Lincolnshire Partnership NHS Foundation Trust
Quality Report
2014/15
www.lpft.nhs.uk
Contents
Part 1: Statement on quality from the Chief Executive Officer and the Chair, Lincolnshire Partnership
NHS Foundation Trust ........................................................................................................................ 4
1.1 Statement on quality from the Chief Executive Officer and the Chair ........................................ 4
1.2 Our services .............................................................................................................................. 7
1.3 Quality developments 2014/15 .................................................................................................. 8
1.4 Recognition of excellence awards 2014/15 ............................................................................. 10
Part 2: Priorities for improvement and statements of assurance from the Board ............................... 12
Part 2a Looking forward: priorities for improvement for 2015/2016 ............................................... 12
Part 2b Statements of Assurance from the Board ......................................................................... 45
Part 3: Other information - looking back ........................................................................................... 90
3.1 Indicators selected by the Board in consultation with stakeholders ......................................... 90
3.2 Local Indicator 2014/15 ........................................................................................................... 93
3.3 Performance against Core Indicators (Monitor targets) ........................................................... 95
3.4 Staff engagement including the 2014 NHS staff survey performance ...................................... 96
3.5 Workforce planning ................................................................................................................. 99
3.6 Positive and proactive care: reducing the need for restrictive intervention............................ 100
3.7 Leadership ............................................................................................................................ 101
3.8 Involvement of the Trust’s Governors .................................................................................... 103
3.9 Board assurance ................................................................................................................... 104
3.10 Accreditations and achievements ........................................................................................ 105
3.11 What service users, carers and the public say .................................................................... 106
2
Annexe 1A: Statement from South West Lincolnshire Clinical Commissioning Group on behalf of
NHS Lincolnshire (Commissioner) .............................................................................................. 111
Annex 1B: Statement from Lincolnshire Health Scrutiny Committee and Healthwatch Lincolnshire
................................................................................................................................................... 112
Annex 1C: Governor comments ................................................................................................. 115
Annex 2: Statement of directors’ responsibilities for the quality report ......................................... 119
3
Part 1: Statement on quality from the Chief Executive Officer and the Chair,
Lincolnshire Partnership NHS Foundation Trust
1.1 Statement on quality from the Chief Executive Officer and the Chair
We, at Lincolnshire Partnership NHS Foundation Trust, are delighted to present the Trust’s sixth quality
report for the financial year April 2014 to March 2015.
We remain focussed on our core purpose, which is to ensure our patients and carers have a positive
experience of high quality evidenced based care, which delivers improved outcomes, the best level of
recovery possible; and results in an enhanced quality of life. We recognise that this can only be
achieved and sustained through good partnership working and strong effective governance processes.
Working in partnership with our patients, carers, staff, governors and key partners is critical to achieving
the highest standards of patient safety, patient experience and clinical effectiveness. We recognise that
our services will only ever be as good as the dedicated and skilled workforce we have and that we invest
in. Our staff are highly skilled in delivering care and treatment; and a number have been recognised in
both local and national awards over the past 12 months (details of which are contained within this
report).
This report provides an overview of the quality governance arrangements that we have in place for
monitoring, identifying trends and risks; and working effectively to improve quality across the Trust. We
are immensely proud of our achievements over this last year; and are passionate about making
improvements going forward wherever possible. We continue to work hard embedding Compassion in
Practice (care, compassion, courage, communication, competence; and commitment); and deliver
services that are safe, effective and constantly improving. Our quality report highlights our successes
and strengths, areas we need to improve upon; and our quality plans for 2015 to 2016.
Our purpose
Enabling people to live well in their communities.
Philosophy of care
Our Trust seeks to deliver high quality, compassionate care, which respects an individual’s choice and
values and incorporates reasonable adjustments aligned to the equality and diversity strands (Equality
Act 2010).
We are committed to providing services that are welcoming, responsive and safe, delivered by
competent, skilled and committed staff that put our service users (patients) at the heart of everything
they do.
We adopt an integrated approach, seeking to provide a seamless experience for service users and
carers, by effective care pathway working across the teams / services / organisations, working in
partnership to provide care for our service users.
We want our service users, carers and staff to recommend us to their families and friends, so aim to
provide standards of care, treatment, advice and support that is consistent and responsive, developed in
partnership, evidence based; and recovery focussed. This means care and treatment that build on
resilience, strengths and hopes; and that support an individual to have as much control in their recovery
journey as possible.
Development of our Quality Report
We have developed our quality report in consultation with the Trust’s governors, service users, carers,
staff and key stakeholders. We have continued to focus on quality during a time of economic constraints,
national and local changes to the way the NHS is managed and commissioned; and significant changes
across both our own organisation and those of our key partners (health, social care and voluntary
sector). We are working hard with our local partners, as part of a Lincolnshire-wide health and social
care economy review (LHAC), to ensure service users and carers continue to receive high quality, safe,
responsive and effective care services at this time and moving forward into 2015/16.
The quality report forms part of the Trust’s annual report, which also includes a summary of our financial
accounts for 2014/15.
5
Our continued focus in 2014/15 on engaging with our service users, carers and staff more effectively,
has resulted in many positive initiatives, many of which are discussed in more detail within this report.
Our staff engagement programme, ‘Making a difference’, continues to promote staff engagement and is
now well embedded; and our cultural barometer and inspirational leadership programme, ensure our
staff in every part of the organisation have a voice, are kept up-to-date; and feel valued and motivated in
their work. We are not complacent and recognise the importance of a strong continued focus on service
user, carer and staff engagement, so this will remain a high Trust priority in 2015/16, reflected in our
quality priorities.
There are a number of inherent limitations in the preparation of quality accounts which may impact the
reliability or accuracy of the data reported. These include:

Data is derived from a large number of different systems and processes. Only some of these are
subject to external assurance, or included in internal audits programme of work each year.

Data is collected by a large number of teams across the Trust alongside their main
responsibilities, which may lead to differences in how policies are applied or interpreted. In many
cases, data reported reflects clinical judgement about individual cases, where another clinician
might have reasonably have classified a case differently.

National data definitions do not necessarily cover all circumstances, and local interpretations may
differ.

Data collection practices and data definitions are evolving, which may lead to differences over
time, both within and between years. The volume of data means that, where changes are made,
it is usually not practical to re-analyse historic data.
The Trust and its Board have sought to take all reasonable steps and exercise appropriate due diligence
to ensure the accuracy of the data reported, but recognises that it is nonetheless subject to the inherent
limitations noted above. Following these steps, to my knowledge, the information in the document is
accurate.
Paul Devlin
Dr John Brewin
Chair
Chief Executive
6
1.2 Our services
The Trust is the principal provider of NHS adult mental health and social care services in Lincolnshire; it
provides a full spectrum of mental health and social care services including:

Acute in-patient services

Adult psychology

Assertive outreach

Child & adolescent mental health services

Chronic fatigue syndrome/Myalgic
(CAMHS) (community and in-patient)
Encephalomyelitis (ME)

Community partnerships team

Dementia services

Dynamic psychotherapy

Early intervention for psychosis

Eating disorders

Improving Access to Psychological Therapies

Forensic mental health services
(IAPT)

Independent living team

Integrated community mental health teams

Assessment & rehabilitation service

Learning disabilities services

Neuro-psychology

Mental health rehabilitation

Primary mental health care

Personality disorder

Specialist psychology

Recovery college

Substance misuse services.
The Trust has a workforce of approximately 2,170 staff working across over 75 sites, providing diverse
services, predominantly mental health and learning disabilities, to the population of Lincolnshire
(approximately 718,800) and North East Lincolnshire and Derbyshire (approximately 1,081,600). The
Trust has 15 in-patient wards, has approximately 55,000 service users accessing services; with
approximately 1,500 service users on the Care Programme Approach (CPA) at any one time.
7
1.3 Quality developments 2014/15
The Trust has sought to reflect, learn and implement actions against each of the six core themes within
the Francis report, namely: culture, compassionate care, leadership, standards, information, and
openness, transparency and candour. The following provides evidence of our responsiveness over
2014/15; and how we have utilised learning to improve the quality and safety of our services:
Culture: The Trust has responded to the calls for a cultural shift, built on candour and continuous
improvement, which recognises and addresses variations in quality. The Trust has implemented its own
cultural barometer ahead of this being nationally available, implemented its speaking up email address
and through its structures encourages open debate about safety and quality bringing service user stories
to Trust Board, service focus at the quality committee; and most recently the establishment of the
nursing council.
Compassionate care: Compassion in Care (known as the 6Cs: communication, care, courage,
competence, compassion and commitment) underpin the Nursing Strategy and wider commitment of
Trust employees. They will continue to be the thrust of the Trust’s organisational development strategy.
Leadership: The Trust fully supports the development of leaders through both internal and external
skills and knowledge development. Our inspirational leadership programme supports staff to increase
leadership capability, support internal regulation, develop greater resilience; and take the actions
required to ensure that service users are the Trust’s priority. There has been significant investment in the
introduction of a coaching culture with key staff being developed as coaches.
Standards: Overall in the last year the Trust has performed well in its external assessments of essential
standards. The Trust has increased external accreditation in both in-patient and community services.
Where action has been indicated internally or externally the Trust has responded swiftly and
comprehensively. To support this, the Trust has further refined its heat map approach across services to
indicate where support, development and improvement are required mapping against the new Care
Quality Commission (CQC) regulations and five domains (safe, caring, responsive, effective and wellled).
8
Information: In the last year the Trust has increased use of information about complaints and patient
experience; and accountability for actions taken. The Trust has publically reported data about key
aspects of patient safety data, complaints and compliance. In doing so the Trust has been able to be
self-critical and honest, and to ensure improvement in performance is achieved. As an organisation, the
Trust is committed to creating an environment in which there is consistency and accuracy in the quality
of its information, used to support embedding of best practice and early detection of risk or failure,
Openness, transparency and candour: The Trust continues to publish its staffing levels with
benchmarks and, embracing the cultural shift required, increase the emphasis on raising concerns
through the change day approach (NHS Change Day). The Trust has benchmarked its complaints
process against the recommendations arising from the review of the management of hospital complaints,
and is working hard to embed Duty of Candour.
The Trust has also taken into account recent changes to the CQC inspection regime, which for mental
health inspection has had one inspection under the new regulations. The key challenge embraced by
the Trust is to ensure sustained high quality care over time across services, together with good evidence
of innovation and shared learning, and driving out unwanted variation.
The completeness of the Trust’s approach has also been informed by the following reviews;

Review into the quality of care and treatment provided by 14 hospital trusts in England, led by
Professor Sir Bruce Keogh, NHS medical director for NHS England. (Department of Health
(DoH), 2013)

The Cavendish Review: An independent review into healthcare assistants and support workers in
the NHS and social care settings, by Camilla Cavendish. (DoH, 2013)

A Promise to Learn: a commitment to act - improving the safety of patients in England, by
Professor Don Berwick. ( National Advisory Group on the Safety of Patients in England, 2013)

A Review of the NHS Hospitals Complaints System: putting patients back in the picture by
Rt Hon Ann Clwyd MP and Professor Tricia Hart. (DoH, 2013)

Challenging bureaucracy, led by the NHS Confederation. (NHS Confederation, 2013)

The report by the Children and Young People’s Health Outcomes Forum, co-chaired by Professor
Ian Lewis and Christine Lenehan. (DoH, 2012)

The Trust’s Board, in addition to direct contact with service users, families and staff, is able to
evidence continued attention to these matters in the programmed reports to the Board, the
9
integrated business plan; and Trust strategies which indicate the Francis Inquiry as a source or
key driver.

Compassion in Practice Two Years On (NHS England/Nursing Directorate, 2014)

5 Year Forward View (NHS England, 2014).
1.4 Recognition of excellence awards 2014/15
The Trust is proud to have celebrated a number of successes in local and national awards in 2014/15
including the following:

Outcomes orientated child and adolescent mental health services (OO-CAMHS) was
awarded £500,000 by the Health Foundation as part of new improvement programme: Scaling
Up Improvement (2015).

Ranked 123rd in the Stonewall workplace equality index. An improvement of 145 places from
2014 position (2015), in recognition of our commitment to best equality and diversity practice.

Excellence rating in Accreditation for In-Patient Mental Health Services (AIMS). Maple
Lodge at Boston, Ashley House at Grantham and all three wards at Lincoln’s Discovery House
received a rating of ‘excellent’ in their AIMS (2015).

Stonewall East Midlands Region role model of the year awarded to the Trust’s interim deputy
director of nursing and quality (2015).

Investing in Volunteers (IiV) quality standard - in recognise the excellent work the Trust does
with its volunteers (2014).

NHS Inclusivity leader of the year, East Midlands Leadership Academy awarded to the
Trust’s equality and diversity lead (2014).

Highly commended in the annual Care Coordination Association Awards for the eighth
successive year (2014) in the category of Excellence in Providing Information about the Care
Process for Service Users and/or Carers, where our CAMHS service were recognised for their
My Care Plan folder. The Wolds Ward at Discovery House was also commended in the category
Excellence in the Care Process for their development and implementation of an enhanced
physical healthcare monitoring programme on the ward.
10

Shortlisted for outstanding collaborative leadership at the East Midlands Leadership
Academy awards and for improvement in acute service redesign category at the HSJ Value
in Healthcare awards (2014). In recognition of our Trust’s collective work with United
Lincolnshire Hospitals NHS Foundation Trust (ULHT), Lincolnshire Community Health Services
NHS Trust (LCHS), Lincolnshire County Council (LCC), East Midlands Ambulance Service
(EMAS), Lincolnshire West CCG, East Lincolnshire CCG) to reduce admissions.

Finalists in the value and improvement in communication category of the HSJ Value in
Healthcare awards (2014). Making a difference, staff engagement programme.

Shortlisted in the patient safety improvement category at the Nursing Times awards
(2014). The Vales at Discovery House, winners in 2013, were shortlisted in this category.
More information on other accreditations and awards is detailed within section 3.10 of this report.
11
Part 2: Priorities for improvement and statements of assurance from the
Board
Part 2a Looking forward: priorities for improvement for 2015/2016
2a. 1 Strategic priorities
The Trust is passionately committed to improving quality and safety; and recognises the importance of
being able to evidence this by positive treatment outcomes and continuously improving services. As
such improving service quality remains the Trust’s primary strategic priority, thus supporting the
embedding of quality in all aspects of the Trust’s practice and business. The Trust is committed to
working in partnership with service users, carers, governors, staff and partners to ensure delivery of high
quality services, underpinned by the recovery approach.
The Trust’s strategic priorities for 2015/16 are detailed within the Trust’s integrated business plan for
2015/20 and are as follows:

Improving service quality

Using resources more efficiently

Retaining and developing the business
The following strategies define the ambition of the organisation for each strategic priority:
Quality: a quality strategy and clinical service strategy to improve clinical services during the next three
to five years. This is informed by service users, carers, governors, partners and our clinical teams; and
reflects our ambition for our services.
Resources: an organisational development plan, financial plan, estates plan and an information
management and technology (IM&T) strategy that support the delivery of high quality clinical services
and the best possible experience for the people who use our services. Lean methodology will be
introduced to achieve the requisite efficiency improvements.
Business: a business development plan that consolidates the existing services provided by the Trust
and protects them into the future. It also supports the Trust’s ambition for growth and positioning in the
market and that enables the Trust to continue to operate effectively in a regulatory environment.
12
The outcomes that are sought are:

Harm free care and improved safety for service users

Improved quality of life, as determined by the individual service user

Improved recovery rates where these can be measured

A good experience for all service users, with the majority recommending us to others

Clinical teams who are trained, developed and valued and who continue to strive for excellence

Integrated service delivery, with the service user and their family at the centre of all that we do

Become the provider and partner of choice for local government and other health and social care
commissioners and agencies.
2a. 2 Quality principles
The Trust’s quality principles, reflected in the Trust’s quality strategy and clinical strategy are:

Improving health and quality of life outcomes for our service users, promoting independence and
resilience

Strengthening service user, carer and staff involvement, utilising the membership of Voice of
1,000, the Council of Governors; and our nursing council to work together to improve quality and
identify the best strategies to embed best practice consistently across services

Safe and responsive, able to evidence robust safeguarding practice, responsiveness to
feedback including complaints; and the willingness to acknowledge failings, with proactive
willingness to put things right and learn lessons

Commitment to improving the quality of data, making better technology accessible across
services, including capturing service user, carer and staff feedback

Developing and implementing measures to evidence clinical effectiveness and to support the
early detection of risk. This includes developing well defined clinical outcome measures across
services

Person-centred, equitable, accessible and tailored to individual need

Developed in partnership with service users and, where appropriate, their carers

Developing SMART (specific measureable achievable realistic and timely) commissioning quality
and innovation payments (CQUINs) with commissioners that result in incentivising excellent
performance that leads to better outcomes for service users, carers and staff

Evidence-based and effective, increasingly benchmarking Trust services against available local
and national data
13

Aligned to Trust values

Retain, recruit and develop the best staff through supporting development, celebrating
successes, investing in staff supervision and appraisals; and enabling staff to deliver care aligned
to Compassion in Practice (6Cs: care, compassion, courage, communication, competence and
commitment)

Delivered within a culture of openness where staff have a duty to speak out if they have
concerns about standards of care

Delivered in well-led services that support and develop strong accountable leaders at all levels;
and ensure all staff understand the Trust’s values and required standards of practice

Consistently achieve compliance (CQC, Health & Safety Executive (HSE) and Monitor) and
excellence in practice whilst managing significant internal and external change and reorganisation in line with the Trust’s integrated business plan and the LHAC.
2a. 3 Quality priorities 2015/16
The Trust Board has agreed four key quality priorities for 2015/16, one in the domain of Patient Safety,
one in the domain of Patient Experience and two in the domain of Clinical Effectiveness. The quality
priorities were selected taking account of a number of sources including the following:

Patient, carer, governor and staff feedback

Department of Health’s national priorities

CQC quality risk profiles replaced with CQC intelligent monitoring November 2014 and visits
feedback

National patient and staff surveys

Monitor reporting requirements

Commissioners requirements and feedback

LHAC

Equality delivery system 2

Healthwatch Lincolnshire feedback

Serious incidents, complaints, coroner and serious case review feedback (local and national)

Stretch targets for performance in respect of all the quality priorities have been agreed, which will
be closely monitored throughout 2015/16. This will assist us in monitoring our progress; and in
developing the understanding and embedding from ward / team to board of our quality priorities.
14

Consultation on the quality priorities for 2015/16 started in November 2014, with an interactive
workshop within a joint Board and Council of Governors’ development day; and continued
through papers and presentations to the quality committee, senior leadership group, Council of
Governors’ meetings and divisional meetings. The draft quality priorities were widely
disseminated for consultation across the Trust via the internal intranet and for wider service user,
carer, public, partner agency and stakeholders externally via the Trust’s external website in
January 2015.
Governors’, staff and Board feedback included:

unanimous agreement to reduce the overall number of quality priorities for 2015/16, with
agreement that six or less would be ideal

comments recommending reference to the Community Mental Health Patient Survey in one of the
measures. This has been captured in the Patient Experience Domain, quality priority 2 via the
metric, improvement in community and in-patient survey results (as compared to previous year).

There was a comment recommending a focus on ensuring the Trust has appropriately trained
staff delivering clinically effective care. This has been captured via the metrics in Clinical
Effectiveness Domain, quality priorities 3 and 4.

There was general discussion that the existing metrics for measurement were good as they do
enable monitoring of progress; and agreement to continue in the same format using such metrics
for measurement for the 2015/16 quality priorities.

A comment that the new quality priorities are a much easier version for staff to use and
understand, stating that a reduction to four quality priorities for 2015/16 supports embedding at
every level of the organisation.
The Trust’s quality priorities for 2015/16 (overleaf) include detail on why the priorities have been
selected; and how they will be monitored and measured:
15
Quality
Priority
Why this is important
priority
continuation
for us
2015 /2016 Target
Patient Safety

1. Evidence
New quality
Reducing the likelihood
improvement
priority for
of repeated incidents and
the safety improvement plan (Sign
in patient
2015/16.
adverse events remains
Up to Safety National Initiative).
a local and national
Identified target areas are: seven-day
safety priority.
follow-up, risk assessment in CRHT;
Embedding learning
and reduction in medication issues
identified from serious
and incidents in in-patient areas.
safety
incidents, complaints,

Achieve quarterly targets set within
Production and dissemination of a
claims, audit and third
Learning Lessons bulletin bi-monthly
party inspections should
throughout the Trust.
enable reduction in

Audit sample of closed serious
likelihood of repeated
incidents reports (1-2 years post
incidents and adverse
closure), evidencing minimum 90%
events so should reduce
actions remain embedded in practice.
harm.

Heat map (early warning indication of
risk) completed and disseminated
widely from ward / team to Board bimonthly.

Case records audits evidence patient
and / or carer involvement in a
minimum of 80% of cases (evidenced
through the healthcare records
audits).
16
Quality
Priority
Why this is important
priority
continuation
for us
2015 /2016 Target
Patient Experience

2. Improve the
Quality priority
Service users and carers
overall
continued and
(where appropriate)
patient survey results (as compared
experience of
further
should be involved in all
to previous year).
service users
developed
aspects of service
and carers
from previous
delivery from individual
evidence service user and / or carer
year
care planning to
involvement (direct or indirect).
selection and recruitment


of employees.
Improvement in community and in-
Minimum 80% recruitment panels
You said, we did: evidence of
responsiveness to service user and
carer feedback displayed in a
minimum of 80% of ward / unit /
service user community waiting areas
inspected as part of the 15 Steps /
mock CQC visits.

Evidence of responsiveness to
feedback, including from
Healthwatch.

90% responses to complaints and
PALS achieved within the agreed
timelines.
17
Quality
Priority
Why this is important
Priority
continuation
for us
2015 /2016 Target
Clinical Effectiveness

3. Invest in
Quality
Better early detection of
staff
priority
risk assists in preventing
results (as compared to previous
leadership
continued
harm occurring; and helps
year).
development
and further
in identifying action and
and improve
developed
support required to reduce
staff
from previous
risk.
engagement
year

Improvement in cultural barometer
Improvement in staff survey results
(as compared to previous year).

95% minimum compliance with
mandatory training.

95% minimum compliance with
annual appraisals.

Evidence of staff engagement in
leadership programmes.

Evidence of active equality and
diversity link nominated staff, working
closely with the Trust’s equality and
diversity lead, with representation
from across all specialities within inpatient and community services.

Achievement of top 100 ranking by
Stonewall (links to equality delivery
system 2).
18
Clinical Effectiveness
4. Increase in
Quality
The delivery of high quality 
AIMS accreditation (or equivalent)
external
priority
services requires a well-
maintained within all in-patient areas.
accreditation,
continued
motivated engaged
participation in
and further
workforce. The Trust is
equivalent) within community
research; and
developed
committed to investing in
services (as compared to previous
benchmarking
from previous
leadership at every level of
year).
of new and
year
the workforce; and to


Increase in AIMs accreditation (or
Evidence an increase in
existing
support staff development,
benchmarking in incident reports (as
services
which in turn supports
compared to previous year).
better outcomes for
service users and carers.

Evidence of continued active
participation in research and audit
(internally and externally led).
Progress to achieve the identified quality priorities 2015/16 will be monitored through the quality and
safety team; and reported three times a year to the quality committee.
19
2a. 4 Quality priorities 2014/15: review of achievement
The Trust identified nine quality priorities for 2014/15 and achievement against these is summarised as
Quality Priorities 2014/15 Final Position
Final Position
Quality Priority 1
Patient Safety
Not achieved
Partially met
Fully met
Data not available
– reason given
Ensure organisational learning is embedded and sustained
Measures:
1. Production and dissemination of a Learning Lessons bulletin bi-monthly
throughout the Trust
2. Audit of sample of closed serious incidents reports (1-2 years post closure),
evidencing minimum 90% actions remain embedded in practice
3. 100% recommendations following external reviews are completed within
the agreed timescales.
Final Position
1.
2.
3.
Action
1. Bi-monthly Learning Lessons bulletin have been collated and widely disseminated across the Trust.
2. Audits took place in each quarter of 2014/15 evidencing embedment of a minimum of 90% of
actions in practice.
3. All external review recommendations have been completed within the agreed timescales.
20
Quality Priority 2
Patient Safety
Improve record keeping, ensuring compliance with CQC essential
standard of quality and safety (outcome 21)
Measures:
1. All teams and services are able to evidence completion of monthly case file
audits; and use of the most recent clinical risk assessment tool.
2. Teams audited, through the annual case records audit, evidence
improvement on previous year’s audit result.
3. Teams audited, through the annual case records audit, evidence
involvement in care planning in a minimum of 80% of cases
Final Position
1.
2.
3.
Action
1. General managers from General Adult Services and Specialist Services confirm their teams and
services complete monthly case file audits; and use the most recent clinical risk assessment tool.
2. CPA audit of in-patient wards by CPA Trust lead evidenced slight improvement overall in average
percentages compared to comparative audit last year (76.8%). Notable improvement in 10 of the 14
wards audited.
3. CPA audit of all- inpatient wards by CPA Trust lead evidenced 85% of records audited (64/75) as
demonstrating patient involvement in care planning.
21
Quality Priority 3
Patient Safety
Improve safety thermometer outcomes; measure medication errors,
triggers of potential harm; and actual harm from medication errors
Measures:
1. Reduction in number of medication errors causing harm by 50% (compared
to previous year)
2. 90% achievement of local CQUIN targets related to medication
management
3. 95% achievement of local CQUIN targets related to safety thermometer
(falls)
4. No Never Events: assurance is now reported quarterly through the Trust’s
patient safety meeting.
Final Position
1.
2.
3.
4.
Action
1. Monthly monitoring of medication errors, including those causing harm, took place throughout the
year. Whilst there has been considerable positive development work in respect of improving
monitoring and reporting of medication related errors and incidents, including those causing harm,
there are issues in respect of comparing 2014/15 data to 2013/14 data accurately. Data is not
easily comparable as reporting has increased with focussed improvement work in place. Due to the
increase in reporting, including of errors causing harm, evidence of reduction by 10% (CQUIN
target) has been challenging to achieve for 2014/15. The stretch target of 50% reduction set within
the quality priority metric has not be achieved in 2014/15, but this does not reflect the considerable
development and preventive work which will continue into 2015/16 across the Trust in respect of
medication incidents and issues management and reduction.
2. We can calculate that last year 9.16% of medication incidents resulted in harm to patients. To
achieve a 10% reduction required 2014/15 percentage was required to be 8.244% or less. This
year’s percentage equals 5.36%.
3.
We reported falls data against the national safety thermometer metric. Despite the continued high
quality falls prevention work in the older adult in-patient wards, the national safety thermometer
target in respect of incidence of falls with harm has not been achieved consistently during 2014/15.
4. No Never Events; and compliance assurance reported through the Trust’s patient safety group and
to commissioners via the quality schedule.
22
Quality Priority 4
Improve the overall experience of service users and carers
Patient Experience
Measures:
1. 80% positive responses from patient satisfaction questionnaires (FFT) in
both in-patients and community areas
2. 90% responses to complaints and PALS achieved within agreed timelines
Final Position
1.
2.
Action
1. Well above 80% positive responses from returned questionnaires has been achieved during
2014/15.
2. Complaints and PALS responses fell short of the 90% target apart from Q4 when 90.5%
achievement was made.
23
Quality Priority 5
Patient Experience
Increase service user and carer involvement in service planning,
workforce development and delivery of care
Measures:
1. Minimum of 80% of recruitment panels evidence service user and/or carer
involvement (directly or indirectly)
2. You said, we did evidences responsiveness to service user and carer
feedback displayed in a minimum of 80% wards/units/service user waiting
areas visited as part of the 15 Steps/mock CQC visits
3. Recovery college development evidences good partnership working with
service users and carers (including those with a learning disability).
Final Position
1.
2.
3.
Action
1.
Alongside previous figures collated for Q2 and Q3, 123 of the 199 interview panels held by the
Trust from July 2014 to April 2015 evidenced ‘direct’ or ‘indirect’ service user involvement in
recruitment panels = 61% in total. Data sourced from NHS Jobs and the employment services
recruitment and vacancy control spreadsheet.
2. Through 15 Steps/mock CQC visits the prevalence of You said, we did, and subsequent evidence
of responsiveness has been monitored. There has been some evidence of excellent and innovative
implementation but overall the Trust requires improvement in this area. This requirement will
continue to be reiterated through the operations governance meeting and through divisional
governance meetings.
3. Recovery college is able to show that development evidences good partnership working with
service users and carers (including those with a learning disability).
24
Quality Priority 6
Patient Experience
Improve responsiveness to service user, carer, staff and partnership
agencies feedback
Measures:
1. Improvement in community and in-patient survey results (as compared to
previous year)
2. Evidence to responsiveness to feedback, including from Healthwatch
3. Evidence of active involvement in the LHAC.
Final Position
1.
2.
3.
Action
1. 2014 Community mental health survey results full report was received (August 2014) and the
findings for the Trust were disappointing, with the Trust scoring below average for mental health
trusts in the categories of crisis care and other areas of life. In the remaining categories, the Trust
scored average. Whilst the results of the 2014 survey are not comparable to previous years due to
the survey questionnaire being substantially redeveloped, the results are not satisfactory and there
is considerable work underway to seek to address the issues identified.
2014 National mental health in-patient survey results were encouraging, with an improvement in 14
areas and a decline in four. Positive findings included that patients felt listened to and treated with
respect and dignity.
2. Healthwatch feedback is greatly valued; and the director of nursing and quality coordinates the
Trust’s response to Healthwatch feedback. Healthwatch feedback is also presented to the Trust’s
patient and carers experience initiatives steering group. All teams across the Trust (in-patient and
community) complete FFT and other patient feedback initiatives.
3. The Trust remains an active member of the LHAC with detailed updates reported internally and
externally.
25
Quality Priority 7
Improve the early detection of risk
Clinical
Effectiveness
Measures:
1. Heat map completed and disseminated widely from ward / team to Board
bi-monthly
2. Monthly risk reports highlight risk trends
3. Risk registers (divisional & corporate) are monitored and reviewed a
minimum of monthly
4. Robust Board assurance & escalation framework is evidenced as being in
place.
Final Position
1.
2.
3.
4.
Action
1. The heat map has been disseminated bi-monthly; and is reviewed in line with internal and external
changes / regulatory requirements. From October 2014 the heat maps have been saved to the
CQC page on the Trust’s intranet site, which all staff can view. In addition, work was completed to
review the heat map metrics to align them to the new CQC essential standards that came into force
in April 2015.
2. Monthly risk reports to the Board highlighted risk trends and associated actions. There was
continuous work to further develop these reports to increase benchmarking and triangulation of risk.
3. General managers ensured that their risk registers were reviewed a minimum of monthly; and the
Trust Secretary ensured the corporate risk register was reviewed a minimum of monthly.
4. The Trust’s board assurance and escalation framework is in place.
26
Quality Priority 8
Invest in staff leadership development and improve staff engagement
Clinical
Effectiveness
Measures:
1. Improvement in cultural barometer results (as compared to previous year)
2. Improvement in staff survey results (as compared to previous year)
3. 90% minimum compliance with mandatory training
4. 80% minimum compliance with annual appraisals
5. Evidence of staff engagement in leadership programmes
6. Achievement of top 200 ranking by Stonewall (links to equality delivery
system 2)
Final Position
1.
2.
3.
4.
5.
6.
Action
1. Q3 update: In Q1, Q2 and Q4 improvement was evidenced compared to the previous year.
2. Q3 update: Ranked as most improved Trust in East Midlands for the staff survey 2013 results.
3. In the last 12 months mandatory training compliance has slightly reduced by 1.32% to 96.62%. This
though is above the national average.
4. Appraisal compliance in the last 12 months has increased by 6.46% to 85.12%. This is above the
national average.
5. Learning and development team are able to evidence significant engagement in leadership
programmes, including inspirational leadership programme and band 7 Programme. The Care
Certificate for health care assistants was launched in October 2014.
6. The Trust achieved a ranking of 123 out of 397 organisations nationally (an increase from 268 out
of 369 organisations last year). This is a very positive reflection of the work in respect of equality
and diversity underway across the Trust, under the leadership of the equality and diversity lead.
The Trust sponsored a participant for the Stonewall leadership programme (November 2014) for
the first time; and has a lot of related development work underway with significant support from
ward to board across the Trust.
27
Quality Priority 9
Clinical
Effectiveness
Increase in external accreditation, participation in research; and
benchmarking of new and existing services
Measures:
1. AIMs accreditation (or equivalent) within all in-patient areas
2. Increase in AIMs accreditation (or equivalent) within community services
(as compared to previous year)
3. Evidence an increase in benchmarking in incident reports (as compared to
previous year)
4. Evidence continued active participation in research and audit (internally
and externally led).
Final Position
1.
2.
3.
4.
Action
1. Funding for AIMs accreditation (or equivalent) has been agreed for all in-patient areas. Older adult
and learning disabilities are the last specialities to secure approval and funding so are anticipated to
be progressing towards accreditation within 2015/16.
2. A number of teams, particularly in the Specialist Services division, pursued AIMs or equivalent
accreditation. Related progress was reported through the Trust’s patient and carer experience
initiatives steering group.
3. The Trust has membership of the bench marking club and is working, under the leadership of the
associate director performance & compliance support to support best use of this facility.
4. The Trust evidenced active participation in research and audit, detail contained later in this report.
28
2a. 5 CQUINs (Commissioning for Quality and Innovation) 2015/16
We have worked closely and effectively with our commissioners, our lead commissioner being
Lincolnshire South West CCG, to identify our CQUINS to align well with our quality priorities and
support the promotion of further quality improvements. We have also worked closely with our
governors to agree both the quality priorities; and to agree our local indicator for 2015/16. Our
governors gave approval (January 2015) for our local indicator for 2015/16 to be medicines
management related.
The Trust’s services span in-patient and community provision and are detailed within this report. With
our commissioners we have sought to set stretching targets for quality improvements across our
services, with the shared goal of evidencing improved outcomes for those using our services.
Included in the table below are the following:

Lincolnshire CCG CQUINs

NHS England low secure and tier 4 CAMHS

North East Lincolnshire CAMHS incentive payment (which are not CQUINs as they are nonNHS commissioned)

Derbyshire IAPT CQUINs

Lincolnshire CCG CQUINS.
LCC tier 2 and tier 3 CAMHS have no CQUINs identified for 2015/16 due to the planned significant
service review.
29
Section 1: Lincolnshire CCGs
MH1a
Improving physical healthcare to reduce premature mortality in people with severe
mental illness (SMI).
Goal
Cardio metabolic assessment and treatment for patients with psychoses.
Indicator
To demonstrate full implementation of appropriate processes for assessing, documenting
and acting on cardio metabolic risk factors in inpatients with psychoses and community
patients in Early Intervention psychosis teams.
MH1b
Improving physical healthcare to reduce premature mortality in people with SMI.
Goal
Communications with GPs.
Indicator
90% of patients should have either an updated CPA or a comprehensive discharge
summary shared with the GP.
MH2
Urgent and emergency care: reducing the proportion of avoidable emergency
admissions to hospital.
To ensure that patients with ambulatory care sensitive and similar conditions that do not
Goal
normally require admission to a hospital bed receive highly responsive urgent care
services outside of hospital.
Indicator
A dedicated team based in the geographical location of A&E departments (Lincoln and
Pilgrim) that will actively prevent admissions and presentations through this route.
MH3
Clinical risk assessment and management.
Goal
Clinical risk assessment and management training.
Indicator
To improve the quality and process of clinical risk assessment and management in the
Trust by training appropriate staff in the use of the clinical risk assessment toolset.
30
MH4
Goal
Health care assistant (HCA) development.
To further develop a regulatory framework for all health care assistants working across the
Trist and a set of standard competencies for all bands 2, 3 and 4 HCAs.
Indicator
Health care assistant development
MH5
Autism
Goal
Autism.
Indicator
Development and roll-out of tiered training.
MH6
Early intervention in psychosis (EIP)
Goal
EIP
Indicator
Establish baseline against both national waiting time’s standards for EIP and NICE quality
standards for EIP. Develop plan to meet any identified gaps and implement the plan.
Section 2: NHS England low secure and tier 4 CAMHS:
LS1
Secure service users active engagement programme
The provider is to produce evidence that 100% of service users have collaborated in
Goal
development of their own risk assessment and safety management plan or to specify a
reason why this has not been possible and what steps have been taken to try to rectify this
situation.
Indicator
LS2
The provision of an active engagement programme to involve all secure service users in a
process of collaborative risk assessment and management.
Supporting service users in secure settings to stop smoking
This CQUIN directly helps to deliver against domain 1 of the NHS outcomes framework:
Goal
preventing people from dying prematurely.
Indicator
Low and medium secure: supporting service users in secure services to stop smoking
31
LS3
Mental health carer involvement strategies
This CQUIN builds on the carer involvement strategies developed during 2014/15 and
Goal
requires providers to evaluate the effectiveness of these strategies and further develop
ways to involve carers, family and friends at a local and regional level.
Indicator
Supporting carer involvement in mental health
LS4
Improving physical healthcare to reduce mortality in people with SMI
Improving physical healthcare to reduce premature mortality in people with SMI cardio
Goal
metabolic assessment and treatment for patients with psychoses
To demonstrate full implementation of appropriate processes for assessing, documenting
Indicator
and acting on cardio metabolic risk factors in inpatients with psychoses and community
patients in EIP teams.
CAMHS 1
Goal
Assuring the appropriateness of unplanned CAMHS admissions
60% improvement in number of reviews held within five working days of unplanned
admission
To provide assurance about the clinical appropriateness of unplanned admissions to tier 4
Indicator
CAMHS (general adolescent services) through a rapid multi-agency review process and
reduce the number of inappropriate admissions
CAMHS 2
Improving patient, family and carers experience of CAMHS admissions
Completion and evidence of the four data sources will release 100% of the CQUIN being
Goal
available
This CQUIN enables providers to better understand the needs of patients, families and
carers when a young person is admitted into a CAMHS inpatient unit.
Indicator
Delivery of this CQUIN will improve the experience of families and carers in relation to their
young person’s admission. It will reduce the anxiety and fear that families often experience
whilst the young person is in an inpatient admission, often a distance from home.
32
CAMHS 3
Improving physical health care to reduce mortality in people with SMI
Improving physical healthcare to reduce premature mortality in people with SMI cardio
Goal
metabolic assessment and treatment for patients with psychoses
To demonstrate full implementation of appropriate processes for assessing, documenting
Indicator
and acting on cardio metabolic risk factors in in-patients with psychoses and community
patients in EIS teams.
Section 4: North East Lincolnshire (NEL) CAMHS
NEL CAMHS
1
Goal
Indicator
12 Weeks’ wait
To ensure that service users are offered a first appointment within 12 weeks of the date
of receipt of referral.
The percentage of service users who are offered a first appointment within 12 weeks of
the date of receipt of referral.
A further two CQUINS were agreed with commissioners at a meeting on 6 June 2015.
33
Section 5: Derbyshire Improving Access to Psychological Therapies (IAPT)
Derbys
IAPT 1
Goal
Data quality: collection and reporting of ethnicity data
90% completed.
Improving access for BME communities is one of the national priorities in the talking
therapies: four-year plan of action 2011. People from BME communities are not
accessing services in the numbers we would expect given population demographics.
Indicator
Accurate ethnicity data will help us to understand gaps and to know where to target
services. Commissioners should be assured that IAPT providers are accurately recording
and reporting ethnicity data as per the requirement of the IAPT minimum data set.
The baseline on which the CQUIN target has been calculated from completed fields
where the ethnic code has been recorded and will exclude “unknown” Code 9.
Derbys
IAPT 2
Goal
Data quality: Collection and reporting of equality data (sexual orientation)
Data quality standards of 90%
The Equality Act 2010 sets out the public sectors equality duty.
IAPT for people with protected characteristics is a national and local priority. The
Indicator
reporting of the sexual orientation of patients helps our understanding of those groups
accessing (or not) available services. Commissioners should be assured that IAPT
providers are accurately recording and reporting sexual orientation data as per the
requirement of the IAPT minimum data set.
Derbys
IAPT 3
Goal
Data quality: recording of problem descriptor
Data quality standards of 90%
Access to comprehensive diagnosis information is fundamental to successful IAPT
outcome reporting and service planning; however not all services effectively report
Indicator
diagnosis within the IAPT data set. This is particularly true of the ‘provisional diagnosis’
field. This is due to the fact that staff types who would normally make a diagnosis do not
typically form a significant proportion of IAPT staff. National reporting, including all HSCIC
reporting, and the NHS England profiles tool, will cease to use the term ‘provisional
34
diagnosis’ and replace it with ‘problem descriptor (ICD-10)’.
Accurate reporting of the problem descriptor will improve our understanding of the
diagnostic groups being referred into IAPT services. This information will enable
commissioners to cross-reference with the local JSNA and public health profiles for
Derbyshire.
Derbys
IAPT 4
Goal
Reduction in ‘did not attend’ (DNA) rates (excluding referral to entering services)
Reduction in DNA rate to be maintained within agreed parameters
DNA rates in mental health settings are reportedly higher than other healthcare settings.
Research suggests that one of the main reasons for patient non-attendance is due to
them forgetting the appointment. Missed appointments can impact on patient
engagement and compliance with an agreed programme of care and as such may
adversely impact on recovery. Those who DNA appointments more than twice in
Indicator
succession are likely to be discharged. Unplanned patient DNA rates impacts on
delivery of services as providers are not able to fill vacant clinical slots at late notice.
Therefore, reduced DNA rates are likely to have a positive impact on service delivery and
outcomes for patients.
DNA recording will focus on the following code:
Attendance code = 3 (Did not attend - no advance warning given).
35
2a. 6 Service development and improvement plans 2015/16
The following provides a brief summary of key clinical service development and improvement plans for
the Trust in 2015/16. In some cases, plans will be subject to business case development, consultation
and governance, identified funding and/or Board of Directors/Council of Governors approval. Greater
detail on the clinical service transformation plans is provided within the Trust’s integrated business plan
(2015/20).
Cross-divisional
There are a number of services that have cross-divisional implications that require joint-working across
the Trust and with external partners to improve pathways and services, including eating disorders and
long term conditions. Developments include:
Single point of access (SPA)

To deliver an integrated SPA across Lincolnshire based around the four CCG localities.

One phone number for service users / referrers, to enhance the end user and commissioner
satisfaction, providing greater confidence in the Trust to manage the referral.

24 hours a day/seven days per week (24/7) access to mental health assessment via crisis, as
appropriate.

24/7 referrals which, whether urgent or non-urgent, are dealt with in a timely manner in an
agreed timeframe.

Provide appropriate signposting to treatment teams and external organisations, which will offer
service user choice and assist the Trust to manage service capacity and demand.

Reduce clinical team inputting by ensuring new referrals are entered onto relevant clinical
systems at the point of referral.
Personality disorder (PD) - Continuing to develop and improve a NICE-compliant PD service for
adults of all ages, which can be delivered through all the Trust’s services, who are supported by a
specialist PD team.
Section 75 agreement - The Trust is planning to continue to provide integrated adult social care
services for people with mental health problems aged 18-64 on behalf of LCC. This will include a joint
continuous improvement plan with LCC to implement the recommendations of a review of the service
completed in 2014. The main areas of service development and improvement are:
36
Social care and social work - The Trust is implementing a service model that provides:

Flexible design capable of responding to emerging service models such as LHAC
neighbourhood teams.

A clear framework for professional social work and social care practice, specifically utilising the
connecting people and communities intervention model.

Activities to build community capacity and the social work practice to actively support this. It
does this by both forging relationships with local community groups, and by directly supporting
service users and carers to access the help and support they provide.
Community Mental Health Support Networks
Managed care network for mental health (MCN) - The network aims to help people who have
already experienced mental health problems, or who are having their first experience of mental illness.
Members of the network have close links with each other to help people prevent, manage and recover
from mental illness, so that people can enjoy the best possible quality of life.
Groups and organisations across the county provide a variety of activities including social and
friendship groups, formal and informal learning, supported volunteering and community participation
activities for adults of all ages. There are around 30 different types of activities for people to choose
from at 73 sites in Lincolnshire.
Unlike personal budgets, people do not need to be eligible under social care eligibility criteria.
Network members also provide mental health promotion activities aimed at people of all ages.
The network currently comprises 44 full member organisations providing projects across Lincolnshire.
In addition the network also comprises associate members, which are those groups and organisations
which do not currently receive an investment from the mental health promotion fund but who remain as
members to retain their links to the network.
The network is funded by the mental health promotion fund. This fund has been established by LCC
and is managed by the Trust. Funding has been secured to sustain the network through 2015/16.
37
Priorities for 2015/16 are:

Safeguards and controls are being further strengthened

Alongside social workers’ community capacity building activities, a support networks apprentice
will use their lived experience to promote the network and strengthen relationships in local
communities

Continue to strengthen joint working and development opportunities between MCN members
and the recovery college

Enhance the support and information provided to MCN members, to further promote their
sustainability and network relationships.
Dementia support network - The Trust has been commissioned to establish a dementia support
network in South West and West CCG areas.
Early priorities are:

Invite applications for investment in the two areas, promoting new activities and innovation as
well as supporting the help and support that people already value

Establishing positive working relationships with all relevant groups and organisations

Building links to relevant services and developments across Lincolnshire.
General Adult Services Division
Steps2change Lincolnshire and Derbyshire (IAPT)

Plan for potential introduction of any qualified provider (AQP) in Lincolnshire

Improved patient choice and experience of services

Increase number of individuals successfully treated (recovered) per £100,000 expenditure

Introduce/sustain patient groups in each CCG

Achieve waiting time targets

Achieve/exceed recovery rates in all CCGs

Train new staff in evidenced based therapies to minimise gaps in delivery resources, focussing
on local people.

Expand range of NICE approved psychological treatments available within the current contract

Sustain/develop a patient group to inform and support development of the service, and ensure
meaningful engagement and consultation.

Meet 95% data completeness.
38
Integrated community teams

Improve, increase and sustain service user and carer experience and satisfaction

Reorganisation of the medical and psychology workforce to ensure an integrated service
delivery

Training of staff in the early intervention (EI) ethos, interventions and treatment in order to
maintain the EI service model

Identification of further training requirements including nurse prescribing

Implementation of psycho-educational groups

Implementation of outcome orientated adult mental health services (OO-AMHS) to support a
move towards improved health and well-being and independent living

Increased communication with and support to the MCN and Shine/third sector providers

Build closer working relationships with key stakeholders such as CCGs and the local council

Develop service user and carer groups

Support service users to utilise the recovery college as appropriate

Develop an increased range of interventions, via statutory and voluntary services, to improve
recovery and psychological well-being and increase quality of life.
Crisis resolution and home treatment (CRHT)

Complete a full service review in line with the Crisis Care Concordat and national standards for
parity of esteem. This will ensure adherence to best practice and maximise capacity of the
service to meet the anticipated increases in demand

Continue to strengthen relationships and partnership working with CCGs, health and statutory
agencies to improve patient pathways of care

Increase service user and carer involvement and evaluation across the services as part of the
Home Treatment Accreditation Scheme (HTAS)

Improve the interface between in-patient services, CRHT and community teams to reduce
admissions and facilitate early discharge and transition through the care pathways
39
Acute adult in-patient wards

Provision of evidence base care and treatment to be delivered by nursing and allied health
professionals that are based on acute care needs

Discharge is linked to outcomes of assessed acute care needs and in line with safeguarding
and joined up with community service provision

Senior clinical staff can lead discharge decision making based on the outcomes identified
through assessed acute care needs

Continual refurbishment programme to ensure an ongoing improvement of the clinical
environment

Reduced bed occupancy with and average length of stay below 28 days

Readmissions avoidance within 28 days of discharge with a rate that does not fall below 95%

Seven-day follow-up for all discharges supported by effective interface with CRHT and
community services

Overall improvement in service user (patient) experience

Positive staff experience

To work towards and achieve AIMS accreditation.
Rapid response

A rapid response service, delivered in partnership by our Trust, LCHS and EMAS, which will
provide a safe and high quality response to people who need support to remain in the
community.

Develop partnership working in Lincolnshire, and begin to examine different cultures and
relationships, and manage public expectations. Integrated health and social care, and
partnership working among different types of provider organisations are part of the national
direction. Within the limitations of time and resources, including potential recruitment, test the
rapid response model as a concept to inform service planning for the future.
40
Specialist Services Division
CAMHS – Lincolnshire
Ash Villa

To strengthen relationships with stakeholders to support service review and development.

Continue to work with local partners to deliver collaborative programmes of care that promote
physical and emotional well-being. To work with CAMHS as a whole service provision and
support innovative ways of delivering care.

Incorporate new technologies into service redesign and care pathways for tier 4 service to
support young people and their families and promote active engagement in the care planning
processes.

Market tier 4 spot purchase beds and service through publicising services. Work with research
and development (R&D) department and clinicians to develop opportunities to increase income
from research. Review alternatives to admission and opportunities for business development.

Complete accommodation review for tier 4 to ensure that care is delivered in a building and
environment that promotes growth and therapeutic wellbeing and risk management.

To develop treatment pathways for young people within CAMHS service as a whole, utilising
NICE guidance and best practice.
Community CAMHS
Tier 2 CAMHS

To develop links with local colleges

To develop further support and advice to agencies supporting vulnerable young people and children
with transitions (i.e. junior school to secondary school and secondary school to college)

To continue to work towards CQUIN - visits to GPs, FAST teams and voluntary agencies

To continue to work towards CQUIN - service user feedback, CHI expressions of satisfaction
Tier 3 CAMHS

Core community team: service redesign with the local authority commissioners to develop tier 3+
services and comprehensive tier 3 service

To continue to work with criminal justice system to extend psychology provision
41
Therapy service for children and young people who are displaying sexually harmful behaviours: develop
integrated care pathway with all relevant agencies across health and social care

To work with the sexual assault referral centre (SARC) to put in a bid for the Trust to be the
provider of a support service for children and young people affected by sexual violence
Self-harm:

To develop workshops with Ash Villa.

To further explore opportunities working with A&E and prevent admissions

To look at alternative assessment sites to A&E
Explore expansion of paediatric psychology services across a range of chronic physical health conditions
to include the current child diabetic psychology service.
CAMHS North East Lincolnshire (NEL)

Developing a gold standard autism pathway which offers a seamless service from 0 years to
adulthood in line with the recommended guidance from NICE

Review opportunity to provide comprehensive interventions for behavioural management based
on evidenced practice

To research and evaluate the cognitive behavioural therapy (CBT) and dialectical behavioural
therapy (DBT) groups (preliminary data gathered is very positive). We would also like to
evaluate the tier 3+ and attention deficit hyperactivity disorder services as these are innovative
successful ways of working that we would like to share with other CAMHS services by
publication

Support the new choose and book appointments system.
Mental health rehabilitation

Develop a streamlined care pathway with a therapeutic length of stay

Clear clinical pathway through the Trust services to meet patient need

To be the provider of choice with the region

To be the specialist of choice for females with personality disorders requiring a locked
environment and females requiring specialist eating disorder interventions in a locked
environment

Maintain AIMS accreditation on all of our rehabilitation wards to an excellent standard

Specialised and enhanced training for staff around PD for females and eating disorders.
42
Drug and alcohol recovery (DART)

Continue to attract over 57.7% of the presenting activity during 2015/16 which will underpin its
position as the market leader

Continue to have outcome based activity rates that ensure full earnings are achieved through
payment by results (PbR) payments ensuring that financial viability is maintained

Continue to achieve against maintained performance measures, monitoring performance
against these measures through a local dashboard to ensure that quarterly payments are
received

Refocus on highly complex drug and alcohol use to ensure that it is seen as the service that is a
specialist in all areas

Provide specific intervention targeted at those people using new psychoactive substances
(‘legal highs’) ensuring that it responds to new trends and changing demands.

Establish service user involvement as a robust system embedding the principle of ‘‘nothing
about me without me’’ and providing opportunity for service users to play an active role within
the treatment system.

Look to innovations in treatment within specific specialist pathway development around
Korsakoffs Syndrome.
Dementia and specialist older adult mental health

Completion of in-patient services review and agreement and progression of business-case and
estates plan

Establishment of agreed separate specialist dementia and complex mental health assessment
and intervention pathways - across all four CCGs

To achieve the very best outcomes in terms of diagnosis, treatment and/or recovery for all
service users

To assist in the meeting of quality and outcomes framework (QOF) diagnostic targets for
dementia

Establish a cross CCG agreement of shared care protocol (SCP)

Provide a clear training plan for staff and provide training and development opportunities;

Development of psychological mindedness agenda

Psychology provision re-alignment

To pursue opportunities for integration where this is in the best interests of services users. To
support broader county wide/cross service objectives.
43
Community forensic service

Take an active role in being part of achieving our aims and vision as the offender health
pathway develop

Actively look at introducing transitional work for those offenders nearing release from prison

Maintain working links with out of area service users on caseload and assist in reducing the
time spent in secure care in our role of care co-ordinators

Ensure that each service user taken onto caseload has a high quality risk assessment

All risk assessments will evidence our input that assists in reducing recidivism.
Francis Willis Unit (low secure in-patient service)

To remain part of the low secure quality network service

For staff to be able to deliver mental health and offence focused work, they require training
which can be provided using internal resources or working collaboratively with external
agencies

To re-launch the productive ward series

Staffing capacity will be sufficient to deliver the care and treatment model and maintain a safe
environment at all times

Development of a carers’ group will be set up with another inpatient setting to ensure our carers
have the opportunity to benefit from the experiences of carers in a larger group setting.
Learning disabilities (LD)

Review of AHP and liaison nursing teams with a view to integration of AHPs and health liaison
nursing into community teams aligned by the four Lincolnshire CCG localities

Review acute liaison nursing service with a view to providing a seven-day, 8am-6pm service.

Workforce review of inpatient services currently delivered for rehabilitation; assessment and
treatment

Review of the diagnostic interview for social and communication disorders (DISCO) contract

Joint working with local authority and CCG commissioning to ensure that the Trust meets the
requirements of autism strategy

For LD inpatient services to achieve quality network learning disabilities (QNLD) accreditation
prior to applying for LD AIMS accreditation

Increased opportunities for service user and carer involvement. To incorporate and develop the
inpatient model of service user directly supporting recruitment and interview processes to the
community teams.
44
Part 2b Statements of Assurance from the Board
The Trust’s Board of Directors is required to satisfy itself that the Trust’s annual quality report is fairly
stated. In doing so, the Trust is required to put in place a system of internal control to ensure that
proper arrangements are in place based on criteria specified by Monitor, the independent regulator of
NHS foundation trusts. The Trust has appointed a member of the Board, the director of nursing and
quality, to lead and advise on all matters relating to the preparation of the Trust’s annual quality report.
To ensure that the Trust’s quality report presents a properly balanced view of performance over the
year, the Trust’s quality committee, accountable to the Board of Directors, provides scrutiny and
challenge. The quality committee ensures robust challenge, review and the provision of assurance to
the Board in respect of quality and risk initiatives and reports, including escalating risks if required, as
per the Trust’s Board assurance and escalation framework (2014).
The Trust has quarterly quality review meetings with its lead commissioner, and has shared the draft
quality report with governors, commissioners, the local health scrutiny committee and Healthwatch
Lincolnshire for comment.
During 2014/15 the Trust provided and/or sub-contacted four relevant health services, these services
being mental health, learning disabilities, drug and alcohol recovery services and prison healthcare (up
to October 2014).
The Trust has reviewed all the data available to them on the quality of care in four of these relevant
health services.
The income generated by the relevant health services reviewed in 2014/15 represents 100% of the
total income generated from the provision of relevant health services by the Trust for 2014/15.
45
2b. 1 Participation in Clinical Audits and National Confidential Enquiries 2014-15
Participation in clinical audits 2014-15
During 2014/15 2 national clinical audits and 0 national confidential enquiries covered relevant health
services the Trust provides.
During that period the Trust participated in 100% national clinical audits of the national clinical audits
which it was eligible to participate in.
The national clinical audits and national confidential enquiries that the Trust was eligible to participate
in during 2014/15 are as follows:

POMH (UK) – National Prescribing Observatory for Mental Health UK

NATIONAL CQUIN Physical Healthcare CQUIN 3.1
The national clinical audits and national confidential enquiries that the Trust participated in during
2014/15 are as follows:

POMH (UK) – National Prescribing Observatory for Mental Health UK

NATIONAL CQUIN Physical Healthcare CQUIN 3.1
The reports of two national clinical audits were reviewed by the provider in 2014/15 and the Trust
intends to take the following actions to improve the quality of healthcare provided:

Disseminate audit results to all relevant clinicians and staff

Develop and monitor action plans to address shortfall in service provision

Carry out re-audits where necessary to monitor compliance.
The reports of 71 local clinical audits were reviewed by the provider in 2014/15 and the Trust intends to
take the following actions to improve the quality of healthcare provided:

Disseminate audit results to all relevant clinicians and staff

Develop and monitor action plans to address shortfall in service provision

Carry out re-audits where necessary to monitor compliance.
For the year up to 31 January 2015, 159 individuals have participated in research studies with the Trust
that have been approved by a research ethics committee.
46
The national clinical audits and national confidential enquires that the Trust 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.
POMH (UK): National Prescribing
0 cases submitted (100% of
Observatory for Mental Health UK.
Completed
available cases)
Topic 14 Prescribing for substance misuse:
April 2014
*0 patients met POMH(UK)’s
alcohol detoxification
criteria for submission
NATIONAL CQUIN
Completed
100 cases submitted (100% of
Physical Healthcare CQUIN 3.1
January 2015
available cases)
Participation in research 2014/15
The number of patients receiving relevant health services provided or sub-contracted by the Trust in
2014/15 that were recruited during that period to participate in research approved by a research ethics
committee 409.
For the year April 2014 to March 2015 (figures as at National Institute for Health Research (NIHR) data
cut 14 November 2014), the Trust is achieving the following NIHR key performance indicators (KPIs):

Recruitment to NIHR studies = 159

Trust % of local NHS permissions within 30 days = 100%
In 2014-15 the Trust was involved in conducting 50 NIHR clinical research studies; Trust NIHR network
funded staff supported these studies. The Trust used national systems to manage the studies in
proportion to risk. All studies were managed under national model agreement and research passport
guidance.
The Trust’s research and development operational capability statement (RDOCS) was reviewed by the
Trust board in July 2014 and is uploaded to the NIHR Clinical Research Network website and published
on the Trust’s website.
47
Examples of NIHR work undertaken by the Trust in 2014-15
Responding to the Dementia Challenge
A key area for action within the Dementia Challenge is improving research; the Trust’s R&D department
is working with Trust clinical staff to increase access to dementia studies in Lincolnshire and offer our
staff, service-users and carers valuable opportunities to help shape improvements in dementia care
through participation in research.
In 2014-15 the R&D department has taken forward two national initiatives that have been developed as
part of the Dementia Challenge:
ENRICH – Enabling Research in Care Homes
Developed by the NIHR, the ENRICH toolkit draws on work from the NIHR School for Social Care
Research (SSCR). Whilst focusing on dementia the toolkit has been designed to be applicable to other
disease areas and conditions, and information provided can be used to support the promotion of all
high-quality research.
There are over 18,000 care homes in England providing homes and care for over 386,000 people. The
ENRICH programme aims to support increasing the amount of research from its current levels in order
to improve the quality of life and quality of care for all care home residents especially people with
dementia http://www.enrich.dendron.nihr.ac.uk/
From July 2014, care homes in Lincolnshire will have been contacted and provided with details of the
ENRICH programme. 15 Lincolnshire care homes are now registered to ENRICH, with a further 18
homes registered as corporate organisations.

The R&D department has developed a Lincolnshire ENRICH monthly newsletter – aimed at
keeping homes informed and engaged.

We have secured our first care home study – see information below.

We have research staff and clinical staff representation on the East Midlands ENRICH forum
group.
48
Join Dementia Research (JDR)
JDR is a national service that offers individuals the chance to register their interest in taking part in
dementia research, find suitable studies in their area, and let researchers know that they might be
interested in taking part in their research.
The service’s development is being funded by the DoH and it will be delivered in a partnership with the
NIHR Clinical Research Network, Alzheimer’s Research UK and the Alzheimer’s Society.
JDR was launched nationally in early 2015 and is supported by the Trust. Our R&D department has
been promoting the initiative as widely as possible across the county.

The R&D department is JDR trained and has researcher access to the system.

We have research staff and clinical staff representation on the East Midlands Clinical Research
Network (CRN) Dementia Challenge steering group
Agitation and quality of life in care homes – Dr Claudia Cooper, University College London
Half of people with dementia experience symptoms of agitation every month. Symptoms of agitation
include restlessness, pacing, shouting and verbal or physical aggression. Many people with agitation
are admitted to care homes as families find they cannot care for them at home. Within the care home,
agitated behaviour takes up staff time and emotional and physical energy but they do not always know
how to respond. The study in this application is one of the streams in an integrated programme to help
tackle agitation in a variety of settings from domestic environments to end of life.
The research department is inviting Lincolnshire ENRICH registered care homes to take part in this
national research project to find out about the quality of life people with memory problems who live in
care homes experience, and how the ways that care home staff manage difficult situations might affect
this. The researchers plan to use this information to develop a new training programme for care home
staff to improve residents’ quality of life.
Performance information on the initiation and delivery of clinical research
The Government wants to see a dramatic and sustained improvement in the performance of providers
of NHS services in initiating and delivering clinical research.
The Government’s Plan for Growth, published in March 2011, announced the transformation of
incentives at local level for efficiency in initiation and delivery of clinical research.
49
The DoH, via the new NIHR contracts with providers of NHS services, the publication on a quarterly
basis of information regarding: the 70-day benchmark for clinical trial initiation; and the recruitment to
time and target for commercial contract clinical trials
1. Providers of NHS services are required to publish information for initiating clinical research
(ie the 70-day benchmark) on a publicly available part of their website.
2. Providers of NHS services are also required to publish information regarding commercial
contract clinical trials, to meet the transparency commitment for delivering clinical research to
time and target on a publicly available part of their website.
The Trust has been asked to start reporting and publishing on initiating and delivering clinical research
from Q3 2014-15, and then on an ongoing quarterly basis. This information is promoted on the Trust
website: www.lpft.nhs.uk/research
NICE guidance implementation 2014/ 2015
The Trust has developed systems and processes in line with recommendations from NICE to ensure
that all implementation of their guidance has a clear process. The overall co-ordination, planning and
monitoring of NICE implementation within and across services is carried out in accordance with
principals set out in this policy. The Trust currently has 10 NICE technology appraisals and 47 clinical
guideline implementation projects in progress. Compliance with implementation is detailed in the tables
below for clinical guidelines, technology appraisals and public health guidelines respectively.
50
Technology appraisals:
Technology
appraisals
Quarter 4
Total
Compliant
10
10
Partially
compliant
Under review
0
0
Clinical guidelines and public health guidelines
Clinical
guidelines/public
Total
Compliant
47
10
health guidelines
Quarter 4
Partially
compliant
Under review
29
8
Where our status is ‘partially compliant’, meaning there are elements of non-compliance with the
guidance, we will undertake a baseline audit to establish areas where improvements are needed to
achieve full compliance. From the results of baseline audits, individual action plans will be developed
detailing implementation requirements over varying timescales.
NICE permits flexibility when implementing clinical guidelines as it is recognised that in some instances
it may take varying periods of time to fully implement the guidance. However, it is the expectation,
unless otherwise noted, that NICE technology appraisals should be implemented within 12 weeks of
publication. The function of the Trust’s research, innovation and effectiveness team is to audit and
monitor progress against agreed action plans with the aim to achieve full implementation over time.
2b. 2 Performance in CQUINs 2014/15
A proportion of the Trust’s income in 2014/15 was conditional on achieving quality improvement and
innovation goals agreed between the Trust and any person or body the Trust entered into a contract,
agreement or arrangement with for the provision of relevant health services, through the CQUINs
payment framework.
Further details of the agreed goals for 2014/15 and for the following 12 month period are available
electronically at http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf .
51
The 2014/15 CQUINs are identified below:

There were seven locally agreed CQUINs. There were seven NHS England (NHSE) low secure
CQUINs; four NHSE CAMHS CQUINs; two CQUINs for NEL CAMHS; three Derbyshire IAPT
CQUINs and three LCC tier 2 and three CAMHS CQUINs.

The overall monetary total for income in 2014/15 conditional upon achieving quality
improvement and innovation goals was £1.82 million (excluding steps2change Derbyshire
(IAPT) CQUIN monies). The monetary total value of the CQUINs 2013/14 was £1.8 million.
Indicator
NHS Safety Thermometer
MH1:
Description of
Full implementation and achievement of requirements of NHS safety thermometer in
indicator
accordance with national targets.
Payment
Fully met
Indicator
MH2a:
Description of
Friends and family test (FFT)
FFT: implementation of staff FFT
indicator
Payment
Indicator
MH2b:
Description of
Fully met
FFT
FFT: early implementation
indicator
Payment
Indicator
MH2c:
Description of
Fully met
FFT
FFT: phased expansion
indicator
Payment
Fully met
52
Indicator
Improving physical healthcare: cardio metabolic assessment for patients with
MH3a:
schizophrenia
Description of
Cardio metabolic assessment for patients with schizophrenia
indicator
Payment
Not met
Indicator
Improving physical healthcare: cardio metabolic assessment for patients with
MH3b:
schizophrenia
Description of
Completion of a programme of local audit of communication with patents’ GPs, focussing
indicator
on patients on CPA
Payment
Partially met
Indicator
MH4:
Autism awareness: training year 1 of 2
Description of
Implementation and agreed percentage roll-out of autism awareness training for patient
indicator
facing staff
Payment
Fully met
Indicator
MH5:
Workforce development: health care assistants (HCAs)
Description of
Development of a regulatory framework for all HCAs working across the Trust and a set
indicator
of standard competencies for all Band 2, 3 and 4 HCAs working in the Trust
Payment
Fully met
Indicator
MH6:
Development of PROMS for dementia
Description of
Implementation and agreed percentage achievement of DEMQOL returns for all in-
indicator
patients with dementia.
Payment
Fully met
53
Indicator
MH7:
Description
of indicator
Payment
Medication management
10% reduction in medication errors resulting in harm across all NPSA harms
Fully met
NHS England Commissioning
Low secure
Improving physical healthcare: cardio metabolic assessment for patients with
(LS) 1
schizophrenia.
Description of
indicator
Demonstrate, through national audit process, full implementation of appropriate
processes for assessing, documenting and acting on cardio metabolic risk factors in
patients with schizophrenia.
Payment
Fully met.
LS 2
FFT
FFT: implementation of staff FFT.
Description of
indicator
FFT: early implementation.
FFT: phased expansion.
Payment
Fully met.
LS 3
Collaborative risk assessment.
Description of
This CQUIN requires providers to develop a strategy to engage and maintain
indicator
relationships with carers where a service user has identified this as a choice.
Payment
Fully met.
54
LS 4
Supporting carer involvement.
Description of
To provide the service user information detailing a formulation of both current and
indicator
potential future needs and how the proposed service might best meet them.
Payment
Fully met.
LS 5
Needs formulation at transition.
Description of
To provide the service user information detailing a formulation of both current and
indicator
potential future needs and how the proposed service might best meet them.
Payment
Fully met.
LS 7
Quality dashboard
Description of
indicator
Payment
CAMHS 1
Description of
indicator
Targets are set out as part of quarterly monitoring and payment requirements.
Fully met.
Improving physical healthcare: cardio metabolic assessment for patients with
schizophrenia.
Demonstrate, through national audit process, full implementation of appropriate
processes for assessing, documenting and acting on cardio metabolic risk factors in
patients with schizophrenia.
Payment
Fully met.
CAMHS 2
FFT
Description of
indicator
Payment
FFT: implementation of staff FFT.
FFT: early implementation.
FFT: phased expansion.
Fully met.
55
CAMHS 3
Review of unplanned admissions.
Description of
Minimum of 60% improvement in number of reviews held within five working days of
indicator
unplanned admission recommended.
Payment
Fully met.
CAMHS 4
Quality dashboard
Description of
indicator
Payment
Targets are set out as part of quarterly monitoring and payment requirements.
Fully met.
North East Lincolnshire (NEL) CAMHS
NEL CAMHS
1
12 weeks’ wait.
Description of
The percentage of service users who are offered a first appointment within 12
indicator
weeks of the date of receipt of referral.
Payment
Fully met.
NEL CAMHS
2
DNA rates
Description of
The total number of DNAs as a percentage of appointments offered per
indicator
month
Payment
Not met.
56
Derbyshire Steps 2 Change
Derbyshire
IAPT 1
Patient Experience: net promoter question positive response rate.
Quarterly returns to commissioners evidencing
Description of
1. Number of patients who have completed therapy and responded extremely likely
indicator
or likely (being defined as positive) for the above NPQ.
2. Number of patients who have completed therapy and have completed a NPQ.
Payment
Fully met.
Derbyshire
IAPT 2
Patient experience: net promoter question - response rate
Quarterly returns to commissioners evidencing
Description of
indicator
1. Number of patients who have completed therapy, completed a patient experience
questionnaire (PEQ) including and have completed a national patient questionnaire
(NPQ).
2. Number of patients who have completed therapy.
Payment
Derbyshire
IAPT 3
Description of
indicator
Fully met.
Patient experience: patient satisfaction - positive response rate
Total number of patients who have completed therapy and responded positively to
the five PEQ listed above. Denominator: Total number of patients who have
completed therapy and have completed the five PEQ questions listed above.
Payment
Derbyshire
IAPT 4
Description of
indicator
Payment
Fully met.
Recovery rate.
Achievement of agreed targets of recovery
Fully met.
57
Lincolnshire County Council Tier 2 & 3 CAMHS
LCC CAMHS
1
Tier 2 Source of Referral
Description
Percentage and number of GP referrals as a proportion of total number of tier 2
of indicator
referrals.
Payment
Fully met
LCC CAMHS
2
Community CAMHS CHI returns improvement
Evidence of actions taken to improve opportunities for service users and carers /
parents to provide service with feedback through completion of the CHI esq
Description
questionnaire. Quarterly agreed increases on returns received from Q2 as indicated.
of indicator
Overall increase in number of returns received will indicate the success rate in
further embedding the practice of collating feedback through the use of this tool (CHI
ESQ) within CAMHS community services.
Payment
LCC CAMHS
3
Description
of indicator
Payment
Fully met.
Tier 3 quality network for community CAMHS accreditation
QNCC accreditation achieved.
Fully met.
58
2b. 3 CQC ratings and opinion, including the Quality Risk Profile (QRP)
The Trust is required to register with the CQC and its current registration status is fully registered. The
Trust has no conditions on registration.
The CQC has not taken any enforcement action against the Trust during 2014/15.
The Trust has not participated in any special reviews or investigations by the CQC during the reporting
period.
The Trust has been registered to carry out the following regulated activities:

Treatment of disease disorder or injury

Assessment and medical treatment of persons detained

Accommodation for persons who require nursing care or personal care.
There are 21 outcomes (standards) used as the framework by which the CQC monitors care, 16 of
these called the essential standards, relate directly to care given and involvement of service users. As
a Trust we are required to evidence our compliance against the CQC’s essential standards. This is the
final year that the Trust will be measured against these standards as the CQC’s new more thorough
surveillance model for mental health has been rolled out during 2014/15.
The new surveillance model is built on a suite of indicators that relate to the five key questions
inspectors will ask of all services – are they safe, effective, caring, responsive, and well led. Visits
conducted during November 2014 were conducted under this new model.
The Trust is subject to periodic reviews by the CQC and a number of our units have been visited during
2014/15; and any actions identified are monitored and assurance given to the CQC on completion of
these actions. All teams have maintained a provider compliance assessment throughout 2014/15,
evidencing how their services complied with the CQC’s essential outcomes; and provided a high level
report every two months for inclusion in the Trust’s early warning indicator heat map.
59
During 2014/15 the Trust received the following CQC visits to its sites:
Mental Health Act Visits
Unit visited
Date of inspection
Ashley House, rehabilitation unit
27/06/2014
Ward 12, Pilgrim Hospital site, adult acute ward
18/07/2014
Francis Willis Unit, Lincoln County Hospital site, low secure unit
19/09/2014
Learning disabilities, bungalows 1 & 2
03/10/2014
Langworth Ward, Witham Court, older adult ward
10/10/2014
Ash Villa, CAMHS unit
09/01/2015
Compliance Visits
Unit visited
HMP North Sea Camp, Boston
Outcomes inspected
4: Care & welfare of people who use services
6: Co-operating with other providers
14: Supporting workers
16: Assessing & monitoring the quality of service
provision
Date of inspection
21/07/2014
Outcomes 14 and 16 the CQC identified that
actions were required to meet full compliance.
The Trust implemented an action plan to
address these issues.
Prison healthcare services have since been
taken over by another provider.
Responsive Visit
Unit visited
Mental health units sited at
Lincoln County Hospital:
Peter Hodgkinson Centre
(Charlesworth & Conolly adult
acute wards)
Francis Willis Unit, low secure
unit
Outcomes inspected
This inspection was carried out under the new
CQC inspection regime:





Date of inspection
26/11/2014
Are services safe?
Are services caring?
Are services responsive?
Are services effective?
Are services well led?
60

The Trust is fully compliant in respect of CQC visits; and has promptly addressed any feedback
and actions identified. CQC visit related action plans are monitored through the Trust’s
operational governance group, with assurance reported to the quality committee.

The CQC and QRP are populated from a number of sources, but key are the findings of our
individual service inspections. Across the year, all of the outcomes have either remained static
or shown a small improvement

The Trust’s Board assurance and escalation framework (2014) details the Trust’s clinical
governance and risk management processes, including the committee structure that ensures
risk and compliance concerns are reported and escalated as appropriate to the Board. One of
the Trust’s compliance assurance mechanisms is a schedule of 15 Steps/mock CQC visits to
clinical areas in both in-patient and community settings. Inspection teams include a Trust
governor, service user / carer; and member of the quality and risk / compliance team. Where
possible an inspection team also includes a staff member from a different clinical setting to
support their professional development. Non-executive directors and directors also carry out
scheduled and non-scheduled visits to clinical areas throughout the year, reporting findings to
the Board.
61
2b. 4 Statement on quality of data, governance assessment report score and clinical coding
The Trust 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 patient’s valid NHS number was:
99.7% for admitted patient care;
100% for out-patient care

Which included the patient’s valid General Medical Practice Code was:
99.9% for admitted patient care;
100% for out-patient care
As a provider of IAPT, the Trust submits the monthly IAPT return. In July 2014 this moved to version
1.5 of the dataset, which the Trust is fully compliant with.

As a provider of drug and alcohol services, the Trust submits the National Drug and Treatment
Monitoring Service monthly dataset returns. Currently dataset L which was implemented on
7 April 2015.

As a mental health trust, the Trust submits data for the mental health and LD dataset which
replaced the mental health minimum dataset on 1 September 2014.

The Trust‘s information governance assessment report overall score for version 11 in 2014/15
was 71% (March 2014) and was graded (red). The Trust failed to achieve level two compliance
or above in two of the standards, that of:
o
11-507 the completeness and validity check for data has been completed and passed (level
1 only achieved)
o
11-514 an audit of clinical coding, based on national standards, has been undertaken by a
NHS classifications service approved clinical coding auditor within the last 12 months (level
1 only achieved).

The Trust reports information governance (IG) toolkit progress in year on a quarterly basis; and
submits this into the IG toolkit portal. The Trust has made progress against last year’s position
improving all but one of its level one scores to level two and increasing many level two scores to
level three.
62
The Trust will be taking the following actions to improve data quality:

Two external audits are undertaken annually in preparation for the final submission of the IG
assessment report by the Trust. These focus on a selection of the standards and the clinical
coding standards. These audits provide further assurance to the Board on the validity of the
Trust’s self-assessment and subsequent submission.

The Trust has an action plan to address these issues which is monitored through the IM&T
committee.
63
IG Toolkit assessment summary report
Information Governance Management
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
0
0
5
Not
Total
Relevant Req'ts
0
5
Not
Total
Overall Score
100%
Confidentiality & Data Protection Assurance
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
0
2
6
Relevant Req'ts
1
9
Not
Total
Overall Score
91%
Information Security Assurance
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
0
6
9
Relevant Req'ts
0
15
Not
Total
Overall Score
86%
Clinical Information Assurance
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
0
3
2
Relevant Req'ts
0
5
Overall Score
80%
64
Secondary Use Assurance
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
1
6
1
Not
Total
Relevant Req'ts
0
8
Not
Total
Overall Score
66%
Corporate Information Assurance
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
0
3
0
Relevant Req'ts
0
3
Not
Total
Overall Score
66%
Overall
Assessment
Version 12
(2014-2015)
Stage
Latest
Level Level Level Level
0
1
2
3
0
1
20
23
Relevant Req'ts
1
45
Overall Score
83%
Grade Key
Not Satisfactory
Satisfactory with
improvement
plan
Satisfactory
Not evidenced attainment level 2 or above on all requirements (version 8 or after)
Not evidenced attainment level 2 or above on all requirements but improvement
actions provided (version 8 or after)
Evidenced attainment level 2 or above on all requirements (version 8 or after).
65
2b. 5 Payment by results (PbR) including priorities 2015/16
The requirements for implementation of the PbR programme for 2015/16 are set out in DoH Mental
Health Payment by Results Guidance for 2014-15 and Monitor: 2015/16 National Tariff Payment
System. The currency, which is the unit of healthcare for mental health services in scope of PbR, is the
care cluster.
The Monitor guidance for 2015/16 stipulates that the cluster should be the currency for agreeing local
prices in 2015/16. This should be underpinned by cap or collar arrangements, to ensure financial
stability. The Trust now has established activity levels and indicative prices against the care clusters.
2015/16 will continue the work to ensure that the practice of clustering is ingrained in practice amongst
clinical teams and ensuring accurate recording of all related activity. This consistent data set of reliable
PbR activity will assist in the final stage of contract negotiation for local costs by cluster.
PbR priorities for 2015/16

Ensure all clinicians are trained in use of the mental health cluster tool (MHCT) and cluster
individuals in a timely manner and in a cluster which reflects care need; cascading of bespoke
train the trainers training to all clinicians working within in scope services.

Project plan to ensure that medical staff are trained and are delivering MHCT within all in scope
outpatient clinics.

IAPT PbR implemented across Steps 2 Change Services in Lincolnshire and Derbyshire.

Have reliable suite of reports, enabling team performance management of clustering.

Initial assessment and ability to measure PbR related activity over a period of time.

Development of super cluster care pathways, with measured outcomes, which are based on
quality standards and NICE guidelines.

Continue to measure quality against defined metrics, as outlined in DoH guidance. Regularly
analyse this with commissioners as part of the quality review.

Finalise cluster costs, based on cost of PbR related activity with commissioners.

Develop Risk Sharing agreement with commissioners.

Benchmark PbR indicators against other trusts in the region.
The Trust was not subject to the PbR clinical coding audit during 2014/15 by the Audit Commission.
66
2b. 6 Performance against core quality account indicators
Since 2012/13 the Trust has been required to report performance against a core set of indicators using
data made available to the Trust by the Health and Social Care Information Centre (HSCIC). This
feeds the hospital episode statistics and the mental health minimum data set.
For each indicator the number, percentage, value, score or rate (as applicable) for at least the last two
reporting periods is presented in the below. Where available, for each indicator, the rate for the last
five reporting periods is presented. In addition, where the data is made available by the HSCIC, a
comparison is made of numbers, percentages, values, scores or rates of each of the Trust’s indicators
with: the national average for the same; and those NHS trusts and NHS foundation trusts with the
highest and lowest for the same.
67
Core indicator
CPA 7-day follow-up
(threshold 95%)
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
96.1%
96.9%
96.2%
96.5%
98.7%
95.9%
Benchmark: NHS average is 75.5% (year to date): highest 100%, lowest:0% (Source: HSCIC)
 The Trust considers that this data is as described for the following reason: reports are validated against
the source system (HSCIC website).
 The Trust intends to take the following actions to improve this percentage, and so the quality of its
services, by completing in year quality audits of CPA 7-day follow-up entries; and ensuring any
identified actions are promptly followed up. Whilst the Trust’s % compliance remains good, the Trust
seeks excellence in associated record keeping, supporting high standards of patient safety.
Core indicator
2009/10
2010/11
2011/12
90.6%
95.6%
91.7%
(threshold
(threshold
(threshold
was 90%)
was 90%)
was 90%)
2012/13
2013/14
2014/15
96.3%
96.7%
99.8%
Admissions to inpatient services have
had access to crisis
resolution home
treatment teams
(threshold 95%)
Source: Trust systems
 The Trust considers that this data is as described for the following reasons: reports are run, manually
reviewed; and uploaded to the Department of Health via the Unify system quarterly.
 The Trust intends to take the following actions to improve this percentage, and so the quality of its
services, by continuing an assertive focus in work to improve its data quality systems.
68
Core indicator
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
0%
6.9%
11.1%
9.4%
8.1%
8.7%
8.1%
8.4%
10.4%
8.3%
9.6%
8.79%
<15
years
28-day re-
old:
admission
(threshold
10%)
>16
years
old:
Source: Trust systems

The Trust considers that this data is as described for the following reasons: admission and discharge
data is manually reviewed monthly to capture data on all re-admissions within the Trust.

The Trust intends to take the following actions to improve this percentage, and so the quality of its
services, by reviewing quality of related data during 2014/15 and implementing any required actions to
support improvement in data quality whilst maintaining performance within required threshold.
Core indicator
Staff who would
recommend the
Trust as a provider
of care to their FFT
2009/10
2010/11
Not
Not
available
available
2011/12
2012/13
2013/14
2014/15
3.25
3.55
3.58
Not
(below
(national
(above
available
national
average)
national
average)
average)
Source: Trust systems

The Trust considers that this data is as described for the following reason: reports are published on
the CQC website.

The Trust has taken the following actions to improve this score; and so the quality of its services by:
delivery of initiatives including the Trust’s staff engagement programme, Making a difference.
69
Core indicator
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
Community mental
health services
patient survey
indicator score with
Not
Not
regard to a patient’s
available
available
experience of
.
8.7/10
8.7/10
8.9/10
(about the
(about the
(better than
same as
same as
national
national
national
average)
average)
average)
contact with a
7.6/10
(about the
same as
national
average)
health or social care
worker
Source: CQC

The Trust considers that this data is as described for the following reason: reports are published as part
of the national community mental health patient survey.

The Trust has taken the following actions to improve this score; and so the quality of its services by:
completing 15 Steps / mock CQC visits to community teams, successful roll out of FFT to community
teams; and responsiveness to related feedback.
70
Core Indicator
2009/10
2010/11
2011/12
incidents
incidents
5,025
(total).
(total).
incidents
1,520
2,074
(total).
reported to
reported to
2,174
Not
NRLS of
NRLS of
reported to
available
which 50
which
NRLS of
(3%)
36 (1.7%)
which 23 (1%)
resulted in
resulted in
resulted in
severe
severe
severe harm
harm or
harm or
or death
death
death
incidents reported
the number and %
of such patient
safety incidents that
resulted in severe
harm or death
Not
available
available
2014/15
4,169
rate of patient safety
Not
2013/14
5,024
The number and
within the Trust; and
2012/13
Source: Trust systems

The Trust considers that this data is as described, as incident reports are submitted to the CQC; and to
the National Reporting and Learning Services (NRLS) where incidents result in severe harm or death.

The Trust has taken the following actions to improve this score; and so the quality of its services by:
mechanisms including the increasing of benchmarking and monitoring of trends via the Trust’s serious
incident review group, with reporting to the Board and the Trust’s quality committee. The Trust’s
evidencing of Duty of Candour; and wide dissemination Learning Lessons bulletins across the Trust.
71
2b. 7 Complaints: Trust’s responsiveness

Data contained within the complaints section of the quality report is data correct as of 8 April
2015

During 2014/2015 (1st April 2014 to 31 March 2015) there were 195 complaints registered with
the Trust.

There are 11 complaints still in process within agreed timescales (6%).

The overall compliance for 2014/2015 is 69% meaning that 69% of all responses were provided
according to plan within the timeframes agreed. This is a reduction in the responsiveness to
complaints in 2013/2014 (77%) and continual review is undertaken to improve compliance with
response times.

Out of the 195 complaints registered in 2014/2015, 41 were locally upheld (23%).

The majority of complaints relate to care and treatment (46%)with access to services at 38%
and attitude of staff 12%

In August 2014, the PHSO issued their findings on a complaint referred to them. The complaint
was partially upheld and is in relation to care planning and involving the patient and
carers/relatives. There were no issues with clinical decision making or care and treatment
offered but more about the impact on the patients experience due to uncertainty about the care
plan. There is no financial redress recommended in this case. The Trust has accepted the
findings of the Ombudsman. The requirement to evidence user involvement in care planning
should be well understood and embedded in practice. There are mechanisms in place to
monitor compliance to this requirement and these include case file audits undertaken within
teams and CPA audits.

Out of 195 complaints received, 135 complaints were completed within agreed timeframes
(69%).

11 complaints remain in process at the time of publishing this report (6%) with the potential to
achieve 75% compliance which falls short of the local standard for compliance (90%).

194 complaints were registered in 2013/2014 compared to 195 in 2014/2015.
72
Compliance with complaint plan: service resolution
2014 / 2015
Q1
Q2
Q3
Q4
Total
Met
33 (72%)
38 (84%)
36 (75%)
22 (67%)
129 (75%)
Unmet
13 (28%)
7 (16%)
12 (25%)
3 (9%)
35 (20%)
In Process
0
0
0
8 (24%)
8 (5%)
Total
46
45
48
33
172
Q1
Q2
Q3
Q4
Total
Met
1 (12%)
2 (33%)
2 (40%)
1 (25%)
6 (26%)
Unmet
7 (88%)
4 (67%)
3 (60%)
0
14 (61%)
In process
0
0
0
3 (75%)
3 (13%)
Total
8
6
5
4
23
Q1
Q2
Q3
Q4
Total
Met
34 (63%)
40 (78%)
38 (72%)
23 (62%)
135 (69%)
Unmet
20 (37%)
11 (22%)
15 (28%)
3 (8%)
49 (25%)
In process
0
0
0
11 (30%)
11 (6%)
Total
54
51
53
37
195
2014 / 2015
Q1
Q2
Q3
Q4
Total
Not proven
22 (48%)
16 (35%)
22 (46%)
13 (39%)
73 (42%)
Partial
15 (33%)
18 (40%)
14 (29%)
3 (10%)
50 (29%)
Upheld
9 (19%)
11 (25%)
12 (25%)
9 (27%)
41 (23%)
In process
0
0
0
8 (24%)
8 (6%)
Total
46
45
48
33
172
Compliance: formal investigations
2014 / 2015
Total compliance with complaint plan
2014 / 2015
Outcomes: service resolution
73
Outcomes: formal resolution
2014 / 2015
Q1
Q2
Q3
Q4
Total
Not proven
1 (12%)
1 (17%)
0
1 (25%)
3 (13%)
Partial
4 (50%)
3 (50%)
3 (60%)
0
10 (44%)
Upheld
3 (38%)
2 (33%)
2 (40%)
0
7 (30%)
In process
0
0
0
3 (75%)
3 (13%)
Total
8
6
5
4
23
2014/2015
Q1
Q2
Q3
Q4
Total
Not proven
23 (43%)
17 (33%)
22 (42%)
14 (38%)
76 (39%)
Partial
19 (35%)
21 (41%)
17 (32%)
3 (8%)
60 (31%)
Upheld
12 (22%)
13 (26%)
14 (26%)
9 (24%)
48 (25%)
In process
0
0
0
11 (30%)
11 (5%)
Total
54
51
53
37
195
Total outcomes
Total outcomes by professional group
Complaint
2014/15
ongoing
Not Proven
Partial
Upheld
Grand total
Medical
5 (46%)
34 (45%)
23 (38%)
11 (22%)
73 (37%)
visiting
3 (27%)
23 (31%)
17 (28%)
16 (33%)
59 (30%)
Other team
3 (27%)
11 (15%)
12 (20%)
15 (31%)
41 (21%)
PAMS
0
5 (7%)
7 (12%)
3 (6%)
15 (7%)
Scientific / technical & prof
0
1 (1%)
0
0
1 (1%)
Social worker
0
0
1 (2%)
0
1 (1%)
Trust admin staff
0
1 (1%)
0
4 (8%)
5 (3%)
Grand Total
11
75
60
49
195
Nursing / midwifery / health
74
Primary subject of complaint: service resolution
2014 / 2015
Q1
Q2
Q3
Q4
Total
Access to services
6 (13%)
12 (27%)
12 (25%)
8 (24%)
38 (22%)
Attitude of staff
8 (18%)
7 (15%)
3 (6%)
5 (15%)
23 (13%)
0
2 (4%)
2 (4%)
0
4 (2%)
Care and treatment
19 (41%)
14 (31%)
22 (46%)
11 (34%)
66 (38%)
Communication
5 (11%)
5 (11%)
4 (8%)
5 (15%)
19 (11%)
Detention under MHA
1 (2%)
0
1 (2%)
0
2 (2%)
0
1 (2%)
0
0
1 (1%)
1 (2%)
1 (2%)
0
0
2 (2%)
Discharge
0
0
1 (2%)
0
1 (1%)
Medication
0
1 (2%)
1 (2%)
0
2 (1%)
Patient safety
0
2 (2%)
1 (2%)
2 (6%)
5 (3%)
Waiting times
6 (13%)
0
1 (2%)
2 (6%)
9 (5%)
46
45
48
33
172
Breach of confidentiality
Diagnosis
Direct payments
Grand total
Primary subject of complaint: formal investigations
2014 / 2015
Care and treatment
Q1
Q2
Q3
Q4
Total
8
6
5
4
23
75
Total: primary subject of complaint
2014 / 2015
Q1
Q2
Q3
Q4
Total
Access to services
6 (11%)
12 (24%)
12 (23%)
8 (21%)
38 (19%)
Attitude of staff
8 (15%)
7 (14%)
3 (6%)
5 (13%)
23 (12%)
0
2 (4%)
2 (4%)
0
4 (2%)
27 (50%)
20 (39%)
27 (50%)
15 (40%)
89 (46%)
Communication
5 (9%)
5 (10%)
4 (7%)
5 (14%)
19 (10%)
Detention under MHA
1 (2%)
0
1 (2%)
0
2 (1%)
0
1 (2%)
0
0
1
1 (2%)
1 (2%)
0
0
2 (1%)
Discharge
0
0
1 (2%)
0
1
Medication
0
1 (2%)
1 (2%)
0
2 (1%)
Patient safety
0
2 (4%)
1 (2%)
2 (6%)
5 (3%)
Waiting times
6 (11%)
0
1 (2%)
2 (6%)
9 (5%)
54
51
53
37
195
Breach of confidentiality
Care and treatment
Diagnosis
Direct payments
Grand total
76
Ethnicity of patient (Source: Trust system, Silverlink)
Service Level Complaints
White British
158
Any Other Black Background
2
Not stated
12
Not applicable
0
Total
172
Formal Investigations
White British
22
Not Stated
1
Total
23
1. Ethnicity of Staff Involved (Source: workforce)
Service Level Complaints
Any Other White Background
8
Any Other Ethnic Group
5
Asian/British Asian - Indian
4
British Black African
5
Other Asian background
3
White British
Not stated
38
6
Not applicable **
103
Total
172
77
Formal Investigations
White British
2
Other Ethnic Group
1
Not applicable **
20
Total
23
Some complaints are about multiple staff members/teams and the ethnicity for these staff members
was recorded separately. The remaining complaints were general concerns about services or teams
where staff ethnicity was not recorded.
** Denotes complaints relating to teams or services not individuals.
78
2b. 8 In-patient element of the Friends and Family Test (FFT) and national inpatient Survey 2014
FFT for in-patient
The Trust continues to actively seek FFT feedback; and has successfully rolled out patient experience
feedback questionnaires, including the FFT question, across in-patient and community teams. Within
in-patients there has been consistency in exceeding the required performance, with the exception of
May 2014.
National In-patient survey 2014
57 completed surveys were returned from the Trust’s sample of 229. A group of 27 service users were
excluded from the sample as they had either moved or were not known at the address. The final
response rate for the Trust was 27%, compared to a 28% response rate in 2013. In comparison to the
2013 survey results the Trust has improved in the following areas:

On arrival on the ward staff made patients feel very welcome

On arrival on the ward staff knew about patients’ previous care received

On arrival on the ward, patients were informed about the daily routine, including meal and
visiting times

The toilets and bathrooms were very clean

The hospital helped patients keep in touch with family and friends
79

Received help needed from hospital staff with organising the home situation

Felt as though the psychiatrist listened

Had confidence and trust in the psychiatrist

The psychiatrist treated patients with respect and dignity

The nurse listened carefully

When sectioned rights were explained in a way that could be understood

Have been contacted by a member of the mental health team since left hospital

9% increase in rating the overall care received as very good

Enough activities available to do during evenings/weekends
In comparison to the 2013 survey results, the questions below have seen a decline in patient
satisfaction:

Never able to get the specific diet that was required from the hospital

Did not find talking therapy helpful

Not given enough notice of discharge from hospital

Discharge was delayed
Whilst the Trust recognises the sample (57 surveys returned from adults aged 16-64) was small, it
remains determined to improve patient experience in all these areas; and to develop services in
partnership with patients / carers and staff. The Trust has developed its quality priorities for 2015/16 to
include metrics to evidence greater service user / carer involvement across all aspects of the Trust’s
work.
80
2b. 9 Patient Experience of Community Mental Health Services – the 2014 Community Mental
Health Patient Survey and FFT
FFT for Community
The FFT question is asked within community services using the ‘Making your Experience Count’ leaflet,
which is also available for completion via the Trust’s web site.
2014 Community Mental Health Survey
The National Community Mental Health service survey of 2014 was published in September 2014 with a
response rate of 33% for the Trust. This was higher than previous years and also above the national
average of 29%. The survey itself changed significantly since 2013 so it is not possible to compare directly
the results for 2014 with previous years.
Results
Most other areas are difficult to compare directly from previous years as the measurements have
changed, however the overall score for the Trust has improved from 6.7 last year to 6.8 this year.
Overall experience of health and social care workers last year was 8.7 compared to 7.6 this year this
about the national avergrage. A reduction was particularly evident within crisis care where the Trust was
deemed worse than other Trusts nationally, and slightly lower than last year.
81
There were also some anomalies with the Trust being the worst rated (6.7) for service users being told
who is in charge of their care but almost maximum score (9.8) for knowing who to contact about their care
and an average score for how well this person organises the care.
The services were below average for involvement in planning of care as well as the review processes
around their care and the treatment received, particularly around responses to crisis. Service users did not
feel supported with the wider aspects of their care such as involvement in local activities and financial
advice.
Whilst still slightly below the average (8.3) the Trust’s respect and dignity score was one of the highest
ratings given for any other section which is a small positive amongst the obvious concerns identified
here.
Section Heading
Score
How this score compares with
other mental health trusts
Health and social care workers
7.6 / 10
About the same
Organising care
8.3 / 10
About the same
Planning care
6.8 / 10
About the same
Reviewing care
7.1 / 10
About the same
Changes in who people see
5.6 / 10
About the same
Crisis care
5.4 / 10
Worse
Treatments
6.7 / 10
About the same
Other areas of life
4.0 / 10
Worse
The Trust is highly committed to maintaining a strong focus of continually improving in all areas and an
action plan and project group have been established to ensure improvement in the areas outlined above
during 2015/2016.
82
Community service user feedback including FFT
Throughout 2014 the Trust has focussed on successfully rolling out community service user questionnaire
feedback (including FFT) and from January 2015 national reporting arrangements for community have
been in place. We are aware that the sample sizes remain small; and this is something will continue to
work to improve throughout 2015/16.
2b. 10 FFT: Staff recommendation
The national staff survey (2014) asked staff the question of whether they would recommend the Trust
to their friends and family if they need such a service. In the results the Trust score was 3.58 (above
the national average), which was an improvement from 2013, where the Trust scored 3.55 (national
average). This finding is encouraging and suggests the hard work implemented over the past 12
months to support staff engagement is valued and effective. The Trust is ambitious, wanting the very
best for patients, carers and staff; and will continue to strive for excellence in staff engagement and
FFT recommendation in the coming year. Further details on the Trust’s performance in the national
staff survey 2014 are detailed later in this report.
2b. 11 Safety thermometer: harm free care
The Trust reports monthly to the NHS safety thermometer on the performance of its in-patient older
adult wards in respect of the four domains measured in harm free care (falls resulting in any degree of
harm, urinary tract infections in patients with in-dwelling catheters, a new venous thrombo embolism
whilst under the Trust’s care, and pressure ulcers acquired anywhere). Throughout 2014/15, with the
exception of May (93.4%) and June (94.4%) the Trust has achieved above the target threshold of 95%
harm free care.
83
Harm free care 2014/15
% of Older Adult Inpatients with Harm Free Care
100%
100.0%
100%
100%
100%
100%
100%
100%
100%
97.0%
95.7%
95.0%
93.8%
% Harm Free
Expectation
91.1%
90.0%
2b. 12 Patient Safety Incidents
Serious incidents
Whenever a serious incident (SI) (such as an attempted suicide, suicide, serious assault or injury)
occurs within Trust services, it is investigated thoroughly so that the risk of such an incident happening
again can be reduced or removed and lessons can be learned. Good communication and involvement,
where appropriate, with families and / or service users concerned in incidents, is very important. The
Trust works hard to ensure this is a part of all SI investigation processes; and will continue to explore
ways to strengthen involvement in investigation processes, including better establishing what outcomes
are important for those most closely impacted by SI incidents.
As part of our continual development and ambition to provide safe and effective services an
independent review of suicides, deliberate self-harm with intent and deaths in custody was
commissioned jointly by the executive nurse for South West Lincolnshire CCG and our director of
nursing. Following this review a robust service improvement action plan has been developed and will
be implemented during the coming year 2015/2016.
84
Patient safety incidents resulting in severe harm or death 2014/15
The most recently published national reporting and learning system (NRLS) data for mental health
trusts (October 2013 - March 2014) has been used to benchmark the Trust’s level of severe harm
incidents. The Trust has consistently had below the national average of 0.4% of severe harm incidents
throughout 2014/15, with current levels at 0.2%.
The Trust has robust systems in place to ensure all serious incidents, including severe harm and death,
are reported externally onto the national database the strategic external information system (STEIS).
All incidents are investigated within the national target of 45 working days from when the incident
occurred, with associated reports submitted to commissioners. Financial penalties are incurred for
reports that do not achieve the deadline.
It is mandatory for all NHS Trusts to report all serious patient safety incidents to the CQC. All incidents
resulting in severe harm or death are reported to the NRLS who in turn report them to the CQC. Whilst
this is not a mandatory process, the Trust reports all patient safety incidents to the NRLS to assist with
learning both locally and nationally. Whilst it is common practice for most NHS Trusts to report to NRLS
it is recognised that there are different approaches to reporting and validation of the categories of
patient safety incidents. The Trust monitors and validates all incidents of severe harm or death via the
quality and safety team.
For the year 2014/15 there were a total of 5,025 incidents reported by the Trust, of which 2,174 were
reported to the NRLS as patient safety incidents. Of these, five were reported as severe harm; and 18
were reported as death with cause being suspected suicide. Cause of death (such as suicide),
confirmed by coroner verdicts, can take several months due to the required investigative and coroner
processes. This delay, whilst entirely understandable, can be particularly difficult for families affected.
In 2015/16 the Trust is keen to strengthen processes, and so seeks to better inform and support
families in these processes and has developed an information leaflet for these carers and relatives
difficult times.
85
The following tables detail 2014/15 reported incidents of violence and aggression, medication incidents;
and falls:
12 Month Comparison of All Reported
Violence/Abuse/Harassment Incidents
140
Number
Average
132
120
109
100
93
100
112
92
90
83
82
84
83
80
68
60
40
20
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Number
Average
12 Month Comparision of All Reported
Medication Errors
25
21
21
20
20
14
15
12
16
15
13
13
12
12
11
10
5
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
86
Number
12 Month Comparison of All Reported Falls
Average
60
51
50
40
46
44
36
37
36
35
34
32
31
29
30
28
20
10
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Number
12 Month Comparison of
All Reported Absconds & AWOLs
Average
14
12
12
11
11
10
10
9
9
9
9
8
8
7
6
6
5
4
2
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
87
The Trust monitors and proactively responds to findings and trends in respect of harm (domains of
Safety Thermometer), violence / abuse / harassment incidents, medication incidents; and falls. There
is close working between the Trust’s quality and safety team manager, clinical lead for restrictive
interventions, the matrons and the general managers to highlight trends and to ensure any required
actions are completed. This includes the clinical lead for restrictive interventions making visits to the
ward areas to discuss individualised care planning, preventative advice; and to ensure staff, patients
and families are supported. The clinical lead for restrictive interventions also takes professional lead
responsibility for developing a specific restrictive interventions care plan for individuals as required.
The Trust is very aware that some of the most vulnerable service users within our care are within the
specialities with the highest number of reported incidents of violence, aggression and harassment
(older adult and learning disabilities). Incidents are reviewed, where appropriate, with the Trust’s
safeguarding team, ensuring those appropriate for safeguarding are promptly referred for safeguarding
investigation. The Trust takes violence, abuse and harassment incidents extremely seriously; and
works to ensure all preventive actions possible are put in place so service users and their carers are
safe; and feel safe, whilst under the care of the Trust’s in-patient services.
The Trust will focus even greater attention in 2015/16 on medication management to both better
understand the causative factors; and work hard to reduce any associated harm. The Trust has
incorporated medication management into the Sign up to Safety action plan; and has identified
medication management as its Local Indicator for 2015/16. The Trust will continue to build on the
quality of medication incident reports; and further develop its local medicines management groups. It is
recognised the issue of medication errors is not discipline specific, so effective cross-discipline learning
from medication related incidents is crucial to ensure lessons are learned and progress is made.
The number of reported falls incidents within the Trust over the past year is averaged at 37 per month.
Both frequency and level of harm from falls are closely monitored and reviewed through the Trust’s falls
steering group under the leadership of one of the matrons. Equipment, procured to support the
reduction and prevention of falls, is available to the Trust’s four older adult in-patient wards; and
feedback on their efficacy is captured and reported through the falls steering group.
All absconding and absent without leave (AWOL) incidents and trends are monitored at the Trust’s
patent safety group, with recommended actions being identified and disseminated by the matron with
responsibility for AWOLs, the patient safety lead; clinical lead for restrictive interventions and the
security and resilience advisor in liaison with the estates department and the general managers.
88
2b. 13 Quality of information
The Trust generates monthly performance reports, with dashboard summaries of the Trust’s position
against key performance indicators. These provide validated performance information on a monthly
basis, which are shared with the Board of Directors, services; and commissioners; and are included in
the Board of Directors’ monthly reports.
Where the Trust has included relevant indicators and performance thresholds within this section (Part 2
of the quality report), in accordance with the quality accounts regulations, it has not reported these
again in part 3 of the quality report.
To review progress and prepare for the completion of a director’s statement in the published quality
report in 2014/15, the Trust has engaged its external auditors to:

Review the arrangements put in place to ensure the quality report framework is robust

Review the data accuracy of the proposed mandated performance measures, which are sevenday follow up and crisis gate keeping and the local indicator for physical healthcare

Identify the requirements of good practice internal control systems for data quality

Provide recommendations to put these best practice arrangements in place in advance of the
2014/15 published audit opinion

The Trust will manage the implementation of the action plan, generated by its external auditors,
through the Board committee structure

Review progress against the locally mandated indicator and the mandated indicator 7 day
follow-up.
89
Part 3: Other information - looking back
The Quality Accounts Regulations specify that Part 3 of the quality account should
be used to present other information relevant to the quality of the relevant health
services provided or sub-contracted by the Trust during 2014/15.
As stated within part 2, where the Trust has included relevant indicators and performance thresholds
within part 2 of the quality report, in accordance with the quality accounts regulations, it has not
reported these again here in part 3 of the quality report.
Unless otherwise stated, all data for local quality indicators is gathered and reported internally.
3.1 Indicators selected by the Board in consultation with stakeholders
As per the requirements for a NHS foundation trust, the following is presented:

An overview of the quality of care offered by the Trust, based on performance in 2014/15
against indicators selected by the Board, in consultation with stakeholders, with an explanation
of the underlying reason/s for selection. The indicator set selected includes:

o
Three indicators for patient safety
o
Three indicators for clinical effectiveness
o
Three indicators for patient experience.
Historical data and benchmarked data, where available, so the reader can understand progress
over time and performance compared to other providers.

Reference to the data sources for the indicators, including whether the data is governed by
standard national definitions.

Confirmation is made that six indicators for 2014/15 are the same as those reported in the
Trust’s 2013/14 quality report; and confirmation is made that the data reported has been
checked to ensure consistency with the 2013/14 report.

Three new indicators have been added for 2014/15 as areas the Trust would like to focus on in
more detail to help improve quality, the indicators are:
o
Numbers receiving early intervention (EI) (patient safety)
o
Percentage of drug users being offered Hep C (target 90%) (clinical effectiveness)
o
28-day re-admission (threshold 10%) <15 years old; >16 years old to meet required
monitor reporting requirements for the indicator.
90

For each core indicator the number, percentage, value, score or rate (as applicable) for the last
two reporting periods is the minimum required; and the Trust has presenting data, where
available, for the last six reporting periods.

Limited data has currently been made available by the HSCIC but, where this is available, a
comparison for previous reporting periods has been made of the numbers, percentages,
values, scores or rates of each of the Trust’s indicators with:
o
The national average for the same; and
o
Those NHS trusts and NHS foundation trusts with the highest and lowest for the same.
The table below details the selected indicators; and includes performance against the two mandated
indicators (seven day follow-up and crisis gate keeping). The local mandated indicator performance is
shown afterwards.
91
The source for the following data is from Trust systems unless otherwise stated.
Patient safety
CPA 7-day follow-up (threshold
95%)
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
96.1%
96.9%
96.2%
96.5%
98.7%
95.9%
Benchmark: NHS average is 75.5% (year to date); Highest 100%; Lowest:0%
No receiving EIS
Infection control no. of MRSA
bacteraemia & C Diff infections
(threshold: a de minimis applies)
Clinical effectiveness
Admissions to inpatient services
have had access to CRHT teams
(threshold 95%)
306
384
361
312
251
275
0
0
0
0
0
0
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
96.3%
96.7%
99.8%
90.6%
95.6%
91.7%
(threshold: (threshold (threshold
90%)
90%)
90%)
Not
available
100%
98.2%
100%
100%
100%
<15yrs old
0%
6.9%
11.1%
9.4%
8.1%
8.7%
>16yrs old
8.1%
8.4%
10.4%
8.3%
9.6%
8.79%
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
% of drug users being offered
Hep C (target 90%)
28-day readmission
(threshold 10%)
Source: HSCIC
Patient experience
Patient survey: overall
experience
Under 16yr olds admitted onto
adult wards
Delayed transfers of care to be
kept at a minimal level (threshold
7.5% or below)
4th
nationally
2nd
nationally
Midrange
Midrange
Midrange
‘About
the
same’
as other
MH
trusts
0
0
0
0
0
0
Target:
7.5%
Actual:
0.9%
Target:
7.5%
Actual:
2.2%
Target:
7.5%
Actual
0.9%*
Target:
7.5%
Actual:
3.9%
Target:
7.5%
Actual:
2.5%
Target:
7.5%
Actual
1.9%
92
The Trust considers that their data is as described, as reports are validated against the source system;
and where evidence from the HSCIC available, reports are validated against this.

Data quality within the Trust is coordinated through the data quality group. Data quality
dashboards are provided monthly as part of service line reports. Assessment against the data
completeness measures, as part of the MHLDDS, shows that the Trust is achieving the required
97% overall.
3.2 Local Indicator 2014/15
The Trust identified medicines management for its local indicator in 2014/15, the aim being to reduce
harms from medication errors by 10% across all clinical areas of the Trust and evidence how, and to
whom, those incidents are attributed.

The data for medication errors from April 2013 to March 2014 provided the benchmark against
which data from April 2014 to March 2015 was compared.

The data for 2013/14 demonstrated that there were 139 medication errors reported, eight
caused low harm and two caused moderate harm. This equates to 7.19% of the total reported
errors causing harm.

The data for 2014/15 demonstrated that there were 180 medication errors reported an increase
of 34% from 2013/14, ten caused low harm and one caused moderate harm. This equates to
6.11% of the total reported errors. During 2014/15 a significant piece of work was undertaken
to improve the level of reporting of medication errors causing harm.

Based on absolute figures a 10% reduction for 2014/15 would equate to nine reported errors
resulting in harm.

Calculated as a ratio against the increased level of reporting, the Trust achieved 6.11%. The
required target reduction was 6.47%; therefore the Trust has made the 10% reduction required.

The trend line for medication incidents across the Trust has remained upwards. There has been
considerable related work across the Trust; and this included seeking to better understand
whether the upward trend was linked to better reporting and clearer understanding of reporting
requirements, or indicated an actual increase in errors. In depth analysis was carried out by the
matron on a monthly basis in relation to issues and errors.
93
Deloittes attended the Trust, for the mid-year testing, on the 19 November 2014, meeting with the Trust
leads to understand the process from an incident occurring to reporting the overall performance. The
interview focussed on understanding the process involved and to discuss any risk areas which should
form the focus of the sample testing. 25 incidents were selected, from April 1st 2014 to September 31st
2014, including incidents that resulted in harm and no harm and incidents that were categorised as
medication errors and as issues. The subsequent report stated that Deloittes testing found no
significant issues with the Trust processes relating to the management of medication.
For 2014/15 the Trust identified one local indicator, with approval from the Trust’s governors (January
2014); and this was medication management focussed. This patient safety priority was also reflected in
a local CQUIN for 2014/15. The rationale for the choice was that this indicator took account of patient
feedback (including findings of the mental health in-patient survey 2013, where the Trust improved
ratings on medication related questions from the 2012 survey results), links to local and national quality
priorities (there was a linked local CQUIN for 2014/15); and built on the considerable work across the
Trust to strengthen all aspects of medicines management and patient safety.
The Trust’s governors (January 2014) supported the Trust Board proposal for continuing to select the
same two mandated indicators for 2014/15 as were selected in 2013/14, namely CPA patients are
receiving follow-up contact within seven days of discharge from hospital; and admissions to in-patient
services have access to crisis resolution home treatment teams.
94
3.3 Performance against Core Indicators (Monitor targets)
Monitor targets not reported in this table are detailed in Section 2b.6.
CPA patients having a formal review
within 12 months (threshold 95%)
Minimising delayed transfers of care
(no more than 7.5%)
2010/11
2011/12
2012/13
2013/14
2014/15
Green
Red
Green
Green
96.9%
Green
Green
Green
Green
1.57%
Green
Green
Green
Green
Red
Green
Green
Green
Meeting commitment to serve new
psychosis cases by EIS teams
134
100%
(threshold 95%)
Data completeness of the mental
health minimum data set (threshold
98.7%
97%)
Mental health data completeness:
77%
outcomes for patients on CPA
(threshold 50%) Indicators below:
Employment status of patients on CPA
In settled accommodation (patients on
CPA)
Health of National Outcome Scales
assessment within the last 12 months
Green
Green
Green
Green
90%
Green
Green
Green
Green
90%
Green
Green
Green
Green
50.2%
95
3.4 Staff engagement including the 2014 NHS staff survey performance
The Trust recognises that providing high quality community and mental health care to service users
and their carers requires a highly skilled and motivated workforce. Like 2013/14, throughout 2014/15,
the Trust has continued with the implementation of its organisational development strategy, which
made a clear commitment to improving staff involvement and engagement through its Making a
difference programme and leadership development. Throughout the year this has seen the
development of a consistent and integrated approach to staff engagement, with staff involved in a
number of significant activities, with team sessions on the outcomes of the cultural barometer, staff
survey, work related stress and freeing time for the frontline. The Trust has continued with its quarterly
cultural barometer (including the staff friends and family test) to receive ‘real time’ data focusing on
specific services in each quarter, General Adults Services (Q1), Specialist Services (Q2) and Corporate
Services (Q3).
The Trust has also continued with its investment in leadership and the Trust has developed over 400
Trust staff through seven separate leadership forums for the whole workforce and not just ‘managers’ in
the last 12 months. The Trust also utilises the East Midland Leadership Academy and participation has
tripled, along with accredited leadership programmes. Feedback from the programmes is positive and
the outcomes for the Trust demonstrate a greater confidence from staff in the support they receive from
their managers, the effectiveness of appraisals and behaviours; as evidenced by the cultural barometer
during 2014 when compared to 2013. The 2014 staff survey also demonstrates improvements in
effective team working; appraisals and support from immediate managers.
96
In October 2014 the twelfth national NHS staff survey was undertaken. In summary the Trust is
performing better nationally than it was in 2013 when compared to MH Trusts. In 2014, the Trust had
25 key findings (KFs) from a total of 29 KFs rated as average or above average. In 2013 the Trust only
had 14 KFs from a total of 28 KFs rated as average or above.
2013 National comparisons to mental health trusts 2014 National comparison to mental health trusts
2 KFs top 20%
0 KFs top 20%
6 KFs better than average
13 KFs better than average
6 KFs national average
12 KFs national average*
9 KFs below average
2 KFs below average
5 KFs bottom 20%
2 KFs bottom 20%
Staff engagement score rated national average
Staff engagement score rated national average
*Includes new 29th KF
97
Compared to the Trust’s 2013 results the Trust scored higher in 16 KFs, lower in six KFs and the
exactly the same in six KFs. The Trust is now in its best position nationally for the last five years.
Trust
National
response
average
Percentage of staff experiencing physical violence from staff in last 12 months
2%
3%
Percentage of staff agreeing that their role makes a difference to patients
91%
89%
Staff motivation at work
3.91
3.84
Percentage of staff having equality and diversity training in last 12 months
73%
67%
93%
92%
Trust
National
response
average
Percentage of staff suffering work-related stress in last 12 months
52%
42%
Percentage of staff working extra hours
76%
71%
Percentage of staff able to contribute towards improvements at work
69%
72%
29%
30%
68%
69%
The top five responses
Percentage of staff reporting errors, near misses or incidents witnessed in the
last month
The bottom five responses
Percentage of staff reporting good communication between senior
management and staff
Percentage of staff agreeing that they would feel secure raising concerns
about unsafe clinical practice
98
The Trust launched its new organisational development and people strategy on 1 April 2015 and sees
communication, involvement, pressure and work related stress as key areas of improvement.
3.5 Workforce planning
Workforce planning is a dynamic process by which the Trust ensures that we have the right number of
people in the right place and with the right skills at the right time. Our approach to workforce planning is
to make sure that we align the workforce to the work, not the other way round. In order to achieve this
workforce representatives have met with all service managers to review the current staffing capacity to
deliver planned services over the business planning period, and identified current workforce trends
which will impact on this over the next 5 years. Specifically focussing on retirement intentions and also
looking at developing new roles within the existing workforce, and creating opportunities for developing
apprenticeships.
The Trust provides workforce information to Health Education England for the future commissioning of
pre-registration professional training places across the region.
We continue to be an active member of the LHAC workforce programme board, and are developing
workforce models which link into the LHAC models of care as well as supporting organisational
development interventions within the emerging neighbourhood teams.
Skills development
Following feedback from staff regarding the Trust’s annual staff appraisal process this has been further
refined to support an engaging and meaningful process. Training and development needs identified
during the appraisal cycle are recorded on a talent management form and are collated by the workforce
department. A cycle of annual training needs analysis has been introduced whereby training plans for
each division based on service needs and priorities is agreed by the divisional general managers.
Training and development activity broadly falls into three main categories
1. Mandatory training
2. Post-registration training
3. Wider workforce development.
99
Funding for post registration and wider workforce development is received from Health Education
England. In addition in 2013/14, tariff payment was introduced to support the provision of quality multi professional clinical placements. A proportion of the tariff funding in 2014/15 was used to support
Trust-wide multi-professional support, with the majority being devolved services through a bidding
process to further develop quality clinical placement opportunities across the Trust.
3.6 Positive and proactive care: reducing the need for restrictive intervention
As part of the positive and proactive care: reducing the need for restrictive interventions document
published in April 2014, the Trust’s annual quality report is required to report on Point 111.
‘Services must also publish a public, annually updated, accessible report on their increased
behaviour support planning and restrictive intervention reduction, which outlines the training
strategy, techniques used (how often) and reasons why, whether any significant injuries
resulted, and details of on-going strategies for bringing about reductions in the use of restrictive
interventions. These should be included within annual quality accounts’.
The Trust ensures that education and training are central to promoting and supporting change. This
involves services in identifying the skills and knowledge held within teams and individuals, putting in
place learning and development plans to meet any gaps and ensure that the workforce continues to
develop. The impact on training has led to many changes within the Trust such as:

All techniques that are taught are approved by the General Services Association and have been
bio-mechanically risk assessed.

The General Services Association Core Curriculum 2015 includes all terminology changes that
the CQC has requested and have been implemented throughout the Trust.
The restrictive interventions team has changed the philosophy of the training in accordance with the
Positive and Proactive Guidelines (DoH, 2014) and the use of supine physical intervention is the
chosen method of the training. The use of prone physical interventions is now only taught to be used as
a last resort.
The director of nursing and quality is the Board level lead and a restrictive interventions steering group
has been established to oversee and monitor the changes throughout the Trust.
The training of staff required to complete restrictive interventions and Mental Capacity Act training is
monitored by our learning and development centre, with monthly figures available for managers.
There are plans for a clinical audit review of positive behaviour support plans, when Health Education
England develop the national strategy for training to support the development of the guidance.
100
3.7 Leadership
Internal development
One of the key areas of focus for the Trust in the last 12 months has been the delivery of a leadership
model that equips managers and staff with the necessary tools, as well as defining the role models that
Trust leaders must be. The Trust has therefore delivered a range of in-house programmes to include
the needs of the whole workforce:
Total No’s
attended
Programme
Aimed at
Frontline Leadership
Programme
Frontline clinicians and non-clinicians with
a managerial portfolio (as well as aspiring
leaders)
35
Clinical Leadership
Frontline clinicians and senior clinicians without
a managerial portfolio
44
Future Leaders
Clinical and non-clinical staff who are not
professionally qualified
42
ILP (inspirational
leadership programme)
All managers with line management
responsibilities up to Chief Executive
146
Introduction to
management
Anyone new to a management role who wishes
to understands the necessary functions and
tools of being a manager
49
Appraisal
All staff conducting appraisals
57
Introduction to coaching All staff
Admin Forum
All admin staff
36
30
439
Work continues to ensure that measurement of impact and return on investment are robust and link to
the organisation’s strategic priorities. A number of the programmes have 360 degree assessments
built-in, as well as a three-way meeting with attendees line managers on completion to capture
outcomes.
101
External development
It is recognised that leadership development cannot be insular in its approach and that learning and
development also comes from outside influences. The Trust has successfully completed the first year
of inspirational leadership programme (ILP), which consisted of five events and has included a wide
range of input from successful role models inside and outside of the NHS. The Trust has also tripled its
participation and involvement with the East Midlands Learning Academy (EMLA) programmes and
seven Trust staff recently graduated from the first cohort of Mary Seacole with another cohort about to
successfully complete. Similarly there are four people on the Elizabeth Garrett Anderson programme.
The Trust has also accessed coaches outside of the Trust for staff to gain external awareness.
Quality assurance and outcomes
Feedback has been positive with delegates citing increased awareness at a local and national level;
networking and building relationships; increased self-awareness in own leadership style and its impact
on others; taking time to stop, think and challenge current processes; increased knowledge, skills and
competence to carry out all aspects of role; difficult conversations and increasing wellbeing and
resilience. The Trust’s cultural barometer has demonstrated improvements in the last 12 months on
questions relating to leadership, namely, support from line manager; effective appraisals and
behaviours of staff support the Trust value of RESPECT. The 2014 staff survey also demonstrates
slight improvements in effective team working; appraisals and support from immediate managers.
However the Trust also knows that there are leadership challenges around communication and
involvement which need further focus. The Trust appraisal process has also been revised with services
following feedback and a more user friendly model has been developed with managers and staff, with a
continued focus on quality patient outcomes.
102
Future development
The Trust will be offering three strands to leadership for 2015/16;

Individual leadership - A series of nine different master classes that will be graded to
appropriate levels, but will serve all clinical and non-clinical staff. They will be provided in-house
with our own trained staff that have elected to be facilitators; and will include subjects, such as
leadership of self, others and change. Building on 2014, the Trust is also implementing an
internal coaching model with an investment in training of 18 staff to become coaches, launching
a coaching forum, peer-supervision and developing a local coaching register.

Team leadership - The team has capacity to work with 2 teams a year, to provide an in-depth
six month programme; utilising techniques and approaches from the Elizabeth Garrett Anderson
course. In addition to this, one-off team days will be provided on request, to look at decision
making, problem solving, change management, dealing with conflict and relationship building.

Trust leadership - The focus of the future ILP events will be focusing on what leaders need to
do collectively, in order to achieve local and national agendas in the NHS.
The rationale behind this three-stage blended approach comes from the Kings Fund white paper
(2014), which argues, in order for leadership to be distributed, with collective accountability, ownership
and engagement throughout the organisation, it has to be developed and embedded on a variety of
levels. It is strongly felt that the combination of the steps above, supported through a committed and
dedicated leadership team, will strategically support the Trust as it continues to move forward.
3.8 Involvement of the Trust’s Governors
The Trust’s governors continue to take an extremely valuable and active role in Trust’s business.
During 2014/15 developments in respect of governors’ involvement include:

Listening to members of the Trust and the wider public’s issues and working with Trust officers
to provide responses to the issues raised

Providing sessions on aspects of mental health services to the public and members of the Trust

Holding the Board to account for the quality standards by receiving regular reports and
challenging performance results

Contributing the views of members and content to the Trust’s clinical strategy and forward plan

Receiving training and development in the roles and responsibilities of governors to ensure an
effective performance in the role
103

Taking part in the Trust’s 15 steps /mock CQC visits as part of inspection teams

Development of the link governor role, with a particularly successful initiative being governors
linking with quality and patient / carer initiative steering group

Staff recruitment processes

Chair of the Trust involvement committee.
3.9 Board assurance
The Trust Board is accountable for ensuring all Trust services genuinely and consistently meet the
essential compliance standards for quality and safety. The Trust Board ensures it remains well
informed and visible across its services. The Board receives detailed quality and risk reports, Board
members visit clinical areas; and Board members seek additional assurance where there are residual
concerns for quality and patient safety. The Board has a robust assurance and escalation process
(2014), which ensures its members are promptly informed of any high risk concerns across services. In
practice, the Board ensures its accountability for quality and patient safety through mechanisms
including the following:

Ensuring focussed Board time is dedicated to discussion on quality and service user safety
issues.

Effectively monitoring the quality of care provided across all Trust services though critically
reviewing internal and external quality and risk reports, including those evidencing
benchmarking of the Trust’s services locally and nationally.

Proactively scrutinising high level risks to quality; and instructing prompt mitigating action if
required.

Challenging poor performance or variation in quality; and actively recognising quality
improvement.

Supporting critical reviews to identify root causes to both poor and exceptional performance, so
ensuring better understanding of factors affecting quality and service user safety.

Leading effective partnership working with other health and social care organisations, including
the LHAC.

Role modelling a culture of listening, transparency, visibility and accountability.

Actively listening and proactively responding to concerns to ensure early detection of problems,
including to allegations of abuse, so reducing the likelihood of serious failings.
104

Being accountable for the quality and safety of care provided, so reducing the likelihood of
missing early indicators of serious risk.

Proactively engaging with service users, carers, governors and staff to support good
communication from board level to ward / team level and vice versa.

Continuing to prioritise hearing service user / carer stories at the Board and proactively seeking
any associated assurance required.

Ensuring the Trust provides its staff with good and safe working environments, where they are
free from discrimination or bullying. The Board remains committed to ensuring all staff have
clear job profiles, with defined expectations; and work in environments where they are
supported to achieve the very best possible for themselves and those they care for.

Utilising and adhering to the operating principles within the national quality board’s framework to
assess the quality impact of cost improvement plans, ensuring that the patient always comes
first.

Undertaking annual appraisals to ensure Board members remain up-to-date, supported; and
well equipped to undertake their role responsibilities in leading the Trust.
3.10 Accreditations and achievements
In addition to the national awards achieved in 2014/15, the Trust’s other achievements included:

LHAC development the Trust continues to work with all health and care organisations across
Lincolnshire to progress this work.

Investors in People successfully retained following reassessment.

Chief executive, director of operations and medical director appointed substantively to the
Trust.

Manthorpe Unit refurbishment officially opened after investment from ‘enhancing the healing
environment’ scheme

Street triage car pilot with East Midlands Ambulance Service and Lincolnshire Police. (June
2014)

Nursing technology fund awarded the Trust £107k to expand use of digital pen technology
across organisation.

Perinatal mental health service expanded from March 2015.
105

Psychological service for adults with learning disabilities approached to provide an
enhanced clinical psychology service to two groups of service users supported by Autism Care
UK.

Sexual assault referral centre delivering on a new contract with LCC to provide the county's
independent sexual violence adviser service

CAMHS self-harm nurses providing extended provision of on paediatric wards at local acute
hospital sites.

Recovery college officially launched.

Head of patient and public engagement appointed in the Trust as a new role.

Managed care network undertaken fourth wave of the mental health promotion fund.

Professional conduct guide for staff on clinical bands 2-4, without a professional registration
launched across the Trust.

Stamford and Grantham home treatment service continues to meet the high standards
needed in their accreditation through HTAS.

Values based recruitment helps with the process of identifying those staff with the values and
beliefs we are looking for as an organisation.

NE Lincs CAMHS team new base officially opened at Freshney Green, Grimsby.

Lincolnshire assessment and reablement service transferred over to the Trust on 1 April
2014 from LCC.
3.11 What service users, carers and the public say
The process for hearing people’s views

There are a number of formal and informal ways service users, carers and the public are able to
give their views, get involved; and provide feedback. These include:

Service user feedback questionnaires (including FFT)

Group of 1,000

Complaints, concerns, comments and compliments

Patient Opinion website

National in-patient and community surveys

Views of the membership and Board of Governors

Patient Advisory Liaison Service (PALS)

MP enquires
106

Healthwatch Lincolnshire feedback

Investigations, including SI investigations

Capturing of feedback from service user involvement events

Capturing of feedback that is service specific through consultations, service user / carer
meetings, announced and unannounced 15 Steps / mock CQC / non-executive director and
Board member visits; and CQC inspection visits to clinical areas

Patient reported outcome measures

Complaints review panel

Internal audits

Hospital managers’ hearings.
Please note that some aspects of service user feedback have been reported earlier within this report,
including patient survey results (2014).
Patient Opinion
The Trust has maintained its contract with the web-based Patient Opinion, a national independent
feedback platform for health services. The non-profit making website allows for a conversation
between patients, service users, carers and health service bodies, by allowing people to:

See what others are saying about the healthcare that each Trust is providing

Share their story so that others can learn from their experience

See how health services have responded to comments from others
Patient Opinion provides a mechanism for the Trust and healthcare professionals to listen and respond
to the experiences of people using this platform. All published opinions go to the CQC and are
republished on NHS Choices.
The Trust had 17 stories posted on Patient Opinion in 2014/15, all of which received responses. We
are keen to continue raising awareness and activity related to Patient Opinion during 2015/16; and
have arranged to as part of a county wide service user and carer engagement event to promote the
resource at these events. We will also include Patient Opinion within the Trust’s quality patient/carers
initiative steering group to maintain its profile and problem solve where required to support activity.
107
Professional / public feedback
“Thank you for your comments. I would like to say to everyone who cared for her that it
was great working together with you to support this lady. She had very challenging symptom issues
and you all worked very hard to support her despite it not being a core area of your service. I look
forward to further collaborations in the future.”
Consultant in Palliative Medicine.
“There are no words that would best describe the gratitude that (patient’s name) family owe to every
member of staff on Langworth ward.” Carer
“I would just like to say thank you for the invite to take part in (sic) inspection visit. I enjoyed it very
much and was a very interesting (sic) insight to how the trust runs it services.
Please keep me in mind for any future visits as I would be very happy to give my time for the benefit of
future visits. Group of 1,000 members’ feedback following involvement with a 15 steps/mock CQC visit.
108
Patient feedback (including complaints)
Where service users and/or carers have raised concerns via PALS or complaints consistent themes
are:

Access to services (different aspects).

Care and treatment (different aspects as case specific).
The Trust continues to seek to work positively with all feedback received; and to work where possible
with service users, carers and staff to problem-solve and find ways to improve experience and outcome
for all those using our services. In 2014/15 we have included a number of patient experience related
metrics to strengthen our effective partnership and involvement work.
A sample of quotes taken from service user feedback:
“After I was medically fit I was seen by two members of the crisis team. These two women although
they probably don’t realise it, are likely to have saved my life. They were down to earth and spoke to
me like I was human, instead of a chore they had to get through before they went home”. CRHT
“The whole ward is wonderful!!! All the staff are fantastic and have amazing empathy which does
wonders for early recovery.” Adult in-patient ward.
“It was a very good service the food was excellent. Anyone entering the unit will have a first class
service the staff are excellent. Thank you for your care throughout my stay, you were all very kind.”
Adult in-patient ward.
“Because I felt that while I’ve been here I’ve been well looked after mentally and physically, I feel that I
can approach staff on a regular basis. I feel that the ward has had a 100% turnaround since my last
admission x.” Adult in-patient ward.
“ Very caring and friendly staff made a very hard time for us much more bearable. Everyone went out
of their way to help us.” Older adult In-patient ward.
“When my wife was in your care, it is reassuring to me that she was with others with similar health
problems. Also she was with experienced staff. Also she was well looked after. Also I got some
respite myself, as I have had almost two years like this with my wife’s condition.” Older Adult In-patient
ward.
“Constantly told what I think my issues are, don’t matter and to take drugs.” Adult in-patient ward.
“Always very helpful.” LD in-patient unit.
109
“My time here has been an amazing opportunity to do something I could never have imagined having
the strength to do myself on the outside. All the staff have been so helpful and supportive with me and
my family.” Adult in-patient ward.
“Anyone can have a problem with their health and need to be in hospital. Some staff have not been not
too helpful. Other staff have been approachable and helpful.” Adult in-patient ward.
“It would seem that with all the heightened awareness governing mental health moves and concerns at
present, the local community in which I reside has been able to address any potential problems and
this has made me feel integral to Lincolnshire coupled with the aforementioned service.” Community
Mental Health Team
“I have never been show (sic) so much kindness & help. I did not know what went on at DART, but I do
now. I can go back whenever I want; I am on the road to recovery thanks to DART. They are all
angels.” DART
“A very useful meeting at which everything was clearly explained. The assessor was very kind and
knowledgeable and the meeting had a good outcome. Thank you.” Older adults community mental
health team
“Not enough time for the patients and some staff are extremely rude in their approach.” Adult in-patient
ward.
“My whole experience of Lincolnshire's NHS mental health service has been a very positive one. The
staff are dedicated, caring and highly professional.” Community forensic team
“The service provided to me has been so caring and helpful, lifeline to me in a crisis, it is gradually
changing my life. If the service were able to expand and provide more help in a more intensive way by
being given more adequate resources to do so it would be even more effective. Having had various
different types of treatment in the past, this is the once place that I feel is really helping me long term.”
Eating disorder service
“Very helpful and reasuring,(sic) they had a positive impact on my recovery.” CRHT
110
Annexe 1A: Statement from South West Lincolnshire Clinical Commissioning Group on
behalf of NHS Lincolnshire (Commissioner)
111
Annex 1B: Statement from Lincolnshire Health Scrutiny Committee and Healthwatch
Lincolnshire
HEALTH SCRUTINY COMMITTEE
FOR LINCOLNSHIRE
Statement on Lincolnshire Partnership Foundation Trust
Quality Report for 2014/15
This statement has been made jointly by the Health Scrutiny Committee for Lincolnshire and
Healthwatch Lincolnshire. It is acknowledged that the Trust report, in its sixth year, is well produced
and is easier for the lay person to understand. However it is still felt that the nationally mandated
structure of the report could be further improved to demonstrate clear distinction between the reported
year, and the planned year to avoid confusion of statistics crossing operational years. We also support
the Trust in its planned development of an easy read version.
At the time we reviewed the draft report, we noted that a significant proportion of the data was awaiting
accuracy checking and the inclusion of Q4 information, which therefore hindered some of the scrutiny
process. It was agreed this data would be submitted as soon as was available.
Priorities for 2015-16
The Health Scrutiny Committee for Lincolnshire and Healthwatch Lincolnshire support the Trust’s four
quality priorities for 2015/16 and the rationale for their inclusion, which builds on the Trust's quality
principles. We also recognise that the reduction in quality priorities from the previous year’s nine is
expected to make the outcomes more understandable and tangible for the provider, staff and service
users.
112
We acknowledge the extensive involvement of partners and members of the public engaged in
developing these priorities and are assured by the Trust that as a result there are no gaps or exclusions
for 2015/16.
We note that the challenges for the forthcoming year will include financial and resource constraints and
we also note the major piece of work being undertaken that will look at the geographical challenges
facing the Trust and its services and how that might impact on demand over a three year period.
We note the concerns raised locally about access to Child and Adolescent Mental Health Services
(CAMHS), particularly around the assessment at A&E for young people and the effective use of early
intervention. It is acknowledged that locally and nationally inpatient beds are limited and that currently,
it is sometimes unavoidable that children will need to go out of county, however we feel the Trust's
drive to deliver a seamless service and the further development of the Liaison Service will help to
improve the situation.
In December 2014 Healthwatch Lincolnshire published “Hear Our Voice” Children and Young People of
Lincolnshire. This report showed that there was a 25% dissatisfaction rate with some services,
including CAMHS. Healthwatch Lincolnshire felt this highlighted a need to perhaps look further at how
these services can be more effective and in turn encourage a more positive attitude towards them and
greater use. Subsequent to this report we acknowledge the work the Trust and the South West
Lincolnshire Clinical Commissioning Group are doing to address the findings as a whole.
Priorities for 2014-15
We acknowledge the Trust's progress with its priorities for 2014/15 and also wish to acknowledge the
numerous individual and organisational awards received during the year demonstrating excellence.
We recognise the success of the 2014/15 clinical and risk assessment tool putting patients’ needs at
the centre, and support the fact that in 2015/16 the tool will now be rolled out to all qualified members
of staff to be trained and embedded in the process.
It is noted that where the Trust has not achieved priorities or targets for the previous year there is a
greater depth of understanding and assurance that the processes in place are positive in ensuring a
better patient experience and greater patient safety.
It is understood that the Trust has some stretching targets because there is a statistical bias, and where
realistically significant improvement rather than achievement is the objective because numbers are so
small, particularly in the area of falls prevention.
113
An area where the public had highlighted a concern and we felt worthy of note was the patient
experience element of accessibility to services countywide. It is recognised that accessibility is
currently being addressed with the Clinical Commissioning Groups and additionally that there is a need
to further develop early intervention and mental health services for young people. We heard that this
will in part be addressed by the expansion of the Liaison Service to a broader patient group and we
welcome this.
Finally it is also noted that given independent data received from Healthwatch that patients had limited
satisfaction levels of the complaints process it is deemed useful to receive a comparison with
complaints and complaint resolution satisfaction rates at national and local level for future discussion.
We welcome and support the Trust in proactively seeking feedback from patients and the work they
had done internally around developing top tips for resolution.
Conclusion
In terms of the overall content of the quality report, we recognise that the Trust has to balance the
requirements in the regulations and guidance.
We recognise and are assured of the involvement of patients and staff in the production of priorities
which has taken place and as such, that there are no key priorities omitted from 2015/16
considerations.
Building on the achievements and lessons learned from 2014/15 we look forward to the developments
to improve equality of services across the county and the further involvement of the Trust in the
Lincolnshire Health and Care Programme particularly in the integration and cohesion of services
provided in health and social care.
It is noted and welcomed that in these times where capacity to recruit and retain staff can sometimes
be challenging, that the Trust has reported good retention rates and good staff survey responses.
The Health Scrutiny Committee for Lincolnshire and Healthwatch Lincolnshire look forward to
continuing engagement with the Trust, and its continued improvement in the services provided to
patients.
114
Annex 1C: Governor comments
Annex 1D: Deloitte limited assurance statements
115
116
117
118
Annex 2: Statement of directors’ responsibilities for the quality report
The directors are required under the Health Act 2009 and the National Health Service (quality
accounts) regulations to prepare quality accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality
reports (which incorporate the above legal requirements) and on the arrangements that NHS
foundation trust boards should put in place to support the data quality for the preparation of the quality
report.
In preparing the quality report, directors are required to take steps to satisfy themselves that:

the content of the quality report meets the requirements set out in the NHS Foundation Trust
Annual Reporting Manual 2014/15 and supporting guidance

the content of the quality report is not inconsistent with internal and external sources of
information including:
o
board minutes and papers for the period April 2014 to March 2015
o
papers relating to quality reported to the board over the period April 2014 to March 2015
o
feedback from commissioners dated 01/05/2015
o
feedback from governors dated 23/04/2015
o
feedback from local Healthwatch organisations dated 27/04/2015
o
feedback from Overview and Scrutiny Committee dated 27/04/2015
o
the Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 08/04/2015
o
the [latest] national patient survey 18/09/2014
o
the [latest] national staff survey 24/02/2015
o
the head of internal audit’s annual opinion over the trust’s control environment dated
April 2015
o

CQC Intelligent Monitoring Report dated November 2014
the quality report presents a balanced picture of the NHS foundation trust’s performance over
the period covered

the performance information reported in the quality report is reliable and accurate

there are proper internal controls over the collection and reporting of the measures of
performance included in the quality report, and these controls are subject to review to confirm
that they are working effectively in practice
119

the data underpinning the measures of performance reported in the quality report is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review and

the quality report has been prepared in accordance with Monitor’s annual reporting guidance
(which incorporates the quality accounts regulations) (published at
www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data quality for
the preparation of the quality report (available at www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the quality report.
By order of the board
Paul Devlin
Dr John Brewin
Chair
Chief Executive
21 May 2015
120