Quality
account
2012/13
Changing lives for the better
Contents
Clinical quality highlights 3
About Partnerships in Care (PiC)
4
Board statement on quality 5
Section 1: Review of quality
performance 2012/2013
6
1.1 P
atient experience, Clinical effectiveness,
Patient safety
1.2 Quality objectives 2013/2014
8
1.3 Commissioning
for Quality and Innovation,
CQUINs9
CQUIN targets 2012/13
CQUIN targets 2013/14
1.4 Quality and compliance with regulation
Section 2: Patient experience
10
14
2.1 Patient Satisfaction Survey
3.4 Information Governance
31
3.5 Clinical Governance
32
i. Key components of clinical governance
ii. Audit and external quality assurance
iii. Quality Network for Forensic Mental Health
iv. Clinical innovation - objectives for 2013/14
v. Specialist networks
a. Learning Disability Specialist Network
b. Brain Injury Services Specialist Network
3.6 Payment by Results
35
3.7 Research and development
36
Section 4: Patient safety
38
4.1 Physical healthcare
4.2 Infection control
39
4.3 Medicines management
39
4.4 Positive risk management
41
i. Incidents
ii. Reporting of Incidents, Diseases and
Dangerous Occurrences Regulations
1995 (RIDDOR)
iii. Serious Untoward Incidents (SUI)s
iv. Short Term Assessment of Risk
and Treatability (START)
2.2 B
espoke Care Programme Approach (CPA)
and CPA Survey 15
2.3 Advocacy 17
2.4 M
y Shared Pathway implementation
and survey 4.5 Safeguarding 43
18
4.6 Seclusion as a last resort
44
2.5 Real Work Opportunities programme
22
4.7 Security
45
2.6 E
xtending patient care pathways
22
i. Acute services
ii. Rehabilitation services
iii. Community support
iv. Low secure services
v. New end of life care pathway
46
5.1 Our staff
2.7 My journey - a patient story 25
2.8 Complaints 25
2.9 Patient, carer, family involvement 26
Section 3: Clinical effectiveness Section 5: Supporting
our workforce
27
3.1 E
ffective management of patient
length of stay 3.2 D
elivering positive ward atmosphere
(EssenCES survey)
28
3.3 H
ealth of the Nation Outcome Scales
(HoNOS) survey
30
5.2 Staff survey
47
5.3 Learning and development 47
5.4 Clinical career development
49
How this report was developed 50
Glossary 51
“Partnerships in Care’s
quality pledge is to deliver
clinical excellence by working
together with patients, carers,
families and commissioners
in a culture of compassionate
and safe care.”
Dr Quazi Haque,
Group Medical Director
My life is so
much better
now because the
staff here really
care and have
helped me a lot
PiC Patient
We are working
together with
Partnerships in Care
teams and with
patients in our care
to achieve high
quality outcomes
Commissioner
I’ve worked with
Partnerships in
Care for the past nine
years and I’ve won a
staff excellence award
for helping patients
create a Drop In Centre.
Only it’s not about me.
It’s about the patients
My daughter
has had a
really hard time in
some care homes but
since she’s moved
here it’s the best I’ve
seen her. I can see she
has more confidence
and she tells me she
is happier
Staff member
Parent of patient
Map of our services
Yorkshire and Scotland
7 Scotland, Ayr Clinic
Low Male / Female
8 York, Stockton-on-the-Forest, Stockton Hall
Medium Male / Female
Midlands
9 Derbyshire, Chesterfield, Hazelwood House
Low Male
10 Nottinghamshire, Newark, The Willows
Inpatient rehabilitation Female
11 Nottinghamshire, Annesley, Annesley House
Low / Inpatient rehabilitation Female
12 Nottinghamshire, Arnold, Calverton Hill
Medium Male / Female
East of England
13 Hertfordshire, Royston, Kneesworth House
Acute / Medium / Low / Inpatient and community
rehabilitation Male / Female
14 Norfolk, Lombard House
Inpatient rehabilitation Male
15 Norfolk, Richmond House
Community rehabilitation Male / Female
7
North West
16 Norfolk, Diss, St John’s House
Medium / Low Male / Female
1 Lancashire, Blackburn, Kemple View
Low / Inpatient rehabilitation / Older age service Male
16 Norfolk, Diss, Burston House
Low Male
2 Manchester, Atherton, The Spinney
Acute / Medium / Low / Inpatient rehabilitation Male
16 Norfolk, The Croft
Community housing Male / Female
3 Warrington, Cheshire, Arbury Court
Medium / Low Female
16 Norfolk, Harrison Yard
Community housing Male / Female
8
16 Norfolk, Roydon Road
Community housing Male / Female
1
Wales & The West
16 Norfolk, Louies Lane
Community housing Male / Female
2
3
4 Worcestershire, Malvern Wells, Abbey House
Inpatient and community rehabilitation Male
9
11
5 Wales, Pontypool, Aderyn
Inpatient rehabilitation Male
6 Wales, Abergavenny, Llanarth Court
Medium / Low / Community rehabilitation
Male / Female
16 Norfolk, Hill House
Community housing Male / Female
10
12
14
4
5
17
13
6
19
15
16
18
21 20
22
23
17 Northampton, Grafton Regis, Grafton Manor
Community rehabilitation Male / Female
17 Northampton, Grafton Regis,
Grafton Manor - The Chantry
Community housing Male / Female
London & South East
17 Northampton, Grafton House, The Drive
Community housing Male / Female
20 Essex, Romford, Suttons Manor
Low / Older age service Male
18 Essex, Tendring, Oaktree Manor
Low / Inpatient rehabilitation Male / Female
21 London, Edmonton, North London Clinic
Medium / Low / Inpatient rehabilitation Male
19 Essex, Colchester, Elm Park
Inpatient rehabilitation Male
22 Surrey, Dorking, Pelham Woods
Inpatient and community rehabilitation Female
19 Essex, Colchester, Elm Cottage
Community rehabilitation Male / Female
23 West Sussex, Hassocks, The Dene
Acute / Medium / Low Male / Female
19 Essex, Colchester, Elm House
Community rehabilitation Male / Female
New Specialist Services
Key
Mental
Illness
2
•• Acute services
Personality
Disorder
Learning
Disability
Autistic
Spectrum
Disorder
Brain
Injury
Partnerships in Care Quality Account 2012/13
•• Stroke services
•• Respite care
•• Older adult care
•• Palliative care
Clinical quality
highlights 2012/13
100%
of CQUIN
targets
82.5%
of patients maintained
or improved in 6
months using HoNOS
Secure
89%
of patients say
they are treated
with dignity and
respect
10.4%
more
rehabilitation
and acute
beds
Strong track
record in
regulatory
compliance
New
community
rehabilitation
pathways
29.9% up
1,680
patients treated
Consistent
high scores for
positive ward
atmosphere
Partnerships in Care Quality Account 2012/13
3
Injury
ain
Br bilitation
ha
Re
Our 23 hospitals
provide services to
over 144 funding
authorities across
England, Scotland,
Northern Ireland
and Wales.
Di
Learning
D
i
sab
ilit
y
Risk reduction
Pers
ona
lity
Auti
stic Spectrum
Disorder
Medium secure
Risk identification,
management and
stabilisation
Assessment of
therapeutic need
Formulation of
therapeutic treatment
programmes
Pharmacological
management /
stabilisation
ss
lne
l Il
a
nt
er
rd
so
Partnerships in Care (PiC) offers one of the largest
independent networks of secure and step down specialist
care hospitals and facilities in the UK. We have over 27
years of caring for men and women with complex mental
health needs including mental illness, learning disability,
personality disorder, autistic spectrum disorder and acquired
brain injury, stroke and respite care. The geographical
spread of our hospitals is among the best in the UK.
M
e
About Partnerships in Care
Low secure
Continued risk management
to include positive risk
processes
Continuation and
further formulation of
therapeutic programmes
Relapse prevention
Community integration
Inpatient
rehabilitation
services
High dependency units
Community rehabilitation
units
Complex care rehabilitation
units
Focus on continued risk
management, relapse
prevention and social
integration
Open and
community
rehabilitation services
Continued risk management
and review
Increased social integration
and vocational opportunities
Safety management
Social integration
Life skills
Relapse prevention
National care pathways with Partnerships in Care
Award-winning services
INDEPENDENT
HEALTHCARE
APEX
IHA Major Secure
Provider of the Year
HSJ Awards 2012
Commendation
Laing’s
Healthcare 20
Laing & Buisson
Independent
Specialist Care
Awards 2013 Winner.
Aderyn Hospital won
for excellence in patient
care pathway
HealthInvestor
Power 50
I valued the opportunity to read Partnerships in Care’s Quality
Account prior to its publication. The document contains the kind
of in-depth and benchmarked clinical data which we require to make
sound commissioning decisions
Sarah Edwards, complex needs commissioner,
Worcestershire County Council
See page 50 for more independent points of view on this Quality Account
4
Partnerships in Care Quality Account 2012/13
Partnerships in Care Board’s
Statement on Quality
Joy Chamberlain
Group Chief Executive
Dr Quazi Haque
Group Medical Director
The Partnerships in Care Board is committed to
delivering the highest quality of patient care and
recognise this demands continuous improvement, open
communication, candour, leadership and professionalism.
Welcome to our Quality Account which details our clinical
performance over the course of the year and also provides
clear, stretching but realistic pledges about our clinical
strategy for 2013/2014.
Throughout this Quality Account I trust you will find
evidence that at Partnerships in Care, the pursuit of quality
is central to all that we do and the way that we do it.
Partnerships in Care has always held closely the
objective of providing high quality evidence-based care
in an environment that is truly patient-involving and
which fosters recovery. I hope that you will agree from
our performance this year that this primary objective
continues to be consistently achieved across all of our
service lines.
This year’s Quality Account reports on our performance,
based on four separate patient-reported surveys,
independent review by four regulatory bodies and
many clinical peer review networks. We have applied
internationally recognised performance assessment tools
to benchmark our provision of care and I am delighted to
find that we exceed national averages.
I have had the great pleasure once again this year of no
less than 24 ‘listen, share, learn and have your say’ visits to
our hospitals where patients displayed enthusiasm and
enjoyed talking to our senior management team.
We work in close partnership with the NHS,
commissioners and partners, including local authorities
and the third sector to deliver care that looks beyond our
patients’ stay in hospital to their future and their hope of
a life in the community.
We also work together with our patients, responding
to their views and ideas, listening to patients, carers
and families on a daily basis about how best they can
progress towards recovery and independence. This is at
the heart of what each of our staff do daily, regardless
of their discipline. We will strive to further enhance the
participation of frontline staff and patients.
Our ultimate test of effectiveness is patient outcomes
and patient experience. We share a journey. The following
performance indicators will help you, the reader, to
evaluate how well we do that.
Partnerships in Care is also unique in providing a
comprehensive national network of care pathways
supported by highly skilled professionals who are able
to deliver on our commitments to patients as well as
developing and implementing innovation that has a
positive and enduring influence on the industry. For this
reason, this year’s Account includes expanded sections
on learning and development as well as research and
innovation.
We have made significant advances in promoting •
patient-centred care through the introduction of a
bespoke CPA package for patients and leading on
the national implementation of My Shared Pathway.
Among our pledges this year is to provide sector leading
approaches to engaging carers, families and friends, as
well as providing increased opportunity for patients to
engage with the community as they advance through •
our care pathways.
Our clinical strategy is delivered within a framework
of robust clinical governance and reflecting NHS
requirements for specific data sets. We also present
our clinical performance alongside sector-specific
comparators which, although some are not designed for
the primary purpose of benchmarking, demonstrates our
commitment towards learning from other organisations.
I am satisfied that evidence presented in this report is
based on high quality data. I hope you enjoy reading it.
Partnerships in Care Quality Account 2012/13
5
Review of quality performance 2012/2013
Quality performance
1 Review of quality
performance 2012/2013
We pledge to continuously improve quality of care around three main priorities:
Patient experience
Clinical effectiveness
Patient safety
The tables below review our performance in 2012/13 against what we pledged in 2011/12.
Patient experience
Quality priority
Actions and achievements
Recovery
• We have fully implemented MSP according to CQUIN requirements
Champion recovery-focused
care by implementing
My Shared Pathway (MSP)
across relevant wards.
• We have published research from our MSP pilot at St John’s House, our learning
disability unit in Norfolk
• We expanded access to our patient buddy system
• We worked closely with the National Shared Pathway Service User Forum
• Patients were among finalists in the national MSP Service User-Led Awards for their
recorded song ‘No decision about me, without me’.
• Our MSP project lead was a finalist in the Nursing Standard Nurse of the Year Awards
for her work
• Our further MSP achievements are described in the paper ‘Shared Pathways in
Commissioning’ Ayub R, Callaghan I, McCann G, Haque Q. HSJ 3 June 2013.*
Social inclusion
• We introduced our Real Work Opportunities (RWO) programme across PiC
Provide and promote social
inclusion and vocational
opportunities for patients.
• One of our patients has paid employment working as a Service User Expert within
the CQC’s Experts by Experience Project
• The RWO programme is a finalist in the Laing & Buisson Independent Hospitals
Award in the Healthcare Outcomes category
• We joined with the Centre for Social Justice in holding talks within the healthcare
provision and policy sector on personalisation and improving access to mental •
health services
• We are trialling new ways, in partnership with external agencies, to help patients live
independently in the community following discharge from our services.
Ward environments
• We spent £7.3m on maintaining and improving our patient environments in 2012
Continue to improve
and invest in our ward
environments.
• We introduced new services within our wards to respond to patient and
commissioner needs
• We increased our provision of low secure, rehabilitation, and community-facing
inpatient rehabilitation services
• We introduced older age and end of life care services with purpose-designed and
fitted accommodation
• Patients have been involved in creating new ‘spaces’ in wards such as Skype rooms,
Recovery Hubs, and in their outdoor environments with new garden areas
• Patients have a say on how wards are run through patient councils and a voice to
management at regular ‘road shows’ attended by Joy Chamberlain, Dr Quazi Haque
and the senior team.
*http://m.hsj.co.uk/5058959.article
6
Partnerships in Care Quality Account 2012/13
Review of quality performance 2012/2013
Quality priority
Actions and achievements
Positive Patient Outcomes
• We introduced routine Clinical Outcome Dashboards – this provides regular and
comparable clinical outcome measures.
Establish paired clinical
outcome measures across
all service lines.
Patient-Reported Outcomes
Introduce routine use of
patients reported outcome
measures.
Care Pathways
Maximise effectiveness
of care pathways.
Quality performance
Clinical effectiveness
• We are continuously improving the range of questions in our •
Patient Satisfaction Survey
• We are preparing to introduce the Friends and Family Test
• PiC holds one of Europe’s largest patient outcomes databases.
• Our development of new services extends care pathways by creating step down
options in the community (see section 2.6)
• We developed our bespoke patient-centred Care Programme Approach (CPA)
• We fully implemented all 20 service user-defined CPA standards.
Physical healthcare
• We have strong governance processes
Enhance physical care
through high– quality
regular health checks,
screening programmes,
vaccinations and treatment.
• Infection control and allied nursing issues are well-managed through our
governance process
Patient Length of Stay
• We regularly review length of stay (LOS) data across PiC with the help of our new
operational dashboard and ward-accessible information
Continue to effectively
manage length of stay
across our services
• We have pioneered a new GP protocol at Llanarth Court Hospital and we are piloting
a virtual physical assessment at our services in Wales
• We introduced the pioneering early warning system (NEWS), which aims to reduce
the occurrence of physical healthcare problems.
• More of our patients are successfully moving through their care pathway and
stepping down in security level than in previous years
• As a result of patients stepping through their care pathways we treated 29.9% more
patients in 2012/13 than in 2011/12.
Patient safety
Quality priority
Actions and achievements
Ward safety
• We use the Essen Climate Evaluation Scale (EssenCES) to evaluate and improve •
ward atmosphere
Continue actively to
manage ward safety for
patients and staff.
• We continue to improve the sharing of lessons learned from incident data •
across all service lines
• We review complaints and act upon them using the information on our •
Clinical Dashboard
Recovery and Risk
management (RAG)
• All wards that can appropriately implement our HSJ Efficiency award-winning •
RAG system during 2012/13 have done so successfully.
Implementation of our
award-winning supported
recovery risk management
system.
Implement lessons learned
from SUIs
Enhance systems for learning
lessons from Serious and
Untoward Incidents (SUIs).
• We fully investigate every SUI and follow through with action plans
• We have a PiC-wide system for ensuring lessons are learned from SUIs
• We triangulate incident data with information on patient experience, •
regulator compliance and management of violence and aggression.
Partnerships in Care Quality Account 2012/13
7
Review of quality performance 2012/2013
Quality performance
1.2 Quality objectives 2013/14
What we pledge to do
Governance
Review clinical governance processes corporately and at individual hospitals
with a view to enhancing engagement with patients and frontline staff.
Patient Experience
Enhance engagement with carers, friends and family
Continue to promote social inclusion and community engagement through
Real Work Opportunities
Continue to place the patient at the centre of care delivery and governance
Implement initiatives to promote carer and family engagement in patient
recovery.
Clinical Effectiveness
Optimise length of stay and support people safely in the least restrictive
environments
Continue to use patient reported outcome measures to review services and
improve quality.
Patient Safety
Increase the integrity, transparency and accuracy of clinical incident
reporting
Continue to actively manage ward safety for patients and staff
Promote the physical health of patients.
Our pledges demonstrate our commitment to
achieving the highest possible standards for clinical
effectiveness, safety and patient recovery.
Dr Quazi Haque
Group Medical Director
8
Partnerships in Care Quality Account 2012/13
Review of quality performance 2012/2013
1.3 Commissioning for Quality and Innovation goals (CQUIN)
Questions and answers about CQUINs
Q. What is a CQUIN?
A. CQUIN stands for Commissioning for Quality and
Innovation, first introduced in 2009. It is a set of targets
or goals that commissioners set for providers to help
improve the quality of services offered. CQUINs address
safety, effectiveness or patient experience, and reflect
innovation.
Q. How did PiC perform on CQUIN targets in
2012/13?
A. P
iC met 100% of all of its CQUIN targets for each
quarter of the year from April 2012 to March 2013.
Quality performance
Partnerships in Care met 100% of all its CQUIN targets for each quarter of last year and often exceeded required
performance levels. We are committed to continue aligning this year’s clinical priorities with the 2013/2014 CQUIN
objectives.
Q. How do CQUINs improve the care that
patients receive?
A. C
QUINs provide an empowering platform for serviceusers, staff and commissioners to work together to
ensure services meet nationally agreed standards and
strive for improvement through innovation.
Q. How can I, as a patient or carer, take part in
helping to achieve a CQUIN target?
A. T
he basis of CQUIN is collaboration and working
together. It is very important to PiC that patients and
carers are involved in all aspects of services within
our hospitals. Speak to your hospital manager about
Patient Councils and Carers Networks.
CQUIN targets 2012/13
CQUIN
Actions and achievements 2012/13
1. Access to Specialised
Mental Health Services
• A new Referral and Assessment for Admission Policy was developed improving care
pathway planning, communication and support to the patient and referrers
• Established Referral Managers are a single point of timely and consistent contact.
2. Secure Forensic Care
Pathway Feasibility
Project / Payment by
Results (PbR)
• PiC has embedded an electronic Payment by Results (PbR) tool within its electronic
patient records (EPR) which reports on and highlights the due-date for a patient cluster*
or one of the 5 forensic pathways
•This tool is programmed with algorithms providing the clinician with a suggested cluster
based on the patient’s information.
*Cluster – patient groupings according to diagnosis which support the PbR system.
3. My Shared Pathway
(MSP) – Recovery and
Outcomes
• MSP is now in its 2nd year (3rd for some PiC sites involved in the pilot)
• The collaborative recovery approach is a core part of each hospital’s care pathway
• The CPA documentation used within PiC has been updated to incorporate the shared
pathway and outcomes framework further embedding the principles
within every day practice
• Patients can chair their own CPA meetings.
4. 2
0 x User-Defined
CPA standards
• All PiC hospitals have implemented all 20 of the CPA standards. Compliance is
routinely monitored and forms part of PiC’s Internal Audit Programme.
My Shared Pathway
(MSP) / Implementing a
Standard Secure Pathway
• A new PiC Referral and Assessment for Admission Policy was developed, making clear
improvements to care pathway planning, communication and support to
the patient
• Clear pathways within regions/hospitals are in place
• PiC communicates with key stakeholders and applies the principles of MSP
and Quality Innovation Productivity Prevention (QIPP).
Optimising Length of Stay
• Supported relationships, clear and consistent care pathways in hospital
and region, are helping to reduce length of stay.
25 hours meaningful
activity
• Activity timetables built into electronic patient records (EPR) are planning and
measuring delivery of meaningful activity.
Partnerships in Care Quality Account 2012/13
9
Review of quality performance 2012/2013
Quality performance
CQUIN targets 2013/14
CQUIN
Planned actions for 2013/14
Improving the CPA process
• Ensuring the care plan approach (CPA) process is effective and appropriately
identifies unmet need.
Implementing Dashboards
• Quality Information Dashboards have been introduced into PiC Governance
structures, providing a mechanism for communication of information to senior
management teams all the way through to front line clinical staff need.
Improving Physical
Healthcare and Well-being
• To improve the physical health and well-being of all patients, as an integral •
part of their overall treatment and rehabilitation plan.
Optimising Pathways
• To develop understanding of the whole care pathway and to plan to optimise •
each patient’s length of stay within specialised mental health services.
Quality Dashboards for
Specialised Services
• To embed and demonstrate routine use of specialised services clinical dashboards.
Innovative access to and
for secure services
• Increased utilisation of communications technology.
Provision of Literacy,
Numeracy, IT and
Vocational Skills
• The provision of resources to improve literacy, numeracy, IT and vocational skills
within secure care environments improves opportunities for patients to participate
in these aspects of life in their future.
1.4 Quality and compliance with regulation
PiC’s care facilities are registered by the Care Quality
Commission (CQC) in England, Healthcare Improvement
Scotland (HIS) or the Healthcare Inspectorate Wales (HIW).
See below for a list of CQC inspections and outcomes.
PiC compares very well on these compared to what the
CQC has found as average in independent hospitals and
clinics. CQC has visited PiC units four times to inspect on
Outcome 21 and found full compliance.
Quality of care and compliance with regulation is
monitored in a structured manner, subject to continuous
review by the Clinical Governance Committee, (CGC) senior
managers and directors.
CQC inspections sometimes highlight areas for
improvement. We respond to these promptly and •
we are re-inspected until confirmed as fully compliant.
(see case studies).
PiC has developed a format for provider compliance
assessment visits based on CQC guidance. The nominated
individual, or his/her representative, visits each hospital
on a six-monthly basis and care homes on a monthly
basis. Reports are reviewed by the Clinical Governance
Committee and copies are sent to the CQC/HIS/HIW.
There are 50 visits to our hospitals and 120 visits to our
care homes every year.
We benchmark our performance against the CQC
Mental Health Act Annual Report. To read about PiC’s
performance with regard to making patients aware of
their right to an Independent Mental Health Advocate
(IMHA) please see pages 16 and 17.
With reference to:
•• CQC Outcome 8 – Management of medicines
•• CQC Outcome 21 – Records
•
10
Partnerships in Care Quality Account 2012/13
The CQC Annual Report records 86% compliance for the
independent healthcare sector on the outcomes assessed
during 2012/13. The CQC does not consider minor
concerns in their calculation. PiC records 94% – 100%
compliance so is above average. (Please see the table on
page 12). We had no ‘never events’ in the reporting period.
Review of quality performance 2012/2013
100
Timely and effective
response to CQC feedback
Calverton Hill hospital, Nottinghamshire
On 15 August 2012 the CQC carried out an
unannounced inspection of Calverton Hill. The review
highlighted issues with the quality of seclusion
records and the process for reviewing episodes
of seclusion. Following the visit the hospital’s
management team developed a comprehensive
action plan resulting in a number of different work
streams, both locally and across PiC. The CQC returned
on 2 October 2012 and the service was found to be
fully compliant.
90
80
70
Compliancy %
Case studies
Quality performance
Compliance with all CQC essential standards –
PiC compared with independent mental health
service providers
60
50
The North London Clinic, Edmonton
40
30
P
iC compliance compared
with independent mental
health service providers
20
10
CQC average
Partnerships in Care
0
A standard compliance inspection of The North
London Clinic (NLC) was undertaken by the CQC in
February 2013 focusing on 3 main areas of care and
treatment. These were seclusion, management of
violence and aggression and CPR practice and First Aid.
The service was found to be fully compliant with
Seclusion and Management of violence and
aggression however some concerns were raised over
CPR practice and First Aid equipment. Systems where
reviewed and the outcomes are:
•• Routine checking of CPR and First Aid equipment
•• Regular practice drills and debriefing to ensure
staff are competent in responding to a medical
emergency
•• Training in self-administration of adrenalin for
patients who have a known risk of anaphylactic
shock
•• Refresher training for registered nurses in how •
to administer adrenalin.
We value the sharing best
practice across the provider
landscape that is fostered by
regulatory inspections and action
plans. Our vision for the future
continues to focus on never being
complacent and striving to take
quality to the highest level
Steven Woolgar
Director of Policy and Regulation
An unannounced follow up visit by CQC on 8th April
2013 confirmed that the hospital was now fully
compliant with all CQC regulation.
Highlights
•• PiC carries out its own bespoke industry-leading
Provider Compliance Assessments (PCA)
•• In 2012 PiC carried out 50 Provider Compliance
Assessment Visits to our hospitals and 120 visits •
to our care homes
•• PiC performed well in 2012/13 exceeding the 86%
compliance for the independent sector reported in
the CQC Annual Report for the same period.
Partnerships in Care Quality Account 2012/13
11
12
Partnerships in Care Quality Account 2012/13
Date of Inspection
09 February 2012
13 February 2012
15 March 2012
21 March 2012
13 April 2012
6 June 2012
6 June 2012
26 June 2012
11 July 2012
31 July 2012
06 August 2012
16 August 2012
20 / 21 August 2012
30 August 2012
31 August 2012
5 September 2012
5 September 2012
12 September 2012
13 September 2012
02 / 03 October 2012
8 October 2012
15 October 2012
13 November 2012
13 November 2012
13 November 2012
20 November 2012
21 November 2012
28 November 2012
5 December 2012
5 December 2012
14 December 2012
16 January 2013
24 January 2013
05 / 11 February 2013
06 / 07 March 2013
06 March 2013
07 March 2013
08 April 2013
16 April 2013
Compliant
A minor concern
12
Not inspected
CQC Outcomes - see key in table below for definition by numbered outcome
1
2
4
5
6
7
8
9
10
11
All reports have either been published or are in final form awaiting publication
See key to colour code and outcome descriptions for this table on page 13
Hospital
Louies Lane
Abbey House
The Spinney
The Croft
Calverton Hill
Grafton House
51 The Drive
Annesley House
Hazelwood House
Suttons Manor
St Johns House
Lombard House
Stockton Hall
Kneesworth House
North London Clinic
Elm House
Elm Cottage
Elm Park
Richmond House
Calverton Hill
Arbury Court
Abbey House
Roydon Road
Louies Lane
Harrisons Yard
The Dene
Kemple View
The Croft
Hill House
Grafton Manor
Richmond House
Burston House
Pelham Woods
Calverton Hill
Annesley House
Oaktree Manor
The Spinney
North London Clinic
Kemple View
PiC hospitals in England – CQC Visits 2012/13
13
16
A moderate concern
14
21
A major concern
17
Quality performance
Review of quality performance 2012/2013
Review of quality performance 2012/2013
Grey
Not inspected
Green
Compliant – means that people who use services are experiencing the outcomes relating to the
essential standard.
Yellow
Minor concern – means that people who use services are safe but are not always experiencing the
outcomes relating to this essential standard
Amber
Moderate concern – means that people who use services are safe but are not always experiencing
the outcomes relating to this essential standard and there is an impact on their health and
wellbeing because of this.
Red
Major concern – means that people who use services are not experiencing the outcomes relating
to this essential standard and are not protected from unsafe or inappropriate care, treatment and
support.
Quality performance
Key to colour code for table of CQC inspections on page 12
Key to CQC/HIS/HIW Outcome measures for table on page 12
Outcome
Description
1
Respecting and involving people who use services (regulation 17)
2
Consent to care and treatment (regulation 18)
4
Care and welfare of people who use services (regulation 9)
5
Meeting nutritional needs (regulation 14)
6
Cooperating with other providers (regulation 24)
7
Safeguarding vulnerable people who use services (regulation 11)
8
Cleanliness and infection control (regulation 12)
9
Management of medicines (regulation 13)
10
Safety and suitability of premises (regulation 15)
11
Safety, availability and suitability of equipment (regulation 16)
12
Requirements relating to workers (regulation 21)
13
Staffing (regulation 22)
14
Supporting workers (regulation 23)
16
Assessing and monitoring the quality of service provision (regulation 10)
17
Complaints (regulation 19)
21
Records (regulation 20)
Note: Regulations refer to Section 20 of the Health and Social Care Act 2008. The CQC framework takes regulations
and expresses them as outcomes.
Partnerships in Care Quality Account 2012/13
13
Patient experience
Patient experience
2 Patient experience
2.1 Patient Satisfaction Survey
69% of our patients rated their overall care as excellent,
very good or good in the year from April 2012 to March
2013 – a higher percentage than in the previous year and
higher than the national average of 61% recorded in the
most recent British Social Attitudes Survey.1
About the survey
Highlights for Patients and Carers
Survey result highlights by topic
•• Half of the patients thought the pre-admission
assessment was a positive experience and the majority
felt welcomed on the ward and were introduced to the
ward routine on admission.
•• Most patients were satisfied with the standard of the
ward environment and with access to special diets.
•• The majority of patients said the hospital helps them
to keep contact with their family and friends
Pre-admission and admission to the ward
•• The majority of patients said they were assessed by
a member of the clinical team. Half of the patients
said they had been asked for their own story prior to
admission.
•• Half of the patients thought the pre-admission
assessment was a positive experience and the majority
felt welcomed on the ward and were introduced to the
ward routine on admission.
•• Half of the patients said they received information
about the hospital prior to admission and
approximately 2/3 of patients felt the staff were
knowledgeable about their history on admission.
Overall how would you rate the care you
are receiving during your stay in hospital?
About the ward
20
The majority of patients said:
24%
23%
25
•• that the general ward areas were clean
•• that they felt safe all or some of the time
16%
9%
10
5
0
Not recommended Poor Fair
Good Very good Excellent
16%
•• special dietary requirements are well catered for
15
12%
Satisfaction %
Surveys were completed with Primary Nurses and data
was entered between 1 April 2012 and 31 March 2013.
382 questionnaires were completed.
•• that they felt the hospital helped keep them in contact
with family and friends.
Relationships with staff
The majority of patients said:
•• that they spent enough time with, and trusted, their
psychiatrist
•• that nurses always listened carefully, spent enough
time to discuss their condition and treatment and they
had weekly time with their primary nurse
•• they were always treated with dignity and respect by
the nurses
Topic: Your care and treatment
•• Most patients said that they had weekly contact with
their multidisciplinary team (MDT)
•• For those patients on medication the majority reported
that staff explained the purpose of the medication and
the possible side effects in a manner that they could
understand
•• The majority of patients said that they were given
enough privacy when discussing their care and
treatment with hospital staff
•• Most patients said they were involved in decisions
about their care
1
14
http://www.bbc.co.uk/news/health-22007487
Partnerships in Care Quality Account 2012/13
Patient experience
•• Of the patients that wanted talking therapy, the
majority said they accessed this. In addition, the
majority of these people said they found this helpful
How would you rate the hospital food?
•• Most patients said they received some form of medical
tests during their stay. The majority of those with longterm physical conditions said they felt their physical
medical needs were supported by the hospital
20
20%
22%
27%
25%
Satisfaction %
25
•• The majority of patients said they were detained by
the Mental Health Act and that they had their rights
explained to them regularly in a way that they could
understand
•• The majority of patients said that they were aware of
how to make a complaint should they need to
15
•• Most patients said that they did not feel •
discriminated against.
6%
10
5
Patient experience
•• Most patients said that there was enough activity
30
We have a wide range of approaches, formal and
informal, to gather and act on patient feedback.
Please see windmill graphic on page 33.
0
Blanks Poor Fair •
Good Very good 2.2 Bespoke Care Programme Approach (CPA) and CPA Survey
Partnerships in Care believes that effective CPA plays an
important role in improving patient care pathways and
patient recovery. My Shared Pathway is now central to our
CPA framework and documentation in 2012.
•• Being involved in their CPA reports by•
– compiling reports•
– commenting on them within an agreed timeframe•
– presenting them in a format of their choosing
We fully implement all 20 service user-defined CPA
standards. We have surveyed patients’ views to assess our
performance against these standards.
•• Deciding who would chair the CPA meeting
•• Attending ward round/multidisciplinary team (MDT)
the week prior to their CPA to discuss any issues
The 2012/13 survey shows 60% of patients reported
that they felt fully involved in CPA process including CPA
meetings.
•• Meeting visitors for coffee prior to the meeting
Patients reported positively on:
Just under half of the patients stated that all the people
who wrote reports were at their meeting.
•• Being included in all parts of their CPA meeting
•• Having conversations about their care
•• Working closely with their Primary Nurse in preparing
for the CPA meeting including
– choice of venue•
– where people will sit•
– visiting the room to discuss layout•
– developing a plan for the meeting
•• Being aware of their right to have advocacy
representation at the CPA meeting
•• Patients and carers given a questionnaire at the end •
of the CPA meeting for immediate feedback
In 2012/13 we embedded the Shared Pathway into care
pathway planning, supporting clinical teams in the
challenge of adopting this alongside the CPA framework.
We visited patients to gain valuable feedback on our CPA
and its effectiveness. We have also been seeking patient
views on this to be our benchmark for multidisciplinary
team effectiveness. Patients, carers, families and
commissioners response, has been overwhelmingly
positive and a great source of encouragement to our
clinical teams. We are committed to further use of this
approach in the year ahead.
Partnerships in Care Quality Account 2012/13
15
Patient experience
Section 2.2 continued – graphs from the CPA Survey
Patient experience
Stay at PiC – General issues
Yes
No
N/A
ST1: Did you feel included in all parts of
your CPA meeting, apart from in exceptional
circumstances, where there is third party
information to be discussed?
Partnerships in Care Quality Account 2012/13
ST3: Your Primary Nurse will discuss with
you who should be invited to your CPA
meeting and how to go about inviting them.
35%
26%
2.2%
2.8%
4.5%
4%
60%
65.5%
ST5: You and your Primary Nurse will talk
through and agree a plan for the meeting.
16
Patient declined
ST10: The chair of the CPA meeting is
usually the Responsible Clinician. Were
you given the option to chair the meeting
yourself or to nominate another member
of your clinical team?
26%
36%
8%
4%
6%
3%
62%
55%
Patient experience
Patient experience
2.3 Advocacy
•• Ensure compliance with PiC policies and procedures
including lone working, data protection, cultural
competency, confidentiality
•• Organise appropriate cover during annual/sickness
leave
•• Facilitate regular advocacy team meetings and
casework discussions
Advocacy – Partnerships in
Care’s contract with Rethink
Partnerships in Care (PiC) currently have a contract for
Rethink to supply advocacy for our patients. Rethink
delivers this service to PiC through a lead contract
manager, area services managers and caseload working
service managers across the UK for each PiC region.
Rethink’s Service Managers actively participate in
advocacy and:
•• Publicise the service to all stakeholders
•• Receive and allocate referrals
•• Set up service protocols such as liaison with
referrers/carers/healthcare professionals
Advocacy awareness result in CPA Survey
ST6: You should be made aware of the
advocacy service and asked if you would
like advocacy support within the CPA
process and meeting.
6%
•• Undertake regular formal supervision with service
staff (this will include individual casework discussion)
The advocacy model in use is the ‘recovery model’
which is designed to support patients to learn the skills
required to self-advocate. Typically, the patient would
bring an issue to the attention of the advocate that
they needed support with. The issue is assessed and
intervention/support identified by the advocate. Cases
are not closed until the issue has been resolved.
Rethink deals with about 8,306 individual contacts with
advocacy services a year. The type of issues includes
patient treatment, legal matters, patient rights, welfare
benefits, financial matters, discharge planning, CPA.
Patient awareness of right to Independent Mental
Health Act Advocacy (IMHA) – indexed score
benchmarked against CQC Mental Health Act
Annual Report 2012/13
14
4%
26%
Yes No N/A Patient declined
Patient awareness index score
64%
12
10
8
6
4
2
Partnerships
in Care
CQC
reported •
national average •
for independent •
mental health •
service provider
0
Partnerships in Care Quality Account 2012/13
17
Patient experience
2.4 My Shared Pathway implementation and survey
Patient experience
Achievements include:
•• Raised awareness of My Shared Pathway
•• New CPA process
•• New Patient Portfolio
In 2012 we have made significant progress with the My
Shared Pathway (MSP) initiative, and have been
recognised by the national MSP project group, with
positive feedback about our pilot work including the level
of patient leadership and involvement and how
successfully this has become central to our culture of
compassionate care at PiC. We tested our progress with a
My Shared Pathway Survey, with a sample of 382 surveys
completed by patients.
All PiC hospitals appointed a local Recovery Lead person
and implemented a joint patient and staff Recovery and
Outcomes group. The local groups play a role in CQUIN
requirements, implement MSP aligned with the CPA
process and multidisciplinary team (MDT) working.
During the first half of 2012 the groups reviewed all
PiC recovery related documentation including our CPA
framework.
To further support this process, we established a
Corporate Support Group to share best practice and
support MSP’s role in CQUIN initiatives.
Per cent of completed MSP surveys by unit
•• NHS networks resources
•• Shared implementation plans
•• Sharing national information from regional •
service user involvement groups.
Patients and staff at all PiC hospitals have worked
together in creative MSP projects:
•• The Spinney patient song ‘No decision about me
without me’ reached finalist for innovation in, and •
was performed at, the national shared pathway group’s
Service User-Led Awards and on their national DVD;
the project and its staff lead, Michelle Parker, reached
finalist status in the Laing & Buisson Independent
Specialist Healthcare Awards
•• Clinicians from PiC’s St John’s Hospital Learning
Disability Services published their experience of •
MSP in the Journal of Learning Disabilities and
Offending Behaviour*
•• Pelham Woods residents and staff formed a •
band, “Jammin’, which meets weekly, and is hoping •
to perform at the 2014 opening of the annual •
Koestler Awards
•• A patient-led committee at Suttons Manor has
developed The Brendan Centre for Horticulture and
The Zen Garden. Patients designed the gardens and
selected the plants, flowers, vegetables and fruits.
Other highlights include creative ‘recovery’ artwork,
patient involvement in staff training, enhanced
patient information, special themed activity weeks,
implementation of patient buddy system and ‘peer plus’
supporting patients during admission and transfer, and
a review of PiC’s electronic patient records relating to
outcomes measurement.
Annesley House
6%
Calverton Hill
6%
Hazelwood House
4%
Arbury Court
6%
The Dene
9% Kemple View
4% Kneesworth House
Learning Disability Service
7%
15% Llanarth Court
10%
Oaktree Manor
4%
The Spinney
4%
North London Clinic
9% Pelham Woods
1% Stockton Hall
10%
The Willows
1%
Suttons Manor
The board and I have had
high visibility across all
hospitals this year, through
roadshow visits, in which patients
play a central role. What stands out
is the value of the role My Shared
Pathway has played in delivering
quality to patients in our care
Joy Chamberlain
Group Chief Executive
4%
*F. Esan (et al) (2012) “Shared Pathway” national pilot project: the experience of the secure learning disability service.
Journal of Learning Disabilities and Offending Behaviour
18
Partnerships in Care Quality Account 2012/13
What our patients say about
My Shared Pathway
Learning from our My Shared
Pathway Survey results
I feel that people are
recognising that I have skills
and encouraging me to use these
positively. I feel a lot happier; have a
sense of self-worth and for me most
importantly a sense of purpose
Sample size and representation (bar charts)
% breakdown of completed surveys
by security level
Breakdown %
43.5%
40
30
0
Rehabilitation
10
11%
20
PiC patient
I love Suttons Manor garden;
it has changed so much it
went from nothing that we never
used to something that I like to use
every day. I helped to make the
decisions every step of the way and
I help to maintain the garden
45.4%
50
PiC patient
I have been Patient Alliance
representative, a member of
the Food Group, attended patient
forums and done phone conferences
with other units
Patient experience
Patient experience
Locked Rehab Low Secure Medium Secure
% breakdown of completed surveys
by service line
20
10
0
1%
30
33%
Breakdown %
40
10%
50
56%
PiC patient
Autistic Spectrum Disorder •
Improving communication
on
Learning Disability•
pre-admission
assessment
Mental Illness Personality Disorder
Partnerships in Care Quality Account 2012/13
19
Patient experience
MSP Survey results pie charts
Patient experience
Q1: If you have been admitted since 1st
October 2012 were you given information
about the pre-admission assessment
before it took place?
Q3: On the day you came to hospital were you
given the opportunity to speak with a “buddy”?
(This is another service user who can show
you around the ward and give you information).
24%
51%
24%
7%
52%
Admitted before October 2012 Yes No
Q2: Were you given information about
the hospital you were going to?
42%
Yes No No response Q4: Was My Shared Pathway
explained to you?
28%
2%
25.3%
23.9%
70%
50.8%
Yes No No response Every now and then you get the
opportunity to see real leadership in
action. My visit to the Spinney was a really
inspirational experience. One might expect
such a unit to feel austere but what I saw
was a wonderful environment, dedicated staff
and a real sense of ownership. The patient
involvement is evident everywhere. It was
wonderful to hear patients presenting and
hearing how they have made real progress
during their stay. The Spinney is a place that
is full of hope with staff demonstrating the
highest level of care and compassion in a
very challenging field of nursing. I have
nothing but admiration for the team.
Andrea Spyropoulos,
President Royal College of Nursing
20
Partnerships in Care Quality Account 2012/13
Yes No No response Q5: Have you been offered a patient portfolio
and given opportunities to add information
to it and keep it updated?
35.5%
1.6%
62.9%
Yes No No response Patient experience
Q9: Are your outcomes/goals reviewed
at MDT meetings and CPAs?
14%
15.6%
1.1%
Patient experience
Q6: Are you clear what you need
to do to move on from secure services?
4%
14%
69.4%
Yes No No response Partly Q7: Do you feel involved in the planning
of these goals?
82%
Yes No No response Q10: Are you clear about where you will
go next (another service or community)?
17%
40.1%
2.2%
18%
57.8%
65%
Yes No Partly Yes No No response Q8: If you are under Ministry of Justice
restrictions do you receive copies of the
correspondence your Responsible Clinician
sends to the Ministry of Justice?
Q11: Are you aware who your community
care coordinator is?
25.3%
2.2%
42.7%
19.1%
72.6%
38.2%
Yes No N/A Yes No No response Action plan following MSP Survey
The following actions will be implemented during 2013/14.
1. To increase the offer of a “buddy” service on admission to the ward.
2. To ensure Responsible Clinicians copy relevant correspondence sent to the Ministry of Justice to patients.
3. Clinical teams to continue to work with individual patients to help increase their understanding of their Care
Pathway and potential placements.
Partnerships in Care Quality Account 2012/13
21
Patient experience
2.5 Real Work Opportunities programme
Patient experience
Partnerships in Care’s Real Work Opportunities
programme, implemented in 2012 and reviewed across
all PiC services, is led by patients and staff. Employment
has been evidenced by research to improve recovery
outcomes, minimise relapse rate and improve social
inclusion and mental health. At the North London Clinic
alone we have created 40 jobs during the year and
received 55 applications from patients.
RWO adopts the ‘place then train’ approach to vocational
rehabilitation. This approach replicates the process of
normal employment as closely as possible, with role
profiles, job applications and interviews. PiC has formed
partnerships with a number of employers who are
positive towards offering supportive employment to
people who have a history of mental ill health.
The aims of PiC’s RWO programme include to:
•• Promote opportunities to practice and develop skills •
in supporting recovery goals.
•• Provide opportunities to develop practical working,
role-specific and problem solving skills
•• Increase confidence in applying for jobs
Interviews are an important part of RWO. Patients
complete a CV and application form, tailor it to the job
and provide references that give an accurate personal
description of the candidate. Assistance is given where
it is wanted. As with a real work situation, patients are
required to submit applications by a closing date.
We have a number of jobs in place which usually last •
for a 12 week period. Jobs include:
•• Charity clothes shop assistant
•• Library assistants
•• Social Enterprise – making craft items •
and selling them at a local markets.
•• Gardening
•• Shop assistant
•• Flower arranging
•• Maintenance •
support
•• Kitchen •
assistant
•• Give patients an opportunity to engage in a work
programme aimed at increasing the likelihood of
securing mainstream work once discharged from •
our care.
2.6 Extending patient care pathways
To meet our commitment to maximise effectiveness of
care pathways we have reconfigured some of our services
in 2012/13.
We:
•• opened an acute service
•• increased low secure and rehabilitation •
service provision
•• enhanced our inpatient rehabilitation services •
to cover a range of patient needs
– high dependency (HDU)•
– complex care•
– community-facing inpatient rehabilitation•
– open rehabilitation
•• introduced, within our brain injury services, •
stroke and respite care
•• introduced specialist forensic older adult service •
with end of life care.
We did this in response to patient and commissioner
needs. This played a role in permitting us to treat 29.9%
more patients in 2012 /13 than in 2011 /12 and helped
more patients to step down to lower levels of security as
appropriate for their recovery.
22
Partnerships in Care Quality Account 2012/13
i. Acute services
In 2012 we opened our first acute service at The Dene
and have since opened at The Spinney and at Kneesworth
House hospital. At The Dene we have 32 acute beds
available over two wards, 16 male and 16 female. We
provide for emergency admissions for patients at risk
to themselves or others and crisis intervention and
treatment of behavioural emergencies, 7 days a week, 24
hours a day. At The Spinney we have 15 male acute beds
and at Kneesworth, 6 female acute beds.
A full multidisciplinary team provides a quick appropriate
response to patient’s needs and clinical care updates are
24 hour, 48 hour, 72 hour and weekly intervals thereafter.
We provide advice regarding future placements and 5
days of medication to takeaway.
Since March 2012, there have been a total of 400 acute
patients admitted to our services.
A Commissioner recommendation:
A large mental health trust is happy with our Acute
service at The Dene. When asked what they rate about
our service this is what they said:
•• High quality care
•• Robust communication with the referring trust •
and community teams from admission to •
discharge/transfer
Patient experience
Acute services flowchart
Referral/Admission
Patient experience
Admission process and orientation to ward and ward routine/policies
72 hour assessment period
Introduction to primary nurse and 1:1 care planning
Daily medication review
Daily mental state review
Liaison with home team
Liaison with family (supported by staff if necessary)
Liaison with GP
Short term
High Dependency service
Acute service
Communication with home team –
24 hour report; 48 hour report; 72 hour report;
weekly report thereafter
Daily1:1 with primary nurse or allocated nurse
Daily liaison with Associate Specialist doctor
Weekly ward round review with Responsible Clinician
Activity programme and S17 leave as necessary
Liaison with family
Liaison with home team to agree discharge plan
Daily1:1 with primary nurse or allocated nurse
Daily Responsible Clinician and Associate
Specialist review
Daily medication review
Daily mental state review
Reintegration into generic acute ward or return
to home team PiCU if does not stablilise
Discharge
Planned and agreed by all parties
TTA Medication provided for 5 days
Liaison with family
Liaison with home team
•• Regular clinical updates
In 2012:
•• Plan for daily activities provided on the ward including
drug and alcohol groups, recreational groups and
relaxation groups
•• At Kneesworth House Hospital we opened Fairview
Ward (inpatient rehabilitation for women) reconfigured Nightingale and Wortham wards as
rehabilitation; the four bungalows (three for men, one
for women) provide open rehabilitation, extending
pathway options for patients moving on from secure
care for both men and women.
•• Excellent facilities with each patient in a private ensuite room within a spacious ward
•• Transparent fees inclusive of enhanced observations
for the first 7 days
•• Daily consultant-led ward rounds
•• Individualised admission and discharge •
risk assessments.
ii. Rehabilitation services
We recognise that an increasing number of patients no
longer require treatment in secure conditions, yet present
very challenging behaviour.
This year we responded to this by developing
rehabilitation services which would safely meet the
needs of this patient group. We offer varied pathway
and treatment options with a portfolio of rehabilitation
services from High Dependency through Complex Care
and Community-Facing Rehabilitation services as well as
Supported Accommodation.
We cared for 15.7% more patients in rehabilitation
settings in the year to end March 2013 than in the
previous year.
•• Oakwood Ward inpatient rehabilitation for men at
Kemple View continues to grow and is a welcome
addition to services in the North West, providing
invaluable step down options for existing patients.
•• Teams from Aderyn (inpatient rehabilitation) and
Abbey House (inpatient and open rehabilitation) have
continued to work closely, embedding the Shared
Pathway principles into their services. Aderyn was
rewarded in March 2013 with a Laing and Buisson
Award for care pathways.
•• In the Midlands, new rehabilitation pathways are
available for women patients at Annesley House
(inpatient rehabilitation alongside low secure) and
The Willows (inpatient rehabilitation) have improved
options for those progressing from secure care and
given greater choice of service provision for local
commissioners.
Partnerships in Care Quality Account 2012/13
23
Patient experience
Patient experience
The development of our rehabilitation services continues
to enhance our existing provision, providing further
pathway opportunities for patients and further choice for
them, families and commissioners.
Within our low secure service for women at Annesley
House we encourage patients to manage their own risk
behaviour and to use our new ‘calming suite’ when they
feel unsafe or require additional support.
The ‘Guidance for commissioners of rehabilitation
services for people with complex mental health needs’
(2012) reflects our direction. Central to our treatment
programmes are five aims:
The seclusion suite is used only as a last resort. Instead,
patients can use a ‘safe’ bedroom, a quiet lounge or our
enhanced care suite. Patient feedback on these new
facilities are very positive. Comments indicate patients
feel they benefit from an additional safe environment.
•• risk reduction
•• relapse prevention
•• independent living skills
•• vocational engagement
•• social inclusion
In partnership with our patients our focus is on
community integration and outcomes resulting from
an optimised Shared Pathway. Our teams continue to
develop strong links with local service providers and
work closely with local communities and social services
to maximise opportunities for social inclusion and
meaningful employment.
Families, friends and carers play a valuable role in the
successful and sustained recovery of our patients and we
are collaborating to improve that experience.
iii. Community support
We are exploring how best to provide post-discharge
continuity of care to our patients. At present, patients we
discharge have their care transferred to other providers.
We believe that a patient’s recovery is improved if the
same multidisciplinary team can provide on-going care.
We are setting up pilot studies in North London and other
regions to trial care outside our existing facilities.
Among the benefits we seek are:
•• continuity of care for patients into the community
•• support for patients by offering short-term higher
levels of care/ security, if their first step into the
community is initially too far, without disrupting their
community placement arrangements
•• more rapid progress for patients and commissioners
v. New End of Life care pathway
In recent years we have seen an increase in referrals of
older patients with complex health issues. We identified
a need to provide palliative care in this setting. We had
found there was currently no palliative or End of Life
pathway implemented at any secure hospital in England.
We opened a custom-designed and modified 10-bed
ward for older adults at Kemple View to meet this need.
We care for detained patients, some of whom have a
history of offending and are as such subject to Ministry
of Justice restrictions. We developed links with prison
services that had developed an End of Life care pathway
so that we could learn from their experiences.
After taking guidance from the End of Life Team from
Cumbria and Lancashire, we developed a learning and
development pathway for staff. This includes the Six
Steps Training Programme and associated workshops,
such as Mental Capacity Act and Sage and Thyme
Communication Workshops. Our support centres on
the needs, wishes and priorities of the individual. As
people approach the end of their lives these may change.
Patterns of care shift to ensure that the individuals and
their families are able to spend time in a way that is
meaningful to them.
Outcomes for patients from Kemple View’s
End of Life care pathway
1. Reduction in admission to general hospital. This
has resulted in less stress for the patient as well as
more efficient use of nursing resources.
•• safety for patients and the wider community through
risk-appropriate placements
2. Increased involvement from community services
such as Macmillan, tissue viability nurses and
speech and language therapists
The patient outcomes resulting from these trials
are being measured. We aim, through partnership
arrangements, to have measures to help patients live
independently in the community following discharge.
3. Improvements in symptom control of
breathlessness/nausea/pain and associated anxiety.
•• accommodation options for patients post discharge
4. Increased family involvement.
iv. Low Secure services
In 2012/13 we cared for 16.9% more patients within low
secure settings than in 2011/12.
At Annesley House we commenced an extensive
refurbishment programme during 2012 to enhance our
low secure admission ward, the Cambridge Ward. We
removed what had been a secure level reception area. We
created an open, spacious reception area which is very
welcoming to all visitors and patients.
24
Partnerships in Care Quality Account 2012/13
10.4%
more
rehabilitation
and acute
beds
Patient experience
Case study ‘Frank’ from London
I was in prison serving a sentence for robbery when
I was diagnosed with a mental illness – a bi-polar
disorder. I was then in and out of a number of secure
hospitals and at one point even back to prison.
I came to Partnerships in Care, at first to Suttons
Manor and now the North London Clinic.
I’d been placed in care at birth and from an early age
became involved in crime. As I grew older, my drink
and drug taking spiralled further and further out of
control. When in prison, I experienced intense mood
swings. When they told me I had a mental illness I
couldn’t accept it. Prison is not set up to deal with
people like me. I’m grateful to the person who noticed
I needed help and the psychiatrist who sent me to
hospital. My journey has not been an easy one. In
many of the hospitals I’ve been in I’ve spent time in
seclusion rooms.
Since arriving at NLC my life has completely turned
around. The psychologists I’ve worked with have
Patient experience
2.7 My journey - a patient story
done some fantastic work in helping me. When
I first arrived I was placed on an acute ward but
thanks to the courses I have done and the input from
the psychologists I have moved right down to the
rehabilitation ward. Recently I was granted a deferred
discharge by the Tribunal Board.
It’s amazing for me to think that 13 years ago l was
considered a danger to society and now I can see
why people thought that. Before, I had no concept of
how to behave, norms, or victim empathy. Courses,
like Life Minus Violence, taught me how my actions
impacted on other people. Other courses, such as
Anger Management, enabled me to put my own
anger into perspective. Hopefully this will stand me in
good stead on release.
Thanks to the brilliant work of the whole team at
this hospital, I now feel ready to face the outside
world with confidence. I know I will not be returning
to prison again.
2.8 Complaints
In our 2011/12 Quality Account we stated our
commitment to improving our services by acting on
compliments or complaints and feedback from patients,
carers and families. Following the Francis report in 2013
there is a sector-wide drive for greater transparency and
accountability through reporting of all aspects of patient
experience and care delivery. We have updated and
expanded the ways patients and carers give us feedback.
When we consider upheld complaints between 2011/12
and 2012/13 there has been a:
During this year PiC received 782 complaints compared
to 826 complaints for the same period last year giving
a reduction of approximately 5%. When we compare
upheld complaints, we see an increase, particularly in
less serious complaints reflecting the fact that absolutely
every complaint is recorded. Overall there is an increase of
28%, at least partly reflecting our more accurate reporting
and recording methods.
•• 73% increase in environment and domestic-related
complaints. During this year we have been upgrading
our facilities at many sites and one unfortunate
downside of this is disruption to our patients.
•• 60% decrease in communication-related complaints
which demonstrate that we are communicating more
effectively with our patients, staff and other agencies.
•• 69% decrease in clinical care-related complaints
showing that we are delivering better care.
•• Small increase in complaints related to physical
assault by a patient. Complaints of this nature are also
captured within safeguarding processes thus ensuring
a timely and effective management response.
See graph on page 26
Partnerships in Care Quality Account 2012/13
25
Patient experience
Patient experience
Complaints
140
120
Complaints Received
100
80
60
40
20
*includes premises, food, etc.
Visiting arrangements
Various
Staff conduct
Sexual assault by staff
Sessions, incl. OT
Sexual assault by patient
Restraint
Security/safety
Privacy/dignity
Racial harassment
Physical assault by patient
Other
Patient leave/access
Nursing care
April 2012 - March 2013
April 2011- March 2012
**includes access to records, consent, etc.
2.9 Patient, carer, family
involvement
PiC continually involves patients and their carers in
decisions surrounding their care and treatment and living
conditions as well as family involvement where possible
for support. We continuously use information, gathered in
a number of ways, to improve the quality of our services.
Some of the ways patients and carers engage include:
•• Local Carers Survey
•• Local Carers days where carers are invited to meet with
clinical and management teams
•• Annual Patient Satisfaction Survey
•• Care Programme Approach Survey
•• My Shared Pathway Survey
•• Weekly ward Patient Meetings
•• Patients Councils – including a representative from
each ward
•• Patient Recovery and Outcomes group chaired by
patients
•• Logs for recording ideas, suggestions and complaints
that can be resolved at ward level
•• Patient representation on Hospital Governance Groups
•• Formal Complaints Procedure
26
Medical care and treatment
Legal matters**
Loss/damage of property/valuables
Environment and domestic*
Information/communication*
Discrimination
Clinical care
Complaints process
Bullying/harassment by staff
Bullying/harassment by patient
Attitude of staff
Breach of confidentiality
Attitude by staff
0
Partnerships in Care Quality Account 2012/13
Highlights
•• Although we have seen a 5% reduction in the
number of complaints this year we have upheld
more complaints than in 2011/12. There has also
been a significant decrease in complaints relating
to communication and clinical care. This would
indicate that we are talking more effectively with
patients, carers and other agencies and that we
are delivering better care.
•• 80% of our patients reported in this year’s Patient
Satisfaction Survey that they are either sometimes
or always involved in the decision-making process
about their care and treatment
What our patients say
I went to ward round
and ask for a phone and
now I can ring my family and
text when I want to
PiC patient
Clinical effectiveness
Clinical effectiveness
3 Clinical effectiveness
3.1 Effective management of patient length of stay
By monitoring patient length of stay we help patients
step down to a lower level of security faster. In 2012/13
our annual number of patients discharged rose by 98% to
678 discharges (up from 342 discharges in 2011).
In 2011 we instructed Independent Social Research to
review our length of stay data. We then developed a
central management information system which tracks
and reports on patient movements between security
levels and reports as a dashboard. This supports the
commitment we made in last year’s Quality Account
to effectively manage length of stay (LOS). It also links
to our commitment to maximise the effectiveness of
care pathways, and to measure this in terms of positive,
recovery-focused patient outcomes.
By extending our care pathways across PiC we enable
consistency, where possible, access to the same clinicians
and treatment across security levels. This can speed
recovery and reduce the time of the discharge process.
The table below shows discharges grouped by diagnosis
and demonstrates how more patients are progressing
through PiC care pathways to successful discharge, even
at a time when patient numbers have grown by 29.9%.
We believe this illustrates customer confidence both in
our services and our commitment to patient recovery.
A patient’s length of stay should be the minimum
time required for a safe sustained recovery. This is a key
customer requirement. Through proactive use of our
bespoke Care Programme Approach, we are planning for
discharge at every stage of the patient journey and this
goes far beyond looking just at length of stay.
Patients discharged grouped by diagnosis
Diagnosis
Year of discharge
Change in number
2012
2011
2012
Acquired Brain Injury*
7
12
+5
Acute
–
212
+212
Learning Disability
64
64
0
Mental Illness
168
291
+ 123
Personality Disorder
44
47
+3
Total
283
626
+343
* Limited analysis due to sample size
We have exceeded occupancy
expectations this year and yet
managed to increase our discharge
rate. This shows the efficiency of our
teams and pathways, and most
importantly, our commitment for
patients to recover and return safely to
the community as quickly as possible
Dr Quazi Haque, Group Medical Director
Partnerships in Care Quality Account 2012/13
27
Clinical effectiveness
Clinical effectiveness
3.2 Delivering positive ward atmosphere
The EssenCES Ward Atmosphere Survey
At Partnerships in Care all our patients and clinical staff
are offered the opportunity to participate in the Essen
Climate Evaluation Scale (EssenCES) Ward Atmosphere
Survey twice a year.
This assesses the social and therapeutic atmosphere of
forensic psychiatric wards and is thought to be linked to
patient recovery and outcomes.
We review our scores year on year and results are shared
routinely with Patients Councils and at Ward Community
Meetings. Patients are actively encouraged to contribute
to the development of action plans to address any issues
identified for improvement. This year we benchmark our
scores against a UK average from Howells research and
find that all our scores are above average (table below).
The Howells paper was published in 2009 reviewing the
use of EssenCES across prisons, high secure and some
medium secure hospitals. The averages found in this
study have been used in the table below to benchmark
our performance across PIC for 2012/13. The table shows
PiC scores exceed the average scores from the research
for both staff and patients across the three domains of
patient cohesion, experienced safety and therapeutic hold.
2012/13 PiC scores by hospital benchmarked against 2009 UK average established by Howells study
Patient cohesion
Experienced safety
Therapeutic hold
PiC
Howells
PiC %
PiC
Howells
PiC %
PiC
Howells
PiC %
Staff
10.51
8.05
30.56
11.57
8.53
35.64
15.71
14.17
11.08
Patient
10.54
9.32
13.09
11.94
8.89
34.31
13.7
9.81
39.65
•
Howells (et al) (2009) The EssenCES measure of social climate: A preliminary validation and normative data in UK high
secure hospital settings.
Definitions:
•• Therapeutic hold – the extent to which the climate is
perceived as supportive of patients’ therapeutic needs
•• Experienced safety – the level of perceived tension and
threat of aggression and violence
•• Patients’ cohesion and Mutual support – whether
mutual support of a kind typically seen as
characteristic of therapeutic communities is present
Highlights
PiC scores exceed Howells research average •
UK scores for EssenCES across the three domains of:
•• Patient cohesion
•• Experienced safety
•• Therapeutic hold.
•• Conducting the EssenCES evaluations is part of our
continuing commitment to the standard NHS contract
for mental health services
What our patients say
The ward staff team began to make
me realise and understand how
engaging in activities made it all come
together and piece a jigsaw together for me
PiC patient
28
Partnerships in Care Quality Account 2012/13
Clinical effectiveness
Clinical effectiveness
The graph below shows PiC EssenCES scores for 2012/13 compared to 2011/12 for each of the three domains mapping
both staff and patient responses. The message is one of stability with a low level of variance.
PiC EssenCES scores for 2012/13 compared to 2011/12
Patient cohesion•
2011/12
2012/13
Experienced safety•
2011/12
2012/13
Reflecting on results above:
•• Patient cohesion – There is an increase in staff •
ratings of approximately 5% and a small reduction •
in patient ratings.
•• Experienced safety – There is a decrease in staff •
ratings of approximately 9% and an increase in patient
ratings of 3%
•• Therapeutic hold – Staff ratings have remained
approximately the same for both years and there is •
a slight decrease for patient ratings.
•• As can be seen from this there has been minimal
variation year-on-year with the maximum being a •
9% change in staff ratings for experienced safety.
35.6%
above UK average
– safety experienced
by PiC staff
56.52%
57.35%
56.86%
52.17%
45.59%
0
49.02%
10
54.9%
20
52.17%
30
48.53%
40
52.94%
50
43.14%
% in above average
60
60.78%
70
Staff Patients
Therapeutic hold•
2011/12
2012/13
Action plans arising from EssenCES
survey results
We have shared results and developed action plans
to improve ward atmosphere with patient and staff
groups. Initiatives for this year include:
•• Implementing the Supported Recovery Risk
Management system on appropriate wards
•• Increasing Real Work Opportunities across PiC to
promote social inclusion
•• Anti-bullying awareness training
•• Focus groups look into hospital/ward-specific
issues
•• In Wales and the West Midlands patients are
presenting My Shared Pathway to new staff on
induction; Senior Management Teams (SMTs) now
meet every other month with the Patients Council;
the Christmas pantomime and Summer Recovery
Week now form part of the hospital calendar
•• Learning Disability Services in Norfolk are running
Mindfulness skills groups for women; a seclusion
and restraint reduction strategy is being developed;
and Dialectical Behaviour Therapy (DBT) continues
to be implemented within the service, in support of
the three EssenCES domains.
Partnerships in Care Quality Account 2012/13
29
Clinical effectiveness
Clinical effectiveness
3.3 Health of the Nation Outcome Scales (HoNOS) survey
Last year we gave our commitment to establish paired
clinical outcome measures across all service lines and
with 100% of our secure patients receiving HoNOS
measurement we are pleased to report that 73% of these
have two completed and comparable HoNOS reviews
– that is 58% more patients scored this way than the
previous year.
For relevant patient groups the HoNOS outcome measure
is an important method for measuring their progress and
evaluating effectiveness of their current treatment and
care plan.
We continue to improve our systems for detailed data
capture to support patients in secure services being
assigned to mental health clusters and into the five
forensic pathways. We intend to be able to report on this
in 2013/14 Quality Account.
Total number of patients
1028
Total number of patients eligible for HoNOS
106
Total number of patients with HoNOS review
806
Total percentage of patients with two completed HoNOS scores
73%
Year on year comparison of PiC HoNOS scores
2011/12
2012/13
HoNOS
HoNOS secure
HoNOS
HoNOS secure
No. of patients with •
2 scores to compare
420
415
673
658
No. of patients with
improvements in score
183
175
269
208
% improvement in score
44%
42%
40%
32%
No. of patients •
maintaining same score
115
147
186
335
% maintaining same score
27%
35%
28%
51%
Total no. of patients •
with lower score
122
93
218
115
Reflection on results:
•• 82.5% of patients either maintained or improved their
HoNOS score in 2012/13 compared to 77% for last year.
Fluctuations take place in the course of the patient’s care
pathway, so that small deterioration or improvements may
not be significant. We have identified that patient length
of stay is not a significant factor in HoNOS score deviation.
We conclude that it is important to aggregate data over a
longer period of time. We will continue to monitor these
results over time through the clinical and outcomes
dashboard. We also plan to examine results in Mental
Health Clusters and the 5 forensic pathways.
30
Partnerships in Care Quality Account 2012/13
82.5%
of patients either
maintained or improved
their HoNOS score
this year
Clinical effectiveness
Stabilisation or improvement in
HoNOS score by security level
Service line
Patients stabilised
or improved
Security level
Patients stabilised
or improved
Autistic Spectrum Disorder
100%
Medium secure
67%
Learning Disability
83%
Low secure
67%
Mental Illness
83%
81%
Inpatient (locked)
rehabilitation
76%
Personality Disorder
Acquired Brain Injury
67%
Open rehabilitation
64%
What are HoNOS ratings?
HoNOS ratings are scales to measure the health and•
social functioning of people with severe mental illness. These were commissioned
by the Department of Health and developed by the Royal College of Psychiatrists
What are these used for?
The scales are completed after routine clinical assessments in any setting and
have a variety of uses for clinicians, researchers and administrators, in particular
health care commissioners and providers
Clinical effectiveness
Stabilisation or improvement in
HoNOS score by service line
3.4 Information Governance
Information Governance and Data Quality in Partnerships in Care
Q: Why is high quality information important?•
A: It underpins the delivery of high quality services and
helps staff provide the best possible care and advice
by having a complete picture.
Q: Why is an Electronic Patient Record (EPR) important?•
A:Having all information about a patient in one place
helps improve the security of information and
patient confidentiality.
Q: What are dashboards and why these important?•
A:Dashboards provide valuable clinical data to
clinicians helping them develop action plans to
improve quality.
At Partnerships in Care we continuously improve our
information systems to provide high quality, complete,
accurate and reliable data in line with our obligation to the
Department of Health.
As reported last year, we have customised CAREnotes
software to develop our Electronic Patient Record (EPR)
system aiming to have all patient information entered
into, and accessible from, a single database. We are pleased
to report that our EPR system has now been rolled out
throughout our organisation with functionality improving
continuously.
In 2012/13 we introduced Clinical and Outcome
Dashboards, which, through the Clinical Governance
structure, help to aid clinical decision-making across
service lines. We will continue to refine these with a view to
improving quality of the content, based on feedback from
clinical and management teams.
A snapshot of what a page from a PiC Dashboard using CAREnotes shows. Some instances of data compliance below
100% are highlighted in amber.
Partnerships in Care Quality Account 2012/13
31
Clinical effectiveness
Clinical effectiveness
Information Governance and data
achievements in 2012/13
•• CAREnotes EPR across all services and locations
•• a reduction in the number of systems where personal
identifiable information is being held
•• the appointment of an Information Governance Officer
who will ensure our systems comply with national
standards
•• Clinical and Outcome CAREnotes Dashboards
•• An Information Governance Group with an identified
lead for each hospital and region
•• Reduced unconfirmed clinical note entries from over
7000 in January to under 2000 by March 2013.
Priorities for 2013/14
In March 2013 we started to audit and map additional
information to transfer to CAREnotes in a programme of
on-going improvement.
Outcomes planning software
engages patients
Improving patient engagement was highlighted by
the Francis report and remains a key focus for PiC. We
have worked closely with patients in planning their
own recovery and this has led to the development
of Outcomes planning software for use by patients
and their clinical team. This will be used to agree
recovery outcomes and related objectives. It will record
individual views on progress against objectives and help
ensure that the patient is living in the least restrictive
environment possible. In 2013/14 we will work with our
patients to embed this system and to integrate it with
our EPR system.
Future plans for our clinical
dashboards
Information that drives decisions is a key component of
high quality healthcare. Information that is hard to get
at, or does not drive decisions, reduces the time clinical
staff have available to care for patients. We aim to permit
our clinical teams to ‘return to care’ through having more
information more easily accessible.
We are working closely with clinicians to develop
dashboards to give meaningful clinical data relevant to
each clinician’s role. We have designed an InCharge Nurse
Dashboard to be used by Charge Nurses to help them run
their wards and this will be implemented this year.
In 2013/14 we will introduce more specific dashboards
within CAREnotes including one for physical healthcare.
3.5 Clinical Governance
Our clinical governance system is robust, accountable,
patient-centred and subject to a number of audit processes
to ensure that patient safety is paramount.
i. Key components of clinical
governance
Clinical governance is defined as a system through
which health service organisations are responsible and
accountable for:
•• Continuously improving the quality of their services
•• Safeguarding high standards of care
•• Ensuring the best clinical outcomes for patient care
•• Creating an environment in which excellence in clinical
care will flourish
This requires:
•• Placing the patient at the centre of care
•• Commitment at all levels of management within PiC
•• The creation of an organisational culture that is
conducive to provide high quality and safe care for
patients. This culture should be characterised by shared
passion for quality, openness, respect, support and
fairness
•• Timely accurate information on patient progress for
healthcare workers
•• Effective teamwork, managing health and health care
risks and ensuring clinical efficiency and effectiveness
32
Partnerships in Care Quality Account 2012/13
The report High Quality Care For All (Lord Darzi, 2008)
highlighted Patient safety, Clinical effectiveness and Patient
experience as the key components to providing a first class
health service.
Among recommendations within the Francis Inquiry
Report (2012) is the need to improve transparency in
how providers use and share information and use patient
feedback. Ways we listen to our patients include surveys,
patient forums, patient and carer groups, while this is
built into daily ward routines, our bespoke CPA process,
and one-on-one protected patient time (PPT). Within PiC
we do this in a number of ways, (see diagram below).
In PiC we learn lessons from:
•• Incident management
•• Serious Untoward Incidents
•• Clinical and outcomes dashboards
•• CQC and PCA visits
•• Regular feedback from patients, families and friends
•• External quality assurance processes
•• Clinical Audits
Clinical effectiveness
Commissioners
and
regulatory
bodies
Patient
CPA
Co-ordinator
Friends,
families
and carers
Reg
Clin ional
ica
a
PIC l gov nd C
er
a
n
d
ex n
t
ws
sho taff,
d
roa and s es
e
v ts com
en Out P
d MS
s,
MDT
team
and
&S
;
l H ture
tra ruc
en ce st audit
an nal
er
Pa
netw tient
ork Cou
Sur s, Pa n
CPA ve ti
Su y, E
rve
Wh
ist
and leblo
Co w
nc
licy
Po e
ing rn lin
e
er
Car ction
d
an isfa
ic ls t Sat ES,
en senC ocacy
s Adv
y,
Clinical effectiveness
Windmill diagram showing how we listen to patients,
carers and stakeholders
Ch
invo ief Ex
R lvin ec
e
c
ove g pa uti
t
r
gro y an i
up
Diagram showing PiC’s ‘Board to ward’ clinical governance
Research
networks
PiC Board
including
Group Medical
Director
and Group
Chief Executive
PiC Clinical
Governance
Group (CGG)
chaired by
Group Medical
Director
Hospital
Clinical
Governance
Group
Regional Executive
Directors & Registered
Managers Clinical
Teams and all staff
caring for patients,
patient involvement in
all aspects of care
and treatment
Patient
Patient involvement
in all aspects of
care and treatment
Service line
specialist
networks
Partnerships in Care Quality Account 2012/13
33
Clinical effectiveness
ii. Audit and external quality assurance
Clinical effectiveness
During the reporting period for 2012/13 PiC was involved
in several external provider audits.
These included:
•• Royal College of Psychiatrists Prescribing Observatory
for Mental Health (POMH – UK)
•• Screening for metabolic side-effects of antipsychotic
drugs
•• Prescribing for people with a personality disorder
•• Quality Network for Forensic Mental Health (QNFMH)
annual Peer Reviews
•• NPSA (National Patient Safety Agency) Suicide Audit
•• NICE: Schizophrenia – Core interventions in the
treatment and management of schizophrenia in
primary and secondary care
•• Management of Violence and Aggression
iii. Quality Network for Forensic
Mental Health
QNFMH published its ‘Cycle 7’ report in May 2013 •
which relates to medium secure services. PiC performed
above the national average in this. Please see table and
graph below:
QNFMH measures
PiC
National
Average % Average %
Procedural security
99.6
96.0
Relational security
93.8
89.0
SUIs
96.4
92.0
Clinical & cost
effectiveness
91.6
86.0
Patient focus
89.4
83.0
Environment & amenities
84.7
82.0
Public health
98.3
95.0
QNFMH measures
120
PiC % Ave vs QNFMH % Ave
100
80
60
40
PiC Average National Score
20
0
Procedural
security
Relational
security
SUIs
Clinical &
cost eff
Patient •
focus
Env & amen
Public •
health
Low secure service peer review reports next year
QNFMH has more recently developed standards for low secure services The Quality Network for Low Secure Services is
undertaking its first (Cycle 1) reviews. This will provide information which we can report on in next year’s Quality Account.
34
Partnerships in Care Quality Account 2012/13
Clinical effectiveness
Objectives for 2013/14
In our commitment to drive quality PiC has been involved
in clinical innovations with a number of professional
networks and organisations. Innovations during 2012/13
which will build into new outcomes in 2013/14 include:
•• A patient outcome plan Project Lead - this work will
link outcomes with CPA to be piloted in 2014 and
reported in next Quality Account
•• Clinical Leads for each of our service lines will ensure
the validity and consistency of our clinical model as
this is modularised to fit with payment by results. The
aim is to concentrate resources on the most effective
clinical resources.
•• Professor Nick Alderman joined PiC as the Clinical
Director for PiC Brain Injury Services. He will oversee
the next phase of development of these services.
•• Drive for consistency in clinical delivery across PiC
v. Specialist Networks
We are driving quality in our Learning Disability and Brain
Injury services through specialist clinical networks. These
report in to our clinical governance framework.
Learning Disability Specialist Network
In 2011/12 the Care Quality Commission (CQC) became
more focused on the most vulnerable groups of patients,
i.e. those with communication difficulties such as those
with a Learning Disability, as a result of the abuse scandal
at Winterbourne View. During this time PiC launched its
Learning Disability Network to ensure our services are
effective and as safe as possible.
The network launched its own quality improvement
programme based on peer review incorporating:
•• CQC Outcome 4 (Care and welfare of people •
who use services)
Clinical effectiveness
iv. Clinical innovation
•• Outcome 7 (Safeguarding people who use •
services from abuse)
•• Medium Secure Learning Disability standards •
from the Royal College of Psychiatry
In 2013 the CQC has rated all our Learning Disability
services that they have visited as 100% compliant with
these outcomes.
With the launch of the network and through peer •
review, we have been able to share best practice
across our services and incorporate this into quality
improvement plans.
Brain Injury Services Specialist Network
This forum brings together Brain Injury Services (BIS)
expertise across PiC with the aim of consistency in •
service delivery, responding to national initiatives and •
to drive quality
PiC BIS is a member of the Independent Neurorehabilitation Providers Alliance (INPA) which regularly
reviews outcome measures and research in this field. We
are also members of the UK Brain Injury Forum, UKABIF.
BIS developed two bespoke clinical tools - TRIP Treatment Rehabilitation Interdisciplinary Pathway and
BUILD - Behaviour Understanding and Independent Life
Development.
Our BIS services exceeded 2012 CQUIN standards which
were set by the PCT funding group of NHS Norfolk, Great
Yarmouth and Waveney.
3.6 Payment by Results
Distribution of Patients into Forensic Pathways
In meeting CQUIN objectives in 2012/13 Partnerships in
Care has prepared to allocate patients with mental illness
who are within secure services to clusters, then into
forensic pathways. This is in preparation for forthcoming
initiatives to introduce Payment By Results (PbR) into
secure services. By the end of March 2013 over 150
patients had been allocated into Forensic Pathways. The
table below shows how our patients distributed across
the clusters and their average age. Category 4 is the least
populated, consistent with a reduction in prison transfers
over the last 12 to 24 months. We will continue to track
this information through 2013/14 to see if trends emerge
by pathway, gender and security level with further
numbers of patients being allocated into these pathways.
Pathway
% in
Pathway
Average
Age
0
1
Treatment
responsive
14.93
32
2
Treatment resistant
- Challenging
behaviour
23.53
33
3
Treatment resistant
- Continuing care
14.48
40
4
Personality Disorder
- prison transfer
1.81
43
5
Personality Disorder
- co-morbidity
20.36
35
Partnerships in Care Quality Account 2012/13
35
Clinical effectiveness
Clinical effectiveness
3.7 Research and development
Partnerships in Care has a dedicated research and
development programme led by Professor Conor Duggan
OBE, and staffed by a number of award-winning •
clinical researchers. Research is central to the process •
of driving quality.
Our long-standing collaboration with the IoP was
reflected in 2013 in our tenth joint hosting of the
National Conference of Research in Forensic Mental
Health Services which promotes international •
forensic research.
In 2012 we strengthened our research infrastructure and
published a new policy document: ‘Conducting, hosting
or collaborating in research’ which offers protection to
researchers and research subjects and sets out clearly
how research will be conducted and approved, helping to
facilitate more research.
We have established research interest groups in Learning
Disability and in Severe Mental Illness/Personality
Disorder. These groups meet quarterly, with the venues
rotating at PiC units across the UK. These meetings are
open to anyone with an interest in research.
Strength in research improves the quality and expertise
of existing staff and positions us well to recruit and retain
leading clinicians.
In 2012 and 2013 we have won a number of research bids
that allow us to continue as a major contributor to new
knowledge in the field of specialist care.
Our Clinical Research Group in Forensic Learning Disability
is working with the University of Nottingham in research
to examine the characteristics and needs of long-stay
patients in high and medium security. Six PiC units will
participate in this research project.
•
Verity Chester, PiC research assistant, joint winner of
Institute of Psychiatry/PiC Young Scholar Award receiving
the award from Dr Quazi Haque.
We are now bidding to research the forensic aspects •
of autism.
We work closely with credible academic and commercial
organisations that share our values and commitment to
improving mental health services including The Institute
of Psychiatry (IoP), the Quality Network for Forensic
Mental Health Services, the Centre for Mental Health and
the NHS Confederation’s Mental Health Network.
36
Partnerships in Care Quality Account 2012/13
Partnerships in
Care is driving
quality through
research
Clinical effectiveness
Our contribution to research 2012/13
Haque Q, Webster C (2013)
‘Structured Professional Judgement and
Sequential Redirections: In press.
Webster C, Haque Q & •
Hucker S (2013)
Violence Risk Assessment and Management
Wiley
Thomas C (2012)
Mindfulness: A reflection
Clinical Psychology & People with
Learning Disabilities, 10(3) 47- 49
Chester V, & Morgan W (2012)
Relational Security in Secure Services:
Summary of Findings from a Literature Review
Quality Network for Forensic
Mental Health Newsletter, Issue 20.
Chester V (2012)
An evaluation of measures of relational
security used within secure services
International Association of
Forensic Mental Health Services
(IAFMHS) Maastricht, Netherlands
Gilulley, M. Cree, A., Thompson, S., &
Haque, Q (2013)
The Evaluation of the Impact of CCTV in a
Forensic Healthcare Setting
International Association of
Forensic Mental Health Services
(IAFMHS) Maastricht, Netherlands
Alexander R, Chester V, Gunaratna I,
Hoare S, Green F (2013)
Patients with fire setting in a forensic service in
intellectual disability: A comparison of clinical
and forensic variables
International Association of
Forensic Mental Health Services
(IAFMHS) Maastricht, Netherlands
Devapriam J, Alexander R (2012)
Tiered Model of Learning Disability Forensic
Service Provision
Journal of Learning Disabilities and
Offending Behaviour, 3(4)
Esan F, Pittaway M, Nyamande B,
Graham A (2012)
Shared Pathway national pilot project: the
experience of a secure learning disability
service
Journal of Learning Disabilities and
Offending Behaviour, 3(2) 98-110
Esan F, Case K, Louis, J, Kirby J,
Cheshire L, Keefe, J, Petty M (2012)
Implementing a patient-centred recovery
approach in a secure learning disabilities
service
Journal of Learning Disabilities and
Offending Behaviour, 3(1) 24-35
Alexander R.T, Green FN,
O’Mahoney B, Gunaratna IJ,
Gangadharan SK, Hoare S (2010)
Personality disorders in offenders with
intellectual disability: a comparison of
clinical, forensic and outcome variables and
implications for service provision
Journal of Intellectual Disablity
Research, 54 (7) 650-658
Ahmed U, Gibbon S, Jones H,
Huband N, Ferriter M, Vollm B,
Stoffers JM, Lieb K, Duggan C
(2012)
Pharmacological interventions for avoidant
personality disorder – Protocol
Cochrane Reviews
Alexander RT, Chester V, Gray, NS,
Snowden RJ (2012)
Patients with Personality Disorders and
Intellectual Disability – Closer to Personality
Disorders or Intellectual Disability? A Threeway Comparison
Journal of Forensic Psychiatry and
Psychology, 23(4) 435-451
Duggan C (2012)
Managing personality disorder in the
community
Chapter in Forensic Psychiatry
Duggan C, Hilder A, Maden A,
Moore T, Taylor P (2011)
Personality Disorder in clinical, •
legal and ethical issues
Eds J Gunn & PJ Taylor 2nd edition
Howard R, Khalifa N, Duggan C,
Lumsden J (2011)
Are patients deemed ‘dangerous and severely
personality disordered’ different from other
personality disordered patients detained in
forensic settings
Criminal Behaviour and Mental
Health
Khalifa N, Duggan C, Lunsden J,
Howard R (2011)
Early-onset alcohol abuse and impulsivity
partially mediate effects of childhood conduct
disorder on adult antisocial behaviour
Personality Disorder: Theory,
Research and Treatment
Howard R, Huband N, Duggan C
(2011)
Antisocial syndrome with co-morbid borderline Annals of Clinical Psychiatry
pathology: association with severe childhood
conduct disorder
Clinical effectiveness
Research on treatment effectiveness and patient outcomes
Research on Learning Disability
Research on Personality Disorder
Research on vocational rehabilitation
McQueen J, Turner J (2012)
Exploring forensic mental health service
users views on work: An interpretative
phenomenological analysis
British Journal of Forensic Practice
Partnerships in Care Quality Account 2012/13
37
Patient safety
4 Patient safety
Patient safety
Partnerships in Care (PiC) Health and Safety Committee (HSC) meets quarterly to review best practice for patient
safety and risk management of hospital environments. A number of specific committees report to the HSC. This year,
PiC combined its Infection Prevention Control team (IPC) with our Practice Nurse Group which looks after physical
healthcare. This formed the new Infection Prevention Control and Physical Health Committee which meets quarterly.
4.1 Physical healthcare
One of our quality priorities to improve clinical
effectiveness last year was to “Enhance physical care
through high quality regular health checks, screening
programmes, vaccinations and treatment.” During this
year we undertook a number of initiatives to improve
quality in this area, developing GP protocols, establishing
early warning systems and incorporating more physical
healthcare practice within our multidisciplinary teams.
All PiC clinical staff are trained in basic life support and by
2013/14 we aim to have increased this to intermediate
life support. Our recently revised Care Programme
Approach (CPA) documentation is again being revised to
include the 2013/14 CQUIN in regard to physical health.
Preventing physical ill health through
National Early Warning Score (NEWS)
In July 2012 The Royal College of Physicians published a
report ‘National Early Warning Score (NEWS) - Standardising
the assessment of acute-illness severity in the NHS’.
The remit of the working party was to develop a NEWS
system that could be adopted across the NHS to provide a
standardised track-and-trigger system for acute illness in
people presenting to, or within hospitals. This Early Warning
Scoring system was adopted by SLaM and they reported
that patient unexpected death rate reduced by 10%.
PiC introduced this system at Llanarth Court Hospital
in Wales as well as creating a Practice Nurse role. Staff
report they feel more confident when discussing physical
concerns they have about a patient with a doctor, as they
can refer to the Early Warning Systems chart and clearly
evidence any physiological deterioration. Due to the
success of this initiative this is being rolled out across PiC.
Virtual physical assessments
Sometimes patients refuse formal physical medical
assessment. In such cases, a GP can instead do a virtual
assessment using historical data, visual observation and
multidisciplinary team (MDT) discussion. This system has
been tried at services in Wales and will soon be rolled out
across PiC and built into our electronic patient record.
38
Partnerships in Care Quality Account 2012/13
NEWS
NEWS is a simple scoring system in which a score
is allocated to physiological measurements already
undertaken when patients present to, or are being
monitored in, hospital.
It takes into consideration:
•• Heart Rate
•• Systolic Blood Pressure
•• Respiratory Rate
•• Consciousness Assessment
•• Temperature
•• Oxygen Saturation
The final score prompts nursing staff on what
action needs to be taken when a patient presents as
physically unwell
Physical healthcare case study
Patient BE, a heavy lifelong smoker, was reluctant
to take part in any formal physical examination.
MDT undertook visual observation creating notes of
episodes of breathlessness and a productive cough,
suggesting the patient may be at risk of Chronic
Obstructive Pulmonary Disorder (COPD). This helped
inform the patient’s care plan.
Patient safety
4.2 Infection control
During this year we introduced an Outbreak
Management Pack. In the case of an outbreak of an
infection, all resources staff will find useful are in this
pack, giving clear guidance.
We continue to conduct a quarterly Infection Control
Audit which produces its own Quarterly Report.
Questions and Answers
Patient safety
Partnerships in Care meets national standards for
infection control and has an excellent record for clean
infection-free hospital environments. Last year we
reported on our new policy manual, training programme
and systems for reporting occurrences of infection.
Q. Why is infection control important in psychiatric
hospitals?
A. Psychiatric wards are not immune from the type
of infections that can occur in general hospitals so
preventative measures must be taken. All staff should
participate in this and patients should be made aware of
health and safety and infection control principles while
in the ward and after they leave.
4.3 Medicines management
We have robust policies for medicines management.
Our Corporate Medications Management Committee
monitors patterns of prescribing across our hospitals. In
2012, to strengthen our external quality assurance and
benchmark our performance we have entered into the
Royal College of Psychiatrists Prescribing Observatory for
Mental Health UK (POMH-UK).
This year, following consultation with medical and
nursing staff we:
•• reviewed and launched a new medicine card
•• trained four of our nurses in Non-Medical Prescribing (NMP)
•• introduced new internal audits
•• performed above national average in two POMHUK audits - Screening for metabolic side-effects of
antipsychotic drugs’ and ‘Prescribing for people with a
personality disorder’
•• In our annual patient satisfaction survey most patients
on medication reported that staff had explained the
purpose of the medication and the possible side effects
in a manner that they could understand.
•• Prescriptions are checked against both British National
Formulary (BNF) limits and against patient consent forms
Non-Medical Prescribing
This year PiC has safely introduced NMP for medical
prescribing into our service including service redesign,
governance, policy and audit through a specially trained
group of nurses from Stockton Hall hospital, working in
partnership with the NHS NMP group in their regions.
This has increased access and choice for patients
and has improved the quality and personalisation of
treatment.
Questions and Answers
Q: What is the Prescribing Observatory for Mental
Health (POMH – UK)?
A: POMH – UK is part of the Royal College of Psychiatry.
It shares member data to benchmark performance
nationally.
Q: How did PiC compare with the national sample
(TNS)?
A: PiC scored 90% compared to 81% for sampled service
providers on treatment target 4.
•• Stock control is audited regularly
•• Medicine Cards are audited quarterly
•• Pharmacy audits are reviewed locally
•• Audit themes are reviewed by our Clinical `•
Governance Group.
Strong
compliance
with POMH-UK
best practice
prescribing
standards
Partnerships in Care Quality Account 2012/13
39
Patient safety
PiC performance in two POMH-UK Audits in 2012/13
Audit 1 Screening for metabolic side
effects of antipsychotic drugs
We performed better than the average for the study
sample, which included 6,078 general patients and
1,224 forensic patients, on:
•• proportion of patients who do not smoke or have
been offered help with smoking cessation
•• measure of obesity / BMI measure of blood pressure
•• measure of plasma glucose
•• measure of lipid profile
Graphs to support above Audit finding. Please view
PiC’s results for Trust 99 shown as a purple dot
against the forensic total national sample (TNS)
shown in blue and the adult total national sample
shown in turquoise.
Audit 2 Prescribing for people with
a personality disorder
The sample size was 2,600 patients nationally. We
scored above average in that:
2012
2012
0
TNS ADT TNS Adult TNS Forensic
Trust 99
2012
2012
2012
2012
0
2010
20
2009
20
2008
40
2007
40
2010
60
2009
60
2008
80
2007
80
%
100
2006
PiC score on measure of dyslipidaemia
100
2006
%
Patient safety
PiC score on measure of plasma glucose
TNS ADT TNS Adult TNS Forensic
Trust 99
•• most of our patients have a crisis plan developed
with patient involvement
•• for over 90% of our patients we documented
the clinical reasons for having prescribed an
antipsychotic
•• we appropriately minimise the use of antipsychotics
and z-hypnotics for patients with a personality •
disorder (PD) diagnosis
•• we appropriately prescribe benzodiazepines for •
people with a PD diagnosis alone (i.e. no co-morbid
psychiatric diagnosis)
•• we matched the sample average for 4-weekly
documented prescription review.
Graph below illustrates PiC (Trust 99) performance
compared to the national sample for ‘Treatment
target 4’ which relates to approach to medication
reviews. Over the three desirable elements of
reviewing the patient’s therapeutic response,
side effects and the documenting of the review
PiC averages 90% compared to 81% for the service
providers included in the sample.
National and PiC results for treatment target 4 - approach to medication review
Proportion
prescribed
medication for
more than 4
weeks
TNS
T99
40
Proportion
of those
prescribed
medication
for more
than four
weeks with
documented
evidence of
a medical
review
Proportion of medication
reviews considering
Outcome of
medication review
documented
Therapeutic
response
Side effects /
tolerability
Yes, clearly
or partially
documented
82%
82%
84%
65%
94%
82%
94%
92%
53%
85%
Partnerships in Care Quality Account 2012/13
Patient safety
4.4 Positive risk management
i. Incidents
no.of incidents
4
2
Violence,/abuse
Self-harm
Other
0
•
Results include:
0.076
0.072
•• clinical incidents down 1%
0.068
ii. Reporting of Injuries, Diseases and
Dangerous Recurrences Regulations
1995 (RIDDOR)
0.064
0.060
6
Security incident
0.080
8
Personal accident
Recorded incidents per patient day
10
Ill health
In 2013/14 we will be moving to a completely electronic
incident reporting system which will reduce clinical
time needed to record incidents while providing better
quality and more timely information.
12
Clinical incident
We have seen a 13% increase in the overall number of
reported and recorded incidents,most of this increase
being minor incidents while more severe incidents have
decreased. There is a reduction of 1% in those incidents
categorised as ‘Clinical Incidents’.
2012/13
14
No. of incidents (0,000)
In 2012/13 we worked hard to increase the transparency
and accuracy of our incident reporting system, particularly
increasing reporting of minor incidents. At the same
time, we have increased patient numbers, occupancy
and therefore patient bed days as well as seeing a trend
towards taking increasingly challenging patients.
2011/12
16
Patient safety
Incidents by category
Fire incident
Managing risks – enhancing strengths
2010/11
2011/12
2012/13
The graph above shows an increase in the recorded
number of incidents per patient bed day indicating •
that there is greater reporting of less severe incidents
(level 1 - 4).
The total number of incidents for 2012/13 is 28,507
compared to 24,879 in 2011/12.
In 2012/13 PiC reported a total of 41 incidents in terms of
RIDDOR as a result of incidents requiring management of
violence and aggression. This is a reduction of 11% when
compared to the total of 26 for the previous year.
iii. Serious Untoward Incidents (SUIs)
To meet our commitment to enhance systems for
learning lessons from serious untoward incidents (SUIs)
we continue to maintain a central database of actions
taken by hospitals. Through clinical governance, we use
an alert system to enhance information and sharing
across hospitals post incident. By 2013/14 we will have
begun putting our SUIs into the NHS Strategic Executive
Information System (STEIS). To assist with this we are
developing our own electronic recording of SUIs and once
this has been tried and tested it will be integrated with the
electronic incident reporting system.Between April 2012
and March 2013, across all commissioner classifications
there were between 10 to 22 SUIs per month.
Partnerships in Care Quality Account 2012/13
41
Patient safety
Patient safety
Patients in mental health services can present with
a broad range of challenging behaviours. These
behaviours can present a risk to staff, other patients and
themselves as well as other risks such as unauthorised
leave and substance abuse. Recovery opportunity can be
linked to a patient’s own ability to manage risk.
START helps with this as it identifies the strengths and
weaknesses the person has in managing 20 risk factors
through using a strengths and vulnerability scale. We
use START regularly across all our service lines and as
part of our CPA process, we assess patients twice a
year. The graph below shows the results of two scores
compared for two tests six months apart during the
2012/13 year.
START is a multidisciplinary decision support guide (or
clinical guideline) designed for use in assessments by
mental health and forensic or correctional professions.
It identifies the strengths and weaknesses the person
has in managing 20 risk factors covering self as well
as other – directed violence, self-harm, victimisation,
unauthorised leave and substance abuse.
iv. Short Term Assessment of Risk and
Treatability (START)*
How PiC implements DoH principles on risk
management*
Department of
Health principles
Fundamentals
In reviewing the results of PiC’s initial START
measurements conducted over the last two years we see
in average scores:
•• an increase in strength scores for female (1.75) •
and male (1.56) patients
•• an increase in vulnerabilities scores for female •
patients (1.16)
•• a reduction in vulnerabilities scores for male •
patients (-0.36)
The graph below shows improvement in
comparable scores for mean strength.
Mean strength index
25
20
15
10
0
42
Mean score 1 •
Mean score 2
5
Male
Female
Partnerships in Care Quality Account 2012/13
•• We put recovery at the
centre of care
•• START places emphasis •
on patient strengths
Basic ideas in risk
management
•• We provide evidencebased harm reduction
treatments.
•• We use evidence-based
risk assessment tools
Working with service •
users and carers
•• We involve the patient.
•• We recognise diversity.
•• We involve family and
friends when possible.
Results of PiC START measurements of male and
female patients
We acknowledge that fluctuations take place in the
course of the patient’s care pathway, so that small
variations may not be significant. We conclude that it
is important to view this aggregate data over a longer
period of time.
Partnerships in Care
way of working
Individual practice and
team working
•• We provide specialist
training through
internationally •
recognised trainers.
*Department of Health (2007) Best Practice in
Managing Risk: Principles and evidence for best practice
in the assessment and management of risk to self and
others in mental health services
Patient safety
4.5 Safeguarding
Partnerships in Care (PiC) has a duty of care towards
all adults whose independence and wellbeing is at risk
due to abuse or neglect. The duty of care refers to any
persons over the age of 18 “who is in, or may be in need
of, community care services, by reason of mental or other
disability, age or illness and who is, or maybe unable to,
take care of him or herself, unable to safeguard him or
herself, or unable to safeguard him or herself against
significant harm”. (No Secrets 2000).
At PiC we investigate all allegations and incidents
where there may be a concern that abuse of patients
may have occurred. We also actively liaise with public
protection, healthcare and social care agencies to share
information in order to ensure that effective systems
are implemented to safeguard vulnerable adults from
abuse. Zero tolerance of abuse is the only philosophy
consistent with protecting a patient or resident.
Safeguarding adults is everyone’s business and therefore
it is the responsibility of all PiC staff to safeguard
vulnerable adults from abuse by undertaking their
duties and responsibilities as defined by our policy.
Patients / residents have a right to have their concerns
heard and to receive advice and support from staff.
Disclosures that abuse may have occurred are always
investigated through local procedures and escalated •
as required.
Clinical teams are responsible for ensuring that
a patient’s capacity is taken into account when
investigating any issues raised. Where patients / residents are considered to have
capacity in accordance with the Mental Capacity Act
2005, they are supported in making complaints or
grievances either through the PiC Complaints Policy, or a
criminal investigation can be sought through a referral
to the Police. If a patient is assessed to lack capacity,
necessary actions are taken on their behalf based on the
“best interest” criteria.
Independent advocacy involvement is encouraged
in order to develop transparency. Advocates forward
information about alleged abuse of patients /
residents to the relevant service in accordance with
their disclosure policy and at the earliest opportunity.
Wherever possible, this involves the consent of the
patient / resident who has disclosed the information.
Annual training of staff who are directly or indirectly
involved with vulnerable adults is provided to raise
awareness of their duties and responsibilities and
ensure a working knowledge of the local protocols.
Patient safety
“Safeguarding adults is everyone’s business.”
PiC ensures that all appropriate staff possess the
necessary knowledge to detect abuse and know how to
address the consequences of abuse. The following areas
are covered as a minimum:
•• All allegations and evidence of abuse are taken
seriously.
•• Appropriate support is provided to the victim(s) and all
other persons involved, including staff and patients
•• Staff are made aware of the indicators and symptoms
of abuse
•• Staff have an understanding of how to respond if they
discover abuse or receive a disclosure that abuse may
have happened
•• Staff receive annual Safeguarding Adults Training
•• Senior clinicians and managers understand the need
to liaise with outside agencies, including the Local
Authority, the Police and Case Managers.
•• All staff are aware of the PiC Whistleblowing policy.
•• All evidence of abuse is reported in line with the local
procedures
•• Staff receive and provide support appropriate to the
situation
Each service designates a person to fulfil the role of
Lead Officer for the safeguarding of vulnerable adults.
The Lead Officer is responsible to provide advice to staff
at the Hospital, monitor / review relevant policies /
procedures and liaise with external agencies, as required.
Each service maintains a database of Safeguarding
Alerts that allows for oversight and audit by the
Registered Manager / SMT and the local Clinical
Governance Committee.
Key information for patients and carers
Safeguarding adults is everyone’s business and it
is the responsibility of all PiC staff to safeguard
vulnerable adults from abuse.
PiC provides regular training to ensure staff possess
the knowledge to detect abuse and how to address
the consequences of this.
Patients / residents have a right to have their
concerns heard and to receive advice and support
from staff.
Disclosures that abuse may have occurred are
always investigated , initially through local
procedures and escalated as required.
Patients are supported in making complaints or
grievances as necessary and these are addressed in
an effective way.
Partnerships in Care Quality Account 2012/13
43
Patient safety
4.6 Seclusion as a last resort
Hospital managers review seclusions daily. We have seen
a significant reduction in both the number of seclusions
and the number of hours of seclusion in the majority of
PiC services.
45
35
30
25
20
15
10
5
0
High •
seclusion rates
Comparison of seclusion events
at Calverton Hill 2012/13
42.5
40
19.43
Outcomes of the review included updating our policy
and reinforcing that patient care and well-being is at the
centre of all interventions. A standard care plan is now
used which includes plans to reintegrate the person to
the ward as well as how to involve them in developing
their own de-escalation strategies.
Comparison of average seclusion hours for wards
with high and low seclusion rates
120
PiC•
Research
Low •
seclusion rates
PiC supports the view that seclusion should be used
only as a last resort and for the shortest possible time.
Seclusion is only used when the professionals involved
are satisfied that the need to protect other people
outweighs any increased risk to the patient and that any
increased risk for the patient can be properly managed.
A paper by W. A. Janssen (et al) (2007) looked at the
differences in seclusion rates between admission wards.
Wards with high seclusion rates were defined as those
with in excess of 10 hours per 1000 bed hours and those
with low seclusion rates as fewer than 10 hours per
1000 bed hours.
6.3
The Mental Health Act defines seclusion as “the
supervised confinement of a patient in a room, which
may be locked. Its sole aim is to contain severely
disturbed behaviour which is likely to cause harm to
others. Seclusion should be used only as a last resort •
and for the shortest possible time.”
Although we acknowledge that the sector lacks high
quality matched comparative data, when we look at
our performance against available research data we
benchmark very well.
1.85
We have seen a dramatic drop in the use of seclusion at
some of our hospitals this year as a result of innovation
and best practice.
How our seclusion numbers compare
Seclusion episodes
Patient safety
During 2012/13 we undertook an exercise to review and
improve our processes surrounding the use of seclusion.
We worked very closely with patients, registered
managers, clinical directors, lead nurses, governance •
and management teams.
80
When we reviewed our data using internationally
accepted definitions for what seclusion levels are ‘high’
or ‘low’ only 3 wards within PiC could be categorised as
having high seclusion rates.
96
No.of seclusion events
100
60
The graph above shows PiC’s average seclusion rates
remains lower than the Janssen research sample
whether compared to ‘high’ or ‘low’ wards.
40
16
20
0
Quarter 2 2012/13
Quarter 4 2012/13
Before and after: the graph above shows the number of
seclusions before actions were taken to reduce the use
of seclusion and the significant reduction after effective
action was taken.
44
Partnerships in Care Quality Account 2012/13
Patient safety
What do we have in place to avoid seclusion?
•• Robust job selection processes
•• Positive behaviour support
•• Many PiC services use RAID* which is an approach
which aims to teach staff a philosophy and practice
not only to deal with challenging behaviour when it
occurs, but also to prevent it by tackling it at source
•• Statements of Wishes which identify the patients’
views on how they would like their behaviour managed
in certain circumstances.
•• Promote use of quiet areas of the ward
Patient safety
•• High quality MVA training including de-escalation
4.7 Security
Partnerships in Care trains all patient-facing staff well
on the therapeutic use of security, risk management,
health and safety, de-escalation techniques, ethical
restraint and management of violence and aggression.
Security is a broad descriptor that embraces a wide
range of activities relating to patients, buildings,
property, staff and visitors. We follow all national
guidance and good practice and include a patient
perspective in policy development and review, overseen
by our Director of Policy and Regulation.
PiC has diverse operations and patient groups and
inevitably, there are local variations. Local security
policies are informed by the corporate security strategy.
In 2012/2013 our security policies were updated to
reflect changes in guidance.
The level of compliance achieved is measured through
an audit process conducted locally by the Group Security
Officer.
A number of initiatives have been introduced or
enhanced through the year including:
The SEE, THINK, ACT document (Department of Health
2010) is embedded into our security training in PiC’s
North West region. We wished to help staff understand
the relationship between therapeutic security and
recovery, so we revised our training and directly involved
patients, which gave a strong patient perspective to
trainees. Our staff realise that therapeutic security is
important in patient care and is a factor in recovery.
Patients voiced their opinions and told first hand of
their own experience of security in a professional forum.
Patients who participated reported they:
•• increased self-confidence and self-esteem
•• improved relationships with staff
•• developed new skills
This project has improved the quality and impact of
training, communication between staff and patients.
This initiative was recognised as a finalist in the
innovation and training category of the Laing & Buisson
2011/12 awards.
1. Development of a competency-based ‘security
portfolio’
2. Rationalisation of security information within
CAREnotes
3. Development and delivery of Security Leads training
package including tools for use when gathering and
analysing security intelligence
*Rapid Assessment Interface and Discharge (RAID)
Partnerships in Care Quality Account 2012/13
45
Supporting our workforce
Supporting our workforce
5 Supporting our workforce
5.1 Our staff
Partnerships in Care employs more than 3,000 staff and
is committed to improving the quality of life of both our
patients and our workforce. We recognise that our staff
are our greatest asset and we are proud of their skill,
talent and dedication.
We offer industry-leading induction, training and clinical
career development opportunities, staff benefits and
above industry average staff retention rates. Absence
rates are reasonably low at an average of 3.4%.
Staff by type
25.9%
We have a confidential concern line that can be used
by staff in the confident knowledge every report will be
investigated.
Among our staff benefits is access to free counselling
and advice through Care first, a confidential employee
assistance scheme. We offer life insurance, pension scheme
and medical insurance and an attractive range of optional
employee benefit discount schemes such as help with child
care, dental treatment costs and travel insurance.
Staff retention
39.2%
4.7%
1.6%
1.7%
67.8%
Nurses, HCWs, OT, Counsellors Support services and administration
Psychiatrists and psychologists
Social workers 46
Partnerships in Care Quality Account 2012/13
59.1%
1-5 years 5-20 years
More than 20 years
Supporting our workforce
Our company-wide staff engagement survey conducted
over three weeks in June/July 2012 showed our staff are
more satisfied than when last surveyed in 2010.
Supporting our workforce
5.2 Staff Survey
satisfaction from the work I do”, “My line manager acts in
accordance with our values” and “I would recommend PiC
to my family and friends as a good employer” among six
key questions to test levels of staff engagement.
79.0% of respondents answered favourably with either
an agreeing or strongly agreeing statement such as “I get
Results of staff survey
Overall staff satisfaction
79.0%
My line manager acts in accordance
with our values
86.0%
My line manager gives me the support •
I need in order for me to do a good job
79.9%
I would like to fulfill my career •
ambitions with PiC
79.7%
I get recognition for a job well done
64.4%
I get satisfaction from the work I do
87.7%
I would recommend PiC to family and
friends as a good company to work for
72.3%
0
20
40
60
80
Satisfaction %
Following the Staff Survey all hospital sites developed action plans to deal with any issues raised and to strengthen
staff engagement even more.
5.3 Learning and development
Partnerships in Care values learning and development
programmes which positively impact on staff motivation
and skills and also make a real difference to the patient
experience.
Staff and patient safety demands training in deescalation, management of violence and aggression,
ethical breakaway techniques and basic to immediate •
life support training for all patient-facing staff. Our
induction programme covers 40 key policy areas. •
We run a comprehensive programme of all mandatory
training. The table on page 48 shows compliancy across
the company.
Our clinical training programmes are constantly reviewed
so they are evidence-based and inform best practice
within PiC. Towards the end of 2012 we revised our
Management and Leadership training framework. As we
move into 2013/14 we are running new supervisory and
middle management training.
We also develop our staff through practice development
forums, coaching, reflection, supervision, e-learning,
sharing best practice days, newsletters and our annual
sharing best practice conference. We identify needs
through appraisals, business objectives and listening to
patients and staff.
Partnerships in Care Quality Account 2012/13
47
Supporting our workforce
Supporting our workforce
PiC training compliancy figures as at 31st March 2013
Breakaway
82%
Clinical Risk Management
81%
Complaints Procedure
94%
COSHH Awareness
95%
CPR & Defibrillation
70%
De-escalation
85%
Display screen equipment and
work station awareness
Equality, Diversity•
and Human Rights
98%
92%
Fire Evacuation
95%
Fire Safety Awareness
85%
First Aid at Work
97%
Food Safety
83%
Health & Safety Refreshers
79.%
Infection Control
90%
Information Governance
91%
Medicine Management
99%
Mental Health Code of Practice•
and Mental Health Act
85%
Moving and Handling
79%
Management of Violence•
and Aggression
90%
Rapid Tranquilisation
99%
Safeguarding vulnerable•
adults level 1
90%
Security
85%
Special observation and Recording
99%
Working at heights
100%
100
90
Partnerships in Care Quality Account 2012/13
80
48
70
60
50
40
30
20
10
0
Compliancy %
Supporting our workforce
We are committed to supporting the development of
professional careers and have strong connections with
universities including York, Leeds, London Metropolitan,
Essex, Cardiff, Glamorgan and also Brighton and Sussex
Medical School (BSMS). We entered into a teaching
contract with BSMS in July 2012 which means The Dene
now takes third year medical students on their psychiatry
rotation. We plan for The Dene to become a recognised
partner and become a Teaching Hospital of BSMS.
I feel that I was welcomed
to the setting by all staff,
particularly the MDT, who took the
time to explain terminology, mental
illness and individual clients.
This has been crucial to my learning
experience. Owing to the involvement
in the team dynamic, I felt a part
of the MDT
OT student
We had very limited teaching
and inpatient contact elsewhere
in our psychiatry rotation so valued
this experience and the opportunity to
witness meetings with the hospital
managers, ward reviews and risk
assessments. It also gave us valuable
opportunity to practice our historytaking and we really appreciate the
feedback for improvement and thank
you for the time you spent with us
Medical student
Supporting our workforce
5.4 Clinical career development
I would just like to give you
some feedback for our rotation
at The Dene in Hassocks.
We found it to be a thoroughly
worthwhile and enjoyable experience.
The staff were really friendly and the
insight we gained into the mental
health service was very in-depth
Medical student
Highlights
•• We foster a culture of excellence through clinical
leadership
•• We offer student placements across all specialist
healthcare professions
•• The Dene and Brighton and Sussex Medical School
have formed a teaching partnership for clinical
psychiatric placements for medical students
•• The absence rate within PiC is below the NHS
average
•• PiC operates an Employee Assistance Programme
for all staff.
•• Most PiC staff are satisfied with their working
environment and their job
•• Our new Management and Leadership framework
is improving our workforce
•• Our compliance with mandatory training
requirements remains high
Partnerships in Care Quality Account 2012/13
49
How this report was developed
This Quality Account has been developed with input from many staff groups across PiC from research and evaluation
studies conducted both by PiC and by external organisations including CQC, HIW, HIS, QNFMH, and POMH-UK. Namely
information has been provided by the Group Medical Director, the Clinical Governance Committee and the Data
and Information Department. Our communication team has helped make the information accessible in terms of
presentation and illustration.
A number of stakeholders have been asked to review the document before publication and their views are reflected below:
I valued the opportunity to read Partnerships in Care’s Quality Account prior to its publication.
The document contains the kind of in-depth and benchmarked clinical data which we require
to make sound commissioning decisions. I would like to add that the PiC contract monitoring returns
are always on time and are really excellent
Sarah Edwards, Complex Needs Commissioner, Worcestershire County Council
It is encouraging to see the integration of service provision and client involvement and a
focus on delivering a quality service described in the document. The quality framework and
achievements highlighted in the report enable staff, patients and the public to grasp a full picture of
the progress made by the group and the areas to focus on in the coming year
Andrea Spyropoulos, President, Royal College of Nursing
I am proud to have been given the opportunity to read the PiC Quality Account 2012/13 prior
to its publication.
I have been very pleased to read that PiC have achieved many of their quality targets from 2012 and
are planning on building on these achievements in the coming year. In particular, I am delighted by
PiC’s successful implementation of My Shared Pathway over the past year and their commitment
to continue to take this forward. I am also particularly impressed by their clear commitment to
improving patient experience, and that they have made this one of their quality pledges for next year.
Projects such as the Real Work Opportunities programme contribute so much to a person’s recovery
and sense of wellbeing. Overall, I am very pleased to endorse this Quality Account as being an
excellent reflection of PiC’s commitment to providing high quality care for all its service users
Ian Callaghan, National Service User Lead, My Shared Pathway
As Associate Director for Families and Mental Health at the Centre for Social Justice (CSJ) I
greatly appreciated the opportunity to view the Partnerships in Care Board’s Statement on
Quality in advance of its publication.
In a recent policy report, sponsored by PiC, the CSJ emphasised the need to “complete the revolution
in mental health care by ensuring that safe and therapeutically robust hospital care is complemented
by superb community-based services which work in respectful partnership with friends and which
enable people to rebuild their lives and escape disadvantage wherever possible”. I welcome that
aspects of PiC’s strategic direction and priorities laid out in this Quality Statement are in keeping
with these aims
Samantha Callan, Centre for Social Justice
Please give us your feedback
This is our fourth Quality Account, published as a
regulatory requirement and available on the NHS
Choices Website as well as sent to the Secretary of
State.
We welcome readers’ comments. Please email
Partnerships in Care Communications Team at •
info@partnershipsincare.co.uk or write to:
50
Partnerships in Care Quality Account 2012/13
Communications Team
Partnerships in Care
2 Imperial Place
Maxwell Road
Borehamwood
Hertfordshire
WD6 1JN
Glossary
ABI
Acquired Brain Injury
NHS
National Health Service
ASD
Autistic Spectrum Disorder
NICE
BIS
Brain Injury Services
National Institute for Health and Care
Excellence
BSMS
Brighton and Sussex Medical School
NLC
North London Clinic
BUILD
Behaviour Understanding and
Independent Life Development
NMP
Non Medical Prescribing
NPSA
National Patient Safety Agency
CSJ
Centre for Social Justice
OT
Occupational Therapy
CGC
Clinical Governance Group
PbR
Payment by Results
CPA
Care Programme Approach
PCA
Provider Compliance Assessment
CPR
Cardio pulmonary resuscitation
PD
Personality Disorder
CQC
Care Quality Commission
PiC
Partnerships in Care
COPD
Chronic Obstructive Pulmonary Disorder
POMH-UK
CQUIN
Commissioning for Quality and
Innovation
Prescribing Observatory for Mental
Health (Royal College of Psychiatrists)
QIPP
EPR
Electronic Patient Records
Quality, Innovation, Productivity and
Prevention
EssenCES
Essen Climate Evaluation Scale
QNFMHS
Quality Network for Forensic Mental
Health
IMHA
Independent Mental Health Advocate
RAG
Red Amber Green
IBM SPSS
Statistical Product and Service Solutions
RAID
IoP
Institute of Psychiatry
Rapid Assessment Interface and
Discharge
HCR-20
Historical/Clinical/Risk Management 20
RC
Responsible Clinician
HCW
Healthcare Worker
RCN
Royal College of Nursing
HDU
High Dependency Unit (within inpatient
rehabilitation services)
RCPsych
Royal College of Psychiatry
RIDDOR
Reporting of Injuries, Diseases and
Dangerous Occurrences Regulations
HoNOS
Health of the Nation Outcome Scales
HIS
Healthcare Improvement Scotland
RWO
Real Work Opportunities
HIW
Health Inspectorate Wales
SMT
Senior Management Team
HSC
Health and Safety Committee
SUI
Serious Untoward Incident
LD
Learning Disability
START
LOS
Length of Stay
Short Term Assessment of Risk and
Treatability
ST1-20
MDT
Multidisciplinary team
CPA standards against which
performance is measured
MHA
Mental Health Act
STEIS
MI
Mental Illness
NHS Strategic Executive Information
System
My Shared Pathway
TNS
MSP
Total national sample
Management of Violence and Agression
TRIP
MVA
Treatment Rehabilitation
Interdisciplinary Pathway
NEWS
National Early Warning Score
UKABIF
UK Acquired Brain Injury Forum
Partnerships in Care Quality Account 2012/13
51
Changing lives for the better
Our values
Valuing people
Respecting our staff, patients, their families and communities
Caring safely
Caring safely for ourselves, our patients, our customers
and communities
Integrity
Uncompromising integrity, respect and honesty
Working together
Working together with everyone
Quality
Taking quality to the highest level
For further information please
visit our website:
www.partnershipsincare.co.uk
Email us on
info@partnershipsincare.co.uk
Or call our head office
020 8327 1800
020 8327 1900
Central Referrals 0800 218 2398
Partnerships in Care
2 Imperial Place
Maxwell Road
Borehamwood
Hertfordshire WD6 1JN
Registered in England Number
05409563