Quality Account
2014 – 2015
PART 1
Statement on Quality from Chief Executive and Chairman
Introduction
Calderstones Partnership NHS Foundation Trust is a specialist learning disability
service, authorised on the 1st April 2009 by Monitor the Independent Regulator for
Foundation Trusts. The Trust provides forensic and high support services to people
with learning disabilities.
We are pleased to present on behalf of the Board the Trust’s annual Quality Account
for 2014-2015. This publication provides the detail on how we have improved the
quality of services as outlined within last year’s Quality Account, together with the
forthcoming year’s quality improvement priorities.
We have a continued commitment to deliver high quality person centred services to
people with learning disabilities, who have complex and challenging needs. For
those that require care in a secure environment the level of security is based on the
least restrictive option, commensurate with the degree of risk to the service user,
staff and public.
The purpose of our Quality Account is twofold. Firstly to demonstrate accountability
to our service users, carers, commissioners, staff and the public for the quality of
services we deliver. Secondly, to ensure the Trust Board assesses and reports on
quality across all of the healthcare services we provide. It demonstrates that the
leaders, Clinicians, Governors and staff are committed to continuous, evidencebased quality improvement.
The principle aims of this publication are to demonstrate:
•
That we continuously review the quality of our services
•
That we are transparent in our reporting of this information, reporting both where
we are doing well, and where improvement is needed.
•
The improvements plans we have for the forthcoming year
•
How we provide information on the quality of services to service users and other
stakeholders, inclusive of our governors
•
Our organisational accountability to the Service Users, Commissioners, Staff,
Governors and other relevant stakeholders.
•
How we enable Service Users, Commissioners, Staff, Governors and other
relevant stakeholders to review your services, comment on performance and
identify priorities for improvement.
1
Our mission as a Foundation Trust is to promote recovery and quality of life through
effective, innovative and caring health, social care and specialist community
services. The best interests of our service users are at the heart of this. Our vision,
'changing lives through excellence’, has been defined by our three clear strategic
aspirations:
To deliver life-changing outcomes for our service users
To be the provider of choice for learning disability services
To be recognised nationally as the industry lead for learning disability services
The Trust’s commitment to continuous quality improvement is based on its shared
values of:
Trust - We keep our promises
Excellence - We continuously strive to deliver the highest standards of care
Compassion - We show empathy and are sympathetic to the needs of others
Respect - We engage, listen to and value the contribution of others
Ownership - We are responsible and accountable for our individual and collective
actions
Communication - We are open and honest in our communication
Partnership - We work together with clients, carers, colleagues, commissioners
and communities
It is a year since we introduced our Clinical Quality Strategy which underpins the
Trust’s Quality Account. This provides us with the opportunity to reflect on the past
year to both highlight the key achievements and forthcoming challenges for 2015 2016.
There has also been a significant improvement in the provision of physical
healthcare with an extensive review of the annual health check and the monitoring of
people taking antipsychotic medicines. There has been an emphasis on embedding
organisational learning across the Trust; we hosted our first learning event in
October 2014 focusing upon the family/carer experience.
Whilst this was
challenging for our staff there has been an increased momentum to build and
develop our engagement with families and carers.
The organisational learning event and the Triangle of Care have been a platform on
which to improve our partnership working with families and carers. At an event in
March 2015, a large number of family members attended to hear about future
strategy and to discuss all aspects of care with directors, senior staff and
experts. Carers voiced their views and agreed to move forward with their
involvement in our services and learning disability provision. We also announced
that the Carers' Trust have awarded Calderstones their Gold Star; a powerful
2
recognition of our partnership with family members. We were proud to share that
with carers and recognise the work we do together.
We are particularly proud as an organisation of the achievements of the service user
activist group ‘The Avenue’. The Avenue, a Lesbian Gay Bisexual and Transgender
group was set up following a direct request from service users with these
backgrounds for a support group, to tackle stigma and as a forum for service users
to talk about things to do with their sexuality in a non-judgemental and safe setting.
In a recent research study related to the group the outcome was that service users
reported improved self-esteem and self-confidence: these factors are thought to
influence some forms of offending, so it is important to tackle them. The Avenue
was shortlisted for a major national award in the ‘Tackling Stigma’ category National
Service User Awards 2015.
Another of our service user led groups is the ‘Media Crew’, which is made up of
service users from across the Trust. They design and create their own information,
including pamphlets and videos about Calderstones.
The Media Crew are
systematically producing a range of accessible information including the “Welcome
to Calderstones pack”. They have developed in film and song a description from a
service user perspective of the importance of working in partnership with staff to
move along their care pathway.
The Trust is committed to investing in modern facilities that meet national
specification. The provision of modern purpose built units at Maplewood has
enabled us to decommission our oldest facilities at Chestnut Drive. We are also
making major changes to West Drive, redesigning our wards, and putting new
facilities in place.
Fundamental to delivering clinical quality has been the programme of themed
director visits to clinical areas. These visits have highlighted issues for wards with
regards to food quality and recruitment challenges, and also emphasised the areas
of good practice, such as the quality of agency staff induction and the improvements
in the ward environments.
Whilst acknowledging the achievement from the 2014 2015 period the Care Quality
Commission Review together with our Specialist Commissioners Performance
Quality Reviews have required us to focus upon key themes. The feedback from
these sources include a number of issues which the Clinical Quality Strategy already
acknowledges, however, there are other areas that require a sharper focus in the
forthcoming year and feature within the priorities for improvement in 2015-2016
detailed in this Quality Account.
These themes include ensuring the Trust achieves and maintains high standards of
cleanliness, improving the governance systems with regards to Mental Health Act
administration, and reviewing the workforce in terms of capacity and capability to
deliver safe and effective care. In addition, following the publication of the
Department of Health ‘Positive and Safe’ (April 2014), ensuring the Trust delivers its
objective to reduce restrictive practices and eliminate prone restraint. Furthermore,
we want to build on our commitment to ‘patient safety’ through the national ‘Sign Up
to Safety’ campaign. We have committed to focus on areas that include improving
3
our environments to make medicine administration safer, reducing all omitted
medicines, ensuring the reduction of restrictive practices are clinically led,
embedding and improving organisational learning by continuing to host learning
events, and developing safer seclusion environments through technological
developments.
The annual staff survey is an important activity in understanding the things that are
important to staff. It is the cornerstone of ensuring that the principles and values set
out within the NHS Constitution are maintained. Furthermore as part of the NHS in
England the 7 pledges outline what staff should expect from NHS employers. The
pledges are part of the commitment of the NHS to provide high-quality working
environments for staff. Calderstones is proud of its organisational development
activity and a key activity is the Trust’s communication strategy which has played an
important role. The Trust is committed to engaging with service users, people who
work with us as well as local people, communities and other stakeholders to improve
services and make changes that are beneficial to all. Our vision, strategic
aspirations, values and behaviours set out an organisational commitment.
The benefits of effective engagement are very relevant for the transformation of the
Trust. The staff survey results for 2014 evidence the importance of a culture of
engagement and the Trust’s position in the top 20% for engagement. We appreciate
that if people who work for us are fully engaged in the vision they are more likely to
maintain performance through change and challenge. They are also more likely to
contribute to innovation, business improvement, and provide higher rates of
discretionary effort. Furthermore, effective engagement is also an opportunity to
improve the organisation brand within the local community and will attract and retain
talent. The staff survey will further inform the Trust through local action plans of how
to respond and build upon the results.
We have implemented a range of innovative staff consultation programmes. These
include devising a Staff Charter; the Chief Executive’s “Big Conversation” and “Big
Breakfasts Meetings”; implementation of regular ward visits from senior managers; a
refreshed staff suggestion scheme; staff awards that supported innovation and Trust
Values was launched; and a range of meaningful activity to engage staff at all levels
was put in place to discuss the key issues in the organisation. We have a
commitment to listen and act upon the things that are important to our workforce.
As part of the wider organisational development activities; the Trust is committed to
implementing new and innovative ways of working. In 2015, the Executive Team will
participate in an Executive Development Tool; the Trust will implement a Cultural
Assessment and will ensure that all first line managers receive leadership training.
Our vision for delivering continuous quality improvement is to ensure that efficiencies
drive quality as opposed to efficiencies delivered at the cost of quality. As a Trust,
we have embedded vision, values, and strategic direction. We continue to invest in
our staff through leadership programmes to ensure they have the knowledge, skills
and capacity to meet the challenges of ensuring our services are efficient, high
quality and good value. This quality account ensures we have a system in place to
ensure implementation and measurement of our quality priorities.
4
As the Chief Executive and Chairman, we are proud to lead the Trust’s commitment
to clinical quality and work with key partners, which include the people who use our
services, staff, the Board, Governors and Commissioners. The Trust’s aspiration is
to deliver the highest possible standards of clinical quality and deliver our vision of
“changing lives through excellence”.
The directors are required under the Health Act 2009 and the National Health
Service Quality Accounts Regulations to prepare quality accounts for each financial
year.
Monitor has issued guidance to NHS foundation trust boards on the form and content
of annual Quality Reports (which incorporate the above legal requirements) and on
the arrangements that NHS foundation trust boards should put in place to support
data quality for the preparation of the Quality Report.
The directors confirm to the best of their knowledge and belief they have complied
with the above requirements in preparing the Quality Report.
By order of the Board
NB: sign and date in any colour ink except black
Mark Hindle
Chief Executive
Rupert Nichols
Chairman
5
PART 2
2.1 Priorities for Improvement 2015-2016
The Quality Priorities outlined within this year’s Quality Account have been
developed in consultation with a number of stakeholders, not only reflecting what is
important to people using our services, staff and governors, but are also aligned to
the CQC inspection in 2014, the Improving Lives Review as part of the Winterbourne
Joint Improvement Programme and the Trust’s strategic objectives for quality. Our
Clinical Quality Strategy 2013-2018 (revised 2014) describes the detail of how we
will ensure quality remains at the heart of how we plan and deliver our services over
the next five years.
This Clinical Quality Strategy 2013 - 2018 brings together all the aspects that
contribute to high quality services: our five year Integrated Business Plan (IBP);
Workforce Strategy, Commissioning for Quality and Innovation Schemes (CQUIN),
Quality Account, and Carer Strategy. It describes the intentions of our Trust to
continually improve the quality of our services and the experiences of people who
use our services. Implementation of the Clinical Quality Strategy includes:
•
Agreeing and promoting quality priorities within services to meet the Trust
strategic goal
•
Raising awareness of what drives quality by defining our quality priorities
•
Promoting leadership at all levels to deliver the quality priorities
•
Creating an understanding of the role and contribution every staff member can
make to improving quality
•
Promoting individual responsibility for taking action to improve safety, experience
and outcomes for the people who use our services, their families and staff
We have defined what ‘quality’ means to the Trust through the following five
commitments:
•
Commitment 1: Maintaining the very highest standards of care
We will demonstrate this by comparing ourselves with other services, checking
and auditing that we are meeting our own and national standards, and acting on
and learning from feedback from the people who use our services.
6
•
Commitment 2: A promise to continuously strive to improve the quality of
services
We will demonstrate this by active involvement in research at a local, national
and international level. We will continue to invest in developing services that are
modern and fit for purpose. In addition, we will keep our staff up to date with the
specialist knowledge to deliver best practice in the treatment and care of the
people who use our services.
•
Commitment 3: Responding to the changing needs of people who use our
services and those who commission them
We will demonstrate this by engaging and working collaboratively with people
who use our services, their families and carers, and our commissioners. We will
be the forefront of developing services by responding to the needs of the
population we serve and develop effective treatment and therapy to ensure they
progress as quickly as possible
•
Commitment 4: Safeguarding the welfare of the people we care for
We will demonstrate this by ensuring we understand the risks that affect the
people we care for and develop plans to protect and ensure the safety of all who
use our services.
•
Commitment 5: Listening and responding to the people we care for, their
families and carers, staff and partners
We will demonstrate this by offering choices and opportunities to the people we
care for to influence service delivery and their own personal treatment and care.
We will ensure that treatment and care is personalised, flexible and responsive to
each and every individual.
Our Clinical Quality Strategy also takes account of the quality framework as outlined
within High Quality Care for All (DH, 2008):
•
Patient Experience
•
Patient Safety
•
Clinical Effectiveness
7
The priorities for 2015-2016 also include the Commissioning for Quality and
Innovation (CQUIN) payment framework. The CQUIN payment framework enables
commissioners to reward excellence, by linking a proportion of English healthcare
providers' income to the achievement of local quality improvement goals. Title:
Priority 1: Positive and Safe at Calderstones
Why are we doing it?
In April 2014, under the auspices of the national Positive and Safe Programme, the
Department of Health published the guidance framework ‘Positive and Proactive
Care: Reducing the Need for Restrictive Interventions’. The guidance required
providers of health and social care services to develop organisational restrictive
intervention reduction plans, with a particular emphasis on the elimination altogether
of prone restraint. Development of a more therapeutic culture, together with an
explicit focus on recovery and positive behavioural support, were highlighted as key
components of strategy. The revised Mental Health Act Code of Practice, which
comes into effect in April 2015, builds on the guidance set out in Positive and
Proactive Care, and provides further direction on achieving best practice. The Trust’s
response is described within the ‘Positive and Safe at Calderstones’ programme,
which was agreed by the Executive Management Team in November 2014, and is
reported to the Quality and Risk Committee on a monthly basis.
How will we measure success?
The programme is comprised of three constituent projects. The first of these aims to
create a more conducive and therapeutic culture and promote excellent nursing
practice through systematic implementation of the ‘Safewards’ model, created by
Professor Len Bowers. The second focuses on workforce development, through roll
out of a competence framework for positive behavioural support. This will have two
key elements: the principles of applied behavioural analysis, captured within primary
and secondary preventative strategies; and review of tertiary strategies, with a
particular focus on physical intervention and development of viable alternatives to
prone restraint. The third and final project is concerned with the use of data to inform
good practice. Monitoring overall trends in the frequency of restrictive interventions,
and sharing this information with frontline staff is a key workstream, together with a
series of audits designed to measure the quality of our positive behavioural support
plans, post-incident debriefs, and the extent of service user, family and carer
involvement in treatment and care planning.
Success will be measured in two main ways: process and outcome. In terms of
process, each project now has a detailed project plan with key deliverables and
8
timescales clearly identified. Project groups provide a monthly highlight report to the
programme board, detailing their progress against delivery of the milestones, which
in turn is reported to the Trust’s Quality and Risk Committee. In terms of outcome,
the ultimate test of the success of the programme is being monitored through
ongoing measurement of the frequency of restrictive interventions against the
trajectories one would expect to see following implementation of Safewards and
positive behavioural support. Other performance indicators will also include
comparison of before and after measures relating to staff and service injuries,
sickness absence, and patient reported outcome measures.
Priority 2:Credits 4 Cleaning (C4C)
Why are we doing it?
A clean, uncluttered, and attractive environment can make a lot of difference for a
person’s attitude and overall mood, and ultimately their recovery. A clean
environment is fundamental to promoting self-care and maximising independence for
a lasting recovery.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
Regulation 15 Premises and equipment states all premises must be ‘clean’. The
National Specification for Cleanliness in the NHS: A Framework for Setting and
Measuring Performance Outcomes (NPSA 2007) is a key priority for the NHS.
Alongside the Code of Practice on the Prevention and Control of Infections and
related guidance (DoH 2010), places further responsibility on NHS Trusts to ensure
that local provision of cleaning services are adequately resourced and defined
through strategic cleaning plans and schedules. This ensures that service users the
public and staff know what they can expect.
Improving and sustaining levels of cleanliness is important if the Trust is to improve
the overall quality of care and experience of people and staff using our services. In
the 2014 CQC inspection, it was highlighted as an area that must be improved by the
Trust. The Ward Manager has a key role in ensuring that national standards of
cleanliness are consistently achieved and that the experience of people using our
services are not overshadowed or recovery delayed because of a failure to provide a
clean safe environment.
The C4C software, was produced with the support of the Department of Health, for
the NHS by the NHS, it assist Domestic Services Managers, Clinical Nurse
Managers and Ward Managers to set, flex and manage cleaning specifications and
standards in Hospitals; monitor performance and comply with National Standards.
Enable the Clinical Nurse Manager or Ward Manager to regularly adjust their
9
functional area cleaning specification to meet the changing needs of their service
users.
How will we measure success?
•
•
•
•
•
By identifying a cleaning specification for all areas
Ensuring that all cleaning services are properly deployed and balanced across all
areas of the Trust
Providing a comprehensive management tool to produce reports on almost any
aspect of cleaning
Ensuring that monthly monitoring leads to significant improvement in the
standards of cleaning particularly across ward areas
Improved feedback scores on standards of cleanliness from people using our
services
Priority 3: Ward Accreditation Scheme
Why are we doing it?
There is an emphasis within NHS services to ensure that minimum standards of care
are met through regulation. However, it is equally important to ensure there is a
coherent and comprehensive approach to recognising teams that provide excellent
standards of care.
Ward Accreditation is a way of recognising the teams that focus upon improving
quality and has the potential to initiate healthy competition among clinicians to
provide the better care
Following Winterbourne, the Francis Inquiry and other reports into the failures of the
health systems in England, ward accreditation is gathering momentum. For
Calderstones partnership NHS FT the recommendation was raised following the
CQC inspection in 2014 and was advocated as a system whereby the Board could
obtain assurance on quality, safety and compliance of services.
Ward Accreditation Schemes:
•
•
•
•
Improve quality, experience and safety
Provide a level of assurance about the quality of care and standards on wards
Inspire trust and confidence for service users, families and key stakeholders in
the quality of care
Support clinical managers to understand how they deliver care, identify what
works well, and where further improvements are needed.
10
How will we measure success?
In 2015-2016 the Trust will ensure:
•
•
•
•
•
•
•
A framework of standards is developed that supports quality improvement and
regulation compliance
All clinical areas are assessed the framework of standards
There are demonstrable improvements in services as a result of assessment
A process to improve quality, experience and patient safety
To provide a level of assurance about the quality of care and standards on wards
To inspire trust and confidence for service users, families and key stakeholders in
the quality of care
To support clinical managers to understand how they deliver care, identify what
works well and where further improvements are needed.
Priority 4:Eliminating Omitted Medicines without Clinical Reason
Why are we doing it?
The Francis Report into Mid Staffordshire Hospitals recommends ensuring that
medicines are given on time and that it is the responsibility of the ward manager to
ensure this happens. Although the NPSA Rapid Response Report 009 Reducing
Harm from omitted and delayed medicines in hospital came out in February 2010
citing an incidence for omitted doses of 5% it would appear there is still room for
improvement. Omitted medicines are still seen in reports to the National Patient
Safety Agency (NPSA). The NPSA as part of NHS England in the Patient Safety
Directorate is introducing a Medicines Safety Thermometer, which will include
Omitted Medicines.
Locally the Trust has been extensively monitoring omitted medicines over the last
year with particular emphasis on critical medicine omissions. For 2015-2016 we
want to focus our attention on all medicine omissions. This involves reviewing the
supply, prescription and administration of medicines.
There are planned changes to the Medicine Administration Card to ensure clearer
prescriptions and easier to follow for nurses in the administration process. We are
also reviewing administration processes to review to ensure less distraction. There
is also ongoing reviews of supply from pharmacy services.
11
How will we measure success?
In 2014 the numbers of omitted medicines have been volatile and there has been no
pattern of consistent improvement.
Figure 1 Omitted Medicines without Clinical reason in 2014
This project aims to ensure that omitted medicines of any type becomes a rare event
Priority 5: Integrated Treatment and Care Planning
Why are we doing it?
The Trust’s CQC Inspection in 2014 highlighted concerns with the treatment, care
and support planning for the people using our services. Whilst committed to
partnership and involvement the overall judgement was that the Trust’s systems
included multiple formulations; different perceptions of the service users and no
central resource or document. This made it difficult to demonstrate how the service
user was moving through the care pathway and how they were co-creators in their
plans. This has also been acknowledged through local audit processes.
The Trust will review the care planning process to ensure clear evidence for:
•
•
•
•
•
•
Whole Person Approach
Comprehensive Assessment
Identify Dynamic Factors
Targeted needs
Treatment Hierarchy and priority needs
Co-creation
12
•
•
•
Strengths and abilities
Multidisciplinary
Single source documentation
How will we measure success?
The Trust will solicit feedback from key stakeholders which includes service users,
carers and families and key stakeholders to test if we are meeting are key objectives
as outlined above.
The Trust also anticipates an improvement in audit results given the single source
documentation should make evidence easier to locate.
Priority 6: National Offender Management Project
Why are we doing it?
For several years the Trust has been leading a national piece of work on behalf of
the National Offender Management Service (NOMS) to improve outcomes for
offenders with leaning disability. Most recently, this has been in the form a jointly
funded project to work with prisons and probation services to improve delivery.
To date the project, which is led by the Forensic Support Service, has successfully
developed a range of tools to enhance practice , lead the development of a clear
practice framework and helped NOMS to revise its national strategy. Work on
implementation across all prisons and probation services, is currently under way at
NOMS.
The project was scheduled to finish at the end of March, but has now been extended
in order to support two important pieces of work across prisons.
How will we measure success?
The first is the national review of suicide and self-harm. NOMS has established and
requested Calderstones to lead a workstream reviewing the experience and needs of
offenders with learning disability. It is expected that this work will produce
recommendations by October.
The second strand is for the project to support a broader Safer Custody Review at
NOMS, with a specific emphasis on improving reception and induction processes for
offenders with learning disabilities.
13
Priority 7: Commissioning for Quality and Innovation (CQUIN) 2015-2016
The Commissioning for Quality and Innovation (CQUIN) aims to enhance the
treatment and care pathway through the work delivered as part of a payment
framework. A proportion of the Trust’s income in 2015-2016 will be conditional upon
achieving quality improvement and innovation goals agreed between the Trust and
the commissioners through the payment framework. The Trust is committed to
improving the quality of services through the innovation and improvement scheme.
The CQUIN Projects for 2015-2016 for NHS England and East Lancashire CCG
include:
•
•
•
•
•
Secure Service Users active engagement programme
Supporting service users in secure/specialised services to stop smoking
Supporting Carer involvement in Mental Health
Improving Physical Healthcare to reduce premature mortality in people with
severe mental illness
o Cardio Metabolic Assessment and treatment for patients with psychoses
Care & Treatment reviews (CTR) task & finish group
14
Part 2.2
2.2.1
Review of Services
Statement of Assurance from the Board
During the reporting period 2014-205 Calderstones Partnership NHS Foundation
Trust provided for people with a learning disability:
•
Specialist on-site in-patient services inclusive of:
 Assessment and treatment service
 Secure service provision
 Enhanced services
 Rehabilitation services
•
Specialist forensic outreach support service
Calderstones has reviewed all the data that is available to them on the quality of care
in the above NHS services (inclusive of social care provision). The income
generated by the NHS services reviewed in the reporting period 2014-2015
represents 89.23% of the total income generated from the provision of NHS services
by the Trust for the reporting period 2014-2015
2.2.2
Participation in Clinical Audits
During 2014-2015 the Trust was not eligible to participate in 1 national clinical audit
83 cases were submitted which is 100% of eligible cases. The national clinical audit
that Calderstones Partnership was eligible to participate in during 2014-2015 was
Physical Healthcare: National Schizophrenia Audit. The report has not yet been
published but Calderstones Partnership will address any recommendations made in
respect of the audit.
There was a nil return for the Trust response to the National Confidential Inquiry into
Suicide and Homicide by People with Mental Illness (CISH) covered NHS services
that the Trust provides.
The reports of 32 local clinical audits were reviewed by the provider in 2014-2015
and the Trust intends to take action to improve the quality of healthcare provided
[See Appendix C for list of clinical audit topics and brief synopsis]
All of the Trust’s clinical audits are presented to and reviewed by the multidisciplinary
Clinical Audit Committee. Selective reports are presented to the Quality and Risk
Committee (as a subcommittee of the Trust Board) and provide the assurance that
quality issues are being addressed at Board level. The Trust encourages all
15
services to be quality focused and as such encourages all clinical areas and
disciplines to participate in the review of services through clinical audit.
2.3.3 Participation in Clinical Research
The number of patients receiving NHS services provided or sub contracted by
Calderstones Partnership NHS Foundation Trust in 2014-2015 that were recruited
during that period to participate in research approved by a research ethics committee
was 75. Other studies have recruited staff numbers (19 participants), and
family/carers of people supported by the Trust (3 participants so far).
The level of participation in clinical research demonstrates Calderstones Partnership
NHS Foundation Trust’s commitment to improving the quality of care offered and to
make a contribution to wider health improvement.
Calderstones Partnership NHS Foundation Trust was involved in conducting 15
clinical research studies. The Trust completed 100% of these studies as designed
within the agreed time and to the agreed recruitment target. The Trust used national
systems to manage the studies in proportion to risk. Of the 15 studies given
permission to start, 15 were given permission by an authorised person less than 30
days from receipt of a valid complete application. 15 of the studies were established
and managed under national model agreements and 2 of the 15 eligible research
involved used a Research Passport.
In 2014-2015 the National Institute for Health Research (NIHR) supported 2 of these
studies through its research networks, with 2 further external studies also given
permission from Calderstones through the NIHR portfolio. 2 of the 15 studies
recruiting in 2014-2015 were registered on the NIHR portfolio and recruited a total of
5 people (4 patients and 1 staff). In total 5 studies on the NIHR portfolio remain open
and eligible to recruit from the Trust; 2 closed during 2014/15.
In the last three years 25 publications have resulted from our involvement in clinical
research or innovative practice at Calderstones, helping to improve patient outcomes
and experience in this specialist field. Of these, 1 paper and 2 book chapters in
2014-2015 relate to the first NIHR portfolio study sponsored by Calderstones and
there have been further papers and conference / exhibition / workshop papers
submitted in relation to this study during 2014-2015.
The Trust has established working partnership links with Lancaster University and
continues to be a member organisation of the Lancaster Health Hub (formerly known
as the Clinical Research Hub), working collaboratively in developing research
proposals.
16
2.3.4 Goals Agreed with Commissioners – The Use of CQUIN Payment
Framework
A proportion of the Trust’s income in 2014-2015 was conditional on achieving quality
improvement and innovation goals agreed between the Trust, NHS England – North
of England Specialised Commissioning and East Lancashire CCG (on behalf of 17
Associate CCGs within the North West).
The amount of income for 2015/16 is £34.4m and is conditional upon achieving
quality improvement and innovation. The Trust achieved the indicators in 2014/15
and successfully received the payment of £877k.
Table 1 2014-2015 Payment Schedule for CQUIN Goals
Contract Income
East Lancashire CCG
(on behalf of 17 North
West Associate CCGs)
2014-2015 Contract
CQUIN
Total
North of England
Specialised
Commissioning
£000
£000
8,182
26,863
205
672
8,387
27,535
The Trust continues to work with the North of England Specialised Commissioning
Team and the Clinical Commissioning Groups (CCGs), to agree goals that reflect
measured improvements in the performance of quality
The Trust is required to undertake a CQUIN Programme for the period 2015-2016
which is 2.5% of contracted income which amounts to £839k.
2.3.5
Statements from the Care Quality Commission
The Trust is required to register with the Care Quality Commission and its current
registration status is registered to carry out the following regulated activities:
17
•
Treatment of disease, disorder or injury
•
Assessment or medical treatment for persons detained under the Mental
Health Act 1983
•
Accommodation for persons who require nursing or personal care
The Trust is registered without conditions.
During 2013-14, the Trust identified serious weaknesses in its overall governance
processes and following the commission of an independent review by Deloitte and
receipt of an enforcement notice from Monitor, a significant amount of improvement
work was carried out during 2014-15. These areas of weakness were addressed
and the final Quality Governance Assurance Framework recommendation was
signed off during quarter three period (October to December) 2014-15. The
improvements made include:
•
•
•
•
•
•
•
•
•
Appointment of a substantive Company Secretary
The creation of a new Assistant Company Secretary post
Restructure of the Trust Secretariat to provide adequate support to Board and
Governors in discharging their statutory responsibilities
Appointment of two Non-Executive Directors to the Board, representing an
increased capacity of one NED
Separation of the Director of Nursing role from the Director of Operations role
resulting in the appointment of an Executive Director of Nursing & Quality
The delivery of an ongoing comprehensive Board Development Programme to
address the identified areas for improvement of individual Board members and
the Board collectively
The implementation of the revised protocol for the maintenance and monitoring
by the Board of the BAF
The completion of the review of Board Committees to support the governance
and escalation framework
The embedding of a restructured and augmented Trust Secretariat to ensure that
the Board and Governors are appropriately supported to deliver their
responsibilities
On 29 April 2015, Monitor issued a compliance certificate, in respect of Paragraph 2
of the Trust’s enforcement undertakings accepted by Monitor on 20 December 2013
stating:
18
“…inspection of the Licensee [Calderstones Partnership NHS FT] by the Care
Quality Commission in July 2014 found that some of the Licensee’s Governance
systems were not effective. This was demonstrated by the quality concerns
highlighted, including: failure to maintain clean ward environments and to fully
implement infection control procedures; non enforcement of medicines management
procedures; a lack of awareness of and failure to follow; trust policies relating to
seclusion, segregation and restraint; and a failure to adequately monitor the Mental
Health Act at Board level”
The CQC has not taken enforcement action against the Trust during 2014 – 2015.
However, following the CQC special review based upon the draft of the Mental
Health Pilot Standards during July 2014 Calderstones Partnership has made the
following progress by 31st March 2015 in taking such action:
•
•
•
•
•
•
•
•
Introduced systems to improve practice and adherence to cleanliness and
infection control. These include:
• Credits for Cleaning (C4C) electronic cleanliness audit tool
• Introducing ‘PLACE Lite’
Improved practices and adherence to food labelling, fridge temperature
monitoring (including medicine fridges) and the maintenance of equipment, and
introduced daily monitoring at ward level to ensure compliance
Reviewed the policy for restraint, and taken account of the DH guidance ‘Positive
Proactive Care: reducing the need for restrictive interventions’.
Introduced a central register for all people requiring ‘mechanical restraint’
Developed a Mental Health Act Administrator work programme and a quarterly
assurance report to the Trust Board
Introduced systems to ensure emergency equipment on the wards is checked to
confirm it is current, working and correctly labelled so all staff can access it
quickly in an emergency.
Introduced a monthly Safe Staffing Report to the Trust Board to provide
assurance that appropriate resource requirements are allocated to meet the
assessed clinical, relational and activity needs of service users in each area. This
includes use of Agency and Bank Nurse staffing over the 24 hour period
Reviewed communication treatment and care plans and for all service users, and
the communication passports for those service users where needed
19
2.3.6 Data Quality
NHS Number and General Medical Practice Code Validity
Calderstones Partnership did not submit records during 2014-2015 to the Secondary
Uses service for inclusion in the Hospital Episode Statistics which are included in the
latest published data.
2.3.7 Information Governance Toolkit attainment levels
The Trust score for 2014-2015 for Information Quality and Records Management
assessed using the Information Governance Toolkit was 71% based upon the score
of level 2 for 41 applicable items and level 3 for 3 applicable items (total 44
applicable items) and was graded satisfactory. The key features in developing the
action plan for 2015-2016 include:
•
•
•
•
•
•
•
Standardising clinicians approach to coding for consistent use of
primary/secondary diagnosis codes
Review of systems/data to ensure appropriate recording and reporting in line
with NHS Data Dictionary
Review processes for clinical staff validating care records following recent
changes to allow support worker involvement in confirming notes
Monthly MHLDDS being provided by Information Manager to HSCIC and
Information Governance Steering Group
Further development of Informatics intranet page as a means to enable staff
awareness
Routine spot check reports to be provided to Information Governance
Steering Group
Review related procedures to incorporate any additions or amendments
supporting the above work
2.3.8 Clinical coding error rate
The Trust was not subject to the Payment by Results clinical coding audit during
2014-2015 by the Audit Commission.
20
PART 3:
3.1 Review of Quality Performance: Priorities for Improvement
2014-2015
In June 2014 the Trust produced its fifth Quality Account aligned to the Trust’s
quality commitments as outlined in the Clinical Quality Strategy 2013-2018 and the
quality framework of patient safety, patient experience and clinical effectiveness.
The following section outlines what we have achieved over the past year both
against our quality improvement priorities and our quality dashboard.
Testing the Vision and Values of the Organisation
In 2013-2014 a the Trust vision, values and strategic aspirations were revised (see
figure 2) to ensure the Trust’s workforce has a common purpose of providing high
quality services. During 2014-2015 we have been integrating the values to develop
an organisational culture that fits the Trust’s vision. Implicit to the achievement of the
Trust’s strategy is the core values and associated behaviours, which respond to the
current and changing needs of our service users.
Figure 2
Director Walkabouts
One of the means of testing the values of an organisation is through ward based
director visits. Board members undertake both Director Walkabouts and ‘Patient
Safety Visits’ for the purpose of visiting service users, staff and clinical areas to
21
ensure:
•
•
•
•
Through visibility and familiarisation directors, staff and service users establish
‘trust’ and ‘communication’ channels.
Board members become an integral part of developing and recognising
‘excellence’
By taking ‘ownership’ of ward based quality issues Board members can work in
‘partnership’ with clinical teams
Providing service users and staff with an informal opportunity to give the Board a
window of insight as to what it is like to live and work in Calderstones shows
‘respect’ and ‘compassion’
During 2014-2015 the following themes and issues have emerged as part of the
Director visits schedule:
Medicine Management
Staff talked frankly about their concerns about medication safety and the number of
initiatives to support improvement. There were risk factors identified as part of the
visits, which include location of medication cupboards in older ward; this currently
part of a programme of review, and general distractions in the ward environment.
The Directors were also able to discuss the staffs’ protective plans to try and prevent
medication errors, such as; stable staff teams; service users not moving wards
without good clinical reason; briefing of registered nurses on a daily basis regarding
medication changes; and lessons learned from medication errors being briefed to
staff.
Physical Healthcare
Staff reported to Directors that they received good support from the Trust Health
Centre. Additional support was identified from Specialty Doctors especially those
who have primary healthcare experience. However, Directors noted differences in
health provision for service users living away from the Calderstones site. These
service users were registered with local GPs and the Directors were seeking
assurance that these service users were receiving an equitable service. As a result,
any gap in local provision will be filled via access to all the health services on the
Calderstones site.
Clinical Audit
The Trust’s annual clinical audit programme is aligned to the Trust quality
commitments with the principle emphasis upon delivering ‘excellence’ through
‘ownership’, ‘partnership’ and ‘communication’.
22
The effectiveness of clinical audit is underpinned by ensuring audit projects are
relevant. Concerns regarding clinical care are often identified through clinical
governance structures. Within the Trust, it is these concerns alongside national
guidance that inform our annual programme.
1. Service user views or complaints.
2. Adverse incident/near miss reporting
3. Identified local priorities or concerns
Within the 2014-2015 Clinical Audit Programme we have aimed to increase the
number of NICE audits to 10 completed audits, Appendix C outlines the Trust’s
achievements to completing this objective.
However, it is locally driven audits that are driving improvement most notably with
Medicine Management, linking to Director Walkabouts and adverse events and
ensuring improvement in standards of record keeping.
With the emphasis on restrictive practices, the clinical audit programme has audited
seclusion practices, rapid tranquillisation and positive behaviour support plans.
There has been significant improvement work in terms of redefining standards and
improving record keeping compliance. These audits also triangulate with surveys
undertaken with both service users and carers, ensuring ‘compassion’ and ‘respect’
are at the heart of clinical practices.
Physical Health Monitoring
In 2014-2015, we extended our commitment to improve the physical health
monitoring of service users, both in relation to their general physical health and
increased monitoring around those people who take antipsychotic medicines.
People with learning disabilities are known to have increased risks of health
problems compared to the rest of the population. They are also less likely to have
good access to healthcare services. Therefore, we committed to provide an annual
physical health check for all service users but also complex case management
support from a dedicated advanced nurse practitioner for service users with a long
term health condition.
We have implemented a standardised ‘annual physical health check’. Monitoring of
annual health check is completed every month as part of the Quality Dashboard,
average compliance score is 98.66%, not quite meeting 100% target. Nevertheless
there have been significant improvements both in relation to engagement and
completion of checks. The Advanced Nurse Practitioner role is using the ‘complex
23
case management’ model and has made good progress in helping service users who
usually find the health check too distressing to have active monitoring of their health.
In support of the annual health check the Trust has also started using the Health
Equalities Framework (HEF) (iHAL, 2013) as part of the CQUIN programme. The
HEF is a tool that provides overarching health-focused outcomes framework which
informs and supports both commissioning and service provision and across health
and social care settings.
We have compiled a database of all current service users’ physical health conditions.
Analysis is underway of the data compiled in order to write a profile of physical
health needs for the Trust population, completed at the end of March 2015 and will
be used to inform the development of a health inequalities strategy during 2015/16.
This will support the Trust physical health steering group to target resources to the
areas of most need for the health of the service user population.
In addition to the annual health check we have ensured that all service users
prescribed antipsychotic medication receive comprehensive physical health
screening. Antipsychotic medicine can help people as part of the recovery process
but there are also risks to health with long-term use that can be addressed if regular
health checks are completed.
To achieve this we have developed a set of standards and a reporting process in the
healthcare record aligned to the standards. This is administered via a centralised
clinic at the Health Centre, which also incorporates a recall process.
This is audited twice a year and the audit results continue to show better systems for
monitoring and following up people who have not attended via a dedicated clinic.
Figure 3 gives an overview of the results from audits in 2013 and 2014. There still
needs to be improvement in record keeping for ward-based health monitoring in
particular BP and BMI.
24
Figure 3
2013 and 2014 Comparison
100%
89%
87%
88%
69%
58%
56%
60%
43%
40%
84%
80%
80%
29% 30%
32%
98%
92%
69%
60%
2013
43%
2014
27%
20%
0%
BMI
BP
Blood
Liver
Glucose Function
Lipid
Profile
U&E
FBC
Prolactin
ECG
In addition to physical health monitoring associated with antipsychotics we also
continue to embed the use of the Liverpool University Neuroleptic Side Effects rating
Scale: (LUNSERS) as an outcome measure from the service users’ perspective in
relation to the monitoring and management of the side effects of antipsychotics.
LUNSERS is a widely used self-assessment tool for measuring the side effects of
antipsychotic medications. Regular reviews and discussions about tolerability are an
important factor in helping people to adhere to treatment. Side–effects should be
assessed in the early stages of starting any new treatment and at regular intervals
throughout treatment. Side effects should also be assessed after any dose changes
and at treatment review meetings.
The original LUNSERS was hard for people with learning disabilities to understand
so in 2012-2013 there was a Trust wide project to support people using services to
develop a version of LUNSERS that was easier to understand. This included adding
pictures and additional text. In 2014-2015 we developed LUNSERS as part of the
care record with an inbuilt prompt response (Carenotes Assist) to notify clinicians
when the person needs to review their experience of side-effects of antipsychotic
medication. Development within the electronic care records will improve the
regularity of review both in line with the quarterly requirement and in response to a
change in clinical presentation
At the point of reporting, no service users are self-reporting high levels of side
effects, which is an indication of the effectiveness of monitoring and intervention by
25
the care team. This is especially important when trying to establish good medicine
adherence with service users and is integral to discharge planning. Whilst there is
evidence that care teams take the issue of medication side effects seriously and
demonstrate strong commitment to address these for the benefit of service users, in
the past 12 months the wards have not achieved the target of ensuring all service
users were assessed every 12 weeks.
Standards for Wards Transfers
An initiative introduced by the Trust last year was driven through consultation with
service user Governors, and was to improve the experience for people in our service
when they are transferring wards. Based upon feedback from service users their
families, and from complaints information we need to improve the experience of
people in our services when they are moving wards within the care pathways
This was done by developing standards in partnership with the service users and
support staff.
A number of consultation events were held through our ‘Speak Up’ network. There
were a number of key themes that emerged through the consultation process:
•
•
•
•
•
Orientation to the ward
Having access to current and updated information
Care of personal belongings
Continuity of Activity Schedule
Handover as part of the Care programme Approach
A set of standards has been drafted to address these themes, and we were hoping
to audit the implementation and compliance during 2014-2015, however, this has not
been possible so this has been added to the audit programme for 2015-2016. We
will also continue to monitor feedback on ward transfers through our complaint data.
MaPSAF Analysis Report 2014
Background and Introduction
The Manchester Patient Safety Framework (MaPSAF) was originally developed for
use in primary care services by Manchester University. The framework is based on
Ron Westrum’s (1993) theory of organisational safety – “organisational personality”,
used within the oil industry but developed for further use in acute, mental health,
ambulance settings
26
MaPSAF covers nine dimensions of safety:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Overall commitment to quality
Priority given to patient safety
Perceptions of the causes of patient safety incidents and their identification
Investigating patient safety incidents
Organizational learning following PSIs
Communication about safety issues
Personnel management and safety issues
Staff education and training about safety
Team working around safety issues
Patient safety is a complex multidimensional concept; using the tool enables the
Trust to self-reflect on our maturity as a learning organisation, and how we continue
to develop and embed patient safety across the Trust. It also supports and
stimulates discussion about the strengths, weaknesses and differences of the patient
safety culture within teams across the Trust. MaPSAF also helps us evaluate any
specific intervention to change the safety culture
In 2011, Calderstones developed MaPSAF Mental Health (NPSA, 2006) into an
online survey tool, and have been collecting data between 2011 and 2014. In 2014,
this was part of the local CQUIN Programme.
The principle behind interpreting the result is that the more scores obtained at the
lower end of the scale the less safe an organisation is and the more score at the
upper end of the scale the organisation is deemed safer. The respective dimensions
are measured against the following criteria:
•
•
•
•
•
A – Pathological - Why do we need to waste our time on patient safety issues?
B – Reactive - We take patient safety seriously and do something when we
have an incident
C – Bureaucratic - We have systems in place to manage patient safety.
D – Proactive - We are always on the alert/thinking
about patien
that might emerge.
E – Generative - Managing patient safety is an integral part of everything we do.
We hope to be able to demonstrate that our feedback results are predominantly in
the ‘D and E’ dimensions and that year on year comparison show improved ‘patient
safety culture’.
27
2014 MaPSAF Results
Figure 4 Profile of results across all MaPSAF dimensions
An initial glance of the profile of results; the Trust has achieved the objective of
ensuring the results of the survey are predominantly weighted towards ‘D –
proactive’ and ‘E – generative’ results, for all dimensions these responses sets are
the highest, with the exception of ‘7 – Personal management and safety issues’.
This is clearly the area that suggests a need for improvement.
The chart below (figure 5) gives an overview of the average results across all
dimensions for the five response sets and that gives a good indication that the Trust
is receiving positive feedback with regards to ‘safety culture’.
28
Figure 5 Average scores across all dimensions 2014
When reviewing the results for the three data collection periods of 2011, 2013 and
2014 (table 2) there is no evidence that the Trust has achieved its objective of year
on year improvement, however, neither is there a concerning picture of declining
results. There is good evidence of variation of responses across all domains and
reporting periods, which gives an indication that staff have made considered
responses to each question.
The survey was completed anonymously and no demo graphic information has been
collected. For 2015 the Trust intends to develop the survey to identify clinical groups
or care pathways so we can focus our efforts with regards to patient safety.
Table 2 Comparison of Results for 2011, 2013 and 2014
APathological
'Why do we
need to waste
our time on
patient safety
issues?'
B - Reactive
'We take
patient safety
seriously and
do something
when we have
an incident.'
CBureaucratic
'We have
systems in
place to
manage
patient safety.'
D - Proactive
'We are always
on the
alert/thinking
about patient
safety issues
that might
emerge.'
E - Generative
'Managing
patient safety
is an integral
part of
everything we
do.'
1. Overall commitment to quality
2011
2%
9%
8%
59%
22%
2013
2%
14%
7%
53%
25%
29
APathological
'Why do we
need to waste
our time on
patient safety
issues?'
2014
B - Reactive
'We take
patient safety
seriously and
do something
when we have
an incident.'
1%
CBureaucratic
'We have
systems in
place to
manage
patient safety.'
D - Proactive
'We are always
on the
alert/thinking
about patient
safety issues
that might
emerge.'
E - Generative
'Managing
patient safety
is an integral
part of
everything we
do.'
13%
10%
57%
18%
2. Priority given to patient safety
2011
1%
17%
30%
24%
29%
2013
1%
12%
17%
34%
36%
2014
0%
15%
20%
28%
36%
3. Perceptions of the causes of patient safety incidents and their identification
2011
4%
1%
13%
36%
46%
2013
5%
1%
15%
32%
47%
2014
4%
1%
17%
36%
42%
4. Investigating patient safety incidents
2011
0%
2%
32%
24%
42%
2013
3%
7%
20%
27%
43%
2014
1%
7%
19%
24%
49%
5. Organisational learning following PSIs
2011
0%
6%
21%
43%
30%
2013
3%
4%
26%
40%
27%
2014
2%
5%
23%
39%
31%
6. Communication about safety issues
2011
3%
6%
39%
26%
26%
2013
6%
9%
34%
25%
25%
2014
5%
7%
32%
23%
32%
7. Personnel management and safety issues
2011
4%
7%
38%
28%
23%
2013
4%
15%
23%
36%
21%
2014
9%
12%
29%
31%
20%
8. Staff education and training about safety
2011
2%
2%
19%
42%
34%
2013
4%
3%
18%
41%
34%
2014
1%
5%
21%
36%
37%
9. Team working around safety issues
2011
1%
7%
15%
43%
34%
2013
5%
5%
21%
35%
34%
2014
2%
10%
22%
32%
34%
30
We have responded to this years survey results by ensuring there is an action plan
in place to ensure that ‘patient safety’ continues to be embedded and at the fore
across all Trust service delivery lines.
Patient Safety Improvement Plan
Information from the Patient Safety metrics will continue to be used to raise the
quality of interventions with the Service Users; this will be shared alongside monthly
incident data reports per area with the local team meetings and the Patient Safety
Champions based within the Wards so that local ownership exists of the information
outputs and responses required.
The new risk management system (Ulysses) will be more efficient in its outputs
particularly in relation to Patient Safety Incidents – this information will enable teams
to respond to information trends within their own areas of responsibility.
Incident Managers in closing Ulysses incidents will require a greater analysis of
report content which will then be scrutinised as part of output reports for learning that
has taken place. Incident requiring RCA investigation will continue to be completed
using experienced investigators with less experienced investigators.
Support will be delivered for the Organisational learning sessions being organised
and also in the delivery of lessons learned to the NHS England Quality and Safety
Network meetings.
Patient Safety Walkabouts will continue with Directors of the Trust feeding back into
the Board Meeting and Clinical Management Teams.
Patient Safety will be delivered as a key message for all new employees as they
start at the Trust via the induction programme content per topic area. Improvements
to Team and Partnership working is the desire for the next MaPSAF survey in 2015.
Escalation and Assurance
In 2013-2014, the Trust commissioned an independent review of quality governance.
This review highlighted concerns regarding how the Trust’s quality systems and
organisational learning were monitored. Calderstones Partnership NHS FT Trust
has developed a range of policies, systems and processes, which together comprise
an integrated assurance and escalation framework.
The Trust uses Monitor’s definition of quality governance as being the combination of
structures and processes at and below board level to lead on trust-wide quality
performance.
We have introduced a number of systems and processes that support delivery of
high quality care and ensure good governance. These processes enable those
31
responsible for delivering, monitoring and receiving care to provide assurance to the
Trust Board and also identify and raise concerns.
Staff Involvement
We have a number of policies and systems, which encourage staff at all levels to be
involved in monitoring quality and performance and to raise concerns about any
issues. To improve this process we have introduced further engagement initiatives,
all hosted by the Chief Executive, both routinely and in response to changing
circumstances:
•
•
‘The Big Breakfast’ is a monthly engagement event, which invites all staff with a
birthday in the month to meet with the Chief Executive.
‘The Big Conversation’ was our initial consultation event followed by the ‘The Big
Picture’ as the Trust strategic direction continues to develop.
Service User and Carer Involvement
The Trust positively engages with service users, carers and the public and welcomes
their involvement and feedback on how they can become more involved in decision
making processes. There are a number of established mechanisms.
•
•
•
•
•
PALS (Patient Advice and Liaison Service)
Complaints
Experience surveys
Involvement Forums
HealthWatch
Over the past year, we have developed our structures to engage with carers both via
a regular six-weekly support group with a growing membership, and holding two halfday events at the weekend hosted by the Chief Executive. The feedback has been
very positive and there is a commitment from the Trust to continue with these events.
Reportable Issues Log
A weekly Trust wide Reportable Issues Log has been introduced. The log provides
comprehensive information for Board members on new significant issues that have
occurred each week. The log also tracks progress on action against previously
reported issues. The Quality and Risk Committee monitor the log. Reportable Issues
relate to information, which has identified potential issues with quality, safety or
organisation reputation.
32
Committee Structure
To support the Trust Board in carrying out its duties effectively, the subcommittees
reporting to the Board were reviewed. The remit and terms of reference of these
subcommittees were reviewed to ensure robust governance and assurance
arrangements are now in place. Each subcommittee receives a set of regular
assurance reports from other committees and group, as outlined within their terms of
reference and provides summary reports to Trust Board after each meeting.
Risk Monitoring Escalation and Assurance Framework
The Trust introduced a new risk management system, replacing PRISM with
Ulysses, which enabled us to develop to improve our systems for escalating risk and
refining the ‘Significant Risk Register’.
Further work continues into 2015-2016 with the development of ‘Balanced
Scorecards’ and a defined set of key performance indicators as ‘Early Warning
System Scorecards’.
Organisational Learning
Calderstones Partnership NHS FT aspires to continually expand our capacity to
improve through shared learning. The primary objective for our service delivery is
getting it right the first time, however, if this is not achieved than we need feedback
and evaluation to learn and implement changes to practice. When things go wrong
in services it is important that all staff have the opportunity to hear what happened
and what has been done to address the issues.
We have systems in place to get feedback about the services we provide, and use
this feedback to improve. We review all adverse events as an opportunity to learn,
and as a prospect for improvement, and ensure these are communicated to staff. In
2014-2015 we introduced a mechanism in which staff listened first hand to feedback
about organisational learning from serious incidents, safeguarding, and serious
complaints. This reinforced the principle of that all staff are part of the organisational
learning process.
We have organised themed two events during the year, aligned to key strategic
goals:
‘The Carer Experience’
This was a half-day event, which involved a session co presented by a carer and
ward manager both sharing their distinct perspective of the same adverse event.
This session involved both presenters telling their personal story including the
personal impact mistakes have both on service users and carers, but also staff
33
members. Whilst, it was a challenging session to deliver the evaluations from both
internal and external stakeholders were extremely positive.
‘Positive and Safe – Service User Perspective’
This half-day event aligns to the Positive and Safe Programme and links to the
feeding back the survey results from regarding the use of restrictive practices, and
also the opportunity for one of our service users and staff to recount their unique
experiences of restrictive practices whilst at living at Calderstones.
The Service User’s Perspective on the Impact and Outcomes from Crisis
Management
The aim of the initiative was to obtain the service user’s perspective on the impact
and outcomes from crisis management using high risk practices, which include
physical intervention, seclusion and rapid tranquillisation; using this information to
inform and improve the service user’s outcomes and experience. We hope to
measure those critical aspects of service delivery that provide insight from the
service users’ perspective around the use of restrictive practices, and maximise the
service user opportunity to articulate the impact, effectiveness and experience of
restrictive practices.
There has been extensive consultation with service users about their experiences of
the use of restrictive practices. It was evident from the feedback that a number of
care and management interventions, which are high risk and intensive, do not
always deliver a good outcome for the service user. In addition, the Trust’s CQC
inspection in 2014 highlighted concerns regarding the amount of restraint used with
service users. The importance of soliciting and responding to feedback from people
experiencing restrictive practices is highlighted through the ‘Positive and Safe
Programme’ and is an essential element of the 2015-2016 work plan.
Work has taken place to address these issues through awareness raising and
procedural guidance, to ensure privacy and dignity is given an equal priority to
clinical risk. The implementation of these interventions are described primarily
though Positive Behaviour Support Plans (PBSP) both in proactive and reactive
terms, which in best practice are co-created with the service user and describe a
good outcome for the service user as a result of the care and support interventions.
This is the second year of data collection. In 2013-2014 data collection was monthly
and as near as possible to the time of an incident. For 2014-2015 due to the
increased volume of consultation exercises during the year the interview schedule
was changed to four data collection exercises in May, August, October and January.
Consequently, the numbers of people interviewed are significantly different, 170 in
2013-2014 and 86 in 2014-2015. The service users were interviewed post crisis by
34
an interviewer independent of the ward usually within 14 days of the incident.
Service users were only interviewed once every 3 months regardless of the number
of incidents involving restrictive practices. This was to avoid survey fatigue amongst
the service users.
On occasions, service users may have had multiple incidents before the interview
was actually completed. However, the focus of the questions is not situation specific
and is about their level of support in general post incident. There are no discussions
in relation to the events leading up to, during or after the incident.
The questions are based upon themes aligned to a Human Rights Based Approach
to Healthcare:
•
•
•
•
•
•
Involvement
Safety
Dignity
Support
Communication
Relationships
Analysis of results is based upon three distinct categories:
•
•
•
All service users
Service users fully aware of the ‘positive behaviour support plan’
Service users unaware of their ‘positive behaviour support plan’
Involvement
Compared to last years results (44%) there has been a minor improvement (50% in
2014-2015) in the level of involvement of service users reporting that they are fully
aware of their ‘positive behaviour support plan’. However there has been no change
in relation to the percentage of service users reporting co-creation of their plan
(63%). This features significantly within the ‘Positive and Safe Programme’ for 20152016, with emphasis upon co-creation both with service users and families and
carers wherever possible.
Safety
We ask service users about their perception of personal safety during the use of
restrictive practices (see figure 6). For 2014-2015, there has been a reduction in the
top response ‘all of the time’ for ‘feeling safe’. With the Positive and Safe
Programme highlighting both the physical and psychological risks from restrictive
practices service users may understandably be expressing greater concern. When
reviewing those service users who report not being aware of their ‘positive behaviour
support plan’. This adds greater emphasis upon the need for co-creation of ‘positive
35
behaviour support plans’ so that if restrictive practices are used the service user is
familiar with the techniques.
Figure 6
Dignity
One of the key objectives of this survey is to evaluate whether we are achieving our
aim of ensuring that privacy and dignity are given equal consideration to risk
management issues.
The feedback regarding the sense of ‘being watched’ during restraint has risen this
year (figure 7) and is not what we would have hoped for as a Trust. This question is
regarding the service user’s perceptions as it may be hard to discriminate if people
are actually watching. However, it is important that service users have a sense of
privacy when they are experiencing the use of restrictive practices. When we review
figure 8 we get a sense of the negative impact this has on service users, and when
we review by groups of perceived watchers then it is other service users watching
that appears to cause the most distress. This information is critical as part of the
Prevention and Management of Aggression Training as the need to offer
reassurance around privacy and dignity issues is critical. This principle also extends
to the need to make sure people are covered up and their clothing adjusted.
36
Figure 7
Figure 8
Support
There is a marked difference between perceived levels of support during restrictive
practices and afterwards with very little variation between the different reporting
groups (see figure 9). It is likely that this correlates with the privacy and dignity
issues and the focus upon reassurance during any restrictive practices.
The feedback for support afterwards is very positive and it is good evidence that the
staff quickly begin to re-engage with the service user and build therapeutic
relationship.
37
There is also a marked difference in how much mutual peer support there is for
service users. Peer support is beneficial and service users have an important role to
play in their own and in their peers' recovery. This feedback requires us to look
towards collaborative working partnerships with service users, and reviewing the
Positive and Safe Programme exploring the potential for peer support as part of the
debrief process.
Figure 9
Communication
Again we see a marked difference in the feedback(see figure 10) during the
restrictive practice and afterwards. Service users are reporting lower levels of
satisfaction with the communication than we would anticipate during the restrictive
practice, but generally report that communication afterwards is very helpful.
As in the ‘support’ section, this needs to be a key feature of training, particularly
around the level of engagement with service users whilst they are in crisis and
distress. This will be a key factor in the Trusts revised training for Prevention and
Management of Violence and Aggression, as part of the Positive and Safe
Programme.
38
Figure 10
Relationships
These results are quite unusual (see figure 11). Both questions use a four point
likert scale and the results are for the ‘very good’ response. There is a widely held
belief that restraint and restrictive practices can damage the staff and service user
therapeutic relationship, whereas these results suggest something very different.
This is a good indication that staff recognise the negative of experience of service
user after restrictive practices and endeavour to rebuild relationships. This
correlates with the communication findings.
Figure 11
39
Overall, the results from 2014-2015 have not demonstrated the improvements we
had anticipated. However, there has been significant investment in the Positive and
Safe Programme and as service users become more engaged with the debate
around restrictive practices they can actually become more discerning in their
judgements of their experiences. For 2015-2016 the service user experience will
inform the underpinning knowledge delivery of the Prevention and Management of
Aggression training.
Customer Care
During the financial year 2014-2015 the Trust’s Membership and Involvement Office
has been restructured so that the Patient and Public Involvement element of the
work has now been incorporated into the Trust Governance Department. This move
has enabled the development of a Customer Care Service which incorporates Trust
Patient Advice and Liaison (PALS) with the aim of improving customer focused
approach to responding to concerns in a timely and effective manner.
The steps taken to improve the effectiveness of how concerns and requests for help
information and advice are received and dealt with, have been implemented in an
incremental way to ensure that this new service is embedded in each aspect of
service delivery.
The elements introduced as part of this phrased implementation are as follows:
•
•
•
•
•
•
•
The development of a Trust Customer Care Strategy and Customer Care Action
Plan
Establishing a bespoke Customer Care Service confidential telephone line;
voicemail and email account
Re-launching the Patient and Advice and Liaison Service supported by posters
and leaflets which include the new telephone numbers and email address of
Customer Care Services
The introduction of a 24 hour voicemail and email contact which goes to a
Customer Care Service confidential inbox which is can be picked up by the
Customer Care Service Manager, Complaints Lead or Head of Governance so
that contacts can be responded to within 2 working days
Inclusion of PALs Information into the newly designed Trust Website
Revision of the PALS Procedure 17.6 and Involvement Group Procedure 17.5
Delivery of Customer Care Training as part of the Trust Induction Programme
and further Customer Care training is provided to Trust staff on an ongoing basis
as a one day training course delivered by the Trust Learning and Development
Department.
Family and Carer Involvement has been improved through the development of the
Trust Carer Strategy and supporting action plan. This has been developed in
40
partnership with the Trust Social Worker/Carer Lead. The strategy includes the
setting up of a Family and Carer Group and the group has been in operation since
January 2014. The group meets on a six weekly basis and the numbers of families
that attend is growing steadily. The group have guest speakers to provide
opportunities families to find out about the services that the Trust provides. The Trust
has also signed up to the Triangle of Care which is an accredited family and carer
framework/assessment scheme designed by Family and Carer Organisations. As an
integral part of this framework an annual survey has been completed by families and
a self-assessment audit have been completed during the year. The Triangle of Care
have been a platform on which to improve our partnership working with families and
carers. A Family and Carer Event took place on Saturday 29th November 2014 with
the aim of reaching more family contacts. The theme of the day was support for
Families and Carers. The results of the work completed at the event have informed
the Triangle of Care/Family and Carer Work plan. A further event was held 27th
March 2015, a large number of family members attended to hear about future
strategy and to discuss all aspects of care with directors, senior staff and experts.
Carers voiced their views and agreed to move forward with their involvement in our
services and learning disability provision. We also announced that the Carers' Trust
have awarded Calderstones their Gold Star; a powerful recognition of our
partnership with family members. We were proud to share that with carers and
recognise the work we do together.
Speak Up Groups provide opportunities in another format for service users to have
their say. The discussions topics groups from these groups inform the Governance
and Quality agenda. The discussion topics this year have been Food and Staff to
Support Me. The information collated from this work have been fed back to the
Speak Up Groups and reported through Clinical Management Team, Quality
Committee and Contract Monitoring structures.
Recording and monitoring feedback is currently captured through reports presented
at Clinical Management Team in a bi-monthly report and to the Quality and Risk
Committee annually.
The implementation of the Trust’s new Risk Management System which will be
available in April 2015 will record both the PALS and Complaints information which
will further enhance the Customer Care reporting.
The Friends and family test is not a statistical robust league table measure however
the free text will hopefully provide another valuable patient experience measure that
will inform the Trust Governance programme and service delivery.
The uptake of contacting Customer Care Services using the Customer Care Line
does remain small. It would appear at present that the preferred method of contact
for service users, staff, families, advocates and outside agencies is by contacting the
Customer Care Manager direct and in person. This might be due the fact that they
41
want to speak to someone in person rather than leave a message. Further work will
be completed during 2015-2016 to publicise the 24 hour Customer Care Line.
The re-launch of the PALS has seen an increased amount of PALS requests during
the last six months of the year (September to February 2015). There has been large
increase in families getting in touch with the service. This is probably due to the
increased opportunities for family and carer support and involvement.
The Customer Care Service Manager has presented at the organisational learning
event in October 2014 providing information about involvement initiatives and patient
experience with the emphasis on Family and Carer Involvement, and also in March
2015 looking at Restraint. The Customer Service Manager will support service users
to present their patient experience stories, which will inform this staff learning
forum.
In January 2015 the Friends and Family Test was introduced to Mental Health and
Community Services by NHS England.
The Test asks the question “Would you recommend this service to your Friends and
Family?” it also enables participants to enter free text to support the answer option
they choose.
Prior to implementation discussion has taken place with Commissioners to agree the
best way of incorporating the Friends and Family Test Question into the Trust
survey/audit programme. It has been agreed that the question should be included as
the first question in the Service User Satisfaction Survey. The benefits of which is to
ensure that all service users have the opportunity to be asked this question on a
quarterly basis and avoid the potential for survey fatigue within our small and long
stay client group.
The Friends and family test is not a statistical robust league table measure however
the free text will hopefully provide another valuable patient experience measure that
will inform the Trust Governance programme and service delivery.
The Friends and Family Test (FFT) requires all patients to be asked:
“How likely are you to recommend our Trust to friends and family if they needed
similar care or treatment?”
The answers given are used to give a score which is the percentage of patients who
responded that they would recommend our service to their friends and family. The
Trust had a score of 74% recommended for the Friends and Family Test
42
Multi-Focused Training Package for Individualised Support Packages
Individual packages of care (IPCs) are bespoke services for individuals whose
behaviour presents significant challenges to services. Such packages of care are
person centred; involve extensive specialist multi-disciplinary support and high
staffing levels; and are facilitated within single person living environments with
specific consideration of the broad range of resources required to meet the
individual’s needs.
It is recognised that both the working conditions and the training requirements of
staff teams supporting individuals within IPC’s and with those displaying challenging
rather than offending behaviour, mean that an additional specialist approach to
training is warranted. The development of a multi-focused training package,
facilitated by individuals from a range of professional backgrounds and with
specialist expertise was proposed. This proposal reflects the importance of training
in enhancing skills, capabilities and knowledge in order to enable staff teams to
support the development of multi-disciplinary interventions and appropriate treatment
and care.
It was recognised that training should address the key training needs of teams
supporting individuals with complex needs and challenging behaviour. A substantial
proportion of the individuals supported within this context have a diagnosis of autism,
and therefore there is a requirement for all attendees to have attended prior level 1
autism awareness training and to have completed the British Psychological Society
online autism training modules level 1 and level 2.
A two day multi-focused training package was developed with the following content:
•
•
•
•
•
•
•
Discussion regarding the differences associated with working into IPC’s
Shared framework of care Positive behavioural support
Recording of Challenging behaviour
Communication
Sensory Difficulties
Activity Planning
Working in IPC teams
The training has been facilitated by the following professionals: Clinical
psychologists, Lecture in Positive behavioural Support, Behaviour Nurse Therapists,
Speech and Language Therapists, Occupational Therapists and qualified nursing
staff. All professionals involved are experienced at working in to IPC’s. Service user
input has to date been limited to a video provided by the parents of one individual
supported within an IPC, discussing their experiences of collaborating in developing
43
and providing ongoing support to the team providing an individual package of care to
their son.
The first cycle of training was facilitated in June 2014. Since that date a further six
sessions (two days duration) have been facilitated with a total of 46 staff having
attended. Attendees have been both qualified nursing staff and support workers.
Four sessions have been cancelled due to difficulties with staffing and a lack of
attendance.
Feedback from staff attending the training has on the whole been extremely positive.
‘Fantastic training really emphasises core values which underpin new care pathway.
Positive and highly motivating.’
‘Very helpful to working life, more training of this nature (specific to IPCs) would be
good.’
44
CQUIN 2014-2015
A range of CQUIN targets were agreed for both the Forensic and High Support
Services. The end of year outcomes is shown in fig 2. (CQUIN Targets, 2014-2015).
Table 3: CQUIN for 2014-2015
CQUIN Target
Outcome
Rationale
Forensic Services
1.
Family and Friends
Achieved
2.
Improving Physical Health
Achieved
3.
Collaborative Risk Assessment
Not achieved
The 90% target of training
packages delivered was not
achieved by Q4 due to
competing work pressures
and
reduced
staffing
resources
Action has been undertaken
to address the underlying
workforce issues to reduce
working pressures which will
facilitate staff to attend
training programmes.
4.
Supporting Carers Involvement
Achieved
5.
Needs Formulation at Transition
Achieved
High Support
1.
Friends and Family
Achieved
2.
Improving Physical Health
Achieved
3.
Care Planning with Supported Achieved
Discharge
4.
Communication with GP
Achieved
5.
Developing a Safety Culture
Achieved
45
3.2 Review of Quality Performance: Quality Indicators 2014-2015
3.2.1 Department of Health Quality Indicators
The Trust will report on the following indicators as required by Monitor’s Compliance
Framework/Risk Assessment Framework:
Indicator
Rate of patient safety incidents reported within the trust during the
reporting period, and the number and percentage of such patient safety
incidents that resulted in severe harm or death.
The data made available to the trust by the Information Centre with regard
to the percentage of patients aged—
(i) 0 to 15; and
(ii) 16 or over,
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.
•
Score
National
Average
Highest
Scoring
Trust
Lowest
Scoring
Trust
0%
(0/1159)
Not
Applicable
Not
Applicable
Not
Applicable
Not
Applicable
Not
Applicable
Not
Applicable
0%
The Trust does not routinely report this information to the Health and Social Care
Information Centre because as a specialist learning disability service we are not
included in the Mental Health Minimum Dataset, therefore there is no
comparative data for either indicator. However, there are plans to introduce a
Learning Disability Minimum Dataset.
3.2.2 Development of a Quality Dashboard
The Quality Dashboard has been designed with clinical teams to help improve
performance by providing regular, timely feedback against locally predetermined
measures to assist successful intervention and improvement. They are an active
performance-monitoring tool for safety, effectiveness, clinical outcomes and service
user experience. They also provide opportunities to detect emerging quality and
safety issues and permit timely mitigating actions to be taken - improving the overall
level of high quality, person-centred care.
The Trust recognises that good quality information is a driver of performance
amongst clinical teams, and helps to ensure the right services and best possible care
is provided to service users. A key element of providing good quality information is
ensuring that clinicians delivering the service receive regular and timely feedback on
their performance
46
The Trust has continued to develop the Quality Dashboard in collaboration with the
clinicians, which provides them with the information they need to inform daily
decisions that improve quality of care for people using services.
There are three different versions of the dashboard, one for the ward teams, one for
directorate leads and one for the board. The individual dashboard functionality
means clinicians as well as managers can view their compliance and performance
against the measures for service users’ care planning, risk assessments, outcomes
and experience. With the clinical dashboard you have a visual display, which
enables clinicians and managers to look at differences between wards. Having the
same information, which goes from ‘ward to board’, is key.
The Quality Dashboard largely reflects effectiveness, safety and experience of
service users on their care pathway.
Our metrics are aimed at improving the
efficiency and effectiveness of the care pathway for people using services. For
2015-2016 we are introducing additional metrics associated with the NHS England
initiative ‘Open and Honest Care’:
•
Number of omitted medicines (all medicines)
The following information is an overview of the performance of the metrics that
inform the Trust’s Quality Dashboard. The information is structured around national
priorities and the three domains of High Quality Care for All (DH, 2008):
•
•
•
Patient Safety
Clinical Effectiveness
Patient Experience
The following key is used to explain Trust performance and trend in relation to the
metrics:
NB All the data is sourced via the Trust’s Business Intelligence System or Risk
Management System
•
The direction of the
arrow means:
•
The colour of the
arrow means:
Improving

No change

Worsening

Achieving target

Just below target

Not achieving target

47
National Priorities
Delayed transfers of care are below the national target, but have increased from
previous two years. This is possibly due to the effects of the national programme
‘Improving Lives’ reviews as part of the Winterbourne Joint Improvement Plan. All
people with learning disabilities within inpatient services have been reviewed,
therefore it is expected that more people have been identified as ready for discharge.
This impetus now for the Trust and community services is effective discharge
planning and good partnership working with receiving services.
All Annual Health Checks are undertaken in the Trust’s Primary Care Service based
within the Calderstones site, and physical healthcare of service users is seen as an
integral part of the care pathway. Advanced Nurse Practitioners continue to play a
lead role in delivering annual physical, and have implemented systems to ensure all
reporting is standardised through the EMIS system (electronic record of primary
care). Every service user is provided with an appointment and the recall system for
the service users who do not attend has improved. However, we are still not
engaging all service users in the Annual Health Check, either due to their level of
understanding or unwillingness to engage; there still needs to be further work with
this small group to find creative ways of involving them in the process and realising
the benefits.
The Advanced Practitioner addresses this through caseload
management of people with complex needs.
Data quality on ethnic groups has achieved target this year.
Table 4 National Priorities
Metric
12-13
13-14
14-15
Target
Trend
Delayed transfers of care
1.25%
0.76%
2.69%
<= 7%

Annual health check
<100%
96%
98.23%
100%

Data quality in ethnic group
<100%
<100%
100%
100%

Patient Safety
One of the key aims of the Trust is to ensure everyone plays a part in helping to
reduce harm and improve the safety of services. The vulnerable nature of many
service users means staff play a particularly active and important role in
safeguarding and improving safety. The Trust is dedicated to building a service
where every member of staff has the commitment, confidence and skills to eliminate
48
harm to service users, and by doing so builds the capacity and capability for
improving the quality and safety of services.
The Trust’s profile of metrics outlines the Trust’s priority concern for the safety and to
provide a safer environment for service users. The Trust is committed to ensuring
there is a strong safety culture. The metrics focus on the systems for assessing and
managing the highest risks to service users, at specific junctures in the care pathway
and across clinical teams.
Safe and Effective Physical Intervention
The Trust continues to try and deal with the challenges of service users and staff
becoming injured during physical intervention. There have been a number of
initiatives attempting to address the significant differential between service user and
staff injuries. There is standardised training for all staff using both the non-aversive
British Institute of Learning Disabilities approved training, and the more commonly
used care and responsibility methods with much more secure holds for people.
During 2014-2015 aligned to the Positive and Safe Programme the Trust has
introduced alternative training methods, which do not require the use of prone (facedown) restraint.
There has been an improvement from the previous year’s results; analysis of the
injuries has revealed that they are minor harm incidents usually soft tissue or
abrasions, and that the majority of injuries to staff are caused by a very few service
users. The majority of injuries are still cause by service users cared for in
personalised packages of care with enduring and complex needs that continue to
present challenges to services.
Table 5 Injuries during physical intervention
Metric
12-13
13-14
14-15
Target
Trend
Reduction of injuries sustained by service
users as a result of physical intervention
2.5%
1.5%
0.8%
<= 2%

Reduction of injuries sustained by staff as a
result of physical intervention
11%
11%
7.94%
<= 5%

Care Planning
In relation to ‘Advanced Support Plans’, it is disappointing that we have not achieved
our target. The transition work positive behaviour support plans will address this
issue, as advanced planning will be integrated into this part of the ‘Integrated
Treatment and Care Plan’. This new systems still ensures that service users are
49
supported to help develop their own plans for any aspect of crisis or period of
distress.
With regards to the ‘Suicide Risk Screening Assessment’, the results of 85%
(n17/20) are still not meeting the 100% target, however this is an improvement on
previous years. The failure to meet the target is again associated with the 24-hour
timeframe from admission. All service users are assessed within 48 hours. However,
the target remains unchanged as it is important that we seek assurance that the
wards recognise the increased risk of attempted suicide in the crucial first 24 hours
of admission to hospital and ensure the safety of service users.
Table 6 Care Planning Measures
Metric
12-13
13-14
14-15
Target
Trend
All service users who self injure (clinically
assessed as high risk) will have an
advanced support plan
99%
78%
91.75%
>= 95%

All new admissions to the Trust will have a
‘Suicide Risk Screening Assessment’
completed within 24 hours of admission
100%
67%
85%
>= 95%

Medicine Management
The purpose of the Trust’s Medicines Management Strategy is to proactively support
staff and service users in achieving safe and effective medicines management.
Medicine management for the Trust means service users getting the maximum
benefit from their medicines whilst at the same time minimising potential harm. All
healthcare practitioners have a duty to competently perform safe medicines
management.
Table 6 outlines the measures for missed medications and high risk errors based
upon the number of people affected. The Trust also revised the target to 0% for
critical medicine omissions and high-risk medication errors.
There has been increased monitoring of safe and effective medicines management,
with an emphasis on missed dose incidents.
There has been significant
improvement on the number of incidents of ‘critical medicine omissions’. The
incidents that have occurred have been ‘near-misses’ so no actual harm occurred to
the service users affected. However, the Trust recognises that there is potential for
serious harm from omitted critical medicines.
Where the main reasons for missed doses related to physical unavailability of
medicines, effective interventions to improve this situation included: increasing the
50
range of stock held in the emergency cupboard and the availability of a 24 hour taxi
service to collect urgent medicines from pharmacy.
For high-risk errors the emphasis is upon continuing professional development.
These include errors like wrong dose or wrong frequency. There is a programme in
place for both registered nurses and medical staff that focuses upon safety and
accountability in practice. Medicine safety was a key theme for Director walkabout
visits and has led to changes in practice associated with changes in the environment
and how registered nurses administer medicines.
With all errors the priority is to ensure that the service user does not come to harm
and we can report than no service users suffered harm as a result of medication
errors.
Table 7 High Risk Medication Errors
Metric
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar 15
Critical
Medicine
Omissions
High Risk
Medication
Errors
0.5%
(n1)
0%
1%
(n2)
0%
0%
0.5%
(n1)
0%
0%
0%
0.5%
(n1)
0%
0%
2.25%
(n5)
0.5%
(n1)
1%
(n2)
2%
(n4)
0%
1.5%
(n3)
2%
(n4)
1%
(n2)
1.5%
(n3)
1%
(n2)
1%
(n2)
1.5%
(n3)
Clinical Effectiveness
Clinical effectiveness is about whether or not a service users treatment, care and
support was successful and whether it has the impact that it is supposed to have, is
it achieving the best possible result or outcome for the service user?
Providing effective treatment, care and support is at the heart of our vision to make a
meaningful impact and change to our service users’ lives. We aim to make sure that
the care we provide to our service users and their families achieves the best possible
impact on their health, wellbeing and quality of life.
We continue to work with our clinical team to develop a set of clinical effectiveness
metrics because we believe they act as an incentive to improve quality. Clinical
effectiveness metrics also inform our service users and others to see how we are
doing in relation to the effectiveness of the care pathway, and enable the Trust
board, through its Quality and Risk committee, to monitor performance.
51
Safe and Effective Identification of Risk of Choking
The metrics in relation to risk of choking indications of the Trust focusing on an
evidenced based approach to mitigating against one of the highest risk of injury to
our service users.
The Trust has been at the forefront of developing a riskscreening tool for dysphagia, and has previously been nominated for a national
‘Patient Safety Award’. There has been a focused effort on ensuring that all service
users are risk assessed routinely and in response to a change in clinical
presentation. It is disappointing that for the screening upon admission, it has not
made the target. However, we are assured that all service users had a risk screen
on admission but not within the first 2 weeks.
The annual review of risk of choking has significantly improved. Ward managers
have worked with case managers to ensure that they recognise it as a priority to
maintain the safety of service users and encourage them to maintain compliance
with routine annual screening.
Table 8 Risk of Choking Assessments
Metric
12-13
13-14
14-15
Target
Trend
All new admissions to the Trust have
received a risk of choking screening
assessment by week 2 of the care pathway
92%
79%
78%
100%

All service users receive an annual risk of
choking screening assessment
99.5%
97%
99%
100%

The Care Pathway
The purpose of the Trust’s care pathways is to show a clear journey of care for
service users, which set out what they can expect from their treatment, how long it
may take and who will provide their care. Table 9 gives an overview of the metrics
that identify key processes in the care pathway, and give an indication of the
effectiveness of the Trust’s care pathways.
The clinical teams have made continued and sustained improvement over the past
three years, to ensure there is a comprehensive treatment and care plan in place by
week 12 of the care pathway. Historically, the target was 70% but given previous
year’s improvements this has been reviewed and increased to 95%. The clinical
teams have missed the target in 2014-2015 achieving 88% (22 out of 25). We are
assured that all service users have a treatment and care plan, although completion
within 12 weeks of the care pathway has not always been achieved. We will
continue to try and achieve this target to ensure that all our service users have a
52
treatment and care plan in place at the earliest opportunity to ensure that their stay is
no longer than it needs to be.
There is almost full compliance with six-monthly review of the risk assessment, the
areas of non-compliance are related to the risk assessment being fully authorised by
the consultant psychiatrist, although the multi disciplinary team had fully reviewed
the risk assessments.
In September 2014 we introduced a new metric in response to concerns raised as
part of the ‘Improving Lives’ reviews. The review team stated it was difficult to find
evidence of service users having an MDT review other than during formal ward
round. This measure has been introduced alongside the relocation of all clinical staff
(not direct care) in to clinical areas.
As previously reported we have not had any reported cases of service users
experiencing side-effects resulting in a ‘high’ score. However, we continue to
monitor that service e users are reviewed routinely every 12 weeks.
Table 9 Care Pathway Measures
Metric
12-13
13-14
14-15
Target
Trend
All service users will have a
comprehensive multi disciplinary
treatment and care plan by week 12 of the
care pathway
All service users will have a review of
their current risk profile by the MDT at
least every six months
93%
83%
88%
>= 95%

<100%
99%
99.%
>= 95%

Service users have had a review in
between their ward round review (new
September 2014)
NA
NA
51%
100%
3 monthly monitoring of side effects of
antipsychotics using Liverpool University
Neuroleptic Side Effect rating Scale
(LUNSERS)
NA
NA
35%
>= 95%
Patient Experience
Listening to service users' views is essential to provide person-centred services.
The experience metrics systematically gather the views of service users about the
care they have recently received.
53
The metrics outlined in tables 10 to 15 focus upon the experience of service users,
and endeavour to address the importance of the service user experience within the
Trust, and ensure that service users are treated with compassion, dignity and
respect within a clean, safe and well-managed environment (High Quality Care for
All, 2008). The Trust has a revised set of experience metrics aligned to the NICE
Clinical Guidelines 136 (2011) “Service User Experience in Adult Mental Health”, and
the Department of Health’s Final review of Winterbourne View (DH, 2012), the
CNO’s 6Cs, and the values and principles underpinning the preferred ‘model of
care’. Therefore it is not possible to publish comparative results for previous years
so the three data collection points for the 2013-2014 reporting period are reported to
provide an overview of consistency of performance.
Partnership and Involvement
The Trust is committed to ensuring that service users are at the centre of their own
care. Our priority is to ensure that personalisation and person-centred planning, are
embedded in all of our services. Involvement is the central tenet for ensuring that
person-centred planning is key to ensuring that every service user is being
supported and cared for appropriately. The Trust’s vision of ‘changing lives through
excellence’ is underpinned by the values that people have learning disabilities are
capable of being involved in the decisions that affect their lives, through the value of
‘partnership’ , putting service users at the heart of their own care planning leads to
better outcomes. Whilst this year there has been a drop in the results they remain
consistently high performing with all the measures for partnership and involvement
with particular reference to the support that our service users receive from their case
managers ensure they are fully engaged in the CPA process.
Table 10 Partnership and Involvement Metrics
Partnership and Involvement Metrics
Target
13-14
14-15
Trend
I am involved in my treatment and care
80%
90%
86%

I am listened to when talking about my treatment and care
80%
86%
83%

I am confident that my treatment and care at Calderstones will
help me move on
I know what I need to do to move on from Calderstones
80%
89%
86%

80%
87%
90%

I understand my treatment and care plan
80%
87%
85%

I am supported by my case manager with ward rounds
80%
90%
85%

I am supported by my case manager with my CPA/117
meeting
80%
93%
92%

54
Trust and Support
A service users’ ‘trust’ in their care teams is recognised as vital as it underpins a
positive therapeutic relationship. We understand the concept of ‘trust’ to mean ‘we
keep our promises’ to our service users. The notion of ‘trust’ is not only relevant to
individual clinicians but is also relevant to how our service users feel towards
Calderstones as an organisation.
We endeavour to build ‘trust’ through good
support throughout their care pathway. Service users are much more likely to
establish ‘trust’ if they receive good support and have a voice in the planning and
delivery of their care.
These metrics are a means of assessing service user satisfaction with the level of
support they receive. All of the measures are meeting the 80% threshold, and in the
case of supporting contact with significant others the feedback is excellent. This is
important when considering future planning for service users and supporting the
relationship between service users, family/friends and the care team.
Table 11 Trust and Support Metrics
Trust and Support Metrics
Target
13-14
14-15
Trend
I can get the help that I need when I'm having problems
80%
85%
86%

I am supported to maintain contact with the people who are
important to me
I am supported to make choices in my daily life
80%
94%
93%

80%
88%
89%

I know the staff are supporting me
80%
89%
87%

I trust the staff who are supporting me
80%
85%
81%

I feel safe
80%
82%
81%

Communication and Support
Communication is vital in ensuring that people with learning disabilities can express
themselves and make sense of what is happening within their treatment and care
pathway. With the right support, people with a learning disability can achieve their full
potential, as long as support is communicated in an understanding way.
Communication as a Trust value means ‘we are open and honest in our
communication’. The metrics in table xx outlined in our experience metrics are a
way of enabling us to evaluate how well we communicate with service users.
55
There is variation in feedback from service users to this set of measures, which is
good indication that they are making considered responses. Although the service
users appear to have confidence in talking to the staff, again this year there is
disparity in the responses to questions related to ‘time with staff’ and ‘perceived
understanding’.
The Trust has a current standard that all service users will have the opportunity of
one-to-one time with a member of staff daily, a weekly meeting with their case
manager and monthly with their consultant psychiatrist to discuss their care pathway.
There has been an increased emphasis up on multidisciplinary team members
having more time in the clinical area. This is to ensure that service users have
access to this group of people not just within appointment time. It was hoped that tis
would improve feedback from service users.
In this financial year, there has continued to be high bank and agency staff use
compounded by vacancies and sickness absence. There is an exercise underway to
review and rationalise staff resources across Forensic and High Support Services.
Table 12 Communication and Support Metrics
Communication and Support Metrics
Target
13-14
14-15
Trend
I can talk to the staff who are supporting me
80%
87%
84%

I get one to one time every day with a member of staff that I
know
I get enough information to help me make important decisions
80%
74%
74%

80%
81%
82%

Staff understand me and my problems
80%
79%
78%

My legal rights are explained to me in a way that I understand
80%
91%
91%

Ownership and Empowerment
People with learning disabilities when viewed as service users are not seen as equal
partners in designing and implanting solutions to a wide range of issues and
problems. These metrics are designed to get feedback from our service users on
how empowered they feel about taking control and making decisions about personal
care and service delivery at Calderstones.
The feedback relation to their personal treatment and care is very positive, and
correlates with previous measures about involvement with treatment and care, which
scored 86%.
56
However, in relation to wider Calderstones issues the feedback is not as positive as
we would have hoped given the increase in Customer Care Services and the
coordination of consultation and involvement. This will be considered as part of the
‘Speak Up’ groups core topics to try and get a better understanding of what would
change service users expect to see.
Table 13 Ownership and Empowerment Metrics
Ownership and Empowerment Metrics
Target
13-14
14-15
Trend
I have the chance to make decisions with my team that are
right for me
80%
85%
85%

I think what I say matters to make Calderstones better
80%
76%
77%

Compassion and Respect
For the Trust values ‘compassion’ and ‘respect’ we endeavour to show empathy and
sympathy to the needs of others, as well as engage, listen to and value the
contribution of others. As a Trust, we believe that 'kindness' is central core value to
ensure service users recovery.
It is reassuring that our service users have given such positive feedback regarding
the level of kindness they receive from staff, however, whilst the score for politeness
is above the target there is a 5% reduction from previous years. Interestingly there
is a renewed emphasis upon customer care within the Trust with training being
available to all staff. This feedback will be reviewed in detail with increased
granularity to see if there are any target areas for improvement.
Table 14 Compassion and Respect Metrics
Compassion and Respect Metrics
Target
13-14
Mid
14-15
Trend
Staff are kind to me
80%
88%
87%

Staff are polite to me
80%
88%
83%

57
Excellence and the Meaningful Day
NICE Quality Standard 14 Service User Experience in Adult Mental Health states
people in hospital for mental health care will access meaningful and culturally
appropriate activities seven days a week and not restricted to 9am to 5pm. This
should be tested through experience surveys and feedback that service users in
hospital.
These metrics have been developed to test our compliance with the NICE standard,
and how well we align to our Trust value of ‘excellence’. We have been able to meet
the targets in relation to meaningful activities across seven days a week. This metric
is based upon service user feedback. Occupation and leisure services have been
redesigned around the Integrated Therapy Model. The aim is to ensure that service
users will have improved access to therapeutic, occupation and leisure services,
which are aligned to their personal goals and treatment outcomes.
This is of high importance to services and service users, and there is ongoing
consultation with service users to ensure responsiveness to service users’ issues.
Table 15 Excellence and Meaningful Day Metrics
Excellence and Meaningful Day Metrics
Target
13-14
Mid
14-15
Trend
I have a shared activity planner
80%
94%
92%

My shared activity planner has activities I like to do on it
80%
84%
89%

If I don't like my activities I can change them with my OT or
case manager
80%
82%
86%

I get 25 hours of activity every week e.g. trips out,
social/leisure time, domestic skills, meetings and
individual/group therapy
80%
79%
82%

There is a timetable of evening and weekend activity in my
ward/house
80%
68%
81%

I am satisfied with how I spend my time in the evenings
80%
81%
82%

I am satisfied with how I spend my time at the weekends
80%
80%
80%

58
Appendix A: Statements from Local Involvement Networks, Service Users
Forum, Overview and Scrutiny Committee, Primary Care Trust and Specialist
Commissioning
Healthwatch Lancashire’s Response to Calderstones Partnership NHS
Foundation Trust’s Quality Account 2014/15
Thank you for giving Healthwatch Lancashire the opportunity to feedback on
Calderstones Partnership NHS Foundation Trust 2014/15 Quality Account. The
report contextualises services provided at a challenging time for the NHS and
indicates the Trust's commitment to improve the quality of medium secure, low
secure and specialist NHS services which it delivers to adult men and women with
learning disabilities or other developmental disorders, mental health problems or
extremes of serious offending behaviour.
It's pleasing to see the Trust is making good progress with its clinical quality strategy
and its commitment to engagement, not only with service users but also with their
families /carers and staff too. Achievements with 'The Avenue' and 'The Media Crew'
are to be particularly commended.
Projects to improve the Trust's accommodation and facilities is encouraging to see
as the Trust provides a home for its service users, sometimes for a number of years.
In this respect its also good to see the Trust focusing on improving standards of
cleanliness.
The Trust is also to be commended for reviewing the workforce's capacity and
capability to deliver safe and effective care and in reducing restrictive practices. The
positive outcome from the annual staff survey in respect of effective engagement
and initiatives such as the Staff Charter, the Chief Executive's Big Conversation, Big
Breakfast Meetings and Director Walkabouts are an indication of an engaged
workforce which is critical to achieve the Trust's quality priorities. Such outcomes
also evidence the Trust's focus, commitment and aspirations as a good employer,
which again is pleasing to note. However high bank and agency use, compounded
by vacancies and sickness absence indicates the Trust has had a very challenging
year.
The Trust's quality improvement priorities selected for 2015-16 will help to underpin
and progress the Trust's clinical quality strategy and are therefore are to be
applauded, as is the Trust's commitment to clinical research and audit programmes.
Review of the Trust's 2014-15 priorities for improvement shows a number of areas
where progress has been made eg Physical Health Monitoring. However, areas
which the Trust recognises where further improvement is required are also noted eg
Use of restrictive practices and care planning, but it is reassuring to note that work
has taken place to improve these particular programmes including the
aforementioned review of the workforce's capacity and capability to deliver safe and
effective care.
59
Overall, the Quality Account provides the reader with an honest and comprehensive
account of the Trust's commitment to improving the quality of healthcare service
delivery for a particularly vulnerable group of adults at a very challenging time for
health and social care.
Service Users Forum Response to Calderstones Partnership NHS Foundation
Trust’s Quality Account 2014/15
Thank you for coming to talk to us about the Trust’s Quality Accounts at our meeting
on Monday 5th January. We thought that you did really well explaining the accounts
to us as there was a lot of information to tell us.
We were very interested to hear about the work that is being done to keep everyone
as safe as possible, have good treatment and care and that there have been lots of
ways that service users and their families have been able to be involved.. We were
also pleased that the Trust wants to know about our experience of the care we have
at Calderstones.
We went through the Quality Accounts again at our meeting on Monday 11th May
and were very pleased to see all the work that had been done.
If you need any help this year with the Quality Accounts the members of the
Calderstones Involvement Group would be happy to involve.
Lancashire Overview and Scrutiny Committee Response to Calderstones
Partnership NHS Foundation Trust’s Quality Account 2014 - 2015
The role of the Lancashire Health Scrutiny Committee is to review and scrutinise any
matter relating to the planning, provision and operation of the health service in the
area and make reports and recommendations to NHS bodies as appropriate.
The Committee undertake this responsibility through engagement and discussions
with the Trust, addressing any areas of concern as they arise. It is the intention of
the Committee that this methodology of ensuring that the Trust improve patient
safety and deliver the highest quality care to the residents of Lancashire will continue
by having an oversight of how the Trust evidence the provision of quality and safe
services. In addition the Health Scrutiny Committee will seek reassurance that every
effort is being made to ensure financial stability and the safeguarding of the most
vulnerable.
60
Specialised Commissioning, Cheshire West and Wirral Local Area Team, NHS
England have reviewed the Trusts Quality Account 2014-2015, and appreciate
the opportunity to comment on this document.
It must be noted there is room for significant improvement as highlighted by the CQC
and Specialised Commissioning’s quality review process. This is primarily around
staffing levels, use of bank and agency staff, sick leave, supervision and appraisals,
and environmental issues including cleanliness of wards some of which are no
longer up to national secure standards. However the Trust continues to work with
commissioners to strive to improve quality, patient pathways and the overall patient
experience and consistently demonstrate extensive patient involvement. Relevant
action and improvement plans are in place which are regularly monitored and
reviewed, and the Trust actively participate in local and regional meetings to
positively impact on organisational change.
East Lancashire Clinical Commissioning Group Response to Calderstones
Partnership NHS Foundation Trust’s Quality Account 2013/14
East Lancashire Clinical Commissioning Group (EL CCG) welcomes the opportunity
to comment on the 2014/15 Quality Account for Calderstones Partnership NHS
Foundation Trust (CPFT).
The CCG acknowledges that CPFT has been through a challenging year prior to and
following the Care Quality Commission (CQC) inspection during July 2014.
Considerable work has been undertaken both within CPFT and across the health
and care economy to address the concerns raised to ensure a safe, effective and
patient focused service.
The CQC inspection highlighted a number of areas where improvements ‘must and
should’ be made and the CCG have been committed to working with CPFT and other
relevant stakeholders to ensure all fundamental standards of quality and safety are
delivered so that the Trust can become highly regarded and trusted by the people of
East Lancashire and beyond.
In light of this the CCG believes that the draft Quality Account does not fully
demonstrate the context of the current position and challenges faced by CPFT
during 2014/15 as a result of this and the ongoing challenges through 2015/16. The
Quality Account lacks detail of the resulting Quality & Risk Summits and engagement
with the National Team and the ongoing Quality Improvement Board process.
61
Priorities 2015/16
EL CCG support the priorities put forward for 2015/16 and have worked with the
Trust to agree Quality and CQUIN measures for the coming year which will
compliment these priorities, including the development of the Care and Treatment
Reviews (CTR) task and finish group CQUIN.
It is positive to see the development of key actions highlighted in the CQC review,
such as Credits for Cleaning (C4C), in the CPFT priorities for 2015/16.
The CCG will continue to work closely with the Trust throughout 2015/16 on the
Quality agenda, including meeting regularly with the Trust and engaging in a series
of announced and unannounced safe, personal and effective care walk-rounds.
Quality Indicators and CQUIN 14/15
To date there are a number of outstanding issues, including data time lags, on
requirements of the National and Local quality indicators included in the CPFT
contract. EL CCG continues to work with CPFT to work through these issues. Four
out of the six Commissioning for Quality and Innovation (CQUIN) schemes have
been achieved, while further information is due to be submitted for the remaining
two. EL CCG notes that CPFT has seen an improvement in harm free care from
previous years.
Priorities 2014/15
Progress has been made against some of the priorities set out in last year’s account
although clear evidence is not consistently demonstrated to show achievement in all
priority areas. EL CCG will continue to support CPFT in their commitment to
ensuring outstanding actions are addressed.
EL CCG commends CPFT on the Director Visits which have been implemented
during 2014/15 and would like to highlight the visibility of senior staff and the
familiarity between those staff and service users which is clearly evident during CCG
visits to the Trust.
Although work around restraint is still ongoing, the CCG is particularly pleased to see
the improvements made regarding the amount of restraint used and the importance
of feedback from service users experiencing restrictive practice to ensure privacy
and dignity is maintained in these instances. Concerns around the amount of
restraint used at the Trust were also highlighted during the CQC inspection in 2014
62
and CPFT presented at the EL CCG Quality and Safety Committee to provide
assurance to commissioners around some of these concerns.
EL CCG notes a number of clinical audits have taken place during 2014/15 with
changes being implemented to improve outcomes. There is some concern around a
number of projects previously audited which have seen little or no improvement
despite having action plans implemented previously. EL CCG looks forward to
working with CPFT to ensure robust action plans are now in place to address these
concerns.
Annual physical health checks for all inpatients has seen significant improvement in
both engagement and completion of checks and has narrowly missed out on
achieving the desired target of 100% with an average compliance score of 98.66%.
The CCG is pleased to see a dedicated Advanced Nurse Practitioner using the
complex case management model, making good progress in supporting service
users who usually find the health checks too distressing.
CPFT have ensured all service users prescribed antipsychotic medication receive
comprehensive physical health checks and a set of standards have been developed
to guide the reporting process.
A number of initiatives have been implemented to collect and share feedback from
service users and staff around serious incidents, safeguarding and complaints. One
specific programme of work is the use of the Manchester Patient Safety Framework
(MaPSAF) which was also part of the 14/15 CQUIN scheme.
This tool is used to collect staff feedback on patient safety incidents and CPFT will
ensure that action plans are in place to embed patient safety across all Trust service
delivery lines.
The Information Governance Toolkit attainment was 71% based upon the score of
level 2 for 41 applicable items, and level 3 for 3 applicable items. This was graded as
satisfactory and is an improvement on the 2013/14 position of 68%.
EL CCG look forward to working with CPFT over the next year to ensure
that services commissioned are of a high quality standard and provide safe,
personal and effective care.
63
Annex 2: Statement of directors’ responsibilities for the quality
report
The directors are required under the Health Act 2009 and the National
Health Service (Quality Accounts) Regulations to prepare Quality
Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form
and content of annual quality reports (which incorporate the above legal
requirements) and on the arrangements that NHS foundation trust
boards should put in place to support the data quality for the preparation
of the quality report.
In preparing the Quality Report, directors are required to take steps to
satisfy themselves that:
• the content of the Quality Report meets the requirements set out in
the NHS Foundation Trust Annual Reporting Manual 2014/15 and
supporting guidance
• the content of the Quality Report is not inconsistent with internal and
external sources of information including:
o board minutes and papers for the period April 2014 to 28 May
2015
o papers relating to Quality reported to the board over the period
April 2014 to 28 May 2015
o feedback from commissioners dated 13/05/2015
o feedback from governors dated 12/02/2015 & 16/04/2015
o feedback from local Healthwatch organisations dated
01/05/2015
o feedback from Overview and Scrutiny Committee dated
29/04/2015
o the trust’s complaints report published under regulation 18 of
the Local Authority Social Services and NHS Complaints
Regulations 2009, dated 28/05/2015
o the 2014 national staff survey 24/02/2015
64
o the Head of Internal Audit’s annual opinion over the trust’s
control environment dated 29/04/2015
• the Quality Report presents a balanced picture of the NHS foundation
trust’s performance over the period covered
• the performance information reported in the Quality Report is reliable
and accurate
• there are proper internal controls over the collection and reporting of
the measures of performance included in the Quality Report, and
these controls are subject to review to confirm that they are working
effectively in practice
• the data underpinning the measures of performance reported in the
Quality Report is robust and reliable, conforms to specified data
quality standards and prescribed definitions, is subject to appropriate
scrutiny and review and
• the Quality Report has been prepared in accordance with Monitor’s
annual reporting guidance (which incorporates the Quality Accounts
regulations)
(published at www.monitor.gov.uk/annualreportingmanual) as well as
the standards to support data quality for the preparation of the Quality
Report (available at www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have
complied with the above requirements in preparing the Quality Report.
By order of the board
.28 May 2015 ......Date..
..Chairman
.28 May 2015 ...... Date...
Chief Executive
65
Appendix C Clinical Audit Projects 2014-2015
1.
Project Title
Synopsis of Findings and Actions
National Learning
Disability Census
The Department of Health published Transforming Care: A national
response to Winterbourne View Hospital and the Concordat: Programme of
Action in December 2012. The review of services received indicated that
failings were widespread within the operating organisation but importantly
also evident across the wiser care system. The concordat and sixty three
actions detailed within the review seek to address poor and inappropriate
care and achieve the best outcomes for people with a learning disability, or
autism, who may also have mental health needs or behaviour that
challenges.
The Learning Disability Census will be the mechanism employed by the
Department of Health, Care Quality Commission, Public Health England
and Health and Social Care Information Centre to deliver action (17), which
says that, “The Department of Health will commission an audit of current
services for people with challenging behaviour to take a snapshot of
provision, numbers of out of area placements and lengths of stay.”
All requested data was collected and submitted.
2.
3.
4.
Compliance with
National
Standards for
Annual Health
Check
The use of
Physical Restraint
Completed as part of the Physical Healthcare Schizophrenia Audit. See
project number 13.
Positive
Behavioural
Support Plans
This was a new audit within secure services. 13 service users were
included in the audit as they each received high numbers of interventions,
to see if the Positive Behaviour Support Plans were compliant with the
Positive and Proactive Care standards.
This is completed via a monthly restraint report which is presented to the
Operational Governance Committee. It is instrumental in the Trusts overall
Restraint Reduction Strategy and supports delivery of the Positive and
Safe Programme.
The audit found all service users had a Positive Behaviour Support Plan
but identified the following concerns:
• Most service users did not have a functional analysis.
• Most service users did not have a post crisis support plan
• All service users had elements missing within their primary,
secondary and tertiary strategies.
• In the event of an incident 50% did not detail evidence that the
positive behaviour support plan was followed.
• On looking at the treatment & care plans these were far more
detailed than the positive behaviour support plans.
The positive behaviour support plans are currently being replaced with an
integrated Treatment & Care Plan.
66
Project Title
Synopsis of Findings and Actions
A re-audit on these new integrated treatment and care plans is scheduled
for 2015/2016.
5.
NHS
Benchmarking:
Learning
Disability Provider
Benchmarking
Calderstones Partnership NHS FT was one of 33 provider organisations
who submitted data to this pilot project for learning disabilities.
Four key domains were used in this benchmarking work; activity,
workforce, finance and quality measures.
A project report was written by the NHS Benchmark Network in December
2014 on the results.
The next cycle of benchmarking will take place in 2016.
6.
NHS
Benchmarking:
Restraint
This data was requested on behalf of Norman Lamb, Minister of State for
Care and Support. The first phase of data collection was in August 2014
and the second phase of data collection was January 2015. All required
data was collected and submitted.
7.
NHS
Benchmarking:
Out of Area
Treatments
In November 2014 the NHS Benchmark Network asked organisations to
answer the following questions relating to patients who were occupying
their beds on the census date of 30/09/2014:
• Number of beds (by bed type) across MH, CAMHS and LD
• Number of beds occupied by people from the local area
• Number of beds occupied by people from outside the local CCG
area i.e. Out of Area
Of these ‘Out of Area’ beds:
• Number occupied by people still within their host Trust area
• Number occupied by people from a different area than their host
Trust.
All required data was collected and submitted.
8.
Critical Medicines
This was a re-audit within secure services reviewing whether the use of
critical medicines is compliant with Patient Safety Alert NPSA RRR009.
This includes identifying a list of critical medicines and identifying any
medication errors involving a critical medicine.
Comparing with last year’s audit there has been an increase in the number
of reported incidents involving critical medicines. This could be due to the
critical medicines list having been updated and improved quality of
documentation.
Critical medicines is now included as a metric each month on the Quality
Dashboard and is reported on quarterly in the Medicine Error Report.
9.
Medical
Appraisals
There were two audits completed involving Medical Appraisals. An
‘Exception’ Audit for all missed/ incomplete appraisals and an Audit of the
67
Project Title
Synopsis of Findings and Actions
Medical Appraisal Systems.
The ‘Exception’ Audit for all missed/ incomplete appraisals is a
mandatory audit. Audit standards are contained within ‘Appraisal and
Revalidation Procedure’ (Trust procedure 9.37). This audit is required by
NHS North via requirements of the ‘Annual Organisational Audit (AOA).
94% of doctors had a completed appraisal.
An action plan was developed and communicated through the doctors
CPD meeting to ensure:
• Doctors avoid leaving their appraisals until March 2015.
• An active prompts/reminder system for doctors will continue to be
used.
• Collection of information throughout the appraisal year.
Audit of Medical Appraisal Systems was a re-audit and is now a
mandatory audit. It is a structured review or audit of the designated body’s
appraisal system against the standards described in GMC guidance and
AOA (Annual Organisational Audit) Issued by NHS England in March 2014.
Comparing with the previous audit there were very significant
improvements (compared with 2012) in all areas of the Doctor’s portfolios
of evidence including all portfolios being well organised, complete and
detailed.
An action plan was developed from the audit and the procedure was
updated to recommend that doctors change their appraiser every three
years and will be re-audited in 2015/2016.
68
10.
Project Title
Synopsis of Findings and Actions
Controlled Drugs
This audit was a re-audit completed within secure services to establish
compliance with Controlled Drugs Trust Procedure M9.0 written in
accordance with (Safer Management of Controlled Drugs: A guide to good
practice in secondary care (England) – Oct 2007). This included:
•
•
•
•
•
Requisitioning
Storage
Key holding
Record keeping
Destruction and disposal of controlled drugs in clinical areas.
The audit discovered issues with:
•
•
Completing and respecting record books and controlled drugs
stationary.
Controlled Drugs cabinets did not comply with standards and in most
cases needed properly securing to the wall.
From the audit an action plan was developed and is currently ongoing.
The Trust also completes a report on controlled drug activity across the
Forensic and High Support Services three times a year. As part of the
report all incidents involving controlled drugs are audited to ensure all the
statutory reporting requirements have been met. The Trust was fully
compliant.
This will be re-audited in 2015/2016.
11.
Compliance with
prescribing
practice for ADHD
in adults
This audit was completed to check compliance against the
recommendations in the NICE CG72 (2008) in patients with a diagnosis of
ADHD.
The audit found that physical health monitoring achieved 100%, no
patients were prescribed antipsychotic medication for the treatment of
ADHD and that referral’s to PTS are considered in the MDT Meetings.
Areas for improvement were around the processes before starting
treatment and the availability of easy read documents regarding
medication.
An action plan was developed which included an action to re-audit in 6
months’ time on patients newly starting on ADHD medication, however no
new patients were identified.
12.
Obesity
This audit was completed due to a systematic rise in obesity in the
hospitals patient population over the past four years and to see whether
this relates to background trends in the population or to clinical practices.
The audit found issues with the following:
•
•
•
Unhealthy eating habits
Poor physical activity
No consistent approach to recording both weight and BMI
69
Project Title
Synopsis of Findings and Actions
An action plan was developed and the issues raised are currently being
looked at by the Trusts Physical Health Steering Group.
13.
14.
Physical
Healthcare
Schizophrenia
Clozapine
Audit completed. Awaiting the National audit results.
This was a retrospective audit of service users who started treatment on
Clozapine medication between January 2014 and October 2014 and was a
re-audit of the audit completed in 13-14.
The audit found reasonable levels of good practice and recommended a
review of the procedure with some minor amendments to improve practice
further.
There is no requirement for this to be re-audited.
15.
Rapid
Tranquilisation
Non Oral
This was a re-audit to review current practice in accordance with the Trust
(M9.1) and NICE guidelines. The audit focussed on patients at medium
secure wards of Calderstones hospital who received non oral rapid
tranquillisation (IM and Buccal Midazolam) during April 2014.
During the audit no evidence could be found in PRISM or Care notes
regarding the requirement of regular observations being recorded following
administration of rapid tranquillisation.
Although a PRISM incident record had been completed for each occasion
rapid tranquillisation had been administered the record was missing the
required information on physical/visual observations by staff.
An action plan was developed and the audit was re-audited again between
August and September 2014.
The re-audit found the same failings resulting in a new action plan being
implemented along with a rapid improvement notice.
The audit will be re-audited in 2015/2016.
16.
Hypertension
This was a re-audit to identify whether NICE CG 34 Hypertension is
followed for the diagnosis and treatment of hypertension involving Forensic
and High Support Services.
The findings show some slight improvements but there are still issues and
room for improvement in the following areas:
•
•
•
•
24hr Ambulatory Blood pressure monitoring
Immediate start on hypertensive drugs where client was diagnosed
with severe hypertension
Investigations and formal assessments while awaiting confirmation
of diagnoses of hypertension
Treatment guidelines.
The trust has implemented an action plan to address the audit results and
70
Project Title
Synopsis of Findings and Actions
to support compliance with the guidance and this will be re-audited in
2015/2016.
17.
Health Monitoring
of people taking
antipsychotic
medicines
This was a re-audit against Trust Policy and Procedure M2.2 to determine
whether recommended tests are being carried out within specified time
periods. Patients from Forensic and High Support Services were included
in the audit. Those patients on Clozapine and High Dose Antipsychotics
were excluded from the audit as there are specified protocols in
Calderstones for the regular monitoring of these drugs.
The audit found an increase from the previous year with all tests apart from
BMI and blood pressure scoring between 90-100% compliance.
An Action plan was implemented and a decision was made to re-audit
within the year just the two areas of concern. This took place in
February/March 2015 with little improvement
A further action plan is currently being discussed by senior managers to
find a way forward and once agreed will be implemented.
These two components will be re-audited in 2015/2016.
18.
Sharps
This is an annual audit to establish whether sharps are being disposed of
in a safe manner. The audit was carried out by Daniels Healthcare.
12 wards/departments were visited and 27 sharps containers were sighted.
The audit showed an improvement in practice from the previous audit but
still found issues with the following:
•
•
•
Sharps containers were unlabelled during use.
Sharps containers containing a significant amount of inappropriate
non-sharp contents.
Sharp containers did not have temporary closure lids in place
when left unattended or during movement.
The trust has developed an action plan which is currently being
implemented.
Daniels will re-audit in 2015-2016.
19.
Follow up on
actions from CPA
Meetings
This audit was completed to see if actions and service tasks identified and
set at CPA/117 meetings, have documented evidence at subsequent
CPA/117 meetings to say if they have been completed or not or are no
longer applicable.
Nearly two thirds 63% of the Service Tasks/Action generated from
CPA/117 meetings were found to be Completed and a nearly a quarter
23% were found to be Incomplete. During the course of the audit it was
found that there was a number of Service Tasks/Action documented as
Complete in the Meetings minutes but there was no evidence found in the
71
Project Title
Synopsis of Findings and Actions
CPA Care notes to confirm this.
An action plan was devised in which the results were broken down and
disseminated to each individual ward.
20.
Medication errors
reported and
investigated by
the Clinical
Director
This audit was conducted to identify the different types of medication errors
from the investigations which have been conducted by the Clinical Director.
Every medication error attributable wholly or in part to a doctor is referred
to the Clinical Director for investigation and thereafter reporting to Clinical
Governance.
There were 39 incidents of medication errors that had been investigated
and recorded between January 2013 and May 2014.
The reasons stated for the medication errors included:
•
•
•
•
•
•
•
Too many medication cards were written on the same occasion
hence increasing the risk of errors being made.
Locum GP conducting clinics without having been inducted on the
trust medication practice.
Writing cards away from the ward.
Cards not vetted for accuracy by a nursing staff after they have
been written up.
Patients having multiple medicine cards.
Not triangulating prescription with medications tab in Care notes.
Medication tabs in Care notes not adequately completed to include
all prescribed medications.
All the issues that arose from the audit were dealt with through the Trusts
Medicine Management Committee.
21.
Consultants Work
Plans
This audit was completed to ensure that consultants work plans set out
their duties, responsibilities and objectives for the coming year is
accordance to the publication by the British Medical Association (BMA).
The job plan should outline the consultant’s commitments to the NHS,
specifically to the Trust that has employed them.
The audit found that although there were areas of full compliance there
was need for improvement in the following areas:
•
•
•
22.
Capacity to
Consent to
Personal objectives need to be well developed so it can be
embedded into future Job planning meeting, as these are meant to
be distinct from the personal Development plan in appraisal.
The needs of the Trust, including organisational objectives should
be aligned with the Consultants job plans.
There is a need to recognise areas of increase workload, including
incidental demands from commissioners, Care Quality
Commission (CQC) visits and CQUIN.
This audit was completed to ensure that Section 58 (Consent to
72
Project Title
Synopsis of Findings and Actions
Medication
Treatment) of the Mental Health Act is being adhered to.
A list of 137 service users from across the Trust, who had a T2/T3/T6 or
section 61 in place and which had recently been revised or renewed, was
produced. and care notes was examined to answer 5 questions:
•
•
•
•
•
Is the capacity to consent documented in the clinical notes at the
time of the T2/T3/T6/Section 61?
Is consent /refusal/no capacity documented in the clinical notes?
If yes to Q (2) did the client refuse/consent or lack capacity to
consent?
If the service user has capacity to consent is there evidence in the
clinical notes of a discussion with the service user with regard to
this?
If the service user has capacity to consent is there evidence of a
discussion with the service user about the treatment, side effects
and alternatives?
The audit showed areas of good practice but notes of concern were:
•
•
23.
Seclusion
Clinical notes in different areas of the electronic system do not
correlate with one another.
Less than half of service users who had the capacity to consent
had a fully completed clinical note evidencing a discussion with
them, with regard to their capacity to consent, when a change of
T2/T3/T6/section was documented.
This audit was completed to measure compliance with the aspects of the
Trusts Seclusion Policy 20.2 issued 25th April 2014, with regard to the
Duty Doctor attending incidents of seclusion and ensuring the correct
recording of their assessment of the service user in seclusion.
There were 44 incidents requiring seclusion during July 2014 which were
included in the audit and the following issues were found:
•
•
•
•
•
2 of the incidents were not attended by the Duty Dr.
On 2 occasions there was no record of the Duty Doctor assessing
the service user in seclusion.
For 13 of the assessments, it was unclear from the records where
the assessment took place.
11 did not have a record of the Duty Doctor authorising the
continued use of seclusion.
Of the duty Doctor’s assessment records audited only 10 were
recorded in Care Notes and on the Seclusion Observation Chart.
Following the audit the results were broken down by individual ward areas
and disseminated via the ward managers and a re-audit is scheduled for
2015/2016.
24.
Medicine
This audit was conducted in order to establish the quality of information
73
Project Title
Synopsis of Findings and Actions
Management
recorded on medication cards, in relation to prescribing, dispensing,
checking and administration of medicines. It forms part of the Trust’s
Quality Account – Metrics in relation to measures identifying the potential
for errors due to the quality of record keeping. This is a Trust wide audit.
The audit discovered issues with:
•
•
Omitted medicines for short term prescriptions.
Nurse’s witness signing (initialling) medicine cards after medication
is administered.
However, overall there has been a sustained improvement from both the
medical and nursing staff. There is an action plan in place to address areas
of poor compliance and a re-audit is scheduled for 2015/2016.
25.
T2
This audit was conducted in order to check compliance of T2 forms against
prescribed medications.
All patients across the Trust with a T2 form in place were included in the
audit. The T2 form was checked against medications prescribed for the
treatment of “Mental Disorder” listed on the MAR Medicines Administration
Sheet.
The audit found the majority of T2 forms were fully compliant with
requirements with only the following issues:
•
•
There was one instance of a drug not being authorised on the T2
form.
There were two instances of the maximum dose not being clearly
specified on the relevant T2 form.
An action plan was implemented and a re-audit is scheduled for
2015/2016.
26.
Staff First Aid Kits
This audit was a re-audit of that completed in March 2014 and was
undertaken to ascertain whether the Trust’s First Aid at Work policy (H & S
4) was being implemented with regards to there being:
•
•
•
•
•
Suitable first aid boxes and kit that were accessible for staff
A conspicuously positioned notice locating the box and kit and
detailing staff first aiders in that area, which had been updated in
the past six months
Daily briefing of staff by the person in charge regarding their
nearest first aider
Appropriate content in the first aid box
Appropriate numbers of personnel trained and holding a current
First Aid at Work certificate.
The audit found an improvement in the levels of compliance but there were
still concerns in regards to the following:
74
Project Title
Synopsis of Findings and Actions
•
•
•
Some areas had no conspicuous notices displayed.
Appropriate content in the first aid box
Appropriate numbers of personnel trained and holding a current
First Aid at Work certificate.
An action plan has been implemented and a re-audit has been scheduled
for 2015/2016.
27.
Rapid
Tranquilisation
This audit was a re-audit to establish if all instances involving the use of
rapid tranquillisation have been documented in PRISM by the appropriate
person(s). Also to establish if recommendations from previous audits have
been achieved.
The audit was carried out in both May and October 2014 due to poor levels
of compliance. All service users residing at Calderstones hospital who
received non oral rapid tranquillisation (IM /buccal) were included in the
audit.
During the audit it was found that - one incident recorded on care notes
was fully compliant with regards to recording the refusal of the patient to
have any physical observation carried out for the 12 hours following the
administration on Rapid tranquillisation (non – oral). The audit, highlighted
another incident that went someway to complying to the requirements of
the procedure by recording Physical Observations being taken for up to 2
hours following rapid tranquillisation (non-oral)
On one occasion the relevant person did not enter the PRISM following an
incident requiring rapid tranquillisation (non oral).
One service users had been administered rapid tranquillisation but the
medication had not been recorded in PRISM or Carenotes.
An action plan was implemented and a re-audit has been scheduled for
2015/2016.
28.
Clinical Risk
Management
This was a re-audit of that completed in 2013-2014 and whose strategic
drivers were the CQC outcomes framework.
The audit’s objectives were to establish the Trust compliance with its
clinical risk management procedures, to provider reasonable assurance
that the Trust is complying with CQC Outcome Frame Work 4 and to
determine the involvement of clients in their risk assessment.
Data was obtained on all incidents reported to StEIS for Quarter 1 20132014 Apr-Jun, Quarter 2 2013-2014 Jul-Sept and Quarter 3 2013-2014 Oct
– Dec. Three abscond incidents were audited to determine whether their
risk assessment was reviewed or reassessed and whether the incident
was recorded in the ward round following the incident and documented in
care notes.
The audit results showed the following:
75
Project Title
Synopsis of Findings and Actions
•
•
•
•
Good compliance with reporting and Service Users being seen
post incident by Case Managers
Client involvement with the risk assessment review poor although
risks were reviewed
Risks sometimes not reviewed until sometime after the incident
Ward rounds cover the incidents but you have to wait for the next
one. These only take place monthly.
An action plan is currently in development.
29.
Security of
Contractors Tools
entering
Woodview
This was a re-audit and the aim of the audit was to establish the
compliance with the Trusts Security and Control of Tools, Equipment and
Materials policy S1.21, with regard to contractors and their tools entering
and leaving the Woodview MSU environment and contractor’s tools being
appropriately identifiable.
The previous audits showed no evidence that the action recommendations
were implemented. Approved lists were not signed off, tools were not
permanently marked, no spot checks were carried out.
This audit showed some evidence that remedial works from the last audit
have been implemented, however there were still significant concerns
raised about the safety and effective functioning in the management of
tools prior to entering a medium secure unit.
An action plan has been developed and the practice and procedural
elements of this activity require a complete multi-disciplinary review as a
matter of urgency.
30.
Handcuffs
This was a new audit completed to establish the compliance with the
Trusts Handcuffs Policy (S1.34). The primary aim of the activity is to assist
in the management of patients, outside a clearly defined secure perimeter,
whereby the significant risk factors of absconding and serious violence and
aggression can be assisted by the use of a handcuffing device.
The audit results highlighted significant concerns about the safety and
effective functioning in the management of handcuff activity.
An action plan was devised and practice and procedural elements of this
activity are undergoing a complete multi-disciplinary review. A re-audit has
been scheduled for 2015/2016
31.
Shared Pathway
Goal Setting
This was a new audit completed to test how well embedded goal planning
is into the ‘shared pathway’.
A total of 30 service users were included looking at the following:
•
•
Whether goals were SMART (Using clinical judgement)
Reviewing ward round notes and CPA minutes for ongoing
evidence of review, monitoring and achievement.
76
Project Title
Synopsis of Findings and Actions
•
Looking for key words associated with personal goals.
The audit results found several concerns including:
•
•
•
A lack of understanding of what constitutes a change, behaviour or
goal.
Goal setting only by nurses so no MDT ownership.
Extensive evidence of staff writing literally what the service user
says e.g. ‘behave’ ‘get out’ ‘get married’
An action plan was implemented and the shared pathway goal setting was
integrated into the Model of Care Framework.
32.
Management of
choking incidents
This was a re-audit to ensure that all service users who have had a
choking incident have been screened to assess the risk of choking in
accordance with Trust Procedure 4.15: Dysphagia dated 1st December
2013.
All choking incidents that had occurred between the 1st April 2014 and
31st October 2014 were included and the following areas looked at:
•
•
•
•
•
•
Screen reviews
Severity of incident
Referrals
Discussions with service users
Risk
Training
Significant failings were found in the audit. This is currently being looked at
in depth by the Trusts senior managers following which an action plan will
be implemented.
A re-audit has been scheduled for 2015/2016.
77