Lancashire Care NHS Foundation Trust
Lancashire Care
NHS Foundation
Trust
Quality Account 2012/13
Contents
Part 1: Statement on Quality from the Chief Executive of the
2a) Priorities for Improvement - Forward Looking 2013/14 ............................... 2
2b) Statements of Assurance from the Board .................................................... 5
Part 3: Review of Quality Performance 2012/13.................................. 9
Annex: Statements from Healthwatch, Overview and Scrutiny
Committees and Clinical Commissioning Groups ........................... 58
Amendments Made to Initial Draft Quality Account Following Feedback from
Statement of Directors’ Responsibilities in Respect of the Quality Report ... 66
Glossary .............................................................................................. 68
Part 1: Statement on Quality from the Chief Executive of the Organisation
This year has seen Lancashire Care NHS Foundation Trust grow as a health and wellbeing organisation providing a holistic service that is able to meet a wide range of health needs, supported by our mission to provide high quality care with wellbeing at its heart.
This Quality Account is our report about the quality of services we deliver. In this report we describe an account of the quality of services we provided for the period April 2012 to March
2013 and in addition to this, we set out our priorities for improving quality over the coming year from April 2013 to March 2014.
We have a duty to publish a Quality Account and we welcome this as a valuable opportunity to help raise awareness of our work. In conjunction with our Annual Report, this Quality
Account will give you an overview of what we do and the range of our activities and current performance.
In developing our Quality Account our staff have been able to reflect on and demonstrate their commitment to continuous, evidence-based quality improvement. We want to be open as well, demonstrating real improvements where we can, and being honest about where we need to improve.
Quality is at the heart of everything we do in the organisation and is reflected within our
Quality Strategy which ensures year on year quality improvements. There is no doubt that the future priorities are ambitious but they have been selected to have the highest possible impact on quality across Lancashire Care NHS Foundation Trust and reflect key national agendas.
We want our Quality Account to be part of our evolving conversation with the people we serve about what quality means and about how we must work together to deliver quality across the organisation. In offering you an overview of our approach to quality, we invite your scrutiny, debate, reflection and feedback.
The Council of Governors and Lancashire Care NHS Foundation Trust Board have approved this Quality Account which covers the full range of services we provide. To the best of our knowledge the information contained in this account is accurate. I hope that you find this
Quality Account to be enlightening and informative.
Professor Heather Tierney-Moore
Chief Executive
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Part 2: Priorities for Improvement and Statements of
Assurance from the Board
2a) Priorities for Improvement - Forward Looking 2013/14
This se ction of the Quality Account is the ‘forward looking’ section. It describes the improvements related to the quality of services provided which Lancashire Care NHS
Foundation Trust plans to take over the next year. This section explains why the Trust priorities have been chosen, how they will be monitored and reported.
Quality is about giving people treatments that work (effectiveness), making sure that they have a good experience of care (patient experience) and protecting them from harm (safety). Quality is part of our
Trust value of excellence.
Safety
Quality
Effectiveness
Following changes to Lancashire Care
NHS Foundation Trust in June 2011 and the updating of the Quality
Patient
Experience
Strategy, a review of the existing quality priorities was undertaken. Three priorities were chosen following consultation with a range of stakeholders including service users, carers, members, staff, network directors, deputy directors of nursing and professional leads. Each priority related to one of the quality domains of safety, patient experience and effectiveness, and reflected the new health and
wellbeing organisation, and these are reported in Part 3: Review of Quality Performance
The Mid Staffordshire NHS Foundation Trust Public Inquiry February 2013 (Francis 2)
1 highlights the importance of focusing on quality at the point of care emphasising a compassionate approach and the need for effective leadership at all levels of an organisation. In Lancashire Care NHS Foundation Trust both the Quality Strategy and the
Appreciative Leadership Programme have given us a strong foundation from which to further build and develop quality services.
Across 2012/13 the Care Quality Commission (CQC) visited Lancashire Care Foundation
Trust to assess compliance with the Essential Standards of Quality and Safety
2
. Five minor concerns were identified which have led to action plans being developed and submitted to the CQC. The progress of these action plans is monitored on an on-going basis through network governance meetings. An example of Lancashire Care Foundation Trust’s commitment to delivering quality services is reflected by the decision to temporarily close an inpatient ward following the identification of concerns that could impact on the quality of care
1 http://www.midstaffspublicinquiry.com/report
2 http://www.cqc.org.uk/organisations-we-regulate/registered-services/guidance-meeting-standards
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provided. These concerns are being investigated to ensure that the staffing level, skill mix, leadership and governance arrangements are extremely robust in order to provide high quality care. Currently staffing levels are problematic and highlight that the ward is at risk of not meeting some of the expected quality standards. Therefore action has been taken straight away to address the concerns. The ward will re-open in September. In the meantime, improvement work will be undertaken and will focus on:
Ensuring that the skill mix and staffing levels on the ward are appropriate
Strengthening the leadership arrangements in the service
Undertaking improvement work to the ward environment
Implementation of an improvement plan in line with the Trust’s Quality Strategy
Strengthening governance arrangements to monitor quality standards and ensure that standards are met
The implementation of the Quality Strategy
3
during 2012/13 has focused on gaining a picture of quality across all clinical teams against the Essential Standards of Quality and Safety. The
Quality SEEL is centred on the domains of Safety, Effectiveness, Experience and
Leadership (SEEL) and is a self-assessment framework which enables team leaders to review the quality of care provided, at the point of care, and identify and address any issues which may compromise this. This approach of ‘self-assessment’ is entirely consistent with
Lancashire Care NHS Fou ndation Trust’s ambition to both win the hearts and minds of staff and to grow clinical leaders, who can lead their teams to deliver excellence. The assessment involves speaking to staff, patients, service users, carers, families, observing the care setting and reviewing clinical records. In presenting the outcomes in this way, the teams can start to build a picture of quality and have conversations as a team to continually monitor the quality of care provided and strive to constantly develop.
Risks identified in relation to the Essential Standards of Quality and Safety will be included on team level risk registers with clear action plans which will be monitored and reviewed by the clinical team and escalated through network governance processes as appropriate.
Work has been undertaken in 2012/13 to develop a single Datix system to replace the four transferred into Lancashire Care NHS Foundation Trust from the previous organisations.
This has included aligning identified risks to the Essential Standards of Quality and Safety to strengthen the lessons learned process. As a result of the Quality SEEL and the identification of potential risks the Trust has a clear organisational picture regarding delivery of the Essential Standards of Quality and Safety, at the point of care delivery, which will provide assurance to the board regarding compliance.
During 2012/13 all clinical teams have self-assessed using the Quality SEEL and begun to establish team information boards and risk registers. A reporting system is currently being developed and the results will be reported in the Quality Account for 2013/14. This system ensures a strong foundation from which to further improve the services and care we provide. In response to this the quality priorities have been reviewed and revised to enable individual members of staff and teams to clearly relate to the quality priorities and their role in achieving these.
3 http://www.lancashirecare.nhs.uk/CubeCore/.uploads/Publications/Quality_Account/Quality%20Impro vement%20Strategy%20II.pdf
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The quality priorities for 2013-15 are detailed below:
Priority 1 Quality Strategy Implementation
Domain
Rationale
Target
How progress will be monitored
How progress will be reported
Effectiveness
Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry February
2013 (Francis 2). Quality in the new health system – maintaining and improving quality from April 2013. The NHS Outcomes Framework 2013/14.
All teams will have completed the Quality SEEL
All teams will have monitored progress against the Quality SEEL
All teams will have completed the risk register and managed risks appropriately
All teams will have team information boards and use these to drive quality improvements
Monitoring through team level to Network Governance to the Quality
Committee
Network Governance to the Quality Committee
Priority 2
All teams will seek the views of service users and carers to inform quality improvements
Domain
Rationale
Target
How progress will be monitored
How progress will be reported
Patient Experience
Department of Health - The NHS Friends and Family Test
Implementation of NHS Friends and Family Test in accordance with the Trust project plan (to be determined)
Quality SEEL outcomes, team information boards and friends and family implementation plan
Team level progress will be discussed through Team Information Boards and escalated through Network Governance to Quality Committee
Compliance with Harm Free Care national priority:
Reduction in the number of pressure ulcers developed in our care
Priority 3
Reduction in the number of falls
Reduction in the number of catheter acquired infections
Domain
Rationale
Target
How progress will be monitored
How progress will be reported
Safety
Harm Free Care quality initiative. Commissioning for Quality and Innovation
(CQUIN). Quality Strategy.
Monthly submissions of all applicable services to the Information Centre to establish a 6 month baseline of good quality data following which quality improvement targets will be agreed with Commissioners.
Monthly reporting to Health and Social Care Information Centre and quarterly submission to Commissioners
Harm Free Care sub groups, steering group and Quality Committee
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2b) Statements of Assurance from the Board
This section of the Quality Account is governed by regulations which require the content to include statements in a specified format; this allows the reader to compare statements for different Trusts. These statements serve to offer assurance to the public that Lancashire
Care NHS Foundation Trust is performing to essential standards, providing high quality care, measuring clinical processes and involved in initiatives to improve quality.
Review of Services
During 2012/13 Lancashire Care NHS Foundation Trust provided three types of NHS services (mental health & learning disability services, community services and specialist services).
Lancashire Care NHS Foundation Trust has reviewed all the data available to them on the quality of care in these three NHS services via the quality schedule of the NHS standard contract and through the reconciliation of Commissioning for Quality & Innovation scheme
(CQUIN).
The income generated by the NHS services reviewed in 2012/13 represents 100% of the total income generated from the provision of NHS services by Lancashire Care NHS
Foundation Trust for 2012/13.
Participation in Clinical Audits
During 2012/13, 3 national clinical audits and 1 national confidential enquiry covered NHS services that Lancashire Care NHS Foundation Trust provides.
During that period Lancashire Care NHS Foundation Trust participated in 75% national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Lancashire Care NHS
Foundation Trust was eligible to participate in during 2012/13 are:
National Confidential Inquiry into Suicide and Homicide for People with Mental Illness
(NCISH)
National Audit of Psychological Therapies (NAPT)
Prescribing Observatory for Mental Health (POMH) - Prescribing in Mental Health
Services
Sentinel Stroke National Audit Programme (SSNAP) - programme combines the following audits, which were previously listed separately in QA: a) Sentinel Stroke Audit (2010/11, 2012/13) b) Stroke Improvement National Audit project (2011/12, 2012/13)
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The national clinical audits and national confidential enquiries that Lancashire Care NHS
Foundation Trust participated in during 2012/13 are listed below:
National Confidential Inquiry into Suicide and Homicide for People with Mental Illness
(NCISH)
National Audit of Psychological Therapies (NAPT)
Prescribing Observatory for Mental Health (POMH) - Prescribing in Mental Health
Services
The Sentinel Stroke National Audit Programme commenced clinical data collection in
December 2012. Lancashire Care NHS Foundation Trust is part of a Lancashire and
Cumbria Network which has started to collect data within Acute settings and plans to introduce data collection in Community settings in 2013, Lancashire Care NHS Foundation
Trust have submitted the application to commence data collection in 2013/14.
The national clinical audits and national confidential enquiries that Lancashire Care NHS
Foundation Trust participated in, and for which data collection was completed during
2012/13, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
Name of Audit
National audit of psychological therapies (NAPT)
Participation
Yes
% Cases Submitted
100%
Prescribing Observatory for Mental Health (POMH)
- Prescribing in mental health services
Name of National Confidential Enquiry
Yes 100%
Participation % Cases Submitted
National Confidential Inquiry into Suicide and
Homicide for people with Mental Illness (NCISH)
Yes Suicide 73%
Homicide 100%
The reason for the lower response rate for the suicide enquiry is that a number of questionnaires were only sent out in early 2013 and are still going through the normal reminder process. They are not expected to be returned in time to report in the 2012/13
Quality Account.
The reports of the national clinical audits and national confidential enquiries that Lancashire
Care NHS Foundation Trust participated in in 2012/13 will be reviewed and acted upon when published.
The reports of 16 local clinical audits were reviewed by the provider in 2012/13 and the following are a selection of the actions Lancashire Care NHS Foundation Trust intends to take to improve the quality of healthcare provided:
Documenting whether service users have personal preferences regarding food and drink within the physical health section of the patient record
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Lancashire Care NHS Foundation Trust wide Self-injury Strategy Group are leading on a coordinated implementation of basic awareness training and understanding learning package to cover key areas as identified in National Institute for Health and Care
Excellence (NICE) guidance
Project Leads to raise awareness, by disseminating information to the Networks, of the completion of the nutrition tool for service users with identified nutritional needs
Reviewing the paper record of seclusion to ensure that a clear working definition of seclusion is included and that all necessary information is gathered in one place
Participation in Clinical Research
The number of patients receiving NHS services provided or sub-contracted by Lancashire
Care NHS Foundation Trust in 2012/13, recruited in that period to participate in research approved by a research ethics committee was 1422.
Goals Agreed with Commissioners
Use of the CQUIN Payment Framework
A proportion of Lancashire Care NHS Foundation Trust income in 2012/13 was conditional on achieving quality improvement and innovation goals agreed between Lancashire Care
NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2012/13 and for the following 12 month period are available electronically at: http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
Statements from the Care Quality Commission
Lancashire Care NHS Foundation Trust is required to register with the Care Quality
Commission (CQC) and its current registration status is ‘registered’. Lancashire Care NHS
Foundation Trust does not have any conditions placed on its registration.
The CQC has not taken enforcement action against Lancashire Care NHS Foundation Trust during 2012/13.
Lancashire Care NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period.
Data Quality
Statement on Relevance of Data Quality and Actions to Improve Data Quality
Lancashire Care NHS Foundation Trust will be taking the following actions to improve data quality:
Developing a range of Business Intelligence Tools such as the Balanced Scorecard to deliver a holistic view of performance to the Board and down to Network level in 2013/14
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Underpinning these developments will be a data quality initiative, which will initially report and resolve issues around the top 10 data quality issues within the Trust
Development of a data quality repository will ensure that operational services have the information they need to maximise their data quality
NHS Number and General Medical Practice Code Validity
Lancashire Care NHS Foundation Trust submitted records during 2012/13 to the Secondary
Uses Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data.
Record Type Area
Trust Compliance
2012/13
Patients Valid NHS Number Admitted Patient Care
Outpatient Care
100%
100%
Patients Valid General Practitioner
Registration Code
Admitted Patient Care
Outpatient Care
100%
100%
Source: SUS Data Quality Dashboard Data is governed by Standard National Definitions
This data includes all Lancashire Care NHS Foundation Trust inpatient facilities (e.g. mental health wards and Longridge community hospital) and outpatient clinics (e.g. Musculoskeletal and Rheumatology).
Information Governance Toolkit Attainment Levels
Lancashire Care NHS Foundation Trust Information Governance Assessment Report score overall score for 2012/13 was 85% and was graded Green .
Clinical Coding Error Rate
Lancashire Care NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2012/13 by the Audit Commission. Lancashire Care NHS Foundation
Trust did participate in the Connecting for Health Clinical Coding Audit in February 2013.
This audit looks at the accuracy of diagnosis and procedure coding recording for all inpatient episodes. The results should not be extrapolated further than the actual sample audited.
Coding Field
Information
Governance
Requirement 514
Level 2 Target
Information
Governance
Requirement 514
Level 2 Target
Level
Achieved
2011-2012
Level
Achieved
2013-2014
Primary Diagnosis
Secondary Diagnosis
>=85%
>=75%
>=90%
>=80%
92%
93%
96%
94%
Primary Diagnosis
>=85% >=90% 100% 100%
Secondary Diagnosis
>=75% >=80% 87% 100%
Source: SUS Data Quality Dashboard Data is governed by Standard National Definitions
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Part 3: Review of Quality Performance 2012/13
This section of the document reports on the quality performance across Lancashire Care
NHS Foundation Trust in the past year. Quality is reported using a combination of measurable indicators and best practice examples from our services.
Overview of Services Provided
The table below gives an overview of the services provided by each of the Networks; this is not an exhaustive list but gives a flavour of the services provided. A comprehensive list can be found at http://www.lancashirecare.nhs.uk/services
Adult Community Specialist Services Adult Mental Health Children and Families
Adult Learning
Disabilities
Community Matrons
Community Older
Adult Mental Health
Teams
Dental Services
Dermatology
Diabetes
District Nursing
Health Improvement
Inpatient Dementia beds
Longridge Hospital
Memory
Assessment
Services
Occupational
Therapy
Physiotherapy
Podiatry
Speech and
Language Therapy
Stroke and
Rehabilitation
Treatment Rooms
Criminal Justice
Mental Health Team
Forensic Community
Mental Health Team
Low Secure
Inpatient Units
Medium Secure
Inpatient Units
Mentally Disordered
Offenders
Prison Healthcare
Substance Misuse
Services
Adult Mental Health
Inpatient Care
Complex Care and
Treatment Teams
Eating Disorder
Services
Mental Health
Liaison Teams
Mindfulness
Primary Care Mental
Health Services
Restart Social
Inclusion and Day
Services
Specialist
Psychological
Interventions
Supported accommodation and group homes
Veterans Mental
Health
Alcohol and Drugs,
Education
Child and Adolescent
Mental Health Services
Children and Family
Psychological Services
Contraceptive and
Sexual Health Services
Early Intervention
Service
Health Improvement
Services
Health Visiting and
School Nursing
Homeless Team
Safeguarding
Vulnerable Adults and
Children
Services for Children with Complex and
Additional Needs
Corporate Services support across the networks, this includes the following functions: Quality and
Governance, Human Resources, Finance, Equality and Diversity, Learning and Organisational
Development, Transformation Team, Research and Development, Clinical Audit and Safeguarding.
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In June 2011 following Transforming Community Services, Lancashire Care NHS
Foundation Trust changed from a specialist mental health organisation to a health and wellbeing organisation.
As a result of the significant organisational changes a decision has been made not to report historical data prior to this date as it would not be comparable. The review of quality performance will report data from 2011 and 2012 which is comparable.
In this section we will report against the quality priorities for 2012/13. Networks and corporate services have provided case studies which illustrate the high quality services they provide. Team leaders were asked to provide examples of service improvements and innovations building on areas of development identified by the team for example: from patient feedback, clinical audit findings, CQC visits and appreciative leadership action research projects. In the Quality Account for 2011/12 Lancashire Care NHS Foundation
Trust reported on the Mental Health Trusts previous seven quality priorities. To maintain consistency and build on the quality story we have chosen to continue to report some elements.
Mandatory Quality Indicators
This section of the document contains the mandatory indicators as set by the Department of
Health and Monitor. For Lancashire Care NHS Foundation Trust this includes indicators relevant to all trusts and all trusts providing mental health services. There are no mandatory quality indicators for community services.
The indicators are linked to the five domains of the NHS Outcomes Framework and the quality domains of safety, experience and effectiveness.
NHS Outcomes Framework and Quality Domains
Effectiveness
Domain 1
Preventing people from dying prematurely
Domain 2
Enhancing quality of life for people with long-term conditions
Domain 3
Helping people to recover from episodes of ill health or following injury
Patient Experience
Domain 4
Ensuring that people have a positive experience of care
Safety
Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm
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Effectiveness
Domain 1: Preventing people from dying prematurely
Domain 2: Enhancing quality of life for people with long-term conditions
Indicator Target 2011/12
Outcome
2012/13
Outcome
2012/13
National
Average
Targets
Achieved
Patients on Care Programme
Approach (CPA) who are followed up within seven days of discharge from psychiatric inpatient care
95% 97% 96% 97%
Admissions to inpatients services for which the Crisis
Resolution Home Treatment
Team acted as a gatekeeper
95% 99% 98% 98%
Data source: Department of Health Data is governed by standard definitions http://transparency.dh.gov.uk/2012/06/21/mental-health-community-teams-activity-data-downloads/
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
The data has been taken from the Health and Social Care Information Centre
To enable direct comparison data reflects quarter 1, 2 and 3
Quarter 4 data has not been uploaded to the Health and Social Care Information
Centre at time of publication
Lancashire Care NHS Foundation Trust intends to take the following actions to improve this percentage and so the quality of its services, by:
Continuing to prioritise the collection of this data
Ensuring that this data is available through the team information board at team level, supporting ownership, self-monitoring and improvement
Domain 2: Enhancing quality of life for people with long-term conditions
Indicator
Minimising mental health delayed transfers of care
Target
≤ 7.5%
2011/12
Outcome
4.0%
2012/13
Outcome
4.6%
Targets
Achieved
Meeting commitment to serve new psychosis cases by early intervention teams
100% 140% 152%
Data source: LCFT Internal Information System (eCPA and NCRS) Data is governed by standard definitions
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
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The data has been taken from internal reporting systems
The >100% figure is owing to the commissioned caseload target being exceeded, this is due to a rise in demand for treatment
Lancashire Care NHS Foundation Trust intends to take the following actions to improve this percentage and so the quality of its services, by:
Continuing to prioritise the collection of this data
Ensuring that this data is available through the team information board at team level, supporting ownership, self-monitoring and improvement
Domain 2: Enhancing quality of life for people with long-term conditions
Increasing Access to Psychological Therapies (IAPT)
The % of people who are moving to recovery as a proportion of those who have completed a course of psychological treatment
2011/12 2012/13 Variance between
2011/12 & 2012/13
North Lancashire (5NF)
East Lancashire (5NH)
34%
43%
38%
44%
4%
1%
BwD (5CC) 31% 40%
9%
Central (5NG) - 36%
Not comparable as no previous data
Data Source: LCFT Information systems Data is governed by standard definitions
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
The data has been taken from internal reporting systems
There is no data for Blackpool as primary care mental health services are provided by the Acute Trust
There is no comparative data for Central for 2011/12 as Central were not producing figures for IAPT in 2011/12
Quarter 1 data for central was collected manually and is therefore an estimate.
Electronic systems have now been developed and implemented to ensure robust data collection
Lancashire Care NHS Foundation Trust intends to take/has taken the following actions to improve this percentage, and so the quality of its services, by:
Further developing access to psychological therapies through reducing barriers to service through developing self-referral pathways
Targeted access for special interest groups such as long term physical conditions, older adults, veterans, 16 - 18 year olds
Facilitators have been recruited to increase access to facilitated self-help such as computerised cognitive behavioural therapy
A review of service configuration for complex needs entering IAPT services
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Improve prevalence rates by recruiting to vacant posts
Considering waiting list initiatives in priority areas
Recruiting psychology staff in required localities
Patient Experience
Domain 4: Ensuring that people have a positive experience of care
Indicator 2011
Outcome
2012
Outcome
National
Average
2012
Comparison to National
Average
Community Mental Health Services:
% of patients who rate the overall service they received in the last 12 months as excellent, very good or good.
79% 76% 79%
3%
Inpatient Mental Health Services:
% of patients who rate the overall care they received during their recent stay in hospital as excellent, very good or good.
71% 72% 72%
0%
Date Source: National Community Mental Health Survey Data is governed by standard definitions
Mental Health Inpatient Survey
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
This data has been taken from the national survey data
The Community Mental Health Survey rated Lancashire Care NHS Foundation Trust as
“about the same as other Trusts” on each of the 9 criteria
Individual scores for Lancashire Care NHS Foundation Trust were better than other
Trusts for care review meetings and being informed a friend or relative could attend
Individual scores for Lancashire Care NHS Foundation Trust showed that scores were lower than other Trusts for out of hours contact details and information about medication and side effects
The overall score for the inpatient survey is similar to the national average but there was a lower score for one question relating to ward cleanliness
Lancashire Care NHS Foundation Trust intends to take/has taken the following actions to improve this percentage, and so the quality of its services, by:
A revised care co-ordination policy has been launched along with standards and training on care planning
There has been a review of crisis and contingency plans to ensure all service users have the contact numbers they require
The cleaning contractor for the inpatient wards has been changed to resolve the issue relating to cleanliness
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Domain 4: Ensuring that people have a positive experience of care
Indicator 2011
Outcome
2012
Outcome
National
Average
2012
Comparison to National
Average
% of staff employed by Lancashire
Care NHS Foundation Trust, who would recommend Lancashire Care
NHS Foundation Trust as a provider of care to their family or friends.
63% 67% 60%
7%
Date Source: National NHS Staff Survey Co-ordination Centre Data is governed by standard definitions http://nhsstaffsurveys.com/cms/index.php?page=staff-survey-2011
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
The data has been taken from the national staff survey
Lancashire Care NHS Foundation Trust intends to take the following actions to improve this percentage, and so the quality of its services, by:
Implementing the recommendations of The Mid Staffordshire NHS Foundation Trust
Public Inquiry February 2013 (Francis 2) including: o Continuing to support and embed appreciative leadership within the culture of the organisation o The implementation of the family and friends tests is one of the organisational quality priorities for 2013/15
Domain 2: Enhancing quality of life for people with long-term conditions
Domain 4: Ensuring that people have a positive experience of care
Indicator 2011
Outcome
2012
Outcome
2012
National
Average
Comparison to
National
Average
Patient experience of contact with community mental health services staff (Score out of 100)
85.3 85.9 86.6
0.7
Data Source: Community Mental Health Survey Data is governed by standard definitions https://indicators.ic.nhs.uk/webview/ P01413
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
The data has been taken from the Health and Social Care Information Centre
Data is calculated as the average of 4 survey questions, an average weighted score
(by age and sex) is calculated for each of the questions: o Did this person listen carefully to you? o Did this person take your views into account? o Did you have trust and confidence in this person? o Did this person treat you respect and dignity?
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Lancashire Care NHS Foundation Trust intends to take the following actions to improve this score, and so the quality of its services, by:
Ensuring that everyone allocated to a Mental Health Team has a named care coordinator and a crisis contingency plan
Developing standards of care planning and launching care planning training for staff.
Safety
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm
Indicator
Rate of patient safety incidents
Percentage resulting in severe harm
1 April to 30 September 2012
(NRLS report)
LCFT
39 per 1,000 bed days
National
Average
24 per 1,000 bed days
0.2%
(7 cases)
0.8%
Comparison to
National Average
15 per 1,000 bed days
1 October 2012 to 31 March
2013
(LCFT internal reporting)
29 per 1,000 bed days
0.6% 0.7%
(22 cases)
Percentage resulting in death
0.1%
(3 cases)
0.8%
0.7% 0.2%
(6 cases)
Data source: National Reporting and Learning System Data is governed by standard definitions http://www.nrls.npsa.nhs.uk/patient-safety-data/organisation-patient-safety-incidentreports/directory/?entryid33=25766&char=L
LCFT Internal reporting systems
Lancashire Care NHS Foundation Trust considers that this data is as described for the following reasons:
The data has been taken from the National Reporting and Learning System (NRLS)
National patient safety reports
The latest data available from the NRLS reports is for 1 April to 30 September 2012 therefore data from internal systems has been reported for the period 1 October
2012 to 31 March 2013
Data reports are made available six months in arrears
NRLS
4
encourage high reporting of patient safety incidents. “Scrupulous reporting and analysis of safety related incidents, particularly incidents resulting in no or low harm, provides an opportunity to reduce the risk of future incidents. Research shows that
4
NRLS Frequently asked questions (FAQs) about the Data http://www.nrls.npsa.nhs.uk/patient-safetydata/organisation-patient-safety-incident-reports/#11
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organisations which report more usually have a stronger learning culture where patient safety is a high priority. Through high reporting the whole of the NHS can learn from the experiences of individual organisations ”.
The reporting rates are higher than average which represents a maturing safety culture and the Trust remains in the top percentile of reporters (NRLS, 2013) in the current comparable cluster of Trusts. The incident reporting data is reviewed and quarterly reports are provided organisation wide alongside a 6 monthly thematic report of serious incidents.
The internal figures reported for Oct 12 to Mar 13 may not match the figures that will be published by the NPSA in September 13. This is due to changes in the data post submission to the NPSA.
Due to the judgemental nature of this indicator it is difficult to be certain that all incidents are identified and reported and that all incidents are classified consistently within the organisation and nationally. One individual’s view of what constitutes severe harm can differ from another’s substantially. As a Trust we work hard to ensure all our staff are aware of and comply with internal policies on incident reporting and standardisation in clinical judgements
Further details of patients safety incidents and reporting of serious incidents can be
found in the Safety section of this document
Lancashire Care NHS Foundation Trust intends to take/has taken the following actions to improve this percentage/rate, and so the quality of its services, by:
The Policy for the Reporting, Management and Investigation of Incidents has been reviewed following service transformation and the change to one organisation wide Datix system; the new policy and guidance implementation plan was launched in April 2013.
This policy covers the requirements for reporting, management and investigation of all incidents including serious incidents and has been developed alongside a comprehensive guidance document named Guidance for the Reporting and Investigation of Incidents. Both the policy and guidance will link to a number of toolkits which will be launched alongside the policy on the Risk SharePoint site on the intranet. These aim to provide a central point of comprehensive supportive help and information for the whole process for all users and managers. The policy and guidance were developed after consultation with all networks and working across different departments. The Datix system is the incident reporting and risk management software system across the whole organisation and has been developed to support the policy and guidance.
The Policy for the Reporting, Management and Investigation of Incidents includes serious incidents formally known as serious untoward incidents. The organisation intends to remove the term ‘untoward’ and in future will call these serious incidents as the term applies to all serious incidents and this is in line with current national guidance.
There has been on-going consultation in the development of this Policy and associated documents which have included representatives from all networks. The revised serious incident process is currently being piloted in the Mental Health Network. Further improvements in the process and management of incidents will be progressed as part of the implementation alongside with the development of training packages for investigators and administration support.
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Effectiveness
This section of the document explains the effectiveness of treatment or care provided by services. This is demonstrated using clinical measures or patient/service users’ feedback, this may also include people’s wellbeing and ability to live independent lives.
Quality Priority 1 Target Progress
Reducing time on non-value added activity
Establish baseline and reporting.
Agree targets for year 2 and 3 at the end of year 1.
See below
Quality Priority 1 aims to reduce the time spent on nonvalue added activity thus “releasing time to care”. A key enabler in this has been lean which focuses on preserving value and eliminating waste. A number of projects have been initiated during 2012/13:
15 individual lean projects have been completed by Lean in Practice Delegates in
2012/13 increasing value added time in their work areas.
A rolling programme of Team Information Board development across Lancashire Care
NHS Foundation Trust supports a culture of ownership of quality improvement and performance information by teams. This also facilitates best use of time in relation to communication between team members in terms of improving the timeliness of information sharing and reducing the time spent in meetings.
Lean continues to be embedded in the organisation with the current network business plans identifying specific areas for focus in 2013/14. There is an on-going organisational training programme accessible for all staff to support their understanding of value added activity across a range of activities. This is further supported with the roll out of the Productive
Community Service modules and the Productive Leader Programme within the Children and
Families Network. In addition a lean approach has supported the elimination of waste in the
Space Utilisation Programme to maximise building occupancy.
The Preston High Intensity Team have reviewed their daily team meetings and routines to remove duplication of effort and to support the team to get out to their patients sooner in the mornings. By making simple changes the team were able to reduce the time spent on record keeping, improve the quality of the handover of information and reduce the meeting length by 50%. They tested the new process within the week and the changes have released
34 weeks per year of clinical time for the team and 69 days of administration time back into value added activity.
One delegate said :
An extremely productive and thoroughly worthwhile event. I’ve worked in the NHS for 20 years and this has been the most productive week I have ever spent.
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Darwen 0-19 Team (Health Visitors and School Nurses) participated in phase 1 of the
Quality Strategy and completed the Quality SEEL self-assessment of the quality of the services they provide. Following this the team now meet and have a daily “huddle” meeting
(an informal meeting), lasting 10 minutes, around a Team Information Board where they discuss quality and service developments. Minutes from the meeting are hand written on a template at the huddle meeting for staff to read who have been unable to attend the meeting.
Darwen 0-19 team information board
Prior to the huddle meeting:
Administration staff would spend a minimum of 6 hours per week preparing for a big weekly team meeting and afterwards typing the minutes and the distributing to staff.
The weekly team meeting took 2 hours and all staff aimed to attend this unless on annual leave or at safeguarding meetings.
The Team Leader would allocate the work weekly, taking approximately 45-60 minutes per week.
The Team Leader would spend at least 10-15 minutes a day organising cover for meetings and clinics when colleagues were on leave. This is now done daily at the huddle which saves time.
Following the changes:
Staff pick up their allocations daily and then go straight out on their visits.
Staff report that they have more time for client contact.
Administration staff report feeling more organised and a lot of the duplication has been reduced.
Staff write the huddle agenda.
Darwen 0-19 Team Leader said:
I cannot stress the value of the huddle meetings – better team communications, daily opportunity to celebrate successes, discuss team improvements, and the huddles are inclusive to all disciplines.
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Clinical Supervision
Clinical supervision is an activity which allows clinical staff to meet with a skilled supervisor in order to reflect upon their practice. The purpose of these meetings is to improve practice by identifying solutions to problems and increase understanding of professional problems.
There are various approaches to clinical supervision for example: one-to-one supervision, group supervision or peer group supervision (Royal College of Nursing, 2004).
A clinical audit was completed in 2011/12 to monitor compliance against standards for clinical supervision. This audit was repeated in 2012/13 to measure improvements, the results have been combined for community and inpatient staff, these are shown in the table below:
Audit Standard 2011/12 2012/13
All staff have a right to formal supervision 73% 91%
Variance between
2011/12 &
2012/13
18%
Supervision meetings will be made in advance and prioritised and held in a suitable private room free from interruptions
A record of each clinical supervision session will be held by both participants
A record of each clinical supervision session will be held confidentiality
All clinical/supervisory relationships will be governed by the supervision contract
Individual staff have a responsibility to adhere to their professional code of practice (where applicable) with regards to clinical/professional supervision
Data source: LCFT Clinical Supervision Audit 2012-13
90%
88%
69%
54%
73%
92%
89%
89%
62%
88%
2%
1%
20%
8%
15%
Lancashire Care NHS Foundation Trust is committed to supporting staff to understand their roles, responsibilities and key objectives, enabling them to undertake their job as effectively as possible. The supervision of staff is one of the ways that this can be achieved and as such was identified as a key priority for Lancashire Care NHS Foundation Trust
Work done in relation to supervision has been to completely revise and rewrite the supervision policy making it a tool to support staff in all settings across Lancashire Care
NHS Foundation Trust. It provides a clear framework so staff are supported and managed at all times and are clear about their lines of accountability.
Successful implementation of this policy has involved the development of local protocols in all services. This new approach has improved both management and clinical supervision activity within Lancashire Care NHS Foundation Trust thus improving the resilience to staff to meet the complex ever changing demands of modern healthcare. Staff are supported to deliver high quality services safely, efficiently and effectively.
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Research and Development
Lancashire Care NHS Foundation Trust is dedicated to improving the health of its service users, carers and stakeholders by providing its staff with the most current research findings in the country and by actively taking part and leading in high quality research.
Lancashire Care NHS Foundation Trust North is a member of the newly formed North West
Coast Academic Health Science Network (NWC AHSN) which covers Merseyside, South
Cumbria, and most of Cheshire and Lancashire.
Academic Health Science Networks are NHS led Networks, and are intended to include all of the Clinical Commissioning Groups, providers of primary, community, secondary and tertiary
NHS services, universities, industrial and other organisations and partners.
To access further information on the North West Academic Health Science Network go to: http://www.nwcahsn.nhs.uk/index.php
Adult Community
Learning Disability Service
Raising Awareness of the Needs of People with a Learning Disability in Acute Hospital
Settings
The service supports people with learning disabilities to live as valued members of society by providing and arranging specialist health and social care. There are 13 teams across
Central, North and East Lancashire comprising specialist community nurses, therapists, psychologists and psychiatrists.
The hospital passport
Following various Government led investigations, it was identified that improvements needed to be made to improve the experience of people with a learning disability who needed to access treatment within acute settings.
The project was undertaken to address this issue. This on-going project is aimed at improving the knowledge, skills and understanding of staff within acute facilities in order that they can provide efficient and safe treatment for people with a learning disability whose communication skills may be impaired. The introduction of the hospital passport (shown above) across Lancashire has been seen to be effective in assisting acute staff to be aware of the needs of people with a learning disability while they are in their care.
Outcome: Improved patient experience and health outcomes for people with learning disabilities, alongside their carers, when accessing treatment within acute settings.
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Podiatry Service
Benefits of Non-Medical Prescribing in a MDT Diabetic Foot Clinic
Non-medical prescribing (NMP) is prescribing by specially trained nurses, optometrists, pharmacists, physiotherapists, podiatrists and radiographers. The aim of NMP is to provide better and quicker patient care by utilising the skills of healthcare professionals whilst, at the same time, safeguarding patient safety and ensuring that Non-Medical Prescribers prescribe within their scope of practice (National Prescribing Centre, 2004).
Initially a detailed patient history is taken and a draft Clinical Management Plan (CMP) is produced during the patient’s podiatry appointment. The CMP is then discussed and agreed at the patient’s diabetic foot clinic appointment with the Non-Medical Prescriber.
The patient’s medication, compliance and supply prescriptions are checked during their followup podiatry appointments. All prescriptions given, CMPs agreed and the patient’s main medical history are inputted onto a spread sheet for auditing.
Outcome:
Patients only require an initial assessment by the Prescriber
Seamless provision of care across primary and secondary care
Patients are encouraged to bring their dressings to the clinic to ensure continuity
NMP has increased the number of patients who take their medication as prescribed
Patients who have their own dressings are empowered to take control of their diabetic foot disease
This system has also been used to improve Painful Diabetic Neuropathy, patient's access to treatment and monitoring their medication in primary care
Improved compliance with long term antibiotic therapy
Speedy access to antibiotic therapy
Specialist Services
Her M ajesty’s Prison Kirkham
Increased Uptake in Vaccination of Hepatitis B and Blood Borne Virus Screening
Her Majesty’s Prison (HMP) Kirkham is a category D open prison, housing 630 adult male sentenced prisoners. It provides physical and mental health primary care. Blood Borne virus
(BBV) infections are high in prisoners because of the high incidence of intravenous drug use.
Of main concern is Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Human immunodeficiency virus (HIV).
HCV is almost 20 times higher in the prison population and HIV approximately 15 times higher, than in the general population. (British HIV, 2008). Almost a quarter of men and women arriving in prison have had previous contact with BBV services; most of them report a history of intravenous drug use (75.4%). Approximately, 45,000
– 65,000 of all new receptions into prison each year are thought to be problem drug users of these nearly half report having injected drugs within the previous 28 days (Department of Health, 2011).
There is high incidence of sharing equipment because of the prohibition of injecting
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equipment in prison. A recent study in HIV prevalence among prisoners, reported as many as 75% of male intravenous drug users in prison sharing equipment. This is a very high risk of BBV transmission.
Following analysis of uptake rates in HMP Kirkham and a review of best practice evidence, a need was identified to review the current system. The overall aim was to increase the uptake and ensure that we were able to treat men who were positive to Hepatitis C and protect the men from transmission of Hepatitis B.
At HMP Kirkham all prisoners are transferred in from other prisons, so in theory, all men should have completed a course of HBV vaccine and require boosters. In practice, this was not happening, with many men having not previously been offered the vaccine.
We initially looked at how the nurses record the vaccines at the reception screen and what the uptake was of these vaccinations. Men were offered the vaccine and then an appointment made for later in the week which was often declined due to poor understanding.
An awareness session by the HIV and Hepatitis C specialist nurses for staff and the introduction of opt out for screening improved the rates of declining. Following the visits to other prisons it was apparent that there were higher uptake rates in the prisons where vaccinations were performed immediately at reception. We introduced a second nurse into the reception screen and men were vaccinated and screened immediately at the reception screen, thus reducing did not attend rates and increasing the uptake rates. All vaccinations were recorded via a template ensuring that nurses were recording consistently. This template ensured that staff could only choose one of three options, which were read coded: already immunised, declined or vaccine administered. The Administration Manager was able to run reports each month that were accurate.
Outcome: Following the project HMP Kirkham have consistently achieved 100% coverage of vaccinations of Hepatitis B for more than 2 years, and have consistently performed highly in this area. HMP Kirkham have also consistently achieved very high uptake rates for BBV screening.
HMP Wymott
Inclusion in the NHS National Bowel Cancer Screening Programme
Following a review at HMP Wymott it became apparent that prisoners were not being invited into the national bowel screening programme. The reason for this is that all prisoners are still registered with their General Practitioner (GP) and invitations are sent to the registered GP.
Following a meeting with the national screening team an action plan was developed and a new process agreed. With the support of clinical governance we now send a list of NHS numbers within the target group on a monthly basis to the NHS National Screening
Programme hub based in Preston. The invitations are sent to the patient, care of prison healthcare, and the process completed as in the community.
This has been a great example of joint working with very positive feedback; the programme has now been rolled out across all Lancashire prisons and further prisons in the country.
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All those within the inclusion criteria are supported in healthcare by the lead nurse through the process; we have offered screening to 80 men throughout the last 12 months. Only 8 have declined, with 1 requiring further investigation and treatment.
Outcome: All 60-75 year old prisoners are now offered the screening to improve the early detection of bowel cancer or associated conditions
Adult Mental Health
Complex Care & Treatment Teams
Mind the Gap – Reducing the Need for Service Users to be admitted to Hospital
Complex Care and Treatment Teams (CCTTs) provide services to people with severe mental illness, such as psychoses, bipolar disorder and severe mood disorders. Our service users may have a range of issues that benefit from our input, from mental health difficulties, to housing issues and occupational needs. CCTTs include a range of professionals including doctors, nurses, social workers, psychologists, pharmacists, occupational therapists and support time & recovery workers.
CCTTs are a recent development in community mental health provision. They have been designed with the aim of improving the quality of care that we deliver through improved skills and a range of recommended treatments. A key measure of our success is a reduction in the number of people who are involved in our CCTTs who need to be admitted to hospital each year. We know that some people will at some point benefit from being admitted to hospital, and we do not want to do anything that stops people going into hospital if it is the right thing for their mental health. We also think that if we improve our community service and as a result we reduce the need for people to be admitted to hospital, then this is an indicator that we are improving our community services.
Throughout 2012/13, we have monitored the number of people who have been admitted from CCTTs to our inpatient wards and the total number of patients on the CCTT caseload
(shown below):
700
600
500
400
300
200
100
0
Number of People Admitted to Hospital from CCTT vs. Caseload
Admissions 11/12 Current Caseload Admissions 12/13
% figure = % patients admitted on current caseload
15% 17%
20% 21%
20%
19%
31%
24% 20%
Data source: LCFT internal data systems
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The results show there has been a reduction in the number of service users admitted to hospital from CCTTs this year compared to last year’s data.
We are really pleased that we have managed to reduce the need for some of our service users to have time in hospital. A key factor has been an improvement in the quality of Crisis and Contingency Planning. We are also beginning to see the benefits of the Specialist
Practitioner roles and specialist interventions such as Dialectical Behavioural Therapy which aim to reduce the need for people to be admitted to hospital.
We know that hospital is the right decision for some people at some point, and will always use hospital when it is right to do so. We will also look to further improve our community services so that people need to be admitted to hospital less often.
Outcome: Reduction in the number of service users requiring admission to hospital
The mind the gap project also links to the quality domains of patient experience .
East Lancashire Community Restart Team
The Benefits of Ecotherapy on Mental Health Conditions
Ecotherapy is an umbrella term for treatments that include the natural world and which aim to enhance physical and/or mental health and wellbeing. The Branch Out project is a partnership made up of East Lancashire Community Restart (Lancashire Care NHS
Foundation Trust) and six charitable organisations, delivering a variety of ecotherapies to people with a range of mental health conditions.
Community Restart, on engaging with voluntary sector organisations in their local area who were providing ecotherapies, understood that a greater range of ecotherapies could be provided to service users if such third sector organisations pooled their resources.
Community Restart mobilised these third sector organisations to form one partnership, i.e.
Branch Out. One such organisation (Pennine Lancashire Community Farm) became the lead partner, and Branch Out were successful in winning a bid of £250,000 from Big Lottery funding, to provide ecotherapy to mental health service users in the East Lancashire area.
Community Restart - Branch Out Referrals - Average WEMWBS - by Diagnoses
Classification
35.0
Avg Baseline WEMWBs score Avg WEMWBs score after Eco-therapy
31.0
26.85 - Mean General Population WEMWBS score - East Lancs PCT Area (North West Mental Wellbeing Survey, 2009 )
27.0
22.8
23.5
22.5
23.0
20.0
20.7
18.8
19.6
19.0
17.3
15.5 15.7
15.0
11.0
7.0
Severe & Enduring Depression Anxiety Mixed Anxiety &
Depression
Other
Data source: LCFT internal data systems
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The graph on page 24 shows the results: 202 service users were referred in to the Branch
Out project from Community Restart. 105 of these completed the Warwick and Edinburgh
Mental Well Being Scale (WEMWBS) both pre and post ecotherapy intervention. Results demonstrate an increase in WEMWBS scores across a range of mental health conditions, indicating that engaging in ecotherapy occupations improves service user perceptions of mental wellbeing amongst those with mental health problems.
Community Restart won funding of £5,000 from the NHS North West Innovation Fund to disseminate the results of the Branch Out project. We are currently working with the
University of Salford to assist us in analysing these results.
Outcome: An increase in WEMWBS scores across a range of mental health conditions indicating improved perceptions of mental health
Children and Families
Child ren’s Psychological Services and Child and Adolescent Mental Health Services
Children & Young People Increasing Access to Psychological Therapies Programme
(CYP IAPT) - North & Central Lancashire
CYP IAPT aims to increase access to evidence based psychological interventions (‘talking therapies’ and ‘group work’) for depression, anxiety, trauma, conduct disorders and child behavioural problems.
It was recognised that the delivery of evidence based psychological therapies for children and young people was variable across the Trust. This programme works closely with third sector partners to introduce consistency in terms of the quality delivery of evidence based interventions and parenting programmes across Lancashire so that Children, young people and their parents can easily access these services at the right time and in the right place.
The whole CYP IAPT programme is centred around a value of evidence based intervention.
Subsequently, a key part of this programme is that practitioners and service users actively collaborate in treatment goals and use session by session feedback to review and track progress towards these goals.
Anecdotal evidence from other Trusts who have already implemented CYP
IAPT suggests that young
The underlying philosophy of CYP IAPT is summarised below:
Increased
Accessibility for young people and parents
Participation prioritised so - services shaped and influenced by Young
People and parents
Highly trained staff offering
Quality services
Use of
Routine
Outcome
Monitoring to provide evidence based
Services
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people and parents feel more actively involved in treatment when this is the case. A wide range of standard outcome measures are available as part of the CYP IAPT programme and time is spent training practitioners to use these measures effectively and to develop a sophisticated understanding of outcomes and the routine use of these as an active part of the therapeutic process.
Outcomes: Young people and parents feel more actively involved in treatment
The CYP IAPT programme also links to the quality domains of patient experience and patient safety .
Early Start Team
Early Start Programme
The Early Start Team is a bespoke, local service in Blackburn with Darwen. It was developed 3 years ago to ensure early intervention in order to improve health outcomes to some of the most vulnerable first time parents (i.e. care leavers, teenage parents and parents with mental health issues). The Programme provides a dynamic new way of working, offering intensive health visiting support, early intervention and preventative programme of parenting support. It engages with these families using a ‘Think Family’ approach from early in the antenatal period until the first child reaches the age of two years.
The Early Start Programme was developed in response to the cycle of deprivation and poor health outcomes for the vulnerable families within our community who suffer from major life challenges such as mental ill health, drug and alcohol abuse, poverty, social care involvement and homelessness, to name a few. This client group are less likely to uptake services and engage with professionals delivering the healthy child programme, and as a result, their children are more likely to suffer the same intergenerational cycles of deprivation, including failing in education, involvement with the police and poor health outcomes as a result of poor parenting and their parents lifestyles.
Pre set up, the team consulted parents and carers through a number of focus groups to establish how they felt the programme should be developed. Since then, the team has won an award from the Foundation of Nursing Studies and the prize money was used to consult with current families using focus groups and creative work. The feedback has been used to improve the service
The team meets regularly to discuss the needs of families in clinical supervision and psychology supervision; this has ensured all families have access to the expertise of all members of the team and consultant psychologist.
Outcomes: High levels of parent/carer efficacy, low numbers of accident & emergency attendance and high vaccination & immunisation uptake
The Early Start programme also links to the quality domain patient experience .
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300
250
200
150
100
50
0
Corporate Services
Clinical Safety and Effectiveness Team
The Care Aims Approach - Outcomes that Matter
The Care Aims approach supports clinicians to be partners in care rather than the traditional approach of being providers of care. Requests for help from teams and services are most commonly expressed as requests for input rather than outcome. The approach supports clinicians to focus on the impact of a presenting problem and not the problem itself with the key being understanding what the service user would like to be different about their life, understanding what this would mean for them, what has to change to make this happen and what will best help at this time. The approach recognises and reinforces the importance of clinicians empowering people to manage their own challenges and to skill others in communities to make changes or to use strategies to support people to best effect ensuring that resources are used most effectively with those people who need treatment/interventions being able to access services in a timely way.
The example below reflects the work of the Intermediate Care Team in Preston across a 3 month period using the care aims decision making tool. An impact rating of the presenting health problem is taken at initial assessment and at the end of an episode of care with a score of between 0-12 desirable. The end of episode ratings show an increase in impact scores of 12 or less with an associated reduction across the other scoring ranges.
Impact score at initial assessment and at end of care
244
At initial assessment End of care episode
NB. Low score = less impact
72
Less than 12
132
43
12 to 25
77
>26
4
10
3
No outcome recorded
Data source: Intermediate Care Team database 3 month period March 2012
Outcome: The care delivered has effectively reduced the impact of the problems experienced with successful outcomes for service users
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200
180
160
140
120
100
80
60
40
20
0
Pharmacy - Non-Medical Prescribing
North West Non-Medical Prescribers Clinicians Audit
Non-medical prescribing (NMP) is prescribing by specially trained nurses, optometrists, pharmacists, physiotherapists, podiatrists and radiographers. Non-Medical prescribers work across a number of services within Lancashire Care NHS Foundation Trust and enable patients/service users to have faster access to medicines. They do this by assessing the patient’s clinical condition and issuing a prescription where appropriate. They also review the pat ient’s current medication to ensure safety and effectiveness of medicines.
All non-medical prescribers within Lancashire Care NHS Foundation Trust were invited to take part in a clinicians audit during September 2012 to evaluate the impact and benefits of non-medical prescribing.
A total of 699 episodes of care were recorded. The results demonstrated that non-medical prescribing enabled patients to access medicines more quickly. In 96% of cases the nonmedical prescriber was able to prescribe immediately. This enabled the episode of care to be completed in 87% of consultations. Following non-medical prescribing medication review
494 out of 708 consultations (70%) showed adverse side effects of medication were identified and medications adjusted accordingly at the time of consultation.
The chart below shows the impact of an NMP consultation:
188
Which of the following best represents the impact of your consultation?
144
89
52
45 43 42
32 30
23
7 6 3 2 2
Data source: Wirral Health Informatics Service Database
Outcome: Non-medical prescribing was demonstrated to be an effective intervention in preventing hospital admission or follow-up by other health care professionals.
The Non-Medical Prescribers Clinicians Audit also links to the quality domains of patient experience and patient safety .
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Patient Experience
This section of the document aims to demonstrate the experience of patients, service users and carers who are using or have used our services.
Quality Priority 2 Target Progress
Increase in service user involvement
Establish baseline and report against the baseline.
All applicable services have carried out a baseline assessment against the NICE Clinical
Guidelines 136 or 138
All networks have established a service user participation group, reporting through governance structures, to address gaps identified through baseline assessment.
Corporate experience team have developed a baseline of qualitative and quantitative methodologies for obtaining service user feedback.
Mixed-sex Accommodation Breaches
Lancashire Care NHS Foundation Trust is compliant with the Government’s requirement to eliminate mixed sex accommodation, except when it is in the patient’s overall best interest, or reflects their personal choice. If Lancashire Care NHS Foundation Trust should fall short of the required standard it will report it to the Department of Health and Commissioners.
Lancashire Care NHS Foundation Trust ’s declaration of compliance is located on the website: http://www.lancashirecare.nhs.uk/Privacy-Dignity.php
Adult Community
Fylde & Wyre Memory Assessment Service
Memory Corner
The Fylde & Wyre Memory Assessment Service aims to deliver quick and timely diagnosis to people whose symptoms suggest that they may have dementia. It will provide all patients who meet the referral criteria with a person-centred service, designed to empower people with dementia and their carers to make informed decisions about their care to help maximise quality of life. Involvement with the service should also help to reduce the risk of crises later in the illness and enable the patient to be cared for at home for as long as is possible, whilst this is their preferred place of care.
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Example memory corner
Patients attending the memory clinic for the first time were often noted to be displaying acutely high levels of anxiety, wondering who they will see, what will be expected of them in clinic and what the outcome of the visit will be. In order to help alleviate some of these concerns a team from the Memory Service came together to develop a ‘Memory
Corner’. This is situated in the clinic waiting room and is a combination of video and photo memories of the past designed to stimulate communication, conversation and reminiscence in those with memory problems thus also helping to alleviate anxiety.
As clinics are both an on-going and growing part of our remit in the Memory Service the outcomes of this project will always be on-going and therefore the project will change according to feedback received. The theme of the Memory Corner currently changes every month or so depending on the time of year. Many verbal comments were made about the
Christmas version which was particularly well received, generating a great deal of discussion amongst those waiting for clinic appointments.
Evidence of the outcomes is encouraged and collected on feedback forms which are then seen, read and acted upon by the team before being registered with the Trust.
East Lancashire Older Adult Mental Health
Carers Awareness Raising Sessions
Carers have an invaluable role in helping people to manage at home. Lancashire Care NHS
Foundation Trust recognises that carers may need help and support. This project was designed and developed in partnership with Carers Lancashire. The aim of these sessions is to give clinical staff awareness and knowledge of the rights and needs of carers, increasing staff confidence and skills in identifying and engaging with the many different types of carer they come in contact with. This project gives clinical staff the information they need to signpost carers to expert independent information, advice, advocacy and support from carers centres in their local community.
The sessions focused upon:
How to identify a carer (definitions, impacts, signs etc.)
The importance of carer identification and support
Four step programme to being a Carer Champion: o Ask patients if they are a carer o Encourage carers to seek appropriate support (refer to local Carers Centres) o Register as a professional with local Carers Centre (via free professionals resource files given to each participant following the training) o Display Carers Centre posters and literature in waiting areas
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The training focused upon the very simple ways Older Peoples Mental Health Services could support carers and the benefits this could bring, benefits are shown below:
Outcome:
Added value to service – seamless transition to further support
Improved patient and carer experience
Carers feeling valued as a ‘partner in care’
Support for professionals working with challenging situations involving patients with carers
Reduce or eliminate the need for staff to offer a Carers Assessment, at a time when
Carers feel it is inappropriate as their focus is upon the patient, thereby saving valuable time and resources for Older Peoples Mental Health Services.
Additional on-going support for carers once a patient is discharged, including in-depth initial support to exercise their rights to a Carers Assessment, benefits checks, emergency support planning
Specialist Services
Forest Beck
Evaluation of Planned Activity on Forest Beck
Forest Beck is a step down facility for women in the grounds of Guild Lodge. It offers accommodation for up to eight service users. This facility provides an environment for service users who no longer require medium secure care but still require further assessment and treatment prior to discharge. Forest Beck allows service users to live more independently and in an open facility before moving into the community. The building was opened in November 2011 and consists of four bedrooms within the core part of the building and four self-contained flats either side of the building.
During community meetings service users requested activities on and off the ward that they found rewarding and enjoyable. A comprehensive list of activities that the women wanted to participate in was made.
This list was then translated into a timetable of activities that suited both the service users and the routine of the unit. The activities included a games afternoon, board games, brunch group, healthy eating group, coffee morning, walking group and grow your own project. In addition the service users now meet regularly to discuss and agree new activities and places to see.
Forest Beck example timetable
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The focus of the groups is to provide structure to the se rvice user’s day and help with selfesteem and confidence difficulties. The healthy eating group is particularly well attended and helps to encourage healthier lifestyles and choices. Service users are encouraged to buy ingredients, cook and eat in a communal setting promoting social activity. The initiative has been particularly helpful when new service users are visiting the ward before being transferred, giving opportunity to join in and form friendships with other service users prior to being transferred.
A new project that the service
Grow your own project notice board users are eagerly awaiting is the
Grow your own project where service users have access to a poly tunnel and raised beds to grow their own organic produce.
In March 2013 this project will be providing more activity and education on healthy lifestyles.
Fairoak Ward
Developing a Care Approach
Fairoak is a low security facility for men in the grounds of Guild Lodge; it offers accommodation for up to 18 service users from a number of different client groups, including people stepping down from medium security, service users referred from general adult mental health services, and those referred from the courts and prisons.
Discussions within individual and group supervision sessions have identified ways of improving our care approach for the service users on Fairoak ward. We explored a variety of options and agreed that organising a carer’s event on the ward would be a positive achievement for both the staff and service users to allow individuals to demonstrate their accomplishments.
The team agreed that the best way forward would be to gain as much service user involvement as possible in the planning and organising of the event, therefore we discussed this within service user’s community meetings. This allowed the service users to share their views on the kind of items they would like exhibited within the carers event and who they would like to invite e.g. family members, ex-service users and a variety of members from the multi-disciplinary team and other professionals within the hospital.
All the service users on the ward were given individual responsibilities and tasks to fulfil in preparation for the carers event which led to the event being well organised and a great success. The service users on the ward have given positive feedback about the day and most reported that they were excited to be able to show everybody their achievements at
Guild Lodge and the skills they have developed throughout their recovery pathway.
The feedback from the carers who were invited was also very positive and all have said that it was refreshing to be able to see and understand what the service is about and the
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achievements their loved ones have made. The event was a great success and a very positive experience for all involved including service users, carers and staff.
Service user comments:
It was a good opportunity for everyone to get together and discuss and present our achievements. Leading up to the event we were offered a variety of activities to help us prepare for the carers event. I feel this was a successful activity; everybody did their part and enjoyed this together.
I was happy with the carers day because I made a nice curry and showed family, friends and service users what Guild Lodge is about.
Adult Mental Health
Restart and Recovery Team (Blackpool)
Partnership Working
The Restart and Recovery Team are a Multidisciplinary team consisting of Occupational
Therapists, Clinical Practitioners, a Health and Leisure coordinator, Activity Coordinators,
Technical Instructors, Volunteers, College and Outside Agencies providing social inclusion opportunities and recovery focused care to enhance service user experience.
Partnership working was introduced to promote, enhance and enable social inclusion and recovery opportunities for all service users and carers to access and feel supported in their local communities with the emphasis on meeting Key Performance Targets for Lancashire
Care NHS Foundation Trust. Partnership working successes include; preventing readmissions, reducing length of stay for individuals, enabling people to stay in their own homes with support and developing better environments for service users in Parkwood.
Following recommendations from a Care
Quality Commission visit in December
2011, Shaw Trust, volunteers and service users at Parkwood have worked weekly to provide a variety of different art work that will enhance the unit’s environment. The final work was completed at the end of September
2012. Following installation the open day in December 2012 showcased the art
Example of art work work.
Following on from this successful event other partnership working has taken place with art colleges and outside agencies providing support to enable the next stage of the units
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development to enhance outside environments and produce a relaxing and calming relaxation room for all service users at Parkwood to access.
The team won the staff awards 2013 for demonstrating effective partnership working.
Outcome:
All individuals on the ward are being provided more therapeutic time with their named nurse
The team are now planning to work more evenings so service users and carers can have access to additional support and advice from staff and outside agencies
Social Inclusion and Recovery Service
Wyre Clubhouse Feedback from Service User
Staff, volunteers and other service users at Wyre Clubhouse promote social inclusion and recovery working with people who have had serious or complex mental health problems.
The team support people to feel included in life and their community, in whichever way they choose. As a small team of just two staff supported by service users/volunteers with limited funding we see our main strength being the support of the local community and our friendly partnerships with other local organisations. This allows us to develop innovative projects such as the African drum group and the male support group.
The service received a letter of appreciation in March 2013 from a clubhouse service user and volunteer, for which we have had permission to display within this document.
Service user letter:
“ I am writing to thank you for all your help over the past seven years at Clubhouse, both as a
Service User and also with the Community Groups that I have established and co-ordinate.
I myself have moved forward in so many ways since attending Clubhouse, firstly as a patient and now as a Clubhouse Volunteer. As you know I have been able to develop the Drumming
Workshops that we started at Clubhouse into a Community Drumming Group "Beat The Drum" and we now have two meetings each week and the number of people whom benefit from attending it is growing all the time.
With reference to my work with the Fylde Coast Men's
Support Association (FCMSA), I really appreciate your kind support - by allowing us to see our own Service
Users at Clubhouse. This has been lifeline for all the
Survivors, knowing that they can receive the help that they require in warm and safe environment.
Please find attached a photograph of when I went to receive my MBE in January this year - this I was awarded for my work with the (FCMSA). Without the encouragement that you have provided I feel this would not of been possible - so many, many thanks ”.
Clubhouse volunteer with MBE
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Children and Families
Blackburn Engage Child Sexual Exploitation Team
PhotoVoice – Participatory Photography for Social Change
The Engage Child Sexual Exploitation Team was first established in 2005 and is now a fully operating multiagency team supporting young people at risk of suffering from sexual exploitation. The Engage Team aim to reduce children and families vulnerabilities to sexual exploitation by working in partnership with other agencies, preventing involvement, protecting victims and prosecuting offenders. Since 2009 a Specialist Nurse from Lancashire
Care NHS Foundation Trust has been working within the Engage team to support young people with health needs and to ensure appropriate services are in place. The Specialist
Nurse also raises awareness of child sexual exploitation (CSE) in the organisation and supports professionals.
Addressing CSE is a national priority.
PhotoVoice have been working in partnership with the National Working
Group for Sexually Exploited Children and
Young People in running five participatory photography projects with specialist support organizations working with young people identified as at risk of sexual exploitation or who have been affected by sexual exploitation. The young people involved through Blackburn Engage team had the opportunity to participate in a 3-month photography project throughout the summer.
A self portrait
A poem
Young people explored different themes that offer a context to sexual exploitation including gender, power, relationships and sex. They represented their thoughts, responses and experiences through photography, text and music and created their own digital stories. A selection of the project images from Blackburn were featured as part of Brighton Photo Fringe
Photography Festival in 2012. The young people also had the opportunity to complete a BTEC certificate as part of the project.
This project offered an opportunity for therapeutic intervention through art and also opportunities for young people’s voices and experiences to be heard and to inform others, addressing Child Sexual Exploitation is a national priority to protect young people from harm.
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Child and Family Health Teams (0-19 Universal)
School Health Needs Assessment
The service provides a collaborative approach between children, stakeholders and universal
019 services to identify and respond to both individual children’s needs and those of a school community.
The service was developed in order to respond to a number of key issues including emerging Government Policy, The Healthy Child Programme, lack of involvement of children and young people in our service, the need to develop a proactive approach to early intervention and to target resources effectively in order to achieve outcomes that could be evidenced.
A systematic and pragmatic participatory approach was developed to assessing and responding to individual and public health needs of school children – also affecting a fundamental shift in service design. We applied lessons from methods and tools commonly used within the international health development community.
Benefits for children and families:
29,000 children attending primary schools will benefit from action plans developed with each school
7,400 children and parents have participated and had their individual health and wellbeing needs assessed
Over 600 children have received additional individual support so far.
Benefits for schools and interagency collaboration
All 149 primary schools have an evidence based action plan resulting from consistent needs assessment processes
Positive re-engagement between education and health
Stronger platforms for inter-sector partnerships to address better evidenced problems
Corporate Services
Equality and Diversity
Embedding the National NHS Equality Delivery System Scrutiny Processes
The Equality and Diversity (E & D) Team works across Lancashire Care NHS Foundation
Trust. Its main aim is to lead on issues around compliance with the Equality Act 2010 including advising on high quality Equality Impact Assessments, access to Interpreter and
Translation Services, delivery E & D related training, signposting service users, staff and community members to relevant support within Lancashire Care NHS Foundation Trust or externally with other agencies. The team also ensure that the systems and structures are in place for E&D delivery across all services and all E & D information is published on the intranet and internet as required to meet the Equality Act Public Sector Equality duties in terms of information and communication.
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The Department of Health rolled out the Equality Delivery System (EDS) across the NHS in
2011/12. Lancashire Care NHS Foundation Trust utilised the EDS processes to support embedding E & D across Lancashire Care NHS Foundation Trust which in turn ensures compliance with equality law.
Lancashire Care NHS Foundation Trust have carried out two events called Opportunity
Knocks in 2012 which involved service users, carers, staff and leaders in scrutinising activity across Lancashire Care NHS Foundation Trust against 4 EDS Goals and supporting 18 health outcomes. The events were held in partnership with Lancashire Constabulary due to the interface they have with Trust services and they serve the same geographical area and community. Over 120 people attended the two ‘Opportunity Knocks’ events in 2012. The events consisted of presentations from senior leaders in Lancashire Care NHS Foundation
Trust and Police talking about the organisations commitment to E & D and its importance in terms of ensuring that high quality services are provided to all. Evidence against the EDS
Goals from across services was presented and the attendees had to vote on whether the organisations were developing, achieving or excellent at addressing Equality Act Protected
Characteristics (the nine Protected Characteristics are Age, Disability, Sex, Race, Gender
Identity, Pregnancy and Maternity, Marriage and Civil Partnership, Sexual Orientation,
Religion and Belief)
The evidence presented was in the form of service user and staff stories, case studies and data collection improvements. The event was very well evaluated by participants and a scan of the 53 NHS Trusts in the North West that are involved in the EDS showed that Lancashire
Care NHS Foundation Trust came out in fourth place in terms of the numbe r of ‘developing’ an d ‘achieving’ scores given. No Trusts as yet are demonstrating ‘excellent’. During 2013
Lancashire Care NHS Foundation Trust will carry out internal scrutiny as well as external scrutiny. This will support the delivery of the Transformation and Equality Statement of
Intent, the Quality Strategy and the Health and Wellbeing Agenda as well as supporting embedding of Lancashire Care NHS Foundation Trust Values across services.
‘Opportunity Knocks’ attendees
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Engagement Team
The use of Member Panel Surveys and Events to Improve Patient Involvement and
Experience
Lancashire Care NHS Foundation Trust is committed to hearing the thoughts and experiences of the people we provide services for. One of the methods for collating this feedback is the use of panel surveys, created around a particular topic, and targeted events for particular audiences.
Regular engagement with members has allowed Lancashire Care NHS Foundation Trust to open up conversations that would have otherwise have taken place internally and has given members clear opportunities to influence Lancashire Care NHS Foundation Trust ’s decision making. For example a membership panel survey on innovation and a membership conference on the same theme allowed members to influence Lancashire Care NHS
Foundation Trust ’s decisions about innovation. At the time of the conference, Lancashire
Care NHS Foundation Trust was considering proposals for innovative projects. Members discussed the proposals with Trust staff at the conference and voted for those proposals that they thought would deliver greatest benefit for patients. The voting results were shared with a panel that had been set up to make decisions about which proposals to back with resources. The process of member involvement culminated in member participation in a
‘Dragon’s Den’ exercise which scrutinised the innovation proposals in detail before making a decision about which proposals became real projects. By engaging members about innovation, Lancashire Care NHS Foundation Trust can be more confident that its decisions took account of the views of the people who the innovative ideas were intended to benefit.
Example membership panel survey
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Safety
This section of the document shows the measures Lancashire Care NHS Foundation Trust is taking to reduce harm to patients and staff.
Quality Priority 3 Target Progress
Compliance with harm free care national priority:
Reduction in the number of pressure ulcers developed in our care
Reduction in the number of falls
Reduction in the number of catheter acquired infections
Reduction in the number of Venous
Thromboembolism (VTE)
Monthly submissions to
Health and Social Care
Information Centre across all eligible services
Rolling programme of implementation across
Lancashire Care NHS
Foundation Trust, 2012-13
CQUIN target achieved.
The table below demonstrates the monthly increase in patients surveyed across Lancashire
Care NHS Foundation Trust and the % of patients who are measured as harm free.
Month
Apr
12
May
12
Jun
12
Jul
12
Aug
12
Sep
12
Oct
12
Nov
12
Dec
12
Jan
13
Feb
13
Mar
13
Number of teams submitting survey
1 1 1 1 1 7 14 24 37 43 45 44
Number of patients surveyed
% Harm
Free Care
12 9 11 12 11 153 425 726 775 962 988 951
92% 100% 91% 83% 91% 92% 91% 90% 90% 91% 91% 91%
Source: NHS Safety Thermometer Data is governed by Standard National Definitions
The Harm Free Care
5
initiative focuses on thinking about complications for patients aiming as far as is possible for the absence of all four harms for each and every patient. The initiative supports best practice and quality improvement.
We have a training programme in place which reinforces this approach with an associated collection of information to build a picture to evidence quality and identify areas for further improvement.
5 http://harmfreecare.org/
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Fluctuations in the data reflect the gradual roll-out of the data collection across Lancashire
Care NHS Foundation Trust in line with Commissioning requirements for 2012/13. During
April to September 2013 baseline data will be established which will be used to identify improvement targets.
Reporting of Incidents
The chart below shows the overall Trust position for severity of patient safety incidents in
2012-13 followed by the breakdown by network. The definitions of categories are explained below the chart.
Severity of Patient Safety Incidents for 2012-13
12000
10000
8000
6000
4000
2000
0
9763
110
2007
672
67 79 40
5037
588 122 13 52 55
3967
1078
511 46 12 13 752 341 39 7 14 2 7 1 1
Trust Position Adult Mental Health Adult Community and Specialised
Services
Children & Families Corporate
Services
Definitions of Severity:
None - no injury or adverse/outcome. No treatment/intervention required
Low - short term injury/first aid given
Moderate - semi-permanent injury/damage. Moderate increase in treatment. Medical treatment required e.g. x-ray/broken bones
Severe - permanent injury. Loss of body part. Mis-diagnosis, poor progress. Injury to individual not life threatening but actually jeopardise the wellbeing of the patient.
Catastrophic - death or serious harm that may place individuals life in jeopardy i.e. suicide or homicide
It has not been possible to compare incident data with 2-011/12 data as prior to merger of the datix systems former organisations used different incident reporting categories. The new
Trust policy for incident reporting addresses this by providing clear definitions and categories of incidents. This will help to enable more consistent reporting and provide comparable data cross all parts of the organisation.
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Top 5 Reported Patient Safety Incidents
The top 5 reported patient safety incidents are shown in the table below:
Network Category Total
Adult Mental Health Health records (errors) 1128
% of 2012-13
Total
(12698)
9%
Adult Mental Health
Specialist Services
Adult Community
Self-harm
Self-harm
Medication incident
1028
603
597
8%
5%
5%
Adult Community Slips/trips/falls 582 5%
LCFT Internal Reporting System: Datix
Although data is not directly comparable due to the upgrading and merger of the former organisation systems, the indicative themes from the former systems reflect the current top 5 reported patient safety incidents.
Incidents are collated and reported on a quarterly basis through network governance structures. In addition, thematic reviews are completed throughout the year to ensure that risk of re-occurrences are reduced, lessons are learned, we improve the quality of services provided and demonstrate a caring environment.
Reporting of Serious Incidents
Serious Incidents describe incidents which relate to NHS services or care provided. These can include: serious harm or unexpected death of patients, staff, visitors or members of the public; situations which prevent the organisations ability to deliver a service; allegations of abuse; adverse media coverage or public concern. All Serious Incidents are subject to a post incident review investigation, this includes recommendations and action plans.
Reporting of Serious Incidents
100%
80%
60%
40%
20%
0%
81%
87%
88% 92%
% completed in 48 hrs
2011/12 2012/13
% completed in 45 Days
Target (90%)
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The data shows an increase of 6% in reporting serious incidents within 48 hours which is 3% under the target. There was an increase of 4% in reports completed within 45 days and this is now 2% over the target. A programme of work is on-going to support these targets, which is described below. The Datix incident reporting system has been upgraded and integrated into one system, to reflect the new structure of information for the organisation.
The Risk Team have led a review of the 3 policy and procedure documents covering incident reporting (including serious incidents and near misses), management and investigation process. There has also been a rapid improvement event including representation from all networks. The new revised and updated policy and associated guidance has been approved and is in the process of being implemented. A pilot of the post incident review process is in progress in the Adult Mental Health Network. The pilot is testing a development of the role of the Datix system to follow the progress of an incident and releases administration time in the networks to support the investigation process. The role of the investigator and senior manager has also been reviewed which with improved guidance and checklists will improve the quality of the end report and reduce validation times. Information from this pilot will form part of the overall review, this will be reported on further in the 2013/14 Quality Account.
The process for reviewing serious incidents has been reviewed during 2012/13 to enable more in-depth analysis of a wider breadth of incident data. The new process of serious incident analysis significantly involves the networks, providing the opportunity to discuss the analysis of themes, trends and hotspots, and provide assurance to Board in terms of action taken in response to risks identified. The result of this activity has led to a richer discussion about the findings of serious incidents and the actions taken to address any themes, trends and hotspots.
The revised process has enabled key risks to be identified from the serious incident analysis which are monitored by the Serious Incident Advisory Group and reported 6 monthly to Trust
Board. Thematic analysis of serious incidents in particular supports this process through a cumulative approach of the analysis of post incident reviews.
The Deputy Director of Nursing chaired a monthly serious incident performance meeting with
Commissioners where thematic analysis reports were discussed and action plans monitored.
Mandatory Training
Indicator Target 2011/12 2012/13
Target
Achieved
Staff Mandatory Training
75% 74% 77%
Data source: LCFT Internal Data Source (Training Department)
The Mandatory Training Compliance target for 2012/13 was set at 75% and as at 31st March
2013 compliance against this target was 77%.
The new mandatory training policy and matrix was launched in April 2012 and improvements have been implemented throughout the year to the supporting training programme to ensure
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staff can access appropriate face to face training and e-learning modules. This programme is fully aligned to the North West Core Skills Framework and delivers the agreed outcomes which ensures that training completed can be transferred between NHS organisations in order to avoid duplication.
The Mandatory Training programme for 2013/14 has been launched and includes flexibility in terms of face to face delivery and access; single sessions, pick and mix days - where a number of sessions are delivered and staff can book onto the most appropriate module, and integrated days which provide modules focused on specific clinical requirements. E-learning modules support the core skills framework and additional modules are also available to support clinical staff.
Lancashire Care NHS Foundation Trust has set a target of a minimum of 75% in April
2012/13, 80% April 2013/14 and 85% April 2014/15 for all employees to have completed mandatory training within the prescribed timescales; this is based upon NHS Litigation
Authority recommendations.
Adult Community
Intermediate Support Team - Lancaster and Fylde, Wyre and Blackpool
Community Mental Health Team - Lancaster
‘Just Checking’ System and Evaluation project
The aim of the Intermediate Support Team (IST) is to provide a rapid response specialist intermediate care function for people with complex needs related to dementia or with a significant functional mental health need. The
IST provides intensive home treatment in circumstances where hospital or residential admission may otherwise have been necessary.
‘Just Checking’ System
The Just Checking system is used by the IST and the Community Mental Health Team
(older adults) to support the assessment process in the community of people who have dementia or face other cognitive difficulties who live alone. The system comprises of wireless sensors placed in the rooms of a person ’s home and on main exit doors. The sensors are triggered as the person enters and leaves the rooms and main exit doors. The system produces a record of a person’s pattern of use in different rooms and of a person’s pattern of exit from and entrance to the home during the day and crucially during the night, when observation by health and social care professionals is not possible. The interpretation of the resulting activity chart which is made available through a password protected website over the internet, informs the assessment of a person ’s health and social care needs. Nine
Just Checking systems are in use for the teams.
An evaluation of the impacts of the Just Checking system was undertaken with the teams involved and a survey was also undertaken to gather opinions from the health and social care professionals about the effectiveness of the Just Checking system.
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Professionals said:
There is no other way of assessing a client’s overnight activity patterns
It gives an objective assessment of what reported “wandering” exists i.e. frequency and regularity, assisting with clinical reasoning and risk assessment
Outcome:
Professionals have a more accurate understanding of the client’s levels of functioning
Data has supported scheduling targeted visits by IST team, thus freeing up staff time to support others
Provided professionals with information unable to be retrieved from anywhere else, e.g. assessment during the night
Professionals felt that it produced better outcomes for people with dementia and their families and unpaid carers
Podiatry Service
Post-Operative Infection Rates for Nail Surgery
The podiatry service within Lancashire Care NHS Foundation Trust follows the North West
Effectiveness Group for Nail Surgery guidelines. These guide lines provide a “gold standard” for podiatrists to be able to carry out nail surgery from patient referral to after surgery advice.
An existing audit asking patients their experience of the nail surgery service was already in place, it was agreed with staff to extend this form to include infection rates following nail surgery. The surgery advice letter and the audit form were given to each nail surgery patient.
The results of the audit are shown below:
Podiatry Service
Post-Operative Infection Rates for Nail Surgery
Number of procedures taken place in quarter
Post-surgical infection noted
July to End of September 2012
223 0
October to End of December 2012
274 1
TOTAL
497 1
Outcome: Over a 6 month period there was only one infection after surgery reported. This patient had a history of infection and required antibiotics before they had the surgery, it was not clear from the audit form if the infection was present before or after the surgery.
This information has been provided to Commissioners and monitored. As post-operative infection rates are so low this is no longer a key measure for Commissioners, the Podiatry service will continue to collect this information to make sure that we keep up these excellent results.
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Specialist Services
Blackpool Substance Misuse Service
Substance Misuse Service Prescribing Protocol
The Substance Misuse Specialist Prescribing Service (SMS) provides treatment and support for those who are dependent on drugs and alcohol. Patient safety is a major issue within
Substance Misuse Services, not only because heroin use is high risk behaviour but also because the medications we prescribe, often in large amounts, have the potential to harm the service user and/or others if they are not used and stored safely.
Given the issues mentioned above, we need to be sure that we are practising as safely as possible. Our approach to prescribing drugs such as methadone and buprenorphine is very structured and underpinned by a number of safety processes designed to minimise the risk to service users and others. We have a specifically written SMS Prescribing Protocol that supplements the overarching Trust Policy and Procedure of All Aspects of Medication which directs staff’s actions to maintain patient safety.
The fundamentals of safe and effective prescribing of substitute narcotics are:
Establish actual dependency and patterns of use/drug(s) used – by use of comprehensive assessment and urine testing for common street drugs
Provide education on the risks and benefits of substitute prescribing
Prescribing is only part of a comprehensive recovery plan that also includes psychosocial interventions to help break the addictive pattern of behaviour
Commence substitute prescribing under a supervised consumption regime on a low dose and titrate upwards until withdrawal symptoms are controlled, but the client is not oversedated
Provide a safe storage box for medications if there are children in the household
Review the recovery plan at regular intervals and conduct random urine screening to check for compliance with the prescribed regime and for any illicit use ‘on top’ of the prescription
Supervised consumption is maintained until the client has demonstrated compliance with treatment, with no use of illicit drugs ‘on top’ of prescribed medication.
Outcome: Zero significant medication-related incidents within the Substance Misuse
Service during the past 2 years.
Langden Ward
Reduction of Violence and Aggression Rates on the Newly Reconfigured Acquired
Brain Injury ward
Langden ward is a low secure unit which offers care for adult males who have suffered a head injury and have care issues related to aggression and violence. The ward has 15 beds with nursing 24/7 and is the largest Acquired Brain Injury (ABI) ward at Guild Lodge. The ward was opened in 2010 as a generic low secure mental health ward and changed in
January 2012 to cater for those with a brain injury. Since becoming an ABI ward, aggression
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50
45
40
35
30
25
20
15
10
5
0 and violence has markedly increased, nursing intervention in a secure service should reduce this risk as a core part of the care we offer.
A project commenced in July 2012 to reduce levels of violence and aggression within the ward environment by new working arrangements, structures and changes to principles of working. The approach would have many facets and be judged by the monitoring of violent incidents, staff experience expressed in shift meetings and service user feedback in our community meetings.
The direct changes and completion:
Change of nursing shift system to fit requirements of ABI nursing - good feedback received from full staff group
Change of approach in nursing shift meetings to an ‘appreciative inquiry’ format/model
(see
Staff Development and Quality ) - good feedback regarding the new positive
approach and ‘being your own solution’ focus
Full use of new ‘ABI aggression management plans’ - all service users had plan completed, the focus is on a consistent approach to events and how we avoid triggers to such violence
Development of a new generic ABI assault cycle model
– the model has been designed and discussed within the ward and with the wider Violence Reduction Team. As this is a new unique piece of work, discussions are now taking place with a view to publishing and sharing practice
The chart below shows the reported violence and aggression incidents during 2012:
Violence and Aggression Incidents Jan - Dec 2012
Outcome: Reported violence and aggression rates have reduced and are now at low levels.
The chart above shows the reduction in violence and aggression rates in 2012:
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Adult Mental Health
Bowland Unit – Parkwood
To Improve the Patient Experience on the Psychiatric Intensive Care Unit and Promote
Recovery in a Safe Environment
Bowland Unit is a 6 bedded psychiatric intensive care unit
(PICU) which accepts males aged 18-65 years detained under the Mental Health Act; the unit has a ratio of
Bowland Unit Staff
5 staff to 6 patients.
Our aim is always to nurse the patient in the least restrictive environment. Our patients often do not believe they are unwell and have little insight; therefore they may not want to be with us, this can add extra challenges for the team in building therapeutic relationships.
We wanted to excel in the care we provide our patients and sometimes push the boundaries to make calculated risks for positive outcomes, and following our successes, share our learning with others. We engaged with patients and staff individually and in groups.
Issues raised were; the lack of activities on the ward, the décor, poor quality furniture, the need for more cigarette/fresh air breaks, the need for patient’s privacy whilst maintaining safety, and the number of violent assaults taking place on the staff and patients.
Following consultation with patients and subsequent budget allocation, the ward has been completely refurbished making it much more therapeutic and inviting, with all furniture PICU standard. There is a dedicated Occupational Therapist based on the ward that assesses patients following admission, plans a programme of activities and initiatives solely related to those patient s’ needs and aspirations. We have a local artist who is visiting the ward weekly to paint inspirational pictures on the unit walls. We also have a chalk board painted on the wall that patients and staff can draw on.
When reviewing the violence and aggression statistics, there was a sharp increase at weekends, and following feedback in the patient working groups, patients said they were bored. We have put in place; Sky TV, film nights, takeaway nights, breakfast clubs, walking groups, shopping trips, zoo trips, use of gym and a variety of other therapeutic activities, all following a risk assessment.
We are currently looking at short-term courses working alongside external agencies following needs which have been identified by patients. Some of these courses can be continued after discharge.
Outcome: Violence and aggression rates have decreased; there have been 126 reports from the period December 2011 - November 2012 compared to 482 incidents in December
2010 – November 2011.
The Bowland Unit project also links to the quality domain of patient experience .
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West Lancashire Complex Care and Treatment Team
Joint Working Initiative between West Lancashire Complex Care and Treatment Team and Lancashire Fire and Rescue Service
This project is an example of some excellent work that was conducted between the West
Lancashire Complex Care and Treatment Team (CCTT) and Lancashire Fire and Rescue
Service. The project aimed to provide as many service users as possible who were under the care of the West Lancashire CCTT with a fire safety assessment.
This project commenced with staff from mental health services meeting with staff from the local fire service to plan how the initiative would work. Fire Officers then provided training to staff on fire awareness and the risks associated for service users with severe mental health problems. The CCTT then provided training to Fire and Rescue service staff on mental health problems and assessing risk.
West Lancashire CCTT & Lancashire Fire and Rescue
Service
From this Care Coordinators arranged for a Fire Officer to meet with the service user on a ‘joint visit’ and recorded this on the service users electronic care record. The
Fire and Rescue Service gave service users advice around fire safety, installed smoke alarms, provided fire retardant bedding, replaced chip pans with deep fat fryers, etc.
This initiative has been very well received by service users, carers and staff. The CCTT and local Fire Officers have excellent working relationships and hope this initiative will help avoid any preventable serious incidents in service user’s homes
Children and Families
North Complex Needs Nursing and Therapies team
Multi-agency Transition Pathway Pilot
The transition pathway is a coordination of services in the Greater Preston area to ensure the seamless transition of care of young people moving to adult services. The aim of this pathway is to facilitate consistent best practice across Children and Families services.
The project was undertaken due to the lack of coordination of services in this area for families which resulted in poor patient experience and care handover when the young person moved into adult services. It was identified as a need by service user feedback and underpinned by national guidance.
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The pathway addresses the risk of future harm for a young person moving from paediatric to adult services by ensuring the collation of information on the young person’s on going need for care and how that should be delivered. It ensures that referrals to relevant services are made and handovers are completed. It allows services to look at safe discharge and ensure self-management systems are in place if no on-going service is required.
The transition pathway has provided a process in which to address transition issues. The identification of a lead professional means there is one point of contact for the family at this anxious time, improving their experience of the process.
One family reported:
Having all professionals all together to answer questions that needed answering was really helpful
Professionals involved with the pathway have reported that it has improved team working and had a positive effect on how parents have viewed the transition from paediatric services:
With support from a team that has known the young adult/family some fears can be alleviated. Providing information of how to access services also empowers them to manage the change.
The improved information sharing has assisted the promotion of self-help and management as part of a review and coordinated plan of future need.
The transition pathway also links to the quality domains of effectiveness and patient experience .
Freedom Team
Tackling Sexual Exploitation in East Lancashire
There has been significant improvement in services and outcomes for the children who are victims of Child Sexual
Exploitation (CSE) as a result of multiagency working. By utilising the skills of the different organisations the team provides real changes to the lives of
Freedom Team children, by offering support. Any child can be at risk of sexual exploitation and
Freedom works with children of both genders, from all social classes and ethnic groups. There are 3 main aims: prevention, protection and prosecution.
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It is essential that anyone working with children and young people has an understanding of
CSE and is able to identify young people who are at risk of abuse. The team has targeted specific professional groups to raise awareness and has created leaflets for professionals and parents.
Staff from the team have worked closely with a victim of CSE to produce a DVD ‘Rosie’s
Story’’. Rosie was a victim of CSE at the age of 14 and was helped to exit from her abuse by staff from key agencies and received support from every agency within the Freedom Team.
Her mother addressed a police conference in June 2011 and spoke of the support that she received. She also spoke to the local media and was on national TV, the DVD was also shown on national TV.
Team Achievements:
The team won the MJ Award in 2011 for ‘Best Achievement in Children’s Services’.
Twelve national teams were shortlisted for the award for the ‘Best Achievement in
Children’s Services’. The winning team had to have linked successfully with different services and partners in innovative and constructive ways and created forward thinking services for children, young people and their families.
Lancashire Care NHS Foundation Trust Staff Awards
– ‘Team of the Year Award’-
2012
Lancashire Care NHS Foundation Trust Staff Awards 2012 – Highly Commended for
Kath Thompson Award for safeguarding
The Freedom Team work also links to the quality domains of effectiveness and patient experience .
Corporate Services
Infection Prevention and Control Team
Utilising leadership to embed Infection Prevention and Control within services
The Infection Prevention and
Control (IPC) team provide advice, support, leadership and guidance to all networks/services across
Lancashire Care NHS Foundation
Trust in relation to clinical practice and the environment i.e. clean and fit for purpose. This is also provided to service users and carers as required. The team also work collaboratively across the health economy locally, regionally and nationally.
IPC Engagement Event
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The key activities are audit, education and training, surveillance, policy/procedure production and supporting estates in relation to new builds/refurbishments. Excellent care for patients and supporting staff is at the core of everything the IPC team do.
The team have worked hard during 2012 to enhance the team’s performance through engagement and teamwork, and to roll this culture change out to the services to embed infection pr evention and control as part of their ‘routine’ practice to improve quality and safety. Put simply ‘how to embed infection prevention and control into people’s minds so that it becomes part and parcel of every day practice ’. Why do we want to do this? Because patient safety and the quality of service in relation to clinical care (reducing the potential risk of infection) and ensuring that the environment in which care is provided is clean and well maintained is our core aim.
Outcome:
The Essential Steps Clinical Practice Audit Programme is completed quarterly. In
January – June 2011 the number of staff audited against hand hygiene was under
1,000; following training from the IPC team and commitment from senior Managers for
April – June 2012 the number of staff audited increased to 2,100 .
Community services have achieved a level of zero community associated Methicillin
Resistant Staphylococcus Aureus (MRSA) & Methicillin Susceptible Staphylococcus
Aureus (MSSA) Bacteraemia and Clostridium Difficile associated infections since joining Lancashire Care NHS Foundation Trust which is an excellent achievement as national evidence demonstrates a decline in hospital-acquired infections and an increase in community-acquired infections.
Quality and Governance Directorate
Reducing Violence and Aggression
Lancashire Care NHS Foundation Trust includes violent incidents against patients and staff as an important indicator and this data is reported on a regular basis to the Trust Board.
In Adult Mental Health services a network had been developed, to work closely with wards to look at ways of reducing incidents. The leads from this network input into care plans and give specific advice on management issues, and techniques for specific issues. The advice is underpinned by a comprehensive and well researched risk assessment process, supported by formulation and care planning. There is a general culture of keeping wards as peaceful as possible by controlling unnecessary noise and offering respite for patients affected by, or responding to, excessive stimulation.
A number of pieces of work have been initiated to support the work around the management of violence and aggression:
The Accident Incident Rate (AIR) is now used to report violence and aggression (see following graph). Moving forward the AIR will be used as part of the ward information boards and reported to the executive performance meeting where necessary, thus providing a direct line of sight to identify if the level of violence and aggression is trending up or down and where the increases are occurring.
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20
15
10
5
0
35
30
25
Accident Incident Rates (AIR*) for all Inpatient Wards for all
Incident Type
Trust Q1 Position
27.3
29.8
33.1
27.1 27.5
26.3
29.5
28.1
23.8
21.9
25.5
21.6
Data Source: Internal Data System Datix *AIR = number of incidents/occupied bed days x 1000
A programme of work is underway on four wards supported by Advancing Quality Alliance
(AQuA) to identify strategies to reduce violence and aggression. This work is due to be completed and reported back in July 2013.
The environment impacts on the service user experience. This includes available living space, personal space, access to outside facilities, access to extra care areas, access to quiet areas and seclusion facilities. Overcrowding was identified as a potential trigger on the dementia units and there has been a reduction in total number of beds on units.
The reduction in inpatient beds has had a noticeable effect on the acuity of the service users being admitted. Inpatient care is now reserved for those service users who are acutely unwell and present a significant risk to themselves or to others. This is recognised in the general increase across Lancashire Care NHS Foundation Trust of violent and aggressive incidents reported. Spikes in incidents, when investigated are often associated with a small number of individual service users.
The implementation of the Quality Strategy will support service line reporting of violence and aggression and the use of risk registers will identify robust controls and assurances to manage, reduce and prevent violence and aggression at ward level.
The revised Serious Incident report includes both qualitative and quantitative analysis of violent incidents and action taken by networks to address issues arising from the report.
There is some correlation with units reporting high incidents of violence and aggression and also high levels of bank and agency use. Work is taking place to reduce the use of bank and agency staff and this is being led by Human Resources and the Quality and Governance
Directorate.
Where violence and aggression trends are showing significant increases service reviews are undertaken to address any underlying issues.
The current training curriculum for inpatient services has been reviewed and the curriculum is being enhanced to ensure key policies are included and there is greater focus on conflict resolution, violence reduction and prevention strategies in addition to the robust element of control and restraint .
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Awards
Adult Mental Health
Central and West Lancashire Community Restart Team
Central Lancashire’s Got Talent Provider Award 2013
Community Restart was established to support service users who are or could be at risk of becoming socially excluded. The model of delivery strives to replace traditional day services by providing robust community support from specialist support time and recovery workers.
The team endeavours to engage service users who experience both common and severe mental health problems, and interventions are based on aspirations. Service users come from diverse backgrounds and are often hidden members of society. The methodology and ethos of interventions are delivered from an anti-discriminatory and anti-oppressive perspective which facilitates social inclusion wherever possible.
The team encompasses a variety of domains which include: volunteering, arts and culture, family and neighbourhood, equality and diversity, education, health and wellbeing.
Additionally the service also support groups and helps these to become autonomous, this has led to groups establishing a number service user enterprises. It is our goal to enable independence through social inclusion.
In March 2013 Central and
West Lancashire Community
Restart staff received the
Central Lancashire’s Got
Talent Provider Highly
Commended award for
'partnership working'. There were over one hundred nominations made in all categories with eighteen short listed for nine awards.
Children and Families
Early Intervention Service (EIS)
Lancashire Care NHS Foundation Trust’s Early Intervention Service (EIS) is one of only two in the country to be selected by the Department of Health as a demonstration site for
Increasing Access to Psychological Therapies in Severe Mental Illness (IAPT SMI).
The project aims to improve mental health services for people with psychosis and will help the Trust to share information and best practice with other health organisations about how it
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organises and delivers psychological therapies to its service users.
The Lancashire Care Early Intervention Service (EIS) specialises in working with individuals aged 14 to 35 at risk of, or currently experiencing, first episode psychosis. The EIS delivers specialist interventions through a modular programme, which will provide new opportunities for clients and their carers, and promote optimism through to recovery.
The Trust’s EIS psychological therapies team has developed an innovative ‘tiered’ approach to the provision of psychosocial interventions (PSI), training all staff in PSI to ensure that service users receive psychosocially informed care throughout their involvement with the
Lancashire EIS. The tiered approach also allows the service to match the nature and degree of PSI care provided to the level of need of the service user and family. The EIS is also currently involved in other pioneering work including the ReaCh programme which aims to develop expertise in routine enquiry about childhood adversity, with a view to improving outcomes for service users.
The wider IAPT SMI programme, aims to improve access to a range of National Institute for
Health and Care Excellence (NICE) recommended psychological therapies for those with psychosis, bipolar disorder and personality disorders. The ultimate long-term ambition of the programme is to ensure that everyone with psychosis, bipolar or personality disorders who could benefit from evidence-based psychological therapies has access to these interventions. Lancashire Care NHS Foundation Trust was also awarded funding earlier this ye ar to transform children’s and adolescence mental health access to psychosocial services and is one of the few sites nationally to offer Increasing access to Psychological Therapies across its range of mental health services.
Accredited Services
Network Service Accreditation Status
Adult
Community
Memory Assessment Service: Lancaster,
Fylde and Wyre, Blackpool.
Memory Service
National Accreditation
Programme (MSNAP)
Adult Mental
Health
Electroconvulsive Therapy (ECT) Service:
Parkwood Hospital, Royal Blackburn
Hospital and Royal Preston Hospital.
The Electroconvulsive
Therapy Accreditation
Service (ECTAS)
Children and
Families
Child and Adolescent Mental Health
Services (CAMHS) –The Junction
Children and
Families
Child and Adolescent Mental Health
Services (CAMHS) –The Platform
Quality Network for
Inpatient CAMHS
(QNIC) Accreditation
Quality Network for
Inpatient CAMHS
(QNIC) Accreditation
Excellent
Excellent
Accredited
Accredited
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Staff Development and Quality
Lancashire Care NHS Foundation Trust recognises the relationship between positive staff experience and positive patient experience. Lancashire Care NHS Foundation Trust works to improve staff experience through:
Supporting staff including workforce planning
Leadership including the Appreciative Leadership Programme
Staff engagement including the staff survey
Health and wellbeing including the strategy
Lancashire Care NHS Foundation Trust has launched an ambitious transformation programme ‘Engaging for Excellence’ to revolutionise the way that care and treatment is delivered to people in Lancashire. Providing joined up care and supporting the health and wellbeing of our local communities sits at the heart of that journey.
We have to plan ahead to make sure we are able to hold our own in an increasingly competitive marketplace. We also want to ensure that services meet the needs of
Lancashire as a whole but at the same time remain responsive to local need. We describe this as ‘Lancashire and local’.
Lancashire Care NHS Foundation Trust continues to work hard to successfully embed the
NHS Constitution and the Trust ’s own values to ensure delivery of high quality care:
Teamwork
Compassion
Integrity
Respect
Excellence
Accountability
These values are the foundation stones for everything Lancashire Care NHS Foundation
Trust does and the behaviours of each and every member of staff. This has enabled
Lancashire Care NHS Foundation Trust to develop an engaging, supportive and performance focused culture.
Workforce Planning
Lancashire Care NHS Foundation Trust recognises that its capacity and capability to plan its current and future workforce is pivotal to success. Services within Lancashire Care NHS
Foundation Trust must look forward, as well as dealing with the here and now, managing demand and providing care in efficient and effective ways to ensure patients receive the right service in the right place at the right time. Embedding a culture of workforce planning across the organisation, as well as the appropriate workforce planning skills and competence, is a key priority for Lancashire Care NHS Foundation Trust.
Lancashire Care NHS Foundation Trust has adopted the Skills for Health Six Step approach as its integrated workforce planning model of choice. An in-house workforce planning
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training course is available to up-skill our managers and our Workforce Business Partners are positioned to proactively support local planning. To ensure that these service level planning outputs drive strategic planning Lancashire Care NHS Foundation Trust conducts an annual business planning round. Our networks produce integrated business, financial and workforce plans looking forward to the next 3 to 5 years. These plans are then used to inform corporate strategy developme nt and resource planning. This ‘bottom up’ planning infrastructure ensures that the services provided by Lancashire Care NHS Foundation Trust meet the needs of the population we serve and that patients sit at the centre of everything we do.
Leadership Development
The Appreciative Leadership Programme continues to be rolled out across the organisation to underpin the organisation’s culture change programme. The programme has engaged leaders in using the core strategies of appreciative leadership e.g. appreciative inquiry, powerful conversations, the Trust values and a strengths based approach. Groups of leaders reported positive energy and excitement when they led appreciatively, whilst demonstrating the main characteristics of appreciative leadership. A Sustainability Steering
Group has been established to ensure that Appreciative Leadership is embedded in every day practice through personal development reviews, on-going learning and evaluation, learning sets, mentoring, and role modelling appreciative leadership behaviours.
By 31 st
March 2013, 796 staff from across the organisation will have attended a series of workshops, leadership learning sets, world café events and have completed an appreciative inquiry based action research project. Forty leaders have been developed as internal facilitators to support the leadership learning sets.
Leadership and Management Development modules
Good leadership at the level of every team is fundamental to the organisation’s effectiveness. It is important that leaders are at the forefront of openly and actively ‘living’
Lancashire Care NHS Foundation Trust values and being focused on health improvement for the people of Lancashire. A Leadership and Management Development Framework has been developed which includes a comprehensive programme of development for all levels of staff across the organisation.
Aligned to our strategic objectives, the framework provides wide ranging development opportunities based on individual need. The framework consists of various development pathways. This sustained approach to leadership opportunities, with embedded processes at all levels, demonstrates the organisation’s commitment to developing all staff across
Lancashire Care NHS Foundation Trust.
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Staff Engagement
Lancashire Care NHS Foundation Trust continues to recognise the value of the staff survey data in helping to better understand where to focus resources in improving the working lives of staff. The latest survey results published in February 2013, showed an improvement in the overall staff engagement score from 3.71 to 3.79 which compares favourably to the 2012 national average for Mental Health/Learning Disability Trusts of 3.70 and places Lancashire Care NHS Foundation Trust in the top 20% of Mental
Health/Learning Disabilities Trusts nationally for staff engagement. The survey results show that areas where staff experiences have most improved since 2011 are; percentage of staff being appraised in the last 12 months, percentage of staff witnessing potentially harmful errors, incidents or near misses in the past month, staff job satisfaction, percentage of staff having well-structured appraisals in the last 12 months and percentage of staff having
Equality and Diversity Training in the last 12 months. When these most improved areas are compared to performance across all Mental Health/Learning Disabilities Trusts Lancashire
Care NHS Foundation Trust is above average/in the top 20% for four of the five areas listed.
The key areas for action related to our bottom ranking scores are: % staff receiving health and safety training in the last 12 months, and % of staff reporting errors, near misses or incidents witnessed in the last month.
A detailed action plan will be put in place across the organisation to address these areas, working towards improvements for the next staff survey.
Health and Wellbeing
Lancashire Care NHS Foundation Trust recognises that the health and wellbeing of its employees is vital to drive the delivery of business plans and associated improvements in patient care. Lancashire Care NHS Foundation Trust is now a Mindful Employer and has a
Health and Wellbeing Strategy in place to ensure that wellbeing is at the heart of the employment experience for all staff.
The strategy is underpinned by key strategic documents and supports existing policy documents embedded in the organisation. The five high impact changes, together with six core services outlined in the ‘Healthy Staff, Better Care for Patients’ (2001, Department of
Health) document and the recommendations of the Boorman Review (2009, Department of
Health), have been developed into a strategic framework focusing on prevention, intervention and promotion.
The implementation of the framework and delivery of the strategy is underpinned by a three year action plan. This year will see further developments in embedding health and wellbeing as Lancashire Care NHS Foundation Trust has made a commitment to the Workplace
Wellbeing Charter which is a government initiative to protect and improve the health and wellbeing of working age people. It promotes the positive links between health and work and provides a framework to demonstrate wellbeing standards which will support improving wellbeing throughout Lancashire Care NHS Foundation Trust demonstrating our commitment to the health and wellbeing of our workforce.
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Annex: Statements from Healthwatch, Overview and
Scrutiny Committees and Clinical Commissioning Groups
Healthwatch (Lancashire)
As you will be aware, Lancashire LINk ceased operations on 31st March 2013. Many of its functions, including responsibility for commenting on health trust’s quality accounts, have been transferred to Healthwatch Lancashire.
Healthwatch Lancashire is a very new organisation which is in the process of setting up its structures, including a new board, and is not in a position to undertake any major pieces of work in the immediate future. Therefore it has been decided that this year Healthwatch
Lancashire will not comment on quality accounts. We will, of course, by next year be fully operational and able to take part in this important work.
Gail Stanley
Chairman
Overview and Scrutiny Committees
Blackburn with Darwen Borough Council
Each year we receive many requests from a plethora of organisations and outside bodies to comment on their annual reports or accounts for the preceding year.
We have for several years now taken the approach of not providing comment unless the organisations role has been fundamental to the Committees work programme. Whilst we accept there has been some very positive engagement this year through the dementia consultation, that has been a joint venture with colleagues at Lancashire County Council and
Blackpool. We are however not in a position to comment wider on the work of Lancashire
Care NHS Foundation Trust at this time.
In order to assist future requests, we note the request to comment has come in April. Please be aware that all of our Overview and Scrutiny Committees have already ended for the municipal year. Any requests next year from organisations taking an active and fundamental role in the work programmes we choose will be requested to submit their requests in
January in order for the Chair of the relevant Committee to consider as part of the remainder of the Committee cycle.
Ben Aspinall
Scrutiny Manager
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Blackpool Council
The Health Scrutiny Committee will be unable to comment on this year's Quality Account due to time constraints.
Steve Sienkiewicz
Scrutiny Manager
Lancashire County Council
The Lancashire Health Scrutiny Committee has made a commitment to ensure that members are aware of, and take a keen interest in the facilities, services and performance of the Trust. To maintain this they will continue to have an overview of the design and development of quality services provided to the residents of Lancashire. In addition a priority of the Committee is to reassure the public that an honest and transparent relationship is developed with the Trust to enable effective scrutiny to take place.
Wendy Broadley
Principal Overview & Scrutiny Officer
Clinical Commissioning Group
This statement represents feedback from Blackburn with Darwen CCG as Lead
Commissioner together with from CCG co-commissioners and we welcome the opportunity to appraise the content of the Quality Account for 2012-2013 and are pleased to acknowledge that there is a real focus on the key quality elements and Lancashire Care
NHS Foundation Trust has clearly referenced its organisational objectives, focusing on the three key dimensions of quality as outlined within ‘High Quality Care For All’ (DH, 2008):
Safe Care
Effective care
Patient Experience
Building on its position as a mature mental health provider, the 2012/13 Quality Account describes the strategic quality improvements implemented across the whole organisation, following the transfer and inclusion of additional community and learning disabilities services from former PCTs. A coherent organisational strategy and consistency of approach is a positive improvement.
The case examples help illustrate service-specific quality improvement initiatives which have been carried out and hence the report is well laid out and is easy to read. For a provider delivering a wide range of services over a large geographical area, the report is reasonably well-balanced, although greater focus on the community services including community nurses and matrons may be relevant in future Quality Accounts.
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Patient Safety
Introduction of the SEEL model which is centred on the domains of Safety, Effectiveness,
Experience and Leadership (SEEL) is commended however CCGs would like to see more detail on how the department-level SEEL will be escalated and relate to the Board
Assurance Framework i.e. how will LCFT avoid a Mid-Staffs at Board level? In addition it would be good practice to correlate CQC data and reviews against SEEL self-assessments to provide a marker for how robust the SEEL process is.
The organisation deals with some high risk patients and as such, the generic safety section of the report should be more robust, demonstrating a depth of understanding of the risks, the controls, their effectiveness and positive evidence of improvements in safety, although the individual service examples are very positive. The CCGs are pleased to note the work undertaken in 2012/13 to develop a single Datix system to replace the four transferred into
Lancashire Care NHS Foundation Trust from the previous organisations and the reduction in risk as a result of amalgamating data capture into one system. However, the report could indicate whether the top 5 reported patient incidents in 12/13 are broadly in line with similar former organisations’ trends. Some examples of how the in-year thematic reviews have identified appropriate safety improvements would add assurance.
Data shows an increase of 6% in reporting serious untoward incidents within 48 hours however this is still 3% under the target and we trust Lancashire Care NHS Foundation Trust will continue to work towards achieving reporting within target. Whilst, it is our understanding that LCFT overall are exceptionally good reporters compared to other mental health trusts – with lower levels of harm, CCGs would like to see mention of the 79 catastrophic incidents and associated actions together with a benchmarking against other Mental Health Trusts.
Clinical Effectiveness
Lancashire Care NHS Foundation Trust participated in 75% national clinical audits and
100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in. Whilst this is a clear indication of an organisation with a commitment to delivery of evidence based and safe care, CCGs would like to see participation in eligible clinical audits to increase to 100% for 2013/14. In addition
CCGs would like to see the percentage of clinical audits that have been developed collaboratively between provider, commissioner and service users referenced explicitly.
Research appears to be well supported at Lancashire Care NHS Foundation Trust and
CCGs confirm that a research active provider demonstrates a strong commitment to clinical effectiveness in support of improving the quality of care delivered but we would like to see a reference and commitment to working with the newly formed Academic Health Research
Networks.
Patient Experience
Patient Experience and feedback shows some areas for improvement and CCGs are pleased to note robust action plans to address areas that are below the national average.
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General content
CCGs note that Lancashire Care NHS Foundation Trust has scored green against the requirements of the Information Governance Toolkit with no serious breaches in data security and as such patients and the public can be assured that data held is stored, used and transferred securely and confidentially.
Although Lancashire Care NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2012/13 by the Audit Commission, CCGs would like to see local assessment of clinical coding particularly when validity of coding supports clinical care, treatment and outcomes and is directly linked to payment and costs. It was noted that
Lancashire Care NHS Foundation Trust has scored green against the mandatory quality indicators but would like to see an increase in the % improvement for patients moving to recovery following a course of IAPT.
It would be helpful if links were made between statements for example, did the ward self assessment against the CQC Essential Standards correlate with the users concerns about the cleanliness of wards and the CQC mild concerns? Statements about improvements in processes need to be directly linked to evidence of the potential or actual impact for patients.
Whilst the CCGs note the work undertaken with regard to total number of people admitted to hospital from adult mental health complex care & treatment teams and a reduction throughout the year, CCGs would like to see reference and data regarding waiting times for community mental health services particularly counselling and access to consultants which is still considered difficult/slow.
CCGs are unable to comment on prison services referenced in the Quality Account as this service is not commissioned by CCGs.
Following the recommendations arising from the Francis review we would like to see reference to in hospital standardised mortality. Whilst Lancashire Care NHS Foundation
Trust has made reference to improving the percentage of staff who would recommend
Lancashire Care NHS Foundation Trust as a provider of care to their family or friends by
Implementing the recommendations of The Mid Staffordshire NHS Foundation Trust Public
Inquiry February 2013 (Francis 2) the CCG would like to see all areas within the services provided that correlate with the Francis 2 review and what the position is in terms of assurance or associated action plans.
Whilst the CCGs commend the wealth of data and charts referenced throughout the document, some of the tables provide only numbers, and the CCGs would like to see an indication of whether they are high / low or within the expected range together with some trend analysis and/or run charts.
In conclusion the Quality Account is well-presented and an interesting summary of the progress across and within the three areas of safety, effectiveness and patient experience.
As such it has received a positive response from Lancashire CCGs and we would like to commend the approach to including patient stories, quotes and real examples of
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implementation throughout the document. This is particularly relevant as patients and the public are the key audience for Quality Accounts.
Lancashire CCGs trust that you will find our observations in relation to your Quality Account for 2012/13 pertinent and of value and we confirm the data underpinning the measures of performance and quality reported in the Quality Report are robust and reliable. We look forward to continuing to work closely with Lancashire Care NHS Foundation Trust in the coming year and to seeing the improvements to the quality of services provided as outlined in this year’s Trust’s Quality Account. We trust Lancashire Care NHS Foundation Trust will continue to strive for excellence to successfully deliver the priorities identified for the forthcoming year. We are happy to discuss any of the above in more detail if required.
Dr Chris Clayton
Clinical Chief Officer
Amendments Made to Initial Draft Quality Account Following
Feedback from Stakeholders
Lancashire Care NHS Foundation Trust welcomes the positive feedback we have received on the format of the Quality Account this year. All comments received have been acknowledged and if it has not been possible to incorporate these into this Quality Account, they will be considered as part of the review process in 2013-14.
The amendments listed below have been made following feedback from stakeholders:
Page 8: Added results from Connecting for Health Clinical Coding Audit in February 2013.
Mandatory Indicators Effectiveness: The 28 day readmission data has been removed from the account as mental health specialty codes (700-715) are excluded in the national guidance. Comparisons with national figures are not appropriate as they show readmission rates of zero which is misleading.
Page 15-16: Patient Safety Mandatory Indicator – added statement regarding data quality:
Due to the judgemental nature of this indicator it is difficult to be certain that all incidents are identified and reported and that all incidents are classified consistently within the organisation and nationally. One individual’s view of what constitutes severe harm can differ from another’s substantially. As a Trust we work hard to ensure all our staff are aware of and comply with internal policies on incident reporting and standardisation in clinical judgements.
Page 20: Added Research and Development section.
Page 41: Top 5 Incidents – added statement regarding indicative themes from former organisation systems.
Page 42: Serious Incidents – added clarification of process for identifying themes and monitoring action plans.
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External Audit Statement
Independent Auditor’s Report to the Council of Governors of Lancashire Care NHS
Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of Lancashire Care NHS Foundation
Trust to perform an independent assurance engagement in respect of Lancashire Care NHS
Foundation Trust’s Quality Report for the year ended 31 March 2013 (the “Quality Report”) and certain performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 subject to limited assurance consist of the national priority indicators as mandated by Monitor:
Minimising delayed transfer of care ;
Admissions to inpatient services had access to crisis resolution home treatment teams.
We refer to these national priority indicators collectively as the “indicators”.
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:
the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual;
the Quality Report is not consistent in all material respects with the sources specified below; and
the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on
Quality Reports.
We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially inconsistent with the sources specified below:
Board minutes for the period April 2012 to May 2013;
Papers relating to Quality reported to the Board over the period April 2012 to May 2013;
Feedback from the Commissioners dated 15th May 2013;
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Feedback from LINks dated 26th March 2013;
The Tr ust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 28th March 2013;
The 2012 national patient survey ;
The 2012 national staff survey ;
Care Quality Commission quality and risk profiles dated February 2013; and
The Head of Internal Audit’s annual opinion over the Trust’s control environment dated
April 2013.
We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our team comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Lancashire Care NHS Foundation Trust as a body, to assist the Council of Governors in reporting Lancashire Care NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year ended
31 March 2013, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors as a body and
Lancashire Care NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and
Assurance Standards Board (
‘ISAE 3000’). Our limited assurance procedures included:
Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators.
Making enquiries of management.
Testing key management controls.
Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation.
Comparing the content requirements of the NHS Foundation Trust Annual Reporting
Manual to the categories reported in the Quality Report.
Reading the documents.
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A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual.
The scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Lancashire Care NHS
Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2013:
the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual;
the Quality Report is not consistent in all material respects with the sources specified above; and
the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all material respects in accordance with the NHS Foundation Trust
Annual Reporting Manual.
KPMG LLP, Statutory Auditor
St James Square
Manchester
M2 6DS
29th May 2013
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Statement of Directors’ Responsibilities in Respect of the
Quality Report
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put in place to support the data quality for the preparation of the Quality Report.
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;
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 May 2013;
- Papers relating to Quality reported to the Board over the period April 2012 to May
2013;
- Feedback from the commissioners dated 10/05/2013;
- Feedback from governors dated 08/04/2013;
- Feedback from local Healthwatch organisations dated 01/05/2013;
- The trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated 28/03/2013;
- The 2012 national patient survey;
- The 2012 national staff survey;
- The Head of Internal Audit’s annual opinion over the trust’s control environment dated May 2013;
- Care Quality Commission quality and risk profiles dated February 2013;
the Quality Report presents a balanced picture of the NHS foundation t rust’s performance over the period covered;
the performance information reported in the Quality Report is reliable and accurate;
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.monitornhsft.gov.uk/annualreportingmanual ) as well as the standards to support data quality for the preparation of the Quality Report (available at www.monitornhsft.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.
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By order of the Board
Chairman
29 th
June 2013
Chief Executive
29 th
June 2013
Page 67 of 70
Glossary
FCMSA
GP
HBV
HCV
HES
HIV
HMP
IAPT
IAPT SMI
Abbreviations
ABI Acquired Brain Injury
AIR
AQuA
BBV
CAMHS
Accident Incident Rate
Advancing Quality Alliance
Blood Borne Virus
Child and Adolescent Mental Health Services
CCTT
CMP
CQC
CSE
CYP IAPT
Complex Care and Treatment Teams
Clinical Management Plan
Care Quality Commission
Child Sexual Exploitation
Children & Young People Increasing Access to Psychological Therapies
Programme
ECT
ECTAS
EDS
EIS
E & D
Electroconvulsive Therapy
The Electroconvulsive Therapy Accreditation Service
Equality Delivery System
Early Intervention Service
Equality and Diversity
Fylde Coast Men’s Support Association
General Practitioner
Hepatitis B Virus
Hepatitis C Virus
Hospital Episode Statistics
Human Immunodeficiency Virus
Her Majesty’s Prison
Increasing access to Psychological Therapies
Increasing access to Psychological Therapies in Severe Mental Illness
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IPC
IST
LCFT
MBE
MSNAP
NAPT
NCISH
NICE
NMP
Infection Prevention and Control
Intermediate Support Team
Lancashire Care NHS Foundation Trust
Member of the Order of the British Empire
Memory Service National Accreditation Programme
National Audit of Psychological Therapies
National Confidential Inquiry into Suicide and Homicide
National Institute for Health and Care Excellence
Non-Medical Prescribing
NRLS
PICU
POMH
National Reporting and Learning System National
Psychiatric Intensive Care Unit
Prescribing Observatory for Mental Health
PSI
QNIC
Psychosocial Interventions
Quality Network for Inpatient CAMHS Accreditation
Quality SEEL Quality, Safety, Experience, Effectiveness and Leadership
SMS Substance Misuse Specialist Prescribing Service
SSNAP
SUS
Sentinel Stroke National Audit Programme
Secondary Uses Service
VTE
WEMWBS
Key Terms
Accreditation
Commissioners
Venous Thromboembolism
Warwick and Edinburgh Mental Well Being Scale
CQUIN
A recognised scheme of approval for services.
The people who buy or fund our services to meet the needs of patients.
CQUIN means Commissioning for Quality and Innovation. A proportion of the income we receive from commissioners depends on achieving agreed quality improvement and innovation goals.
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Datix
Domains
Harm Free Care
The scope or areas which are included within a subject area.
A national programme which measures “harms” to a patient whilst in the care of NHS services. The harms include: pressure ulcers, falls and urinary infections (in patients with a catheter).
“Huddle” Informal team meeting held around a team information board.
Health and Social Care
Information Centre
England’s national source of health and social care information.
They collect data, analyse it and convert it into useful information. This helps providers improve their services and supports academics, researchers, regulators and policy makers in their work.
Long Term Conditions
Software package used to record incidents, complaints and risks.
Quality
Quality SEEL
Risk Register
A health problem that can not be cured but can be controlled by medication or other therapies. This could be a mental health or physical health condition.
Quality is about giving people treatments that work
(effectiveness), making sure that they have a good experience of care (patient experience) and protecting them from harm
(safety).
Lancashire Care NHS Foundation Trust’s internal self assessment framework which enables leaders to review the
Essential Standards of Quality and Safety.
A document that records risk to achievement of an objective, service or project and identifies the actions in place to reduce the likelihood of the risk.
SharePoint Microsoft SharePoint is the web application used to manage the intranet site. This allows staff across the Trust to access documents and information.
Team Information Board Team information boards support conversations by teams about the quality of care delivered. Teams meet around the board regularly to review quality and performance and agree actions to deliver improvements.
The Mid Staffordshire
NHS Foundation Trust
Public Inquiry February
2013 (Francis 2)
The report of findings into the examination of the commissioning, supervisory and regulatory organisations in relation to their monitoring role at Mid Staffordshire NHS
Foundation Trust between January 2005 and March 2009.
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