Qa
Quality
account
:
2014 2015
Contents
Quality Account 2014 : 2015
04
Introduction
05 Statement of directors’ responsibilities in
respect of the Quality Account
Section 1:
A review of quality in LCH
07 07
08 09 10 11 11 12 14
16 16 17 18 19 21 22 22 23 24
25 26 Safety
A review of safety
Safeguarding
Incident management
Sign up to safety
Pressure ulcers
Falls
Infection prevention and control
Effective
Appraisals
Clinical supervision
Outcome measures
Caring
Patient satisfaction
Responsive
Serious incident look back
Complaints
Equality and diversity
Well-led
Leadership and staff engagement
Members priorities
Section 2:
Statements on quality as mandated in the
regulations
29 Review of services
29 Transformation: Service Reviews and
Developing Improvement Capability
31 National clinical audits
33 Local clinical audit
35 Clinical research
36 Commissioning for quality and innovation
(CQUIN)
37 CQC registration
38 Secondary uses and hospital episode data
38 Information governance
38 Payment by results
39 Staff satisfaction
40 Patient experience of community mental
health services
42 Patient safety incidents
Section 3:
Quality improvements for the coming year
44 44 45 46 46 47 Safety
Effectiveness
Caring
Responsiveness
Well-led
How quality will be monitored
throughout the year
Section 4:
Statements from others on the quality of LCH
services
52 Acknowledgements
52 How to comment on the Quality Account
53 Glossary
Introduction
W
elcome to the 2014 / 15 Quality Account for
Leeds Community Healthcare NHS Trust (LCH).
This account sets out our achievements and
challenges in relation to quality in the last year and
the areas we have identified as quality priorities for the
coming year.
to see and assess children in
the community children’s and
adolescent mental health service
and how we make sure that any
risks we have identified in the
inpatient unit are recorded where
everyone can see them.
LCH has seen a number of
changes in the executive and
non-executive team this year.
We welcome our new Chief
Executive, Thea Stein and a new
non-executive director, Brodie
Clark. Our Executive (Nurse)
Director of Quality has retired and
we are currently in the process of
recruiting an Executive Director of
nursing and therapies.
The CQC agreed with us that
staff morale at the moment is low
even though most people feel
well supported by their immediate
line manager. They noted that the
culture of the organisation is open
and supportive of learning from
incidents, however, staff are weary
of change. They would like us to
look at how we share the learning
from incidents across the services.
This is something that we have
included in the priorities for quality
improvement for next year.
The overall performance of LCH in
2014 / 15 has been strong and we
have continued to deliver against
the majority of quality targets. LCH
has a strong incident reporting
culture and continues to be in the
top three community organisations
for reporting incidents. We have
increased the percentage of staff
that have received an appraisal
and staff have continued to
ensure they have relevant training
for their role.
Twenty services have been
through a service review and have
identified the measures we will
monitor to ensure the changes do
not impact on quality. We have
co-located community nursing
and adult social care establishing
13 neighbourhood teams to
work closely with GP practices.
We have introduced the patient
friends and family test and patient
satisfaction remains above 95%.
[04] Quality Account
We know that we still have
improvements to make in some
areas of quality. We have had
a high incidence of falls within
the inpatient units and a high
incidence of pressure ulcers across
our community nursing services.
We have also seen an increase in
the number of serious incidents in
our inpatient units.
Staff morale is low and staff
engagement is poor. We continue
to have higher than average
staff off sick. We have also faced
the same challenges as other
organisations with regards to
nurse recruitment. As a result
of this some services have been
under considerable pressure. We
have managed this risk through
the year by using agency staff.
This year we have had our first
full inspection from the Care
Quality Commission (CQC). They
found our staff to be very caring
and the services that we provide
to be effective. They noted that
patient feedback was good and
that patients were treated with
dignity and respect.
The CQC felt that we need to
improve our responsiveness,
leadership and safety. They
particularly want us to look
at how quickly we are able
Neil Franklin, Chair
Thea Stein, Chief Executive
Statement of directors’
responsibilities in respect of
the Quality Account
The directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the
National Health Service (Quality Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
the Quality Accounts presents a balanced picture of the trust’s performance over the
period covered;
the performance information reported in the Quality Account is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Account
is robust and reliable, conforms to specified data quality standards and prescribed
definitions, and is subject to appropriate scrutiny and review; and
the Quality Account has been prepared in accordance with Department of Health
guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
Signed ...........................................................................................
04 June 2015
Date ..................................................................
Chair
Signed ...........................................................................................
04 June 2015
Date ..................................................................
Chief Executive
Quality Account [05]
Section 1 :
A review of quality
in LCH
L
ta
Hi
gh
Well-led
en
of
s|
ls
[06] Quality Account
quality
Fundam
eeds Community Healthcare NHS Trust (LCH) published
a quality strategy in 2012 setting out our vision for
quality improvement until 2015. The definition of quality
in that document described quality as effectiveness, safety
and experience. In last year’s quality account we expanded
that definition to reflect the Care Quality
Commission (CQC) domains of quality
lity of care
(safe, effective, caring, responsive and
Qua
well-led). This section of the quality
account will review the priorities
we set for ourselves under each
Safe
of the CQC domains as well
as describing some of the
Effective
achievements and challenges
Caring
over the last year.
Responsive
ca
re
| Expe ted sta
c
a
nd
rd
Safety
The table below shows the priorities relating to safety that we set last
year, the progress we have made against each target and what we
will now do in relation to each priority.
Quality area
for action
Safeguarding
adults and
children:
90% of staff to
have received
training
Achievements to date
100
80
60
40
20
0
2012 / 13
2013 / 14
Percentage staff
trained - adults
Percentage
staff trained childrens
Protect people
from harm:
90% of staff
trained in
infection
prevention and
control
70% of incidents
reported will
have resulted in
no harm
Percentage
staff trained MCA
Target
100
80
60
40
20
0
2012 / 13
2013 / 14
Percentage
staff trained
Reporting
incidents:
2014 / 15
2014 / 15
Target
100
80
60
40
20
0
2012 / 13
2013 / 14
Percentage
no harm
2014 / 15
Target
Comments
We have increased the number
of staff who have been trained in
safeguarding children compared
to 3 years ago and this year
we have made progress with
increasing the number of staff
who are trained in safeguarding
adults. Next year we would like
to focus on the quality of our
services in relation to the areas
that have been identified in
safeguarding referrals. We will
continue to monitor safeguarding
training as part of individual
service performance reviews.
Over the last 3 years we
have consistently improved
the percentage of staff that
have been trained in infection
prevention and control. This
will remain a priority for staff
training and will be monitored
through the service performance
review process.
The percentage of incidents that
occur in our care that result in
no harm is consistently better
than similar organisations.
We will continue to monitor
this through the performance
process and next year replace
it with a priority that looks at
learning form incidents rather
than the process of reporting.
Quality Account [07]
Safeguarding
Improving uptake of safeguarding training has been a priority for us in each
of our quality accounts for the last 3 years. Staff are supported in fulfilling their
responsibilities by the trusts safeguarding team.
O
ver the past year the
safeguarding team has
focused on learning
from best practice, incidents,
complaints, serious case reviews
and domestic homicide reviews to
safeguard those who are least able
to protect themselves. Learning has
contributed to the development
of guidance and policies for our
staff and those working in other
agencies. This includes advice on
how to manage bruises in nonambulant children, and how to
identify possible Child Sexual
Exploitation in young people.
Learning is also shared through
‘Lunch and Learn’ sessions, team
meetings and briefings to staff.
In March 2014 the Supreme Court
made a ruling that anyone over
the age of eighteen, who lacks
mental capacity to make decisions
about care and treatment and “is
under continuous care and control
and not free to leave” cannot
lawfully be detained without a
Deprivation of Liberty Safeguard
(DoLS) authorisation. This has
resulted in a rise in the number of
DoLS assessments our in-patient
units need to make. Bespoke
training and regular support visits
to the units have been introduced
to equip staff with the knowledge
and skills to safeguard individuals
in our care, to ensure staff always
act in the best interests of our
patients and to ensure staff
consider what solution is the
least restrictive. Furthermore the
LCH Restraint Policy has been
developed to ensure we consider
all aspects of restraint and employ
the least restrictive measures.
Bespoke
training and
regular support visits
to the units have been
introduced to equip staff
with the knowledge
and skills to safeguard
individuals in our
care
[08] Quality Account
In the past twelve months a
tremendous amount of work
has been done to increase
awareness around dementia with
the introduction of ‘dementia
friends’ with customer service staff
and practitioners. The Trust has
recently become a member of the
Dementia Action Alliance.
This year we have completed the
safeguarding action plan for the
Community Intermediate Care
Unit (CICU). The safeguarding
board commended the work that
the CICU team had undertaken
to address the issues raised. We
have had further safeguarding
issues this year in the South Leeds
Independence Centre (SLIC)
and we are currently working
with commissioners and the
safeguarding board to address this.
Incident management
We have a good incident reporting culture within LCH and the number of
reported incidents benchmark well with other similarly profiled organisations.
A good level of incident reporting is considered positive in creating a
robust reporting culture where staff recognise and learn from patient safety
incidents. Last year we said we would improve our incident management by:
Continuing to require staff to report
incidents.
Continuing to train staff in how to
report incidents.
Continuing to investigate every
patient safety incident to find out
why and how the incident occurred
and what can be done to prevent it
happening again.
Continuing to ensure we learn from
incidents through the development
and implementation of action plans
and learning for patient safety
memos.
Developing processes to ensure the
appropriate escalation of incidents.
We have supported staff to report incidents through: a
poster campaign to remind staff how to report concerns
and incidents; providing information about reporting
incidents at the monthly trust induction event; providing
dedicated support with incident reporting and visiting staff
and teams on a request basis to provide refresher training
and advice. Our incident reporting has increased this year
showing a good reporting culture across the organisation.
The incident management process ensures that all patient
safety incidents are assigned to an appropriate manager
for investigation as quickly as possible. Specialist reviewers
work with the managers for specified categories of
incidents, such as pressure ulcers. The specialist reviewer
will monitor any trends and identify any actions required
to address gaps in the standard of service or areas for
improvement.
A monthly report to the senior management team identifies
themes and trends from all reported incidents and examines
major harm and serious incidents in detail. Any areas of
concern are identified and required actions detailed. The
senior management team are responsible for sharing this
information with the relevant committees and Board.
All of the information gathered, including concerns
and action required, is shared with the business unit
managers. The business unit managers and clinical leads
are responsible for seeing that teams receive feedback
about incidents, lessons learnt and actions to be taken.
Safety memos are used to widely communicate learning
from incidents across services. We are currently looking at
new ways of sharing and communicating learning with
services such as encouraging services to access the Datix
dashboards, exploring setting up an incident and experience
group, and developing a newsletter for staff sharing quality
matters.
Details of incidents reported this year and how we compare
with other organisations is included with the statements
that we are mandated to make further on in the quality
account under patient safety incidents.
Quality Account [09]
This year we joined the sign up to safety campaign. This is a national campaign
launched by NHS England that aims to deliver harm free care to every patient,
every time, everywhere. The campaign challenges every organisation that signs
up to identify what actions they will take to reduce harm over the next 3 years.
Organisations are expected to develop an action plan and publish this on their
website. There are 5 pledges for which each organisation has to agree actions.
These, along with our pledge are summarised in the table below.
Pledge
Our actions
Putting safety first.
Commit to reduce
avoidable harm in the NHS
by half and make public our
locally developed goals and
plans
We will continue to be a high reporter of incidents with a high percentage of low or no
harm incidents reported.
We will develop and implement safety improvement plans for the main causes of avoidable
patient harm identified through our incident reporting – falls and pressure ulcers.
We will reduce by 75% over 3 years the number of reported falls on LCH in-patient units.
We will reduce by 30% over 3 years the number of reported falls resulting in avoidable
harm on LCH in-patient units.
We will reduce by 50% over 3 years the number of reported falls in our Neighbourhood
teams.
We will reduce by 50% the number of category 2 and 3 pressure ulcers acquired by
patients in LCH care and have no category 4 pressure ulcers.
Continually learn.
Make our organisation
more resilient to risks, by
acting on the feedback
from patients and staff and
by constantly measuring
and monitoring how safe
our services are
Triangulate data from patient feedback including Friends and Family, patient survey,
compliments, comments and complaints to ensure that patient experience in relation to
safety influences safety improvement plans.
Complete root cause analysis investigations for all major harm incidents that are
assessed as avoidable or as a direct result of LCH care.
Establish safety notices that are visible in our inpatient units to publish incident figures,
days free from harm and learning from incidents.
Ensure learning from incidents are a standard agenda item on all clinical forum and
team meetings.
Explore new media for sharing the learning from incidents and LCH quality data.
Being honest.
Be transparent with people
about our progress to
tackle patient safety issues
and support staff to be
candid with patients and
their families if something
goes wrong
Embed duty of candour within the organisation and develop staff to feel comfortable
saying sorry when harm has been caused.
Encourage open and honest reporting of when mistakes occur by providing feedback
and support to teams and services.
Develop the integrated performance report to identify where improvements are required
and monitor progress.
Collaborating.
Take a lead role in
supporting local
collaborative learning, so
that improvements are
made across all of the local
services that patients use
LCH will work with key stakeholders in both the neighbourhood teams and community
bed bases in order to share knowledge and reduce avoidable patient harm as a result of
falls.
LCH will share learning with key stakeholders who were involved in the patient’s care
where major or moderate harm occurred.
LCH will work with other key stakeholders on the city wide pressure ulcer action plan.
Being supportive.
Help people understand
why things go wrong and
how to put them right. Give
staff the time and support
to improve and celebrate
progress
Increase shared learning when mistakes are made through service/team level feedback.
Support teams by providing service specific incident/complaints feedback to improve
motivation to report and share learning.
Develop service specific Clinical Supervision Models.
Explore use of the LCH intranet to share learning and good news stories.
Develop staff to use improvement science (Improvement Academy) as a means of
reducing incidents resulting in harm.
We have included some of the targets identified in this campaign in our quality priorities for this year in
section 3. We are currently working with services to agree what actions we need to take and agree the
action plans.
[10] Quality Account
Pressure ulcers
The national institute for health and care excellence
(NICE) describes a pressure ulcer as damaged
caused to the skin and the tissue below when it is
placed under enough pressure to stop the blood
flowing. This can occur when a person spends a
lot of time in a chair or a bed because of illness.
The damage caused is categorised into one of 4
categories with 4 being the worst. We ask staff to
report all pressure ulcers as safety incidents.
This year we had agreed a quality improvement
plan with our commissioners aimed at reducing
the prevalence of pressure ulcers happening in
our organisation and to work with the teaching
hospital to reduce the prevalence of pressure ulcers
altogether.
We did not meet the target for reducing pressure
ulcer prevalence agreed with commissioners and
we have reported 59 pressure ulcers as serious
incidents. Four of these were category 4 pressure
ulcers. We recognise that this is high and we have
a plan in place to reduce this to zero for next year.
We have introduced a standardised assessment tool
that has been developed with university partners
and we have ensured that all our nursing staff
are up to date with their training. We have also
developed and introduced a training programme
for allied health professionals and support workers
so that they are trained in spotting the signs and
symptoms of a pressure ulcer developing.
Falls
F
alls continue to be a major healthcare
concern. Falls have accounted for up to
19% per quarter of all reported incidents in
the last year within the Trust. This is a reduction
on the 22% we reported in last year’s quality
account. The consequences of a fall can impact
on quality of life and wellbeing of both patients
and their carers / families, therefore it is important
to have effective falls risk assessment and
management strategies in place to address this.
The Trust has developed a work plan identifying
actions required to address, monitor and
manage falls within LCH. The following are key
areas being implemented and monitored to
ensure that falls risk is being effectively managed
within the Trust:
Falls education sessions to key LCH services to
promote greater awareness of falls risk, and
encourage a more standardised approach to
falls risk assessment and management across
these services.
Development of Standard Operating
Procedures for reducing the risk of falls
among patients in their own homes, and
within the bed bases and inpatient units.
Update of the LCH Prevention of Patient Slips,
Trips and Falls Policy.
Ongoing review of the LCH falls pathway
in line with NICE guidance and in light of
the health and social care
integration.
Partnership working with
other organisations such
as Age UK and Public
Health to pilot evidencebased community group
falls prevention exercise
programmes.
Sign up to Safety campaign
with focus on falls
reduction.
Quality Account [11]
Infection prevention and control
LCH does not accept that healthcare
associated infections (HCAIs) are an inevitable
part of, or acceptable risk related to care delivery.
I
n the pursuit of a zero tolerance for avoidable HCAI the Infection Prevention team
have worked closely with all LCH care delivery teams and will continue to systematically
review practice and performance against locally and nationally established targets.
Effective hand hygiene is the single
most important way to reduce the
spread of infection. Within LCH all
staff have to attend specific infection
prevention and control training, where
the importance of correct hand washing
and being ‘bare below the elbows’ is
emphasised. Compliance with hand
hygiene requirements is monitored
throughout the organisation
using peer assessments and
also ad hoc reviews from the
Infection Prevention team. Over
the past year new technology
has been introduced to
scientifically identify how clean
staff members hands really are.
Use of ATP machine to assess hand cleanliness
Although there are no specific government targets for infections caused by germs such as Meticillin resistant
Staphylococcus aureus (MRSA) and Clostridium difficile (CDI), the organisation has a locally agreed target of
no more than 2 cases of MRSA blood stream infection and 3 cases of CDI, directly attributed to LCH within the
year. Graph 1 shows the year on year comparison for MRSA bacteraemia within LCH.
Graph 1:
MRSA bacteraemia cases attributed to LCH 2009 - 2015
3
2
2
1
1
1
1
0
2009 / 10 2010 / 11 2011 / 12 2012 / 13 2013 / 14 2014 / 15
[12] Quality Account
For the year 2014 / 15 one case of
MRSA bacteraemia was attributed to
LCH involvement during June 2014. A
full review of the circumstances relating
to this incident was undertaken and
learning around the management of
urinary catheters, clinical documentation
and antibiotic prescribing was identified
and shared both locally and throughout
the organisation. The implementation of
this learning within the respective clinical
teams has been monitored, with progress
being reported to the Infection Prevention
Group and Senior Management Team.
Graph 2:
Clostridium difficile cases attributed to LCH 2009 - 2015
8
6
4
7
2
0
1
3
1
2009 / 10 2010 / 11 2011 / 12 2012 / 13 2013 / 14 2014 / 15
Work has been done with the Trust
Development Authority (TDA) to review
and progress the infection prevention
agenda within the organisation.
An educational event, facilitated by
the TDA was held in February. This
workshop explored the processes
involved in reviewing untoward
incidents and provided staff with an
enhanced understanding of the Root
Cause Analysis (RCA) method of
investigating these situations.
Further work is being done to enhance
the surveillance of specific infections
within the wider community healthcare
economy. LCH, as part of a programme
called the Safety Thermometer monitors
the infection status of patients receiving
care from LCH services to provide
assurances as to the standards of safe
practice being provided by care teams.
LCH members
assessing infection
prevention practices
at an LCH health
centre
Graph 3:
Percentage of patients with a CAUTI
LCH (excl. SLIC)
1
National average
(community
services)**
Percentage
The Infection Prevention team has
continued to foster relationships with
the Trust membership and involved a
number of members in the assessment
of infection prevention activities within
both in-patient areas and health
centres. The Safe Clean Care Project,
which forms the framework for the
patient assessment has received a
runner up prize at the recent Nursing
Times awards.
During the report period 2014 / 15 three
cases of CDI have been identified on
LCH in-patient areas (Graph 2). All
three of the cases have been subject to a
review process as recommended by NHS
England and deemed to be unavoidable,
with no lapse in care from LCH teams
being identified. The 3 cases are not
attributable to LCH care and we therefore
did not reach our locally agreed target.
0
Feb 14
Apr 14
Jun 14
Aug 14
Oct 14
Dec 14
Graph 3 above shows the monthly prevalence figures for
infections experienced by patients with indwelling urinary
catheters. As demonstrated in the graph, the average rate of
infection within the LCH patient cohort is significantly lower than
the national average for all months except August 2014.
Each case identified is reviewed, with any learning shared
throughout the organisation.
The prevention of HCAI remains a key organisational priority for
LCH. The effective prevention and control of HCAI will continue
to remain at the forefront of LCH strategy and form an important
part of the delivery of ‘quality’ healthcare within Leeds.
Quality Account [13]
Effective
The table below shows the priorities relating to effectiveness that we
set last year, the progress we have made against each target and
what we will do in relation to each priority.
Quality area
for action
Continue to
develop the
robustness
of outcome
measures:
Services will have
agreed individual
outcome measure
targets
Achievements to date
We have not made as much progress with this area
of quality improvement as we would have liked to.
Service Reviews have posed a challenge to some
services in progressing this work. Services have
been classified as being in one of three different
positions with regard to their progress in embedding
outcome measures in practice. These are:
•Position 1: the service has outcome measures in
use and is able to collect, analyse and report on
the data. (30% of services)
Comments
Work is being undertaken within
the business units, with support
from the clinical leads, to
positively improve the position
at which services currently sit.
This work will continue next year
with some specific targets being
agreed for identified services.
•Position 2: the service has identified relevant
outcome measures, ways to collect data and is
collecting data. They are not yet fully analysing or
reporting on the data collected. (35% of services)
•Position 3: services are currently reporting their
outcomes as outputs. (31.5% of services)
Continue to
embed clinical
supervision for
clinical staff:
75% of clinical
staff engaging in
supervision
100
80
60
40
20
0
2012 / 13
2013 / 14
Percentage staff
receiving clinical
supervision
Ensure all staff
receive an
appraisal:
90% of staff have
had an appraisal in
the last year
Target
100
80
60
40
20
0
2012 / 13
2013 / 14
Percentage staff
with appraisal
[14] Quality Account
2014 / 15
We aim to ensure our clinical
staff are supported through
clinical supervision. We have set
a target of 75% for the last 3
years. We gave not yet achieved
this target so we are keeping
this as a priority for quality
improvement next year.
2014 / 15
Target
This year we have increased
appraisal activity by 5% moving
towards our target of 90% of
staff having an appraisal. We
will continue to monitor this
through service performance
reviews and focus next year on
benchmarking well-structured
appraisals.
Quality area
for action
Achievements to date
Contribute to
transformation
of services for
the people in
Leeds:
20 service reviews have been undertaken this year.
Staff and service users have been actively involved
in the service re-design process through attendance
at workshops, newsletters and active involvement
in working groups.
Relevant services
to have taken
part in a service
review
Over 50 staff have been involved in active learning
programmes around developing their improvement
and innovation knowledge and skills.
Patient records:
•Criteria 3: Assessment of patient needs
75% of all
audited notes
will show the
following criteria
as complete:
•Criteria 4: An action / treatment plan in relation
to the identified needs including any risks
•Criteria 5: Interventions being implemented
according to the action / treatment plan as fully
met
LCH met its target for all 3 of the criteria with
performance well exceeding 75%. Performance for
all 3 criteria has also significantly improved from
2013/14.
95%
94%
93%
Comments
We have successfully
undertaken a number of service
reviews. We will continue to
monitor the impact of these
changes through individual
service performance panels.
Action plans are in place to
monitor those services that
are not fully compliant with
record keeping standards.
Regular audits are undertaken
to monitor performance and
ensure that the quality of record
keeping is improving across the
Trust. Staff have been issued
with documentation prompt
cards and record keeping
is included in all relevant
appraisals. We will continue
to focus on improving patient
records next year.
92%
91%
90%
89%
88%
87%
Criterion 3
2013 / 14
Criterion 4
Criterion 5
2014 / 15
Quality Account [15]
Appraisals
The 5% increase in appraisal activity has been supported by the development
and introduction of a toolkit, refocused training content and the feedback
received from the qualitative review. The toolkit highlights the core
appraisal documentation that managers and staff are required to use
which supports the appraisal conversation, provides consistency and
gives a benchmark for the qualitative review. The training content has
had renewed focus on feedback skills which provides managers with a
framework to support their conversations.
e
our workforc
Over the past 12 months there has been significant progress with the
appraisal system as a whole.
ti
con
nu
ou
s
ui
ng
Appraisal
l
va
f
process o
In 2015 / 16 the Trust will be rolling out a behavioural framework which will
refocus our appraisal arrangements and training. Our priority in 2015 / 16 is to
aspire to improve and meet the Community Trust benchmark for a well-structured appraisal.
Clinical supervision
Clinical supervision provides an opportunity for staff to:
Reflect on and review their practice.
Discuss individual cases in depth.
Change or modify their practice and identify training and
continuing development needs (CQC 2013).
Over 2014 / 15 LCH has actively
engaged with clinical staff to
develop a culture that supports
practitioners to seek supervision
and value it has part of their
practice. We established a Clinical
Supervision Working Group to
review, develop and implement a
new trust wide Clinical Supervision
Policy. The development process
involved practitioners from every
service.
All clinical services now have an
agreed model that describes how
they will deliver the new policy’s
standards and principles from April
2015. Taking this approach reflects
the diversity of services provided
to communities in Leeds and the
differing needs of practitioners
delivering clinical care.
[16] Quality Account
Already the change in culture has
seen services:
Changing and increasing the
number practitioners requiring
clinical supervision. Dental /
medical staff and unregistered
practitioners providing direct care
to patients along with registered
nurses and AHPs are now
required to have supervision.
The development of service
improvement programme
within Health and Justice
in partnership with Leeds
University meeting the
complexity of clinical situations
within prison and custody
healthcare settings.
The development of an
introduction to clinical
supervision incorporated into
service inductions programmes.
Improved recording of
supervision using the electronic
staff record and linking to staff
appraisal and objectives.
Making these changes has identified
the lack of a robust means for all
services to collate information on
clinical supervision uptake. The Trust
has moved to using the Electronic
Staff Record [ESR], which provides
both practitioners and managers
with rapid access to information.
Where services are fully using the
ESR system 96% of practitioners are
having clinical supervision according
to guidance, compared to 54%
for the trust as a whole. This
recognises that there is more work
to do. 2015 / 16 will see:
All services using the ESR
reporting process.
A database of supervisors
across the organisation.
Development of developmental
and support for supervisors.
Development of processes to
demonstrate the quality of
supervision.
Outcome measures
Clinical outcome measures are “Measures that demonstrate the
impact of clinical intervention over time for the patient and / or carers”.
S
ervices have been asked to
identify at least one clinical
outcome measure as an
indicator of the effectiveness
of the care they have given. As
shown in the table on page 14,
the progress that services have
made with identifying and using
clinical outcome measures have
been grouped into 3 different
positions. The aim is that all
services are able to attain position
1 (where they have outcome
measures in use and are able to
collect, analyse and report on
the data). Thirty percent of our
services have achieved this. The
clinical leads and the Quality
and Professional Development
Department are supporting the
remaining services to achieve this.
Developing clinical outcome
measures has been a priority
for LCH for the last 3 years. It is
disappointing that we have not
yet got outcome measures in every
service. Despite this there has been
some innovative work and our
dietetics service have lead on the
development of a clinical outcome
measure that has been adopted in
many other organisations.
The dietetics service developed a
set of Therapy Outcome Measures
(TOMs) which can be used to
enable the service to: identify
the effectiveness of dietetic
interventions; improve reflection
on practice and job satisfaction;
support service development
and improvement; and, provide
evidence that services are clinically
and cost effective.
A 6 month pilot involved TOMs
being developed for the following
6 areas: obesity, under nutrition,
home enteral feeding (HEF),
diabetes, irritable bowel syndrome
(IBS) and cardiovascular disease
(CVD). After piloting, analysis was
carried out based on the findings
from the patient sample and focus
groups were undertaken with the
staff to understand how TOMs
could contribute to their work,
professional practice and job
satisfaction.
The focus groups identified that
developing TOMs has meant a
cultural change in how dieticians
perceive their practice and reflect on
both practitioner and intervention
effectiveness. TOMs have led to
change in practice discussions.
The evaluation of the first
six months’ of dietetic TOMs
has demonstrated that TOMs
can enable us to assess our
effectiveness, make improvements,
demonstrate to our ‘customers’
the effectiveness of what we do,
to ensure we continue to improve
and deliver the best possible
care to the community of Leeds.
Further work and greater numbers
are required to embed TOMs, and
understand how to develop and
improve practice further.
Quality Account [17]
Caring
The table below shows the priorities relating to caring and experience
that we set last year, the progress we have made against each target
and what we will do in relation to each priority.
Quality area
for action
Involving
people and
partners:
90% report that
they are involved
in the planning of
their care
Achievements to date
Comments
The percentage of people who
feel involved in the planning
of their care has dropped. The
drop has happened in the last
3 months of the year and we
are still working with services
to understand why this is. We
will continue to monitor this
through patient satisfaction
surveys and service performance
panels.
100
80
60
40
20
0
2012 / 13
2013 / 14
2014 / 15
Percentage
involved in care
Friends and
family test (FFT)
for patients:
Target
Uptake of Friends and Family Test 2014 - 15
LCH total
the test will be
implemented in all
services
Specialist
Adults
Children
2000
1800
Number of responses
1600
1400
1200
1000
800
600
400
200
0
Apr
May June July Aug Sept Oct Nov Dec Jan Feb Mar
We have met the requirements set out by NHS England and achieved our target to
impliment FFT in all services. Our focus for next year will be on the quality of services
people receive so they continue to recommend our services to others.
[18] Quality Account
Patient satisfaction
For the past three years LCH has gained the views from patients /
service users through the organisational Patient Satisfaction
Survey (PSS) which asks a total of 6 questions and provides the
opportunity for ‘free text’ responses to three questions:
“What do we do well?”
“What can we do better?”
“Is there anything else you want to tell us?”
The Friends and Family Test (FFT) was introduced for some NHS providers in 2013 to ask patients whether
they would recommend services to their friends and family if they needed similar care or treatment. The
FFT was expanded to mental health and community services on 1 January 2015. LCH has incorporated the
nationally required Friends and Family Test (FFT) into the local Patient Satisfaction Survey (PSS). We have
been collecting FFT data for the majority of services since April 2014, and all services since January 2015.
The table below shows that patient satisfaction declined between October and January and is now
beginning to improve again.
Average patient satisfaction across all LCH services
2012-2013
2013-2014
2014-2015
Target 95%
Satisfaction (%)
100
95
90
85
80
75
Apr
May June July Aug Sept Oct Nov Dec Jan Feb Mar
Quality Account [19]
The decline in patient satisfaction happened at the same time as the majority of our services were going
through the service review process. Staff moral has been affected and this has clearly had an impact on how
satisfied patients are with the care they received. As services are settling into new structures and changes,
patient satisfaction is beginning to rise again. Services have been working to understand the reasons for the
decline and actions needed to reverse this. This work will continue throughout 2015 / 16.
FFT results “I would recommend this service to friends and family” by
business unit
Percentage score
FFT overall
Specialist
Adults
Children
100
80
60
Apr
May June July Aug Sept Oct Nov Dec Jan Feb Mar
While satisfaction
with the services
has decreased,
patients would still
recommend our
services to family
and friends. The
overall FFT score for
the organisation has
remained above 90%
since April 2014.
Care, Compassion, Competence,
Communication, Courage, Commitment
In December 2012 the NHS England Chief Nursing Officer
Jane Cummings launched the 6Cs. Care, compassion, courage,
communication, commitment and competence form the bedrock
of the national nursing strategy and apply to all staff and services
in LCH. Work is ongoing to ensure that the values and standards
required to create the right culture to provide really excellent care
are consistently delivered by staff.
South Leeds Independence Centre (SLCI) staff have
a detailed improvement plan which includes:
Ensuring patients have the opportunity to discuss
their wishes, goals and aims for planning their
discharge from admission and assessing care.
Developing further the way information is
shared with patients with compassion, with the
team being open and honest improving their
communication to each other, handing over
care from shift to shift.
The commitment of staff always listening
to patients, discussing their experiences and
stay, gaining an objective view. An activity coordinator is currently working alongside staff
to provide stimulating sessions which patients
have requested. The environment is also being
improved for patients diagnosed with dementia.
[20] Quality Account
An updated training programme for new staff
on their induction is supporting staff in their
development and gaining competencies so that
the right staff have the right skills for the job to
be done.
Staff are encouraged and supported to speak up
and having courage to do so when they have a
concern about any part of their job and service
so that actions can be taken to improve staff and
patient experiences.
Rachel Barber and Katherine Davies, Therapists
say that “we are committed to providing high
quality care, which is the best possible care for our
patients, through valuing patient experiences and
by seeking feedback from them and their visitors in
a number of ways. We are continuously listening to
the views of our patients and visitors to learn and
improve our service.”
Responsive
The table below shows the priorities relating to responsiveness that we
set last year, the progress we have made against each target and
what we will do in relation to each priority.
Quality area
for action
Learning from
major harm
incidents:
100% of major
harm incidents
will have a
completed Root
Cause Analysis
Achievements to date
•All major harm incidents were reviewed as per
the Trust criteria to see if we need to carry out a
Root Cause Analysis (RCA). Out of the 16 major
harm incidents, four were deemed not to require
an RCA, as the patient fell within their own
home. The preliminary investigation found, they
had been appropriately assessed and the correct
action plan was in place. Five of the incidents
have completed RCA investigation. Seven remain
under investigation.
Comments
We are consistently good
at completing RCAs were
necessary and ensuring that the
findings are shared in patient
safety memos. We need to audit
how effectively we learn from
incidents and we will continue
this as a priority for next year.
•A detailed audit of the process has not been
undertaken. A look back at Serious Incident
management was prioritised as an alternative
following recommendations made by the Trust
Development Authority. An audit will be planned
for the forthcoming year.
•11 LPS memos were sent out to share learning
from incidents across the organisation.
Continuously
improve our
learning
from patient
feedback:
regularly collect
feedback from
our inpatient
units and share
this on our
website
This year we began to hold regular feedback
sessions on 2 of our inpatient units. Tea parties
have been held on CICU since May 2014 and SLIC
since August 2014 to provide both social activity
and facilitate feedback. All feedback is responded
to and learning and improvement identified. This
is shared through ‘you said…we did’ displays and
publiscised on the Members’ Zone of the website
http://www.leedscommunityhealthcare.nhs.uk/
membership_/members_zone1/feedback_and_
reports_2014/
We will continue to hold
tea parties on our inpatient
unit to collect feedback. We
will monitor the action plans
developed from complaints and
publish action we have taken as
a result on our website.
We have not done as well as we would have liked
with sharing learning from complaints beyond the
service in which they occurred. We have refreshed
the complaints procedure and process at the
beginning of January 2015 to address this.
Quality Account [21]
Serious incident look back
This year the Trust Development Authority suggested that
we look back at the incidents from the previous year to
identify if any of those that cause harm would this year
have been classified as a serious incident as the criteria
had changed.
This study concluded that LCH would have reported an additional
41 incidents to the commissioners if the new criteria was applied
to 2013 / 14 incidents. Each of the 41 incidents identified had a
completed investigation that would not have been carried out
differently had the new criteria applied.
The change in reporting requirements has led to an increase in
the reporting of Serious Incidents (SIs); these incidents being
category 3 pressure ulcer and fractured neck or femur incidents.
Excluding those additional incidents reported this year in response
to the change in criteria: 7 SIs have been reported so far this year in
comparison to a total of 13 for 2013 / 14. This indicates no significant
change in the number of other SIs reported.
Complaints
In January 2015 LCH introduced a revised compliments and complaints
process which aims to ensure all concerns and complaints are handled
timely to meet statutory requirements and public expectations.
This year LCH logged 338 complaints. 238 complaints related to services that we provide (see table below). The
remaining complaints were passed to other organisations for investigation. The total number complaints we
have received this year is slightly less than last year (261) but still more than in 2012 / 13 (171).
300
250
200
150
100
50
0
2012 / 13
2013 / 14
Complaints received
[22] Quality Account
2014 / 15
Most of the complaints that we receive were about
clinical treatment, delayed or cancelled appointment
or the attitude of staff. So far we have resolved
131 complaints. Eighty five of these were either
fully or partially upheld and we have written to the
complainant to apologise and explain what we will
now do differently. To ensure that we are not making
the same mistakes again we will share the learning
from complaints along with good practice through
a newly created organisational Patient Experience
Group.
Equality and diversity
2015
In 2015, LCH achieved the NHS Equality
Delivery System 2 overall grade of ‘achieving’.
In working towards this we have also been
recognised in the national setting with:
we’re
#3!
An improved ranking with the Stonewall Workplace Equality Index from 244 to 154
An improvement to 3rd in the Stonewall Healthcare Equality Index from 7th last year
An Employers Network for Equality and Inclusion (ENEI) silver award
Jobcentre Plus ‘Positive about Disability’ re accreditation
LCH continues to work with Black
Health Initiative Leeds (BHI) in
the delivery of the ‘Who am I?’
BME lesbian, gay and bisexual
(LGB) awareness conference. The
aim of this conference was to
support people in declaring their
sexuality and feeling comfortable
in accessing appropriate support
and services.
With other partners in the city, as
the Leeds Equality Network, we
fedback that there was a lack
have been working in partnership
of information from health
to improve access and experiences
visitors suitable for same sex
of lesbian, gay, bisexual and
couples. As a result of this
transgender (LGBT) people in
we raised awareness
the city. We supported
amongst staff
the Leeds LGBT
We have
about language
Challenge event
been
working
and support
held at Leeds
in partnership to
available
Civic Centre
improve access and
from other
in July. At
this event
experiences of lesbian, agencies.
members of
gay, bisexual and
the public
transgender (LGBT)
people in
the city
Quality Account [23]
Well-led
The table below shows the priorities relating to well-led that we set last
year, the progress we have made against each target and what we
will do in relation to each priority.
Quality area
for action
Develop
leadership
within the
organisation
Communication
and staff
engagement:
70% of staff
report that they
would fell happy
for a relative to
be treated by our
organisation
[24] Quality Account
Achievements to date
Leadership development work has been maintained
with participants continuing to complete courses in
ILM at levels 4, 5 and 7. Bespoke leadership events
have taken place to support the introduction of
revised leadership structures.
100
80
60
40
20
0
2012 / 13
2013 / 14
Average satisfaction
2014 / 15
Comments
We will continue to develop
leadership as a priority next year.
We are pleased that the
percentage of staff that would
fell happy for a relative to be
treated in our services has
increased since last year. We
recognise that this is still not
as high as the national average
and we have plans in place to
increase this for next year.
Leadership and staff engagement
This year we have continued to develop leadership within the
organisation and ensured that we have retained clinical leadership
through the service reviews.
For example, the neighbourhood teams that we
have created in the adult services have a clinical
and an operational leader to reflect the clinical and
managerial leadership of the business unit.
The CQC noted that leadership in the organisation
is improving and that staff felt supported by their
immediate line managers. They also noted that at the
time of their inspection, many services were going
through a service review and there was low staff
morale. This was also reflected in the low response
rate from staff to the annual staff survey. Our overall
response rate for the national staff survey was lower
than anticipated at 34%.
The Trust’s top five ranking scores in 2014 were
as follows:
3.67 Fairness and effectiveness of incident
reporting (benchmark 3.58)
93% Percentage staff reporting errors, near misses /
incidents (benchmark 91%)
86% Staff receiving training on Learning or
Development (benchmark 83%)
91% Percentage of staff appraised in last 12
months (benchmark 90%)
19% Percentage of staff experiencing, harassment,
bullying or abuse from staff (benchmark 19%)
The Trust’s bottom five ranking scores in 2014
were as follows:
3.63 Support from immediate managers
(benchmark 3.75)
Quarter 1
Quarter 2 Quarter 3 Quarter 4
81.3%
77%
National
76.5%
Staff Survey
64%
In addition to the national survey LCH also introduced
the staff friends and family test as part of the national
commissioning for quality and innovation guidance.
As part of this survey, staff were asked each quarter
if they would be happy for a friend or relative to be
treated in the services we provide. The results are
shown in the box above.
The average staff satisfaction over the year is over
70%. We recognise that there is still work to be done
to improve staff engagement and leadership in the
organisation. The new Organisational Development
strategy, which encompasses our approach to
leadership development, was adopted by the board
in June 2014 and a detailed action plan agreed in
October 2014. A coordinated programme of staff
engagement, led by the Chief Executive, has started
this year and will continue in 2015 / 16 with the
aim of people feeling connected and aligned to our
vision and values. This includes organisation wide
engagement events and a continued focus on how
we ensure better engagement and visibility between
senior leadership and staff. We have commissioned
various strands of work which includes continued
work on developing a behavioural framework and
investment in individual and team coaching.
53% Staff suffering work related stress (benchmark
41%)
3.54 Staff job satisfaction (benchmark 3.67)
32% Staff having equality and diversity training*
69% Staff feeling satisfied with the quality of
work and patient care they are able to deliver
(benchmark 75%)
* Our obligation for statutory and mandatory
requirements are met; staff joining the Trust at
induction also have e-learning access in the first 3
months.
Quality Account [25]
Members’ priorities
Last year we invited members to identify priorities for quality improvement
and we included these in our quality account. There were 3 specific areas
that we said we would look at.
1
We said we would:
demonstrate how
we have listened to
and acted upon the
feedback given by those
that use our services
Were
very happy,
everyone was
chatting. The theme
seemed to draw
people in.
We have held 7 focus groups in
the form of ‘tea parties’ at
Community Intermediate
Care Unit (CICU) and South
Leeds Independence
Centre (SLIC). These
are held quarterly and
provide an opportunity
for patients at those
units to feedback to LCH
members who are not
involved in delivering care.
The views gathered direct
from patients and carers, with
observations made by LCH members, are collated and fed back
to the units with action as a result shared on “you said …we did”
displays on the units and made publicly available on the Members’
Zone of the website http://www.leedscommunityhealthcare.
nhs.uk/membership_/members_zone1/
A key change being made as a result of feedback is to increase social activity through the development of
volunteer roles and individually engage patients not able to attend the tea-party itself.
2
We said we would:
create visible markers
for people to know and
be reassured that the
practitioner treating /caring
for them is competent
All the staff wore
badges. They were very
helpful and polite. The staff
did provide a lot of useful
information about the
diseases.
[26] Quality Account
We set up a Quality Steering Group for
patients, carers and public members
to design tools and markers for
different areas of competence.
The group developed a tool
based on mystery shopper
principles, called ‘my LCH
experience’ and prioritised
safety as the first area they
wished to consider. 35 health
centres and clinics were invited
to take part and there were 139 respondents from 17
different health centres covering 11 different LCH services.
my LCH
experience
98.6% respondents were satisfied or very
satisfied with the visible markers for safety by
staff delivering their care.
An annual programme of markers has been developed by the
Quality Steering Group. The next marker being developed is
around caring.
3
We said we would:
use mystery shopper
principles to evaluate the
communication of nonclinical staff e.g. receptionists,
to provide reassurance that
clinical and non-clinical staff
communicate effectively and
treat people as individuals
Everything
was professional
and comfortable.
Staff made me feel
welcome and at
ease
Patients, carers and public members in the Quality Steering
Group designed a tool called ‘my LCH experience’ which
was used to gather people’s views on their experience of
front of house.
92.9% respondents to date were either
satisfied or very satisfied with their
experience of reception.
The markers identified for this included whether
staff identified themselves, communicated clearly,
had a positive attitude (were helpful), created a
welcoming atmosphere (smiled).
Quality Account [27]
Section 2 :
Statements on
quality as mandated
in the regulations
T
his section of the quality accounts contains all the statements that
we are required to make. These statements enable our services to be
compared directly with other services submitting a quality account.
[28] Quality Account
Review of services
Staff drive transformation and innovation through:
Contributing to the organisation-wide service review and
redesign project for their service.
Developing their improvement and innovation capability
expertise through taking part in the Improvement Learning
Programme or ILM improvement and innovation module.
LCH is midway through a
significant transformation
programme, which has
included the initiation of
twenty service reviews during
2014 / 15. The service reviews
have focused on designing and
delivering improvements in
service quality and outcomes
for service users whilst utilising
resources more efficiently.
Examples of
improvements in quality
include:
Integrated Children’s
Additional Needs Service
(ICAN): The service review has
centred on integrating a number
of separate Children’s nursing,
therapy and medical services into
a single coordinated and joined-up
child and family orientated service
focused on outcomes, using goalsetting to direct care planning.
This will promote coordination
of care, ensure quality of service
provision, reduce duplication and
allow for discharge planning.
Aspects of service provision will
be redesigned by April 2015 to
most effectively deliver this care,
including:
Management and leadership
reorganised to support
inter-disciplinary working
and to provide operational
management closer to the
teams.
cha
Transformation: Service Reviews and
Developing Improvement Capability
nge
During 2014 / 15 LCH provided and/or sub-contracted 65 NHS services.
LCH has reviewed all the data available to it on the quality of care in
all of these NHS services. The income generated by the NHS services
reviewed in 2014 / 15 represents 100 per cent of the total income
generated from the provision of NHS services by the LCH for 2014/15.
e
h
be t
Clinical pathways will be
reorganized to ensure
children are seen by the most
appropriate professional and
given the right support as early
as possible in their care.
Development of robust service
user involvement in ongoing
service design and delivery.
Improving access to
and coordination of
services through, for
example, a single
point of access;
ensuring that all
appointments are in
the right service first
time, have a clear
purpose, allow choice
and thereby adding
value to children and their
families.
Quality Account [29]
Integrated Health and Social Care services for adults:
In a similar way to the changes described above, there
is a major programme of work to join up services for
(older) adults in a more effective way. This includes
services within LCH but also services provided
by adult social care and GPs. The aim will be to
create neighbourhood teams that work with
identified GP practices. The quality improvements
this will deliver to service users include:
Better planned and coordinated care between
professionals with less duplication and repetition
for service users.
Delivery of standardised care across the city
through 13 integrated neighbourhood teams.
More efficient referral and information
management systems supported by an electronic patient
record, enabling information to be shared more effectively
and thus leading to safer, more effective care.
School Nursing and Immunisation service: This service review has focused on maximising the capacity of
frontline school nurses and support workers to provide pro-active support and care for school age children. This
will be achieved through:
Centralising referrals and administration within a single point of access
to the service. This will ensure a faster, more effective response to
service users / referrers, and will be supported by improved webbased access to information, enabling more self-management,
in response to feedback from children and families.
Reducing overhead costs by streamlining from 6 teams to 3
teams, to be based across the city.
Standardising the school nursing and immunisations service
offer to children and families across the city and ensuring the
3 teams are staffed with the appropriate staffing levels and
skills / experience to deliver this offer effectively.
Improving the sharing of information and other communications
through an electronic patient record.
Transformation: Involvement in city wide service improvement:
This year we have worked with other organisations
in Leeds as part of the Leeds Institute for Quality
Improvement (LIQH). The aim of the LIQH is to create
a culture of best quality clinical care across Leeds.
It has supported organisations in doing this by
developing skills and abilities in understanding data
and variation; developing a shared understanding
of quality improvement: facilitating system wide
leadership and championing co-production.
[30] Quality Account
As well as having staff represented on the steering
groups developing the LIQH, we have supported
4 members of staff in undertaking the Advanced
Leaders programme and approximately 15 staff in
undertaking the Professional Leaders Programme. The
programmes we have worked on across Leeds include
the COPD, Cardiac and Fractured Neck of Femur
pathways. Staff have been able to take the learning
from this work and apply it in other areas.
National clinical audits
D
uring 2014 / 15 five national clinical audits and 1 national confidential inquiry covered the NHS services
that LCH provides.
During that period LCH participated in 80% of national clinical audits and 100% of national confidential
enquiries, of the national clinical audits and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that LCH was eligible to participate in during
2014 / 15 are as follows:
Eligible national clinical audits
Eligible national confidential enquiries
Chronic Pain (National Pain Audit)
National Confidential Inquiry (NCI) into
Suicide and Homicide by People with
Mental Illness (NCI / NCISH)
Epilepsy 12 (RCPH National Childhood Epilepsy Audit)
Parkinson’s Disease (National Parkinson’s Audit)
National Diabetic Foot Care Audit
National Audit of Intermediate Care
The national clinical audits and national confidential enquiries that LCH participated in during 2014 / 15
are as follows:
National clinical audits participated in
Chronic Pain (National Pain Audit)
Epilepsy 12 (RCPH National Childhood Epilepsy Audit)
Parkinson’s Disease (National Parkinson’s Audit)
National confidential enquiries
participated in
National Confidential Inquiry (NCI) into
Suicide and Homicide by People with
Mental Illness (NCI / NCISH)
National Audit of Intermediate Care
The national clinical audits and national confidential enquiries that LCH participated in, and for which data
collection was completed during 2014 / 15 are listed below alongside the number of cases submitted to each
audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.
National audit
Number of cases submitted
Percentage
National Audit of
Intermediate Care
The audit was not looking at the
quality of care but was looking at
service configuration.
N/A
Epilepsy 12 (RCPH
National Childhood
Epilepsy Audit)
This is a city wide audit across 2
Trusts therefore number of cases
per Trust is not available.
Not
available
National confidential enquiries
Number of
cases submitted
Percentage
National Confidential Inquiry into
Suicide and Homicide by People
with Mental Illness (NCI/NCISH)
3
Not
available
Data was submitted for one
of the four audits. The other
three audits were not in the
data collection phase during
2014 / 15 so no cases were
submitted for these audits.
The Trust agreed that it would
not participate in the National
Diabetic foot care audit during
2014 / 15 but that it would
alternatively audit foot ulcer
care during 2015 / 16.
Quality Account [31]
The reports of four national clinical audits were reviewed by the provider in 2014 / 15 and LCH intends to take
the following actions to improve the quality of healthcare provided:
National Audit
LCH action 2014 / 15
Chronic Pain
(National Pain Audit)
The Trust continues to be involved in the Leeds Chronic Pain Steering Group. There is
now a revised pathway and the revised service specification/model of delivery has been
tendered. New contracts will be awarded mid-March with a view to service provision
commencing in April 2015. The Trust is planning to bid for the service with a view to
continuing to provide a high quality evidence based pain management service that meets
the recommendations regarding Multidisciplinary working and patient centred care.
Epilepsy 12
(RCPH National
Childhood Epilepsy
Audit)
• The Epilepsy 12 audit is a city wide audit across two Trusts; it is therefore not
possible to separate the dataset for analysis per Trust.
• LCH has participated in the re-audit process and is compliant with access to patient
information with availability of leaflets and web based information from appropriate
organisations.
• Whilst there are no Epilepsy Nurse Practitioners in LCH, there is a trained nurse to
provide training for parents and other inter-agency staff for administration of rescue
medication.
• LCH paediatricians work closely with Tertiary Paediatric Neurology services and have
access to LTHT Epilepsy Nurse Practitioners in shared care patients and is exploring
the possibility of an extended nurse practitioner role within CDCs which will further
improve counselling and training for patients, families and professionals.
Parkinson’s Disease
(National Parkinson’s
Audit)
The 3.5 wte Parkinson’s Disease Nurse Specialists are now in post. There was no audit
in 2014 but LCH will be participating in the 2015 audit in conjunction with LTHT. The
service redesign is ongoing since this is a two-year project.
Falls and non-hip
fractures
(National Falls and
Bone Health Audit)
• Community teams continue to screen patients for their risk of falls using the Tier 1 falls
risk screening questions, which determines if a more in-depth falls risk assessment
is required (Tier 2). Tiers 1 and 2 falls risk assessments are being developed onto
Electronic Patient Record (EPR) templates. Community LCH services that complete the
Tier 2 falls risk assessment have access to community geriatricians and the Falls Clinic
at the local acute hospital for further medical assessment and support if required.
• Falls education sessions are currently being run for registered staff in the
neighbourhood teams.
• Standard Operating Procedures have been developed for falls occurring in the
community and in inpatient / Community Intermediate Care bed bases.
• The Prevention of Patient Slips, Trips and Falls Policy is currently being reviewed. A
falls work plan has been developed to reflect the ongoing work being undertaken
in the Trust which in turn will identify any areas of further work required.
• The audit was not required during 2014/15.
National Audit of
Intermediate Care
The National Audit of Intermediate Care (NAIC), now it its third year, provides a
unique, “bird’s eye” view of intermediate care commissioning and provision in
England. The organisational level aspects of the audit covered four service categories
(crisis response, home based intermediate care, bed based intermediate care and reablement services) for the second year running. This demonstrates a comprehensive
picture of services that support people after leaving hospital, or at risk of being sent
to hospital, and allows changes between the years to be reviewed.
The audit highlighted a wide variation in service configuration, scale and performance
between services in different areas of the country. For Leeds, this is the first time that
the Trust, CCG and Adult Social Care colleagues have participated in this national
audit. The local and national results for providers and commissioners will assist in
shaping the future community and a bed based model for the community of Leeds.
[32] Quality Account
Local clinical audits
T
he reports of 35 local clinical audits were reviewed by the provider in 2014 / 15 and LCH intends to take the
following actions to improve the quality of healthcare provided:
It is planned to develop a pathway and prescribing
checklist for young people on ADHD medication at
the time of detention; young people where ADHD
medication has lapsed; and young people with
ADHD symptoms without a diagnosis. The check
list will include important past medical history and
physical monitoring.
An audit of missed and delayed doses of
medication at the adult inpatient units at SLIC and
CICU identified an area for improvement when
there was a missed dose with an approved missed
dose code recorded (good practice), the full details
for the reason(s) for omission were not always
documented on the appropriate section of the
prescription chart. The requirement for the detail
to be recorded has been reinforced to staff and it
is planned to re-audit this at both inpatient centres
during 2015 / 16.
An audit of the use of Therapy Outcome Measures
within the Childrens’ Physiotherapy Service.
An audit of compliance of the use of the 6 month
plan in West CDC.
During 2014 / 15 all services were required to
participate in the annual documentation audit
and produce an action plan to identify required
improvements. 92% of services completed their
annual documentation audit and the remainder
(4 services) were deemed as exceptions due to the
impact of service reviews. A revised audit tool was
developed for staff to use to undertake their annual
documentation audit. In addition a documentation
prompt card was developed and disseminated
to clinical staff to remind them of the expected
standards for record keeping.
All audits undertaken are recorded
An audit of Controlled Drugs (CDs) was carried
on the Trust’s registration
out at LCH inpatient settings and the overall
database. 2014 / 15 has
Audits are
results demonstrated safe and secure use
seen a reduced number
and handling of CDs. There were some
being prioritised
of clinical audits being
further good practice points identified
undertaken due to the
to focus on
where record keeping of dosage forms
impact of the work
could be improved to ensure clarity. Two outcomes of serious
involved in completing the
further standard operating procedures
and
major
harm
service reviews. Audits are
(SOPS) were developed around the supply
being
prioritised to focus
incidents
of CDs and clinical monitoring of prescribed
on outcomes of serious and
CDs to ensure that LCH meets regulatory
major harm incidents, which
requirements in this area.
include updating relevant policies and
A re-audit of prescribing standards within SLIC
procedures and ensuring staff are supported with
demonstrated a high level of compliance overall.
their clinical competencies.
One area requiring improvement identified was
that medicine names must be recorded on the
medication chart in capital letters as per the Trust
Medicines Code, which was not always adhered
to. A further developmental area focused on
cancellations of medicines and ensuring these
are signed and dated to ensure that all staff are
aware when medicines have been stopped, and
by whom. These two areas for improvement were
discussed with prescribers on the unit. A further
re-audit will be undertaken in 2015 / 16.
Quality Account [33]
Local clinical audits
•Prescribing Standards Audit on inpatient units
•Audit of Controlled Drugs on inpatient units
•Missed and Delayed Doses of Medication on
•Children’s Physiotherapy Treatment Handling Risk
•Infection Prevention and Control Environmental
•Falls Audit in LCH Inpatient Units
•Monitoring of physical health in young people
adult inpatient units
Audit South Leeds Independence Centre (SLIC)
•General Cleaning Audit in South Leeds
Independence Centre (SLIC)
•Review of completed Part C Health Plans on the
BAAF Form (British Association for Adoption and
Fostering)
•Paracetamol Prescribing Practice Within (Inpatient
Unit)Little Woodhouse Hall (LWH)
•Audit of patients with ulceration having care plan
E applied and wound forms completed within the
patient record (Podiatry)
Assessment
•Audit on Assessment and Treatment of cases with
ADHD in Wetherby Youth Prison
with intellectual disabilities who are prescribed
antipsychotic medication for challenging
behaviour
•Fire Safety Re-audit
•SUDIC Process
•Medical Devices Inventory
•Review of practice for time interval between
pessary changes between different types of
pessary, different clinicians and establishing
standard practice.
•Audit of physical health monitoring of patients on
•Evaluating the Implementation of the Leeds Child
•Compliance with Standard Operating Procedures
•Re-Audit of personal evacuation plans - process
antipsychotics and Opioid Substitution Therapy
(OST)
(SOPS) Safeguarding Adults
•Audit of assessment and management of pain for
inpatients on the Community Intermediate Care
Unit (CICU)
•Measuring compliance with Nice Guidelines Management of Spasticity with children
•Children’s Occupational Therapy Routine
Outcome Measurement (ROM) Audit Project
and Adolescent Mental Health Service Eating
Disorders Assessment Pathway
for wheelchair users attending podiatry clinic at
Yeadon HC
•Quick starting and bridging prior to implant
insertion
•Assess use of the Visual Analogue [pain] Scale
(VAS), or other subjective / objective record
entry, to record efficacy of insole provision within
generic LCH Podiatry clinics
•Audit of Use of Therapy Outcome Measures
•Infection Prevention and Control Health Centre
•Appropriate use of referral pathways within the
•IBS Prospective - Community Dietetics
•Measuring the efficacy of prescription orthotic
(TOMS) within the children’s physiotherapy
service
podiatry service for non-diabetic and diabetic feet
•Audit of standards of care provided to women
who request emergency contraceptioncompletion of audit loop
•Audit on outcomes for all patients referred from
the new entrant TB screening clinic to Leeds
Chest Clinic
•Quit Manager compliance audit
•Medicines Reconciliation
[34] Quality Account
Environmental Audits
devices issued by LCH Podiatry
•Leg ulcer - Any Qualified Provider (AQP) Outcomes
•Audit of the Pressure Ulcer Action Plan
•Out of Hours Admissions
•Patients who lack capacity to consent to care and
treatment
•DNA Appointments
•Audit of Delayed Discharges in the Adolescent
Inpatient Service
Clinical research
The number of patients receiving NHS services
provided or subcontracted by LCH in 2014 /
15 that were recruited during that period to
participate in research approved by a research
ethics committee was 550.
Research activity in LCH continues to grow and new teams are becoming
involved in the research agenda. Locally and nationally, there is a drive to
initiate and deliver clinical research that increases the opportunity for patients
to participate. Teams such as the Musculoskeletal service and the Stroke
Rehabilitation and Neurology services are keen to ensure they have support both
financially and from the Research and Development (R & D) team to achieve this.
One service which has shown the impact of research is
seen within the prison setting. The research team
developed a risk assessment tool for prisoners
to better assess risk of self-harm to facilitate
closing of the Assessment, Care in Custody
and Teamwork (suicide monitoring)
document. They also published a paper
on an 8 year dataset of methadone
prescribing in HMP Leeds. The key
message was that despite rapid increase
in prescribing, there were no methadone
related deaths over the 8 year period. The
paper highlighted the competency and
clinical governance framework to ensure
patient safety.
Quality Account [35]
Commissioning for Quality and Innovation (CQUIN)
A
proportion of LCH income in 2014 / 15 was conditional on achieving quality improvement and
innovation goals agreed between LCH and any person or body they entered into a contract, agreement
or arrangement with for the provision of NHS services, through the Commissioning for Quality and
Innovation payment framework.
Further details of the agreed goals for 2014 / 15 and for the following 12 month period are available on
request from lorraine.chapman4@nhs.net
CQUIN Goal
Target
Actual
Friends and
Family Test –
Implementation of
staff FFT
Demonstrate indicator has been
achieved
Achieved
Friends and
Family Test – Early
Implementation and
phased expansion of
patient FFT
To implement in some services
by April 2014 and all by March
2015
Achieved
Safety Thermometer
- Improvement Goal
Reduction to 4.5% prevalence
or lower – calculated based on
the median of five consecutive
monthly data points up to 31
March 2015
Not
achieved
We did not achieve 4.5% for 5
consecutive months. We were
below of close to the national
average for the last 4 months of
the year
Pressure Ulcer
Reduction Plan
100% of admitted patients
should be screened for pressure
ulcers and those at risk should
have management plan in place
Achieved
We worked closely with partner
organisations in the city to
develop an action plan to
achieve this
Dementia Find,
assess refer Community Matrons
≥ 90% patients are: asked
dementia case finding question;
have diagnostic assessment; are
referred for diagnostic advice
Achieved
Dementia Find, assess
refer – Community
Intermediate Care
Beds
90% of admitted patients should
be screened for dementia and
referred for specialist diagnosis
where required
Achieved
Best Start - Children
with Complex Needs
Joint development and delivery
of a whole pathway service for
children with complex needs
Achieved
Development of
neighbourhood
teams
Development of neighbourhood
plans detailing how integrated
neighbourhood teams will work
with GP practices
Achieved
Joint Review of
Discharge Incidents
Improve discharge for patients
thorough joint review of
discharge incidents
Achieved
[36] Quality Account
Comment
CQUIN Goal
Target
Actual
Comment
Prison Healthcare
- Escort and Bed
Watch (EBW)
Reduction Plan
10% reduction in escort and bed
watch activity
Achieved
CAMHS Inpatient
- Cardiometabolic
assessment for
patients with
Schizophrenia
Completion of national audit
of schizophrenia demonstrating
90% of patients assessed in
relation to 6 key cardio metabolic
indicators
Achieved
CAMHS Inpatient
- Communication
with General
Practitioners
Number of patients who’s GP
has been provided with an up to
date care plan
Achieved
CAMHS Inpatient
- Assuring the
appropriateness
of unplanned
admissions
60% improvement in reviews
carried out within 5 days
Achieved
CAMHS Inpatient Specialised services
quality dashboard
Develop a clinical dashboard
Achieved
Pain - Clinic Letters
>95% of clinical letters sent to
GP within 2 days of appointment
Achieved
By then end of the year we were
achieving 100% consistently
Pain - Clinic
Cancellation
Reduction in cancellation of
clinics to no more than 1% of
total appointments
Not
achieved
We did not achieve the 1%
target
Pain - Inappropriate
referrals
>80% of inappropriate referrals
returned to GP with reason
for rejection and advise on
appropriate treatment given
Achieved
Pain - Patient
Experience
Development of patient
satisfaction questionnaire and
achievement of >50% return
rate
Achieved
We achieved an average return
rate of 61%
CQC registration
LCH is required to register with the Care Quality Commission and its current registration
status is full registration without condition. LCH has the following Compliance notices
on registration:
We must make sure that we protect patients at Little Woodhouse Hall against the risks
associated with unsafe or unsuitable premises.
We must make sure that we record on the computer systems as well as on paper any risks we
have identified for individual patients in the Child and Adolescent Mental Health services.
Quality Account [37]
Secondary uses and hospital episode data
LCH submitted records during 2014 /15 to the Secondary Uses Service for inclusion in the Hospital
Episode Statistics which are included in the latest published data. The percentage of records in the
published data:
Which included the patients valid NHS Number was 100% for admitted care and was 99.97%
for outpatient care.
Which included the patient’s valid General Medical Practice Code was 99.76% for outpatient care.
General Medical Practice code was an optional field in version 6.1 of the Commissioning Dataset
that the trust was using but this is now mandatory in version 6.2 and is included in submissions
from January 2015.
Information governance
Leeds Community Healthcare NHS Trust will achieve level 2 compliance in
2014 / 15 and be graded green as part of the Information Governance Toolkit
assessment conducted annually. This ensures that LCH has the relevant policies,
procedures and working practices in place to comply with the requirements of
the Data Protection Act and mitigate risk across the organisation.
LCH also deal with large volumes of requests for personal data and consistently
meets statutory deadlines in compliance with the Data Protection Act 1998 and
Access to Health Records Act 1990 legislation. Deadlines are also consistently
met in compliance with the Freedom of Information Act 2000.
Payment by results
LCH was not subject to the Payments by
Results clinical coding audit during 2014 /
15 by the audit commission.
[38] Quality Account
Staff satisfaction
T
he table below shows the percentage of staff employed by, or under contract
to, the Trust during the reporting period who would recommend the Trust as a
provider of care to their family or friends as reported on the staff satisfaction survey.
Year
Number
of staff
employed
% of those staff employed
who recommend the trust
to family or friends
National
average
2013 / 14
2970
60%
67%
76% / 60%
2014 / 15
2960
64%
70%
83% / 62%
The LCH considers that this percentage are as
described for the following reasons:
There has been a degree of change
across all services and management
arrangements that may have impact on
perceptions of quality.
83% of staff feel positive about their role
making a difference to patients in response
to questions on the national staff survey.
81% of staff feel they get support from
their work colleagues.
Highest /
lowest
The LCH intends to take / has taken the following actions to
improve this percentage and so the quality of its services by:
The executive team have engaged with staff through
listening events.
Local newsletters update staff on changes happening in
their teams and area of work.
The health and well-being team are continuing to
organise events to promote staff health such as the
pedometer challenge.
The organisation is celebrating the contribution of staff
through the innovation and research forum and staff awards.
Quality Account [39]
Patient experience of community
mental health services
T
he table below summarises service user satisfaction with Specialist
Child and Adolescent Mental Health Service (CAMHS) interventions
during this reporting period and the last reporting period.
Reporting
year
Community CAMHS
Inpatient CAMHS
Young
Parents
Young
Parents
persons’
and carers’
persons’
and carers’
satisfaction satisfaction satisfaction satisfaction
2013 / 14
80.81%
88.98%
49.51%
73.21%
2014 / 15
78.24%
88.50%
38.54%
40%
Source: CHI-ESQ, a CAMHS-specific satisfaction questionnaire used nationwide
LCH considers that this data is as described for the following reasons:
The notable drop in satisfaction within CAMHS in patient’s services
can be accounted for by a change in data collection method to
include an increased range of satisfaction indicators. This will be
tracked in future years.
[40] Quality Account
LCH intends to take the following actions to improve
this indicator score, and so the quality of its services, by:
LCH considers that this data is as described for the
following reasons:
Reviewing all user feedback on a regular basis,
sharing learning across the service and using
feedback to guide service developments, for
example changing time of appointments.
Patient Experience data collection is a national
requirement of all IAPT services, with satisfaction
measured post screening and at the end of
treatment.
Involving young people in recruitment and selection
processes for practitioners working in CAMHS.
Audits are carried out once a year by the service.
Using our new staff training DVDs, developed with
young people and their parents / carers willing to
share their experiences.
Leeds IAPT intends to take the following actions to
improve this indicator score, and so the quality of its
services by:
Facilitating a young persons’ self-harm focus group
to explore young people’s experiences of attending
Emergency Department and receiving CAMHS
assessment and follow-up after an episode of selfharm.
Reviewing all patient feedback on a regular basis
and sharing learning across the service. This
process will include patient representation.
Developing and extending the range of ways we
measure the effectiveness of our interventions,
for example session rating scales and goal-based
outcome measures.
Continuing to co-ordinate a support group for
parents / carers of young people with eating
disorders providing an opportunity for carers
to meet others in the same situation and share
experiences.
Supporting our user involvement champions within
the service to identify different ways to involve
young people and families in the service design
and development.
More information regarding these developments is
available upon request by emailing:
karen.worton@nhs.net or
hannah.beal@nhs.net
Satisfaction within Leeds Improving Access to
Psychological Therapies services (IAPT) is collected
and recorded as part of a national data set. The
trust’s patient experience of community mental health
services indicator score with regard to a patient’s
experience of contact with a health or social care
worker during the reporting period is given in the
table below.
Reporting year
2012 / 13
2013 / 14
2014 / 15
Working collaboratively with GP practices to help
patients be better informed about the services
when discussing possible referral.
Using our patient leaflets, developed with patients,
which describe the range of services offered.
Continuing to organise and learn from events with
patients about aspects of our service for example
consultations times and venues.
Continuing to improve access to the service
by reducing waiting times which has seen a
significant number of patients now being offered
treatment within 3-4 weeks.
More information regarding these developments
is available upon request by contacting Bernie Bell,
Head of Service bernie.bell@nhs.net
Change the
way you
think.
Leeds IAPT (Improving
Access to Psycholgical
Therapies) is a partnership
between Leeds Community
Healthcare NHS Trust, Leeds
Counselling, Community Links and
Touchstone.
Leeds
IAPT
Percentage satisfaction
all of the time
78%
77%
83.5%
Quality Account [41]
Patient safety incidents
T
he table below shows the number and percentage 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:
Reporting
year
Number
of all
patient
safety
incidents
Number of
patient safety
incidents that
resulted in
severe harm or
death
Number as a
percentage
of all
patient
safety
incidents
2011 / 12
2540
29
1.1%
2012 / 13
2371
20
0.84%
2013 / 14
3199
35 (30 severe
harm + 5 deaths)
1.09%
2014 / 15
3927
27 (25 severe
harms + 2 deaths)
0.69%
LCH considers that this number is as described for the following
reasons:
Staff are encouraged to acknowledge and be open when
something has gone wrong through the reporting and
learning from incidents.
We are continually developing the incident reporting
processes to improve the quality of the data produced.
We have raised the profile of reporting all falls that result in a
fractured neck of femur as a severe (major) harm incident.
Leeds Community Healthcare NHS Trust intends to take the
following actions to improve this number and / or rate, and so
the quality of its services, by:
Continue with the established pressure ulcer panels to review
all category 3 pressure ulcers.
Develop panels for incidents resulting in a fracture neck of
femur.
Introduce a quarterly newsletter for staff identifying quality
matters.
Continue to promote incident reporting.
Continue to provide training at all levels within the
organisation.
[42] Quality Account
Since September 2014 we have been able
to differentiate between incidents that
occur whilst patients are under our care
and those that do not. Of the 25 severe
harm incidents that were reported, 18
occurred whilst the patient was being
cared for by us. The two incidents that
resulted in death occurred while patients
were under our care. One is still under
investigation and the other was as a
result of an MRSA infection. We have
completed the investigation into this
incident and have been working with the
Trust Development Authority (TDA) on
implementing our action plan. This has
included the TDA supporting our services
with a training session.
Section 3 :
Quality improvements for
the coming year
W
e are currently in the process of reviewing our quality strategy. The new strategy will
consider quality in relation to the five Care Quality Commission (CQC) domains of quality and
will explain our model for continuous quality improvement. This year we have organised our
priorities for the quality account under each of the CQC domains. To identify what actions we need
to take to improve quality this year we have:
Invested resource in developing and
undertaking a Quality Challenge tool that
enabled services to self and peer assess their
services in relation to the five CQC domains.
Engaged with stakeholders through
membership events.
Reviewed the performance data that is
regularly reported to the Board.
Considered the feedback received from CQC,
Trust Development Authority and Clinical
Commissioning Groups.
Reflected on the learning from incidents and
complaints.
Patient and carer priorities for 2015 / 16 come from the
common themes identified through involvement and
patient experience. Feedback from patients and carers
has identified the frustration of being asked the same
questions again without the issues raised previously being
addressed. Improving patient experience of the following
issues are therefore member’s quality priorities:
Access to services
Dignity, choice and respect
Carers’ needs and involvement
Communication – interpersonal skills, documentation
and sharing information.
Quality Account [43]
Safety
This year our priorities for improving safety are:
Quality area for
action
Suggested projected outcome
2015 / 16
Suggested indicators
Protecting patients
from harm that
happens in our
care
Reduce the number of patients who
develop a pressure ulcer or have a fall
while in our care.
5% reduction in category 2 and 3 pressure
ulcers, aspire to no category 4 pressure
ulcers and 5% reduction in falls resulting
in avoidable harm in our inpatient units.
Safeguarding
Implementation of the Think family,
Work family protocol across children’s
and adult services.
Briefing sessions for all staff.
Process in place to endure learning is
shared.
Over the last 3 years in our quality accounts we have
focused our improvement on ensuring that there
are appropriate processes in place and that staff are
trained to be able to deliver safe care. We have been
successful in creating a good reporting culture that
we want to build upon. This year we have chosen
safety improvement priorities that reduce harm caused
to patients that could be avoided. Some of these
priorities link with the Sign up to Safety Campaign.
In September 2014, Leeds safeguarding children’s
and safeguarding adults boards published a Think
Family, Work Family protocol. The protocol guides staff
working with a child or an adult to “be aware of the
individuals in the household; assess any needs those
household members may have; consider potential
impact of any identified needs on the child or adult;
and respond to needs appropriately.” We support this
protocol and have chosen the implementation of the
protocol as an area for quality improvement in our
services. We will work this year on embedding the
protocol by firstly raising awareness through briefing
sessions and ensuring that our processes support
learning across orgnaisations.
Effectiveness
This year our priorities for improving effectiveness are:
Quality area for
action
Suggested projected outcome
2015 / 16
Suggested indicators
Outcome measures
Therapy Outcome Measures (TOMs) are
embedded in all relevant services. Services
are able to demonstrate the difference
they have made to patients health and
well-being.
TOMs data is collected and analysed
for all relevant services. Baseline
performance is agreed.
Audits
Patient care is effective and regularly
reviewed to ensure practice is up to date,
meets standards and addresses areas of
concern.
Clinical audit plan will be agreed and
published.
Supervision for
clinical staff
All services will have agreed model of
supervision and demonstrate that staff are
actively engaging in quality supervision.
Supervision audit showing compliance
with service model.
Patient records
All patients have an accurate and
complete record of their care facilitated
by the Trust.
Increase in the percentage of patients
with complete care records as measured
by the annual documentation audit.
[44] Quality Account
We have been working on introducing outcome
measures in our services over a number of years.
Progress has been slower than we would have liked so
it is important that we continue with this priority for
the coming year. This year we have chosen to focus
on one particular outcome measure, the Therapy
Outcome Measure (TOMs). This is a measure designed
to capture the improvement in a patient’s health and
wellbeing. It is suitable for all staff to use not just
therapists and can be used with both children and
adults. This year we would like to embed the measure
in our services and collect baseline data on which we
can identify areas for improvement.
Supervision for clinical staff is important for patient
care to make sure that our staff are continually
reflecting and learning from the care they have given.
There have been many changes within services as a
result of the service reviews so this year we will be
looking to embed models of supervision suitable
for the individual services. We have had difficulty
in consistently recording when staff have had
supervision. We will address this as we implement the
new models and measure the compliance against this.
Caring
This year our priorities for improving experience are:
Quality area for
action
Suggested projected outcome
2015 / 16
Suggested indicators
Staff health and
well-being
Reduce the percentage of staff that
report work related stress.
Reduce to 41% staff that report they
have experienced work related stress as
measured by the staff survey.
Patient satisfaction
Patients are satisfied with the care they
have received and would recommend
LCH as a place to be treated.
95% of patients report that they would
recommend LCH as a place to receive
treatment.
We know form the staff survey and the changes that
services have been through this year that there is low
staff moral and high levels of sickness. We have a
dedicated health and wellbeing team that are supporting
managers and staff to reduce the level of staff sickness.
We would like to reduce to the number of staff who
report experience work related stress to the national
average of 41%.
We have been collecting patient satisfaction rates for 3
years now. This year we introduced the patient’s friends
and family test (FFT). We have always had high levels
of patient satisfaction and we want to continue to be
assured that we are providing services that meet the
expectations of our patients. Our patient FFT scores have
been slightly lower that the patient satisfaction scores so
this year we would like to bring the FFT score up to 95%.
The NHS Friends
and Family Test
“How likely are you to recommend
our service to friends and family
if they needed similar care or
treatment?”
Have your say. Tell us what’s working well…
and what we could improve.
Quality Account [45]
Responsiveness
This year our priorities for improving responsiveness are:
Quality area for
action
Suggested projected outcome
2015 / 16
Suggested indicators
Learning form
incidents and
complaints
All incidents and complaints have
a completed action plan at the
time of closure.
100% of incidents and complaints with
completed action plans at the time they are
closed.
Publication of
complaints
We are open and transparent
about complaints and the learning
from them.
Number and themes of complaints along with
learning will be published quarterly on the LCH
website starting in September 2015.
Access to services
People are seen at the right time
and are not kept waiting any
longer than is reasonable within
the given resources.
We will meet 18 week targets for mandated
services. We will identify, baseline and agree
reduction targets for secondary waiting lists.
We have reviewed and embedded processes to
manage incidents and complaints. We now need to
ensure that we are learning effectively from this and
that the learning is shared wider than the service
where it occurred. The first stage in achieving this is to
ensure that all complaints and incidents have action
plans completed when they are closed. We will audit
action plans at the end of the year to measure this.
One of the values of the organisation is to be open
and transparent and do what we say we will do. To
demonstrate that we are doing this we will publish on
our website a summary of the complaints that we
have received, what we have learnt from this and the
action that we are taking as a result.
Our members have identified that access to services
is important. We already manage our waiting list to
ensure that we see people within the nationally set 18
week targets. We have recognised that some people
come into our care through one service and are then
referred onto another. We do not think that people
should wait longer than is reasonable within the
given resources when this happens. To make sure that
people do not have excessive waiting times we will
identify when this happen, baseline how long people
are waiting and agree a target to reduce this.
Well-led
This year our priorities for improving leadership are:
Quality area for
action
Suggested projected outcome
2015 / 16
Suggested indicators
Appraisal
Increase the percentage of staff
reporting that they have had a
well-structured appraisal.
Increase to 38% the number of staff who report
that they have had a well-structured appraisal
as reported by the staff satisfaction survey.
Leadership
Behaviours expected of leaders are
identified and shared with all staff.
Publication of an agreed behavioural
framework.
Baseline behaviours in appraisal.
Staff engagement
All staff will feel more engaged in
the organisation and its work.
Increase the percentage of staff as reported in
the staff survey and the staff friends and family
test who feel engaged in the organisation and
its work.
[46] Quality Account
We have increased the percentage of staff within
the organisation having an appraisal within the
year by 15%. The percentage of staff who reported
on the staff survey that they felt this was a wellstructured appraisal was below the national average.
For appraisals to be meaningful and staff to feel
supported in delivering the best care to patients we
need to ensure appraisals are well-structured. We
want to achieve at least the national average (which
currently stands at 38%) for this. Next year we will
incorporate the behavioural framework we are
developing for leaders into the appraisal process. We
will baseline the behaviours we expect to see in the
leaders of our organisation and hold them to account
through the appraisal process.
Moral in the organisation is low. If staff do not feel
engaged in the organisation or its work, they are
not able to provide good care. We have started a
coordinated programme of staff engagement, led by
the Chief Executive with the aim of people feeling
connected and aligned to our vision and values. We
will continue this into 2015 / 16 with the hope of
improving the percentage of staff who complete
the staff survey that report they feel engaged in the
organisation and its work.
How quality will
be monitored
throughout the year
Key indicators from the quality account priorities
will be included in the organisations Integrated
Performance report (IPR). The IPR is reviewed
monthly by the senior management team and
shared with the business and quality committees
before being reported to Board. This will make
sure that senior managers are aware of how we
are doing with our quality priorities.
A more detailed review of the indicators are
included in the information shared with services
as part of their regular performance reviews and
on the quality impact assessment dashboards
published monthly. This will make sure that the
services are aware of how they are doing in
relation to meeting the quality priorities.
Progress against all of the priorities in the quality
account will be monitored through the Clinical
Effectiveness group and the Quality committee.
The clinical effectiveness group will receive a
report each quarter on the progress we have
made with all the priorities in the quality account.
This will enable us to ensure that we are on track
to make the progress we want by the end of the
year. The clinical effectiveness group will report
the progress to the quality committee at least
twice in the year.
Quality Account [47]
Section 4 :
Statements from others on
the quality of LCH services
Comments from
Leeds South and
East CCG
(on behalf of Leeds CCGs)
Thank you for the opportunity to
review and provide a response
to your Quality Account for
2014/15. We have sought views
from a range of stakeholders and
clinicians, and our response is as
follows:
Leeds South and East Clinical
Commissioning Group (CCG)
welcome the opportunity to
comment on Leeds Community
Healthcare Trust’s quality account
for 2014 / 15. Leeds South & East
Clinical Commissioning group is
providing this narrative on behalf
of all three Leeds Commissioning
Groups including Leeds West CCG
and Leeds North CCG.
We have reviewed the account
and we believe that the
information published, that is also
provided as part of the contractual
agreement, is accurate. We are
supportive of the priorities that
have been proposed for the
forthcoming year, and pleased to
note the specification of standards
and thresholds.
In November 2013 the
Government published its
[48] Quality Account
response to Sir Robert Francis’s
report into the events at MidStaffordshire hospital. This report,
entitled Hard Truths, accepted
the vast majority of Sir Robert’s
recommendations and confirmed
the need to focus on high quality
health care. It is crucial that
commissioners and providers work
together to ensure this continues.
We are therefore pleased to see
that the Trust’s priorities focus on
the three main elements of quality
outlined in the Francis report
and the two additional elements
recommended by the Care Quality
Commission (CQC).
We appreciate that LCH is
midway through a significant
transformation programme,
which has included the initiation
of twenty service reviews during
2014 / 15, which has presented
the Trust with some complex
challenges regarding staff
engagement. We are concerned
about the low staff survey
return (34%) and the ongoing
low morale of the workforce,
staff engagement and staff not
feeling involved in change. These
concerns were reflected in CQC
and CCG quality visits and we
note the Trust’s acknowledgment
that improvements need to be
made. We support all actions
to improve morale and the
consequent retention of the
workforce as we recognise the
impact on patient experience
and reported satisfaction of the
service received. It would be
reassuring to see this work linked
to staff appraisals, mentorship and
leadership.
We note that the number
of patient safety incidents
reported within the Trust during
the reporting period, and the
number of patient safety harm
incidents that resulted in severe
harm or death has increased
in 2014/15. LCH has a strong
incident reporting culture and
continues to be in the top three
community organisations for
reporting incidents, therefore we
acknowledge that this increase
may be attributed to the uptake
in the number of staff reporting
incidents in 2014 / 15. It is
reassuring that you have focused
on patient safety as one of the
key priorities for 2015 / 16, with
particular attention on learning
from incidents rather than the
process of reporting. We believe
that the trust should have
referenced Leeds Institute for
Quality Healthcare as a means
to help deliver system wide
improvements.
The Trust experienced some
safeguarding concerns in
2014 / 15 at South Leeds
Independence Centre (SLIC), the
Trust worked collaboratively with
CCG, Local Authority and Health
Watch to develop a detailed
improvement plan to address these
concerns. It would be reassuring
to see a standardized approach
to learning from these incidents
across all 3 bed bases within the
Trust, to maintain the positive
changes.
We welcome the audits which
are being prioritised to focus
on outcomes of serious and
major harm incidents, which
include updating relevant policies
and procedures and ensuring
staff are supported with their
clinical competencies. It is
very encouraging to see a 5%
increase from last year’s position
in the number of staff receiving
appraisals and clinical supervision.
We believe that the Trust should
have acknowledged their plans
for nursing revalidation, which
commence in December 2015.
LCH have acknowledged that
they have not performed as
well as expected with regard to
sharing learning from complaints
beyond the service in which they
occurred. This reflects the findings
from the CQC and CCG quality
visits; therefore we welcome the
Trust developing a newsletter and
exploring new media options for
sharing LCH quality data and the
learning from incidents.
In 2014 / 15 the Trust did not
meet the target for reducing
pressure ulcer prevalence agreed
with commissioners, reporting 59
category 3 and 4 pressure ulcers as
serious incidents. We are pleased
to note the intention for continued
scrutiny and reporting of pressure
ulcers with the ambition to make
improvement against the current
position a priority for 2015 / 16.
We note that numbers of staff
receiving training in relation to
healthcare associated infections
has fallen. We are pleased to see
that staff training will remain a
priority for 2015 / 16 and will be
monitored through the service
performance review process.
It would have been useful to
acknowledge that NHS England
guidance recommends that
community services should be
assessing avoidable cases of
Clostridium Difficile against the
same toolkit that acute trusts are
required to use. The 3 Clostridium
Difficile cases discussed in the
quality account should not
be described as ‘discounted’;
they will be formally classed as
‘unavoidable’, if deemed to be so,
through the correct governance
process.
The trusts Information Governance
Assessment Report Score for
2014 / 15 and green rating is an
excellent achievement for the trust.
This acknowledgment also extends
to the continued year on year
improvement.
We would also like to congratulate
the Trust for the achievement with
The Safe Clean Care Project, and
receiving a runner up prize at the
Nursing Times awards.
to better understand some of the
local clinical audits undertaken
during 2014 / 15; particularly
related to intermediate care
beds, pressure ulcers, falls and
Continuing Healthcare plans.
Given the level of challenge and
effort of the frontline staff this
year to integrate adult services
within Neighbourhood Teams
and improve the consequent
working relationship with primary
care (a key CQUIN for the Trust);
We believe that it would have
been good to recognise the
achievements made within the
quality account. We note that
the Trust has not achieved 2
of the Performance for quality
and innovation (CQUIN) quality
improvement and innovation goals
for the Trust in 2014 / 15.
We acknowledge that 2014 / 15
has been a challenging time for
nursing and quality within the
Trust. We hope that the Trust
will continue to support the
collaborative working which
needs to take place with the
commissioners and we look
forward to working more closely
with Leeds Community Healthcare
Trust in 2014 / 15 with the aim of
delivering the highest standards of
community care possible.
We found it reassuring that Leeds
Community Healthcare NHS Trust
participated in five (80%) of the
national clinical audits and one
(100%) of the national confidential
enquiries which it was eligible to
participate in during this period.
We would value an opportunity
Quality Account [49]
Comments from
Healthwatch Leeds
Healthwatch Leeds hosted a
session for all the organisations
providing NHS services in Leeds
who are required to provide
annual Quality Accounts and
have invited Healthwatch Leeds
to comment on them as a part
of their statutory duty. Each
organisation was invited to
present their account with a focus
on accessibility, evidence of links
between patient feedback or
engagement and priorities, the
measures of planned improvement
and progress and benchmarking.
Healthwatch volunteers were
also invited to identify areas of
good practice. As the actual
copies of the QA were not
provided by everyone, a general
recommendation is to produce a
more accessible summary, possibly
in easy read that has a focus on
the issues identified as important
and influenced by patients, service
users or their carers.
Leeds Community Trust
demonstrated how Quality
Accounts engagement and
priorities have become a part
of organisation wide work to
improve engagement and show
where decision making has been
influenced by feedback. The ongoing approach to engagement
is to be commended. The Trust
recognises that it has challenges
and provides examples on how it
is working to improve including
measures for performance.
Priorities have been influenced by
both patient and staff feedback
and patient specific outcomes
are being developed. There is
[50] Quality Account
benchmarking with other similar
organisations and some of the
priorities have been influenced
by national patient safety
priorities. The Trust is committed
to producing a more accessible
summary of their account which
we recognise as good practice.
Comments from
the Scrutiny
Committee
Many thanks for sharing your draft
Quality Accounts for 2014 / 15
and apologies for any delay in
getting back to you regarding
comments from the Scrutiny
Board. However, please be aware
that at its meeting in April 2015
the Scrutiny Board agreed not to
make any formal comments on
any draft Quality Accounts for
2014 / 15. This was largely due
to the timescales for producing
the QA and the Scrutiny Board’s
capacity to make a meaningful
contribution.
I trust this is helpful, but please
let me know should you have any
queries.
Response to
comments by
Leeds Community
Healthcare NHS
Trust
Thank you to the CCGs and
Healthwatch for taking time to
consider and respond to our
quality account. We appreciate
the acknowledgment of the
progress that we have made and
the challenges we have faced this
year.
We agree with the CCG that we
could have included a summary
of our work with partners across
the health economy to improve
quality. We have added a summary
of our work with Leeds Institute
for Quality Healthcare to the final
document.
Learning form complaints
and incidents is a focus of our
quality improvement for next
year and part of our Sign Up
To Safety pledge. We welcome
the suggestion form the CCGs
that we could standardise our
approach to learning from all
incidents and feedback including
the safeguarding referrals. We will
look at how we integrate this as
we progress.
NMC will be introducing nursing
revalidation in December 2015.
They are currently undertaking a
number of pilots and will share
their findings and any changes to
the proposals in October 2015.
We have identified an executive
lead for this piece of work within
the organisation and we are
currently scoping what it will
mean for our staff. We have not
included nursing revalidation as a
priority for quality improvement
this year and we have not yet
clearly established how we
will measure this in relation to
improved quality of patient care.
It may well be that this is a priority
for quality improvement next year.
We will keep the CCGs up to
date with our plans at our regular
quality meetings.
We have amended the comments
in relation to the 3 Clostridium
difficile (CDI) cases to reflect that
all 3 were reviewed in line with the
guidance issued by NHS England,
were found to be unavoidable
and not attributable to the care
provided by LCH.
We thank particularly the
Healthwatch approach to reviewing
quality accounts this year. Having
an opportunity to present our
areas for quality improvement
to members of the public and
demonstrate where their feedback
is making a difference is helpful in
making this document meaningful.
We are pleased that the ongoing
commitment to engagement and
work of our engagement team is
recognised.
As a result of this feedback we
have:
Included a paragraph about
our involvement in system wide
quality improvement
Clarified the statements about
Clostridium difficile (CDI)
For the coming year we will:
Share audit information with
CCG thorugh the quality
meetings
Publish an easy access version of
our quality account
Share with the CCG our plans
for nursing revalidation as they
develop
Quality Account [51]
Acknowledgements
We would like to thank everyone who helped to influence the content and publication of
our Quality Account. This includes but is not limited to patients and representative groups,
our staff, the senior management team and the board of directors.
This Quality Account provides insight into how our vision, values and strategic objectives
have quality at their heart. It demonstrates how quality is embedded within the organisation
and, with examples from each portfolio of services; we will show how quality defines us.
We have also produced an Annual Report and Accounts to outline our financial and other
key performance measures during 2014 / 15. You can find the Annual Report and Accounts
on our website at www.leedscommunityhealthcare.nhs.uk
How to comment on the
Quality Account
If you would like to comment on this document you may do so:
By email to lch.comms@nhs.net
Please ensure you place the phrase ‘Quality Account 2014 / 15 feedback’
as the subject of your email.
In writing to:
Quality Account 2014 / 15 Feedback
Leeds Community Healthcare NHS Trust
Quality and Professional Development Department
1st Floor, Stockdale House
Headingley Office Park
Victoria Road
Headingley
Leeds LS6 1PF
Services provided by
Leeds Community Healthcare NHS Trust
For a full list of our services, please visit our website:
www.leedscommunityhealthcare.nhs.uk/our_services_az/
[52] Quality Account
Glossary
Appraisal – a method of reviewing the performance
of an employee against nationally agreed standards
within the NHS.
Information governance – the rules and guidance
that organisations follow to ensure accurate record
keeping and secure information storage.
Audit – a review or examination and verification of
accounts and records.
LINk – Leeds Local Involvement network is an
independent organisation set up by the government
to bring local people, community groups and
organisations together. They aim to improve health
and social care services in their local communities.
Audit Commission – the organisation responsible
for auditing public bodies.
Clinical supervision – a reflection process which
allows clinical staff to develop their skills and solve
problems or professional issues. This can take place
on an individual basis or in a group.
Council of Governors – an elected body of people
from the community who have a role in holding the
organisation to account.
Looked After Children – children who are in the
care of social care. This includes children in foster
care and children who have been placed with
relations as a result of the birth parents being unable
to provide care.
Care Quality Commission – Health and Social Care
regulator for England.
Medical devices inventory – a list of medical
equipment owned by the Trust. The list is used to
ensure that we carry out maintenance at regular
intervals.
Child protection – measures and structures used to
prevent and respond to abuse, neglect, exploitation
and violence affecting children.
Medicines management – processes and
guidelines which ensure that medicines are managed
and used appropriately and safely
Clinical coding – a coded format which describes
the condition and treatment given to a patient.
Membership – people within the local community;
users of services and staff can apply to become
members of an NHS foundation trust. The
membership has a role in holding the organisation
to account.
Commissioners – organisations that agree
how money should be spent on health within a
community. This is currently done by CCGs.
Cdiff – a Clostridium difficile infection is a type
of bacterial infection that can affect the digestive
system. It most commonly affects people who have
been treated with antibiotics.
CQUIN (Commissioning for Quality and Innovation)
– a financial incentive encouraging Trusts to improve
the quality of care provided.
Department of Health (DH) – the government
department responsible for the health and well
being of people in England.
Friends and Family Test – a new marker of
satisfaction which asks whether staff / patients
would recommend the service they received to their
friends or family.
MHRA – the MHRA is responsible for regulating all
medicines and medical devices in the UK by ensuring
they work and are acceptably safe.
MRSA – Methicillin-resistant Staphylococcus aureus
(MRSA) is a bacterium responsible for several
difficult-to-treat infections.
National Institute for Health Research (NIHR) –
the NIHR was set up by the DH to transform research
in the NHS. NIHR seeks to improve the health and
wealth of the nation through research and works
in partnership with many sectors including other
Government funders, academia, charities and industry.
NHS Litigation Authority (NHSLA) – the
organisation responsible for overseeing the
insurance scheme for NHS providers.
It is part of the NHS and accountable to the
Secretary of State.
Quality Account [53]
National Institute for Health and Care
Excellence (NICE) – aims to assist in the prevention
and treatment of ill health and to improve
population health. NICE provides guidance, sets
quality standards and manages a national database.
Patient experience – feedback from patients on
‘what actually happened’ in the course of receiving
care or treatment. Some measures such as waiting
times can be from routine data rather then patient
feedback.
National Patient Safety Association (NPSA) –
an arms length body of the NHS. The NPSA aims
to improve patient safety and care by informing,
supporting and influencing organisations and people
working in the health sector.
Patient satisfaction – a measurement of how
satisfied a person felt about their care or treatment.
National Service Framework (NSF) – strategies
that set clear quality requirements for care. These
are based on the best available evidence of what
treatments and services work most effectively for
patients.
NHS Community Foundation Trust – an NHS
provider organisation that has freedom from
Secretary of State control. They will have a clear
accountability framework and will be able to plan
and direct their services to more closely meet the
needs of the communities they serve.
Payment by results – the system where by NHS
providers are paid for the work that they have
completed.
Performance Matrix – a report that details the
performance of LCH against key national and
contractual targets.
Pressure ulcers – a type of injury that affects areas
of the skin and underlying tissue. They are caused
when the affected area of skin is placed under too
much pressure over long periods of time.
Real time measurement – tools or measurements
to seek people’s feedback soon or immediately after
having contact with the service.
OFSTED – Office for Standards in Education,
Children’s Services and Skills inspect and regulate
services which care for children and young people,
and those providing education and skills for learners
of all ages.
Root cause analysis – a method of analysing
problems that aims to identify the root cause.
Outcome Measure – a tool used to assess change
in a patient or patient’s circumstances over time.
They measure change in meaningful areas of a
person’s life in a way that informs collaborative
decisions about treatment.
Schwartz Centre Rounds – a program to support
staff that brings doctors, nurses and other caregivers
together to discuss the human side of healthcare.
PALS – the Patient Advice and Liaison Services (PALS)
provide a listening and advocacy service to ensure
that patients and their relatives, carers and friends
can have their questions and concerns resolved as
quickly as possible.
Patient, Carer and Public Involvement (PPI) –
activities designed to build ongoing relationships and
contact with patients, carers and local communities
so they can be involved in developing, designing and
the planning of services.
[54] Quality Account
Royal College – the professional body of many
professions including doctors, nurses and allied
health professionals.
Scrutiny Board (Health) – a function of the local
authority with responsibility to hold decision makers
to account for the services they provide.
Strategy – the overall plan an organisation has to
achieve its goals.
Trust board – the team of executives and nonexecutives that are responsible for the day to day
running of an organisation.
VTE – venous thromboembolism. A clot that can
block arteries and lead to a number of conditions
including stroke.
www.leedscommunityhealthcare.nhs.uk
© Leeds Community Healthcare NHS Trust, May 2015 ref: 1364