Quality
Account
2012/2013
Contents
Part 1: Statement on quality from the Chief Executive,
Steve Shrubb
Part 2: Priorities for improvement & statements of assurance from the Board
Looking back - Our quality priorities 2012/13
Looking forward - Our quality priorities for 2013/14
Statements of assurance from the Board
1. Review of services
2. Participation in clinical audit
3. Participation in clinical research
4. Goals agreed with commissioners: Commissioning for Quality & Innovation payment framework (CQUIN)
5. Care Quality Commission registration
6. Quality indicators
7. Data quality
Part 3: Information on the quality of the services
Message from the Medical Director, Dr Nick Broughton
What service users, carers and the public say – key messages and action
taken during 2012/13
1. From our clinical service areas
2. From complaints received
3. In response to Incidents and serious Incidents
4. Safeguarding children and vulnerable adults
What others say about our services
Other quality improvements in 2012/13
Annex 1: Statements from Local Involvement
Networks, Overview & Scrutiny Committees and Primary Care Trusts / Commissioners
Annex 2: Statement of Directors’ responsibilities
Annex 3: Internal reporting structures
Annex 4: West London Mental Health NHS Trust services
Annex 5: Independent Auditor’s Limited Assurance Report
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quality account
Part 1: Statement on quality from
the Chief Executive, Steve Shrubb
Welcome to our fourth Quality Account, which
summarises the work we’ve done during 2012/13
on improving the quality of our services and
our plans for the year ahead. We have a quality
strategy, which all of our Board members have
signed up to, which sets out our quality priorities
and the actions we’re taking to deliver high quality
services to all who come into contact with us.
It’s been nearly a year since I joined the Trust.
From day one I’ve been struck by the compassion
and quality of care I’ve seen from staff when I’ve
been out and about across the organisation. But
wherever I look I see colleagues working hard
to improve the quality of care and service user
experience while laying firm foundations for the
Trust’s future. For example this year we have
launched a staff engagement project to help
us address the issues raised by staff about their
experiences of working here. The starting point
was the recruitment of 30 staff reporters who have
gone out and interviewed ten of their colleagues
to get clear information about what it’s like to be
a member of staff here and what we need to do
to make things better. This project is important to
us because we know that engaged staff provide
better quality patient care and we’re now working
on an action plan to address the issues raised by
staff. This year we’ve also completed a full review
of our service user and carer involvement which
will inform how we move forward and drive further
improvement in this area.
Thanks to the hard work of our staff we remain
registered without conditions with the Care Quality
Commission’s regulations.
The role that each and every one of us plays
in delivering safe, effective and continuously
improving care has been brought home forcefully
this year by the Francis report into what went
wrong at Mid Staffordshire hospital. We need to be
mindful of its findings in all the decisions we make
and in everything we do, which is why the report’s
findings have been discussed by our board and
communicated to staff in our organisation.
This Quality Account provides detailed information
on the quality of our clinical services. We highlight
a number of areas where there have been
improvements this year and some areas where we
know further improvement is required.
As we were reminded in the Francis report, it’s
critical that we engage with and listen to our staff,
service users, their carers and the wider public. In
this Quality Account we share some of the feedback
we’ve had from stakeholders, along with the actions
we have taken to address the issues raised.
Quality will remain the Board’s overarching priority
as we strive to provide excellence in mental health
care across the communities we serve.
To the best of my knowledge the information
contained in this Quality Account is accurate.
Steve Shrubb
Chief Executive
Quality is central to our values and is fundamental
to the ways in which we conduct our business
as we strive to become a foundation trust
in 2014. Becoming an FT is all about demonstrating
that we can consistently deliver the very highest
standards of care.
2012/2013
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Part 2: Priorities for improvement
Looking back - Our quality
priorities 2012/13: what were they,
why and how did we do?
Local Services Clinical Service Unit:
Clinical effectiveness
Improve communication with Primary Care
Why did we focus on this?
Good communication between ourselves and primary care is a vital component of safe
and effective care. We have received feedback from both GP and service users that
communication between us can be improved.
What did we aim to do?
We aimed to improve communication through some specific initiatives. These included
piloting the “Choose & Book” on-line referral system between assessment teams and
primary care teams; ensuring that local GPs receive regular written updates regarding
service changes; and obtaining feedback by regular face-to-face contact with GPs and
other more formal feed back mechanisms.
What did we expect
to achieve?
We aimed to improve referral times, provide more timely information and obtain
feedback from GPs.
How did we plan to
monitor and report?
We established a GP engagement project group, chaired by the Head of Partnerships
and attended by the Director of Primary Care and Clinical Director, which
monitors progress.
How well did we do?
The Choose and Book on-line referral system was introduced in two boroughs.
We have received positive feedback and it has resulted in faster appointment times.
The waiting time between referrals and first appointment for the reporting period
was 5 weeks.
We obtained feedback from GPs via the recently established integrated care pilot (ICP)
groups. Feedback included that the recently introduced GP advice lines were much
appreciated but that they were confused about recent service changes and that they
wanted more information.
As a result of the GP feedback we developed a GP portal on the WLMHT website. This
provides a service directory of all our local services, advice for GPs on making referrals
and relevant clinical information.
What next?
We need to understand why uptake of the Choose and Book system is variable and
work with our commissioners to increase use of the system, and explore the possibility
of introducing it in Ealing. We are introducing regular monitoring of referral to
assessment times on community dashboards.
We will continue to develop our GP portal and explore other ways of providing useful
information to local GPs.
We will continue to obtain feedback from GPs via the ICP groups, and look for other
opportunities to obtain feedback.
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quality account
What else?
Improving physical health care on inpatient units and CAMHS
People with mental health problems have a high
mortality rate. Addressing physical health needs
is as important as addressing mental health
needs and having the right resources to do so is
paramount to achieving good standards of care.
We have established a CSU physical health group
to oversee the development of physical health
procedures across the services. All patients have
an assessment of their physical health within 72
hours of admission and a care package for each
patient is developed to meet their needs.
Standards for physical health are set. All wards
have physical health equipment to ensure an
immediate response in the event of a medical
emergency in the unit. Staff have the appropriate
training in managing physical emergencies.
The 72 hour assessments of physical health
at admission are performance monitored.
Medical equipment is checked daily/weekly and
monthly audits of the equipment takes place.
We are developing in-house training for staff to
ensure that their knowledge of physical health
is updated and continue to monitor mandatory
training for staff.
A programme of audits on physical healthcare
in CAMHS was completed, and the findings
and recommendations have been developed
into a quality improvement programme for
the coming year; safe prescribing in childhood
and adolescence, safety of physical healthcare
facilities, management of physical healthcare
needs in children with eating disorders,
ADHD, psychosis.
Integrated care pathway pilot for diabetes
Liaison Psychiatry Services have been participating
in the integrated care pathway pilot for patients
with diabetes across all three boroughs. This pilot
aims to improve patient outcomes and experience
through collaboration and coordination of care
across acute care, primary care, social care and
mental health trusts.
Developing professional relationships with
individual GPs from the majority of practices in
the three boroughs has resulted in reciprocal
learning between clinicians and high levels of
satisfaction from GPs regarding the contribution
from WLMHT staff at the multi-disciplinary
groups (MDGs).
Consultant liaison psychiatrists participate in
multidisciplinary groups alongside GPs to plan
care for the most complex patients, providing
expertise around the psychological and psychiatric
aspects of diabetes. Patients consent to have
their care discussed at the groups and are pleased
to know that communication between the
professionals involved in their care is happening
in a more effective and joined-up way.
As the ICP pilots expand this year, consultant
liaison psychiatrists will be participating in MDGs
for respiratory and cardiac conditions, as well as
developing community services for patients with
psychological and psychiatric problems related
to their diabetes.
Mobile/remote working in the community
The adoption of mobile working allows staff
the ability to work anywhere, irrespective of
place and time, enabling staff to access and
update information and communicate on the
go. Staff were issued with a mixture of devices,
laptops and Tough books providing healthcare
professionals with real-time access to valuable
records such as RiO, emails and the Trust-wide
database at the point of care delivery.
2012/2013
Mobile working also provides HCPs with
the means to better manage their time and
workload. They can communicate more freely
with colleagues and service users, and have
the flexibility to work in the office, in the
community or at home. It’s also an opportunity
for the organisation to modernise, develop more
streamlined service models and make better use
of valuable resources.
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The benefits realised through the introduction of mobile working in the community during 2012 are:• Reduced administrative time
Progress notes entered into the patient record within 24hrs.
• Improvement in care quality
Face to face contacts are generall­y increasing.
• Travel Savings in time and expenses
The Trust intends to extend this programme with a total of 607 Tough books in use in community care by April 2014.
Patient experience
Improve access to out-of-hours service
Why did we focus on this?
Previous feedback from community surveys indicated that service users did not feel they
had good access to help or advice outside of normal office hours.
What did we aim to do?
Provide a 24/7 telephone service for our service users and carers.
What did we expect
to achieve?
To provide support and advice to service users and carers 24/7.
How did we plan to
monitor and report?
We established a working group to oversee the introduction of the telephone service
which would include monitoring the outcome of all calls via a routine call back
service. The steering group includes clinical input to ensure that the service is safe and
follows agreed protocols.
How well did we do?
An initial pilot service was introduced, staffed by the contact centre. Calls were
transferred to on-call clinical staff. The number of calls quickly demonstrated that
there was a considerable demand for the service. Additional resources were agreed
and dedicated staff were recruited and trained to provide a stand alone service which
was not dependent on staff with other duties. The service is now established and the
number of calls continues to increase.
The results from the 2012 Community Mental Health Survey were published on the
Care Quality Commission website on Thursday 13th September 2012. In total there
were 242 responses, with the following results:
55% reported that they had the number of someone from their local NHS mental
health service to contact out of office hours.
35% said they had called this number, and 81% of these said they received the help
they wanted when they made contact.
The fieldwork to complete the 2013 survey is underway at the time of the report
and full report of the findings will be available to the Trust in July 2013. The Trust will
use this report to monitor progress with the intention of taking any action required
to make improvements.
What next?
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We will continue the service, monitor and respond to feedback from the call
back service, and look for other opportunities to integrate it with all elements of
local services. We are also ensuring that the service is integrated with the new
national 111 phone line.
quality account
What else?
Standards of care on inpatient wards
We developed a set of standards around each
stage of a patient’s stay in hospital to ensure that
best practice was being adopted and quality care
delivered 24/7, and that patients are informed
about and involved in their care.
We are continuing to embed these standards into
routine practice across services and ensure that
staff are developed to meet the needs of a wide
range of challenges which patients may present.
The standards were drafted and consulted upon
with staff and services users. They were cascaded
to every member of staff and discussed in team
meetings so that staff became familiar with the
expectations of their role and the importance of
involving patients in their care.
Improving access to specialist mental health assessment
and treatment for patients in general hospitals
Two new pilot liaison services were established
this year at West Middlesex University Hospital
and Ealing General Hospital. Patients seen by the
service primarily have psychological or psychiatric
symptoms related to a physical health condition,
or present as a psychiatric emergency to A&E.
These services provide rapid access to assessment
and treatment for any patient in the general
hospital that needs it, regardless of age.
Previously there was limited access to specialist
liaison psychiatry care.
Patients now have their mental and physical
health needs met at the same time, resulting in
holistic care which can also reduce the amount
of time spent in hospital. As part of the pilot
service evaluation we surveyed patients about
their experience of care.
95% of patients surveyed at Ealing and 100%
of patients at West Middlesex hospital that had
used the service said they would recommend it
to a friend or family member if they required it.
Where patients had had previous contact with
mental health services, 80% of Ealing patients
felt the experience was better than previous
contact – they felt listened to, they were given a
clear care plan and good advice and they felt the
assessment was a collaborative one.
At West Middlesex Hospital 90% of patients
surveyed were ‘very satisfied’ with the remaining
10% ‘satisfied’ with the interaction they had had
with mental health professionals.
Improving patient experience within CAMHS
We have standardised the recording of medication
reviews in children with ADHD, and the
communication of the outcome with patients,
carers, and GPs. We have conducted a review of
best practice guidance on effective care planning
across adult and children’s mental health
services with a focus on the patient experience
of “transition” and clinical safety.
2012/2013
We developed young people-centred audiovisual
material to promote engagement with services
on first contact at CAMHS in Hammersmith &
Fulham. Young people have been trained to be
able to participate in interview panels for staff
appointments into CAMHS.
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Patient safety
Improve interactions between staff and service users
Why did we focus on this?
To make our services as safe as possible it is essential that our staff have meaningful
interactions with service users and that there is good documentation of all contacts.
What did we aim to do?
With the Meaningful Quotations Assessment and Planning (MQAP) programme, we
wanted to ensure that staff record meaningful interactions with patients and that they
incorporate the outcome of patient interactions into risk assessments and care plans.
What did we expect
to achieve?
To improve the quality of communication between staff and service users and to
improve the quality of documentation.
How did we plan to
monitor and report?
Regular audits of documentation following targeted staff training and routine
feedback from services users via the newly introduced Meridian electronic
patient feedback system.
How well did we do?
The MQAP programme was rolled out across inpatient units, and has recently been
introduced in two community teams.
Documentation audits have demonstrated improvements by changing the
documentation which has helped to ascertain the quality of interactions between staff
and clients. Process changes made to the audit format has allowed the process to be
driven by each ward/service whilst continuing to allow for external audit.
The ultimate goal is to ensure an excellent client focussed service, whilst retaining a
mechanism to measure individual staff performance. The routine patient safety audit
will continue to monitor the standard of documentation.
We have now begun to receive service user feedback through the Meridian system.
What next?
Staff training will continue within the community teams. The Patient Safety Audit
will continue on a routine basis and the results will be monitored alongside feedback
from the Meridian system which is now being embedded into all clinical areas.
This will ensure that staff receive timely and regular feedback.
What else?
Reducing ligature points on inpatient areas
We identified ligatures on wards and graded
these in relation to the likelihood of risk. These
risks areas were then presented as the top priority
areas to be addressed by the estates and facilities
department in removing the ligature. A work
plan was established with a time table for the
work to be completed on each ward.
There is an annual audit of ligatures across all
inpatient wards which help us to keep focused
on what may present as a potential risk.
Any incidents involving possible self-harm on
wards are reviewed to establish learning and
actions are put in place to address these.
The re-design of new wards in our move of services
in Ealing provided a good opportunity to ensure
the new premises had minimal ligatures, thus
reducing further the likelihood of harm.
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quality account
Suicidality and self-harm in young people
In conjunction with staff from West Middlesex
University Hospital we have developed a joint
clinical protocol governing the management
of children who are admitted to the
paediatric wards with deliberate self-harm.
We have also produced good practice guidance
on managing suicidality with Children’s Social
Care in the Borough of Ealing.
Local services transformation programme
During the reporting period, the transformation
programme for local services in West London
Mental Health Trust was established to take
forward the work on redesign and changes
required for commissioning intentions and contracts.
The main delivery concentrated on reducing in-patient bed numbers, redesigning the community
mental health teams into assessment and recovery
teams, and modernising CAMHS services.
The transformation programme is in response
to the mental health delivery from the strategic
direction of Shaping a Healthier Future, Shaping
Healthier Lives, and No Health without Mental
Health. The programme consists of membership
from senior clinical and corporate Trust staff,
CCG mental health clinical leads (one of whom
co-chairs the programme board with the Trust
Medical Director), local authority representation,
and third/voluntary sector and we are in the process
of recruiting service users and carers as members.
The programme has been endorsed by the Trust Board, and by the CCG executive boards in all three
local boroughs: Hammersmith and Fulham, Hounslow and Ealing. The priorities agreed are:
• Shifting settings of care
• Psychiatric liaison services
• Long-term conditions
• CAMHS
• Dementia
• OD and clinical engagement
• Infrastructure
Payment by Results
Going forward in 2013/14, the Trust and integrated programme board will prioritise the work streams,
although there is currently not the resource to support them all. The priority for the first half of the
year, and work which has been commenced, is in shifting settings of care:
• Decreased CMHT – moving service users from secondary to primary care
• Decreased inpatient bed numbers
• Repatriation.
2012/2013
9
There are a number of operational and clinical risks and issues, which will be managed through
the newly-established Trust, integrated shifting settings of care project board, which links to and has membership from across the health and social care system, and the three local borough CCG project boards:
• Dementia
Revising the dementia and older people’s services project board, to include inpatients and linking to the three borough
dementia project boards. This will be an integrated Dementia Project Board. This will also link more externally in the North West sector to whole-systems integrated care, ICP and the AHSN.
• PbR
A project manager has been appointed to this project and will progress the work during 2013/14.
• Infrastructure
A project manager is now in post and will establish an Infrastructure project board to manage IM&T, estates etc. which arise
as part of the transformational change programme, e.g. Choose and Book, SystmOne.
• OD and clinical engagement
It is hoped that funding will be provided to recruit a senior and experienced OD lead to work with the programme director
and senior management team in local services, in order to develop and deliver the workforce changes needed to support the
transformational change.
High Secure Services Clinical Service Unit:
Patient experience
Reducing internal transfers by achieving stability
Why did we focus on this?
The hospital had been undergoing a significant reconfiguration in preparation for the
rebuild due to open in December 2016. In order to vacate land which the new hospital
will occupy, it was necessary to close five wards, and rearrange the use of wards
previously occupied by the Dangerous & Severe Personality Disorder service and wards
upgraded in Bedford House. The reconfiguration also reflected the reduction in size
of the hospital from 220 to 210 beds. Consequently, between March and September
2012 we had to move 198 patients, including accommodating new admissions and discharging patients who no longer needed high-secure care.
The hospital is now in a stable configuration with no more major ward moves expected
until we reconfigure teams and patient groups in anticipation of the move to the new
hospital at the end of 2016.
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What did we aim to do?
To accomplish the rearrangement of ward based services without detriment to the
patients’ care pathways and preserving therapeutic relationships.
What did we expect
to achieve?
A stable ward configuration which will be in place until the new accommodation
becomes available in late 2016.
How did we plan to
monitor and report?
We met as a senior group each week to plan the week’s moves, taking into account
unplanned moves the previous week which take place when a patient’s mental
state relapses or when a patient is able to progress to a more open ward taking
the place of someone who has been discharged. We reported moves through our
senior management team internally and to our commissioners through our contract
monitoring externally.
quality account
How well did we do?
The process was accomplished without mishap: with most patients transferring with
their peer group and their clinical team, and only two patients moving ward twice for
reasons connected with the redevelopment. Every patient’s move went as planned:
estates and facilities and security were fully involved so that belongings, dietary
requirements etc were also supported and no two patients with a history of serious
mutual violence ended up on the same ward.
What next?
The hospital is in a stable configuration for the next four years. The process we adopted will be used for the next series of moves when we move to the new
buildings in 2016/17.
What else have we done to support patient experience?
Patient forum
Senior managerial attendance at the patient forum has been more consistent.
This has generated expectations that managers of other support services so important
to patients also commit to attending: so we have estates managers there to pick up
comments on heating etc direct from patients; we have catering managers there to
pick up comments regarding food; we have security managers there to discuss patients’
aspirations for more technology and how these may or may not be possible within the
safety & security directions.
Board meetings at Broadmoor
The Trust Board meets at Broadmoor three times annually. These meetings include a
patient attendee discussing his care and treatment at the hospital direct to the Board.
The number of Board member visits has increased over the year with visits to support
facilities on the agenda as well as simply to ward areas.
Patient participation on interview panels
We have extended patient participation on staff appointment panels: over the last
year these have included the incoming Director of Security and the clinical lead for the
Mental Illness Directorate. The patients’ views are generally consistent with those of the
appointing managers.
150th Anniversary
Celebrations
2013 marks the 150th anniversary of the opening of Broadmoor Hospital. There are a
series of events over the course of the year celebrating the anniversary: the patients are
very involved in the anniversary planning.
Patient safety
Reducing seclusion and long term segregation
Why did we focus on this?
Broadmoor only admits men who need psychiatric treatment and who pose too high
a risk to be safely managed elsewhere. For their care to be taken forward safely, from
time to time, particularly in the period immediately after admission, it may be necessary
to manage someone in seclusion for the safety of staff and the other patients. It is imperative that the duration of such seclusions is kept to a minimum.
What did we aim to do?
The overall aim was to reduce the number of seclusion and long-term segregation
hours/episodes and increase safe staff/patient engagement.
What did we expect to achieve?
We expected to achieve a reduction in overall seclusion and long term segregation
hours/episodes, within the context of providing a safe and secure environment for our patients and staff.
2012/2013
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How did we plan to
monitor and report?
Seclusion and long term segregation information is monitored through the hospital’s
seclusion monitoring and review group, as well as being reported monthly to the Board
and to the commissioners as part of the hospital’s key performance indicators.
How well did we do?
Our achievements in reducing long term segregation and seclusion hours and episodes
have been mixed. During the year, we introduced a revised ward operational policy on
Epsom Ward due to growing security concerns, which resulted in the patients being
managed under a long-term segregation arrangement (LTS). This arrangement has been
successful in addressing a number of safety and security concerns and patients have
responded well. We are now planning to move to the next stage in the operational
policy, which will increase the patient integration further but in a managed way.
On Cranfield Ward, our intensive care unit, all patients are subject to a LTS arrangement
in recognition of the clinical risks posed. There is currently a practice development
programme underway on the ward, designed to increase patient reintegration and to
improve the process of clinical team decision making related to reason for seclusion/LTS
and discontinuation.
Another piece of work is being undertaken to review data comparing clinical
characteristics of patients in seclusion and LTS with those who aren’t. The aim is to understand case load dependency, threshold for commencing and
discontinuing seclusion and clinical team decision making relating to ‘reasons for use’, frequency and duration.
Seclusion hours and episodes are measured each month and we calculate the
percentage of our patients who have been subject to seclusion during the month.
During the year, this has predominantly seen the percentage of patients subject to
seclusion at 10% or below. However, we have recognised some difficulties with
recoding seclusion data and have taken steps to improve the data gathering for this so that we can more accurately assess our progress.
What next?
Work on reintegrating patients on Cranfield will continue and the arrangements on Epsom will continue to be reviewed and refined. The success of the Epsom ward
operational policy means that this model may be considered for use elsewhere in the hospital should safety and security concerns require it, as being a way to manage
patient integration more effectively and also to reduce the potential frequency and severity of incidents.
A humane restraint has been developed between clinical teams and specialist violence
reduction staff in the hospital to allow patients who are persistently violent to safely
spend time out of their bedroom.
A more robust recording system for seclusion and long-term segregation data came into
operation in April 2013, which will provide better data for us to assess our progress.
The seclusion monitoring and review group will continue.
What else have we done to support patient experience?
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Night-time confinement
national review
The three high secure hospitals are all introducing compulsory confinement of patients
to their rooms at night: this has been necessitated by the consensus that it is more
important to maintain therapeutic daytime activities than to staff wards at night and
by financial imperatives. In order to achieve best and safest practice in this change to
practice, we hosted a national seminar in May 2012 with attendees from the three
high-secure hospitals; medium secure services who admit patients from high security;
solicitors representing patients; Trust solicitors; the Dept of Health and commissioners.
The output from the seminar informed subsequent policy.
NOMS security audit
As part of the Safety and Security Directions the hospital is required to undergo an
annual independent security audit by prison service security assessors. Broadmoor
scored 99% for a second year running, an unprecedented success.
quality account
Clinical effectiveness
More timely admission process
Why did we focus on this?
We recognise that when patients are referred to our service, admission elsewhere is
considered to be unsafe; so we need to be accessible and to ensure our assessment
processes are efficient.
What did we aim to do?
We wanted to reduce the time taken to assess and, where appropriate, admit patients,
ensuring the waiting list for beds is kept to a minimum.
What did we expect
to achieve?
A reduction in the time between referral to our service, assessment and actual admission.
How did we plan to
monitor and report?
By monitoring length of time from:
i. referral to assessment
ii. assessment to decision
iii. decision to admission
and reporting bi-monthly to the clinical governance group
How well did we do?
In the first four months of the year we had patients waiting between 15 and 25 weeks
for admission from the date of referral, well in excess of the 12 week maximum wait
we are targeted to achieve in our key performance indicators. By August, by working
with other agencies (e.g. the prison service) and focussing on our own practices,
there were no breaches of the 12 week maximum wait time for admission and this
continued for the rest of the year. This has been aided by the completion of the ward
reconfiguration programme, during which we had fewer beds available than needed
resulting in delays in admission.
Similarly, the number of patients waiting for a bed, which is reported monthly, has
dropped over the year.
High Secure Service are now operating to allocated bed numbers, in previous months
we have been operating above the expected numbers which has had a knock on effect
on the desired admission times.
What next?
We know that last year there were times our bed availability for new admissions
was compromised by the need to move patients around to new wards as part of the
preparation for closing buildings for demolition for the redevelopment. Despite that we
did really well in keeping the system moving. This year we will face a different challenge
as our occupancy levels are higher than we would like: so our efforts are increasingly
in seeking prompt onward movement for patients ready for discharge, so that we can
continue to provide an efficient admission service. We are working more closely with
our commissioners to achieve this.
What else have we done to support clinical effectiveness?
Length of stay
2012/2013
We have reduced our average length of stay by 50% over the past decade: from just
over 10 years for patients who left Broadmoor in 2001 to just over 5 years for patients
who left in 2012. We will continue to press for timely discharges whilst monitoring
readmission rates to ensure we are not getting to the point of premature discharge.
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Examples of some specific key messages and actions taken within our services
Our healthcare centre achieves Quality and Outcome Framework (QOF) standards equivalent to or in excess
of those achieved by most practices in the community: these are subject to Independent audit each year.
The team were shortlisted for a national award for the quality of their work in relation to cardiovascular
risk in December 2012. As part of the CQUIN work we were joint organisers of a national conference on
physical health support for detained patients in November last year. There were attendees from across the spectrum of secure mental health services. The feedback from the attendees was excellent.
Specialist & Forensic Clinical Service
Unit: Patient experience
Developing service user involvement in their care pathway through services
What did we aim to do?
Engage service users in their care pathway.
What did we expect
to achieve?
We would continue to develop service users in writing their care plans in the first
person with their care coordinator.
Through ImRoC and the shared care pathway pilot we would develop a consistent
pathway for service users such that they are aware of their care pathway and what
is required of them as soon as they are admitted to the service and ensure that this
continues throughout their stay in services.
How did we plan to
measure & monitor?
We developed recording mechanisms for reporting service user’s engagement with their
shared care pathway.
We monitored service user satisfaction through Meridian patient satisfaction monitor.
How well did we do?
Care plans written in the first person
In 2011/2012, 55% of service users had care plans written in the first person. Service to
conduct further audit to measure increase/decrease in compliance. Aim by Q4 of 75%.
Recovery facilitator is supporting wards to develop first-person care plans.
Audit of care plans and recommendations completed in Q4. Target achieved as detailed below:
Recovery care plan:
•
84% (139 service users) were offered the opportunity to complete a personalised
recovery care plan
•
66% (110 service users) completed/engaged in developing a personalised recovery
care plan
Meridian – patient experience system
Meridian feedback and audit system in place. Increasing completion trends and overall
satisfaction is consistently positive at approx 80%. Technical issues resolved. Embedding
governance framework and cycle of improvement. Action plan being implemented
to continue to enhance service user engagement in the tool including: notice boards,
recovery and involvement workers providing peer support; and the development of new questionnaires/audits.
What next?
14
We want to continue to embed the recovery approach into all clinical areas (except GIC) by:
•
Providing one day a month recovery training.
•
Providing one day a month training on STAR
•
Providing all service users with choice of using personal recovery plan or STAR
•
I ntegrating recovery tools into other processes, eg CPA process, care plans
•
Evaluating the pilot of peer review workers
quality account
Patient safety
Improve and ensure consistent nursing practice across the CSU
What did we aim to do?
Development of nursing practice across the CSU.
What did we expect
to achieve?
To start a project aiming to improve the quality of the nursing process.
To have clinical team leaders demonstrating robust clinical, managerial and professional leadership.
To have Band 5 nurses demonstrating clear understanding and application of the nursing
process, skills, attitudes and values to deliver recovery oriented primary nursing.
How did we plan to
measure & monitor?
Improved standards of nursing process as measured by nursing process audit.
Production and delivery of band 6 development programme and evidence of improved leadership skills as measured by reduced incidents and increased patient
and staff satisfaction.
Production and delivery of band 5 development programme and improved quality of nursing practice as measured by reduced complaints about staff attitude, and by audit of nursing records.
Senior Nurse Back to the Floor Programme will see senior nurses working a minimum of 1 day per month on the wards. This will be monitored by monthly reports of experience and issues raised while working on the wards.
How well did we do?
Band 6 management and co-ordinator training commenced.
Band 5 development programme commenced.
Senior nurse ‘Back to the Floor’ commenced.
The senior nurse runs one shift per month with a clinical focus: is present in most patient
and staff meetings every day of the week: in month 3 there was a focus on care plans.
Primary nurse and patient meet on a twice weekly basis either in forums or informally;
nurses supported to attend regular weekly activities with patients through the duty
request system for shifts; nurses involved in pre-admission work from the time that funding for patient is confirmed eg, organising home or day visits, CPAs and organising professionals meetings.
Expert by Experience is now collecting feedback from patients about their experiences
of participating in their treatment with nurses. Quarter 1 is currently being written up.
Back to the floor ongoing. Review of numbers of completed sessions will be undertaken in April 2013.
Band 6 development Programme: clinical component now agreed to focus on Psycho-social interventions. Training in progress and ongoing. Training records
system in development.
Band 5 development, three cohorts completed. Positive evaluation. Programme reviewed and amended and further 2 cohorts planned for 2013/2014.
Nursing Metrics/Practice Development project re-baseline to be completed April’ 13.
Forward planning to be included in 2014/2015 Business Plan.
Nursing Care Planning Directive issued (Feb 2013). All nursing care plans transferring to RiO care plans.
What next?
2012/2013
Going forward we plan to continue with the Band 6 & Band 5 development
programme and the senior nurse Back to the Floor programme. Nursing metrics/
practice development project re-baseline to be completed April 2013. Forward planning
to be included in 2014/2015 business plan.
15
Clinical effectiveness
Provide timely and effective care to service users
What did we aim to do?
Improve patients’ pathway through services.
What did we expect
to achieve?
A clinical pathway through medium secure services has been agreed between London
secure service providers and the London Specialist Commissioning Group. This sets milestones along the care pathway for service users during their journey through
medium secure care. Our aim is to ensure that all service users attain these points in their care pathways.
How did we plan to
measure & monitor?
We will put recording structures in place that will monitor the care pathway of all
patients admitted to medium secure care and the time they reach the milestones set.
This will be reported monthly to the SMT and quarterly in the CSU performance meetings.
How well did we do?
Optimising Length of Stay
One of the CQUIN requirements for this financial year includes the implementation of the 12 week care pathway. Mechanism in place to monitor this.
At the end of Q2 we achieved 81% compliance against the 12 week care pathway (CQUIN target). New system implemented on the 1st October 2012 to monitor progress.
Care pathway workshops
Care pathway workshops were held in December where all patients within the
medium-secure rehab settings and low secure wards care pathway were reviewed.
The Q3 CQUIN target against the 12-week care pathway was reviewed by the case
managers on the 18th January 2013.
A recording template has been devised which has to be updated for each stage of the pathway. This forms part of the integrated performance report and is reviewed in directorate management & governance meetings. Any areas of non-compliance are escalated to the CSU SMT to ensure action is taken to rectify any deficits.
What next?
To build on our work so far on improving the care pathway we want to:
•
Agree a model of care and criteria for patients in low-secure and patients in long
term secure care which fits with NCB specifications by September 2013.
•
Agree and implement revised service model for women’s service by end of July
2013.
•
Implement discharge care pathway in line with CQUIN requirements.
Through the care pathway workshops we have identified a large number of delayed
discharges. Monthly meeting in place to ensure peer review and shared learning re
delayed discharges, leading to reduction in number of delayed discharges.
16
quality account
Forensic services quality priorities:
Patient experience
Improving support and education for carers
What did we aim to do?
Review carer/ family support arrangements within CSU
What did we expect
to achieve?
Increased engagement of carers by undertaking an outreach project to gain a greater
understanding of what carers would like from our services and how we can better
engage and provide support.
Provide carer training.
How did we plan to
measure & monitor?
Increased number of carers receiving carer assessments.
Increased number of carers engaging with involvement team.
Production and delivery of carer training.
How well did we do?
CSU carer engagement group has been set up.
6 month carer support group has been agreed. Terms of reference agreed and
facilitators identified. Co-produced carer training programme developed.
CSU carer support group has commenced. Carer follow-up telephone calls have
commenced on a weekly basis. Carer training programme in draft to be ratified at the carers meeting.
What next?
We want to increase the engagement of carers by:
•
Developing an up to date list of contact details for carers/family/friends as identified
by the service users
•
Developing a standardised letter and relevant information to be forwarded to
identified carer/relative within three days of admission to service
•
Delivering and evaluating a carer education training programme
•
Continuing to facilitate carer support group
•
Inviting carers/families to initial social network meetings on pilot wards
To evaluate the information from phone calls by senior staff to carers regarding visits.
Risk Assessments
What did we aim to do?
Review our psychological therapies
What did we expect
to achieve?
Review our centralised group programme to ensure it meets the needs of our
population and also is delivered as effectively as possible.
How did we plan to
measure & monitor?
We will monitor waiting times for assessment/groups, regularly review the offender
groups required, and monitor whether these groups can be delivered in other ways or via shortened programmes. This will be reported via the PRICGG and through
performance data.
2012/2013
17
How well did we do?
Face-to-face contacts
This is monitored via the monthly performance reports. Data provided by the following
disciplines:
What next?
•
Psychology
•
Arts therapist
•
Education
•
Psychotherapists & family therapist
•
Occupational therapist
•
Consultation regarding new clinical model agreed and implemented in Q2.
To review the centralised group programme.
Activity data has been reported to the directorate management & governance
meetings. This approach has not proved as informative as we had hoped therefore one
of our Quality Priorities for 13/14 is to review the programme in more detail to ensure
any changes required are implemented to improve the service offered.
Clinical effectiveness
Length of stay
What did we aim to do?
Reduction of length of stay in secure services.
What did we expect
to achieve?
In 2012/ 13 we aim to close a male medium secure ward and re invest some of this saving into the development of a community forensic psychiatry service in the catchment area where one does not exist.
Our aim is that by providing a seamless care pathway for service users we will reduce
length of stay as an inpatient.
How did we plan to
measure & monitor?
Thorough 2011/12 we have agreed with other London secure providers and the London SCG a consistent method of measuring length of stay.
Systems are now in place for monitoring this.
What did we aim to do?
Reduction in delayed transfers: agreed process in place to monitor this.
How well did we do?
We closed a male medium-secure ward.
Reduction in delayed transfers:
•
Work continues to reduce delayed transfers/discharge, clinical teams working
closely with case managers to reduce delayed transfers. This is being monitored
monthly, included in monthly scorecards and IPR.
•
Increase in the number of delayed transfers/discharge as a direct result of the care
pathway workshops. Continue to work with clinical teams and case managers to reduce delayed transfers. This is being monitored monthly, included in monthly
scorecards and IPR and reviewed at weekly referral meetings.
Service users remaining in the service were classed as a delayed transfer/discharge. By trying to ensure people move on to appropriate facilities more quickly we are as a result reducing the length of stay. The current process is that there is a forum to monitor delayed discharges but during 2013/14 we will be making it more explicit in the process in referencing a reduction in the length of stay.
18
quality account
What next?
Through the care pathway workshops we have identified a large number of delayed
discharges. Monthly meeting in place to ensure peer review and shared learning re delayed discharges, leading to reduction in number of delayed discharges.
Cassel Hospital quality priorities:
Patient experience
Developing service user involvement in their care pathway through services
What did we aim to do?
Engage service users in their care pathway.
What did we expect
to achieve?
Cassel psychosocial nurses will engage with the patients that they are care coordinators for by using the care plan in an active way to engage their patients in
assessing their treatment aims and care pathway; and by encouraging them to write up
their care plan in the first person.
How did we plan to
measure & monitor?
This will be regularly discussed with nurses in their clinical supervision, and care plans
will be regularly monitored to assess whether this is being achieved.
How well did we do?
Patients chair their own CPA meetings if they feel comfortable doing so.
100% of CPA care plans are now written in the first person.
Nurse and patient meet up on a monthly basis for an hour to discuss their Care Plan
and record this on RiO.
One nurse meeting a month is to focus on a patient’s care plan and discussed in detail.
Care plans are raised in nurses’ supervision.
Once a month psychotherapist attends nurse meeting for clinical case discussion.
What next?
We want to increase our engagement with families/carers to ensure that service users
can be supported to make best use of their treatment programme.
Patient Safety
Improve and ensure consistent nursing practice across the CSU
What did we aim to do?
Development of nursing practice across the CSU
What did we expect
to achieve?
Project aiming to improved the quality of the nursing process.
Clinical team leaders demonstrating robust clinical, managerial and professional leadership.
Band 5 nurses demonstrating clear understanding and application of the nursing
process, skills, attitudes and values to deliver recovery oriented primary nursing.
Senior nurses visible on the front line of services.
Sustain and develop nurse-patient engagement in the inpatient and outreach services to
ensure that the psychosocial model of treatment at the Cassel is maintained and developed.
2012/2013
19
How did we plan to
measure & monitor?
Improved standards of nursing process as measured by nursing process audit.
Production and delivery of band 6 development programme and evidence of improved
leadership skills as measured by reduced incidents and increased patient and staff satisfaction.
Production and delivery of band 5 development programme and improved quality of nursing practice as measured by reduced complaints about staff attitude and by audit of nursing records.
Senior nurse Back to the Floor programme will see senior nurses working a minimum of one day per month on the wards. This will be monitored by monthly reports of experience and issues raised while working on the wards.
How well did we do?
The senior nurse runs one shift per month with a clinical focus: is present in most patient
and staff meetings every day of the week: in month 3 there was a focus on care plans.
Primary nurse and patient meet on a twice-weekly basis either in forums or informally;
nurses supported to attend regular weekly activities with patients through the duty
request system for shifts; nurses involved in pre-admission work from the time that
funding for patient is confirmed eg organising home or day visits, CPAs and organising
professionals meetings.
Band 5 nurses are now enrolled on the Tavistock Centre’s post graduate course and
enrolled in the Living Learning Experience.
Feedback from the patients about their experience of participating in their treatment
has been collected and written up by the Expert by Experience. This has been sent to the head of service and senior nurse for further discussion.
Weekly community management meeting addresses roles and jobs allocated to nurses and patients.
This last quarter drive to get regular and monthly activities up and running, e.g. weekly
dog walking and activities in Ealing gym and kitchen garden.
Clinical effectiveness
Maintain contact with local services
What did we aim to do?
Keep local services engaged as the service user moves through the service.
What did we expect
to achieve?
Ensure that the interface with the patient’s local team and commissioner is managed
well by the Cassel inpatient clinical team from point of referral, during treatment and
discharge back into local services.
How did we plan to
measure & monitor?
Prior to admission it is agreed how often the primary nurse will contact the local
workers and how.
Local services contacted more if anything untoward happens.
A demographic front sheet and contacts created from the date of referral.
All contact recorded on RiO.
Multi Disciplinary Team meeting and action points about contacting local services are recorded.
All local services and commissioners invited to the review and CPA meeting.
20
quality account
How well did we do?
Local commissioners are invited to attend meeting and if appropriate attend the Cassel
Hospital’s half day visitor’s day.
A questionnaire has been developed and commissioners and referrers are being
contacted to gain feedback on the patient’s pathway through the Cassel Hospital, from referral to discharge back to their local service.
A number of commissioners and referrers have been contacted. Referrers are happy
with the patient’s pathway from referral to discharge. Communication with outside
teams on the whole is acceptable however there is still room for improvement. Other feedback from commissioners is that the Cassel is frequently seen as putting
pressure on them to fund extensions of treatment. It is said that we appear to have little understanding of the standard practice around long-term funding and we do not clearly demonstrate necessary outcomes.
What next?
Our commissioning arrangements will change in 2013/14 so we will need to review
how we communicate with commissioners and services involved with patients.
Gender Identity Clinic quality priorities:
Patient Experience
Further developing service user information, involvement
and feedback in the Gender Service
What did we aim to do?
Utilise results of Patient satisfaction Questionnaires and improve patient experiences of the GIC.
What did we expect
to achieve?
We will improve the levels of satisfaction in the patients of the GIC.
In doing so we aim to reduce the numbers of complaints and increase the numbers of compliments received by the service.
We will develop and publish patient information leaflets. Patients will also be asked to evaluate care received on discharge.
How did we plan to
measure & monitor?
Having reviewed the results of the 2011 survey we will develop an action plan to address any shortfalls. This will be published on the clinic website.
Patient information leaflets published by the end of the financial year.
How well did we do?
Paper is now ready to be published, schedule to be agreed.
What next?
The aim is to publish the paper in a journal. This takes considerable time as it has to go through a peer review process. Nottingham GIC’s lead clinician is leading on this.
We are also looking at ways to increase the capacity of the service in order to reduce
waiting times and improve service user experience.
2012/2013
21
Patient Safety
GIC Discharge Pack
What did we aim to do?
Develop a Discharge pack with guidance for individuals and GPs
What did we expect
to achieve?
When a patient is discharged from the gender service we will provide detailed
recommendations and guidance to support the individual and to enable primary care to take full responsibility thereafter. A further aim is to do so in collaboration with another GIC.
How did we plan to
measure & monitor?
Discharge pack has been developed and is in use by the end of the financial year.
How well did we do?
We have discussed the proposal with other GICs who are committed to taking this
forward. It is anticipated that the pack will form part of national policy having first been
signed off by the clinical reference group. Outline pack has now been developed.
What next?
Once we have agreed service specification we will be able to finalise the discharge
pack. Going forward we want to set up a discharge clinic.
Clinical effectiveness
Gender care protocol
What did we aim to do?
Develop a Gender care protocol which is applicable to all NHS GICs
What did we expect
to achieve?
Finalise and agree a collaborative care protocol with other gender clinics, including
Nottingham, Leeds and Sunderland, for publication by the DOH.
How did we plan to
measure & monitor?
Agreed protocol is published by the DOH following a period of consultation.
How well did we do?
A final draft has been produced and submitted to the DOH.
What next?
Once we have agreed service specification we will be in a position to finalise the protocol.
Looking forward – our quality priorities
for 2013/14: What they will be and how
we will know if we have achieved them?
The Trust Board has approved a revised Quality Strategy 2013 - 2018 and also agreed the quality
priorities for 2013/14.
In order to identify the quality priorities for 2013/14 each of the Trust’s three clinical
service units (CSUs) was tasked with canvassing
the opinions of staff, service users and carers as to what should be the areas the service should focus on for quality improvement.
22
There were a variety of approaches used to involve
as many as possible in setting the priorities.
Feedback was received following discussion at
patient forums, staff clinics, directorate meetings,
carer forums and involvement of service user
involvement leads.
quality account
As a result numerous different ideas were
suggested reflecting the range of different
services provided by the Trust. These ideas
were then presented at the Trust-wide clinical
effectiveness and compliance meeting where, after
lengthy discussion, four key themes for quality
improvement was agreed:
• improving physical health care
• improving the management of patient
transitions
• ensuring service users are treated with the highest levels of dignity, compassion and respect
• improving the dissemination of learning and best practice.
This approach reflects the breadth of the services
provided by the Trust and the differing needs of
the service users our CSUs care for (see annex 4)
Throughout the year our CSU management
teams will report their progress on successful
achievement of these priorities through their
internal management and governance structure.
The CSUs will report their progress on a quarterly
basis to the Quality Assurance Committee, which
has been delegated as the responsible committee
by the Trust Board. In addition, commissioners will
receive quarterly updates through their meetings
with the Trust.
(Internal reporting structures can be found in
annex 3).
Each CSU was then tasked with agreeing specific
local priorities reflecting the Trust-wide themes.
The final priorities were then considered by the
Quality Assurance Committee before final Board
approval.
Local Services Clinical Service Unit
1. Improving physical
healthcare
• Improve prescribing for children and adolescents who have a physical health condition alongside
their mental health condition.
• Ensure community physical healthcare facilities are adequate to support high quality physical health
care.
• Agree and implement good practice guidelines for the monitoring and management of patients
with diabetes when they are admitted to the inpatient wards.
2012/2013
23
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Improve
prescribing for
children and
adolescents who
have a physical
health condition
alongside their
mental health
condition.
Review NICE
and other
good practice
guidelines on
prescribing
for children
with a physical
health condition
alongside their
mental health
condition.
Review of
current protocols
and practice.
Development of
new protocols.
Implement
new protocols
to improve
the quality of
prescribing.
Protocols in place
and compliance.
Ensure community
physical healthcare
facilities are
adequate to
support high
quality physical
health care.
Agree scope of
work plan with
Community and
CAMHS.
Establish
minimum
standards for
PHC facilities
with respect to
equipment and
privacy.
Conduct review
of all community
PHC facilities.
Draw up
improvement
plans.
Review
results and
identify where
improvement is
required.
Identify resource
for needed
improvements.
Agree and
implement good
practice guidelines
for the monitoring
and management
of patients with
diabetes when
they are admitted
to the inpatient
wards.
Complete audit
of Long Term
Conditions care
in inpatients.
Disseminate
GPGs via
inpatient SMT
to nursing and
medical staff in
all inpatient sites.
Implement GPGs
on all wards.
Audit the use of GPGs.
Complete draft
good practice
guidelines
(GPGs) for the
monitoring and
management
of diabetes in
inpatients.
Develop audit
plan for 14/15 to
measure impact.
Action plan
completed.
Positive audit.
Compare results
with original
audit findings.
2. Improving the management
of patient transitions
(ie transfers of care)
• Agree and implement best practice transition protocols governing transfers of care between:
I. Community teams to inpatient wards
II. Different inpatient wards
III. Inpatient wards to community teams
IV. Different teams and services eg assessment to recovery, children to adult services
V. WLMHT and primary care
VI. WLMHT and other specialist mental providers.
24
quality account
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Improve clinical
practice when
patients are
transferred
between teams.
Agree scope of
work with respect
to the type of
transitions and
the content of protocols.
Establish where
transition
protocols are
currently in
operation
and review
in line with
best practice
and national
guidelines.
Agree new
transition
protocols where
required.
Disseminate
and implement
transition
protocols.
Agree audit
plan for 14/15.
Monitor SI
reports for
failures of
transition
management.
Protocols in
place.
Identify clinician
to provide
leadership and
support to work
plan.
Monitor SI
reports for
failures of
transition
management.
Monitor SI
reports for
failures of
transition
management.
3. Ensuring service users are treated
with the highest levels of dignity,
compassion and respect
• Hold focus groups and/or workshops for service users and staff to engage in an honest two-way
dialogue so we can genuinely understand what being treated with dignity, compassion and respect
looks like and feels like to our local communities.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Hold focus groups
and/or workshops
for service users
and staff to
engage in an
honest two-way
dialogue so we
can genuinely
understand what
being treated
with dignity,
compassion and
respect looks
like and feels
like to our local
communities
Establish view
with service users.
Medications
event.
Event organisation.
Event and action
plan complete.
Support service
user conference
to identify
priorities.
SSOC- review of
crisis plans.
Review inpatient
project plan and
baseline.
2012/2013
Identify priorities
and involve
service users
in each of the
projects.
Implement
interim crisis
plan.
Inpatient project
team established.
Work plan
established.
Establish work
group and agree
implementation
plan for the
service user
and carer
involvement
from the
recommendation
from the Hough
review.
Review interim
crisis plan – lessons
learned – adapt
plans as necessaryidentify pilot area
for new crisis plan
implementation.
Develop
medications
project group and
project plan from
event.
Pilot wards/
areas identified
for inpatient
project- establish
baseline recording
information.
Evaluate
implementation
of crisis plan
pilot.
Evaluate
medications
project plan and
forward plan for
2014/15.
Establish
involvement
structure.
Plan future
events.
Implement service
user and carer
involvement
structure in local
services.
25
4. Improving the dissemination
of learning and best practice
• Have a patient-centered “bottom-up” staff learning event with a focus on developing a lifespan
approach to the mental health needs of the local communities we serve, with an emphasis on early
intervention, recovery, and evidence-based treatments
• Disseminate summary cards to relevant clinical areas of serious incident reviews to highlight lessons learnt.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Hold a patientcentred “bottomup” staff learning
event with a focus
on developing a
lifespan approach
to the mental
health needs of the
local communities
we serve, with
an emphasis on
early intervention,
recovery, and
evidence-based
treatments
Agree best
mechanism for
involvement of
front line staff,
service users and
carers.
Commence
event
organisation.
Hold event.
Establish learning
and disseminate
findings
via clinical
governance
routes so that
outcomes can
influence future
care provision.
Action plans
complete.
Disseminate
summary cards to
relevant clinical
areas of serious
incident reviews to
highlight lessons
learnt.
Agree best
format for cards.
Finalise layout.
Collate into on-line library for
reference by all
staff.
Conduct
thematic review
of all cards.
Summary cards
audit evaluation.
Trial use and
dissemination
within Incident
Review Group
and Senior
Management
Teams.
Identify resource
required.
Establish routine
dissemination.
Disseminate
finding of
thematic review
to improve
cross-borough
learning.
High Secure Services Clinical Service Unit
1. Improving physical
healthcare
• Provide high quality evidence-based care for long term conditions.
• Patients’ physical healthcare needs will be assessed as part of their care planning process.
• Achieve physical healthcare targets agreed in CQUIN.
26
quality account
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Provide high
quality evidencebased care
for long term
conditions.
90% achievement
of maximum
clinical outcomes
as set out in QOF
score.
90%
achievement of
maximum clinical
outcomes as set
out in QOF score.
90%
achievement of
maximum clinical
outcomes as set
out in QOF score.
90%
achievement of
maximum clinical
outcomes as set
out in QOF score.
NICE designed
national
benchmarking
for PC.
Patients’ physical
healthcare needs
will be assessed as
part of their care
planning process.
Audit of CPA
reports by health
centre to establish
% of physical
health examinations
achieved.
70% of CPA
reports audited
will include
physical
health needs
assessment.
80% of CPA
reports audited
will include
physical
health needs
assessment.
90% of CPA
reports audited
will include
physical
health needs
assessment.
Audit results and
action plans.
Achieve physical
healthcare targets
agreed in CQUIN.
70% CQUIN
targets achieved
including baseline
measures.
80% milestones
of agreed CQUIN
plan met and
reported.
90% milestones
of agreed CQUIN
plan met and
reported.
100% milestones
of agreed CQUIN
plan met and
reported.
Audits and
CQUIN reports.
Commissioner’s
assessment.
2. Improving the management
of patient transitions
• Improve the process for assessment and decision making in relation to inter-ward transfer referrals.
• Increase patient involvement in recovery plans.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Improve the
process for
assessment and
decision making
in relation to
inter-ward transfer
referrals.
Inter-ward referral
paperwork
amended to
include date of
referral and date
of decision being
fed back (in cases
where immediate
assessment
is thought
appropriate).
70% of interward referrals
assessed within
7 working days
and decision
communicated
to referring team
and patient.
Report presented
monthly at
CIGs to include
reasons for any
delays identified.
80% of interward referrals
assessed within
7 working days
and decision
communicated
to referring team
and patient.
Report presented
monthly at CIGs
to include reasons
for any delays
identified.
90% of interward referrals
assessed within
7 working days
and decision
communicated
to referring team
and patient.
Report presented
monthly at
CIGs to include
reasons for any
delays identified.
Improved
communication
evidenced by
CIG minutes
and referral
paperwork.
60% of patients
on assertive
rehab wards to
be invited to
present their
outcome or
WRAP at CPA
meetings. Report
on findings
presented at
Directorate CIG.
75% of patients
on assertive
rehab wards to
be invited to
present their
outcome or
WRAP at CPA
meetings. Report
on findings
presented at
Directorate CIG.
90% of patients
on assertive
rehab wards to
be invited to
present their
outcome or
WRAP at CPA
meetings. Report
on findings
presented at
Directorate CIG.
Directorate
CIG reports
& minutes,
Performance
meeting
minutes. Audit
reports available.
Direct patient
feedback.
Data monitored
quarterly and
discussed at
Directorate CIG.
Increase patient
involvement in
recovery plans.
2012/2013
Patients invited
to present their
outcome framework
or WRAP at
CPA meetings.
Communicate
expectation to all
teams. Performance
team to develop
audit process with
directorates.
27
3. Improving the dissemination
of learning and best practice
• Increase attendance of clinical team members at ward clinical improvement group meetings.
• Use data from incident reports and reviews to provide learning material for staff.
• Development of a clinical supervision training programme to improve standards.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Increase attendance
of clinical team
members at
ward clinical
improvement group
meetings.
All clinical team
members aware of
70% standard of
Multi Disciplinary
Team attendance
Circulation of
attendance list
for all community
meetings to ward
administrators.
70% of MDT
attend clinical
improvement
group meetings.
Audit of
attendance.
70% of MDT
attend clinical
improvement
group meetings.
Audit of attendance.
Review Q1 and Q2
against standard
and devise action
plan should
standards not be
met.
70% of MDT
attend clinical
improvement
group meetings.
Audit of
attendance.
Attendance
lists. Improved
attendance,
meeting standard.
Use data from
incident reports and
reviews to provide
learning material
for staff.
Learning lessons
fact sheet prepared
and presented
to clinical
effectiveness
group.
Learning lessons
fact sheet
distributed to all 15
wards. Monitored
through clinical
effectiveness
group.
Audit that
learning lessons
fact sheet in
situ on wards.
To present at
learning lessons
conference.
Collate
information to be
included in new
learning lessons
fact sheet ready
for publication at
the end of Q4.
Fact sheets.
clinical
effectiveness
group minutes.
Development of a
clinical supervision
training programme
to improve
standards.
Target 1: collect
and analyse data
on supervision
quality and
establish baseline.
Target 1:
implement pilot of
new supervision
arrangements in 3
wards.
Target 1: pilot
on 3 wards
continues.
Target 1: re-survey
staff on quality of
supervision and
analyse.
Updated policy
reflecting CSU
requirements.
Target 2: train the
trainer supervision
programme
completed.
Target 2: evaluate
train the trainer
programme.
Target 3: establish
supervision support
group for train the
trainer’s cohort.
Target 2: review
trust clinical
supervision policy.
Target 3: refresher
training for train
the trainer cohort.
Target 2:
evaluation of
pilot programme.
Target 3: agree
policy.
Clinical
supervision
training
programme
Target 4: proposal
for supervision
training presented
to Trust.
4. Ensure service users are treated
with the highest level of dignity,
compassion and respect
• Community meetings are well attended by staff to provide meaningful opportunity for patients to
discuss their care and environment.
• Respond to patients’ concerns about their care and treatment effectively and in a timely way,
particularly with regard to staff attitudes..
28
quality account
• Identify trends in how patients are feeling and look for ways to address any issues.
• Use feedback from Meridian system to address issues and improve practice.
• Implementation of peer review initiative.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Community
meetings are well
attended by staff to
provide meaningful
opportunity for
patients to discuss
their care and
environment.
All clinical team
members aware
of 50% standard
of attendance.
Circulation of
attendance list
for all community
meetings to Ward
Administrators
Baseline
attendance level
established.
50% of meetings
are attended
by MDT. 1 in
4 meetings
attended by
SMT member.
Audit of
attendance.
50% of meetings
are attended
by MDT. 1 in 4
meetings attended
by SMT member.
Audit of
attendance.
Review Q1 &2
against standard
and devise action
plan should
standards not be met.
50% of meetings
are attended
by MDT. 1 in
4 meetings
attended by
SMT member.
Audit of
attendance.
Minutes of
meetings
and audit of
attendance.
Respond to
patients’ concerns
about their care
and treatment
effectively and
in a timely way,
particularly with
regard to staff
attitudes.
Bi-monthly
patient experience
meeting
established. TORs
written.
TORs presented
to clinical
effectiveness
meeting for sign
off. Establish
baseline data from
complaints and
compliments.
Develop and
implement a
robust reporting
process for
responding to
and learning from
complaints.
Reports reviewed
at monthly
performance
meetings.
Performance
meeting notes
and SMT minutes.
Identify trends in
how patients are
feeling and look for
ways to address any
issues.
Identify patient
satisfaction tool
with patients and
SMT. Agree wards
to pilot survey.
Develop
quarterly patient
satisfaction survey
and pilot on 3
wards. Evaluate
pilot.
Amend survey
as appropriate
following
evaluation.
Establish
baseline measure
of patient
satisfaction in all
15 wards.
Establish process
for undertaking
and reporting
quarterly patient
satisfaction
survey. Develop
and implement
action plan for
improvement.
Survey results and
action plans.
Use feedback from
Meridian system to
address issues and
improve practice.
Revise and reissue Meridian
governance
structure.
50% community
meetings evidence
discussion
on meridian
feedback. Also
reported at
directorate CIGs
and patient
experience group.
75% community
meetings evidence
discussion
on meridian
feedback. Also
reported at
directorate CIGs
and patient
experience group.
90% community
meetings evidence
discussion
on meridian
feedback. Also
reported at
directorate CIGs
and patient
experience group.
Reports and
updated
governance
arrangements.
Complaints/
compliments
information to
be reviewed
at monthly
performance
meetings.
Identify directorate
leads for Meridian.
25% community
meetings evidence
discussion on
meridian feedback.
2012/2013
Baseline data
analysed and
KPIs established
for ongoing
monitoring and
improvement.
Improvement in
results.
29
Implementation
of peer review
initiative.
Train MDT
to undertake
peer reviews.
Establish rota of
peer review visits.
All 15 wards have
first peer review.
Evaluation of
process by
peer reviewers
Amendments
to process as
necessary. All 15 wards
have second peer
review.
First report to
Patient Safety
and Safeguarding
Committee by
service directors.
All 15 wards have
third peer review.
Project evaluation
& Executive
Director to report
to Board on
process. Feedback
to/from patients at
Patients’ Forum.
All 15 wards have
4th peer review.
Reports and visits.
Specialist and forensic Clinical Service Unit
1. Improving physical
healthcare
• Provide high- quality evidence-based care for long-term conditions.
• Review physical health needs within CPA process.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Provide highquality evidencebased care for longterm conditions.
Review physical
health needs
within CPA
process. Patients
eligible for all
national screening
programmes.
90% achievement
of maximum
clinical outcomes
as set out in QOF
score.
90% achievement
of maximum
clinical outcomes
as set out in QOF score.
90% achievement
of maximum
clinical outcomes
as set out in QOF score.
90% achievement
of maximum
clinical outcomes
as set out in QOF score.
Monitored
through
the physical
healthcare group.
Call/recall system
by end of Q2 for
cervical cytology,
breast screening,
and bowel cancer.
95% CPA
meetings receive a
completed health
proforma.
2. Improving the management
of patient transitions
• Improve patients’ pathway through services.
• Provide evidence-based psychological interventions.
• Improve patients’ pathway through services and reduce length of stay.
• Improve practice around delayed discharges.
30
quality account
Priority
Key milestones
Q1
Improve patients’
pathway through
services.
Patient needs assessment completed in
12/13. Project group to develop new
model and agree implementation plan
with commissioners. Consultation to be
completed by September.
Provide evidencebased psychological
interventions.
Review of current
group programme
and available
resources.
Improve patients’
pathway through
services and reduce
length of stay.
Improve practice
around delayed
discharges.
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
New model to
be operational by
December 2013.
Review of service
user’s journey
through the
pathway to
ensure that new
model is meeting
needs identified in
12/13.
Project plan to
report to SMT.
Identify high
demand groups
and develop a
revised timetable
for the high
demand.
Develop a
programme for
admission wards.
Implement group
programme.
Monitored
through
psychological
therapies, rehab &
recovery steering
group.
Admission 12
week care pathway
monitored and
discharge care
pathway published
(including the
provision of clear
guidelines to
teams in relation to
discharge pathway
and funding
stream).
75% of all
patients to
have received
intervention
within timescale
set out in
admission
and discharge
pathway.
85% of all
patients to
have received
intervention
within timescale
set out in
admission
and discharge
pathway.
95% of all
patients to
have received
intervention
within timescale
set out in
admission
and discharge
pathway.
Reported via
monthly IPR/
SMT and
commissioners
quarterly reports.
Monthly meeting
in place to ensure
peer review and
shared learning re
delayed discharges.
Monthly meeting
has an up-to-date
list of all delayed
discharges across
forensic services.
Monthly meeting
has an up to date
list of all delayed
discharges with
reasons for delay
identified and
action plan in place.
Monthly meeting
embedded in the
service and will
develop a plan to
reduce delayed
discharges in
14/15.
Meeting minutes.
High demand
groups identified
in Q2 will be run
more frequently.
Review ‘to be
completed
’‘individual
interventions.
Monitored at
SMT.
3. Improving the dissemination of learning and best practise
• Review the incident & error Systems (SIs, near misses) to improve shared learning across the CSU.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Review the incident
& error Systems
(SIs, near misses)
to improve shared
learning across the
CSU.
Thematic review
of all incidents &
effectiveness of
action plans in
12/13.
The TOR for
the CSU suicide
prevention
and incident
monitoring group
to be reviewed.
Database to be
revised.
Action plans to
be routinely sent
to CIG meetings.
Weekly review
meeting with ward
managers to be
established to look
at action plans.
CSU wide learning
lessons event to
be held to review
developments in
the year.
Monitored via
suicide prevention
and incident group
& reported to
Trust governance
structure. Evidence
of action plan
implementation
and effectiveness.
2012/2013
31
4. Ensure service users are treated
with the highest level of dignity,
compassion and respect
• Pilot of systemic/family engagement project where initial social network meetings are held soon
after admission and significant people in the service user’s life – family, carers, professional network
– are invited to meet with the Multi Disciplinary Team.
• Agree system for senior staff to have a dialogue and obtain general feedback and feedback about
specific issues from representative group of patients re their views about what works well and what
could be different.
• Skype facilities to be piloted in 2 areas to facilitate family contact.
• Engage service users in their care pathway.
Priority
Key milestones
Q1
Key milestones
Q2
Key milestones
Q3
Key milestones
Q4
Evidence
Pilot systemic/
family engagement
project.
Convening initial
social network
meetings for
new admissions
and systemic
map as part of
the 12-week
care pathway
assessment.
A systemic map
will be developed
for all new
admissions which
may include
family members
and friends,
professional
network,
affiliations in the
community. The
map can identify
potential resources
in the service user’s
recovery and return
to the community.
Feedback to be
collected for service
users, carers and
staff around their
experience of the
project.
Review of pilot to
be presented to
SMT.
Meetings
convened.
Engage service
users in their care
pathway.
Continue to
embed recovery
approach into
all clinical areas
except GIC.
Continue to
embed recovery
approach into
all clinical areas
except GIC.
Continue to
embed recovery
approach into
all clinical areas
except GIC.
Continue to
embed recovery
approach into
all clinical areas
except GIC.
Monitored
through nursing
governance.
Training in place.
Training in place.
Training in place.
Training in place.
Audit use of
recovery tool/
STAR.
Audit use of
recovery tools in
CPA.
Meridian in use in
all clinical areas’
32
Meridian in use in
all clinical areas.
Meridian in use in
all clinical areas.
Meridian in use in
all clinical areas.
Clinical areas
to agree how
feedback is
collated, discussed
and fed back to
service users.
Service specific
questions in use.
Service specific
questions in use.
Review and report
on pilot to SMT.
Monitored
through Nursing
Governance and
DM&CG.
quality account
Protocol for using
Skype to be
written.
Protocol for using
Skype to be
agreed by Security
Steering Group.
Skype facilities to
be piloted in 2
areas to facilitate
family contact.
Review of pilot
to be reported to
Security Steering
Group & Senior
Management
Team.
Monitored
through Security
Steering Group
and Directorate
Management
& Clinical
Governance.
Statements of assurance from the Board
Review of services
During 2012/13 the West London Mental Health
NHS Trust provided and/or sub-contracted 17
relevant health services.
The West London Mental Health NHS Trust has
reviewed all the data available to them on the
quality of care in 17 of these relevant health services.
The income generated by the relevant health
services reviewed in 2012/13 represents 100 per
cent of the total income generated from the
provision of relevant health services by the West
London Mental Health NHS Trust for 2012/13.
Participation in clinical audits
During 2012/13, 2 national clinical audits and 1
national confidential enquiries covered relevant
health services that the West London Mental
Health NHS Trust provides.
During 2012/13 the West London Mental
Health NHS Trust participated in 100% of the
national clinical audits and 100% of the national
confidential enquiries of the national clinical audits
and national confidential enquiries which it was
eligible to participate in.
The national clinical audits and national
confidential enquiries that the West London
Mental Health NHS Trust participated in during
2012/13 are as follows:
National Clinical Audits
• Prescribing Observatory Mental Health-UK (POMH-UK): Prescribing in mental health services:
• Topic 2f – Screening for metabolic side effects of antipsychotic drugs.
• Topic 11b - Prescribing antipsychotics for people with dementia.
• Topic 12a – Prescribing for people with personality disorder.
• National Audit of Schizophrenia (NAS)
National Confidential Enquiries
The national clinical audits and national confidential enquiries that West London Mental Health NHS
Trust participated in during 2012/13 are as follows:
• The National Confidential Inquiry into Suicide and Homicide for People with Mental Health Illness (NCISH)
The national clinical audits and national confidential enquiries that the West London Mental Health
NHS Trust participated in, and for which data collection was completed during 2012/13, are listed
below alongside the number of cases submitted to each audit or enquiry as a percentage of the
number of registered cases required by the terms of that audit or enquiry.
2012/2013
33
Name of National Clinical Audit
POMH-UK Topic 11b – Prescribing
antipsychotics for people with dementia
Number Submitted
%
1762
100%
POMH-UK Topic 2f – Screening for metabolic
side effects of antipsychotic drugs
177
100%
POMH-UK Topic 12a – Prescribing for people
with personality disorder
147
100%
National Audit of Schizophrenia
100
100%
Name of National Confidential Inquiry
The Confidential Inquiry into Suicidal and
Homicide by People with Mental Illness (CISH)
Number Submitted
8
%
100%
The reports of 6 national clinical audits were reviewed by the provider in 2012/13 and West London Mental
Health NHS Trust intends to take the following actions to improve the quality of healthcare provided:
1.
POMH-UK Topic 2f - Screening for metabolic side effects of antipsychotic drugs
Data collection: June 2012
Report: September 2012
Lead: Clinical leads
Re-audit: POMH to confirm date
This was the fifth audit of this topic run by POMH-UK. Two assertive outreach teams within the Trust
participated in this supplementary audit, contributing data from 177 service user records.
Audit standard
All patients prescribed continuing antipsychotic medication should have their blood pressure, body
mass index (or other measure of obesity), blood glucose (or HbA1C) and lipids measured at least
once a year. Annual screening is the minimum acceptable practice; most guidelines recommend more
frequent screening of some or all of these measures depending on the drug prescribed or a patient’s
demographic or clinical characteristics.
Relevant targets
1. For health care premises to become virtually smoke-free environments for patients, service users, visitors and staff (Smoking Kills; DoH, 1998).
2. To reduce the proportion of adults who smoke from 28% to 24% or less by the year 2010 (Health of the Nation white paper; DoH, 1999).
Overall the re-audit showed that practice had continued to improve and the Trust performed well
above the national average for three out of the four tests required.
34
quality account
Action taken:
Assertive outreach teams have implemented the following:
•
Use of side effect monitoring checklist for people who are prescribed depot antipsychotics: this is attached to all depot prescription charts and is an attachment to this email.
•
Annual request for GP encounter record.
•
Physical healthcare section to care plan.
•
Incorporation of information from GP encounter record into physical health care plan.
•
Encouraging all patients to register with GP (if not already).
•
Encouraging all patients to attend GP for 6 monthly blood tests and annual health check.
2.
POMH-UK Topic 12a - Prescribing for people with personality disorder
Data collection: April 2012
Report: August 2012
Lead: Clinical leads
Re-audit: October 2013
Audit standard
1. There is a written crisis plan in the clinical records.
2. There is evidence that the patient’s views have been sought in the development of the crisis plan.
3. A clinician’s reasons for prescribing antipsychotic medication Eg target symptoms or behaviour) are documented in the clinical records.
Treatment targets
1. Antipsychotic drugs should not be prescribed for more than four consecutive weeks in the absence of a co-morbid psychotic illness.
Derived from NICE CG078 recommendation 6.12.1.2: Antipsychotic drugs should not be used for the
medium and long-term treatment of borderline personality disorder; and 3.12.1.3: Drug treatment may
be considered in the overall treatment of co-morbid conditions.
2. Z-hypnotics should not be prescribed for more than four consecutive weeks.
3. Benzodiazepines should not be prescribed for more than four consecutive weeks.
4. Medication prescribed for more than four consecutive weeks should be reviewed, and such a review should take into account a) therapeutic response and b) possible adverse effects, and also c) be documented in the clinical records.
Overall this baseline audit identified 80% of patients who had medications prescribed for more than
four weeks, of whom 48% had a review documented.
2012/2013
35
Action to be taken:
•
To conduct a further audit due to low returns.
•
Action plan to be presented to the personality disorder pathway project board to consider:
o
How we can ensure prescribing practices are to a high standard.
o
Off-label prescribing – how can we ensure trust policies and guidelines are being followed.
o
How we can provide a systematic approach to personality disorder that makes best use of alternative interventions and hence lessen prescribing.
3.
POMH-UK Topic 11b - Prescribing antipsychotics for people with dementia
Data collection: September 2012
Report: January 2013
Lead: Dr Sujoy Mukherjee
Re-audit: POMH to confirm date
This was the second cycle of audit of this topic run by POMH-UK. Improvement noted from the baseline audit.
Audit standard
1. The clinical indications (target symptoms) for antipsychotic treatment should be clearly documented in the clinical records.
2. Before prescribing antipsychotic medication for BPSD (behavioural and psychological symptoms in dementia), likely factors that may generate, aggravate or improve such
behaviours should be considered.
3. The potential risks and benefits of antipsychotic medication should be considered and documented by the clinical team prior to initiation.
4. The potential risks and benefits of antipsychotic medication should be discussed with the patient and/or carer(s) prior to initiation.
5. Medication should be regularly reviewed and the outcome of the review should be documented in the clinical records. The medication review should take account of a) therapeutic response and b) possible adverse effects.
The trust performed well in comparison to the national average having the lowest proportion of
patients prescribed an antipsychotic for dementia. However, it showed a slight decrease in the clear
documented indication for antipsychotic treatment.
36
quality account
Action to be taken:
•
The report will be presented to the next clinical improvement group meeting for the cognitive impairment dementia service.
•
The report to be distributed to all senior clinicians and team leaders.
•
Individual teams will be given feedback on their performance and improvement targets will be formulated and monitored.
•
Re-audit by participating in the next POMH UK audit in 2013.
•
A database of all patients who have dementia and are on antipsychotic medications is currently being finalised and it is also being explored how a regular review can be ensured.
•
The aim would be to achieve all the targets by the end of this year.
4.
POMH-UK Topic 10b – Use of antipsychotic medicine in CAMHS
Data collection: November 2011
Report Due: March 2012
Lead: Dr Meenal Sohani
Re-audit: January 2014
This was the second cycle of audit of this topic run by POMH-UK.
Audit standard
1. For all children and adolescents prescribed antipsychotic medication the indication(s) for treatment with antipsychotic(s) should be documented in the clinical records.
2. For all children and adolescents prescribed antipsychotic medication, the side effects of antipsychotics should be reviewed at least once every six months. This review should include, as appropriate, the assessment of body weight, blood pressure, blood glucose, plasma lipids and raised plasma prolactin, and examination for the presence of extrapyramidal side effects (EPS).
The Trust performed particularly well regarding compliance with recording and reviewing use of medication.
It was noted however, that monitoring of prolactin levels was lower than the national average.
Action to be taken:
•
To increase compliance in monitoring of prolactin levels
•
To increase the proportion of documented six month reviews
•
It was agreed the action plan be split between the Wells Unit and Child & Adolescent Mental Health Services
•
Benchmark good practice across CAMHS and the Wells Unit.
2012/2013
37
5.
POMH-UK Topics 1f and 3d - Prescribing high dose and combination antipsychotics on adult psychiatric and forensic wards
Data collection: March 2012
Report: May 2012
Lead: Clinical leads
Re-audit: POMH to confirm date
This was the fifth cycle of audit within the adult acute services and the third cycle of audit within the
forensic services of this topic run by POMH-UK.
Audit standard 1: The total daily prescribed dose
of antipsychotic drugs is within SPC/BNF limits.
A high-dose is defined here as a total daily dose (whether of a single antipsychotic or combined
antipsychotics) greater than 100% of the maximum recommended daily dose (Royal College of Psychiatrists, 2006).
Audit standard 2: Individuals are prescribed only
one antipsychotic at a time.
This standard applies to 100% of individuals with schizophrenia. Exceptions: ‘Individuals with
schizophrenia who are receiving clozapine but who have not responded sufficiently; and individuals
who are changing from one antipsychotic to another’ (NICE schizophrenia treatment guideline).
Significant improvements to practice continue to be made.
Action to be taken:
•
Dissemination of audit results.
•
Individual consultants to reflect on their prescribing and take data to their appraisal.
•
Non participating consultants to participate in future local audits and next POMH-UK audit.
6.
National Audit of Schizophrenia – Royal College of Psychiatrist’s Centre for Quality Improvement (CQQI)
Data collection: August 2011
Report: April 2012
Lead: Professor Thomas Barnes
Re-audit: June 2013
The Trust participated in the National Audit of Schizophrenia which commenced in August 2011 and was completed in February 2012.
Audit standards
The standards set for this audit are based on the NICE Guideline (2009). Thus, the audit particularly
focuses on the satisfaction of service users and carers with the services offered to them, prescribing
practice, psychological interventions offered and the quality of monitoring of physical health for these
service users.
38
quality account
Trust performance:
•
In middle range on most key standards.
•
In relation to prescribing clozapine, in the top group of Trusts at 100%.
•
Above average in relation to antipsychotic polypharmacy.
Action to be taken:
A National Audit of Schizophrenia Task Group has been established and is responsible for reviewing the
report and developing change intervention to improve practice. The Trust have now joined the network
established by the Schizophrenia Commission to implement the recommendations of their report
regarding the treatment of schizophrenia which was published last November.
The reports of 11 local clinical audits were reviewed by the provider in 2012/13 and West London Mental
Health NHS Trust intends to take the following actions to improve the quality of healthcare provided:
1.
Patient safety audit
Data collection: Monthly
Report: March 2013
Lead: Dr Anne Aiyegbusi
Re-audit: July 2013
•
Over the last 3 years the trust has carried out a number of clinical audits and quality monitoring activity including:
•
CPA compliance.
•
Standards of record keeping.
•
Self-harm and suicide prevention.
•
Risk assessment and risk management.
With the advent of the Commissioning for Quality
and Innovation (CQUINS) and the Quality Account
thus requiring further clinical audit and monitoring
processes it was essential that the trust adopted
a more standardised approach to the way it
conducted its priority clinical audits.
The recommendations of previous clinical audits
undertaken and recent incident reviews had also
identified the need to focus on the quality of the
patient record, and that this should become the
focus of staff supervision. Furthermore clinicians
were feeling the effects of audit fatigue, being
requested more frequently to participate in one off clinical audits.
This approach provides up to the moment
evidence of practice which can be used as part of
management and clinical supervision, it acts as a
means of signposting more localised clinical audit
activity. The audit identifies areas requiring a more
focussed piece of audit, thus increasing ownership
and promoting the benefits of the process.
To date we have had 184 patient safety audit tools
completed and submitted, overall the results to date
are looking very positive, with the majority above
90%. The snap shots used from Meridian are live
and change each time a new form is submitted.
Action to be taken:
Each CSU will be provided with a summary which will be submitted to each of the CSU governance
groups for local action plans to be developed and local clinical audits to be identified.
The audit will continue on a monthly basis.
2012/2013
39
2.
Audit of incidents and management of deliberate self-harm across inpatient services
Data collection: October 2012
Report: December 2012
Lead: Dr Anne Aiyegbusi
Re-audit: April 2013
The re-audit examined all self harm incidents reported in Quarter 2 (July-September) 2012. All incident
reporting forms (IR1) with an incident sub category of “self injury” were obtained from the Trust’s
electronic incident management system.
The focus of the audit was on two main standards:
•
Individuals who self harm are involved in their care.
•
Treatment options are appropriately offered and discussed with individuals who self harm.
A total of 185 incident report forms were analysed. Of these, 20 incidents were reported in High
Secure Services, 32 incidents were recorded in local services and the remaining 133 incidents taking
place in the West London forensic and specialist service.
19 patients were responsible for 21 incidents recorded in high secure services with two patients having
2 incidents each recorded. 23 patients were responsible for the incidents in local services with one
patient responsible for 5 of those incidents. Within the specialist and forensic service, the majority of
the incidents took place in the women’s enhanced medium secure service, followed by the Cassel unit.
Action to be taken:
•
To extend the audit methodology and re- audit in Quarter 1.
•
Future re-audits to be more targeted to the service and will be a rolling programme over the quarters. The next re-audit will initially look at clinical records and will target specific areas and measure against the Self-harm long term guidance CG133 as well. This will provide a better measure for compliance as not all clinical details are recorded in the IR1 forms.
3.
Observational audit of engagement and observation practice Trust-wide
Data collection: Monthly
Report: March 2013
Lead: Dr Anne Aiyegbusi
Re-audit: July 2013
Overall, the findings show an increase of 26% compliance from July 2012 to January 2013:
40
•
Staff engaging increased 52%.
•
Up-to-date care plans increased 31%.
•
Preventing suicide increased by 21%. •
Staff awareness of requirements under specific observations increased 17%.
•
The patient questionnaire increased 10%. quality account
Action to be taken:
•
Provide engagement & observation information to all patients with their copy of the engagement & observation care plan.
•
Staff awareness of requirement under specific observations assessed
frequency of care plan updates.
•
Audit of privacy & dignity.
•
Encouragement to patients to attend therapeutic/activity programmes.
A Trust-wide action plan has been developed incorporating areas that were identified as red and
amber. The action plan will be agreed and monitored quarterly via the service user & carer experience
group to obtain trends and changes to practice. The service user & carer experience group will offer
the expertise in advising changes to practice.
4.
Review of West London Mental Health Trust implementation of the Safeguarding Adults Policy – experience and knowledge of clinicians
Data collection: November 2012
Report: March 2013
Lead: Dr Johan Redelinghuys
Re-audit: June 2013
This baseline audit was commissioned following a Care Quality Commission visit in August 2012. The
objective of the audit was to gather information re compliance with the safeguarding adults policy.
Overall all staff were aware of their responsibility to safeguard adults and were able to describe the
procedures for assessment and reporting instances requiring action. What did become apparent was
the complexity of the process and the need to streamline the current process.
Action to be taken:
CSUs and local safeguarding adult leads have a responsibility to ensure all staff are aware of who their
local leads are for safeguarding adults.
All staff are aware of the issues and risks pertaining to safeguarding adults and have attended either
the Trust’s mandatory training or the local council’s training, however, more work is required to ensure
policy and good practice is fully embedded within the culture of the organisation. The following
recommendations have therefore been identified:
o
Further work required to establish true partnership working between the trust and social services and adopt the processes where this is already working well, trust wide.
o
Investigate the likelihood of joint training.
o
Develop a reporting system which reflects the processes used for safeguarding children and which strengthens feedback processes.
o
Review the resources required for safeguarding adults within the Trust. To take into account administration time, a review of current paperwork, safeguarding lead role and consider a safeguarding triage system.
o
Consider current methods of communication particularly ‘Alerts’ to ensure all staff are aware of ‘need to know’ information immediately.
2012/2013
41
o
To establish the need for a separate Trust policy for safeguarding adults considering social services have one already which is felt useful by staff produce a flowchart of safeguarding adults’ process and widely disseminate to Trust staff.
o
Produce information for service users.
o
Implement the trust safeguarding adults’ competency framework forthwith.
5.
Audit of completion of lithium monitoring record books - National Patient Safety Agency (NPSA) alert - inpatient Services
Data collection: November 2012
Report: December 2012
Lead: Michele Sie
Re-audit: December 2013
Trust-wide results showed that most patients are
having the required blood tests, however the
NPSA purple record book is not being utilised
to record the results. There was considerable
variation between areas, with SFS having 100%
of recommended blood tests carried out and HSS
having between 90 and 100% of recommended
blood tests carried out.
Local services were not able to achieve the
same result however this audit was looking at
documentation so the blood tests may well have
been carried out but not documented.
It is important to look at the changes in lithium level
over time as this may well predict a changing trend
which may require dose adjustment.
It is also interesting to note that of the 75 eGFR
results 40 fall into the mild reduced kidney function
and 3 in the moderate reduced kidney function.
The SPC for lithium states that ‘if patients with mild
or moderate renal impairment are being treated
with lithium, serum lithium levels should be closely
monitored’. Of the 92 TFTs, 13 results were low
and 8 results were high.
Action to be taken:
42
•
Lithium register on the exchange to be reviewed, commented on, approved and implemented.
•
All lithium patients and blood results to be added to the Trust exchange register, this will initially be supported by the pharmacy and primary care then it will be the responsibility of the initiating consultant to ensure patients newly initiated on lithium are added and patients who cease treatment have a stop date entered.
•
Medicines reconciliation for patients on lithium to include a check as to whether patient has a purple record book.
•
Pharmacy and clinicians having access to the lithium register will negate the need for the lithium books to be kept with the prescription chart. Lithium record books will be updated/
supplied at discharge with the last years results entered into them by pharmacy/doctor discharging if blood results available.
6.
Audit of completion of lithium monitoring record books - National Patient Safety Agency (NPSA) Alert – community services
Data collection: November 2012
Report: December 2012
Lead: Michele Sie
Re-audit: December 2013
quality account
Trust-wide results showed that there was poor
documentation of blood results and that the NPSA
purple record book is not being utilised to record the
results. There was considerable variation between
different community areas and not all areas submitted
data. It is important to look at the changes in lithium
level over time as this may well predict a changing
trend which may require dose adjustment.Of the
155 lithium levels documented, 39 were below the
normal range which may indicate a sub-therapeutic
dose or poor compliance, 110 were within the normal
range and 6 were above the normal range. It is also
interesting to note that of the 71 eGFR results 35
fall into the mild reduced kidney function and 16 in
the moderate reduced kidney function. The SPC for
lithium states that ‘if patients with mild or moderate
renal impairment are being treated with lithium, serum
lithium levels should be closely monitored’. Of the 94
TFTs, 23 results were low and 12 results were high.
Action to be taken:
•
Lithium register on the exchange to be reviewed, commented on, approved and implemented.
•
All lithium patients and blood results to be added to the Trust exchange register, this will initially be supported by the pharmacy and primary care then it will be the responsibility of the initiating consultant to ensure patients newly initiated on lithium are added and patients who cease treatment have a stop date entered.
•
Processes for management of lithium patients in local services to be clearly defined.
•
Outpatient review of lithium patients should include a check of the patients purple lithium record book and monitoring carried out.
7. NICE Infection Control (Clinical Guideline 139)
Data collection: October 2012
Report: April 2013
Lead: Dr Anne Aiyegbusi/Elaine Smith Re-audit: October 2013
The objective of the annual infection control audit
is to establish compliance with the infection control
standards. The audit establishes whether kitchens
are maintained to reduce the risk of cross infection
in accordance with legislation. The environment is
maintained appropriately to reduce the risk of cross
infection. Waste is disposed of safely without risk
of contamination or injury and in accordance with
legislation. Linen is handled appropriately to prevent
cross infection and the correct personal protective
equipment is being utilised across all three CSUs.
Sharps are managed appropriately to reduce the risk
of accidental inoculation injury. Clinical equipment
is managed appropriately to reduce the risk of cross
infection and cross contamination.
Hand washing facilities are adequate to ensure
hand hygiene can be carried out effectively. Clinical
practice reflects infection control guidelines and
reduces the risk of cross infection to patients whilst
providing appropriate protection to staff.
Overall Trust-wide were 88% compliant against the
standards compared to 87% last year. The highest
scoring sections were clinical practice and waste
management and the lowest scoring section applied
to the laundry room. This shows an overall increase
of 1%, three areas within the audit have increased,
five areas have declined and one remained the same
over the year. The highest increase was 13% in
clinical practice.
Action to be taken:
•
Each CSU will develop an action plan specific to their individual findings. The CSUs are responsible for the implementation of the actions via the local infection control & patient environment group meetings.
•
A Trust-wide action plan will be produced from the action plans developed by each Clinical Service Unit. Progress will be monitored locally within the CSU and at the Trust infection control & patient environment group meeting.
2012/2013
43
8.
Hand hygiene
Data collection: Monthly
Report: April 2013
Lead: Dr Anne Aiyegbusi/Elaine Smith
Re-audit: May 2013
Over the past 12 months all three CSUs have been
carrying out monthly random hand hygiene audits.
In June 2012 the audit was uploaded onto Meridian
so data obtained for 2012/2013 is only a snap shot
owing to issues surrounding the Meridian systems.
The findings for 2012/2013 have identified that
one area, ‘staff carrying tottles’ has increased its
compliance by 18% and has gone from red to amber.
It also identified a 6% decline in overall compliance.
In 2011/12 we had nine areas with compliance
above 85% (ragged green) and one area below
50% (ragged red). In 2012/13 we have six areas
above 85% (ragged green) and four areas between
50 and 84% (ragged amber).
Action to be taken:
•
Each ward to develop an action plan specific to their individual findings. The ward manager is responsible for the implementation of the actions.
•
Updates on progress will be monitored via the infection control & patient environment group clinical service unit meetings and at the Trust quarterly infection control & patient environment group meetings.
9.
NICE Alzheimer’s disease - donepezil, galantamine, rivastigmine (review) and memantine (Technology Appraisal 111)
Data collection: June 2012
Report: November 2012
Lead: Dr Sujoy Mukherjee
Re-audit: May 2015
Data was compiled for 90 patients across the three boroughs and the audit has highlighted that the
Trust is compliant with the NICE Guidelines in relation to initiation and monitoring of Cholinesterase
inhibitors. Trust compliant.
Action to be taken:
•
To continue following NICE Guidelines TA217.
•
All teams to complete review of cognitive, behaviour and global function during medication reviews.
10. Self assessment checklist for mental health trusts: eliminating mixed sex accommodation
Data collection: March 2012
Report: April 2012
Lead: Dr Anne Aiyegbusi
Re-audit: March 2013
This review was requested as part of the trust’s
reporting requirements on eliminating same sex
accommodation. Each ward was visited on the 2nd
April 2012 by a review team consisting of a senior
nurse, practice development nurse and the Head of
Clinical Effectiveness & Audit. The review team, along
with the ward manager, completed the checklist,
44
observed the area and used reference material/
records where available to complete the review.
Overall, all wards achieved compliance with the
majority of the best practice principles contained
within the review checklist.
quality account
Areas of note:
•
Board/ward commitment to improve and maintain privacy and dignity arrangements.
•
Improvement and maintenance in cleanliness standards at ward level.
•
Good physical separation of sleeping accommodation, toilet and bathing/washing facilities for men and women.
•
Reduction of and consistent reporting of breeches if and/or when they occur.
Action to be taken:
•
Explore single sex accommodation.
•
Copy of the privacy and dignity policy to be made available at ward level.
•
Privacy and dignity standards to be implemented and audit to take place.
•
Copies of standards to be provided to service users and carer’s upon admission.
•
An action plan will be developed to take forward the recommendations outlined above.
11.
Physical health observations
Data collection: May 2012
Report: July 2012
Lead: Dr Alan Cohen
Re-audit: September 2013
To assist in the standardisation of the recording
of physical health observations across the Trust,
we undertook an audit to identify the current
processes. 50 ward managers across the Trust were
asked to send/email a copy of the form they were
currently using on the ward to record physical health
observations. The audit identified that physical health
observations are being undertaken and recorded
across the Trust. It also highlighted the numerous
ways of recording physical health observations. We received a selection of recording sheets, varying
from Excel spreadsheet; tables produced in Word
documents and Modified Early Warning Score (MEWS).
Action to be taken:
•
Ensure consistency across the Trust, all wards will be asked to implement the MEWS recording chart.
•
Re-audit 6 months following implementation of the MEWS recording chart.
The Trust has a comprehensive clinical audit annual programme which includes a number of Trust-wide
clinical audits the themes of which have been derived from learning from untoward incidents and in
addition the programme is aligned to our risk registers.
What RSM Tenon, our
internal auditors said:The following audits were undertaken as part of the approved internal audit plan for 2012/13.
•
Care Quality Commission rolling review of compliance.
•
Compliance with the hygiene code.
•
Incident management.
•
Data quality.
2012/2013
45
Care Quality Commission rolling review of compliance
They concluded that the Trust has a satisfactory framework for monitoring compliance with Care
Quality Commission registration requirements, although improvements are needed to strengthen the framework.
This was the first of a rolling programme of reviews to be undertaken in an effort to provide the Board
with rolling assurance on compliance with Care Quality Commission registration requirements.
The Trust has accepted their recommendations and the following areas of work are underway:
•
An internal procedural / guidance document for Care Quality Commission is currently being developed to clarify and support staff on the process for the collection, scrutiny and challenge of evidence to ensure compliance.
•
A Care Quality Commission framework template is currently being updated for each outcome to ensure sufficient evidence is available to support the Care Quality Commission outcomes.
•
The centralised Care Quality Commission process is being reviewed to strengthen the compliance process and ensure it is effectively managed.
Compliance with the hygiene code
The Board can take assurance that the controls upon which the organisation relies to manage their
compliance with the hygiene code are suitably designed, consistently applied and effective, and identified
areas of good practice, such as 94%, 2,524 staff members across the Trust completing mandatory
infection control training and that there had been only one isolated case of C Diff and no cases of MRSA
Bacteraemia between January 2011 and March 2012, which is in line with targets set by Monitor.
Incident management
The audit concluded that whilst the Board can take some assurance that the controls upon which the organisation relies to manage this risk are suitably designed, consistently applied and effective,
action needs to be taken to ensure that risk is managed.
Their recommendations were accepted and the Trust will implement as a result:
•
To ensure that all incidents are being recorded on RiO so that a full incident history is readily accessible to staff.
•
Incident forms not reviewed by a designated manager, and 24 and 72 hour reports not completed within the timescale required under the Trust’s incident management and reporting policy will be part of the data reported to the quality committee on a quarterly basis and reported to the service areas on a monthly basis.
Data quality audit
The audit concluded that the Board can take reasonable assurance that the controls upon which the
organisation relies to manage this area are suitably designed, consistently applied and effective. However
they identified issues that, if not addressed, increase the likelihood of risk materialising in this area.
Their recommendations were accepted and the Trust will implement as a result:-
46
•
Further RiO training and regular reminders for all HCP staff on the importance of inputting data accurately and its effects on the Trust’s key performance indicators, and how it affects the quality of data.
•
Regular local data quality reports to be run to ensure the accurate recording of data on a timely basis.
quality account
Participation in clinical research
The number of patients receiving relevant health
services provided or sub-contracted by the West
London Mental Health NHS Trust in 2012/13 that were
recruited during that period to participate in research
approved by a research ethics committee was 521.
We are committed to ongoing development of the
research profile of the Trust and see research as a
central component of clinical care. We know that
research will improve the quality of care our service
users receive.
In 2012/13 we have continued to enjoy the
success of the prosecution of the R&D Strategy
with highlights being the continued prominence
of cognitive impairment and dementia research
at WLMHT on a national and international stage,
the opening of an R&D Business Development
Unit and the successful initiation of the Corsellis
Modernisation project indexed by new and important
research collaborations across the UK.
We have also neared sign off on the wholesale
re-housing and integration of the R&D department
to our Lakeside campus, to include a new, bespoke
facility for the Corsellis collection, a greatly expanded
clinical trials facility and new offices for the whole
R&D team who help support our research.
We are also developing much better integration with
all our CSUs to ensure patients have easy access to
research and that clinical colleagues can participate in
or be informed by the research we do.
The Trust continues to collaborate with other trusts
in and out of London and with our key academic
partner, Imperial College London.
We also have enjoyed strong representation on the
senior executive of the London (Northwest) CLRN
and have been a strong voice in the developing
Academic Health Sciences Network.
In 2010/11 there were a total of 76 ongoing studies
with 47% being funded. In 2011/12, we undertook
a similar number of studies but 53% were funded.
In 2012/13 we increased the total number of
studies we were involved with by 34% to 102 and
now 64% are funded projects. In other words, the
number of funded studies we are running at WLMHT
has increased each year from 36 in 2010/11 to 40 in
2011/12 to 65 in 2012/13.
One of the main drivers of this has been the rapid
development of the cognitive impairment and
dementia portfolio. Last year, WLMHT was the
number one NHS centre in the UK for life sciences
dementia clinical trials in terms of number of open
studies we could offer to our patients and their
carers.
We can also measure our success through the
contribution our academics make to the scientific
mental health and dementia literature. In 2011/12
our researchers and academics published 112
articles. This year, the number has increased to 130
with scores of book chapters, conference abstracts
and invited lectures.
In 2013/14 we expect further growth of the
portfolio, the instillation of the research registers
in the trust, growth through our innovations work
stream and a continued closing of the gap between
clinical research and clinical practice.
Imperial Partners Limited
Through 2012/13 the NHS has undergone massive reorganisation. One structural change that
envisages national integration of research with clinical care is the establishment of 15 Academic Health
Sciences Networks in England. Imperial Partners has been established and WLMHT is a core member
of the partnership; we are also engaged actively in the reconfiguration of the comprehensive local
research network into the local clinical research network which sees DeNDRoN and MHRN being
integrated into this larger network as prominent research themes. We have a strong voice not just in those themes, but also in the delivery and strategy of the existing CLRN which we hope will continue
as the new structure takes shape.
2012/2013
47
Goals agreed with commissioners – Commissioning for Quality & Innovation payment framework (CQUIN)
A proportion of West London Mental Health NHS Trust’s income in 2012/13 was conditional upon
achieving quality improvement and innovation goals agreed between the West London Mental Health
NHS Trust and any person or body they entered into a contract, agreement or arrangement with for the
provision of relevant health services, through the Commissioning for Quality and Innovation payment
framework. Further details of the agreed goals for 2012/13 and for the following 12 month period are available on line at:
http://www.monitor-nhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/openTKFile.php?id=3275
Local services CSU: Hounslow,
Q1
Q2
Q3
Q4
Ealing and Hammersmith & Fulham
1. Physical healthcare
N/A
Met
N/A
Achieved pending
CCG sign off.
N/A
Partially met
N/A
Achieved pending
CCG sign off.
N/A
Met
Partially met
Achieved pending
CCG sign off.
N/A
N/A
Met
Achieved pending
CCG sign off.
N/A
Partially met
Partially met
Achieved pending
CCG sign off.
N/A
Partially met
Partially met
Achieved pending
CCG sign off.
N/A
Not met
Not met
Achieved pending
CCG sign off.
N/A
Met
N/A
Achieved pending
CCG sign off.
N/A
Partially met
Partially met
Achieved pending
CCG sign off.
a) Sharing of CPA Register with Primary Care
1. Physical healthcare
b) 95% patients on CPA to have complete physical and mental health diagnostic coding (ICD 10)
1. Physical healthcare
c) 75% patients on CPA supported to access physical health care check.
1. Physical healthcare
d) Reduction of medication errors through medicines reconciliation on admission to hospital
1. Physical healthcare
e) GPs receive discharge notification within 72 hrs of discharge from hospital.
1. Physical healthcare
f) GPs receive a CPA review outcome letter/or copy of care plan within two weeks of CPA review for 70% of patients.
1. Physical healthcare
h) GPs receive assessment outcome(s) or reason for DNA within 5 working days of completing the assessment for community services.
2. Recovery
a) Audit of recovery orientated practice within the organisation
2. Recovery
b) Collaborative care planning & personal recovery goals
48
quality account
3. Dementia
a)
Met
Met
Met
Achieved pending
CCG sign off.
Met
Not met
Not met
Achieved pending
CCG sign off.
Met
Not met
Not met
Achieved pending
CCG sign off.
Met
Not met
Not met
Achieved pending
CCG sign off.
N/A
Met
Met
Achieved pending
CCG sign off.
N/A
Met
Met
Achieved pending
CCG sign off.
N/A
Met
Met
Achieved pending
CCG sign off.
N/A
Met
Met
Achieved pending
CCG sign off.
N/A
Partially met
Met
Achieved pending
CCG sign off.
N/A
Partially met
Partially met
Achieved pending
CCG sign off.
Met
Met
Partially met
Achieved pending
CCG sign off.
Auditing antipsychotic prescribing to patients with dementia, using the POMH-UK audit tool, and the sampling frame provided by NHS London (please see Appendix 1 - Audit Standards). Sharing the results of this audit with NHS London
3. Dementia
b) Regular reviews of antipsychotic prescriptions are conducted for people with dementia and communicated to GPs and patients/families
3. Dementia
c)
Develop and deliver a local sustainable quality improvement plan to reduce inappropriate antipsychotic prescribing to people with dementia and improve the quality of that prescribing, in line with NICE guidance. The plan will set out key actions which will be undertaken with local partners to achieve this goal.
3. Dementia
d) Improving discharge summaries for people with dementia, including those on antipsychotics
4. Safe discharge
a) Establishment of safe supported discharge protocols
4. Safe Discharge
b) Identification of needs for training and support of primary care colleagues
4. Safe discharge
c) Agreeing a template with primary care colleagues for discharge and CPA information that meets primary care needs, which includes an assessment of risk, a crisis plan and contact numbers to fast track back to secondary care where this is indicated.
5. Safety thermometer
Improve collection of data in relation to pressure
ulcers, falls, urinary tract infection in those with a
catheter, and VTE
6. Carers
a) Evaluate and improve on how we assess carer experience
6. Carers
b) Carers feeling supported and aware of how to access services in a crisis
7. SystmOne (Hounslow only CQUIN target)
The main Provider WLMHT to purchase licences
for the relevant module of SystemOne and install and
use these at the Trust by key staff.
2012/2013
49
At time of going to press the Q4 CQUIN report and analysis was with the commissioners for sign off.
High secure services
The following CQUIN targets were set for High Secure Services for 2012/13
High secure services
Q1
Q2
Q3
Q4
Broadmoor
1. Physical healthcare
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
a) Delivering access to an appropriate equivalent primary care health service as would be available in the community
1. Physical healthcare
b) All patients have a care plan identifying physical health needs and how they will be met
1. Physical healthcare
c) All patients screened for long term physical health needs and all eligible patients have access to support equivalent to that offered in the community
1. Physical healthcare
d) All eligible patients having access to national screening programmes equivalent to those offered in the community
1. Physical healthcare
e) All eligible patients to have access to BBV screening and appropriate vaccination
1. Physical healthcare
f) All patients to have access to flu vaccination
1. Physical healthcare
g) Improve dental care
1. Physical healthcare
h) Support learning and shared best practice in delivery of primary health care in secure settings
1. Physical healthcare
Achieved 100%
h) Support learning and shared best practice in delivery of primary health care in secure settings
50
quality account
2. Recovery
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Met
Met
Met
Achieved 100%
Continue with the implementation of a recognised
tool for recovery planning across all services as part of
the improvement in engagement with patients in their
own recovery. Extend the approach by introducing
the use of an outcomes framework. This includes
demonstrating a recovery orientated approach,
proactive in identifying, planning and achieving joint
goals and outcomes. Develop co-produced training
programmes with patients to promote recovery
approach underpinned by the patients’ experience.
3. Healthy community wards
Ensure a consistent approach to achieving a healthy
community across the three high secure hospitals.
Provide a safer environment for patients and staff.
Increase awareness of bullying behaviours and
promote clear, consistent reporting and effective
management of bullying across the hospital.
4. Productive wards
Continue to implement Innovative Ward practices to
release more time to care for patients and improve
ward practice and productivity.
5. Payment by results
Implement the secure payment by results currency
feasibility project. This includes implementation
of the clinical toolkit for the clustering of patients
and grouping into forensic care pathways using the
mental health clustering tool and the five forensic
pathways tool.
6. Patient engagement
a)
Develop minimum multi-disciplinary team (MDT) standards for face-to-face contact time between clinicians and patients. Increase face-to-face time between MDT and patients
6. Patient engagement
b) Development of other associated initiatives to increase the menu of interventions available to patients.
6. Patient engagement
c) Increase staff/patient engagement to support responsibility and self accountability in patient care planning.
6. Patient engagement
d) Out-of-hours activities (evenings/weekends) increased
6. Patient engagement
e) Roll out of activity co-ordinator role to improve ward based choices and interventions. Increase in time spent on the wards.
2012/2013
51
Specialist and forensic clinical service unit
The following CQUIN targets were set for Specialist and Forensic Service for 2012/13.
Specialist and forensic service CSU
Q1
Q2
Q3
Q4
1. Optimising LoS, through the medium-secure and low-secure care
pathways for the first 12 weeks of admission. The aim of this CQUIN
target is to ensure that service users are not within secure services
longer, or shorter, than is clinically appropriate, contributing to an
enhanced service user experience.
Met
Met
Met
Achieved
100%
2. To improve physical health and wellbeing for all inpatients,
particularly those with long term medical/physical conditions. This
target is linked to QOF measure which includes achievement against
evidence based indicators.
On
track
On
track
On
track
Achieved
100%
3. Implementation of secure services PbR currency feasibility project.
The aim of this CQUIN is to test out the ability of the secure services
to use PbR.
Met
Met
Met
Achieved
100%
4. Implementing clinical dashboard for specialised services
Met
Met
Met
Achieved
100%
By year end, the Specialist & Forensic CSU had met all targets and required service improvements and
the service achieved 100% of its CQUIN financial target.
Care Quality Commission registration
West London Mental Health NHS is required to register with the Care Quality Commission (CQC) and
its current registration status is ‘registered without conditions’.
The Care Quality Commission has not taken any enforcement action against West London Mental
Health NHS Trust during 2012/13.
West London Mental Health NHS Trust has not participated in any special reviews or investigations by
the Care Quality Commission during the reporting period. However, as part of their routine schedule
of visits we received two reports from the CQC that assessed our compliance against the ‘Essential
Standards of Quality and Safety’.
Following the visits they concluded that the Trust was not fully meeting the outcomes below:
Outcome 07: Safeguarding people who use services from abuse
CQC judged that the Limes was not meeting this standard and that this has a moderate impact on
service users. CQC felt that service users were not fully protected from risk of abuse because Trust staff
was not always able to take reasonable steps to ensure staff always responded appropriately to any
allegation of abuse.
The actions taken to address this issue were:
52
•
Immediate internal alert disseminated across the Trust to ensure all staff knew the process for highlighting safeguarding concerns
•
Focus groups were held to establish the underlying cause of this concern.
•
Bespoke training was implemented with immediate effect
•
All incidents/concerns discussed at service area weekly meetings
•
Policy reviewed, updated and staff consultation completed.
quality account
Outcome 14: supporting workers
CQC judged that people are supported by staff who receive training to deliver care to an appropriate
standard. However, staff themselves did not feel appropriately supported in relation to their
responsibilities, which they felt had an impact on the care people received, and could put people who
use the service at risk.
The actions taken to address this issue were:
•
The development and implementation of a staff engagement programme, where feedback is received from a wide selection of staff and comments directly reported to the Trust Board.
•
The Board agreed the implementation of the Trust-wide workforce and organisational development strategy.
•
The whistleblowing policy was immediately reviewed, updated and reissued across the Trust.
These outcomes are due to be re-assessed by CQC in June 2013 to ensure full compliance has been
achieved.
2012/2013
53
Quality Indicators
The following section of the Quality Account
describes how we have performed against a
core set of indicators as set out NHS (Quality
Accounts) Amendment Regulations 20121 related
to NHS Outcomes Framework Domains. We
have reviewed these indicators and are pleased
to provide you with our position against all
indicators relevant to our services for the last two
reporting periods (years).
1. CPA 7 Day Follow-Up: Percentage of
patients on Care Programme Approach
who were followed up within 7 days
after discharge from psychiatric in-patient
care during reporting period.
This measure enables us to ensure our service user’s
needs are cared for and remain safe, following
discharge from hospital to community care.
2012/13
Q3 Q2 Q1Q4
2011/12
Q3Q2Q1Q4
WLMHT
96.6% 96.9% 95.4%97.8%
97.5%96.1%96.6%94.8%
National Average
97.3% 97.6% 97.3%97.5%
97.6%97.4%97.3%96.7%
Highest Nationally
100% 100% 100%100%
100%100%100%100%
Lowest Nationally
93.6% 92.5% 89.8%94.9%
92.4%93.5%90.3%78.4%
Lowest Nationally
93.6% 92.5% 89.8%94.9%
92.4%93.5%90.3%78.4%
WLMHT Annual
Outturn
96.6%
96.3%
Target
95%
95%
Data Source: http://transparency.dh.gov.uk/2012/06/21/mental-health-community-teams-activity-data-downloads/
WLMHT considers that this data is as described
for the following reasons: the data has been
extracted from central DOH repository and
correlates with the data submitted by WLMHT
during the reporting periods.
WLMHT has taken the following actions to
improve this percentage by:• Monitoring compliance routinely via the Trusts
Business Intelligence tool to identify clients
discharged and followed up and/or requiring
action.
• Improving the quality of data submitted and
definition applied with the inclusion of older
peoples and Forensic services.
• Identifying any areas of underperformance
and feeding back for service improvements.
The indicator is reviewed locally and via the
Trust governance framework (see annex 3).
The Trust intends to continue to improve the
percentage by learning from routine monitoring
and taking action as appropriate.
1 http://www.legislation.gov.uk/uksi/2012/3081/contents/made
1 2012 Quality Account Amendment Regulations
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quality account
2. Crisis Resolution Gate Keeping:
Percentage of admissions to acute wards
for which the Crisis Resolution Home
Treatment Team acted as a Gate keeper
during the reporting Period.
The Crisis Resolution teams provide prompt and
effective home treatment for people in mental
health crisis and quickly determine whether service
users should be admitted to hospital or if suitable
for home treatment. It is important to our service
users they are treated effectively and promptly in
the most appropriate settings of care.
2012/13
Q3 Q2 Q1Q4
2011/12
Q3Q2Q1Q4
WLMHT
95.9% 95.3% 97.6%96.4%
96.2%95.4%95.9%96.1%
England Average
98.6% 98.4% 98.0%97.8%
97.7%97.7%97.3%97.0%
England Highest
Performer
100% 100% 100%100%
100%100%100%100%
England Lowest
Performer
84.9% 90.7% 84.4%83.0%
89.6%75.7%29.8%37.2%
WLMHT Annual
Outturn
96.6%
96.3%
Target
95%
95%
WLMHT trust considers that this data is as
described for the following reasons: the data has
been extracted from central DOH repository and
correlates with the data submitted by WLMHT
during the reporting periods. Compliance is
monitored routinely via the Trusts Business
Intelligence tool which identifies clients admitted
and gate kept. This helps the service identify any
areas where actions are required. Performance
is monitored through the Trusts governance
framework (see annex 3).
2012/2013
WLMHT intends to take the following actions to
improve this percentage and so the quality of its
services, by:• Embedding consistent admission protocols
across all Trust sites where the same care
specialities are delivered.
• Continue to monitor routinely and action any
learning across the Trust.
55
3. Readmission Rate: The percentage of
patients readmitted to a hospital which
forms part of the trust within 28 days
of being discharged from a hospital
which forms part of the trust during the
reporting period.
Readmission rates are monitored primarily to
provide assurance that large numbers of service
users are not being readmitted following hospital
post discharge within a given period. It is important
for us to measure this, so we can monitor and
review our clinical practice of safe discharge and
service users effectively managed within the
community services. We are pleased to report our
readmission rates within 28 days of discharge are
below 10% target.
2012/132011/12
0 to 14 years
0%
0%
15 years or over
8.1%
7.8%
Target
<10%<10%
WLMHT considers that this data is as described
for the following reasons: This is locally produced
percentage based on all readmissions within 28
days as a percentage of all discharges (Forensic
& Specialist and Acute Speciality). No national
benchmarking has been possible as there is no
recent data published.
West London Mental NHS Trust has taken the
following action to improve this percentage,
and so the quality of its services by: improving
discharge and care planning process following
discharge from in-patient to community services
to minimise rates of readmission.
4. Staff recommendation of the trust as a
place to work or receive treatment
Measure
Staff recommendation
of the Trust as a place to work or receive
treatment
WLMHT WLMHT
Performance Performance
2012
2011
3.46/ 5
3.46/ 5
National Top Performing
Average for
MH Trust
MH Trusts
Score
3.54/ 5
4.06/ 5
Data source: http://nhsstaffsurveys.com/cms/uploads/Individual%20Trust%20reports%202012/NHS_staff_survey_2012_RKL_sum.pdf
56
quality account
WLMHT considers that this data is as described
for the following reasons as the data source is
reliable and taken from responses to the National
NHS staff Survey 2012.
• Engaging managers and empowering them
to adopt a positive management style which
encourages and rewards staff rather than one
which restricts and controls.
A major initiative is being undertaken by WLMHT
to improve staff engagement this includes
a number of enablers and related actions to
improve this percentage score and so the quality
of its services by:
• Giving staff ‘a voice’ so they are listened
to and know that their options count and
enabling them to express concerns openly.
• Being clear and consistent about our vision
and strategy so that staff understand what the
Trust is aiming to achieve and how their role
contributes.
• Embedding our values from the top down
– achieving culture change starts with the
leadership of the organisation.
• Promoting and improving staff health and
wellbeing within the workplace.
5. The Trust’s “Patient experience of community mental health services” indicator score
with regard to a patient’s experience of contact with a health or social care worker
during the reporting period.
CQC National Community Mental Health Service
User Survey
National Average
2012
2011
Highest
Lowest
Did this person listen
carefully to you?
8.7
8.8
9.3
8.2
Did this person take you
views into account?
8.2
8.4
9.0
7.9
Did you have trust and
confidence in this person?
8.3
8.2
9.0
7.6
Did this person treat you
with respect and dignity?
9.0
9.2
9.7
8.8
Were you given enough
time to discuss your
condition and treatment?
8.3
8.2
8.7
7.7
Overall, how would you
rate the care you have
received from NHS Mental
Health Services in the last
12 months?
6.8
6.8
7.8
6.5
Data source: http://www.cqc.org.uk/survey/mentalhealth/RKL
2012/2013
57
The data for this report has been extracted from
the Care Quality Commission Patient Survey Report
2012 and correlates to the data supplied by Quality
Health who undertook the survey on behalf of
WLMHT.
WLMHT has taken the following actions to improve
this percentage, and so improve the quality of its
services, by:
• Completed a review of current service user/carer
involvement via an external agency to improve
communication and feedback mechanisms.
• Conduct bespoke surveys within the services
using technology to report back real time
information, to enable us support service user
experiences.
• Out of hours arrangements have been reviewed
to ensure service users and carers can contact
WLMHT when required.
• Listening Event held to develop a realistic and
achievable action plan.
• Ensure that service user’s families and others
close to them are as involved as the service user
wants them to be in decisions about their care
and treatment.
6. The number and where available the rate of patient safety incidents reported within the
trust during the reporting period, and the number and percentage of such patient safety
incidents that resulted in sever harm or death.
The purpose of this indicator is to help monitor shifts in the risk of severe harm or death to patients and to
identify new emerging risks so that we are able to proactively identify potential impacts on patient care.
Indicator
Performance
Severe
harm/death
2012-13
2012-13 2011/12
2011/12
Q3/Q4 Q1/Q2 Q3/Q4Q1Q2
WLMHT
1.2% (12) *
1.9% (19)
1.2% (11) 0.6% (6)
National Average
n/a
1.6% (1747)
Highest MHT
n/a
9.4% (334)
6.9(57)
5.6%(85)
Lowest MHT
n/a
0% (0)
0%(0)
0%(0)
1.2%(1310) 0.9% (936)
Data source: http://www.nrls.nhs.uk/resources/?entryid45=135147
WLMHT considers that this data is as described for
the following reasons; the data for National figures
is taken from the National Reporting and Learning
System (NRLS) feedback reports, where reported
data has been verified by them up to and including
30th Sept 2012. With regards 1st October 2012
– 31st March 2013 data this has been uploaded
to the NRLS but recorded here with * to indicate
that this is not published data but taken from our
internal system until it is confirmed as verified data
by NRLS in October 2013. The national average
and highest and lowest MHT was provided by the
NRLS in their 6 monthly feedback reports. The
figures for quarter 3 and 4 for 2012/13 have been
reported to WLMHT’s Quality Committee and Trust
Board as part of the Patient Experience Annual Report.
58
WLMHT has taken steps to improve the rate and
quality of its services by following up on the actions
and recommendations from the review of the
severe harm and death incidents, holding regular
learning lesson events and improving system
processes for the quality checking and timeliness
of reported data. This has resulted in a sustained
improvement in our reporting rate and number of
days taken to report incidents to the NRLS.
The central and local governance teams have been
actively involved around the assurance of data
quality and its robustness as part of a working
group for the Data Assurance and Reporting Group.
quality account
Quality Indicators – Other indicators
Delayed Transfers of care:
This indicator measures the percentage of
inpatients beds that are being used by service
users who are ready to move on from the
hospital environment once they are safe to
discharge. We believe service users should receive
the right care, in the right place, at the right
time, and work closely with partner agencies to
minimise the length of hospital stay for users
ready for discharge. In 2012/13 we achieved our
target of <7.5%.
The table below shows our performance over the
last two years:
2012/13* 2011/12Target
% Delayed Transfers of care
6.4%
9.8%
< 7.5%
Quality Indicators – Other indicators
The Trust recognises that good data quality is
a key tool to support delivery of high quality
care, safety and to help identify areas for
improvements. We believe staff across the Trust
need to understand how their work contributes
to our ability in providing quality data to support
decision making and service effectiveness. We
will be focusing on promoting this message
and empowering staff with access to relevant
information and tools to monitor and enable
improvements.
West London Mental Health NHS Trust will be
taking the following actions to improve data
quality:
•further development and roll out of data
quality dashboards to include new indicator
targets
•routine provision of data quality reports to
validate and quality assure cluster allocations.
•review of our current information systems and
ensure we are able to support new reporting
requirements and challenges i.e. Payment by
Results, service line reporting
•complete and review our Information
Assurance Framework which identifies gaps
in controls or assurance, which will support
subsequent action plans
•review and monitor internal and external
benchmarking data to support our
improvements and compare favourably against
other providers
•continue to use automated data quality reports
which are valuable for managers to monitor
data quality performance and for staff to
identify and resolve specific data quality issues.
These will continue to expand as we focus on
new areas
2012/2013
59
NHS Number and General Medical Practice Code
Validity
attitude of clinical staff across almost all parts of
the Trust.
WLMHT submitted records during 2012/13 to
the secondary uses service for inclusion in the
hospital episode statistics which are included
in the latest published data. The percentage of
records in the published data:
We share visiting commissioners’ concerns about
three areas that continue to need improvement
and the Trust is committed to resolving these to
achieve improved compliance with the Mental
Health Act 1983 and its Code of Practice. These
are:
which included the patient’s valid NHS number
was:
• 98.9% for admitted patient care
• variable recording of capacity assessments
when obtaining consent to treatment
• N/A for accident and emergency care.
• Section 132 – Information for detained
patients. Lack of evidence of ongoing
reminders of rights of appeal
which included the patient’s valid general
practitioner registration code was:
• need to improve involvement of patients and
service users in their own care planning.
• 100% for admitted patient care
WLMHT represents all London mental health
trusts on the London (Mental Health Act)
Approval Panel.
• 99.5% for outpatient care
• 100% for outpatient care
• N/A for accident and emergency care.
Additionally, the Trust has been represented
by a manager and a non-executive director
at the London Mental Health Act Network,
West London Mental Health NHS Trust‘s
information governance assessment report overall actively working towards sharing legal training
and agreed standards between counterparts
score for 2012/13 was 71% and was graded
in London, including facilitating a visit to High
“green”.
Secure Services for members of the network.
The Trust achieved level 2 reaching the required
NHS London appointed WLMHT as a pilot
standards in all 45 requirements of the
information governance toolkit as required by the organisation for checking and improving the
accuracy of reported usage of the Mental Health
NHS Operating Framework.
Act.
Clinical coding error rate
Improving nursing practice
West London Mental Health Trust was not
Significant resources have been invested in
subject to the payment by results clinical coding
training and development for nursing and health
audit during the reporting period by the Audit
care assistants in the Trust. In the 2012/13
Commission.
financial year the Trust used all of its non-medical
Safeguarding the rights of patients detained
education and training funding (allocated
under the Mental Health Act
from NHS London), which included in excess
of £300,000 of training courses, which were
In line with their visiting strategy, the Care
delivered to nurses across the Trust. A further
Quality Commission carried out unannounced
£265,000 was allocated from Trust monies to
visits to wards and services across the Trust
deliver recovery and psychosocial interventions
during the year. Every visit was followed by a
training to the non-medical workforce. In August
report highlighting both concerns and good
2012 the Trust invested in a new post, the Head
practice. A summary of issues from all visits is
of Nursing Education and Standards, to coregularly reported to the Trust Board and the
ordinate nursing development activities.
Quality Committee.
Information governance toolkit
In many cases, the CQC noted improvements
in relation to privacy issues and there has been
consistent improved feedback by patients and
commissioners about the positive and respectful
60
quality account
Some key training and development initiatives
which have been delivered are:
• a 20-day psychosocial interventions training
package for nursing staff – this course focuses
on engagement, assessment and intervention
skills to improve nurses’ confidence and skills
in working with patients. Forty staff (mainly
nurses) participated in this programme in 2012,
100% of participants indicated that the course
has changed the way they practice
• 20 staff have been trained in the Meridian
family interventions programme and one
person was trained as a trainer in this
approach
• a dedicated recovery training manager has
been appointed to deliver training in recovery
orientated approaches; this includes an
exploration of staff attitude and approach to
working with service users
• 10 people are on a newly commissioned
medication management course at the
Institute of Psychiatry. This course develops
communication skills with staff and in
particular motivational interviewing
techniques; it has been re-commissioned for
2013
• The Hearing Voices network has delivered
training across all three CSUs
• bespoke engagement and assessment training
was delivered to community assessment teams
• a quality measure to evaluate the level of
service user and carer engagement and
recovery focus in care planning and risk
assessment has been developed and is being
piloted in community services
• additionally a number of nurses are being
supported to undertake degree, masters and
doctorate level education programmes at our
partner universities.
A number of initiatives are also being rolled out
by the clinical service units who have all invested
in training and quality improvement programmes.
Examples include:
• the Trust has been a national recovery pilot
site since 2011. Investment has been made
in embedding recovery oriented practices
into teams by providing monthly learning
sets facilitated by a recovery consultant
2012/2013
and monthly recovery training programmes
delivered to both service users and staff
• a Trust-wide supervision clinical supervision
evaluation and development training
programme is being led from Broadmoor.
This project has included surveying all nurses,
occupational therapists and HCAs in the Trust,
using the Manchester Clinical Supervision
Scale, and using this to inform a training
programme which has been led by Bridgid
Proctor, a leading national expert
• the Trust has established and is setting
up an Institute of Mental Health with
Buckinghamshire New University; we have a
jointly-appointed nursing professor in post to
support this project
• across the Trust experts by experience are
supporting the co-production and delivery of
training
• local services have rolled out a project to
enhance the quality of clinical documentation
through direct observation of practice. This
has impacted on the way nurses use their one
to one sessions, improving listening skills and
making care plans more client focussed
• all local services inpatient wards now run
reflective practice groups for staff
• listening to experience has been key to our
plans; magnetic door locks were put in place
in local services wards in direct response to
client concerns about safety and security.
In addition to these work streams plans are in
place for the forthcoming year to deliver the
following:
• a Trust-wide preceptorship programme for
newly qualified nurses will commence in
September 2013 (six days over six months)
• a Trust-wide support worker training
programme for all CSUs will be starting in
September. This course utilises carer and
service user trainers alongside senior trust staff
to deliver five study days over four4 months.
This was developed using feedback from
the Trust’s first annual health care assistant
conference which took place in 2012 and
engaged over 100 support workers from
across the Trust
61
• a Trust-wide recruitment assessment centre
for nurses and health care assistants has been
developed; this will be piloted in June for roll
out in September 2013
• a further 40 places are available on our PSI
training programme
• our recovery trainer will continue to roll out
training to teams across the Trust
• £163,000 has been allocated from Trust funds
to support ongoing central PSI and recovery
training
• in addition £306,000 has been invested
this year in other training and educational
programmes for nurses. These courses will
be advertised across the Trust for the new
academic year
Staff survey and involving staff
Despite robust actions plans to address the
findings of last year’s staff survey we have seen a
further decline in the staff survey results this year.
As a result the Board has made improving staff
engagement one of its key priorities, because
we know that levels of staff engagement have a
direct impact on satisfaction and motivation and
therefore on the quality of care provided by our
staff.
Each of our clinical service units and corporate
services is now working to develop their own
action plans in consultation with staff. In addition
to this we have recruited 30 staff reporters
from across the organisation. Each reporter has
gone out to speak to ten colleagues about their
experiences and opinions of working here. These
views have been shared with the Board so they’re
clear about what staff feel needs to be done
to improve the culture and ways of working at
the Trust. The Board is now working on a farreaching action plan to address the issues they
heard from the reporters.
Progress against all of these actions will be widely
communicated to staff and monitored by the
Board and the staff engagement committee.
To further improve staff engagement the chief
executive has been holding regular listening
events for staff across the Trust, which we’re
planning to open up to other directors and
increase the frequency of. The Chief Executive
now writes a weekly blog which is shared with
staff through our intranet, and because we
want to improve communications with all our
stakeholders, it’s available on the website too.
We’re working on developing more two way
communication tools for staff by making parts
of our staff intranet more interactive so staff can
more openly comment on activities at the Trust
and ask questions.
We have also re-launched a leadership forum
at the Trust, to ensure all senior leaders within
the organisation are involved in planning and
implementing the strategic priorities for the Trust.
This year our membership team has recruited
members across our local communities and
amongst our staff. The Trust now has 8,000
members who are representative of our
diverse populations, including staff members.
We are doing this to support our foundation
trust application, which requires us to have
at least 10,000 active members from our
local communities. We’ are expanding our
communications activities with members so they
receive a regular update on our progress toward
FT status, developments at the Trust and our
plans for electing a Council of Governors.
The Trust has recently reviewed and re-issued
the whistleblowing policy. Staff clinics have been
established where staffs attending are able to
discuss and explore any concerns/questions they
may have.
Staff are encouraged to speak openly to Board
members during the annual visit programme.
Peer review process is in operation and all staff
are encouraged and able to participate in CQC
unannounced visits.
62
quality account
Part 3: Information on the quality
of services provided
Message from the Medical Director,
Dr Nick Broughton
Welcome to West London Mental Health NHS
Trust’s fourth Quality Account. This document
summarises the progress made by the Trust over
the last 12 months in improving the quality of
our clinical services.
The last year has undoubtedly been challenging
on account of the economic climate and as such
many of the Trust’s services have undergone
significant change in order to improve both the
efficiency and quality of the care we provide.
Such changes however, are often difficult,
not least for those service users and patients
affected. Last year has therefore highlighted
the fundamental importance of the Trust
communicating effectively with service users
and all our other key stakeholders. The Quality
Account has an important role to play in this
regard as it serves as an opportunity for the
Trust to provide comprehensive and detailed
information regarding the quality of its clinical
services and highlight those areas where
improvement is required.
The opinions of our service users, patients and
their carers and the wider public we serve are
extremely important to us and will continue
to guide the future direction of the Trust. It is
for this reason that we have again started our
Quality Account with sharing the feedback we
have received from these key stakeholders and in
addition have summarised the actions we have
taken in response to such feedback.
The account then summarises some of the
significant developments that have occurred
during 2012/13 which highlight the Trust’s
commitment to continuously improve the quality
of our clinical services and to achieve our vision of
becoming one of the country’s leading providers
of mental health services and providing excellent
mental health care to all our service users.
2012/2013
An example of this is the Trust’s membership of
Imperial College Health Partners which is the
Academic Health Partnership formed in North
West London in early 2012. The partnership
brings together acute trusts, community trusts,
clinical commissioning groups and mental health
trusts together with Imperial College with the
aim of developing innovative and collaborative
models of healthcare delivery which will better
serve the needs of the population of North West
London. West London Mental Health NHS Trust
is very proud to be one of the founding members
of the partnership. We are committed to playing
an active role in the ongoing work of the
partnership and ensuring that mental health plays
a central role in the various planned programmes
of work.
Our commitment to collaboration and integration
is also reflected in the Trust’s further development
of Liaison Psychiatry Services during the last year
at Ealing, West Middlesex and Hammersmith
Hospitals, in addition to the contributions made
to develop the North West London Integrated
Care Pilot.
The development of integrated care and liaison
psychiatry services is undoubtedly extremely
welcome and in keeping with the increased
awareness of the high rates of psychiatric
morbidity in patients suffering from long term
physical conditions. In order to provide care
of the highest quality it is essential that mental
health services work closely with colleagues in
both primary care and acute care in order to
deliver holistic treatment which addresses an
individual’s full range of health needs. New
models of care will continue to be developed by
the Trust during the years ahead in collaboration
with key partners. In order to enable us to do
this we have now established a Transformation
Programme Board along with our 3 local Clinical
63
Commissioning Groups. The purpose of the
board is to lead the change programme for
the mental health services we provide in the
boroughs of Hounslow, Ealing and Hammersmith
& Fulham, with the aim that these become some
of the best services available nationally.
Whilst the last year has seen significant changes
in service provision we have also strived to
improve the way we monitor the quality of the
services we provide. 2012 saw the appointment
of Janet Bell as the Trust’s Head of Integrated
Governance and a further revision of the Trust’s
governance structures. The Trust’s performance
reporting has continued to evolve and this now
includes a detailed report regarding the quality of
physical healthcare provided by the Trust to those
service users detained in our secure services.
External reviews have demonstrated that the
standard of primary care provided in these
services is comparable, if not better, than that
provided by some of the best general practices
in the country. This is something that the Trust
is extremely proud of as we are acutely aware
that many of our service users also suffer from
significant physical health problems.
possible mental health care to our service users
is reflected in the recent revision of the Trust’s
quality strategy, our strategic aims, our quality
priorities for the next financial year and the
Trust’s vision for the future. Quality will remain
the Trust’s overarching priority and the primary
focus of the Trust Board.
There perhaps has been no time during the
history of the National Health Service when it
has been so important for provider organisations
to ensure that their service user’s needs are
prioritised and effective systems are in place to
provide assurance regarding the quality of care
provided. West London Mental Health NHS Trust
is committed to doing this.
The Trust remains committed to developing its
research profile and more importantly ensuring
that our research activities are closely aligned
to the delivery of clinical care. We believe this
model will improve the quality of our clinical
services and in addition ensure that our service
users are able to access when appropriate new
medications and therapies. The Trust’s research
& development strategy is now in its third year of
implementation. Clinical research domains have
now been established across the organisation.
The cognitive impairment and dementia research
domain has remained particularly active. To
support further developments in this field the
Trust has recently recruited a leading academic
psychiatrist from Germany, Dr Robert Perneczky,
who has an international reputation in the field
of Early Diagnosis of Dementia and Biomarkers.
Our Quality Account highlights many of the
Trust’s achievements during 2012/13. In light
of this we are confident that as an organisation
we will be able to achieve Foundation Trust
status during 2013/14. We are not however,
complacent and fully appreciate the importance
of continuously improving the quality of care we
provide. Our commitment to delivering the best
64
quality account
What service users, carers and the public say:
key messages and actions taken during 2012/13
We are proud of our continuing efforts to
capture the voices of service users, patients,
carers and the public regarding their experiences
of our services and their ideas about how we
might improve. We employ the feedback we
receive to develop our services. Importantly,
togetherness is one of our Trust values and we
feel this is especially reflected in our approach to
involvement. We recognise that we need to work
together and believe that it is in partnership that
our most effective work occurs.
Some of the ways we listen to service users,
carers and the public include:
• our numerous service user forums, which
operate at a local and Trust level
• monthly patient forum at Broadmoor Hospital
• carers’ forums
• Patient Advice and Liaison Service (PALS) and
complaints process
• focus groups, audits, local and national surveys
e.g. CQC community and inpatient surveys
• Meridian service user and carer feedback in
real time
• community meetings
• suggestion boxes
• Trust meetings – Quality Committee, clinical
effectiveness & compliance group, service user
and carer group etc
• Local Involvement Networks (LINks), Overview
& Scrutiny Committees
• Special events eg conferences and workshops
which are co-produced, co-delivered and cochaired with service users and carers
• one of our annual conferences was entitled
‘Everyone has a story to tell’ and focused on
the importance of listening to service users
• advocacy services
• policy reviews
• participation on staff recruitment panels
• involvement in developing individual care
plans and chairing care programme approach
meetings for individuals
• employing current and former service users
and carers in roles to inspire hope in those
who are at the early stages of care and
treatment.
Meridian
The Meridian system is a software tool which was
rolled out across the Trust in June 2012 to replace
the patient experience trackers that were used to
obtain feedback in our inpatients and community
mental care settings.
The system is designed to collect real time patient
experience feedback utilising iPad tablet and
desktop facilities, and has been purchased for the
purposes of administering and analysing patient
and carer feedback as it happens allowing the
Trust to respond as soon as it is practicable, and
help identify issues that require prompt attention.
The Meridian system went live in July 2012,
allowing service users and carers to give real
time feedback about their experiences of care,
the environment and of staff. It is available in
the majority of clinical areas within the Trust and
externally via the WLMHT website. A Meridian
project board has been established to support the
ongoing operationalisation and implementation
of the Meridian system. The current focus is on
embedding a robust governance framework,
including providing assurance that actions are
developed and implemented in response to
feedback received and a cycle of improvement
is employed. A poster and information leaflet is
also in development to help raise awareness and
support engagement.
• service users and carers are invited to work
alongside staff to capture service user
feedback
2012/2013
65
Quality notice boards designed to support
service user-focussed improvements
As a Trust we recognised the need to better
communicate with our service users, carers and
staff about the quality and performance of their
local services, as well as the need to demonstrate
our ability to listen and respond to the feedback
we receive. In order to try and devise the best
way of doing this, we looked at methods used
by local authorities, private companies and other
healthcare organisations, and also consulted
with our services users in terms of what they
would like to see. As a result of the information
gathered quality notice boards have been
designed for all teams across the Trust to display.
They will show real time, regularly updated
information including patient feedback (Meridian)
results, a ‘you said, we did’ section and
relevant safety and effectiveness performance
information. The hope is that by displaying such
information and acting on results if necessary, this
will enable services to be better shaped to our
services users needs. Ten teams across the Trust
have been selected to pilot the boards for a six
week period, and it is hoped that soon they will
be rolled out Trust-wide.
Actions taken as a result of service user and
carer feedback
High secure services clinical service unit
• Community meetings held at lunchtime on
a Friday were changed to Mondays which
allowed Muslim patients to attend the meeting
and the Mosque for Friday prayer.
• One ward had difficulty getting patient
representatives for the Clinical Improvement
Group (CIG), so the team made arrangements
for the CIG to be held in the patient day area
and link with the community meeting with
positive results.
• Patients have been actively involved in
developing the CPA process, especially in
relation to their recovery plans. This has
involved partnership working with patients.
• Feedback from patients has strongly influenced
various aspects of the design for the
redevelopment of the hospital, with patients
proposing the names of the wards and
involvement in landscape gardening.
• Carers requested that different speakers attend
their quarterly carers’ forum meeting, this
was agreed and the forums have included
presentations on the redevelopment and
psychological therapies.
• Carers requested and have now been on a tour
of the hospital which included visiting some
wards.
• Patients have been instrumental in the
organisation and arrangements for the
hospital’s 150th celebrations through the ‘150
group’ comprising patients and staff.
Specialist and forensic clinical service unit
• Service users requested implementation of the
recovery star. Staff have now been trained with
and ongoing training sessions provided and codelivered by staff and a service user consultant.
• A system was implemented to telephone
carers following their visits to service users, this
has provided considerable feedback leading
to service improvements. Carers had raised
concerns about seeing their relative in the
designated visiting area and feeling that they
do not have a real sense of the environment
in which their relative is being cared for.
Carers have now visited the ward environment
with plans for this to routinely happen in
development.
• During Dignity in Care week service users
• Equipment was put on the terrace and on
participated in focus groups to help with
a ward following requests from patients for
understanding their lived experience of
sports and exercise equipment, with plans to
seclusion. As a result a practice development
continue adding equipment, eg a football goal.
project group has been established to action
the recommendations that were made and
• Issues came to light regarding ensuring
which include a review of staff training and
compliance with NHS regulations when the
developing post-seclusion debrief guidelines to
ppatients’ café was used to host catered
support practice.
functions. However as patients were keen to
continue Estate services have reviewed their
process to allow this to continue.
66
quality account
• Concerns regarding staff attitudes have
featured as a theme of service user complaints
and via the Meridian feedback system.
This feedback has led to various practice
developments:
-a recovery conference held In January 2013
-staff development programmes, and
enhanced engagement for HCAs. Both
training programmes have active service
user involvement to help specifically address
attitude
-staff attitude has now been included in the
Forensic Service induction programme
-local (ward level) actions are developed
as issues arise. For example, one team has
incorporated discussing feedback on staff
attitude within their reflective practice groups
and staff meetings.
Local services clinical service unit
• Following a request from Hammersmith
and Fulham service users and carers for the
hearing voices group to be opened to a
wider audience, we have trained 20 staff and
service users to facilitate paranoia/distressing
beliefs/hearing voices groups. A network of
these groups is has been set up across three
boroughs. The groups in Hammersmith
and Fulham are run in partnership with
Hammersmith and Fulham MIND. Currently
we have one inpatient group in Ealing, one
group in Hammersmith and Fulham, and two
groups are planned in Hounslow and Ealing
community. All are open groups.
•In response to a number of meetings and
forums raising concerns about the support and
training for carers, a pilot training package
for carers was developed and delivered by
carers and WLMHT staff during 2012. The
programme has now been delivered across 3
boroughs via the Recovery Hub by carers and
WLMHT staff.
2012/2013
• In the Trust service user and carer forum
concerns were raised regarding service user
representation at local services transformation
board rather than organising a reference
group which had been suggested. As a result
the Transformation Board reviewed service
user and carer involvement and the terms of
reference which resulted in five service users
being invited as representatives on the board
and on other project groups flowing from this
board.
• The Recovery Hub received feedback that there
was limited uptake of personal budgets with
limited team and service user knowledge of
the process. The Hub has now commissioned
the peer-led Personalisation project to support
and increase service users’ and staff access to
personal budgets. This also includes service
users training as Personalisation brokers to
support the project.
• The community survey identified that as a
trust we were not able to support service users
in a crisis out of hours, therefore we have
established a 24 hour help line launched in
April 2013 based within the call centre with
specifically trained staff.
• During a local services workshop service
users and carers suggested setting up text
messaging reminders for appointments as a
way of reducing appointment Did Not Attends.
In response the text messaging enabling
project group was set up, which included
service user and carer representatives. Text
messaging reminders are now sent to service
users with further plans to develop a carers’
text messaging service.
67
Examples of key messages and actions taken
in response to complaints and concerns
During the reporting period 1st April 2012 to
31st March 2013, we received and registered
a total of 307 complaints which is an increase
of 54% when compared to the 199 complaints
registered in 2011-12, and 224 in 2010-11.
This is substantially higher than the previous year
when 199 formal complaints were registered.
Our local services CSU received 102 complaints,
specialist and forensic services received 87 and
our high secure services had 118 complaints.
This is relatively higher in comparison with
previous years, although as the service structure
was different an exact comparison is difficult.
Since July 2011, we changed the delivery of our
Patient Advice and Liaison Service (PALS). A
full-time PALS co-ordinator was put in post and
is now working with the individual service user/
carer, etc to seek answers or provide advice in
consultation with clinical services, advocates
or other agencies as appropriate. This way of
working has proved to be very effective and the
service is being fully utilised by our patients,
service users and families. During 2012/13 PALS
received 1,383 contacts which is substantially
higher than last year’s 891. The graph below
shows what a positive effect this service has
had on the number of queries that have been
addressed in this way.
We consider it essential to respond to and seek
to resolve concerns in a timely and effective way.
We are pleased that 89% of complaints received
during the reporting period were promptly
resolved and this compares slightly lower with
our performance in 2011/12 (97%).
In the forthcoming year we will be looking to
improve the response timeframe from 89%. We
aim to make the complaint investigations more
robust and provide responses more quickly, by
commissioning complaint investigator training
within each CSU and monitoring the complaint
deadlines more closely through reporting. In
addition, we will also be benchmarking the Trust
performance against other NHS Trusts.
The table below illustrates the themes to which
complaints are allocated and a trend analysis
between each quarter of the year. These themes
are in keeping with the Department of Health
guidance.
During 2013/14 the Trust will be aggregating
the PALS data to further develop benchmarking
and themes relevant to the organisation. This will
allow the development and implementation of
actions to further improve service user and carer
experience.
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quality account
Most of the complaints made about our services
fall into 3 categories
• All aspects of care and treatment
– this category includes issues such as
treatment, medication, assessment, ward
moves, home visits, detention, diagnosis,
seclusion, progress of treatment/care
pathway, treatment of physical ailments and
general aspects of inpatient and community
care
• Other
– this category includes allegations of physical
assault, verbal abuse, bullying, patient safety
concerns, breaches of confidentiality, in
addition to complaints regarding cultural
issues, staffing levels, allegations of fraud,
access to leave.
• Staff attitude
2012/2013
69
In terms of learning from complaints and sharing
good practice, the following outcomes have been
achieved:
Examples of key
messages from
complaints
Care & treatment
Good communication between ourselves and primary care is a vital component
of safe and effective care. We have received feedback from both GP and
service users that communication between us can be improved.
A service user’s concerns regarding the assessment completed by a second opinion
doctor to be passed to the Mental Health Act office so that they can be communicated
to the CQC.
Staff to follow hospital policies in relation to medication errors and dispensing
medication.
If medication is to be given every four hours it should be written up as a regular dose
and not as a PRN.
If a team is unable to contact a patient on the phone or at a visit a note should be
left at their home to indicate that a visit was made and to give details of follow up
arrangements.
Other
The management of patients’ property procedures are being reviewed and several
forms amended.
Development of a new process to improve timeliness of visitor access. Clinical nurse
managers are ensuring that staff collects visitors promptly.
Staff and patients developing a dress code protocol.
The removal of clothing such as a hijab will be discussed on a case by case basis and
not automatically removed.
Staff attitude
Mediation sessions have been conducted between staff and patients with regards to
staff attitude so that therapeutic relationships can be maintained.
To continue with discussion regarding staff-patient relationship with the user
involvement project.
Data on complaints and compliments is collated
and reported throughout the organisation.
Complaints, PALS and compliments are reported
monthly to the Board, bi-monthly to the service
user & carer experience sub-committee and
quarterly to the Quality Committee.
WLMHT complaints process is accessible
to all, both within each CSU and the wider
organisation.
We have reorganised our governance structures
so that each CSU has a governance lead instead
of a centrally based team. All complaints are now
Themes, trends and learning from complaints,
registered electronically on the Trust Exchange
compliments and PALS are collated, analysed and system. This has helped to coordinate and
presented at CSU SMTs and CIGs as well as to the monitor complaints more efficiently. In the future
SU&C sub committee and the Quality Committee. we will need to work on making the lessons
An annual complaints report is also published
learnt and closing the loop more robust so that
as part of our statutory requirements. HSS
it will make it easier for us to monitor the impact
collated information is shared with the learning
and outcomes agreed.
& development department who will incorporate
it into the staff training programme, and this
approach will be incorporated in 2013/14
throughout the organisation.
70
quality account
Examples of key messages and actions taken in
response to incidents and serious incidents
The Trust aims to provide patient care that is
safe, effective and high quality for a diverse
range of service users. Our priority is to reduce
avoidable harm in line with the Trust’s Incident
management policy.
Table 1 and 2 shows the total number of
incidents reported in the Trust, for the year
2012/13 compared with 2011/12, by quarter.
Table 1
All Incidents Trust-wide
Q1Q2Q3Q4
2012/13 Incident total 8393
2188212420172064
2011/12 Incident total 8448
2043218922152001
The highest number of incidents in 2012/13 fell
into the following categories:
closely monitored to inform learning to make
services safer for our patients.
Verbal assaults to staff- consisted of verbal
abuse and threats to staff when patients are
being challenged about either their behaviour
or breach of ward policy. Staff are working on a
1-1 basis with patients about their behaviour and
providing opportunities to engage with activities
provided by occupational therapy and vocational
services.
Self injury to patient – a Trust-wide suicide
strategy which includes the reduction of ligature
points has been implemented and is reported
to the quality committee. Where any identified
ligature points cannot be removed it is recorded
onto the risk register and local action plans are
developed which will include the use of increased
levels of engagement and observation.
Security incidents - the majority of security
incidents reported are where there have been
either actual or attempted breaches of ward
policy on managing prohibited items. The
themes and trends of such incidents are being
Where harm is recorded following an incident,
a review is undertaken by senior managers and
heads of service to consider whether the incident
should be escalated to a serious incident review.
Table 2
2012/2013
71
Table 3 and 4 shows the total number of serious
incidents reported in the Trust, for the year
2012/13 compared with 2011/12, by quarter.
Table 3
Trust-wide serious incident reviews
Q1 Q2Q3Q4
Year to date serious incident review total 49
14
14
8
13
2011/12 serious incident review total 50
4
13
16
17
The most reviewed serious incidents in 2012/13
are unexpected death of community patient,
assault by inpatient against staff, suicide by an
outpatient.
Table 4
All serious incidents have been investigated
using root cause analysis and the actions arising
from those investigations have been collated
and presented into local and Trust-wide incident
review groups for implementation. All incidents
are reviewed both locally and Trust-wide and
learning is shared in a number of different ways.
The Trust held 3 learning lessons events during
the reporting period.
72
All incident data is currently being collated to
form a Trust-wide aggregated data report which
will be presented to the Trust Board and an
action plan for improvement will be developed
and implemented as a result.
quality account
Coroners Rule 43
The Trust has not received any rule 43 instructions from the coroner during the reporting period.
Health and Safety Executive (HSE)
The HSE has issued no improvement or prohibition notices to the Trust during the last year.
Safeguarding children and vulnerable adults
The Trust is committed to safeguarding all service
users, both children and vulnerable adults, to
support the continuous improvement of the quality
and safety of the services we provide.
Quality assurance data:
The range of safeguarding indicators that we
developed in the previous year has been well
established and data collection processes have
now bedded in. The data was extended to include
information about safeguarding adults and children
as we wanted it to reflect functioning across the
whole trust.
Safeguarding governance:
Following the Trust’s governance restructure, we
prioritised developing a safeguarding governance
structure for both children and vulnerable adults
that reflects these new governance arrangements,
ensures accountability and allows efficient
dissemination of information and guidance as well
as maintaining links with local safeguarding boards.
We aimed to establish a breadth of mechanisms
that inform the organisation’s intelligence on all
matters related to safeguarding. In addition, we
wanted to capitalise on our external relationships,
through safeguarding boards, to support our
internal assurance mechanisms.
The last year has seen significant changes in how
we monitor and report on our safeguarding quality
governance.
The monitoring of safeguarding practice and
performance has been extended to include
reporting of all safeguarding issues through the
safeguarding children and safeguarding adult
governance forums. Both these meetings report to
the Patient Safety and Safeguarding Committee, a
sub-committee of the Trust Board.
The Trust Board receives information about our
performance in respect of safeguarding on a
monthly basis. All the performance information is
also shared with CSU management for review and
information about priorities.
2012/2013
The annual report for safeguarding reflects on all
aspects of Safeguarding and after reporting to the
Board we share it with all our local safeguarding
board partners in the three boroughs where we
provide mental health services.
Externally, we report quality and performance data
for local services to commissioners quarterly.
The Trust also completed the Safeguarding Adult
Self Assessment and Assurance Framework (SAAF)
process this year and we completed a Section 11
Audit for Safeguarding Children for the LSCB in
Hounslow
Safeguarding children:
We appointed a new named nurse in June 2012,
who took up the post in October 2012. This
has supported our relationships with the local
safeguarding boards by improving our capacity to
engage with the various subgroups of these boards
that we are involved with – with a direct impact on
our quality assurance by improving our ability to
reflect and consider our performance.
In addition, we have been able to review
our safeguarding children training and make
improvements to the quality of the content of
the training, but also support the staff through
streamlining the way the training is delivered. This
will free up a significant amount of time for staff to
spend with patients.
We completed a Section 11 Audit for Hounslow
LSCB in January 2013. We have had positive
feedback about our services and we have been able
to agree areas for focus in the next year to improve
our awareness of children who might have parents
in our adult services.
There were no new serious case reviews during
the year and the one serious case review from the
previous year, resulted in an overview report that
made no specific recommendations for the Trust
although it did require is to support partner agencies
in completing the actions identified for those
agencies. One result is that we have supported the
73
LSCB in Ealing to develop interagency guidance for
all the partners about assisting children who report
self-harm to receive the help they need.
The safeguarding children policy has been reviewed
and rewritten during the last year.
A new version of Working Together was published
in March 2013 and we have reviewed all our
safeguarding policies to ensure that we comply with
the new arrangements to safeguard children and
young people that are set out in the document.
Safeguarding adults
Our SAAFs were reviewed by NHS London as part of
a benchmarking exercise across London. We were
pleased that several aspects of our submissions were
identified in the London Overview Report as best
practice examples. As a trust we have identified
development points from our submissions to
support progress in anticipation of our next selfassessment in June 2013.
We have progressed the PREVENT agenda as part of
our safeguarding awareness and the first awarenessraising sessions have been delivered. We plan to
make this training a standard part of induction
training over the next year.
We have reviewed our safeguarding adult’s policy
and it is presently being rewritten.
Allegations involving Jimmy Saville
The Trust was named in a historical allegation
relation to the late Jimmy Saville. In response,
the Trust has co-operated fully with all aspects
of the subsequent investigations, by assisting the
police and by participating an external review
commissioned by the Department of Health into
the period when it managed Broadmoor Hospital.
In the interim, we have comprehensively reviewed
our safeguarding processes to offer assurance to our
commissioners about our current practice.
We reviewed the Trust Board assurance mechanisms
and a non-executive board member was identified
to have safeguarding in their portfolio specifically.
The non-executive director has been actively involved
in the safeguarding governance processes for
additional assurance and will be offering additional
scrutiny when we prepare future reviews of our
processes for safeguarding children and adults.
We reviewed our approach to facilitating visits to
service users to ensure that we strike the correct
balance between their needs for safety and their
need to maintain contact with their families
and friends. The Trust Board has been receiving
74
information monthly on all children visiting adult
inpatients across the organisation since mid-2012.
We also reviewed our processes for all professionals
and trainees who join the Trust to assure ourselves
that all our processes for recruitment and our
relationships with training organisations include
safer recruitment practice.
We have redesigned the Trust intranet page for
safeguarding to be more accessible and provide a
better range of information. This will be launched
in 2013.
Quality assurance
The quality assurance data process has now bedded
in and we are extending it beyond local services, to
include all three CSUs. This means the board has
much greater awareness of safeguarding in the
organisation.
We plan to continue to refine data quality and the
priority in the next year is to develop our knowledge
about service users with dependent children. We
are working with our IT department to develop
an accurate reporting mechanism and the data is
included in our monthly safeguarding dataset.
We have already improved our user involvement by
starting a process of consultation about developing
a safeguarding information leaflet for users to
help them understand the referral process and to
facilitate Trust staff working with service users when
we need to make a safeguarding referral. We plan
to implement a user-involvement questionnaire
asking service users about their experience of the
referral process and its outcome over the next year.
We are also developing improved data with our
human resources partners to improve accuracy of
reporting of allegations against staff.
We began the revision of the Trust’s safeguarding
governance mechanism by adding the
safeguarding adults governance forum to coordinate assurance for this aspect of safeguarding.
While the new Trust structures have been bedding
in, we completed external assurance reviews
required by the Section 11 audit for safeguarding
children and the SAAFs. As a result we are in
a much better position to create an integrated
strategy for safeguarding children and adults, in
keeping with the recently-published document
Safeguarding Vulnerable People in the Reformed
NHS - Accountability and Assurance Framework.
This document provides guidance from NHS
commissioners about standards for safeguarding
in the new NHS structure.
quality account
These are the safeguarding performance
indicators we now routinely report:
Quality Assurance
data for 2012-2013
Local
Services
Ealing Local
Services
H&F
Local
services
Hounslow
Specialist
& Forensics
Services
High
Secure
Services
Number referrals to Children’s
Social Care
17
38
27
0
0
Number of child protection
case conferences attended by
provider
0
0
1
10
0
% number of users of the
service who are known to be
parents or carers of children
No data for
Comm 13.12% Comm 7.98%
Comm 3.55%
Inpatient 0.18% Inpatient 0.53% Inpatient 2.13% end March
No data for
end March
% number of users of the
service who are known NOT to
be parents or carers of children
Comm 0.71%
Inpatient 0%
No data for
Comm 1.77%
Comm 3.72%
Inpatient 0.35% Inpatient 0.24% end March
No data for
end March
% Number of users of the
service where their status as
parents or carers of children is
unknown
No data for
Comm 16.49% Comm 10.28% Comm 10.28%
Inpatient 0.53% Inpatient 0.53% Inpatient 0.53% end March
No data for
end March
Number of allegations referred
to LADO. (Safeguarding
Children)
3
2
0
2
0
Number of SIs – where there is a 0
safeguarding children element
0
0
0
0
Number of active SCRs. (NB:
definition of active is prior to
satisfactory Ofsted evaluation)
0
1
0
0
Service Priorities - Quarterly
Governance - Quarterly
0
HR - Quarterly
Number of allegations made
against staff in relation to
children/young people
% of managers who interview
staff; trained in safer
recruitment
HR Reporting mechanisms under review. In collaboration with Director
of Organisation Development & Workforce.
Courses booked have previously cancelled due to low uptake
97%
% of CRB checks that are in
date (in date = checked in last 3
years)
2012/2013
97%
97%
97%
97%
75
What else?
Throughout the last year we have maintained
safeguarding training compliance above the set
standard of keeping more than 80% of our staff
trained to the appropriate level at all times. Figures
are reviewed monthly and current decrease in
figures relates to the stage of the three-year cycle.
Mandatory training scorecard
Trust-wide
As at end of March Scorecard
Safeguarding children Level 1
2997
94%
Safeguarding children Level 2/3
2089
93%
Safeguarding children
Level 3 Specialist
119
79%
Safeguarding adults
2285
100%
Building on the success of the 2012 Safeguarding
Conference, we held a second conference on 17
May 2013. This year, we focussed on safeguarding
adults and had a range of prominent speakers to
address the audience on a theme of the prevention
of institutional abuse.
In learning from the last serious case review during
2011-2012, we have developed practice based
safeguarding learning and this is being implemented
across CAMHS to support practitioner competence
in managing and escalating safeguarding child
concerns. The escalation of concerning cases is
supported by clear escalation mechanisms via lead
doctors for safeguarding children locally.
We have also audited safeguarding child supervision
in the last year and the results showed that staff are
able to raise safeguarding issues during supervision.
In addition, staff indicate they are confident in
76
% Rate
raising issues and it appears all professional groups
are engaged in discussing these issues in their
supervision. However, the audit raises development
points in terms of a need for standardisation of
expectations about supervision for safeguarding
leads and we plan to re-audit using a larger sample
in a year’s time.
We are presently focussed on improving user and
carer involvement in safeguarding. We are preparing
an information leaflet about safeguarding processes
for our service users and are consulting with
service users in preparing the leaflet. We are also
generating user-experience measures in consultation
with users to be included in the patient experience
questionnaire.
quality account
What others say about our services
Accreditation for the Hammersmith and Fulham liaison psychiatry service
The liaison psychiatry team serving Charing Cross and Hammersmith Hospitals received accreditation
from the Royal College of Psychiatrists Psychiatric Liaison Accreditation Network in 2012. This nationwide scheme benchmarks quality of service provided against nationally agreed quality standards and is measured using peer review, audit, and patient and referrer feedback. The service has just undergone
its second peer review accreditation cycle and expects to maintain its accreditation status for 2013.
Quality Network for Forensic Mental Health
Services and Inpatient CAMHS
Forensic services have been part of the Quality
Network for Forensic Mental Health Services since
its inception in 2006 and have now completed the
seventh cycle of peer review. The Wells Unit has been
part of the Quality Network for Inpatients CAMHS
(QNIC) since its opening in 2006 and has now
completed the 11th cycle of peer review.
The networks use an iterative cycle of self- and peerreviews underpinned by a set of service criteria. The
model is one of engagement rather than of inspection. Members are expected to use the results of reviews
to develop action plans to achieve year-on-year
improvement. It is also anticipated that participants
will share their results with key groups locally and
nationally. This will include provider managers,
service commissioners, those making referrals to
the unit, local user and carer groups and healthcare
regulators. It is expected that units will demonstrate
engagement in an ongoing process of improvement,
working on areas highlighted by the previous review.
Compliance
• The Orchard was 100% compliant with the criteria in four standard areas and was found to be 89%
compliant overall.
• The Three Bridges Unit was 100% compliant with the criteria in five standard areas and was found to be
86% compliant overall.
• The Tony Hillis Wing was 100% compliant with the criteria in five standard areas and was found to be
86% compliant overall.
• The reviewers found that Wells Unit is continuing to meet a large amount of the QNIC standards, with
over 90% being met in all of the sections.
Improvements since last reviews
• All remarked that they were impressed with the level of service user involvement.
• Service users told the reviewers that they felt that they were treated with respect.
• They were impressed with the physical healthcare provision.
Challenges going forward
• In the Orchard they found that some staff lacked confidence in reporting incidents due a perceived “blame culture”.
• They felt service users could be more involved in planning their CPAs, such as who to invite and which
venue to use.
• Service users also complained about the quality of the food provided.
• They felt the level of care on Brunel ward was not consistent with the other wards. They felt that the multifaith room should be a dedicated space.
• They said there should be a multi-faith space available on the Wells Unit.
2012/2013
77
Other quality improvements in
2012/13
Physical healthcare Initiatives
Physical health strategy
The physical health strategy continues to be
implemented, with the development of a primary
care service for forensic services at Ealing. The
model for this service, is similar to Broadmoor,
with recruitment of a GP and an extra nurse, to
supplement the two nurses and nurse manager
already present.
The strategy provides for a structured approach
to case finding of long term conditions, and
managing the physical consequences of antipsychotic medication. That approach is to link a
physical health CPA to the current mental health
CPA – at the physical health CPA, each patient is
offered a physical health examination, an ECG,
and a full range of blood tests that are inclusive
of, but more extensive than, NICE guidelines.
This approach allows the cardiovascular and
diabetic morbidity to be predicted, and has been
the source of research papers and a quality award
from a primary care conference. Identification
of high risk patients (nationally defined in NICE
guidance) allows the health centres at both
Ealing and Broadmoor to target resources at the
most at-risk individuals.
MEWS
A structured approach to recording patient
observations has been introduced, called
MEWS – Modified Early Warning Score. This is
an evidenced-based scoring system, of blood
pressure, temperature, pulse etc. that is used
in the acute sector to identify patients who are
likely to become unwell. This has now been
introduced, and is included in mandatory training
for all nurses – it is linked to Basic Life Support
training, and is being rolled out across the Trust.
Physical healthcare conference
In November the Broadmoor service, together
with the Rampton and Ashworth services, ran
a national conference on physical health care in
secure environments. This conference was very
successful, with over 170 delegates attending
and a similar number on the waiting list to
attend. Following the success of this meeting,
78
the first of its kind, links have been made to
the forensic faculty of the Royal College of
Psychiatrists to try and make this conference a
part of the regular agenda.
The key note presentation at the conference
was the report on a study into cardiovascular
risk in high secure environments, identifying the
significantly increased risks in the three high
secure hospitals.
Service specific
Local services: From March 2013 a physical
health care service will be provided to the
two new older peoples wards – Coniston and
Windermere.
West London Forensic Services: Within the
West London forensic service, the temporary
arrangement for physical health care provided by
an external agency ceased on the 31 December
2011. A new service started 1 January 2012, and
included recruiting a new general practitioner,
an extra nurse, and installing a primary care IT
system, so that overall there will be consistency
between our forensic services.
The service was externally reviewed by an
experienced GP, who found the service of high
quality, and made further recommendations for
development.
Broadmoor: The service was reviewed by an
external experienced GP, who once again noted
the high quality of the service and that the
outcomes recorded are at least as good, and in
some cases better, than would be found in the
community.
The primary care team at Broadmoor were
one of three finalists in a national primary care
competition to identify the best cardiovascular
care provided by general practices. This
competition is open to all practices in the UK,
so competition is intense, and it is a significant
achievement for the team for their care is
recognised nationally.
quality account
Pharmacy initiatives
Improving patient experience
The pharmacists have worked closely with the
Recovery Hub to develop and facilitate three
courses requested by service users. ‘The role
of medicines in recovery’, ‘Managing side
effects of medicines’ and ‘Negotiating coming
off medication’ were all successfully delivered
and pharmacy will carry on working with the
Recovery Hub to deliver these courses in the
future as well as developing and delivering
courses for carers.
A pilot of a pharmacist as an integral member of
the memory clinic at Brentford Lodge has been
completed. This pilot provided a quality service
for patients and carers as well as producing
medication cost savings. Unfortunately the
dementia services have not been able to support
this as an ongoing service.
A pilot has also been completed with the
psychiatric liaison team where a pharmacist
provided medication reviews for patients referred
to the team, as well as offering advice and
assisting in audits. The pharmacist was able to
identify a number of medication interactions
and provide recommendations on changes to
treatment which contributed to a reduction in
medication costs.
The pharmacists working in forensic are
introducing pharmacy ‘open house counselling’
sessions on Butler House project where patients
can discuss medications and ask questions,
providing them with a better understanding of
medication before being discharged.
Local services pharmacists have participated in a
number of patient and carers groups to provide
information and education on medication and
allow carers to ask questions about treatments.
Clinical effectiveness
The pharmacy department continues to support
all aspects of medication for clinical trials
medication.
The pharmacy continues to provide in house and
external teaching on a number of medication
related topics.
Dieticians and pharmacy co-developed guidance
on management of Vitamin D deficiency which
has been implemented in the Trust.
Patient safety
The pharmacy department has undertaken
a number of audits to ensure the safe
management of medicines including regular
audits on controlled drugs management, audits
on lithium monitoring and documentation of
depot administration. Medication incidents have
been regularly reviewed at the Trust’s medicines
management group and a quarterly learning
lessons from medication incidents has been
implemented.
Pharmacy has also responded to and, where
appropriate, taken action on alerts on
medication.
Pharmacy has developed an e-learning module
on safe prescribing and practice’ for all
prescribers.
Pharmacists are also involved with supporting
recovery by preparing inpatients for selfadministration by ensuring they understand their
medicines and the processes involved in selfadministration.
The Trust pharmacy continues to subscribe to
the Choice and Medication website, which
provides detailed but easy to digest information
about common mental health conditions and
medications that are encountered in mental
health.
2012/2013
79
Medical revalidation
Revalidation of the medical profession
commenced on 3rd December 2012; it is the
statutory process by which licensed doctors
are required to demonstrate on a regular basis
that they are up-to-date and fit to practice.
Revalidation aims to reassure patients, public
and employers that the practice of their doctor
is being scrutinised by their employer and the
General Medical Council (GMC). All registered
doctors holding a license to practice must
revalidate, usually every five years, by having
an annual appraisal with their employer which
shows the doctor meets the values and principles
expected of the profession as set out by the GMC
in ‘Good Medical Practice’.
The provision of safe medical care is at the heart
of revalidation. It requires doctors to take part
in organisational processes such as appraisal
and other clinical governance activities, while
also placing a statutory duty on healthcare
organisations to provide the environment where
doctors can meet their professional obligations.
Each health care organisation must have a senior
doctor, called the responsible officer (RO), in
place to oversee systems for governance and
appraisal for doctors, for dealing with concerns
about medical performance or behaviour and
for advising the GMC about doctors’ fitness
to practise. These duties mirror the board level
responsibilities of the Medical Director who may
hold the RO role too. The Medical Profession
(Responsible Officers) Regulations 2010 makes
provision for healthcare organisations to be
designated under the act and for each licensed
doctor to have a prescribed connection to a
specific designated body. Within the designated
body the RO requires an infrastructure to support
the requirements of revalidation. The Department
of Health monitors compliance of all designated
bodies in an annual Organisational Readiness
Self-Assessment (ORSA).
focus on performance and learning needs
and make changes as needed. Revalidation
recommendations will be made by the RO to the
GMC on a five-yearly cycle based on a variety of
data sources, including annual appraisal, patient
and colleague 360% multi-source feedback,
information from incidents, complaints and
compliments, clinical outcomes and performance
monitoring. The RO will begin making
revalidation recommendations to the GMC in
June 2013. The first cycle will be complete by
2016.
WLMHT is a designated body and currently
has 150 doctors with a prescribed connection.
Dr Nick Broughton is the Trust’s Responsible
Officer. The Trust has a well established clinical
governance structure and supporting processes
which enable doctors to meet their professional
obligations. WLMHT has completed annual ORSA
and is fully compliant with DOH requirements
including the necessary policy framework. The
RO provides the Board with a report about
revalidation annually. Stakeholder engagement
in revalidation is good. The Trust has purchased
an electronic revalidation management support
system which went live mid April 2013. This will
ensure reliable data about appraisal outcomes
and will meet RO reporting needs as part of
managing doctors’ performance.
Medical revalidation is crucial in assuring doctors
are keeping up-to-date and are fit to practice.
WLMHT has embraced it enthusiastically and is
working with doctors to ensure revalidation is
one way to ensure we provide high-quality care
for our patients.
Annual medical appraisal is the cornerstone of
revalidation. All medical appraisers are trained
to ensure appraisal meets set quality assurance
standards. Appraisal enables each doctor to
80
quality account
Annex 1:
Statements from local involvement
networks, overview & scrutiny committees
and primary care trusts/commissioners
1) Clinical commissioning groups
Ealing, Hounslow and Hammersmith and Fulham
CCGs welcome the opportunity to review
and comment on the Trust’s quality account.
Feedback set out in this statement is based on
the presentation and discussion at the Ealing
Quality and Safety Committee which included
a presentation by Dr Nick Broughton, Medical
Director of the Trust. Members from Hounslow
and Hammersmith and Fulham CCGs were
invited to attend as were colleagues from the
commissioning support unit.
Overall the three CCGs think the draft quality
account is a fair reflection of the work the Trust
has undertaken. It recognises the level of change
that has taken place for users and carers and
recognises that this will continue over the next
few years. CCGs and the Trust have agreed to
work together, along with service users, carers
and the voluntary sector, to transform local
services and ensure these are coordinated with
other local changes such as the developing
CCGs out of hospital strategies. Whilst there
have been some marked improvements in the
engagement with primary care, principally GPs,
CCGs would want to see the Trust continue to
focus on local services and move away from its
focus on forensic services which have dominated
the quality accounts for many years. A number
of initiatives to aid communication such as
Consultant hot lines are starting to be put in
place but more work is needed in this area to
ensure that there is better support to primary care
as services transition and shifting settings of care
are implemented.
CCGs recognise that to support this agenda the
Trust has made a number of changes and these
are welcomed. For example the investment in
improving the physical health of service users.
CCGs are also aware that the Trust has started
to prepare in other ways, eg in Hounslow ICRs
has benefited from an RMN presence in the
2012/2013
team, and local trusts such as Ealing and West
Middlesex have found it clinically very beneficial
to have access to on site psychiatric liaison
services. CCGs welcome these positive moves to
work more effectively with GP colleagues.
In terms of CQC registration, CCGs note that the
Trust had two routine inspections in 2012/13 and
was found not to be meeting the outcomes on
safeguarding people from abuse and supporting
staff. The Trust provided an action plan and the
outcomes will be formally reassessed in June
to ensure full compliance, although the Trust
has provided assurance that immediate steps to
rectify these concerns happened post the visit. It
would be helpful for the Trust to have provided
some comments around this. However CCGs
also note the other changes the Trust has made
to strengthen its safeguarding services, both for
adults and children. Clearly with all the focus on
the Trust as part of the Saville Enquiry it’s helpful
to see how the Trust have strengthened some of
their procedures and safeguarding polices and
training.
Progress has also been made on the use of
patient experience and safety data. What
however CCGs would like to see in the next QA
is more information coming from PALS enquires.
CCGs recognise there is a section in the report
on PALS/Complaints but these are not pulled
together by theme, which would be useful.
CCGs would also note that although there is
detailed section on complaints relating to staff
attitudes, more detailed information on themes
would be useful so CCGs could see more clearly
if learning from individual complaints has been
used across the system. It would have also been
useful if there had been some triangulation of
information on the quality of nursing data with
caseloads, numbers of complaints and patient
satisfaction with being treated with dignity
and respect. This would have provided a more
81
thorough understanding of the issues which can
affect quality. Overall at the Trust’s presentation
CCGs commented that the voice of nursing was
not very strong in terms of the narrative of the
document and given this is the largest part of
the Trust’s workforce a greater focus on this area
would have been welcome.
CCGs welcome the Trust’s update on its audit
programme and note the extent and depth of
some of the reviews. We have discussed the
need to share these results of these audits with
CCGs more formally and agree a joint process
for sharing learning and any agreed changes to
practice. A number of the audits, particularly
those that focus on dementia, use of antipsychotics drugs and the audit of completion of
lithium monitoring record books are very relevant
to primary care in terms of best practice. The
lack of primary care involvement also means
that some of the potential changes may not be
sustained if local CCGs are unsighted on the
changes. CCGs are still waiting for the local
sustainable quality improvement plan to reduce
inappropriate antipsychotic prescribing, which
was funded under the 2012/13 dementia CQUIN
but which WLMHT’s local services directorate has
acknowledged it has not yet provided.
The CCGs also note that in response to the rolling
programme of compliance reviews undertaken by
the CQC the Trust is taking steps to strengthen its
compliance process. This is welcomed in terms
of the additional assurance this brings to CCGs
especially in terms of a local understanding of
how national priorities such as ending mixed-sex
accommodation, infection control and incident
management are being monitored as part of
the CQC rolling audit of compliance. CCGs also
welcome the strengthening of the governance
team and its role.
Mohini Parmar - Ealing CCG Chair
Kathryn Magson - Chief Operating Officer,
Interim, Ealing CCG
2) Healthwatch Central West London statement
82
Healthwatch Central West London (Healthwatch
CWL) welcomes the opportunity to comment
on the West London Mental Health NHS Trust
(WLMHT) Quality Account (QA) 2012-13. Under
the provisions of the Health and Social Care Act,
Healthwatch CWL replaced the Local Involvement
Network in Hammersmith and Fulham on April
1st 2013. The work of the LINk has therefore
informed the majority of this submission.
quality committee and commissioners would
receive a monthly update. But, the ‘How Well Did
We Do’ indicators (in 2012-13) in most instances
do not align to or refer to the ‘How Will We
Measure/ Monitor/ Report’ commitments in the
2011-12 report. We would therefore welcome a
much great focus on the quality infrastructure and
robustness of the data reported in the final draft.
Further reported information should include:
Firstly, we would like to thank WLMHT for
continuing to engage with us proactively over
the last financial year on our assessment of the
inpatient unit on the Charing Cross site and of
community services in the borough.
Local services CSU
However, the LINk and Healthwatch have found
it challenging to engage on the quality assurance
processes this year. The 2011-12 and 2012-13
Quality Accounts vary in structure and content
making a year by year comparison difficult.
WLMHT has added the response in the relevant
section of the Quality Account.
In the 2011-12 report, WLMHT promised work
would be monitored and implemented by the
WLMHT has added the response in the relevant
section of the Quality Account.
1. Improve communication with primary care
Waiting times between referrals and first
appointment
2.Improve access to out of hours service
Monitoring through the community patient survey
quality account
3. Improve interactions between staff and
service users
Further information on the quality of the audited
documentation i.e. were they positive for
therapeutic relations? How does the ‘what next’
section relate to the original aim?
WLMHT has added the response in the relevant
section of the Quality Account.
Risk assessment forensic services
WLMHT has noted this comment for further action.
9. Review of psychological therapies
Data is needed to support the explanation of how
monitoring is carried out.
WLMHT has added the response in the relevant
section of the Quality Account.
4. Specialist and forensic CSU
Timely and effective care for service users (the
aim, heading and content seem to be at odds).
High Secure Services - CSU
Measurements are against the 12 week CQUIN
target. How will the aim of ensuring service users
attain milestones be measured and reported on?
Monitoring and reporting on the length of time
guidelines as set out in 2011-12 are not referred to.
10. More timely admission process
WLMHT has added the response in the relevant
section of the Quality Account.
WLMHT has added the response in the relevant
section of the Quality Account.
5. Length of stay
In light of the recent Francis report, Healthwatch
CWL would welcome further information on
actions taken and planned by the Trust to ensure
‘patients not numbers come first.’ Specifically,
we are seeking quarterly monitoring data from
the NHS Trust on compliments and complaints.
We are keen to ensure local complaints
mechanisms are accessible for all and all learning
is incorporated in staff training.
The content provided in this section is confusing as
it does not report on the results of the monitoring
from 2011-12. For example, it refers to a
‘reduction in delayed transfers’ (not length of stay)
and an ‘agreed process in place to monitor this’.
WLMHT has added the response in the relevant
section of the Quality Account.
6. Maintain contact with local services - Casell
Although this response is detailed, indicators
were not included in 2011-12.
WLMHT has noted this comment for further action.
7. Developing service user involvement in
their care pathway through services
The response is split between Cassel and
specialist and forensic CSU in 2012-3 but is listed
as core in 2011.
This is outlined in the in the relevant section of
the quality account.
8. Improve and ensure consistent nursing
practice across the CSU
WLMHT has added the response in the relevant
section of the Quality Account.
We would also welcome further detail on how the
Trust will ensure all staff have the opportunity to
speak openly and honestly but with confidentiality
if needed so as to foster a culture of openness,
transparency that puts the patient first.
WLMHT has added the response in the relevant
section of the Quality Account.
For further information, please contact:
Healthwatch Central West London
Email: healthwatchcwl@hestia.org
Answered in 2012-13 for Cassel and forensic CSU
Tel: 020 8968 7049
Forensic - statistics are needed on the 2011-12
proposed outcomes, ie reduced incidents and
increased staff /patient satisfaction
Date: 28 May 2013
Cassel - whilst work is clearly being carried out in
this area, this section of reporting doesn’t really
address the aim.
2012/2013
83
3) Hounslow Health & Adult Care Scrutiny Panel
“Due to other work priorities this year, the
Hounslow Health & Adult Care Scrutiny Panel
has not had the opportunity to scrutinise services
provided by the Trust in any detail. Members note
the contents of this report.”
Cllr Poonam Dhillon, Chair, Hounslow Health &
Adults Care Scrutiny Panel
4) Ealing LINk
Below is our response to the Quality account
2013/14.
2. Ensuring service users are treated with the
highest levels of dignity, compassion and respect:
Looking back - Patient Experience:
We will continue to invite the Trust to be outward
looking and raise its profile in the community and
with its service users in the community. Much of
the service user involvement on individual projects
is invited from inpatients only such as the B block
naming competition. As the Trust continues to
move to a recovery focus, a reciprocal relationship
can be established with service users to provide
ideas and feedback.
As Ealing LINk we had some poor feedback on
the out of- hours 24/7 telephone service, whereby
service users didn’t receive a call back or were
put through to someone who wouldn’t deal with
them. We have raised this issue at our quarterly
meetings with the Trust and have been reassured
the service was in development at the time the
feedback was given and that callers will be dealt
with by the person who picks up the phone.
Looking forward:
1. Transfers of care: Healthwatch Ealing continues
to receive information on housing-related issues
for people with mental health, for which it holds
no monitoring functions. We hope the Trust will
work closely with the local authority to support
transfer to the community and housing.
84
3. Patient Information: Healthwatch Ealing has
been working with the Trust to draft a leaflet
for community services. We invite the Trust
to make use of our reading group for proof
reading documents designed for services users
in local services.
quality account
Annex 2:
Statement of directors’
responsibilities
The directors are required under the Health Act
• there are proper internal controls over the
2009, National Health Service (Quality Accounts)
collection and reporting of the measures of
Regulations 2010 and National Health Service
performance included in the Quality Account, and
(Quality account) Amendment Regulation 2011 to
these controls are subject to review to confirm
prepare Quality Accounts for each financial year.
that they are working effectively in practice
The Department of Health issued guidance on
• the data underpinning the measures of
the form and content of annual Quality Accounts
performance reported in the Quality account is
(which incorporate the above legal requirements).
robust and reliable, conforms to specified data
quality standards and prescribed definitions, is
In preparing the Quality Account, directors are
subject to appropriate scrutiny and review
required to take steps to satisfy themselves that:
• the Quality Account has been prepared
• the Quality Account presents a balanced
in accordance with Department of Health
picture of the Trust’s performance over the
guidance.
period covered
• the performance information reported in the
Quality Account is reliable and accurate
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
NB: sign and date in any colour ink except black
2012/2013
85
86
quality account
Annex 3:
Estates Liaison
Committee
CSU & Support
Services’ Integrated
Performance Meetings
Medical Education
Committee
Recovery Programme
Board
Trust Records
& Information
Governance
Capital & Asset
Planning Management
Group
CSU Senior
Management Team
Meetings
Data Reporting &
Assurance Oversight
Business Technology
Oversight
IG, Security & Caldicott
Informatics Sub
Committee
Finance & Investment
Committee
Trust Partnership
Forum
Trust Management Team
Audit Committee
Research &
Development Steering
Group
Service User & Carer
Experience Group
Patient Safety &
Safeguarding Sub
Committee
Clinical Effectiveness
& Compliance Sub
Committee
Quality Committee
Remuneration & Nominations Committee
Staff Engagement Committee
Trust Management Team
Charitable Funds Committee
Staff Engagement Committee
Service User & Carer Forum
Chaired by Executive
Broadmoor Redevelopment
Chaired by Non
Executive
MHA Managers
Trust Board
Key:
St Bernard’s Redevelopment
Programme Board
FT Programme Board
Governance and
Reporting Structure
2012/2013
87
Hammersmith & Fulham
Admission
Crisis Resolution Home Treatment
Older People Services
Psychiatric Intensive Care Unit
Hounslow
Assessment
Crisis Resolution Home Treatment
Recovery
Hammersmith & Fulham
Assertive Outreach Team
Assessment
Cognitive Impairment & Dementia
IAPT
Peers Support Work
Recovery
Vocational Work
Work Rehab Service
Hounslow
Assertive Outreach Team
Assessment
Cognitive Impairment & Dementia
Early Intervention Service in Psychosis
Eating Disorders
IAPT
Work Rehab Service
Ealing
Assessment
Cognitive Impairment & Dementia
Early Intervention Service in Psychosis
Eating Disorders
Group Homes & Community Road
IAPT
Recovery
STEPP Team
Substance Misuse
Work Rehab Service
Ealing
Clozapine
Crisis Resolution Home Treatment
Electroconvulsive Therapy
Men assessment
Older People Services
Recovery
Women assessment
MENTAL ILLNESS
Admissions
Assertive Rehabilitation
High Dependency
Intensive Care
PERSONALITY DISORDER
Admissions
Assertive Rehabilitation
High Dependency
Medium Dependency
Community Services
Inpatient Services
Local Services
High Secure Services Clinical
Services Units: Inpatient services
Annex 4:
Our
services
Hammersmith & Fulham
Tier 3
Tier 3 CAMHS
Tier 2
Community Psychology
Looked After Children
Primary Mental Health Workers
Psychotherapy in Schools
Youth Offending Service
Hounslow
Tier 3
Adolescent Team
Children & Families Team
Neurodevelopmental Team
Tier 2
Early Intervention Service
Looked After Children & SISP
TAMHS
WOMEN’S SERVICES
Enhanced Medium Secure
Ealing
Tier 3
Adolescent Service
Eating Discorder Service
Family and Young People’s Service
Neurodevelopment Service
Paediatric Liaison Service
Tier2
ESCAN (Learning Disabilities)
SAFE (Supportive Action for Families
in Ealing)
Other: TAMHS, Primary behaviour
Service, LAC, YOS, Parenting
The Cassel
(Therapeutic community)
Residential & Outreach
GENDER IDENTITY CLINIC
COMMUNITY FORENSIC SERVICE
ADOLESCENT
Community Secure
Specialist & Forensic Services
Clinical Services Unit
CAMHS
Annex 5:
Independent Auditor’s
limited assurance report
We are engaged by the Audit Commission to
perform an independent assurance engagement
in respect of West London Mental Health NHS
Trust’s Quality Account for the year ended 31
March 2013 (“the Quality Account”) and certain
performance indicators contained therein as
part of our work under section 5(1)(e) of the
Audit Commission Act 1998 (“the Act”). NHS
trusts are required by section 8 of the Health
Act 2009 to publish a quality account which
must include prescribed information set out in
The National Health Service (Quality Account)
Regulations 2010, the National Health Service
(Quality Account) Amendment Regulations
2011 and the National Health Service (Quality
Account) Amendment Regulations 2012 (“the
Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2013 subject to limited assurance consist of the
following indicators:
•
Percentage of patient safety incidents that resulted in severe harm or death; and
•
Minimising delayed transfers of care.
We refer to these two indicators collectively as “the specified indicators”.
Respective responsibilities of Directors and auditors
The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:
•
The Quality Account presents a balanced picture of the Trust’s performance over the period covered;
•
The performance information reported in the Quality Account is reliable and accurate;
•
There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, and these controls are subject to review to confirm that they are working effectively in practice;
•
The data underpinning the measures of performance reported in the Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and
•
The Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of
directors’ responsibilities within the Quality Account.
88
quality account
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:
•
The Quality Account is not prepared in all material respects in line with the information requirements prescribed in the Schedule referred to in Section four of the Regulations (“the Schedule”);
•
The Quality Account is not consistent in all material respects with the sources specified below; and
•
The specified indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account have not been prepared in all material respects in accordance with Section 10c of the NHS (Quality Accounts) Amendment Regulations 2012 and the six dimensions of data quality set out in the NHS Quality Accounts - Auditor Guidance 2012/13 issued by the Audit Commission in April 2013 (“the Guidance”).
We read the Quality Account and conclude whether it is consistent with the requirements of the
Regulations and to consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
•
Board minutes for the period April 2012 to May 2013;
•
Papers relating to the Quality Account reported to the Board over the period April 2012 to May 2013;
•
Feedback from the Commissioners Ealing, Hounslow and Hammersmith and Fulham CCGs;
•
The Trust’s complaints report published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009, dated March 2013;
•
The latest national patient survey dated 2012;
•
The latest national staff survey dated 2012;
•
The Head of Internal Audit’s annual opinion over the Trust’s control environment dated 28/05/2013;
•
The annual governance statement dated 29/05/2013;
•
Care Quality Commission quality and risk profiles dated March 2013; and
•
The results of the Payment by Results coding review dated May 2013.
We consider the implications for our report if we
become aware of any apparent misstatements
or material inconsistencies with these
documents (collectively the “documents”).
Our responsibilities do not extend to any other
information.
This report, including the conclusion, is made
solely to the Board of Directors of West London
Mental Health NHS Trust in accordance with
Part II of the Audit Commission Act 1998 and
for no other purpose, as set out in paragraph
45 of the Statement of Responsibilities of
2012/2013
Auditors and Audited Bodies published by the
Audit Commission in March 2010. We permit
the disclosure of this report to enable the Board
of Directors to demonstrate that they have
discharged their governance responsibilities by
commissioning an independent assurance report
in connection with the indicators. To the fullest
extent permissible by law, we do not accept or
assume responsibility to anyone other than the
Board of Directors as a body and West London
Mental Health NHS Trust for our work or this
report save where terms are expressly agreed
and with our prior consent in writing.
89
We conducted this limited assurance engagement in accordance with the Guidance. Our limited
assurance procedures included:
•
Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators;
•
Making enquiries of management;
•
Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation;
•
Comparing the content of the Quality Account to the requirements of the Regulations; and
•
Reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately
limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial
information, given the characteristics of the subject matter and the methods used for determining
such information.
The absence of a significant body of established practice on which to draw allows for the selection
of different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques
may also vary. Furthermore, the nature and methods used to determine such information, as well as
the measurement criteria and the precision thereof, may change over time. It is important to read the
Quality Account in the context of the Schedule set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of
Health. This may result in the omission of information relevant to other users, for example for the
purpose of comparing the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by West London Mental Health NHS Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe
that, for the year ended 31 March 2013:
•
The Quality Account is not prepared in all material respects in line with the requirements of the Regulations and the prescribed information in the Schedule;
•
The Quality Account is not consistent in all material respects with the sources specified above; and
•
The specified indicators in the Quality Account subject to limited assurance have not been prepared in all material respects in accordance with the Section 10c of the NHS (Quality Accounts) Amendment Regulations 2012 and the six dimensions of data quality set out in the Guidance.
PricewaterhouseCoopers LLP Chartered Accountants London
June 2013
90
quality account
West London Mental Health NHS Trust,
Uxbridge Road,
Southall,
Middlesex UB1 3EU
020 8354 8354
www.wlmht.nhs.uk
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