has not
been met with the Trust achieving 70 cases
(84.33% of target).
At year end it is the Trust’s aim to meet the local
commissioner targets of 217 on caseload and 83
new cases. Currently figures for new cases and
caseload are manually collected.
For 2012/13, the Trust has exceeded its total Year
End target of 217 on caseload by achieving a
caseload of 225.
Early Intervention in Psychosis - Caseload
260
250
240
230
220
210
200
Apr
May
Jun
Target
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual
Number of New Cases
Trustwide New Cases - Comparison Chart
90
80
70
60
50
40
30
20
10
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
10-11 Actual
8
11
21
29
33
37
43
47
53
58
65
83
11-12 Actual
2
11
20
28
34
43
48
56
59
68
78
85
12-13 Actual
4
12
18
23
29
36
43
48
51
55
59
70
Seasonal Target
5
13
18
25
30
34
39
45
51
61
66
83
Humber NHS Foundation Trust | Quality Report 2012/13 | 49
The Trust considers that this data is as
described for the following reasons:
1. To show three year comparisons
2. That the number of referrals has reduced
during 2012/13 and impacted on the
number of new cases that have been able to
be taken on
The Trust has taken the following actions to
improve this % and so the quality of its
service by:
1. Monitoring on a weekly basis
2. Monitored every month at the ‘Performance
& Assurance Group’ Meetings
3. Monitored every month at the ‘Trust Board’
Meetings
4. Pro-actively Liaised with education services
5. Marketing the service with local GPs
6. Providing workshops and road shows to
colleges throughout the area in particular
Bishop Burton College in the East Riding and
Hull University. Specifically providing greater
publicity regarding the need to refer young
people who are not so clearly exhibiting
symptoms at present, who are no longer
being referred.
7. Re-negotiation of the East Riding Target due
to the reduction in population for people
aged 14-35, in which the target was
originally set.
50 | Quality Report 2012/13 | Humber NHS Foundation Trust
Domain 3 - Patient Experience
Percentage of Patients Seen
within 18 Weeks for (Admitted
&) Non Admitted Pathways
(Community Services)
Description of priority
The Trust provides consultant-led outpatient
clinics at the Alfred Bean Hospital for a limited
range of acute specialties including orthopaedics
and rheumatology, in order to make the clinics
more accessible to patients who would otherwise
need to travel to the acute trusts in the region.
The national target is for at least 95% of patients
receiving outpatient care for these specialties to
start their treatment within 18 weeks of referral.
Underlying 18 weeks is the principle that patients
should receive excellent care without unnecessary
delay. The target focuses on patient pathways
that do or might involve medical or surgical
consultant-led care, setting a maximum time of
18 weeks from the point of initial referral up to
the start of any treatment necessary for all
patients who want it, and for whom it is clinically
appropriate.
Aim/Goal
Because the target relates to the start of
treatment this will involve the majority of patients
having at least two appointments, the first to
assess their needs and order any diagnostic tests
that might be needed, and the second (or third)
to start treatment. The team therefore works
hard to ensure that the first appointment occurs
early enough to allow for the return of any test
results before the next appointment, which can
take up to six weeks.
Percentage of outpatients starting treatment
within 18 weeks of referral - 2012/13
100
100
99.5
99
100
99.0
98.9
98
97
%
100
99.4
99.0
99.3
98.1
97.4
97.3
Apr
May
96
95
94
93
92
Jun
Jul
Aug
% starting treatment within 18 weeks
Summary of progress
The Trust treated 1,960 patients in the acute
speciality outpatient clinics provided at Alfred
Bean Hospital during 2012/13, and has
consistently ensured that over 97% of patients
attending the clinics start their treatment within
18 weeks, against the target of 95%.
The Trust considers that this data is as
described for the following reasons:
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
The Trust has taken the following actions to
improve this % and so the quality of its
service:
Performance against the target is reported on
a weekly basis. The team plans, monitors and
prioritises each appointment to ensure that all
outpatients at Alfred Bean start their treatment
within the 18 week target. The clock start, end
and (where appropriate) pauses are governed by
national standard definitions.
Performance reporting for this service was
restructured at the start of the year. Exception
reports ensure that the service is notified of every
patient who has not received definitive treatment
and does not have a booked appointment within
the necessary timescale to achieve the 18 week
target. These patients are then targeted to
ensure that appointments are booked.
Humber NHS Foundation Trust | Quality Report 2012/13 | 51
Home Treatments
There are four individual home treatment teams
in operation to ensure that all adult and older
adult patients are served across the geographical
area.
Description of Priority
The home intensive treatment teams support
patients in their own homes and, where
appropriate, may allow for a patient’s earlier
discharge. This works alongside the gate-keeping
function as home treatments may also prevent
unnecessary admission by providing a more
appropriate method of treatment. This ensures
patient pathways continue to be streamlined and
more effective, in keeping with an expected
decrease in admissions and reduced length of
inpatient stay.
Summary of Progress
The Trust Year End Integrated Performance
Measures Return (IPMR) target is 1115 home
treatments. 661 for Hull and 454 for East Riding
Both Hull and East Riding exceeded their
individual targets. Overall the Trust carried out
1254 home treatments by year end (112.47%).
693 for Hull and 561 for East Riding. Home
treatments continue to be monitored on a weekly
basis to ensure the Trust maintains its target. This
is reported on a monthly basis via internal
performance reports and to the Board. It is also
reported monthly (via the contract activity report)
to our commissioners.
For a single home treatment contact to be
registered as being achieved, each service user
must receive treatment in their home or usual
place of residence on a minimum of two
occasions.
2 x Home Treatments - Trustwide
1500
1000
500
0
Apr
Hull
May
Jun
East Riding
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Target
The Trust considers that this data is as
described for the following reasons:
1. To show the number of home treatments has
continually exceeded the locally agreed
target
2. To show the split between Hull and East
Riding
52 | Quality Report 2012/13 | Humber NHS Foundation Trust
The Trust has not had to take any actions to
improve the % but will maintain its good
practice and quality of service.
Description of priority
There is clear evidence that breastfeeding has
positive health benefits for both mother and
baby in the short and longer-term (beyond the
period of breastfeeding). Breastmilk is the best
form of nutrition for infants and exclusive
breastfeeding is recommended for the first six
months (26 weeks) of an infant’s life. However, a
majority of mothers give up breastfeeding in
early weeks and infants therefore lose out on the
many health benefits. Babies who are not
breastfed are many times more likely to acquire
illnesses such as gastroenteritis and respiratory
infections in the first year. In addition, there is
some evidence that babies who are not breastfed
are more likely to become obese in later
childhood. Mothers who do not breastfeed have
an increased risk of breast and ovarian cancers
and may find it more difficult to return to their
pre-pregnancy weight.
Prevalence of breastfeeding at 6-8 weeks is
therefore a key indicator of child health and
wellbeing, with parents getting help and support
with breastfeeding in hospitals and in the
community from health visiting and midwifery
teams, General Practices, Child Health services
and Children’s centres.
Aim/Goal
To support all mothers who have chosen to
initiate breastfeeding to continue to do so, and
increase the proportion of mothers who choose
to continue to breastfeed until at least six to
eight weeks after birth.
Summary of progress
At the start of the year the target ceased to be a
nationally mandated Vital Signs indicator and
became a local Public Health target. A new
target was agreed with our commissioners,
reflecting the recognition that the old national
requirement of a 2% increase per year had not
been achieved nationally and was stretching ever
further out of realistic reach. The new target was
set at 43%, increasing by 0.5% each quarter to
44.5% in Quarter 4, to be reviewed at the end of
the year.
The Trust has not achieved the target for the
majority of the year.
Breastfeeding Prevalence
at 6-8 Weeks - 2012/13
50
Percentage of Mothers Breastfeeding Prevalence (%)
Percentage of Infants
Breastfed at Six to Eight
Weeks
45
40
44.0
41.5
42.1
39.2
35
30
25
20
15
10
5
0
Quarter
1
Quarter
2
Quarter
3
Breastfeeding Prevalence
Quarter
4
Target
Humber NHS Foundation Trust | Quality Report 2012/13 | 53
The Trust considers that this data is as
described for the following reasons:
1. Breastfeeding starts in hospital, supported by
the Hospital’s midwives. Midwives continue
to be responsible for supporting babies and
their mothers for the first 28 days after they
leave hospital, after which they become the
responsibility of the Health Visitors until the
child’s fifth birthday. In the East Riding the
Trust provides the Health Visitor element of
the support for mothers and babies, starting
with the Birth Visit, which takes place within
the first two weeks.
2. In addition to monitoring the breastfeeding
prevalence at six to eight weeks we monitor
the initiation rate (in hospitals), which helps
us to understand the impact our Health
Visitors are able to make once the mother
and baby have left hospital. Over the last
four years the proportion of babies whose
mothers initiated breastfeeding at birth has
dropped by around 9% (see chart below).
Over the same period the proportion of
babies still breastfeeding at six to eight
weeks has only dropped by around 1%.
This means that the Trust has supported an
increasing proportion of mothers who
initiated breastfeeding to continue with it.
54 | Quality Report 2012/13 | Humber NHS Foundation Trust
The Trust has taken the following actions to
improve this % and so the quality of its
service:
The Trust is working with Children’s Centres to
increase the amount of antenatal (pre-birth)
contact pregnant women receive to help them
make informed and healthy choices about
breastfeeding. As noted above, although a
smaller proportion of mothers have initiated
breastfeeding in hospital, once the Trust’s Health
Visitors begin their involvement and support an
increasing proportion of mothers who did initiate
have continued.
Certification against compliance with requirements regarding
access to healthcare for people with a learning disability
Description of Priority
Aim/Goal
Meeting the six criteria for meeting the needs of
people with a learning disability, based on
recommendations set out in Healthcare for All
(DH, 2008).
NHS Foundation Trust Boards are required to
certify that their trusts meet requirements a) to f)
above at the annual plan stage and in each
quarter.
Summary of Progress
This key indicator has also being monitored
closely at the monthly Trust board meetings via
Level 1 Performance Report.
Q1
Q2
Q3
Q4
Does the NHS foundation trust have a mechanism in place to
identify and flag patients with learning disabilities and protocols
that ensure that pathways of care are reasonably adjusted to meet
the health needs of these patients?
Green
Green
Green
Green
Does the NHS foundation trust provide readily available and
comprehensible information to patients with learning disabilities
about the following criteria?
Green
Green
Green
Green
Does the NHS foundation trust have protocols in place to provide
suitable support for family carers who support patients with
learning disabilities
Green
Green
Green
Green
Does the NHS foundation trust have protocols in place to
encourage representation of people with learning disabilities and
their family carers?
Green
Green
Green
Green
Does the NHS foundation trust have protocols in place to regularly
audit its practices for patients with learning disabilities and to
demonstrate the findings in routine public reports?
Green
Green
Green
Green
The Trust can confirm that each
of the 6 criteria (rated Green) have been
achieved each quarter for 2012/13.
Townend Court – our brand-new,
purpose-built facility for people with
learning disabilities which opened in
December 2012.
Humber NHS Foundation Trust | Quality Report 2012/13 | 55
3.2 Patient Experience
Complaints/Patient Advice and
Liaison Service (PALS)
The Complaints and PALS Department continues
to record and respond to complaints, concerns,
comments and compliments received from all
areas of the Trust. It is our procedure to allow the
caller/complainant to decide whether they wish to
have their concerns considered formally through
the NHS Complaints Procedure or informally via
PALS. Offering both services through one
department allows the Trust to monitor all
concerns raised, whether formally or informally,
to see if there are any trends and to provide a
consistent approach to complainants/callers.
56 | Quality Report 2012/13 | Humber NHS Foundation Trust
Formal complaints
For the period 1 April 2012 to 31 March 2013,
the Trust received 160 formal complaints which
compares to 145 for 2011/12. The Trust
responded to 148 formal complaints for the same
period which compares to 144 for 2011/12.
Each complaint is treated individually, as although
the issues raised may be similar to others, the
circumstances are often different for the
individual concerned. The Trust aims to respond
to the majority of formal complaints within 25
working days, although if at the outset it is
considered that a longer investigation period may
be required, the complainant is informed.
It is important to note that not all formal
complaints are the result of a Trust failing or poor
service. For example, a complainant may not be
happy with the service provided because they
consider their needs are different to what the
Trust has assessed them as needing.
At the outset of each complaint we try to
determine the complainant’s desired outcome
from making the complaint, however it is not
always possible to give them what they seek.
The primary subject from the 148 formal
complaints responded to is:
Admission, discharge, transfer arrangements
7
Aids, appliances, equipment, premises
2
Appointment delay/cancel – outpatients
Assessment process
21
4
Attitude of staff
18
Clinical treatment
60
Communication/information to patients
16
Communication/information to relatives/carers
4
Complaints handling
1
Failure to follow agreed procedures
3
Medication issues
5
Mental Health Act
1
Other
1
Personal records
1
Policy and commercial decisions of the Trust
1
Patient’s privacy, dignity, respect and safety
1
Patient’s property and expenses
2
Of the 148 responded to, the Trust is aware of 5
cases being considered by the Parliamentary and
Health Service Ombudsman; 3 of these have been
closed with no investigation and no further action
for the Trust and 2 are still being considered.
During this period, the Ombudsman also
considered a further 6 cases from complaints
responded to in the previous year. All of these
cases were closed with no investigation and no
further action for the Trust.
The following are some examples of actions/
learning from complaints responded to between
1 April 2012 and 31 March 2013; all patient
specific actions have been excluded.
Humber NHS Foundation Trust | Quality Report 2012/13 | 57
Single Point of Access - As referrals are triaged
patients are notified by letter; this letter should
detail which service they have been referred onto
for treatment.
Out of Hours GP Service - To reiterate to all
staff that when triaging for another Primary Care
Centre (PCC), that if there is a need for on-going
clinical treatment in the local PCC a clinician to
clinician discussion must take place and the
patient referred and messages should not be left
with non-clinical staff or a clinical nature.
Physiotherapy - All patients to be given the
injection information leaflet before injection; this
is compulsory.
Recovery and Support Team - Team members
to carry supply of compliment slips and plain
envelopes so that messages can be left in the
event the patient is not at home.
Psychological Medicine - To put in place a more
robust system with the department to ensure that
service users receive the support required during
any absence of their named worker. All
administrative staff within the department to be
given further training regarding the sensitivity
required when responding to service users who
are in distress and the need to take full and
accurate information from patients so that
messages can be left for clinicians.
58 | Quality Report 2012/13 | Humber NHS Foundation Trust
Community Hospital - On admission to the
ward, patients’ property/valuables will be checked
by two staff members and documented in nursing
assessment. If possible, patients should be
encouraged to place any cash and valuables
(financial and/or sentimental) in the safe custody
of a relative and returned home.
Patient Advice and Liaison Service (PALS)
For the period 1 April 2012 to 31 March 2013,
the Trust responded to 747 PALS contacts which
compares to 975 for the previous year.
Of the 747 contacts, 126 were referrals to other
Trusts. Of the 621 contacts for this Trust, 116 of
these were compliments, 283 were routine
concerns, 185 were routine queries and 37 of the
contacts were complex, ie multiple/complex issues
or challenging callers.
Priorities for 2013/14
To continue to manage and respond to
complaints, concerns, comments and
compliments for all our services through changing
times for the Trust and to implement any changes
to the NHS Complaints Procedure following the
outcome of the review. It is important that all
staff are aware of the importance of a
professional and informative response to patients
and carers when they raise a concern or
complaint.
Below are examples of a few of the compliments which have been received:-
“To all the staff, I would like to
thank you all for taking care of
my husband. I know it would
have been quite difficult for you
at times. Without your care and
understanding I wouldn’t have
been able to cope.”
Older People’s Mental Health,
Inpatient
“Since last April 2011 I have been
involved with a change over of medication
and (staff name) has been working with
me during this time. I must point out that
(staff name) has helped me over this
period of time by taking me out an
visiting with me on a regular basis helping
to boost my self esteem. (Staff name)
was very professional in his approach and
I felt very comfortable in sharing
challenges with him during this period”.
Adult Mental Health, Community
“Many thanks for your past care
and attention. This enabled me
to travel to Oxford to see my son
at university and witness his
success which I would have surely
been unable to do without your
help. Many thanks.”
Bladder and Bowel Health
“Since my husband and I have
been attending the clinic for
podiatry we were very fortunate
to meet (staff name) who is a
kind, caring, efficient and
professional person. The podiatry
department is enriched by the
service (staff name) provides.”
Podiatry
“Chair has been delivered
today and (patient) is very
happy with it. Thank you.
Cushion is also much deeper
and (patient) feels comfortable
and secure in the chair.”
Services to Aid Independent
Living
“(name) and I wish to express our heartfelt
thanks to each and every member of staff
involved in his care, rehab and general
wellbeing. Your level of commitment,
kindness, compassion, patience, support
and hard work has enabled him to make
such amazing progress. You have given
him independence and dignity back and
brought the man I love back to me. Thank
you!” Community Hospital
Humber NHS Foundation Trust | Quality Report 2012/13 | 59
Patient Experience working group
A patient experience working group has been
formed to share the feedback between teams and
identify best practice. This is a new group but the
aim is to collate stories, look for themes that go
beyond just one service area and for members to
support each other in what, for some, might be
new territory.
Sometimes feedback simply highlights the positive
experience of service users or patients. In the
recent Wound Care Clinic survey, patients
recorded an overall satisfaction rate of 98.47%
and all respondents reported that they felt they
had been treated with dignity and respect (100%)
and that they were involved in their care and
treatment plan (100%).
Improvement Cycle for
Patient Feedback
The feedback from the patient story work
undertaken in Telehealth has resulted in an
additional co-ordinator being employed. It has
also led to more flexibility and a longer period
where the patients can monitor their vital data.
This was because feedback showed that
sometimes it was difficult for patients to fit in
readings at specific times and monitoring should
fit around the patient needs.
One example of significant change to mental
health inpatient units due to patient feedback is
the way that the multi-disciplinary team meetings
(MDT) are now conducted. Patients reported that
they didn’t have enough time with the psychiatrist
or with the staff who provide their care in the
community and that the traditional MDT can be
intimidating. The MDT has changed to a
professionals meeting to establish the
arrangements for meeting the patient’s aims. This
has created an opportunity for service users to
have individual time with the medics and
community workers instead of using the MDT to
meet this service user need.
Collect
patient
experience
data
Communicate
changes to
service users
and carers
Implement
changes
60 | Quality Report 2012/13 | Humber NHS Foundation Trust
Analyse
responses
and identify
themes
Action
plan for
improvement
National Patient Survey
The National Patient Survey for Community
Mental Health Services is an independently-run
national study commissioned by the Care Quality
Commission. It asks service users to comment on
the mental health services they have received by
means of a postal questionnaire. There are 46
questions which are divided into nine sections:
• Health and social care workers
• Medications
• Talking therapies
• Care co-ordinator
In 2012 the questionnaire was sent to 850 of our
service users. There was a 32% return rate, which
was the same as the national average.
The ‘better/ same/ worse’ categories are intended
to help Trusts to identify areas where they have
performed better or worse than others.
Using this analysis method our Trust scores the
‘same’ as other Trusts nationally. In the region
Humber scores the highest overall. It is ranked
first in ‘medications’ and second in the region for
‘crisis care’. The Trust is comparable to others in
the region on the other domains.
• Care plan
• Care review
• Crisis care
• Day to day living
• Overall.
Section
2012 Results v. All Other Mental Health Trusts
Health and Social Care Workers
Worse
ABOUT THE SAME
Better
Medications
Worse
ABOUT THE SAME
Better
Talking Therapies
Worse
ABOUT THE SAME
Better
Your Care Co-ordinator
Worse
ABOUT THE SAME
Better
Your Care Plan
Worse
ABOUT THE SAME
Better
Your Care Review
Worse
ABOUT THE SAME
Better
Crisis Care
Worse
ABOUT THE SAME
Better
Day to Day Living
Worse
ABOUT THE SAME
Better
Overall
Worse
ABOUT THE SAME
Better
Humber NHS Foundation Trust | Quality Report 2012/13 | 61
Patient Stories
Life after alcohol thanks
to inpatient detox
Julie is enjoying what life has to offer after
stopping drinking with help from our Trust’s
addiction services.
Julie used to drink instead of dealing with her
feelings. She started at 14 and began binge
drinking at 21. ‘I found my mum after she’d had
an aneurysm at the age of 52 and I just wasn’t
the same after that. The hospital refused to
operate on her until my dad came home from sea
to sign the consent forms; by the time that
happened she had brain damage and she was
doubly incontinent, couldn’t speak and couldn’t
walk.
‘When my mum got worse, I’d drink; this went on
for 20 years. I had some counselling and realised
that I blamed myself and that everything
stemmed from my childhood.
‘I’ve had four detox’s altogether. One was in the
community years ago, one at Baker Street that
failed because I was getting hassle from people
and it was Christmas, never a good time to try
and stop drinking. I did a detox at Buckrose in
Bridlington and it was successful for seven
months, so I thought I was normal and I could
have a social drink; soon I was worse than before.
‘I started off drinking after work then it built up
and I was having days off work; they noticed and
things deteriorated. Eventually I was drinking first
thing in a morning just to feel normal and I could
get through up to 16 cans of strong cider a day,
or more.
‘I hit rock bottom and took overdoses. I thought I
was depressed but it was the drinking that made
me feel so bad. My daughter describes me as a
‘monster’ during that time. I hated being like that
and I just wanted a detox to find ‘me’ again.
I couldn’t bear to look in a mirror.
62 | Quality Report 2012/13 | Humber NHS Foundation Trust
‘I went back to the alcohol and drug service and
asked to be referred back to services at Baker
Street. I spent two weeks at Mill View on the
inpatient detox ward in June this year. It took a
while to organise because they had to put a plan
together; it’s not just about the two weeks you’re
in there, it’s about what happens afterwards.
‘It was very relaxing on the detox ward. We sat in
the garden, watched TV, used the art room and
attended groups where we discussed how we
were feeling and doing. As soon as I left I went to
HART and carried on going there for 12 weeks,
five days a week. It was brilliant, the best thing
I’ve ever done. I’m doing peer support there now,
helping other people to come off the drink like I
have.
‘I’m on special medication now to stop the
cravings but I’ve also changed a lot of things in
my life. I didn’t rush back to work and I started
going to AA and Abstain.
‘My kids have been amazing. They said they
thought they’d lost me, but I’m back now and I’m
determined to make it work this time. I’d
recommend the detox programme to anyone
who is ready to take that step.’
Julie’s advice to anyone thinking of going through
detox:
• You’ve got to want to do it, for yourself and
no-one else
• Attend as many groups as possible
• Go through all the agencies; there’s a really
good set-up in Hull
• Keep going back, keep trying
• Don’t blame yourself
• Accept you’ve got a problem – you can’t have
a social drink
• Don’t let your guard down
• Don’t think you can handle a drink
• Take it day by day
Patient Stories
A national talent
A lucky chance led Cottingham schoolboy Joseph
to discover a hidden talent. Joseph, 9, was
enjoying a normal day at Bacon Garth school
when some members of Yorkshire Cricket paid a
visit to years 5 and 6, who it turned out, were on
a trip, so the club spent the time with year 4
instead. After a day’s cricket, the coach told
Joseph’s parents that they should consider putting
him into a team outside school.
‘He’d never picked up a bat
before, but he just took to it
straight away. We didn’t know
where we could go for him to
play because of his special
needs, but Yorkshire Cricket
have been a huge support and
he’s now playing for Welton
and Brough Sports Club.’
Joe has Attention Deficit Hyperactivity Disorder
(ADHD) and severe learning disabilities, which
makes it hard for him to conform and concentrate
and to understand rules, but he’s coming on in
leaps and bounds.
‘Yorkshire Cricket promote cricket for everyone
and when they wanted a mascot, Joe was the
first person they thought of,’ says Kate. ‘They
asked him to lead out the team at a match
between England and the West Indies and
because he doesn’t understand about fame or
celebrity, he wasn’t at all fazed by the idea.’
Joe went to Headingley for the match but it was
rained off. This turned out to be a blessing in
disguise as the England team invited him to their
indoor training centre to meet them, watch them
train and have a chat with them. ‘They were
brilliant,’ enthuses Kate. ‘They just treated Joe like
any other kid; there was no mention of special
needs. He came back filled with enthusiasm.
‘There are no boundaries in cricket; we’ve really
struggled as a family at times and to find him
doing something he loves is wonderful. He goes
every Friday and plays matches on Sundays if he’s
up to it; if he’s not, he doesn’t go and nobody
minds. The other parents have been really helpful
and supportive but it’s been a learning curve for
everyone.
‘Joe’s been in and out of the Child and
Adolescent Mental Health Services (CAMHS) since
he was four years old and he’s going back in
again because of his anxiety. They’ve been really
great and they’re helping him to cope with his
difficulties. Cricket is perfect because it’s relaxed
and fun and we can put him into new situations
but stay nearby in case he needs us.
Joe with Yorkshire cricket team players
‘It’s been wonderful to find a
sport that Joe has a natural
talent for and that welcomes
and encourages him.’
Humber NHS Foundation Trust | Quality Report 2012/13 | 63
3.3 Our Workforce
Staff Survey
443 staff at Humber NHS Foundation Trust took
part in the 2012 NHS National Staff Survey. This
is a response rate of 57% which is in the highest
20% of mental health/learning disability Trusts in
England and is the same response rate as the
2011 survey.
Top 5 Ranking Areas: Trust percentage
compared to the national average for other
Mental Health and Learning Disability Trusts
• Percentage of staff believing the Trust
provides equal opportunities for career
progression or promotion: 95% compared to
the national average of 90%
Areas where staff experience has improved
within the Trust since the 2011 survey:
1. Percentage of staff feeling able to contribute
towards improvements at work: 75% as
compared to 2011 score of 65%
2. Percentage of staff having equality and
diversity training in the last 12 months: 50%
as compared to the 2011 score of 37%
The bottom 5 ranking areas: Trust percentage
compared to the national average for other
mental health and learning disability Trusts
1. Effective team working: 3.74 compared to
national average of 3.83 (based on a scale of
1 – worst and 5 – best).
• Percentage of staff saying hand washing
materials are always available: 64%
compared to the national average of 55%
2. Percentage of staff agreeing that their role
makes a difference to patients: 87%
compared to the national average of 90%
• Percentage of staff experiencing harassment,
bullying or abuse from patients, relatives or
the public in the last 12 months: 26% as
compared to the national average of 30%
3. Percentage of staff having well constructed
appraisals in the last 12 months: 37%
compared to the national average of 41%
• Percentage of staff feeling pressure in the last
3 months to attend work when feeling
unwell: 18% compared to the national
average of 22%
• Percentage of staff experiencing
discrimination at work in the last 12 months:
9% compared to the national average of
13%
64 | Quality Report 2012/13 | Humber NHS Foundation Trust
4. Percentage of staff suffering work related
stress in the last 12 months: 43% compared
to the national average of 41%
5. Percentage of staff having equality and
diversity training in the last 12 months: 50%
compared to the national average of 59%
(although this score has significantly
improved since 2011 score of 37%)
The bottom ranking scores are suggested areas
that might be seen as a starting point for local
action for the Trust to improve on as an employer.
The Trust Board responded to last year’s survey
with a “You said, we did” action plan that has
been published on the Trust website together
with a summary of results of the national staff
survey for 2012. The Health and Wellbeing
steering group are taking forward the two key
areas identified by the Trust Board from the 2011
staff attitude survey for improvement.
These are:
improving internal communications and the
quality of PADRs received by staff. The Trust Board
will again identify two key areas for improvement
from this year’s national staff survey.
Workforce Development
Humber Foundation NHS Trust (recognised the
need for an improvement in the physical health
care of patients with mental health problems and
part of this process was the commissioning of the
Skills Identification Profile (SIP).
It was recognised that the majority of staff at the
Trust are committed to all aspects of patient care,
including their patients’ physical health needs.
However, as with most organisations there are
some gaps in their training, some of which are
already being addressed by the training and
education department. The majority of the staff
interviewed commented on their desire to attend
training and recognised that this is fundamental
to patient care. They articulated their willingness
and eagerness to embrace further personal
development. There is, without doubt, always
room for further development and the committed
staff and management recognise the way to
quality patient care is to ensure that the whole
team is appropriately trained and educated.
Therefore, to support this work a skills
identification profile (SIP) has been created and
implemented by the Strategic Clinical Skills
Advisors (SCSA).
Humber NHS Foundation Trust | Quality Report 2012/13 | 65
Staff Awards
Trust Chairman Jane Fenwick said,
Staff from across the organisation received
recognition for their hard work and dedication at
our Annual Staff Awards.
‘I am delighted that we had so
many nominations for Who Cares,
Wins and I feel that Kirsteen is a
really worthy winner. We actually
had more than one nomination
for her and she clearly makes a
huge and positive difference to
the lives of her patients.’
Taking place as part of the Annual Members
Meeting (formerly our Annual General Meeting)
over 150 staff and members of the public
attended the event at The Country Park Inn in
Hessle to hear about the Trust’s achievements
over the year and to applaud the winners in eight
categories.
These included the Chairman’s ‘Who Cares, Wins’
award, which was voted for by members of the
public and staff and recognises someone who has
really gone the extra mile in a caring role. This
year’s award was won by clinical specialist
physiotherapist Kirsteen Hasney, for running a
pulmonary rehabilitation programme, focussing
on education and exercise, which has changed
patients’ lives. One patient who nominated
Kirsteen said he was “amazed by the results” and
that it was “the most successful course” he has
ever undertaken. He also praised the
encouragement and advice given and the
atmosphere during sessions. He said that since
attending the course he has been admitted to
hospital less and his wife (having attended the
sessions with him) has learnt more about his
condition.
66 | Quality Report 2012/13 | Humber NHS Foundation Trust
The Chief Executive’s ‘Making a Difference’ award
went to the Lorenzo project team. ‘As the early
implementer for the mental health element of the
national programme, this is the only scheme of its
type in England to be delivered on time and
within budget, and is a credit to all those who
have been involved,’ said Chief Executive, David
Snowdon. ‘As the rest of the project is
implemented Lorenzo will enable us to make
significant improvements in the way we manage
and record patient care.’
Category Winners
Innovation and Progress – Humber Centre
Service Delivery - East Riding Cardiac
FC, who have introduced a programme of
football for staff and patients to help speed up
recovery, encourage social inclusion with staff and
the public and change how patients are engaged
with.
Rehabilitation Service for their work using the
HEARTlink programme to fast-track patients into
community cardiac rehabilitation provided nearer
to patient homes. They have also successfully
developed Graduate Groups, which enable
patients to exercise independently and maintain
the health-related benefits they have achieved in
cardiac rehabilitation programmes.
Humber Centre FC match
Humber NHS Foundation Trust | Quality Report 2012/13 | 67
Improving Patient Dignity and Respect
and Team of the Year – Estates
Development team for organising and facilitating
the build of the Forget-me-not suite at the
children’s hospice Sunshine House. The Forgetme-not suite is for end-of-life care for children.
The suite is a place where families can stay with
their children during the last hours of their time
together.
Improving Patient Safety - Antipsychotic
Review Project Team for their project work, which
reviewed antipsychotic prescribing in dementia
patients. The review has led to the reduction or
discontinuation of antipsychotic medication given
to dementia patients, with real and positive
results.
Promoting Equality in Service
Provision – Health Trainers, for the work
they’ve done with minority groups through the
Fisherman’s pilot which took part in Bridlington
down to Spurn Point and the Migrant Project in
Goole and West Wolds.
Inspirational Leader – Natalie Belt achieved
first place in the Most Inspirational Leader
category.
Natalie is truly an inspirational leader who is
exceptionally hard working and who has great
commitment to a cause that she is exceptionally
devoted to. She leads a small team across the East
Riding who work with the public to improve
health and wellbeing - particularly hard to reach
groups in isolated communities.
Bedroom at Children’s hospice Sunshine House following the build
of the Forget-me-not suite
An example of Natalie’s success is the new health
trainer shop which opened in Bridlington in April
2012. The shop has been such a success that
Natalie is now seeking funding to open a further
shop in Goole - an area where it is particularly
difficult to engage people.
Natalie’s team have also been applauded in the
media for the innovative work they carried out
with the Bridlington fisherman, helping them to
change their lifestyle and improve their health.
Natalie receiving her award
68 | Quality Report 2012/13 | Humber NHS Foundation Trust
3.4 Improving Services
New Community Hospital New Community Hospital in Beverley
Our community hospitals are based in Beverley,
Withernsea and Bridlington and they accept
patients from all over the East Riding. In July 2012
the new East Riding Community Hospital (ERCH)
opened its doors. One of the first patients was
taken to their new room and thought they had
been put into a private suite by mistake; in fact, it
was one of our 18 single-bedded units.
The new ward at ERCH takes a variety of patients
with a range of needs, including rehabilitation
following surgery, a stroke, or a long term health
problem; palliative care for patients who choose
to stay with us in their last few days or weeks or
who want some support before going home to
be with their loved ones. We accept admissions
from people who have just been discharged from
an acute hospital or those at home who need
some medical and nursing support.
Humber NHS Foundation Trust | Quality Report 2012/13 | 69
The hospital has a full multi disciplinary team that
includes nurses, healthcare assistants,
physiotherapists, occupational therapists, speech
and language therapists and associate
practitioners. The team is committed to putting
patients first and their philosophy is “helping
patients to help themselves” by creating a
therapeutic environment as similar to their own
home as possible. The building enhances the
therapeutic environment with a variety of indoor
and outdoor space that enables staff to work
with patients in a range of ways, such as a game
of skittles to develop and improve balance and
manual dexterity.
The Trust has plans to continue to improve the
service we offer to the local community and our
patients over the next year. We are developing
falls suites for patients who are at high risk of
falls, dementia suites to give a higher quality of
care to patients who have memory impairment,
reducing the levels of anxiety of the hospital
environment by improving orientation and
increasing our staff skills and knowledge to
ensure we mirror the patient’s home environment
as much as possible. We are lucky enough to
have a large ward, with lots of corridors and to
make the most of this space we are developing
an indoor rehab track which will take you on a
‘walk through the East Riding’, so all our patients
should have a destination on the track that is
close to their home.
70 | Quality Report 2012/13 | Humber NHS Foundation Trust
We are building links with our local community,
including schools, to offer work experience and
create seasonal art work that can be displayed on
the ward to support orientation of our patients
who have memory impairment. We will also offer
students a project on technology-based
rehabilitation that they can come and support our
patients to use. We are building our volunteer
base by asking people from the local community
to come and volunteer on the ward. We are
increasing the range of roles we can offer
volunteers so that they can become part of a
range of ward activities. Our philosophy is to give
back as much to the community as we are given,
including supporting local charities by building
links, offering support and raising money. We are
developing a community group where we can all
work together to support our local area.
We are really proud of our community hospitals,
our staff and our patients, as we are all working
together to make a difference and to continually
improve the level of service we provide. Initiatives
such as ‘Message For Matron’ suggestion leaflets
and “You Said, We Did” boards are used to
encourage feedback.
Where feedback suggests there are themes
emerging, these are used to influence the way
the service develops and grows. This is done
through action planning by the service manager
and clinical teams, perhaps with the involvement
of service users and carers. Once opportunities
for improvement have been identified, the
changes are implemented. The cycle then starts
again to make sure that the changes have made
the difference that was expected.
East Riding Community Hospital Community Ward
“You Said”
“We Did”
“The grab rails in the shower areas are
difficult to use effectively”
We have contacted our estates department,
who are re-positioning the rails
“The drinking water in the jugs is too hot.”
Patients water jugs to be changed twice a day
“That the food served on the ward was not
hot enough”
Catering manager will explore the options of
purchasing new heated food trolleys that could
be positioned on the corridor of the ward and
plugged into the electric to ensure that the
food served is closer to the patient’s room and
hotter.
“The ward is fantastically clean”
Hotel services manager feeding back
congratulations to her staff.
“That the food being served on the ward
was very tasty with good choices.”
“The spacious surroundings are matched by
helpful and willing staff who made my stay
easier to cope with”
Matron feeding back congratulations to the
multi disciplinary team.
“I would just like to say that the nursing
staff are wonderful. So caring and kind to
both mum, who is on the Liverpool
pathway and to myself - making sure we
are both comfortable as possible”.
“A recliner chair with a foot rest would
have been beneficial for oedema of legs”
Recliner chairs are available on the ward. To
ensure staff communicate this to the patients
“The chairs are not very comfortable”
“The chairs are too low”
Service manager exploring the options of
purchasing a new range of chairs
Patient feels they have not had the same
level of physiotherapy as in Hull Royal
Infirmary
Physiotherapy staff are trialling a new way of
working to ensure all patients are allocated
structured therapy time daily.
“I am unsure why I have to sign my file
notes.”
Our philosophy is that you should be fully
involved and informed of your aims and goals.
The nurse/therapist would have asked you to
sign your care plan following discussion with
you about your treatment plan.
Humber NHS Foundation Trust | Quality Report 2012/13 | 71
Single Point of Access
Payment by Results (PbR)
Services for adults with mental health problems
are provided by a range of providers in Hull and
the East Riding. Having multiple entry points to
services was confusing for referrers, service users
and their carers/families. There was a lack of
consistency in decision making meaning that
what service was offered depended on where
someone lived.
PbR is a national initiative being led by the
Department of Health to facilitate choice and
support service innovation and improvements in
quality of provision. This will see mental health
services moving away from block contracts to
being paid according to patient care activity and
outcomes. Implementing mental health PbR will
be challenging at every level, but has many
benefits:
It was our aim to have one point of entry that
Health and Social Care professionals, patients and
carers could contact in order to get access to
community mental health services.
We now have a single point of access for all adult
community mental health services including crisis
resolution and home treatment services. This
includes a dedicated 24-hour self-referral
telephone line.
All referrals to the service receive an initial clinical
decision within 72 hours of receipt. In 95% of the
cases this decision is made within 24 hours. This
enables patients to be directed to either the most
clinically appropriate treatment pathway or for
further specialist assessment thus reducing
waiting times for treatment.
All activity is recorded using the Trust’s clinical
record (Lorenzo) which enables clinical
information to be shared with other parts of the
service as necessary so reducing the need to wait
for paper case notes before treatment can
commence.
All patients and referring GPs receive a letter
detailing the action taken and informing them of
the next step on their journey through the
services.
Our patient survey has indicated that 98% of
patients feel that they were treated with dignity
and respect by SPA staff and 97% felt that they
were listened to.
72 | Quality Report 2012/13 | Humber NHS Foundation Trust
• Enables a better understanding of the needs
of people who use services.
• Ensures that the services we provide are of a
high quality, are safe, effective and a positive
experience for all.
• Clarity over treatment and support options,
which will be known as Care Packages
There are three key elements:
• Everyone aged 14 or over (early interventions
services) who is using mental health services
must be ‘clustered’ into a care package.
• Development of a tariff
• Quality and Outcomes – this is about the
difference we make to people’s lives.
People are clustered using the Mental Health
Clustering Tool, which is a summary of the
person’s risks and needs. Within PbR there are
agreed timescales when people’s needs must be
reviewed, however if a person’s requirements
change at any time, they will also be reviewed to
ensure that people are receiving the treatments
that meet their individual needs.
Achieving Accreditation for
Inpatient Mental Health
Services (AIMS)
All our Trust’s working age adult mental health
inpatient wards across Hull and the East Riding
have achieved AIMS accreditation.
AIMS (Accreditation for Inpatient Mental Health
Services) is a nationally-recognised mark of good
practice awarded by the Royal College of
Psychiatry (RCP). It is designed to improve the
quality of care in inpatient mental health wards.
Accreditation means that staff, service users and
carers, commissioners and regulators can be sure
that a high quality service is being provided.
Chief Executive David Snowdon said, ‘Achieving
AIMS accreditation for all our inpatient wards for
adults of working age is really something to be
proud of. It shows that our staff consistently
provide the highest standards of care and
treatment to our most vulnerable patients and we
are delighted that all our units meet the stringent
criteria necessary to achieve this accreditation.’
National recognition for
Psychological Medicine
A recent report on liaison psychiatry (specialist
mental health support for people in acute
hospitals) was extremely complimentary about
our department of psychological medicine.
We provide the only ageless self-harm service,
(meaning anyone of any age can get help) and
we run the only liaison psychiatry service with a
specialist perinatal health team (for women
before, during and after pregnancy).
Psychological medicine is a big team, including
learning disabilities, Huntington’s disease and
chronic fatigue specialists. It runs a rapid-response
service across all wards at Hull Royal Infirmary and
Castle Hill, A&E and a range of outpatient clinics.
Park Art
event at Castle
Care Villages
Park Art
An afternoon of creative inspiration was enjoyed
at Castle Care Villages when Barchester
Healthcare and Humber NHS Foundation Trust
came together to promote positive mental health
through creative art.
The day was packed with activities ranging from
samba and swing dancing to Tai Chi and
theatrical performance.
Attendees at the event got involved in creating
a magnificent Union Jack embellished 3D teapot
from papier maché. Tai Chi and Lindy Hop
sessions were also on offer and were enjoyed by
visitors and residents. The event raised funds for
Reflections Art health charity and social
enterprise, My Voice.
Park Art is about challenging the stigma and
discrimination around mental health problems
through music, dance and arts and crafts. Hull
Samba, Kingston Swing and The Acting Group
were among local groups that entertained on the
day. A patient from Windermere House
Independent Hospital won an award for best
work of art which was judged by residents from
Castle View. The winning entrant’s design was
created using batik art techniques and depicted
Elvis Presley.
Humber NHS Foundation Trust | Quality Report 2012/13 | 73
Management and Prevention
of Falls
Discharge from Community
Hospitals
The falls team have focused on training and
supporting care home staff to help prevent falls in
these settings. Training sessions have taken place
across care homes in the East Riding. There is now
an established pathway for care home staff to
ring the falls service when they are concerned and
need advice to support safer management of
patients at risk of falls. The pathway enables the
falls specialist to provide a quick response with
telephone advice before visiting the team in the
care home. This has been well received by care
Home staff and is supporting prevention of acute
admissions to hospital where falls have been
prevented as a result of this approach.
In community hospitals, all patients are now
involved in planning their discharge date within 7
days of admission, and usually within 48 hours.
Usually, this discharge date doesn’t change, but if
it does, another date is set with the patients.
Training sessions took place in 2012/13 delivering
falls training to 354 care home staff.
Tissue Viability Training
The specialist tissue viability team have developed
a training programme for all clinical staff
delivering wound care. This continues to be
delivered on a rolling programme basis. The
number of patients getting a pressure sore whilst
in our care remains very low and staff are working
closely with care homes and community social
care staff to help improve training and awareness
of pressure sore prevention.
74 | Quality Report 2012/13 | Humber NHS Foundation Trust
All patients who have had their discharge date
changed have consistently told us through patient
surveys that when their date is changed they
know why and what their new date is. We have
achieved this through improving patient review
meetings, improvements in discharge planning
and an increased focus on multidisciplinary
working.
Recovery Star/Care Planning
My Shared Pathway
Recovery is an integral part of a person’s journey
when they are admitted into services within
working age adults, reviews are now person
centred, and recovery focused meetings
My Shared Pathway is a nationally recognised
user led framework which provides an
opportunity for service users to take as much
control as possible of their journey through secure
services. It encourages service users to engage
with staff and others, work collaboratively and
ensure that goals are achieved: keeping the
length of time in secure care to the shortest time
possible.
The Mental Health Recovery Star™ is an
assessment tool which aims to identify how
mental health services can support patients in
their recovery.
The measure is designed in the shape of a star
and identifies ten important areas of recovery:
• relationships
The Recovery and Outcomes Group takes the lead
in implementing My Shared Pathway within
Humber Foundation Trust and meets every
fortnight. It is made up of staff and service users.
• physical health and self-care
To date, the group has:
• managing mental health • addictive behaviour
• living skills • responsibilities
• social networks • work
• identity and self-esteem • trust and hope
We have four teams who are offering the
recovery star to people using services within our
recovery teams.
• designed template letters to be sent out
which makes sure everyone has the
information they need before admission
• started to develop service user buddies to
support newly admitted service users
• already reviewed the Care Programme
Approach documentation
• started to review the processes to make sure
they fit in with the standard pathway
• developed a training package to be used by
key staff and service user leads to train their
colleagues.
Humber NHS Foundation Trust | Quality Report 2012/13 | 75
Annex 1
Comments From Our Commissioners and Other Key
Stakeholders
Hull Local Involvement Network (LINk)
Hull LINk welcomes the opportunity to comment on Humber
Foundation Trust’s Quality Report. In our view the document is
representative and gives a comprehensive coverage of services. People involved in Hull LINk welcomed being involved in the
development of this year’s account. We are encouraged to see
that there have been opportunities for people to be involved in
setting trust priorities for the future. We would welcome an ‘easy
read’ version of the document to ensure it can reach as wide a
readership as possible.
Jonathan Appleton
LINk Co-Ordinator
Hull Local Involvement Network (LINk)
Hull CVS
The Strand
75 Beverley Road
Hull
HU3 1XL
76 | Quality Report 2012/13 | Humber NHS Foundation Trust
Hull City Council, Health and Social Well Being Overview and Scrutiny Commission
Hull City’s Council Health and Well-Being Overview and Scrutiny
Commission (OSC) received the latest Quality Report Update from
the Humber Foundation Trust in November 2012. The information
presented to Members included an update on performance
against the 2012/13 priorities, and an opportunity to feed into the
priority setting process for 2013/14.
The Commission supported the inclusion of ‘Transition Measures’
within the 2013/14 Quality Accounts and recommended that they
were included under the second draft priority ‘improving the care
treatment for people with long term and chronic health
conditions’. The Commission also recommended that greater
emphasis should be placed on prevention within the 2013/14
Quality Accounts.
Antony Spouse
Hull City Council Health and Well Being OSC
Tel: 01482 613712
East Riding of Yorkshire Local Involvement Network (ERYLINk)
No comments received.
Secure and Specialist Mental Health Commissioning Team, Barnsley Primary Care Trust
No comments received
Humber NHS Foundation Trust | Quality Report 2012/13 | 77
Hull Clinical Commissioning Group (CCG)
NHS Hull Clinical Commissioning Group welcomes the opportunity
to review and comment on Humber NHS Foundation Trust’s
Quality Report 2012/13. Our view is that these quality accounts
represent an improvement on last year’s, both in terms of content
and presentation. In particular, we note the Trust’s good
performance against the achievement and delivery against clinical
priorities during 2012/13 and expect this to be maintained during
2013/14. We would also like to commend the work done over the
year to gather the views and service feedback from patients and
carers using a combination of electronic and paper based survey
tools which strengthen the quality of services. We look forward to
further work in this area during 2013 / 14 which is supported by
the CQUIN scheme.
Scrutiny of serious incidents (SIs) has allowed us
performance manage the quality and timeliness
of the serious incidents (SIs) reports which
historically have been somewhat variable. NHS
Hull Clinical Commissioning Group will continue
to work proactively with the Trust throughout the
coming year on a range of patient safety activities
including SI’s to strengthen the quality of services
provided by the Trust.
We welcome that the report confirms the Trust is
meeting its performance targets and the inclusion
of sections containing Aim/Goal and Summary of
Progress is useful in understanding the links to
improving the quality of services.
Finally, we note that the report is based on data
up to and including the end of Quarter Three
2012/13. Taking that into account, we confirm
that to the best of our knowledge, the report
is a true and accurate reflection of the quality of
care delivered by Humber NHS Foundation Trust
and that the data and information contained in
the report is accurate. NHS Hull Clinical
Commissioning Group looks forward to
continuing to work with the Trust to improve the
quality of services available for our patients in
order to improve patient outcomes.
Chief Officer
Hull CCG
TheMaltings
Silvester Square
Silvester Street
HULL
HU1 3HA 78 | Quality Report 2012/13 | Humber NHS Foundation Trust
NHS East Riding of Yorkshire Clinical Commissioning Group
East Riding of Yorkshire Clinical Commissioning Group is pleased
to be given the opportunity to review and comment on Humber
NHS Foundation Trust’s Quality Report for 2012/13. Our view is
that these quality accounts represent an excellent achievement
during 2012/13 in relation to embedding the systems for
improving the quality of services for patients. We note the Trust’s
key achievements in relation to clinical priorities during 2012/13
and in particular the improvements that have been made
following the implementation of ‘Meridian’ to capture real time
patient experience data. We look forward to working with the
Trust on further work in this area throughout 2013 /14 supported
by the CQUIN scheme.
During 2012/13 we have worked with the Trust
to support the approach to continuously
improving the quality of service provision. We are
pleased to report that the CQUIN schemes which
incentivise quality have been for the most part
achieved, but we recognise that there are still
areas that require improvement.
We support the areas that the Trust has identified
for improvement during 2013/14 which are in line
with our commissioning intentions. We will be
working with the Trust during 2013/14 to ensure
improved quality drives and underpins service
development through joint working approaches
and the implementation of a CQUIN scheme.
We note the Trust position regarding the
attendance rate for Children’s Safeguarding
training which is currently reported as 69%. We
will be looking to the Trust to improve on this
position during 2013/14.
We note that the report is based on data up to
and including the end of Quarter Three 2012/13.
Taking that into account, we confirm that to the
best of our knowledge, the report is a true and
accurate reflection of the quality of care delivered
by Humber NHS Foundation Trust and that the
data and information contained in the report
is accurate. The Clinical Commissioning Group is
looking forward to working with the Trust to
improve the quality of services available for our
patients in order to continually improve patient
outcomes.
J Hawkard
Chief Officer
NHS East Riding Clinical Commissioning Group
Humber NHS Foundation Trust | Quality Report 2012/13 | 79
East Riding of Yorkshire Council Health, Care and Wellbeing Overview
and Scrutiny Sub-Committee
East Riding of Yorkshire Council Health, Care and Wellbeing
Overview and Scrutiny Sub-Committee welcomes the opportunity
to comment on Humber NHS Foundation Trust’s Draft Quality
Accounts 2012/13.
Members of the Sub-Committee attended the
event to vote and select the priorities for 2013/14
and strongly support the priorities which the Trust
has chosen, particularly the ones around
dementia and older people’s mental health
services and palliative and end of life care. The
Sub-Committee looks forward to receiving
updates on how the Trust is performing against
these priorities throughout the year.
Members of the Sub-Committee would like to
commend the Trust on achieving the majority of
its priorities that were set for 2013/13. With
regard to the Early Intervention in Psychosis
priority for 2012/13, the Sub-Committee would
be interested in discussing with the Trust the
reasons behind the reduction in the number of
referrals coming through from the East Riding
and whether the plans that have been put into
place increase the number of referrals.
Members welcome the developments that have
been made to the electronic record keeping
systems Lorenzo and SystmOne and would be
interested to hear to what extent these
developments have helped to provide a more
joined up record keeping system across partner
health and social care providers working with
residents in the East Riding.
The Sub-Committee felt that the requirement by
the Trust to almost double the number of eligible
people accessing IAPT (from 8% now to 10% in
2014 and 15% by 2015) would be particularly
challenging and would have liked to see
information on how the Trust was planning to
achieve this target included in the quality
accounts.
80 | Quality Report 2012/13 | Humber NHS Foundation Trust
With regard to how the performance information
is presented in its quality accounts, it is suggested
that the Trust could use an approach based on
the dashboard system it uses in its performance
reports to the Trust Board. This would provide
a quick, easy to understand snap shot for readers
which would enhance the written commentary
already provided.
The quotes from patients and case studies were a
useful tool in bringing home the work of the Trust
and adding colour to the more formal data within
the accounts.
The Sub-Committee values its relationship with
Humber NHS Foundation Trust and recognises the
importance of maintaining its good working
relationship particularly in light of the difficult
economic times faced by all health and social care
providers. It looks forward to welcoming the
Trust to its meetings in 2013/14.
for Malcolm Sims
Director of Corporate Resource
East Riding of Yorkshire Council
County Hall
Beverley
East Riding of Yorkshire
HU17 9BA
Annex 2
Comments From Our Governors
I have read this year’s Quality Report, they are well laid out,
comprehensive and easy to understand. The impact of Meridian
has been very powerful and many improvements made as a result
of its implementation my hope is that Lorenzo and the ‘modules’
will also match this success.
I believe that the patients’ stories are powerful proof of the
achievements made through working together.
Julie Hastings
Humber NHS Foundation Trust Governor
I do believe this covers a comprehensive range of our services,
and shows a lot of innovation and areas of good practice. However for me in terms of reporting on quality, there are gaps
in the report. A key theme emerged throughout the report and
that is with all of the initiatives, projects, equipment being
provided, audits and pieces of work described that left me asking
‘so what difference has this made in terms of our patients and
their experience/outcomes?’ The report focuses very much on
processes. Julie Jones
Humber NHS Foundation Trust Staff Governor
Humber NHS Foundation Trust | Quality Report 2012/13 | 81
Annex 3
Statement of Directors’ responsibility in respect
of the Quality Report.
The directors are required under the Health Act 2009
and the National Health Service Quality Accounts
Regulations to prepare Quality Accounts for each
financial year.
In preparing the Quality Report, directors are required
to take steps to satisfy themselves that:
• the content of the Quality Report meets the
requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2012/13;
• the content of the Quality Report is not
inconsistent with internal and external sources of
information including:
• Board minutes and papers for the period April
2012 to March 2013
• Papers relating to Quality reported to the Board
over the period April 2012 to March 2013
• Feedback from the Commissioners dated April
2013
• Feedback from Governors dated April 2013
• Feedback from local Healthwatch organisations
dated April 2013
• The Trusts complaints reports published under
regulation 18 of the Local Authority Social
Services and NHS Complaints regulations 2009,
over the period April 2012 to March 2013
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the quality Report, and
these controls are subject to review to confirm
that they are working effectively in practice;
• the data underpinning the measures of
performance reported in the Quality Report is
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
subject to appropriate scrutiny and review; and
the Quality Report has been prepared in
accordance with Monitor’s annual reporting
guidance (which incorporates the Quality
Accounts regulations) (published at
www.monitor-nhsft.gov.uk/
annualreportingmanual) as well as the
standards to support data quality for the
preparation of the Quality Report (available at
www.monitor-nhsft.gov.uk/sites/all/
modules/fckeditor/plugins/ktbrowser/_
openTKFile.php?id=3275).
The directors confirm to the best of their knowledge
and belief they have complied with the above
requirements in preparing the Quality Report.
By order of the Board
• The national patient survey November 2012
• The national staff survey 2012
• The Head of internal audits annual opinion over
the Trusts control environment dated May 24th
2013
01 May 2013 –––––––––––––––––––––––––
Jane Fenwick, Chairman
• CQC quality and risk profiles for the period
April 2012 to March 2013
• The quality report presents a balanced picture of
the NHS Foundation Trusts performance over the
period covered.
• The performance information reported in the
Quality Report is reliable and accurate;
82 | Quality Report 2012/13 | Humber NHS Foundation Trust
01 May 2013 –––––––––––––––––––––––––
David Snowdon, Chief Executive
Annex 4
Independent Auditors’ Assurance Report to the
Governors’ Assembly of Humber NHS Foundation
Trust on the Quality Report
Humber NHS Foundation Trust | Quality Report 2012/13 | 83
84 | Quality Report 2012/13 | Humber NHS Foundation Trust
Humber NHS Foundation Trust | Quality Report 2012/13 | 85
Glossary
CPA
Care Programme Approach
Is the system or framework by which care is arranged and managed. It remains
at the centre of current Mental Health policy, supporting individuals who
experience severe and enduring Mental Health problems to ensure that their
needs and choices remain central in what, are often, complex systems of care.
Clinical PathwayOne of the main tools used to manage the quality in healthcare concerning
the standardisation of care processes. It has been proven that their use reduces
the changes in clinical practice and improves patient outcomes.
CQC
Care Quality Commission
The independent regulator of health and social care in England, aiming to make
sure better care is provided for everyone in hospitals, care homes and peoples
own homes. www.cqc.org.uk
CRHT
Crisis Resolution Home Treatment Teams
Provide intensive support for people in mental health crises in their own home
and stay involved until the problem is resolved. Designed to provide prompt
and effective home treatment, including medication, in order to prevent
hospital admissions and give support to informal carers.
KPI
Key Performance Indicator
A set of quantifiable measures which the Trust adopts, to gauge or compare performance in terms of meeting its strategic and operational goals. KPIs vary, depending on the priorities or performance criteria.
MDT
Multi-Disciplinary Team
Multi disciplinary teams are groups of professionals from different areas who
come together to provide comprehensive assessment and consultation.
86 | Quality Report 2012/13 | Humber NHS Foundation Trust
Monitor
Independent regulator of NHS Foundation Trusts
www.monitor-nhsft.gov.uk
NCT
Neighbourhood Care Team
A Neighbourhood Care Team is a partnership between Health and Social
services. It provides an integrated service which delivers services closer to home
for people aged 18 and older who are registered with a GP.
NICEThe National Institute of Health and Clinical Excellence
Provides guidance and support to healthcare professionals and others to ensure that the care provided is of the best possible quality and offers the best value
for money. They also provide independent, authoritative and evidence based
guidance on the most effective ways to prevent, diagnose and treat disease
and ill health, reducing inequalities and variation.
NIHR
National Institute of Health Research
omissions and funds research. www.nihr.ac.uk
PADR
Performance Appraisal Development Review
The aim of this is to confirm what is required of an individual within their role, feedback on how they are progressing, to identify any learning
and development needs and to agree a personal development plan.
PbR
Payment by Results
The aim of Payment by results is to provide a transparent, rules-based system
for paying trusts. It will reward efficiency, support patient choice and diversity
and encourage activity for sustainable waiting time reductions.
POMH-UK
Prescribing Observatory for Mental Health-UK
A national quality improvement programme for specialist Mental Health
services.
Recovery Star
The Mental Health Recovery Star™ is an assessment tool which aims to identify
how mental health services can support patients in their recovery.
Humber NHS Foundation Trust | Quality Report 2012/13 | 87
SPA
Single Point of Access
The Single Point of Access (SPA) service provides a first point of contact for
people aged 18 and over who have been referred to Working Age and Older
Adult Mental Health Services in Hull and the East Riding.
SI
Serious Incident
An out of the ordinary or unexpected event (not exclusively clinical issues) that
occurs on NHS premises or in the provision of an NHS or a commissioned service, with the potential to cause serious harm.
TeleHealth The use of technology to deliver health and/or social care at a distance and the remote monitoring of a patient’s medical condition in their own homes,
ie blood pressure, ECG or weight.
VSMR
Vital Signs Monitoring Return
Every month we submit to Monitor a measure of our performance to show
how well we are doing.
VTE
Venous Thromboembolism
A venous thrombosis is a blood clot that forms within a vein. Thrombosis is a
medical term for a blood clot occurring inside a blood vessel. A classical venous
thrombosis is deep vein thrombosis (DVT), which can break off and become a
life-threatening pulmonary embolism (PE). The conditions of DVT and PE are
referred to collectively with the term venous thromboembolism.
88 | Quality Report 2012/13 | Humber NHS Foundation Trust
Humber NHS Foundation Trust
Willerby Hill, Beverley Road,
Willerby, East Riding of Yorkshire. HU10 6ED
Tel: 01482 301700
www.humber.nhs.uk