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QUALITY REPORT & QUALITY
ACCOUNT 2014/15
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Contents
Part 1
Statement on quality from the Chief Executive Officer of Southern Health Foundation
NHS Trust
Part 2
Priorities for improvement and statements of assurance from the Board
2.1
Progress in meeting priorities for improvement in 2014/15
Priorities for improvement in 2015/16
2.2
Statements of assurance from the Board
2.3
Reporting against core indicators
Part 3
Other Information
Annexes
Annex 1 Statements from commissioners, local Healthwatch organisations and
Overview and Scrutiny Committees
Annex 2 Statement of directors’ responsibilities for the quality report
Annex 3 External Auditors’ Limited Assurance Report
Annex 4 Data definitions
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Part 1: Statement on quality from Katrina Percy, Chief
Executive Officer of Southern Health Foundation NHS
Trust
Southern Health is committed to and passionate about continuous quality
improvement.
Southern Health NHS Foundation Trust is one of the largest providers of mental
health, specialist mental health, community, learning disability and social care
services in the country with an annual income of £343 million.
The Trust provides these services across the south of England covering Hampshire,
Dorset, Wiltshire, Oxfordshire and Buckinghamshire although 90% of the care
provided is in Hampshire.
This year:
Almost 8000 dedicated staff enabled us to treat or support
243,207 patients by providing
1,349,651community contacts,
243,826 outpatient appointments,
26,813 Minor Injury Unit attendances and
219,665 occupied bed days.
The Trust has
776 inpatient beds and
176 sites including community hospitals, health centres and inpatient units.
As we do constantly, we have closely scrutinised all aspects of our work. We have
made improvements to ensure our services are of the best quality that we can
provide. In tackling financial challenges, we have focused on delivering high quality
services, which are responsive to the needs of patients and the communities in
which we work and which reflect outcome-driven best practice.
At the start of 2014 / 2015, Southern Health faced significant quality challenges in
some of its services. Not least was the enforcement action applied by Monitor, the
health service regulator, to improve the quality aspect of services. This required us
to:
Deliver quality improvement plans across our learning disability services
Implement and deliver action plans to address the Care Quality Commission
(CQC) warning notices applied to a small minority of our services
Deliver improvement of our quality governance strategy and Board
governance.
Monitor’s concerns were taken most seriously and gave us an extra, welcome
opportunity to improve standards for our patients and service users.
In early 2014 I strengthened the Board, with the addition of:
Dr Chris Gordon, Chief Operating Officer and Director of Integrated
Services;
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Della Warren, Director of Nursing and Allied Health Professionals;
Dr Martyn Diaper, Medical Director, and;
Dr Lesley Stevens, Director of Mental Health & Learning Disabilities.
All of these new recruits have extensive experience in operational quality
improvement. Together, this refreshed and strengthened executive leadership is
championing quality improvement. They have led and helped to embed an improved
structured quality improvement process to ensure ownership of this agenda by
operational staff.
In October 2014 the Care Quality Commission, the healthcare quality regulator,
embarked on a week-long inspection of Southern Health. Over 100 CQC inspectors
visited more than 120 of our sites. The overall CQC rating for the Trust was
‘Requires Improvement’ with over two thirds of the individual domains assessed as
‘Good’. The recurring theme throughout the 17 reports was that our staff were
‘caring’ and ‘responsive’, which is no surprise to me or to the thousands of patients
and other people who rely on our services. However, we must continue to improve.
The CQC report acknowledged many areas of success and improvements:
Our bespoke ‘Going Viral’ leadership development programme cascading
throughout the organisation featuring an emphasis on quality improvement
The use of feedback and learning from complaints to guide service
improvement supported by our advocacy service
The development of our internal peer review programme which systematically
assesses all of our services against quality standards
The development of our internal information and data systems which allows
performance to be assessed from ward / team level up to Board
The continuous improvement work we have undertaken in the area of equality
and diversity
The report also demonstrated that improvements still need to be made with key
themes identified:
• Inappropriate seclusion and physical intervention practices due to lack of
suitably trained staff, policies that did not give clear direction and some staff
who lacked awareness of good practices
• Ligature risks at some sites
• Staffing levels and skill mix in some services
• Long waiting times for access to therapy services
• Management of medicines
• Inconsistent understanding and use of the Mental Health Act Code of Practice
and Mental Capacity Act.
We are making changes to address each of the CQC concerns. Our quality
improvement programme is overseeing these changes, checking thoroughly against
a robust action plan. The actions align closely with the improvement priorities which
feature in this Quality Account.
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I would also like to acknowledge the vital role played by our stakeholders:
commissioners, national, regional and local NHS bodies, professional bodies, local
authorities and other providers of health and social care and partners in the
communities we serve. Quality is a shared commitment with each of them and many
of the improvements for patients and service users could not have been achieved
without cooperation and support from those with whom we work.
Changes to improve quality are underway. Many have already taken place, but
others will take time to embed in the way we work every day.
I thank all Southern Health staff for their own personal commitment to quality
development and improvement. Our successes are as a result of their hard work and
already have led to our patients and service users experiencing better care. We must
continue to invest in the quality improvement programme and the training of our
teams, to ensure that quality remains a focus for everyone in the Trust.
The content of the report has been reviewed by the Board of Southern Health NHS
Foundation Trust. I confirm, on behalf of the Board and to the best of my knowledge,
that the information contained in it is accurate.
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About Us
Services We Provide
Over the last year we have continued to make good progress in redesigning our
services and working with partner organisations enabling more people to be cared
for in the community with an emphasis on delivering co-ordinated care which is led
by patients and focuses on goals that are important to them and their carers. The
Trust provides a wide range of services:
Mental health and learning disability
Adult inpatient services including psychiatric intensive care units;
Long stay/rehabilitation services;
Forensic inpatient /secure services;
Adolescent mental health inpatient services;
Inpatient services for people with learning disabilities;
Inpatient services for older people;
Community-based mental health services for adults of working age;
Mental health crisis services and health based places of safety;
Community-based services for older people;
Community mental health services for people with learning disabilities;
Eating disorder services;
Perinatal services; and
Social care services supporting people with learning disabilities and/or mental
health needs.
Community health services
Community services for adults;
Community inpatient services, including day surgery at Lymington New Forest
Hospital;
Community services for children, families and young people;
End of life care;
Urgent care – Minor Injuries Unit; and
Specialist nurse teams supporting specific conditions, for example, diabetes.
The Trust splits its services using an integrated model of care as below:
Integrated mental health, learning disabilities and social care services
Mental health services – adult mental health and specialist secure services for
adults and young people;
Learning disabilities – community and inpatient services providing specialist
support to adults; and
Social care services (also known as TQtwentyone) – social care services for
older people, people with mental and learning disabilities.
Integrated community services
Physical healthcare services for adults and older peoples mental health services;
and
Children’s services including health visiting and school nursing services for
children and families.
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Our Vision
Crucial to our continuing success is having a clear vision of what we aspire to,
values that lay down our expectations of behaviour for all, and clear strategic
objectives that set out what we need to do to realise our aims.
Our vision is to provide high quality, safe services which improve the health,
wellbeing and independence of the people we serve.
To achieve our vision we know that we need to undergo a significant amount of
change to transform the way that we provide healthcare for the better. Our
organisational strategy shows how we are going to bring about this change with
more detailed information provided in the Annual Report.
Our Goals
Our goals guide our strategy and are the basis on which we determine the measures
we use to assess our performance as an organisation.
Our goals centre on providing safe quality care and:Improving the experience patients, service users and their families have
of our services, treating them with dignity and respect;
Improving clinical outcomes for patients, service users and their families;
Reducing the costs of our services so that we deliver better value and live
within our means.
Our Goals
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Our Values
Our values set out what is important to us. They describe our organisational culture,
how we should act and are the foundation that underpins the way we operate. These
values are:
Person and Patient
Realising Ambition
Driving Innovation
Centred
Our service users and
We are constantly striving to Innovation is part of
patients are at the centre of be the best we can be. As
everyone's job. By using
our every thought and every individuals and as an
our imagination,
action. By working
organisation we are
remaining open to new
innovatively yet meticulously committed to providing our
ideas and acting quickly
we deliver care which is
patients, service users and
and responsively we are
tailored around the unique
each other with a dynamic
able to transform the lives
requirements of individuals
and evolving service which
of our patients and
and constantly evolving
leads the way.
service users.
around their changing
expectations.
Forging Relationships
Delivering Value
Valuing Achievement
The best care is integrated
care. Through bringing
together other care and
support providers and
ensuring that we help and
enable each other we all
look for ways to make care
more joined up for our
patients and service users.
We are committed to
providing the best possible
value for money. Through
working smartly, spending
our time on the things that
really count and eliminating
wasteful activities everyone
takes responsibility for
delivering greater value.
We value and encourage
success and
achievement. Those who
improve the patient and
service user experience
and our performance are
rewarded.
Delivering High Quality Services
We have a number of systems in place to ensure we can measure our performance and
monitor that standards are being met and that quality improvements are being made.
The Quality & Safety Committee maintains oversight of the quality and safety of our
clinical services. Reports are presented which demonstrate we are meeting national
and local targets and, for example, the outcomes of Care Quality Commission (CQC)
assessments and our response to any recommendations.
Where it is identified that standards are not being met actions are taken to ensure we
improve the quality of our care and to drive improvement in quality of service by:
a) Improving safety;
b) Improving clinical outcomes; and
c) Improving patient experience.
In 2014 we established a Quality Programme to deliver some of the operational
elements of the Trust’s Quality Governance Strategy and provide a framework to
enable focus to be given to achieving delivery of quality improvement priorities. Work
has progressed through eight workstreams: Governance; Patient Safety, Reporting &
Learning; Peer Review & CQC Compliance; Estates & Infrastructures;
Recordkeeping & Care Planning; Workforce; Patient Experience & Engagement; and
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Medicines Management. Tangible outputs have already been achieved by all eight
workstreams and the Quality Programme will continue to be the vehicle through
which quality improvement priorities are driven and monitored in 2015/16.
As part of our preparation for the Care Quality Commission comprehensive
inspection in October 2014 we developed further our Peer Review programme. Over
60 peer reviews were carried out between June 2014 and October 2014 which
assisted the Trust in identifying the quality improvement areas to focus on during this
period. The peer review workstream are strengthening the current process to mirror
the methodology used by the Care Quality Commission. Peer reviews will be used
as a validation tool to ensure the quality assurance processes in place within the
divisions are effective.
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Part 2: Priorities for improvement and statements of
assurance from the Board
2.1 Priorities for improvement in 2014/15
Every Quality Report must contain a minimum of three indicators each for improving
patient safety, clinical outcomes and patient experience which are to be achieved in
the following year. Our 2014/15 Quality Report included a set of improvement
indicators which were selected in consultation with our stakeholders and approved
by the Trust Board. These priorities are shown below, together with brief
performance details in tables reviewing our performance for clinical quality. More
details about our progress in meeting these indicators are given in Part 3.
Table: Priorities for Improvement 2014/15
Priorities for Improvement 2014/15
1.1 To reduce avoidable pressure ulcers
Improving Patient
Safety
1.2 To improve the management of incidents of
violence and aggression
1.3 To improve medicines reviews for people
2.1 Holistic care planning for people
Improving Clinical
Outcomes
2.2 Learning from information about quality of care
2.3 Learning from deaths
3.1 Improve the experience people have of our
services
Improving Patient
Experience
3.2 Support carer involvement and listen to their
feedback
3.3 Use feedback from complainants to improve our
service
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A review of our performance for clinical quality
The tables below summarise some of the quality information we regularly review as
part of quality performance monitoring and includes the indicators chosen for
2014/15 and which were included in the 2013/14 Quality Report. The 2014/15
targets and whether they were met are included in the tables with other quality
performance measures that were not specific priorities for improvements in that
period shown with shaded cells.
Patient Safety
Healthcare
associated
infection:
Clostridium
difficile
Never events
(serious,largely
preventable
patient safety
incidents)
Serious
Incidents
Requiring
Investigation
(SIRI)
2011/12* 2012/13* 2013/14* 2014/15* 2014/15
Indicator Comments
indicator met?
target
Continued
very low rates
of infection.
7
5
3
3
1
0
0**
0
390
353
395
396
Avoidable
grade 3 and 4
pressure
ulcers (a sub
category of
above SIRI)
149
166
139
Incidents of
prone restraint
1575
1165
1151
127
To
reduce
average
numbers

1033
To
reduce
by 20%

There have
been no
never events
since
2011/12.
Incidents
resulting in
serious harm
not common.
396 out of a
total of 12499
incidents.
Achieved:
Reduction in
numbers due
partly to
introduction of
new
definitions.
Partially
achieved:
annual
SAFER
programme to
reduce use of
prone
restraint has
seen
reduction in
incidents,
however 20%
target not
reached.
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Incidents of
seclusion
1434
1117
1269
386
Medicines
review within
48 hours
n/a
n/a
37%
38.3%
6377
5140
8978
12499
1.35
1.9
1.0
1.5
Patient safety
incidents
reported to
National
Reporting and
Learning
System
% of reported
incidents that
resulted in
severe harm or
death
To
reduce
by 20%
80%
Achieved:
Focused
programme to
reduce
seclusion with
a change in
reporting
process to
capture more
accurate data.
Not
achieved:
increased
number of
reviews being
completed
towards end
of year
following
increase in
staffing.
Improved
reporting
culture has
increased
numbers of
incidents
reported.
% of severe
harm
incidents out
of total
incidents low.

x
**A serious incident relating to ophthalmology surgery in Lymington New Forest
Hospital in May 2013 was discussed with our commissioners who confirmed it did
not meet the criteria for a never event, however the Care Quality Commission report
(February 2015) makes reference to a non-reported never event.
Clinical
Outcomes
Violence and
aggressive
incidents
resulting in
physical injury
Holistic care
2011/12*
2012/13*
2013/14*
2014/15*
736
627
995
990
n/a
n/a
n/a
a)74%
2014/15
indicator
target
a)95%
Indicator
met?
x
Comments
Not
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planning
Sharing and
learning from
quality
information
(number of
complaints
about care
planning)
Learning from
reviewing
deaths (deaths
by suicide)
% of patients
receiving a 7
day follow up
( year-end
position audited
by PwC)
% crisis
resolution
teams acted
as gatekeeper
( year-end
position audited
by PwC)
Readmission
rates within 28
days to
hospital
holistic
assessm
ent
b)71%
patient
identified
goals
c)83%
SMART
care plan
n/a
n/a
27
0
holistic
assessm
ent
b)95%
patient
identified
goals
c)100%
SMART
care plan
achieved:
Second
audit
results
show
good
improvem
ents
made in all
areas but
set targets
not
reached.
10%
reduction:
complaint
referring
to care
planning
Achieved:
There have
been no
complaints
regarding
care
planning.

47
34
43
35
Benchmark
against
National
Confidential
Inquiry
(NCI)
95.4
96.9
96.35
97.5
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Achieved:
Numbers
consistent
with NCI
data per
size of
population
Met
national
Monitor
target
Met
national
Monitor
target
97.9
97.4
99.7
96.1
95
10.2
8.7
7.4
7.6
n/a

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Patient
Experience
2011/12*
2012/13* 2013/14* 2014/15* 2014/15
indicator
target
Indicator
met?
Total
complaints
342
398
470
453
Total concerns
544
475
488
522
Total
compliments
854
1511
1732
1604
‘Action
learning
letters’ sent to
complainants
who requested
them
n/a
n/a
n/a
100%
100%

n/a
96% **
(88%
mental
health
services
96.1%**
(90.6%
mental
health
service)
97.1%**
(92.9%
mental
health
service)
95%**
(75%)

n/a
89%
(66%
mental
health
service)
87.6%
(67.5%
mental
health
service)
89.9%
(82.6%
mental
health
service)
Patient
experience
surveys:
recommend
trust to family
and friends
Patient
experience
surveys:
support for
carers
Carer survey:
service made
me feel
welcome
Comments
Numbers
remain
essentially
same
Slight
increase
Slight
decrease
Achieved:
Smaller
number of
complainant
s requested
‘action
learning’
letters than
anticipated.
Achieved:
Positive
feedback on
care
provided.
Positive
feedback for
support for
carers.
n/a
n/a
n/a
94.9%
85%

Carer survey: I
am recognised
as carer
n/a
n/a
n/a
100%
85%

Carer survey:
recommend
trust to friend
and friends
n/a
n/a
n/a
90.7%
85%

Duty of
Candour
n/a
n/a
100%
100%
Achieved
Positive
feedback
from carers.
Achieved
Positive
feedback
from carers.
Achieved
Positive
feedback
from carers.
This relates
to us being
open with
patients and
families
when things
go wrong.
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*The acquisition of Oxford Learning Disabilities Trust (OLDT) in November 2012
makes the direct comparison of performance data over time difficult as we are now a
larger Trust. Some data has been revised during the year and so figures may be
slightly different from those reported in the 2013/14 Quality Report.
**patient experience surveys launched in May 2012 used question ‘How would you rate
your experience of our service overall?’ This question was adapted for 2013/14 to meet
the Friends and Family Test requirement and is ‘How likely are you to recommend our
services to friends and family if they needed similar care or treatment?’ Different targets for
mental health services are set internally to take into account the different nature of their
caseload.
Priorities for improvement in 2015/16
This year’s Quality Report includes a set of improvement indicators which have been
selected in consultation with stakeholders and approved by the Trust Board. We
emphasise that the chosen indicators form only a small sample of all the quality
improvement activities being undertaken across the Trust and that quality of care is
widely reviewed and monitored at team, service, divisional and Board level.
We have used a range of information to identify the annual priorities including:
What patients have told us about our services and how we can improve;
What our commissioners have told us is important to provide to their patients;
What our Governors have told us is important to them;
What staff have told us is important to them;
What external organisations such as the Care Quality Commission have told us
about our services;
Consultation with Healthwatch organisations;
Our learning from reviewing the performance and quality of our services and
where improvements are required; and
Review of national priorities as identified in the NHS Operating Plan.
These priorities reflect our Quality Governance Strategy 2014- 2016 which supports
delivery of the Trust’s vision and values and overarching Clinical Strategy and sets
out our approach to continually improving the quality of care for our patients, service
users, their families and carers.
The priorities for improvement for 2015/16 are shown below with aims to be
achieved by end March 2016. We have included information about why these
indicators are important, our overall aim and specific ambitions and actions for
2015/16 as well as how we will measure progress towards meeting these aims. All
priorities for improvement will form part of the Trust’s overarching Quality
Programme with delivery being overseen by one of its eight quality workstreams and
progress monitored by the Quality Improvement and Development Forum, Quality
and Safety Committee and Board and included in the Quality Report for 2015/16.
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Priority 1:
Improving Patient Safety 2015/16
Priority 1.1 Reduce the number of pressure ulcers
Aim
Why is this important?
To share and
Pressure ulcers can be painful and increase the
implement
risk of associated infection for a patient. We
learning across
want to minimise this risk and any potential harm
the Trust to
to the patient by doing all we can to prevent
reduce pressure
pressure ulcers developing.
ulcers
In 2014/15 we were successful in reducing
pressure ulcers in many of our teams with the
introduction of new procedures to confirm teams
had taken all appropriate actions to prevent
pressure ulcers developing. We therefore want
to repeat a similar indicator for 2015/16 with
learning and good practice being shared across
the whole Trust, resulting in fewer pressure
ulcers.
The Care Quality Commission (CQC) report
based on their inspection in October 2014 found
proactive actions were in place to reduce
pressure ulcers which we want to build on.
Our ambitions and actions: 2015/16
To reduce number of new avoidable
grade 3 and 4 pressure ulcers by 50%
in 2015/16 as initial phase of three year
plan to reduce numbers by 95%.
To focus on teams with poorest
performance with intensive
improvement plans being implemented
and closely monitored.
How we will measure progress
We will compare the numbers of
new avoidable grade 3 and 4
pressure ulcers acquired in our
care in 2014/15 to the numbers in
2015/16 with clear reduction target
of 50% across the Trust.
To share and embed learning and good
practice from thematic review of best
performing teams; regional initiatives
developing evidence based guidance
and projects across the Trust.
To develop a single assessment tool
that all teams use.
To continue to raise awareness of
pressure ulcer causes, prevention and
signs of tissue damage to patients,
carers and staff.
Priority 1.2 Inpatients in our physical health wards will have a venous thromboembolism (VTE) assessment on admission
Aim
Why is this important?
Our ambitions and actions: 2015/16
How we will measure progress
To identify
Venous Thromboembolism (VTE) is a serious,
90% of acute admission inpatients will
We will develop an audit and
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patients who are
at risk of a
venous
thromboembolism
and take
appropriate
preventative
steps to reduce
the risk.
potentially fatal, medical condition. Although it
can happen to anyone, you are more at risk of
developing blood clots (VTEs) if you can’t move
around very much or if you are unwell. Therefore
anyone who is in hospital is more susceptible to
VTE and should be assessed on admission for
their risk with preventative measures taken to
reduce this risk, for example, blood thinning
drugs, compression stockings.
This is a new indicator for 2015/16 as we want to
ensure there is consistent good practice across
the Trust.
have a VTE risk assessment within 24
hours of admission.
90% of inpatients transferred from
acute providers where VTE risk
assessment has been completed and a
treatment plan is in place, will be reassessed within 1 week.
90% of inpatients at risk receive
appropriate treatment.
assurance programme to measure
standards which are required to
assess and treat the risk of venous
embolism.
We will undertake clinical audits
against the standards to measure
progress in meeting our aims and
to identify areas where action may
be needed to meet standards.
To develop VTE assessment tools and
procedures based on NICE guidance
and roll out across Trust via training, elearning and communication to staff.
To raise awareness and use of the VTE
assessment tools and procedures in
junior doctor education programme and
with primary care colleagues.
Priority 1.3 Inpatients will receive their critical medicines
Aim
Why is this important?
To ensure
Medicine doses may be omitted or delayed for a
patients in our
variety of reasons. Although only a small
inpatient units
percentage of these occurrences may cause
and hospitals
harm or have the potential to cause harm, delays
receive their
or omissions in the administration of some critical
critical medication medicines can cause serious harm or death.
and that any
inappropriate
We want to minimise any potential harm to
Our ambitions and actions: 2015/16
95% of critical medicines will be
administered or there will be an
appropriate clinical reason why omitted.
95% of inappropriate omissions are
investigated with actions taken to
prevent future omissions.
How we will measure progress
We will develop an audit and
assurance programme to measure
standards which are required for
critical medicines management.
We will undertake audits against
the standards to measure progress
in meeting our aims and to identify
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omissions are
investigated with
actions taken to
prevent future
omissions.
patients by ensuring they receive their critical
medicines when they should and that any
inappropriate omissions are reviewed with
actions put in place to minimise future
inappropriate omissions.
The CQC report based on their inspection in
October 2014 found improvements in the
management and administration of medicines
could be made. We have therefore built on the
2014/15 priority which focused on improving
medicines reviews for inpatients and will focus
this year on critical medicine management.
Priority 2:
To review critical medicines list for the
Trust and communicate list to all staff.
areas where action may be needed
to meet standards.
To provide training on critical
medicines, including importance of
reporting inappropriate omissions as an
incident which is investigated.
To implement actions from drugs
omission audit in 2014/15 and repeat
audits in 2015/16.
Improving Clinical Outcomes 2015/16
Priority 2.1 All of our clinical services have a care planning framework in place that is patient led
Aim
To have a care
planning
framework in our
clinical services
that involves
patients and is
led by them.
Why is this important?
Our services are caring for patients who are
increasingly unwell, many of whom have long
term conditions and complex needs. A first step
in our care is to complete a holistic assessment
of all needs and to work in partnership with the
patient and their carers to develop care plans
that are centred on their needs and include goals
important to them. We will work in partnership to
review progress against the care plan and ensure
it is leading to improved outcomes for the patient
and their carers and continues to be focused on
Our ambitions and actions: 2015/16
To undertake a programme of work to
evidence patient involvement in
development of care planning.
95% of patients in identified sub groups
have a personalised care plan
supporting them to develop the
knowledge, skills and confidence to
manage their own health.
To develop and refine care planning
framework and train staff in its use.
How we will measure progress
Quarterly review of delivery of
project plans and progress in
meeting aims overseen by the
Quality Programme: Patient
Experience and Engagement work
stream, Quality Improvement and
Development Forum, Quality and
Safety Committee, Board and
Service User Reference Group.
Audit of case notes of patients in
sub groups to evidence that care
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what is important to them. Our aim is to support
those who use our services to take control of
their care in a structured and clear way.
plans were in place and were
patient led.
Evidence demonstrates effective care planning
ensures better continuity of care, clinical
outcomes, safety and experience for the patient.
This indicator builds on the 2014/15 priority
‘holistic care planning for people’.
Priority 2.2 Physical health of our patients is monitored and any deterioration is acted upon
Aim
To monitor the
physical health of
our patients and
act quickly when
there is
deterioration in
their physical
condition to
ensure they
receive best care.
Why is this important?
Increasingly unwell patients are being cared for
in our inpatient hospitals and units. The Physical
Assessment and Monitoring Policy highlights the
importance of recognising clinical deterioration
with physiological observation charts (‘track and
trigger’ tools) developed as an early warning
system to be used with all patients who are
receiving physiological observations. This
enables quick action to be taken in response to
any deterioration leading to improved outcomes
for patients.
Our ambitions and actions: 2015/16
To embed the use of an early warning
system to identify physical deterioration
in all inpatient units.
To ensure staff act on any triggers of
physical deterioration and escalate
concerns appropriately for 90% of
patients.
All inpatient units to use ‘track and
trigger’ tool with training provided for
staff.
We are repeating a similar indicator from 2012/13
to ensure good practice is embedded across the Each unit to have a standard operating
Trust.
procedure for use of ‘track and trigger’
tool with clear guidance on escalation
process.
Review of all patients transferred by the
ambulance service to evidence that
How we will measure progress
Quarterly review of case notes of all
patients transferred by South
Central Ambulance Service (SCAS)
from inpatient units to evidence that
early warning system is used and
escalation process was followed
appropriately.
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escalation process had been followed.
Priority 2.3 To improve clinical outcomes and post-operative care for day surgery patients
Aim
Why is this important?
Our ambitions and actions: 2015/16
To improve
We want to make sure that patients undergoing
100% of patients have a WHO surgery
clinical outcomes surgery have the best possible outcomes. We
checklist completed prior to day
and postcan help achieve this by using the World Health
surgery.
operative care for Organisation (WHO) checklist to ensure all
day surgery
appropriate processes for surgery are followed.
To introduce a new process to identify
patients at
post-operative infection rates following
Lymington New
There is a risk some patients may develop an
open hernia surgery and learn from this
Forest Hospital.
infection following surgery. Currently we do not
information to improve practice.
have a mechanism to identify patients who have
been discharged from hospital and who may
To continue to audit use of WHO
have a post-operative infection. We want to
checklist six monthly and to re-audit
introduce a simple mechanism to track these
after one month if any serious
patients so that we can improve our practices
shortcomings identified.
and hence outcomes for patients.
To develop new process to document
The CQC report found improvements in the
the team brief for each patient prior to
management of day surgery could be made. We surgery and add to audit tool.
have therefore included this new indicator for
2015/16.
Priority 3:
How we will measure progress
Six monthly audit of use of WHO
surgery checklist to confirm
progress in meeting aims with
actions taken to address any
shortfalls in meeting standards.
Quarterly review of post-operative
infection feedback with themes
identified and actions taken as
required.
Improving Patient Experience 2015/16
Priority 3.1 Our complaints process provides satisfaction to the complainant
Aim
Why is this important?
Our ambitions and actions: 2015/16
To have a
Patient experience is extremely important to us;
90% of final responses to complainants
complaints
receiving complaints shows we haven’t got things
will be sent within the mutually agreed
process that
right for the patient or their carers. The CQC
timeframes.
How we will measure progress
Monitoring of final response rates
for complaints with actions taken
to meet improvements as
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meets the
agreed
deadlines for a
final response
and which
provides
satisfaction to
the complainant
that their
complaint has
been handled
well.
inspection in October 2014 highlighted good
practice in our use of information from patient
feedback and complaints. However we know that
the annual complaints report 2013/14 highlighted
that we do not always respond in a timely way and
that complainant satisfaction with our process
could be improved.
required.
90% of complainants will be satisfied
with how we have handled their
complaint.
Regular satisfaction surveys and
feedback from complainants with
actions taken to meet standards
To introduce and embed improvements where needed.
to the complaints management
process.
We want to improve the timeliness of our
responses and the overall satisfaction with how we
have handled complaints to give reassurance to
complainants we are committed to putting things
right for them.
This builds on the 2014/15 indicator where we
focused on feeding back to complainants that we
took action to improve services following their
complaint.
Priority 3.2 Involve patients in the design of services
Aim
Why is this important?
To involve
We put patients at the heart of everything we do.
patients and
We want to listen to and involve them and their
carers in the
carers in the design of services so that we can best
design of
meet their needs and provide a good patient
services.
experience.
The CQC report based on their inspection in
October 2014 found improvements in our Minor
Injury Units and our End of Life services could be
made. We have therefore included this new
indicator for 2015/16.
Our ambitions and actions: 2015/16
Patients, carers and families are
meaningfully involved in the design of
services, with focus this year on Minor
Injury Units, End of Life services and
Children & Families’ services.
Engage with and involve range of
patients and their representatives to be
part of projects to redesign services.
Share across Trust how involvement
and feedback from patients has
How we will measure progress
Quarterly review of delivery of
project plans and progress in
meeting aims overseen by the
Quality Programme: Patient
Experience and Engagement
workstream, Quality Improvement
and Development Forum, Quality
and Safety Committee, Board
and Service User Reference
Group.
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transformed our services and impacted
on our design of services.
Priority 3.3 Involve patients and carers in the co-design of our restrictive practice framework
Aim
Why is this important?
Our ambitions and actions: 2015/16
To involve and
We aim to support patients with mental health
Patients and carers are meaningfully
engage patients problems to recover in safe, calm and therapeutic
involved in the co-design of our
and carers in
inpatient environments, and to engage patients to
restrictive practices framework,
the design of
work in collaboration with us. We know that
including use of restraint and
our framework
patients experiencing mental health distress can
seclusion.
to minimise our sometimes express this through violent or
restrictive
aggressive behaviour. We want to work with
Patients to be involved in training staff
practices, with a patients to manage their distress and avoid
in restrictive practices.
focus on
violence and aggression wherever possible. If it
restraint.
occurs we want to address it in a way that is safe
Action learning sets to examine and
for all concerned, and maintains the dignity and
reflect on areas of high incidence of
respect for the individual, and minimises the use of restrictive practices.
coercion. We have developed a programme with a
number of key measures to provide safe
Develop story telling project exploring
environments and to minimise the use of restrictive the narrative of patients who have
practices.
experienced restraint and seclusion.
The CQC report based on their inspection in
October 2014 found improvements in the
management of restrictive practices could be
made. We have therefore built on the indicator in
2014/15 which focused on improving the
management of violence and aggression with a
new focus on involvement of patients and carers in
the co-design of our restrictive practice framework.
Promote use of advance directives and
statements for patients who, when
unwell, have required some form of
restraint or intervention for aggression.
How we will measure progress
Quarterly review of delivery of
programme and progress in
meeting aims overseen by the
Quality Programme: Patient
Experience and Engagement
workstream, Quality Improvement
and Development Forum, Quality
and Safety Committee, Board
and Service User Reference
Group.
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2.2 Statements of assurance from the Board
These are nationally mandated statements which provide information to the public
which is common across all quality reports. They help us demonstrate:
•
We are actively measuring and monitoring the quality and performance of our
services.
•
We are involved in national projects and initiatives aimed at improving quality, for
example, implementing quality improvement and innovation goals as agreed with
commissioners using the Commissioning for Quality and Innovation (CQUIN)
payment framework, recruitment to clinical trials or participation in national
clinical audits.
•
We are performing to quality standards (CQC) as well as going above and
beyond this to provide high quality care.
Review of services
During 2014/15 the Southern Health NHS Foundation Trust provided and/or subcontracted 47 relevant health services. The Southern Health NHS Foundation Trust
has reviewed all the data available to them on the quality of care in 47 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 Southern Health NHS Foundation Trust for 2014/15.
Clinical audits and national confidential enquiries
Clinical audit supports the Trust’s overall aim to provide high quality and safe
services; it helps embed clinical quality within services and deliver demonstrable
improvements in patient care through the development and measurement of
evidence based practice.
During 2014/15 5 national clinical audits and 2 national confidential enquiries
covered relevant health services that Southern Health NHS Foundation Trust
provides.
During that period Southern Health NHS Foundation Trust participated in 80%
national clinical audits and 100% national confidential enquiries of the national
clinical audits and national confidential enquiries which it was eligible to participate
in.
The national clinical audits and national confidential enquiries that Southern Health
NHS Foundation Trust was eligible to participate in during 2014/15 are as follows:
National Audit /Confidential Enquiry
Elective Surgery (National PROMS Programme – eligible
for hernia surgery only)
National comparative audit of blood transfusion (eligible
for consent audit only)
Prescribing Observatory for Mental Health (POMH-UK)
Eligible



116
Sentinel Stroke National Audit Programme (SSNAP)
National Audit of Intermediate Care
National Confidential Enquiry into Sepsis
National Confidential Enquiry into Suicide and Homicide
for People with Mental Illness




The national clinical audits and national confidential enquiries that Southern Health
NHS Foundation Trust participated in during 2014/15 are as follows:
National Audit /Confidential Enquiry
Elective Surgery (National PROMS Programme – eligible
for hernia surgery only)
National comparative audit of blood transfusion (eligible
for consent audit only)
Prescribing Observatory for Mental Health (POMH-UK)
Sentinel Stroke National Audit Programme (SSNAP)
National Audit of Intermediate Care
National Confidential Enquiry into Sepsis
National Confidential Enquiry into Suicide and Homicide
for People with Mental Illness
Participated in




x


The national clinical audits and national confidential enquiries that Southern
Health NHS Foundation 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.
National Audit /Confidential Enquiry
Elective Surgery (National PROMS Programme – eligible
for hernia surgery only)
National comparative audit of blood transfusion (eligible
for consent audit only)
Prescribing Observatory for Mental Health (POMH-UK)
Sentinel Stroke National Audit Programme (SSNAP)
National Confidential Enquiry into Sepsis
National Confidential Enquiry into Suicide and Homicide
for people with Mental Illness
% of required
cases
submitted
100%
100%
100%
%
100%
100%
100%
100%
The report of 1 national clinical audit (National Audit of Schizophrenia) was reviewed
by the provider in 2014/15 and Southern Health NHS Foundation Trust intends to
take the following actions to improve the quality of healthcare provided:
A task and finish working group will review the report recommendations and
develop a programme of work with particular focus on access to Cognitive
Behavioural Therapy and improving physical health care for patients seen by
our mental health services.
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The reports of 68 local clinical audits were reviewed by the provider in 2014/15 and
Southern Health NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided.
Audit title
Holistic Care
Planning
Actions
• Staff training and raised awareness in accurate
completion of Holistic assessment.
• Development of standard operating procedure for
Holistic assessment and record keeping standards.
• Progress reviewed through peer review programme and
re-audit.
Care
Programme
Approach
(CPA) and
Risk
Assessment
• Train staff to complete all parts of the assessment with
assessment findings reflected in care plan.
• Increase the use of WRAP/WRAP crisis plans.
• Increase the assessment and care planning related to
patient’s personal strengths, hopes and aspirations, the
quality of engagement and the nature of the working
relationship.
• All clients diagnosed with dementia will have CPA
as per dementia map guidelines.
• Health professionals to offer education and training
on dementia. Carers training pack is being
developed by the dementia subgroups.
• All clients must have a clinical risk assessment
based on the clinical assessment and a
coordinated clinical risk management plan.
• The client advised to have a physical health screen
by the GP prior to going onto the dementia map.
• Training in use of SNOWMED required.
• Teams to use RiO downtime forms and ROVER where
connectivity is problematic so as to record patient record
as part of clinical episode of care.
• Development of integrated personalised care plans for
patients with a paper copy held in secondary care notes.
• Urgent care plans are uploaded onto RiO and a paper
copy kept with the secondary record as appropriate.
• Pilot digital dictation relating to patient initial holistic
assessment.
• When a service user meets the criteria for MRSA
admission screening this must be carried out within
the first 48hrs of their admission. If there is a reason
why this timeframe cannot met, the reason must be
documented in the patient’s records.
• Enhanced cleaning of isolation rooms/bed spaces for
patients testing MRSA positive recorded.
• Improve completion of the MRSA screening audit within
East Integrated Service Division, Mental Health and
Learning Disabilities divisions.
Dementia
Pathway
RiO IG Toolkit
MRSA Screening
118
Medicine
Omissions
• Roll out across Trust of mandatory handover of
medication charts at every nursing shift. This will ensure
omissions are checked as a matter of routine.
• Medicines management team will highlight blanks and
omissions on medication chart at every ward visit and
discuss with senior nurse on duty.
• Medicines management quality checklist to be used as
part of peer review process across units.
• All staff via the Trust’s weekly bulletin reminded of the
critical medicines list and need to complete incident form
for omissions/delays of critical medicines.
TQtwentyone
Infection Control
• Ensure all staff know how to contact IP&C team and
access IPC information leaflets.
• Ensure all staff who provide physical healthcare have
short, visibly clean fingernails and wear no jewellery other
than a plain band ring.
• Ensure all staff know how to contact the Occupational
Health department following a sharps injury and the
correct procedure to follow.
Pressure Ulcer
• All patients requiring repositioning to have clear plan of
care which is recorded in patient notes.
• All staff to explain to patient about pressure ulcer
prevention and document that the patient has capacity to
understand advice given.
• All identified pressure ulcers have a clear plan of care that
is regularly evaluated with SMART objectives.
• Patient’s nutritional status and actions are recorded within
care plan.
• Weekly skin and risk assessments to be cross referenced
in the notes and care plans evaluated.
• Ensure that training needs for new staff are identified by
link nurse.
Clinical Research
Our vision is ‘enabling every patient, clinician and public the opportunity to
participate in research’ in our organisation.
We aspire to:
Encourage a culture of research enabling every patient and clinician the
opportunity to participate in research
Be seen as a leader in research in Mental and Physical Health, Learning Disability
and Community Care regionally and at national level
Attract national and regional research funding
Develop the infrastructure to be able to participate in commercial trials in
accordance with national agenda
Embed research and the use of evidence in every day clinical practice
Have the ability to offer research in every service that the Trust offers
Southern Health NHS Foundation Trust was nominated as a finalist for Clinical
Research and Impact at the 2014 Health Service Journal Awards. The Research &
119
Development Department was also nominated for the Trust Star Awards in 2014/15
and has developed a Research App to support access across the organisation.
In 2014/15 we hosted 90 clinical studies. The number of patients receiving relevant
health services provided or sub-contracted by Southern Health NHS Foundation
Trust in 2014/15 that were recruited during that period to participate in research
approved by a research ethics committee was 840.
In May 2014 we opened the Clinical Trial Facility and as a result have continued to
develop and increase the portfolio of the Trust across mental health and integrated
community services in the uptake of clinical trials. This expansion and provision of a
clinical trials facility will further increase the uptake and recruitment into a wider
variety of trials of commercial and non-commercial trials. As well as enabling every
patient, clinician, and member of public an opportunity to participate in research, our
future vision will also be to expand into a fully-fledged Clinical Trials Unit (CTU).
We have held two successful Research Conferences both of which were well
attended and drew a mix of international and national experts. We have collaborated
with Wessex Academic Health Science Network in hosting “A Revolution in
Psychosis Care, what can we learn from the Stroke pathway” in November 2014.
Increasing Patient and Public Involvement in research is central to the Research
Business Strategy. We will continue engaging service users, carers and members of
the public in research and also support the national launch of the Join Dementia
Register campaign in collaboration with Wessex CRN. We have supported the
Memory Assessment and Research Centre (MARC) in the uptake of commercial
trials through increased Pharmacy funding.
Commissioning for Quality and Innovation Framework (CQUIN)
A proportion of Southern Health NHS Foundation Trust income in 2014/15 was
conditional on achieving quality improvement and innovation goals agreed between
Southern Health NHS Foundation Trust and any person or body they entered into a
contract, agreement or arrangement with for the provision of relevant health
services, through the Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2014/15 and for the following 12 month period
are available electronically at: http://www.england.nhs.uk/wpcontent/uploads/2015/02/cquin-15-16-guidance.pdf
In 2014/15 income totalling £5,800,635 was conditional upon Southern Health NHS
Foundation Trust achieving quality improvement and innovation goals. In 2013/14
income totalling £4,917,481 was conditional upon Southern Health NHS Foundation
Trust achieving quality improvement and innovation goals, of which payment of
£4,402,824 were received.
Our CQUIN schemes for 2014/15 are shown below. CQUINs are negotiated and
agreed with commissioners and reflect both national and local quality improvement
ambitions.
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Commissioner
Service
Area
Hampshire
Integrated
Community
Services
Hampshire &
Southampton
Mental
Health &
Learning
Disabilities
Buckinghamshire
Learning
Disabilities
Oxfordshire
Learning
Disabilities
Specialised
Commissioning
Mental
Health &
Learning
Disabilities
Scheme
Available
£
Completion of NHS Patient
Safety Thermometer
National Friends and Family Test
question included in patient
surveys
Processes for admission,
discharge & transfers reviewed
2,719,532
Safeguarding practices
In-reach pilot with acute hospital
Respiratory services
Transformation of services
project
Heart failure consultant
Falls project to review themes
Completion of NHS Patient
Safety Thermometer
National Friends and Family Test
question included in patient
surveys
Creating links between primary
care and secondary care
Dementia awareness training
1,666,832
Cardio metabolic assessment in
schizophrenia
Physical health monitoring
Processes for admission,
discharge & transfers reviewed
Psychiatric liaison with
acute trusts developed
Personalisation of care
for service users
Communication with
primary care developed
79,314
Positive behaviour
approach to care for
service users
Support for annual
health checks
149,291
Increase physical activity
opportunities
Improving care pathways
Enhancing family support
Mother infant relationships
supported in peri-natal services
782,084
Training to improve interaction and
care
Unplanned admissions
Achieved
£*
2,719,532
1,666,832
79,314
149.291
782,084
121
reviewed
Service User involvement in
formulations of need
Specialised
Commissioning
Specialised
Commissioning
Health
Visiting
Oral
Surgery
Total
395,370
395,370
8,212
8,212
5,800,635
5,800,635
*Final payments are still to be agreed with commissioners. These figures therefore
show the totals that have been invoiced.
Care Quality Commission registration and actions
Southern Health NHS Foundation Trust is required to register with the Care Quality
Commission (CQC) and its current registration status is registered in full with no
conditions. Southern Health NHS Foundation Trust has 46 locations registered with
CQC under the Health and Social Care Act (2008).
The Care Quality Commission has not taken enforcement action against Southern
Health NHS Foundation Trust during 2014/15.
Southern Health NHS Foundation Trust has not participated in any special reviews
or investigations by the CQC during the reporting period.
The Care Quality Commission undertook a comprehensive inspection of the Trust
between 6 – 10th October 2014 with their final report published in February 2015.
Further details of this inspection are given in part three of this report.
Prior to the comprehensive inspection in October 2014 the Trust was inspected by
the Care Quality Commission (CQC) against the Essential Standards of Quality and
Safety on 21 occasions. In total 100 standards were inspected across the Trust’s
services. Of these standards:
• 90 were rated as fully compliant;
• 5 identified minor concerns;
• 5 identified moderate concerns, with compliance action taken;
• None identified moderate concerns, with enforcement action taken; and
• None identified major concerns, with enforcement action taken.
• The Trust received no CQC warning notices in the year
Quality of data
Southern Health NHS Foundation 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:
99.9% for admitted patient care;
100.0% for outpatient care; and
98.1% for accident and emergency care.
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-
which included the patient’s valid General Medical Practice Code was:
100.0 % for admitted patient care;
100.0 % for outpatient care; and
99.6 % for accident and emergency care.
Southern Health NHS Foundation Trust Information Governance Assessment Report
overall score for 2014/5 was 82% and was graded green ‘satisfactory’.
Southern Health NHS Foundation Trust was not subject to the Payment by Results
clinical coding audit during 2014/15 by the Audit Commission.
Southern Health NHS Foundation Trust will be taking the following actions to
improve data quality:
Data quality has continued to have a significant focus over the last 12 months
and will continue to be prioritised within the Trust to ensure our reported
performance is of a sufficiently high standard.
A dedicated data quality work programme has supported clinicians to ensure
the data held within our Electronic Patient Record is robust and updated in a
timely manner. Members of the Trust Executive Board have been closely
involved in ensuring that this work programme continues to be delivered.
The Trust ensures that data collected within the Electronic Patient Record is
used to report performance, avoiding the need for manual collection of
performance information.
2.3 Reporting against Core Indicators
Since 2012/13 NHS foundation trusts have been required to report performance
against a core set of indicators relevant to the services they provide using data made
available to the Trust by the Health and Social Care Information Centre (HSCIC).
Where the necessary data is made available by the HSCIC, a comparison should be
made of the numbers, percentages, values, scores or rates of each of the NHS
foundation trust’s indicators with
a) the national average for the same; and
b) those NHS trusts and NHS foundation trusts with the highest and lowest of the
same.
The data is presented in the same way in all quality accounts published in England
so that readers can make a fair comparison between trusts.
Southern Health NHS Foundation Trust is reported and compared as a Mental
Health/Learning Disabilities Trust.
PwC have considered two mandated indicators against Monitor’s requirements, with
their opinion detailed on page 173, as follows:
• Percentage of patients on Care Programme Approach (CPA) who were followed
up within 7 days after discharge from psychiatric in-patient care (mandated).
• Admissions to inpatient services had access to crisis resolution home treatment
teams (mandated).
PwC have also reviewed a further local indicator as follows:
123
•
Number of patient safety incidents reported to the National Reporting and
Learning Service and i) number and ii) percentage of such patient safety
incidents that resulted in severe harm or death.
Definitions for these indicators are included in Annex 4.
Our Patients on a Care Programme Approach who were followed up within 7
days of discharge
The data made available to the National Health Service Trust or NHS foundation
trust by the Health and Social Care Information Centre with regard to the percentage
of patients on Care Programme Approach who were followed up within 7 days after
discharge from psychiatric in-patient care during the reporting period.
The Southern Health NHS Foundation Trust considers that this data is as described
for the following reasons; taken from national dataset using data provided.
The Southern Health NHS Foundation Trust has taken the following actions to
improve the indicator, and so the quality of services, by:
Re-affirmed guidance based on Monitor criteria to clinical services regarding
documentation in the patient electronic record
Clinical services completing regular data quality audits of this indicator to
ensure consistent application of the guidance.
Indicator
Southern Health
Average Trust
Score
Highest Scoring
Trust
Lowest Scoring
Trust
Percentage of patients on Care Programme Approach
(CPA) who were followed up within 7 days after discharge
from psychiatric in-patient care during the reporting period.
Apr 2013- Mar 14
Apr 2014- Mar 15
Q1
Q2
Q3
Q4
97.7 96.6 98.5 97.9
97.5
97.5
97.5
96.7
97.4
97.2
100
100
98.5
100
100
94.1
95.7
80.5
95.1
93.3
Our crisis resolution teams
The data made available to the National Health Service trust or NHS foundation trust
by the Health and Social Care Information Centre with regard to the percentage of
admissions to acute wards for which the Crisis Resolution Home Treatment Team
acted as a gatekeeper during the reporting period.
The Southern Health NHS Foundation Trust considers this data is as described for
the following reasons; taken from national dataset using data provided.
The Southern Health NHS Foundation Trust has taken the following actions to
improve the indicator and so the quality of services, by:
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Providing information by team, service and division to show performance and
identify areas where improvements may be made.
These are further detailed in our performance reports to board.
Indicator
Southern Health
Average Trust
Score
Highest Scoring
Trust
Lowest Scoring
Trust
The percentage of admissions to acute wards for which the
Crisis Resolution Home Treatment Team acted as a
gatekeeper.
Apr 2013- Mar 14
Apr 2014- Mar 15
99.7%
96.1%
Q1
Q2
Q3
Q4
Q1
Q2
Q3
Q4
97.7
98.7
98.3
98.5
100.0 100.0 100.0 100.0
100.0
74.5
92.7
89.8
98.6
95.9
75.2
Our readmission rate for children and adults
The data made available to the National Health Service trust or NHS foundation trust
by the Health and Social Care Information Centre with regard to the percentage of
patients aged(i)
0 to 15; and
(ii)
16 or over
re-admitted to a hospital which forms part of the trust within 28 days of being
discharged from a hospital which forms part of the Trust during the reporting period.
The Southern Health NHS Foundation Trust considers this data is as described for
the following reasons; taken from national dataset using data provided.
The Southern Health NHS Foundation Trust has taken the following actions to
improve the indicator and so the quality of services, by:
Reviewing our discharge procedures and analysing information to identify
areas for improvement with action plans developed as required.
These are further detailed in our performance reports to board.
Indicator
Southern Health
Average Trust
Score
Highest Scoring
Trust
Lowest Scoring
Trust
The percentage of patients aged 0-15 years readmitted to a
hospital which forms part of the Trust within 28 days of being
discharged from a hospital which forms part of the Trust during
the reporting period.
Apr 2012- Mar 13
Apr 2013- Mar 14
Apr 2014- Mar 15
0.0%
0.0%
0.0%
Not applicable as Southern Health NHS Foundation Trust does
not have any 0-15 year readmissions
Not applicable as Southern Health NHS Foundation Trust does
not have any 0-15 year readmissions
Not applicable as Southern Health NHS Foundation Trust does
not have any 0-15 year readmissions
125
Indicator
Southern Health
Average Trust
Score
Highest Scoring
Trust
Lowest Scoring
Trust
The percentage of patients aged 16 or over years readmitted
to a hospital which forms part of the Trust within 28 days of
being discharged from a hospital which forms part of the Trust
during the reporting period.
Apr 2012- Mar 13
Apr 2013- Mar 14
Apr 2014- Mar 15
8.7%
7.4%
7.6%
Not available
Not available
Not available
Patient experience of community mental health services
The data made available to the National Health Service trust or NHS foundation trust
by the Health and Social Care Information Centre with regard to the trust’s ‘Patient
experience of community mental health services’ indicator score with regard to a
patient’s experience of contact with a health or social care worker during the
reporting period.
The Southern Health NHS Foundation Trust considers this data is as described for
the following reasons; taken from national dataset using the data provided.
The Southern Health NHS Foundation Trust has taken the following actions to
improve the indicator and so the quality of services, by:
Analysing results from the patient survey and discussing with service users
and carers improvements to be made.
These are further detailed in divisional action plans and performance reports
to board.
Indicator
Patient experience of contact with a health or social worker*
2012-13
2013-14
2014-15
Southern Health
7.4
6.8
6.8
Average Trust Score
Not available
Highest Scoring Trust
7.8
7.6
7.5
Lowest Scoring Trust
6.5
6.6
6.5
*Data is based on response ‘Overall, I had a very poor/good experience’ in the last
12 months’.
Our rate of patient safety incident reporting
The data made available to the National Health Service trust or NHS foundation trust
by the Health and Social Care Information Centre with regard to the number and,
where available, rate of patient safety incidents reported within the trust during the
reporting period, and the number and percentage of such patent safety incidents that
resulted in severe harm or death.
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The Southern Health NHS Foundation Trust considers this data is as described for
the following reasons; taken from national dataset using data provided. Internal Trust
data which is yet to be shown in national data sets is given in brackets.
The Southern Health NHS Foundation Trust has taken the following actions to
improve the indicator and so the quality of services, by:
Training programmes and information to staff on accurate completion of
incidents including correct categorisation, auditing random samples of
incidents for accuracy and feedback to managers on the timely review of
incidents.
These are further detailed in our incident reports to board.
Indicator
Southern Health
Number of incidents
reported per 1000
bed days
Southern Health
Average Trust
Score
Highest Scoring
Trust
Lowest Scoring
Trust
Number of patient safety incidents reported to the National
Reporting and Learning Service (NRLS)*
Apr 2012- Mar 13
Apr 2013- Mar 14
Apr 2014- Mar 15
5140
8978
12499 (trust data)
Apr 12 –
Sept 12
Oct 12 –
Mar 13
Apr 13 –
Sept 13
Oct 13 –
Mar 14
Apr 14 –
Sept 14
Oct 14 –
Mar 15
11.6
27.3
21.45
42.1
48.38
n/a
23.8
25.3
26.37
33.7
36.9
n/a
~70
~100
~67
91.1
90.4
n/a
~5
~5
~8
8.6
7.25
n/a
The increase in numbers of incidents reported to the NRLS is due to improvements
made in our mapping of incident categories so that an increased number meet the
NRLS categorisation criteria and improvements made in our reporting culture so that
an increased volume of incidents are reported.
Indicator
Southern Health
i) Number and ii) percentage of such patient safety incidents
that resulted in severe harm or death.*
Apr 12 –
Sept 12*
Oct 12 –
Mar 13
Apr 13 –
Sept 13
Oct 13 –
Mar 14
i) 47
ii) 2.0
i) n/a
ii)1.6
n/a
i) 49
ii) 1.7
i) n/a
ii)1.3
n/a
i) 52
ii) 1.5
i) n/a
ii) 1.3
n/a
(i) 11
ii) 0.3
Apr 14 –
Sept 14
Oct 14 –
Mar 15
i)48
n/a
ii)1.1
Average Trust
i)72
i)33
n/a
Score
ii)1.2
Highest Scoring
n/a
i)87
n/a
Trust
ii)3.4
Lowest Scoring
n/a
n/a
n/a
n/a
i)0
n/a
Trust
ii)0
*Incidents continue to be reported and to be uploaded to the NRLS after the cut-off
date for publication of benchmarking data. Figures are therefore updated over time
and so are different to those reported in the 2013/14 Quality Report.
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Friends and Family Test
It is not mandatory to report on results of the Friends and Family Test, however
Southern Health NHS Foundation Trust currently provides all physical health
community patients with the option of completing a Friends and Family survey and
from early 2015 has introduced the ‘Friends and Family’ question on surveys offered
to patients seen by our mental health and learning disabilities services.
Indicator
Southern Health
Average Trust Score
Highest Scoring Trust
Lowest Scoring Trust
The percentage of patients during the reporting period
who would recommend the Trust as a provider of care
to their family or friends.
Apr 2013- Mar 14
Apr 2014- Mar 15
96.2%
96.5%
Not available
It is not mandatory to report on percentage of staff who would recommend the Trust
as a provider of care to their friends and family; however Southern Health NHS
Foundation Trust collects this information which is shown below.
Indicator
Southern Health
Average Trust Score
Highest Scoring Trust
Lowest Scoring Trust
The percentage of staff employed by, or under contract
to, the Trust during the reporting period who would
recommend the Trust as a provider of care to their family
or friends.
Apr 2012- Mar 13 Apr 2013- Mar 14 Apr 2014- Mar 15
62%
61%
64%
60%
59%
60%
Not available
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Part 3: Other Information
Progress made in meeting our priorities for improvement in 2014/15
In the 2013/14 Quality Report we set out specific areas for improvement based on
the three dimensions of quality identified by Lord Darzi and chosen following
feedback from our patients, stakeholders and staff. As in previous years, we set
ourselves challenging and aspirational targets to support these quality ambitions:
Improving patient safety
Improving clinical outcomes
Improving patient experience
These priorities for improvement are representative of the on-going work we do to
continually improve the quality of care we provide. There are many other areas of
quality improvement across the Trust – these priorities are just a selection. We have
monitored and reported to the Board our performance against these priorities
throughout the year.
Priority 1: Improving Patient Safety
1.1 Reduce the number of pressure ulcers
Target: reduce average numbers of avoidable grade 3 and 4 pressure
ulcers
Aim
Pressure ulcers are wounds that develop when constant pressure or friction on one
area of the body damages the skin. They can be painful and lead to an increased
risk of infection for a patient. Pressure ulcers are graded using the European
Pressure Ulcer Advisory Panel guidelines with grades 1(least serious) to 4 (most
serious). Pressure ulcers are also described as ‘avoidable’ or ‘unavoidable’ reflecting
that sometimes very sick patients develop pressure ulcers even though all
appropriate care has been given. The number of patients who develop pressure
ulcers while in our community hospitals remains very low, while numbers have
fluctuated for patients cared for by our community teams. We want to see a
consistent reduction in avoidable pressure ulcers across all of the Trust and ensure
patients are safe in our care. We therefore repeated a similar indicator from last
year.
In previous years there were the following numbers of avoidable grade 3 and 4
pressure ulcers: 2011/12 149; 2012/13 166; 2013/14 139. National
benchmarking data is not available.
What we have achieved
We have achieved this target with fewer reported avoidable grade 3 and 4 pressure
ulcers this year. In September 2014 we agreed with our commissioners that we were
often reporting pressure ulcers where we were not the primary care giver, for
example, someone may be living in a nursing home or have care provided by carers
129
several times a day, thereby inflating the numbers attributed to the Trust. We have
agreed that we will no longer report those pressure ulcers where we are not the
primary care giver which will over time reduce our reported numbers of avoidable
pressure ulcers. We will continue to provide support and training to other agencies in
the prevention and management of pressure ulcers.
Statistical Process Control (SPC) Graph: Numbers of
avoidable grade 3 and 4 pressure ulcers
02/04
09/04
16/04
23/04
30/04
07/05
14/05
21/05
28/05
04/06
11/06
18/06
25/06
02/07
09/07
16/07
23/07
30/07
06/08
13/08
20/08
27/08
03/09
10/09
17/09
24/09
01/10
08/10
15/10
22/10
29/10
05/11
12/11
19/11
26/11
03/12
10/12
17/12
24/12
31/12
07/01
14/01
21/01
28/01
04/02
11/02
18/02
25/02
04/03
11/03
18/03
25/03
10
8
6
4
2
0
Data Source: Safeguard Ulysses Incident Reporting System
Number of pressure ulcers - SIRI data
Mean
Lower control limit
Upper control limit
What we did in 2014/15 and future plans
We have continued our Trust wide action plan to reduce pressure ulcers which
includes analysis of numbers and themes and shares good practice. A small
number of teams have been identified as consistently having high numbers and
will have intensive support to improve performance.
We have agreed with our commissioners to only report those pressure ulcers
where we are the primary care giver. This will reduce reported numbers over time
and give a more accurate picture of performance.
We have introduced a new procedure to review all pressure ulcers by a pre-panel
to confirm accuracy of reporting with learning shared with teams.
Training is provided by the tissue viability team to all relevant staff including
primary care and residential home staff. They have extended to five days a week
a very successful telephone support line to give advice and guidance.
We continue to be part of the NHS England Pressure Ulcer Strategy Group which
provides opportunities to share learning across the region based on evidence
based practice.
We are keen to benchmark ourselves against other trusts, and in the absence of
national benchmarking data, have made a freedom of information request for
pressure ulcer data across the UK.
130
We are repeating a similar indicator for 2015/16 with specific focus on intensive
improvement plans in teams which have the highest numbers of pressure ulcers.
1.2 To improve the management of incidents of violence and aggression
Target: a) reduce prone restraint by 20% from 2013/14
b) reduce use of seclusion by 20% from 2013/14
Aim
We want to improve the management of incidents of violence and aggression so that
patients are cared for in safe environments which use least restrictive interventions.
We know patients experiencing mental health distress can sometimes express this
through violent or aggressive behaviour. We aim to work with them to manage their
distress and avoid violent and aggressive behaviour whenever possible. If it occurs
we want to address it in a way that is safe for all concerned, and maintains the
dignity and respect for the individual, and minimises the use of coercion, including
restraint and seclusion.
This builds on the indicator in 2013/14 to reduce incidents of violence and
aggression, as defined by the National Reporting and Learning System. Historical
data is shown on pages 102-106. National benchmarking data is not available.
What we have achieved
We have partially achieved this target with over 10% reduction in incidents of prone
restraint compared to 2013/14. It is particularly pleasing to see a sustained reduction
in the past 7 months. We have a proactive response to the objectives outlined by the
Department of Health in their publication ‘Positive and Proactive: Reducing the need
for Restrictive Interventions’ (April 2014)
Incidents of prone restraint in 2014/15
140
120
100
80
60
40
20
0
Data Source: Ulysses Safeguard incident reporting system
Definition:National Reporting and Learning System
Number of incidents
2014/2015 monthly target
131
Incidents of use of seclusion 2014/15
100
80
60
40
20
0
Data Source: Ulysses Safeguard incident reporting system
Definition: National Reporting and Learning System
Number of incidents
2014/2015 monthly target
What we did in 2014/15 and future plans
We have a SAFER annual plan which includes a programme of work to meet the
recommendations in the Department of Health Guidance ‘Positive and Proactive
Care: Reducing the need for Restrictive Interventions’.
In July 2014 we launched the ‘Safewards’ initiative and are now implementing
evidence based interventions aimed at reducing incidents that require restraint.
We have reviewed our policies and practices relating to restraint and seclusion
with a stronger emphasis and clear guidance on minimising the use of prone
restraint and reducing the use of seclusion in response to episodes of violence.
We introduced a framework for Positive Behavioural Support and are using
Behavioural Support Plans which focus specific care and support to address
challenging, violent or aggressive behaviour.
We have recently employed and trained peer support workers which research has
shown helps reduce incidents of violence and aggression.
We will continue to focus on minimising the use of restraint and seclusion in our
inpatient areas and have included in our priorities for 2015/16.
1.3 Improve medicines reviews for people
Target: 80% of inpatients have their medicines reviewed by the
pharmacy team within 48 hours of admission
Aim
Patients are often taking medicines before being admitted to our inpatient units or
hospitals and then may be prescribed more medicines. The National Institute for
Health and Clinical Guidance (NICE) found medication errors most commonly
132
occurred at the time of admission. We aim to review the medicines patients are
taking when admitted to our inpatient units to ensure safe care and reduce any
potential harm to the person from taking the wrong medicines.
We did not consistently meet our target across all inpatient sites in 2013/14 and
therefore repeated a similar indicator for this year. In 2013/14 37% of medicine
reviews were completed within 48 hours. National benchmarking data is not
available.
The definition for medicine reviews (reconciliations) is taken from NICE guidelines &
National Patient Safety Agency 2007, available at
www.nice.org.uk/nicemedia/pdf/PSG001GuidanceWord.doc.
What we have achieved
We have not achieved this target; however there has been a marked increase in
percentage of medicine reviews being completed from October 2014 reflecting
additional staffing and the resolution of web based reporting system difficulties.
Medicine reconciliations completed by pharmacy team
within 48 hours of admission
100%
80%
60%
40%
20%
0%
Data Source: Ulysses Safeguard incident reporting system
Definition: National Reporting and Learning System
% completion rate
2014/2015 target
What we did in 2014/15 and future plans
Additional funding agreed in early 2014 for the medicines management team has
increased staffing capacity with 2 new pharmacists and additional locum cover
starting in October.
A Trust wide plan detailing the actions required to meet the medicines
reconciliation target has been shared widely. It includes a proposed review of
current targets, recognising that existing guidance is aimed more at acute trusts
and was therefore a challenge for a community Trust.
Medicine reconciliation performance is reviewed at the Medicine Safety meeting
with pharmacy leads responsible for taking action in their own areas to address
any performance issues.
133
The web based reporting system introduced in July 2013 has been simplified and
re-launched making data collection easier.
We are continuing to have a medicines management indicator in 2015/16 but are
going to focus on ensuring inpatients receive all their critical medicines.
Priority 2: Improving Clinical Outcomes
2.1 Holistic Care Planning for People
Target: a) 95% patients have a completed Intermediate Assessment
b) 95% patients have a care plan that has patient identified
goals
c) 100% patients have a care plan that is SMART
Aim
A first step in our care of patients is to assess all their needs and to work with them
and their carers to develop a plan of care that is centred on these needs and
includes goals important to them. Effective care planning leads to better clinical
outcomes and a better experience for patients and so we want to ensure we have an
effective care planning process in place across our services.
This was a new indicator for 2014/15. Holistic assessment looks at all a patient’s
needs, both physical and mental health; with a care plan developed based on the
assessment results that is SMART (specific, measurable, achievable, realistic, time
bound). Historical and national benchmarking data is not available.
What we have achieved
We carried out clinical audits across our physical health services on two separate
occasions during the year. The questions below were included in the audit tool. We
have not achieved this target. The initial clinical audit of community services in July
2014 gave baseline figures. The second audit in February/March 2015 shows clear
improvements have been made in all areas; however these did not meet the set
targets:
Initial Audit
Second Audit
Indicator
Target
Score
Target
Score
Patients have a completed Intermediate
Assessment
80%
58%
95%
74%
Patients will have a care plan that has patient
identified goals
70%
49%
95%
71%
Patients will have a care plan that is SMART
70%
76%
100%
83%
134
What we did in 2014/15 and future plans
We shared the results of the initial audit with teams and discussed actions
required to lead to improved practice including developing skills in completing
SMART care plans and in supporting patients to identify their own goals.
A care planning group has led on the development and piloting of a revised
patient centred care plan in collaboration with patients and carers and which is
being rolled out across services.
We are in discussions with colleagues from other agencies, including Hampshire
County Council, primary care and social care, to agree an integrated health and
social care plan approach across organisations. This will benefit patients as there
will be shared communication and understanding of current care goals.
We are reviewing the assessment forms on our electronic patient record system to
ensure they include all appropriate information with clear guidance developed for
staff on completion of the forms.
We will repeat a similar indicator for 2015/16 focusing on developing a care
planning framework that is patient led.
2.2 Learning from information about quality of care
Target: a) reduce average numbers of avoidable pressure ulcers
b) 10% reduction from 2013/14 in number of complaints
mentioning care planning
Aim
We want to be an organisation which recognises the importance of learning from
information we have about quality of care. Identifying and acting on key themes
where we could do better, with changes leading to improvements in quality of care.
This was a new indicator for 2014/15. Historical data is available on pages 102-106.
There is no national benchmarking.
What we have achieved
We have achieved this target with a) reduction in avoidable grade 3 and 4 pressure
ulcers and b) no complaints in 2014/15 that mention care planning issues.
What we did in 2014/15 and future plans
We have developed our organisational learning web pages as a way of sharing
learning and good practice to all staff. These include patient stories, case studies,
and examples of good practice and learning from serious incidents.
The first Trust Quality Conference took place in December with a focus on sharing
learning across services with presentations, external speakers, posters and a
patient describing his experiences of our service. This has become a regular 3
monthly event to support organisational learning and networking.
135
Patient stories are now presented and discussed at our Trust Committees,
Divisional Governance meetings and team meetings to provide opportunities to
share learning leading to changes in practice.
We have developed our ‘triangulation’ approach to data analysis which includes
the introduction of a resource pack to support teams to review a range of quality
based data as part of quality improvement planning. This approach has been
integrated into our leadership programmes.
We will continue to implement our organisational learning strategy through the
next two years, but will not include this as a specific indicator for 2015/16.
2.3 Learning from deaths
Target: a) the Trust is not an outlier when benchmarked to the
National Confidential Inquiry into Suicide and Homicide
b) train 100 staff in our suicide mitigation programme
c) there are no deaths in our physical health services where
our care was a causal factor
Aim
Sadly, some of the patients cared for in our community hospitals die and a small
number of patients supported by our mental health services die by suicide. While the
numbers are small, it is a priority for us to ensure that we learn from each incident,
and take action to ensure that the learning is shared across our services, and that it
results in improvements in the quality of care.
This was a new indicator for 2014/15. Historical data is given on pages 102-106. The
National Confidential Inquiry (NCI) into Suicide and Homicide for People with Mental
Illness provides national benchmarking data with the National Reporting and
Learning System defining what an unexpected death is.
What we have achieved
We have achieved this target:
a) current numbers of reported deaths by suicide are consistent with available
National Confidential Inquiry data for 2013/14 per size of population (with 2014/15
data not available until 2015/16).
b) we have trained over 100 staff in our suicide awareness and mitigation
programme, ‘Connecting with People’.
c) we have investigated all unexpected deaths in our physical health services as
serious incidents and although we have identified learning from the investigations,
we have not found any incidents where our care was a causal factor.
136
What we did in 2014/15 and future plans
All unexpected deaths are reported by staff on the Ulysses reporting system and
investigated by a senior manager who looks at the underlying causes and
contributory factors and makes recommendations for actions and learning.
We recognised that we could further enhance our learning from reviewing all
deaths within physical health inpatient services and have developed a tool which
is being piloted at Lymington New Forest Hospital during February– May 2015
prior to any potential implementation across all other Community Hospitals. The
tool enables consultants to complete an assessment of death with a series of
question answered, for example, are there any learning points?
Learning is shared across services with key themes highlighted in ‘hotspots
posters’, learning forums and team meetings to ensure we use this information to
improve care.
We implemented an evidence based suicide mitigation programme, ‘Connecting
with People’, to raise staff awareness and further develop skills to support patients
seen by our mental health services.
We will continue to investigate all unexpected deaths and to pilot the new mortality
tool in physical health inpatient services but will not include as a specific indicator
for 2015/16.
Priority 3: Improving Patient Experience
3.1 Improve the experience people have of our services
Target: 95% (75% mental health services) positive responses on
patient experience surveys – ‘How likely are you to
recommend the Trust to family and friends if they needed
similar care or treatment?’
Aim
We believe patients should be at the heart of everything we do and should drive the
design and delivery of care we provide. We want to listen to patients and use their
feedback to identify and implement service improvements so that we are continually
improving the experience people have of our services.
The Friends and Family Test (FFT) was introduced as part of NHS England’s
2013/2016 Business Plan Putting Patients First, with a standard question being
asked of patients with the aim of improved patient experience:
“How likely are you to recommend our [service] to friends and family if they needed
similar care or treatment?”
The FFT has been rolled out across the NHS with mental health services being
included from January 2015. We have now included this question in all our patient
137
experience surveys. (Previously we had asked patients seen in our mental health
services ‘How they would rate the Trust overall?). Historical data is shown in the
performance tables on pages 102-106. National benchmarking data is available and
is shown in our patient experience reports.
What we have achieved
We have achieved this target with 97.1% of patients responding positively in our
patient experience surveys in non –mental health services and 92.9% of patients in
our mental health services. Different targets are set internally for mental health
services to take into account the different nature of their caseload.
How likely are you to recommend the Trust to Family and
Friends? (excluding Mental Health Services)
100%
90%
80%
70%
60%
50%
Data Source: Patient Experience Survey
Percentage compliance
2014/2015 monthly target
How would you rate your service overall/How likely are
you to recommend the Trust to Family and Friends?
(Mental Health Services)
100%
90%
80%
70%
60%
50%
Data Source: Patient Experience Survey
Percentage compliance
2014/2015 monthly target
What we did in 2014/15 and future plans
We review patient’s feedback within team, service and divisional meetings and
take action to address issues raised, for example, we changed appointment letters
within Health Visiting Services to include fathers.
138
We are publishing ‘You said, We did’ examples on our website of changes made
following feedback so it is easy to see that actions are taken.
We are exploring new ways of gathering patient feedback with possible use of
ipads and trained peer volunteers in mental health services.
We have implemented actions to increase the numbers of surveys returned.
We will continue to seek patient’s feedback so we can improve their experience of
our services and in 2015/16 will focus on including patients in the redesign of
services.
3.2 Support carer involvement and listen to their feedback
Target: 85% positive responses to key questions on carers survey
Aim
We recognise that carers often provide key support to patients, helping to improve or
maintain a patient’s health and well-being. Our patient experience surveys in
2013/14 continued to show lower positive responses to our support for carers than
other survey questions. We therefore introduced a specific carer’s survey in 2014 to
gain feedback as to how we could improve our services.
This was a new indicator for 2014/15. There is no available historical, national
benchmarking or standard definition data.
What we have achieved
We have achieved this target with positive responses consistently over 85% to key
questions on the carer’s survey.
When I am in contact with your services and/or staff I feel
welcome
100%
90%
80%
70%
60%
50%
Data Source: Carer Experience Survey
Percentage Positive Responses
Target
139
Staff recognise me as a carer of the person who will be
using the service
100%
90%
80%
70%
60%
50%
Data Source: Carer Experience Survey
Percentage Positive Responses
Target
How likely would you be to recommend this service to
friends or family, if they needed similar care or treatment
100%
90%
80%
70%
60%
50%
Data Source: Carer Experience Survey
Percentage Positive Responses
Target
What we did in 2014/15 and future plans
A specific carer’s survey was launched in early 2014 with roll out across all
services during the year. Responses are overwhelmingly positive, however the
number of returned surveys remains low and divisions are considering how best to
facilitate increase in responses received.
Themes from survey results are discussed at team and divisional meetings with
actions implemented to improve services based on the feedback.
The survey is only one way to gain feedback; we are continually listening to and
involving carer’s, for example, including them in planning the care for their relative
so that we are choosing goals that are important to the patient and their carer’s
and are designing services to meet their needs.
140
We involve carers in planning for the discharge of their relative from inpatient
settings so that the most appropriate care is available for the patient when they
leave.
We have carer forums, drop in meetings and open days where advice and
information is available with signposting to local voluntary support groups and
national helplines.
We will continue to listen and involve carers and have included them in indicators
focusing on co-design of pathways in 2015/16.
3.3 Use feedback from complaints to improve our service
Target: 100% of complainants wishing to be contacted receive
feedback at 6 months.
Aim
We want to be an organisation which listens to patients and their families and acts
when they say we have not got things right. We will use this feedback to identify and
implement service improvements so that we are continually improving the
experience people have of our services.
This was a new indicator for 2014/15 and reflects recommendations from national
reviews such as the Francis report: ‘Putting Patients First and Foremost’ (March
2013) and Clywd-Hart report: ‘Review of the NHS Hospitals Complaints System:
Putting Patients back in the Picture’ (October 2013). These recommend it is good
practice to let complainants know it was worth telling us about their experience and
that we have taken actions as a result of their feedback. There is no available
historical or benchmarking data.
What we have achieved
We asked complainants if they would like to receive an ‘action learning’ letter six
months after the resolution of their complaint to show that actions had indeed been
taken. Progress with these requests was tracked via our reporting system, Ulysses
Safeguard.
We have achieved this target with all complainants, who wished to be contacted,
receiving feedback about actions taken following their complaint.
Total complaints since
April 2014
Number of
complainants wishing
‘action learning’ letters
Number of ‘action
learning’ letters sent
453
48
48
What we did in 2014/15 and future plans
From April 2014 we have piloted a new process whereby complainants are asked
if they would like to receive an ‘action learning’ letter summarising actions taken
following their feedback.
141
Initial findings show fewer than anticipated complainants request an ‘action
learning’ letter at 6 months following their complaint. A potential reason may be
that actions have already been completed, for example, appointment times rearranged and included in the original response letter.
The pilot is currently being evaluated and will make recommendations for future
feedback processes to complainants.
Themes from complaints are shared widely to enable learning across services
with improvements in practice made.
We will continue to listen to patients and their families so that we can improve
their experience of our services and have included a similar indicator for 2015/16.
Performance against key national priorities
The dashboard below shows the access to care and outcome standards set by
Monitor for 2014/15 and shows the Trust was compliant with 13 of the 14 Monitor
non-financial indicators by year end. 10 of these indicators were met throughout the
whole year with four indicators (percentage of mental health patients receiving a 7
day follow up, percentage gatekeeping compliance for inpatient admissions, EIP
new referrals, access to care:18 week wait) showing inconsistent achievement
across the year. Focused work within clinical services is being completed in order to
meet these standards.
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Trust performance dashboards
Improving patient and user experience : Achieving Monitor access to care and outcome standards
Version 1.1
Southern Health NHS Foundation Trust is committed to providing performance reporting that is based upon accurate and reliable information. For more information on how NHS Trusts are statutorily required to not provide false and misleading information please view
https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/305814/140422_FOMI_ConDoc.pdf
###
###
###
###
###
###
5
###
###
###
###
###
3
1
0%
% Mental Health patients receiving a 7 day
follow up *
90%
95%
100%
% Mental Health patients receiving a 12
month review *
80%
90%
100%
% gatekeeping compliance for inpatient
admissions *
80%
90%
100%
EIP new referrals (reported as year to
date) *
80%
180%
280%
Mental Health Minimum Data Set Identifiers *
96%
98%
100%
Mental Health Minimum Data Set Outcomes *
50%
75%
100%
5%
10%
15%
Data
Quality
Average
Average
Access to Care : Learning Disabilities
Not applicable
n/a
Access to Care : Admitted 18 week
#
wait
50%
75%
100%
Access to Care : Non admitted 18 week
wait #
60%
80%
100%
Access to Care : Incomplete pathways
within 18 weeks #
50%
75%
100%
A&E attendances completed within 4
hours #
60%
80%
100%
97.0%
95.0%
99.5%
97.0%
60.0%
Good
Good
50.0%
60.0%
50.0%
4
n/a
Green
n/a
92.0%
Good
90.0%
97.0%
Good
95.0%
94.0%
Good
92.0%
97.0%
Good

95.0%
97.0%
Good
Not applicable
97.0%
95.0%
Good
Infection Control (C Difficile reported year
to date)
7.5%
95.0%
Good
Good
5.0%
97.0%
Poor
Awaiting national
data
Community Data Set compliance *
Target /
Tolerance
95%


Last 12
months
Current
quarter
Last month
(or YTD)
1.4%
1.6%
1.5%

97.5%
98.2%
97.6%

100%
95%
90%
85%
98.4%
98.0%
97.8%

100%
95%
90%
96.1%
97.6%
100.0%

100%
95%
90%
90.4%
65.1%
90.4%

200%
100%
0%
99.8%
99.9%
99.9%

100%
99%
98%
86.5%
87.3%
86.4%

100%
80%
60%
98.5%
98.1%
98.0%

100%
90%
80%
n/a
n/a
3
n/a
G
G
G

95.5%
96.9%
96.2%

100%
90%
80%
98.9%
99.1%
99.4%

100%
97%
94%
98.4%
98.5%
97.9%

100%
97%
94%
98.9%
99.4%
99.7%

100%
97%
94%
National average

Trust performance
Range of performance across all Trusts
Achieving internal Monitor stretch compliance
Apr 14
5.0%
2.5%
0.0%
1 standard deviation from the national average
Achieving Monitor compliance
###
Monthly Performance for the last 12 months
3 month
Trend
Rating
% Mental Health patients experiencing a
delayed transfer of care *
Benchmark
chart
Achieving Monitor access to care and outcome standards
National
benchmarking
May 14
Jun 14
Jul 14
Aug 14
Sep 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Mar 15
6
4
2
0
* National benchmarking data is based upon Quarter 4 2013/2014 data provided by Monitor for Mental Health
Foundation Trust Risk Assessment Framework submissions
# National benchmarking data is based upon the latest (approximately 1 month in arrears) published HSCIC Unify 2
submissions
Failing monitor compliance
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Board Leadership, assurance and governance
The Board’s vision for quality is aligned with the Trust’s strategic vision, core values and
business strategy, all of which will be summarised in our operational plan for 2015/16
due to be submitted to Monitor this year.
The Trust Board has been strengthened with the appointment of new non-executive
directors and a number of new executive directors with clear lines of accountability and
responsibility established. Non-executive directors take an active and challenging role at
the Board and board committees. CQC found strong and committed leadership from the
Board, the executive team and senior managers, although recognised that several of
the executive and senior leadership team were relatively new in post and were still
establishing their role.
In January 2014 Deloitte undertook a review of governance arrangements on behalf of
the Trust, finding many positives and areas of good practice but also areas where
improvements could be made. Key recommendations included:
• Strengthening Board oversight and control during transformation to greater
divisional autonomy
• Implementation of the Quality Governance Strategy and associated actions
• Developing and embedding governance frameworks within divisions
• Updating Risk Management Strategy and Policy and strengthening processes for
risk register oversight
The Board accepted the Deloitte findings and recommendations and approved the
management response and action plans at the Board in March 2014. As a result,
several changes have been made to the Trust governance framework to strengthen its
arrangements to maintain the oversight needed. Many of these changes are at an early
stage of implementation, including the introduction of a new board assurance framework
(BAF) agreed at the board meeting in September 2014.
At each board meeting, directors review measures which indicate how the organisation
is performing in relation to quality, safety, clinical performance, finance and workforce,
taking action to address areas where required standards are not being met. The Trust
has introduced an information system which provides high quality performance data to
allow the Board to monitor performance. The Trust also has systems in place to report
and monitor incidents, complaints and risks ensuring the Board has a detailed
understanding of key risks in all areas.
In their Inspection Report February 2015, CQC ‘recognised there were many
challenges facing the trust in developing the right culture and managing a large change
programme but that the trust had made significant progress in developing services and
bringing about improvements and that given time, the provider would realise its vision
and deliver good and outstanding services across the trust’.
Risk Management Development Programme
The Risk Management Development Programme was initiated in response to Deloitte
recommendations and internal audit findings with support for the programme contracted
from Baker Tilly who has worked with the Board and divisions since January 2014. The
programme has been overseen by a programme board chaired by executive director
and reporting progress to the Audit, Assurance and Risk Committee. The Trust has
successfully addressed the majority of recommendations made by Deloitte and internal
144
audit and since June 2014 has introduced a number of changes to its leadership and
governance structures and processes. Key outputs include:
 Increased capacity and intensity of focus within the executive team in relation to
risk management
 Clarifying how risks are identified, managed and escalated in each division with
clear framework for review and discussions of risk registers
 Identification and agreement of the strategic risks to the delivery of the Trust’s
principle objectives and the risks the Board wishes to monitor through the
Assurance framework in 2014/15
 Approved Trust risk appetite statement, tolerance thresholds and risk monitoring
arrangements
 Defining assurance processes divisions should follow in judging effectiveness of
controls
This resulted in the Trust being in a strong position to deliver the remaining risk
management work programme in house by including activities as part of normal
operational business monitored by the Trust Executive Group. This included:
 Revised Risk Management Strategy/Policy and tools
 Divisional and corporate services risk management workshops
 Enhanced risk management training through e-learning and user guides
Care Quality Commission (CQC) inspection October 2014
In October 2014 the Trust welcomed 115 inspectors to its sites as part of the new
comprehensive inspection regime introduced by the Care Quality Commission (CQC).
Whilst the new regime had been piloted by the CQC over several months in 2013/2014,
the Trust was one of the first to be formally inspected using this new methodology.
The inspection covered all of the Trust’s services apart from its social care division as
the new CQC regime has not yet been rolled out to include these types of services.
Instead, 15 separate inspections of social care services provided by the Trust were
carried out by the CQC in the three months prior to the comprehensive inspection.
These were done in accordance with the old methodology and reported on separately.
Prior to the comprehensive inspection week which took place from 6-10th October 2014,
the Trust provided CQC with considerable documentation including organisational
structures, staff data, activity data, governance data, policies, risk registers and much
more. This, together with information gained from other sources, allowed CQC to create
a profile of the Trust prior to their visit.
The team of 115 inspectors was comprised of full time CQC inspectors, clinicians from
services similar to those provided by the Trust and ‘experts by experience’. They visited
over 100 different teams and held over 40 focus groups and interviews. In addition, they
received feedback from hundreds of patients and carers in a variety of different ways.
They returned for some unannounced visits in the weeks following the inspection.
The teams that were inspected were grouped into 17 service lines with 14 of these
constituting ‘core services’ for the purposes of rating aggregation. These service lines,
together with the individual ratings for the domains of safe, caring, effective, responsive
and well-led can be found in the diagram below.
145
70% of the individual ratings were ‘good’ (green) or better, with Perinatal services being
rated as ‘outstanding’. This led to an overarching Trust rating of ‘good’ for both the
caring and responsive domains.
There were a number of areas identified as ‘requiring improvement’ (amber) and this led
to a Trust rating of ‘requires improvement’ overall.
Among the positive findings, CQC found the Trust to have:
• A clear vision, clear set of values, clear strategy, good senior leadership and
commitment
• Kind, caring, passionate staff who treated people with dignity and respect and
want to deliver good quality care
• Effective, evidence-based care with a valued research programme
• A strong recovery focus in mental health services
• A collaborative and inclusive peer review programme
• Innovative working in non-traditional settings
• Strong leadership & development programmes which were delivering benefits
and endorsed by staff
Among the areas identified for improvement were the following:
• Management of ligatures, restraint and seclusion
• Suitability of Ravenswood House as a medium secure forensic unit
• Community staffing levels
• Medicines management
• Mental health crisis care and use of out of area beds
• Information systems
• Timeliness of equipment provision
It was reassuring to the Trust and its commissioners that the majority of the areas
identified for improvement were already known about and had plans in place for
improvement. A significant number of these had been implemented between the time of
the inspection and the receipt of the reports. Existing action plans have been reviewed
146
further to the inspection reports being received and a comprehensive plan of action has
been put into place to drive forward the required improvements.
The Trust will drive delivery of these improvements through its Quality Programme
which is led by the Medical Director (Quality) and reports into the Quality & Safety
Committee (Board sub-committee). All action plans have been agreed with
commissioners and the peer review programme (which includes external stakeholders)
will be used as one of the methods of validation.
The Quality Programme has eight work streams, each led by an Executive Director:
Governance; Patient Safety, Reporting & Learning; Peer Review & CQC Compliance;
Estates & Infrastructures; Recordkeeping & Care Planning; Workforce; Patient
Experience & Engagement; and Medicines Management.
Learning Disability Services
In our 2013/14 Quality Report we described concerns about quality of care in our
Learning Disabilities services in the former Oxfordshire Learning Disability Trust
following CQC inspections. This, together with the review of our governance structures,
led to Monitor, the health service regulator, issuing the Trust with enforcement actions in
April 2014 to improve the quality aspect of services by:
• Delivering quality improvement plans across our learning disability services
• Implementing and delivering on action plans to address the CQC warning notices
applied to a small minority of our services
• Delivery of improvement of our quality governance strategy and Board
governance.
Successful actions to address the CQC warning notices and to improve governance
structures have already been covered. MBI Health was contracted to work with the
Learning Disability Management team to review the model of care and implement a
comprehensive plan of actions that was monitored by a Project Board led by one of the
executive directors. NHS England, Thames Valley led a Quality Assurance Committee
to oversee the improvement plan for the Learning Disability Services and have
recommended in April 2015 that this Committee is stood down and that there is a return
to a ‘business as usual’ approach. This does not mean that we will cease to focus on
continually improving quality of services. A review of Learning Disability services by
Professor Mike Kerr found evidence of world class services now being provided.
Sign up to Safety
Southern Health is delighted to be taking part in the national ‘Sign up to Safety: Listen
Learn Act’ programme designed to help realise the ambition of making the NHS the
safest healthcare system in the world by creating a system devoted to continuous
learning and improvement. We need to give patients confidence that we are doing all
we can to ensure that the care they receive will be safe and effective at all times. We
are developing our three year plan which is built around five core pledges and describes
what the Trust will do to reduce harm and save lives by working to reduce the causes of
harm and take a preventative approach. The five core pledges are:
 we will put safety first (reduce pressure ulcers, assess and treat venous
thromboembolism, make sure patients receive all their medicines, monitor
physical health)
147
 we will continually learn ( improve action plans and learning, quarterly quality
conferences, establish clinical effectiveness group, involve patients in developing
services)
 we will be transparent (say sorry when things have gone wrong, involve patients
and families in investigations of serious incidents, share ’could it happen here?’
stories)
 will collaborate (listen to our patients and their carers and change practice,
involve patients in co-designing clinical pathways)
 we will support (support teams to understand and learn from quality information,
‘speak out’ service to highlight safety issues)
In signing up, we commit to strengthening our patient safety by:
• describing the actions we will undertake in response to the five campaign
pledges
• committing to turning these actions into a safety improvement plan which will
show how our organisation intends to save lives and reduce harm for patients
over the next three years
• identify the patient safety improvement areas we will focus on within the safety
plans
• engage our local community, patients and staff to ensure that the focus of our
plan reflects what is important to our community
• make public our plan and update regularly on our progress against it
Organisational Learning
We recognise the importance of organisational learning in developing safe, effective
services and the sharing of good practice. The Organisational Learning strategy was
launched in 2014 across the Trust. The implementation plan takes account of national
best practice recommendations with implementation actions developed following
consultation with divisional leads and clinical leads Trust-wide, and agreed in May 2014.
Its implementation Trust wide, is supported through the Quality Programme work
streams which integrate a number of elements of the plan.
We have developed a programme of work to ensure we learn from all available
information and feedback about our services, including complaints, incidents, clinical
audits, CQC and peer review inspections and performance indicators. These have
influenced the selection of some of our quality indicators for 2014/15. Information is
triangulated from a wide range of indicators, to identify themes where action may be
needed or good practice shared across the Trust in Trust-wide and divisional reviews.
Quality Governance Strategy
Our Quality Governance Strategy has been in place since September 2013. This
document supports the Trust’s overall aim of providing high quality and safe care, and
sets out a number of patient-centred quality improvement goals for the Trust.
At its centre is the promotion of a culture of continuous improvement where every
member of staff has the pride, compassion, confidence and skills to champion the
delivery of safe and effective care. The Quality Governance Strategy delivery objectives
are based on the continuous improvement principles described in the organisational
learning strategy. They are integrated into the Trust Quality Programme work streams,
and overseen monthly by the quality improvement and development forum.
148
The aims of the Quality Governance Strategy are to: Support the development of a culture of continuous improvement which results in
higher satisfaction and experience for patients, carers and their families
 Engage every member of staff because they all must contribute to a quality
experience and continuous improvement
 Set goals and priorities for improvement based on the NHS definition of quality
 Set out our approach to quality improvement which is based on evidence of what
works in world class organisations
 Set out how we will measure and publish our progress
To achieve this we have set ourselves four quality goals for the next three years.
Workforce
The Trust’s Workforce Performance Suite was introduced in April 2014 to show
performance in relation to three key areas – Competent Workforce, Available Workforce
and Stable Workforce:
Competent Workforce
Participation in the appraisal process has been extremely positive in 2014/15, with 95%
of the workforce having met with their manager to review performance with reference
both to delivery of the role requirements and behavioural competencies, set objectives
for the year and agree a personal development plan. Notable improvements have also
been made in relation to statutory and mandatory training compliance throughout the
financial year
149
Available Workforce
The level of vacancies continued to fall throughout the year as a result of the ongoing
focus on addressing recruitment challenges both within divisions and through the
Trust’s Workforce Resourcing Forum. The rate of sickness absence amongst the
Trust’s workforce has continued to remain a concern with the two most prevalent
reasons for this being mental health issues (anxiety/stress/depression) and musculoskeletal problems. A Health & Well-being lead was, therefore, appointed to ascertain
what support is required to prevent absence due to ill health, share best practice
amongst Trust services, develop a network of well-being champions, focus on early
intervention services/health promotion, improve usage of the range of OH services
available, improve reward and recognition and increase the levels of resilience amongst
the workforce. Although still within the early stages there are a number of changes
which have already been actioned:
 Lunch time walks
 Taster classes in Yoga and Mindfulness
 Team plans for health and well being
 Social media site to share information
Stable Workforce
Turnover has remained steady at 13% throughout the year, although there are areas
where this is significantly higher. The key challenges for the Trust have been to attract
and retain staff within the integrated care teams in the more rural and remote locations,
those that border with services in Surrey where pay rates include London fringe
allowance as well as those mental health and learning disability services that provide
care for people with severe challenging behaviours.
Safer Staffing
We have a project in place led by one of our Associate Directors to meet the national
requirements for the Safer Staffing programme. There is monthly exception reporting to
the Board which highlights staffing levels on each ward. Acuity and dependency tools
have been used to assess the needs of inpatient caseloads with tools being developed
for community services as there are no available national tools.
Organisational Culture
The King’s Fund were commissioned to evaluate the extent to which the envisioned
culture change has taken place; this work focused on key elements of culture such as
organisational vision and values, characteristics of management and leadership,
experiences of team working, clarity of organisational objectives and priorities,
experiences of working at Southern Health and how staff perceived their roles.
Good practice was identified across many areas, with the vast majority of staff agreeing
that they can put NHS values into daily practice, organisational goals are clear, there is
strong commitment to quality and patient care is compassionate and empathic. The
majority of staff provided feedback to the effect that they work in well-functioning teams
and are focused on quality and improvement. Positive feedback for the Going Viral
programme was provided and it was suggested by staff that this should be expanded.
Certain areas for improvement were also highlighted with the major focus being on
improved management skills to support staff more empathically through significant
change and even more support for managers to be better leaders.
150
The Trust was recognised as one the Health Service’s Best Places to work in an annual
celebration of the UK’s elite public sector healthcare employers. These organisations
have proven that they know what it takes to create environments where people love to
come to work. The Trust was proud to receive this recognition as a great employer not
only for the good of our staff but also for the good of the communities we serve. There is
a clear evidenced link between the satisfaction of staff and patient satisfaction levels.
Staff survey results
Our staff engagement score has increased since the last NHS Staff Survey to 3.77; this
compares favourably to the national average of 3.72. We will continue to promote the
benefits of participation and demonstrate the impact this has in terms of bringing about
a positive improvement to staff experience. Our other staff engagement activities will
also continue including staff conferences, focus groups, staff briefings, away days, team
meetings and individual appraisals, all of which are designed to ensure we involve staff
in all aspects of our business and enable them to contribute to decision-making about
issues which are of importance to them.
Key priority areas for the Trust based on the latest set of results are:
•
•
•
•
•
•
•
Improvement of health and well-being, with a focus on staff engagement and
participation in the annual survey/Staff FFT.
Review work planning and scheduling in order to reduce conflicting work
demands on staff.
Focus on appraisals to increase their usefulness in identifying training, learning
and development needs.
Review the provision of training to all staff, as appropriate to job role and
responsibilities.
Communicate key improvements achieved in the last year and where staff have
made a significant contribution.
Ensure that senior managers involve staff in important decision making
processes.
Work directly with staff to understand why some would not recommend the
organisation as a place to work and/or as a place to receive care and take action
accordingly.
Leadership Education and Development
We have continued with our commitment to developing our leaders and managers to
ensure they have the skills and confidence to effectively fulfil their responsibilities. To
date, over 930 of our leaders have completed the Going Viral leadership programme
further embedding our values and supporting our staff to redesign and integrate
services to ensure we are delivering quality care to our service users.
During 2014/15 we launched our Viral Essentials management development
programme, which has been designed to provide support, guidance and resources for
line managers to address a range of management issues. Nearly 500 staff have
accessed these programmes, which are open to all staff with line management
responsibility, consists of both development sessions and a comprehensive website
where managers can access the information they need, when they need it, thereby
releasing capacity to provide quality care.
151
Our behaviourally based appraisal system has been in place since 2012. In 2014/15 we
have incorporated development for our managers in getting the best from our appraisal
system into the Viral Essentials programme, offering a selection of support options; face
to face sessions for managers new to our appraisal system and an online session for
those managers who would like to refresh their skills and confidence in delivering an
effective appraisal.
During the previous 12 months our range of training events has attracted in excess of
55,000 attendances with nearly 60% for statutory and mandatory subjects. We have
continued to recognise that training can be time-consuming when the workforce is
already challenged in many areas. We have therefore continued to promote access to
electronic training resources and over the past year our workforce accessed electronic
assessments on 35,749 occasions with 92% resulting in a pass.
This year, the development of the band 1-5 workforce has been enhanced through the
introduction of the new Health Care Support Worker (HCSW) National “Care Certificate”
as recommended by the Camilla Cavendish review. This is a key component of the
overall induction which an employer must provide, legally and in order to meet the
essential standards set out by the Care Quality Commission.
As part of our response to the shift in delivery of NHS services from acute to community
settings we have continued to progress the development and introduction of clinical
competency frameworks. The introduction of new courses, for example Tissue Viability
training for our learning disability services and Physical Health and Long Term
Conditions training for our mental health inpatient services has further ensured that our
workforce has the right skill mix profiles to provide a holistic approach during the patient
journey.
A significant Induction overhaul is currently underway and this will provide a reduction in
Induction staff release from 5 days down to 1 day. In addition we are developing
electronic “Scenario based decision/dilemma tools” to enhance and bring to life our
visions and values and to demonstrate the expected behaviours of our workforce.
Safeguarding
Safeguarding describes Southern Health’s responsibility to work in partnership with
other agencies to prevent abuse and neglect of vulnerable adults and children and to
deal with it effectively if it does occur. The Trust is a member of Local Safeguarding
Boards for Children and Adults and follows the Multi Agency procedures. The
safeguarding focus within the Trust is ‘Think Family’ to ensure staff consider all
individuals who may need safeguarding in a situation and not just the adult or child for
whom the original concern was raised. The corporate safeguarding team has been
further strengthened in the Trust with the appointment of a Named Doctor for
Safeguarding Children and a Named Doctor for Safeguarding Adults. The corporate
safeguarding team work in an integrated way to support sharing expertise and skills to
benefit staff/patients/service users.
The Trust is committed to ensuring adequate preventative measures are in place to
reduce the risk of abuse. This includes having appropriate policies, staff training,
supervision, management and leadership arrangements in place and clearly defined
professional boundaries. The ‘Think Family’ approach is reflected in both the
152
Safeguarding and Communications Strategies, workforce development and responding
to incidents.
An appropriately skilled workforce is considered key to reducing risk of abuse or
neglect. Safeguarding training has been reviewed across the Trust to ensure effective
high quality training is accessible to all staff. All incidents where safeguarding concerns
are reported are investigated with the Trust focused on learning and sharing widely any
lessons learned thereby reducing future risk. Trust safeguarding dashboards have
been developed which enable monitoring of themes and trends and support a proactive
approach.
The Trust ensures all staff see safeguarding as their responsibility and divisions have
identified internal lead governance structures that feed in to Trust safeguarding
assurance. The Trust acknowledges the changes that may be required by the
implementation of the Care Act 2015, to ensure that it is compliant. The Trust continues
to evolve its safeguarding service to ensure it is future proof and fully integrated in Multi
Agency frameworks. All Serious Case Reviews are fully engaged in and the learning
outcomes owned and driven throughout the workforce to ensure that changes are made
where appropriate. Action plans developed by services to address any identified
shortfalls to meet the recommendations from the Winterbourne Review and Saville case
are monitored through divisional governance structures and the Trust Safeguarding
Forum.
Infection Prevention and Control
We take the risk of infection very seriously and work hard to maintain our low infection
rates. We have our own dedicated infection prevention and control team who work with
all staff to ensure the risk of infection is kept as low as possible for all patients and
service users. A Trust wide infection prevention programme is in place and is monitored
by a Director of Infection Prevention and Control at Board level. As part of this
programme all staff must undertake regular training in infection prevention, control and
hand hygiene. There is an extensive audit programme to monitor clinical practice and
ensure high standards are maintained. In addition an active infection prevention link
advisor system is in place to help share the infection prevention agenda using identified
staff members (Infection Prevention Links) working in teams throughout the Trust,
supported by the Infection Prevention Team.
We have very low rates of healthcare acquired infections. There have been no
Methicillin-resistant Staphylococcus aureus (MRSA) blood stream infections reported
this year and our numbers of Clostridium difficile incidents remains very low as shown in
the graph below:
153
Graph: Clostridium difficile infection numbers
The team monitors other infections such as Meticillin Sensitive Staphylococcus Aureus
(MSSA) and Escherichia coli in blood and also any outbreaks of infection which occur in
inpatient areas. These do not happen very often, but when they do occur, we
investigate to see if there was anything that could have been done differently to prevent
the infection. Any learning from these incidents is shared with staff.
The team work closely with other departments such as Estates and Facilities to ensure
high standards of cleanliness are maintained and also to ensure that any new builds or
refurbishments comply with national guidance in infection prevention and control.
Serious incidents
These are rare and unintended events that can cause significant harm or distress. If it
happens as a result of failure in care or treatment, we want to understand why and how,
and to make sure it doesn’t happen again. We do this by:
Having policies and procedures in place so that staff know what to do in the event of
a serious incident;
Training investigating officers so they are able to identify root causes of incidents
and recommend actions which will make a difference to patient experience and
outcomes;
Having a panel system in place where senior managers and staff involved in serious
incidents can discuss root causes, review action plans and share learning in a
constructive manner;
Audit action plans to check that improvements have been made and learning from
incidents has been embedded into practice with learning shared across the
organisation; and
Ensure staff are aware of their responsibilities in being open with patients, services
users and their carers to say sorry and to discuss openly with them when things may
have gone wrong.
The table below shows the number and type of serious incidents reported by Southern
Health between 2011/12 and 2014/15.
154
Total
Infection Control (outbreaks, C-Diff, MRSA bacteremia,
legionella)
Information Governance
Pressure Ulcers Grade 3 (total:avoidable/unavoidable)
Pressure Ulcers Grade 4 (total:avoidable/unavoidable)
Slip/Trips/Falls
Unexpected Deaths** (includes deaths – related to drug
use, open verdicts and cause unknown following coroner’s
inquests, previously categorised as suicides)
Homicide
Suicide by Outpatient**
Suicide by Inpatient (includes those on home leave, AWOL)
Attempted Suicide (self harm)
Serious Inpatient Incident (surgical error)
Safeguarding (inc: allegations against staff)
Grade 0 (used historically when severity of incident not
clear initially)
Other (AWOL, Lapsed Registration, undocumented patient
outcomes, medication, choking, fire and serious assault by
patient)
Total
2011/
12*
2012/
13*
2013/
14*
14
9
9
2
141
95
31
3
144
101
31
0
143
134
22
8
2
158
132
17
7
5
7
13***
1
44
3
12
6
11
1
33
1
6
3
9
0
46
1
14
1
8
1
30
5
10
0
11
6
0
0
0
17
5
390
353
2014/1
5*
10
395
9
396
*The acquisition of Oxford Learning Disabilities Trust (OLDT) in November 2012 makes the direct comparison of
performance data over time difficult as we are now a larger Trust.
** The figures for unexpected deaths and suicides have been adjusted for 2013/2014 and 2014/2015 to take into
account late reported suicides and those deaths initially reported as suicides and following coroners verdicts have not
been deemed as suicide.
***This includes three deaths currently under investigation, as at 13/4/2015
Overall the numbers of serious incidents reported have increased by one in 2014/15.
There are decreasing numbers of SIRIs reported in several categories:
Infection control
Grade 4 Pressure Ulcers
Slips/Trips/Falls (high harm)
Suicides by Out-patients
Attempted Suicides
Surgical errors
There are five categories showing an increase:
• Information Governance shows an increase from 0 in 2013/14 to 2 this year.
•
Grade 3 Pressure Ulcers show an increase of 10% in total figures, however there
has been an overall 9% reduction in avoidable pressure ulcers.
155
•
The trust reported one homicide committed by a service user with a nil return the
previous year.
•
Suicides – overall the numbers of suicides have reduced by 26%, however,
within these numbers the inpatient suicide numbers have increased from 1 to 5.
These numbers include service users who were on leave from the ward at the
time of their death, with one death occurring in the ward environment.
•
Unexpected Deaths – overall the number of unexpected deaths has increased
from the previous year. The increase has included deaths which were previously
reported as suicide but following coroner’s inquests were found to be death from
other causes. The total also includes three investigations which have yet to be
concluded.
Following an increase last year in the numbers of reported SIRIs for pressure ulcers and
for suicide, the Trust has participated in NHS England initiatives for pressure ulcers and
suicides. This has enabled the sharing of Serious Incidents Requiring Investigation
(SIRI) learning from these two key areas to support the reduction of pressure ulcers and
to enable organisational bench marking for key learning from suicides. In particular, we
have reviewed our whole system for how we learn from SIRIs to prevent them
happening again.
In particular:
• We have made it easier for staff to initially report incidents when they happen and to
manage any investigations that are taking place, working to move to a paperless
electronic reporting system for SIRIs from April 2015. This is in line with our incident
reporting systems already in place.
•
We have strengthened our process for early identification of which incidents
reported will require a full investigation through the SIRI process. To do this,
following any immediate clinical actions needed, we have improved our postincident review panels, to ensure expert senior advice is available within 48 hours,
to teams and support prompt investigations. We have adapted this approach for
reported pressure ulcers to ensure that expert advice is included in the investigation
planning within 7 working days of a pressure ulcer being reported.
Our Medical Director for Quality oversees all the SIRI investigation reports through our
corporate SIRI review panels, to ensure each investigation is of good quality and
identifies where learning is required in teams, divisions, and Trust-wide to prevent
recurrence. We have improved how we share this learning in our divisions, and Trustwide this year through our organisational learning approach and have plans in 2015/16
to strengthen this further through the Trust Quality Programme.
Patient and Service User Experience
We believe all people should be treated with compassion, dignity and respect in a clean,
safe and well managed environment. Providing a good patient experience of our
services is a key value for the trust.
As part of their inspection in October 2014, the Care Quality Commission met with
different groups of patients, held listening events and used comment cards to gain
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feedback. Over 150 feedback cards were received, and the vast majority were positive
with comments such as ‘staff went the extra mile’ to deliver care. The health visiting and
perinatal services were highly praised for their responsiveness to patients and family’s
needs. The majority of the feedback from all sources highlighted how caring and
compassionate staff were and that they took the time to listen to patients and their
carers, giving clear explanations about care and providing good quality care. Feedback
showed that most patients were involved in planning their care. Patients using inpatient
mental health services told of their positive experience of attending therapeutic groups
and their involvement in developing a recovery focused approach to planning and
reviewing care. Some negative patient comments highlighted areas where we can
make improvements and which will be included in an overarching action plan, for
example, access to crisis services for adults and older people, waiting times in Minor
Injury Units and for therapy appointments.
There is a proactive approach to equality and diversity across the trust with a strong
emphasis on respecting people’s diversity and human rights. It has won eight national
awards for Equality and Diversity.
There are multi faith rooms accessible throughout the trusts inpatient settings and a
chaplaincy service which is available to all and which is not faith based. Patients have
reported positive experiences of using the chaplaincy services.
We are keen to listen to patients and their carers and offer a range of opportunities for
them to be involved in influencing developments and improving care. There are patient
groups and forums across several services, patients sitting on recruitment panels,
patient conferences, and patient representation on committees and at governance
meetings.
We use a range of mechanisms to gain patient feedback including complaints and
concerns, NHS Choices, social media and have recently launched an app called
‘Southern Health Listens’. This year we introduced programmes ‘Small Change, Big
Difference’ and ‘If it matters to you, it matters to us’ to highlight to staff the importance of
listening to patients and making changes, however small, to improve patient experience.
‘If it matters to you, it matters to us’ posters are displayed in inpatient areas so that
patients and their carers can see changes have taken place based on their feedback.
“Fathers said they wish to be
involved more in their child’s
development”
“We amended our Health Visitor
appointment letters to include an
invitation to Fathers”
We provide people with information about how to complain and have a dedicated
Complaints and Patient Advice and Liaison Service (PALS) team who are the first point
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of contact for people who require advice or information about any of our services and
who also manage complaints.
In 2014/15 the Trust received 453 formal complaints, 522 concerns that were dealt with
informally and 1604 compliments. The majority of compliments were praising staff for
their clinical care and attitude.
Total
complaints
concerns
compliments
2011/12*
200
322
382
2012/13*
395
464
1501
2013/14*
467
493
1737
2014/15
453
522
1604
The most common complaint categories reflect the national picture and are the same as
reported in previous years within the Trust:
Clinical and nursing care 27% (123);
Attitude 20% (91);
Access to Services 12% (53);
Communication 11% (50).
We want to understand reasons and trends underlying complaints so that we can
change and improve our services. We therefore review all complaints and concerns to
identify themes and share learning across services to improve quality of services.
Overall numbers of complaints are small with 0.03% of total contacts for the year
resulting in a formal complaint compared with 0.1% leading to a compliment; therefore
people are three times more likely to compliment our services.
Conclusion
We are proud of the quality improvements we have made in our services this year but
recognise that as with any organisational change, quality improvement changes take
time to embed within the operational services. We are pleased to share that successes
have been made but also recognise that it will be an ongoing focus of our activities over
the coming year.
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Annex 1: Statements from commissioners, local Healthwatch
organisations and Overview and Scrutiny Committees
Feedback from our local Clinical Commissioning Groups (CCGs)
Feedback from West Hampshire CCG, North Hampshire CCG, Fareham and
Gosport CCG and South Eastern CCG dated 08/05/2015
Southern Health Quality Account 2014/15
West Hampshire CCG, Southampton CCG, North Hampshire CCG, Fareham and
Gosport CCG and South Eastern Hampshire CCG are pleased to comment on
Southern Health NHS Foundation Trust's Quality Accounts for 2014/15 for the services
that the Hampshire and Southampton CCGs commission. All of these CCGs have
worked with the Trust over the past year in monitoring the quality of care provided to
their local population and identifying areas for improvement.
The Trust achieved eight out of the nine quality priorities for 2014/15; holistic care
planning was the one not achieved and there was minimal improvement to be seen
between the two audits undertaken during the year, however this is being taken
forward in the quality indicators for 2015/16, and commissioners will be expecting to
see an improvement in this area.
The Trust was one of the first Mental Health and Community Trusts to receive a visit
from the Care Quality Commission (CQC) in October 2014. After a rigorous week of
inspection the report received gave an overall rating of "requiring improvement"
although there were many positive comments with some domains rated as "good" and
one as "outstanding". An important outcome from the visit was that there were no
surprises identified, as all of the key actions were already known by the Trust, had
commissioner's involvement and some action plans were already in progress. These
action plans have been pulled together into one document in consultation with the
Hampshire Commissioners, who will be monitoring progress and are assured by the
Trust's internal governance arrangements.
There are nine quality priorities identified for 2015/16, which have been generated
through wide consultation with stakeholders including commissioners and a number
of them have been included as quality indicators in the new contract; these also link
to the CQC recommendations. The commissioners fully support these quality
priorities which meet the national requirement of the NHS Outcomes Framework to
drive quality improvement as well as having significant benefits for patients.
However, a few of the quality priorities are worthy of further comment:
a) Pressure ulcers have been of continual concern to commissioners over the past
few years and we have not seen any substantial reduction in numbers
throughout the year; the commissioners will be expecting to see the achievement
of the 50% reduction from last year, particularly as a good number of these will
be as a result of the identification of the primary care giver introduced towards
the end of the year
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b) Medication management has been a recurring theme from previous CQC
reports and the audits undertaken during the year regarding omitted doses do
not provide commissioners with full assurance that the Trust is on top of this,
therefore it is good to see a quantifiable stretch target in this area
c) Monitoring the physical health of inpatients is an important area and
commissioners are pleased to see that further emphasis will be placed on this;
however we would also want to see that there is learning from the information
gained from the review of case notes to see if earlier signs could have been
identified and actions taken to prevent the transfer to the acute hospital
d) Management of day surgery, particularly infection rates and the use of the safe
surgery checklist is an important aspect of patient care before and after surgery,
e) Commissioners would also like to see an improvement in recovery outcomes
such as wound healing rates which continues to be an area that commissioners
are concerned about and will be monitoring through the contract, as it remains
a quality indicator for 2015/16
f) The ambition that 90% of complainants will be satisfied with the response they
receive from the Trust, is good, however commissioners would also like to see
this priority enhanced by ensuring that lessons learnt from complaints are
embedded into services changes
g) Commissioners are pleased to see the emphasis on the engagement of patients
and carers in the design of services particularly asking service users to help in
the co­ design of the restraint and seclusion framework; CCGs are also asked
to participate in the "Putting Quality First" visits to teams and their subsequent
internal accreditation
Recurring themes from Serious Incidents Requiring Investigation (SIRis) include
patients with a dual diagnosis (patients with a mental illness as well as substance
misuse), crisis support and care programme approach and waiting times for early
support for people with a mental illness such as that provided by the Improving Access
to Psychological Therapies (IAPT), do not feature greatly in this report, which is
surprising, since the Trust is undertaking many actions to address these; these are key
areas that commissioners have been included in the quality section of the 2015/16
contract.
One of the greatest challenges the Trust has had during the year is that of
recruitment of nursing and psychiatric staff and the impact of the national shortage of
these professionals has been, and remains of concern to commissioners. However
the staff are doing an excellent job in keeping their patients safe and this has been
reinforced many times in the CQC report when there is frequent reference to the
caring and compassionate staff. In addition, the Trust has a number of initiatives in
place to support staff well-being and Commissioners recognise the good work within
the "Going Viral" leadership programme.
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The Trust has some challenges regarding data quality and timeliness on occasions
which underpin all of these initiatives. Commissioners acknowledge this is recognised
by the Trust and have actions are in place to address some of these, however,
ongoing commitment will be required from the Trust to maintain improvement in this
area.
The Quality Account would, possibly, be enhanced through greater explanation around
prone restraint, seclusion and violence and aggression incidents particularly in
appreciation of the amount of work the Trust has devoted to reducing these. In
addition, commissioners would like to acknowledge the Trust's engagement in system
wide working particularly in respect of the urgent care pathways and the sign up to
safety system standards.
This is a well-structured Quality Account which complies with national guidance
showing areas of achievement as well as areas where improvement is needed.
The CCGs are satisfied that the overall content of the Quality Account meets the
required mandated elements.
Overall West Hampshire CCG, Southampton CCG, North Hampshire CCG, Fareham
and Gosport CCG, South Eastern Hampshire CCG and North East Hampshire and
Farnham CCG are satisfied that the Quality Accounts for 2014/15 provide a clear and
accurate statement, and look forward to working closely with Southern Health NHS FT
over the coming year to further improve the quality of local mental health, learning
disability and community services.
Yours sincerely
Heather Hauschild
Chief Officer
West Hampshire CCG
Feedback from North East Hampshire and Farnham Clinical Commissioning
Group dated 14/05/2015
Commissioner statement
North East Hants and Farnham Clinical Commissioning Group (CCG) welcomes the
opportunity to comment on Southern Health NHS Trust’s Quality Account for
2014/15 and give a specific view on the services it commissions.
Quality improvement priorities for 2014/15
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Southern Health NHS Trust (SHFT) has outlined its priorities for 2015/16 and
broadly the CCG support these. Further clarity will need to be given on how these
priorities will be monitored and implemented.
North East Hants and Farnham CCG (NEHFCCG) also have a commitment from
SHFT to work us in support of the local integration agenda to demonstrate a drive
toward making continuous quality improvements to its services for the benefit of
patients in their care. The Trust actively demonstrates an acknowledgement of
the value in working collaboratively through a whole-system approach with other
stakeholders across the local health and social care sector and to involve patients
and carers in the design of services. The CCG would support the Trust to review
their priorities to ensure that this is reflected.
In October 2014, the Care Quality Commission embarked on a week-long
inspection of Southern Health. The CCG recognises that SHFT therefore had a
challenge in 2014/15 to implement and deliver on action plans to address the
Care Quality Commission (CQC) warning notices applied to a small minority of
services and an enforcement action by Monitor.
Patient safety
We are pleased to note that the Trust has signed up to the ‘Sign up to Safety’
campaign programme designed to help realise the ambition of making the NHS
the safest healthcare system in the world by creating a system devoted to
continuous learning and improvement. The CCG would like to challenge the Trust
to ensure that this work is shared, being clear about how this will impact on what
difference this will make to patients in the coming year and evidence accordingly.
We are also pleased to note that reducing the rate of pressure ulcers continues
and want to ensure that this work is maintained. The CCG welcome the priority to
share and implement learning across the Trust and we have been working directly
with SHFT to improve the quality of reporting and to ensure that pressure ulcer
serious incidents are reviewed appropriately and lessons are learnt and want to
encourage the Trust to ensure that this work delivers effective improvements.
The Trust has invited the CCG to be involved in the assurance and investigation
process and we hope that this will continue into 2015/16. However, we would
also like to see a significant improvement in the quality of reporting and challenge
the Trust to ensure that there is a focus improving the quality and timeliness of
Serious Incident reporting and learning from these.
In a similar vein we welcome the priority to monitor the physical health of
patients and to act quickly when there is deterioration in their physical condition
to ensure they receive best care. We expect this priority to support the early
detection of acutely unwell patients by measurement in a standardised format,
supporting consistent clinical decision-making and appropriate clinical responses
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to a wider holistic care approach. We look forward to seeing how this priority will
be evidenced and how learning continuously improves the level of service that is
offered and ultimately impacts on outcomes for patients.
In line with recommendations in the Francis Enquiry and the Hard Truths report
we are pleased that the Trust recognises the need to monitor and ensure
appropriate and safe staffing levels across all service lines to meet the challenges
of the rising demand for healthcare.
Patient experience
The CCG welcomes the aim to focus on what matters to patients by supporting
patients during their pathway of care through priorities such as assessing patient
needs, working with them and their carers to develop a plan of care that is
centred on these needs and includes goals important to them.
The Trust have been working with us to develop a new local CQUIN for 2015/16
to develop patient and carer led shared care records. We look forward to seeing
the innovative systems that will be delivered from this project and the impact it
will have on the quality of patient, families and carers.
The commitment to real time patient experience data collection, linked to the
Friends and Family Test in all areas of care is also supported. We share the Trust’s
recognition that they should continue to focus attention on gaining feedback
from patients, particularly ‘real-time’ data that can be acted upon in a timely
manner and look forward to improvements in this area, linking to organisations
such as Healthwatch.
The CCG would encourage the Trust to place an emphasis not only on response
rate, but also narrative and patient stories. We find the ‘you said we did’ reports
of what is done following the results of Friends and Family Test particularly
helpful and give a clear picture that the patient voice is being taken seriously and
that changes are made as a result. We would encourage the Trust to also think
about ensuring that patients from marginalised groups, whose voices are often
not heard, have an appropriate opportunity to provide feedback on their
experience of services.
We also welcome the priority of working with carers and understanding their
needs and views and support the need for the introduction of a specific carer’s
survey in 2014 to gain feedback as to how we could improve our services.
We would like to see the section on strengthened, with clearer targets and/or
aims developed with carers, particularly in light of the Care Act 2014.
Clinical effectiveness
Commissioning for Quality and Innovation (CQUIN)
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Commissioners are pleased to note consistent achievement of quality
improvement goals in many of the 2014/15 CQUINs. Namely, the implementation
of the Friends and Family test, Safety Thermometer and Dementia.
There is a new programme of CQUINs in place for 2015/16 which will focus on
patient and carer involvement in care planning, the developing of community
based community health care assessments to support patients coming out of
hospital and ensuring patients receive the right care package in a timely way and
an urgent care admission avoidance national CQUIN. These CQUIN schemes have
been developed with the Trust with meaningful targets to support whole system
healthcare improvement and Commissioners welcome this approach.
Data Quality
We will continue to work with the Trust to ensure that quality data is reported in
a timely manner through clear information schedules.
Clinical Audit and Research
The Trust reports participation in 5 national clinical audits and 2 national
confidential, (80% of eligible national clinical audits and 100% confidential
enquiries). The CCG also note that an additional 68 local audits have been
undertaken across the organisation, and that these provide an opportunity to
benchmark the quality of the Trust’s clinical services locally and nationally.
Commissioner Assessment Summary
North East Hants and Farnham CCG will continue to work with Southern Health
NHS Trust to raise the profile of quality improvement. The engagement of
clinicians will remain crucial in monitoring standards, and improving services for
local people. The Trust is commended for their continued good work and
emphasis on quality of patient care.
Commissioners have a positive relationship with the Trust, one which is based on
‘high support’ and ‘high challenge’ and we look forward to continuing this.
We are confident that we will continue to work together to ensure continuous
improvement in the delivery of safe and effective services for patients.
Chiltern & Aylesbury Vale Clinical Commissioning groups (CCG): Response to
the Southern Health Foundation Trust Quality Report & Quality Account 2014/15
dated 20/05/2015
Southern Health Foundation Trust is one of the largest providers of mental health and
learning disability services across the south of England covering Hampshire, Dorset,
Wiltshire, Oxfordshire and Buckinghamshire.
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As lead commissioners for the learning disability services provided by Southern Health
Foundation Trust in Buckinghamshire we have reviewed the Quality report against the
priorities set in 2014/2015. It is acknowledged that the Trust faced significant quality
challenges at the start of 2014/2015 following enforcement action applied by Monitor,
the health service regulator, to improve quality features of services by continuous
quality improvement across their learning disability services and board governance.
We are satisfied that Southern Health has demonstrated success and improvements
including areas of leadership development across the organisation.
Priority 1: Improving Patient Safety
1.1 Reduce the number of pressure ulcer.
We acknowledge that the Trust has a Trust-wide action plan to reduce pressure ulcer
including analysis of numbers and themes and shares good practice. It is pleasing to
note that the Trust has a system in place to ensure that training is provided by the
tissue viability team to relevant staff. As commissioners, we are confident that the Trust
has achieved the pressure ulcer target with fewer number of incidents reported. We
look forward to a sustained progress in this priority in the coming year as we have
noticed that a similar indicator is being repeated in the coming year 2015/2016
1.2 To improve the management of incidents of violence and aggression by reducing prone
restraint by 20% from 2013/14; and use of seclusion by 20% from 2013/14.
We note that processes were put in place to ensure incidents of restraints and
seclusion are minimised, including the launching of ‘safer wards’ initiatives and other
evidence-based interventions. The Trust has worked hard to meet the
recommendations in the Department of Health guidance ‘Positive and Proactive care:
toward reducing the need for restrictive interventions. We therefore acknowledge that
the Trust has achieved this priority as stated in the 2014-2015 report. We support the
Trust’s future plan to continue to focus on minimising the use of restraint and seclusion
in its in-patient areas and inclusion in their priorities in 2015-2016.
1.3 Improve medicines reviews for people
We welcome the intention of the Trust to review the medicines which patients are
taking when admitted to hospital and the Trust’s inability to meet this priority in the year
2014-2015. The Trust has now re-set this priority for the coming year 2015/2016. As
commissioners we recognise the Trust has embarked on a plan detailing actions
required to ensure that medicine reconciliation target has been shared widely. The
Trust has set out other action plans including web-based reporting and increased
staffing capacity with two new pharmacists and locum staff to bolster the staffing need
necessary to support the achievement of this priority. In addition, the Trust may wish to
work with other Trusts of similar size and share best practice. We therefore agree with
the action plans and look forward to improved report for medicine reconciliation in the
year 2015/2016.
Priority 2: Improving Clinical Outcomes
2.1 Holistic Care Planning for People
The Trust has demonstrated improvements in some areas, but has not achieved this
priority in the year 2014/2015. We welcome the Trust being in discussion with other
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agencies to agree an integrated health and social care plan approach across
organisations. We accept that this will benefit patients as there will be shared
communication and common care goals. We support the intention to repeat a similar
indicator for 2015/2016 focusing on developing a care planning framework that is
patient-led.
2.2 Learning from information about quality of care
We are pleased to note that the Trust has developed organisational learnings web
pages that includes patient stories, case studies and examples of good practice. The
Trust has also worked hard to ensure patient stories are now presented and discussed
at Trust committees, divisional governance meetings to enable shared learnings
leading to change in practice. As commissioners, we are confident that this has
achieved the priority of learning from information about quality of care.
2.3 Learning from Suicide
We recognise that learning from suicides was a new indicator in the year 2014/2015
and the Trust embarked on a number of initiatives to ensure that this priority was met.
This includes an evidence-based suicide mitigation programme, ‘Connecting with
people’, to raise awareness for developing staff skills. As commissioners, we are
confident that the Trust has achieved this priority. We support the Trust in ensuring that
learning is shared across services and key themes are highlighted in specific forums
and team meetings. It is important to note that the Trust will continue to investigate all
unexpected deaths and include this priority as an indicator in 2015/2016.
Priority 3 – Improving Patient experience
3.1
Improve the experience people have of the services
The Trust highlights the achievement of this target with both non mental health patients
and mental health patients responding positively to the patients experience survey.
We recognise the work carried out in publishing: ‘You said, we did’ on the Trust’s
website, with examples of changes made following feedback received. We welcome
different methods of exploring new ways of gathering patients’ feedback including the
use of technology and volunteers in mental health. It is pleasing to note that there will
be a continual emphasis on the monitoring of patient feedback as one of the priorities
for 2015/2016.
3.2
Support Carer involvement and listen to their feedback.
As commissioners we note from the reports that this priority is closely linked with the
patient experience mentioned above and recognise that this priority has been achieved
as well. We acknowledge that the Trust continually listens to carers and includes them
in the planning of care for their relatives. Invariably, this process enables the Trust to
choose goals that are important to the patients. We are pleased that the Trust has
achieved this priority as part of the strategy to improve patient experience.
3.3. Use feedback from complaints to improve our service
There has been a concerted effort in piloting of a new process whereby complainants
receive ‘action learning’ letters which summarise actions taken following their
complaints. We also welcome that this piloting is being evaluated by the Trust to
ensure future feedback processes are improved. In addition, it is beneficial that there
is a system in place to ensure that the theme and lessons learned from complaints are
shared across services with improvements embedded.
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As commissioners, we are confident that this priority was achieved as part of the
patients experience priorities set for 2015/2016. It is appropriate that the Trust has
included a similar indicator in the priorities for 2015/2016.
Conclusion
In October 2014, the Trust was visited by the CQC for a week-long comprehensive
inspection. Following the visit, the Trust did not receive any warning notice in the year
2014/2015. Also, the CQC has not taken enforcement action against the Trust during
the year under review.
The report shows, that prior to the comprehensive inspection in October 2014,
Southern Health was inspected by the Care Quality Commission (CQC) against the
Essential Standards of Quality and Safety on 21 occasions. We understand that, in
total 100 standards were inspected across the Trust’s services. Of these standards, 90
were rated as fully compliant with 5 identified minor concerns. The remaining 5 were
identified moderate concerns, with compliance action taken. This provided a valuable
external review and we therefore acknowledge the hard work that has culminated into
these achievements.
The Clinical Commissioning Group welcome the openness and transparency of the
report and appreciate the successes that have been made whilst also recognising that
the Trust aspires to focus and achieve more over the coming year. We are committed
to supporting the Trust in achieving improvement in the areas identified for the year
2015/16 within the Quality Account through existing contract mechanisms and
collaborative working.
Feedback from Healthwatch organisations
Healthwatch Southampton dated 15/05/2015
Dear Katrina,
Healthwatch Southampton welcomes the opportunity to comment on Southern Health
Foundation Trust’s Quality Account. It appears that strengthening the Board has
resulted in significant quality improvements and we are pleased to hear about the many
areas in which the trust has demonstrated improvements and successes, as outlined in
the recent CQC report. We are particularly pleased to see the positive comments about
Antelope House staff and the special mention of the hospital@home team. We have
been impressed by our first-hand experience of working with the Trust on the redesign
of the Psychosis Care Pathway; particularly concerning the engagement and
involvement of your service users.
Whilst noting both the difficult financial climate within which the Trust operates, and the
increasing challenges of staff recruitment, we are, however, disappointed by the areas
which the CQC has highlighted for improvement. Inappropriate seclusion and physical
intervention practices are, we feel, unacceptable, particularly given the attention these
issues have received over the last 5-10 years; and we will seek assurances from
yourself that these practices have been rectified with appropriate training and
monitoring of staff.
167
Moving forward HealthWatch Southampton is keen to continue to work closely with the
Trust, especially given our special interest in mental health services, and the experience
of people living with mental health conditions in the City. Southampton has made a
commitment to improving services and experiences for people with mental health
problems, and together with yourself, and other partners, we look forward to the
challenge of driving this agenda forward over the next year.
Harry F Dymond MBE
Chairman Healthwatch Southampton
Feedback from Healthwatch Oxfordshire dated 08/05/2015
Ref SHFT Quality Account for 2015/16
Thankyou for inviting us to comment on the Trust’s Quality Account for 2015/16. The issues
raised about SHFT with Healthwatch Oxfordshire this year have related to:
• The problems associated with the transition between children’s and adult services;
• The failure to provide information and support to enable families to make informed
choices about which services to use;
• The need to develop a peer-to-peer network of support and advocacy for families,
with the suggestion that Oxfordshire could be a potential pilot area to test out a peer
advocacy and support model;
• The importance of services and commissioners working with families to seek solutions
rather than perceiving families as part of the problem.
In addition, the avoidable death that occurred in the Trusts Oxfordshire premises in July 2013
raised awareness locally of the importance of families getting the right information, advice
and support in order to understand how to safeguard and protect their loved ones.
In the light of the feedback we have received we welcome the overall strategy and priorities
set out in the Quality Account. However we would like to see any future evaluation of the
care planning indicator address the issues of family and peer support, as well as patient
engagement. Additionally we regret that we could not identify any clear focus in the Quality
Account on improving transition between children and adult services.
Yours sincerely
Rachel Coney
Chief Executive
Feedback from Healthwatch Bucks dated 18/05/2015
Thank you for inviting Healthwatch Bucks to comment on the Trust’s Quality Account for 2015/16.
We have no direct comments to make on the account and support the overall strategy and priorities set
out.
Richard Corbett, Chief Executive
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Feedback from Overview and Scrutiny Committees
Oxfordshire Health and Overview Scrutiny Committee dated 13/05/2015
Many thanks for the invitation but on this occasion the Oxfordshire HOSC is not in a
position to respond to the Quality Account for Southern Health.
Please do continue to keep us informed about the Trust’s activity and quality accounts
in future years.
Southampton Health Overview and Scrutiny Panel Statement dated 14 May 2015
Response to the Southern Health NHS Foundation Trust Quality Account 20142015 from the Southampton Health Overview and Scrutiny Panel
The Southampton Health Overview and Scrutiny Panel welcomes the opportunity to
comment on the Southern Health NHS Foundation Trust Quality Account for 2014/15.
As a general point the Panel would welcome more performance information specifically
related to Southampton, enabling performance to be compared with other areas. The
Panel were however appreciative of the focus on Southampton during the presentation
on the Quality Account at the April 2015 meeting of the HOSP.
Reflecting the actions taken to improve the quality of care the Panel welcomes the
Trust’s achievements in 2014/15, including meeting the majority of the priorities for
improvement set. Holistic care planning was not achieved and the HOSP will be
expecting to see an improvement in this area.
The Panel noted that the priorities for 2015/16 are clearly identified and reflect
stakeholder consultation, include a continuation of work from 14/15 as well as new work
streams for 15/16, and reflect the recommendations following the CQC Inspection in
October 2014.
In recognition that the pathways are becoming more seamless and the need for a whole
systems approach, the Panel recommends that all Quality Accounts from providers
operating in Southampton, when referencing the forthcoming challenges within the
introductory section, include narrative on the importance of working with partners across
the system in Southampton to improve outcomes.
The Southampton HOSP look forward to working closely with Southern Health NHS FT
over the coming year.
Hampshire Health and Adult Social Care Select Committee contribution to
Quality Accounts process dated 21/05/2015
Thank you for sharing with the Hampshire Health and Adult Social Care Select
Committee (HASC) the draft 2014/15 Quality Accounts for Southern Health NHS
Foundation Trust.
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I have circulated these priorities to Members of the HASC for their comments, and
have received general feedback which suggests that the Committee are supportive
of the approach taken. Members were pleased to see that you have achieved the
majority of your quality improvement priorities for 2014/15. Members were especially
pleased with the progress you have made with hospital-associated infections.
I was concerned to see that the number of complaints you received last year had
remained fairly constant, when some might have expected them to decrease in line
with the achievement of your quality priorities. I am however pleased to note that the
Trust plans to introduce and embed improvements to the patient complaints process
for 2015/16.
The report acknowledges the strengths of Southern Health NHS Foundation Trust
and sets out a clear rationale for the 2015/2016 priorities. I am pleased to see that
you have built on your 2014/15 priorities to ensure the close audit of the
administration of critical medicines, and Members support plans to enhance the level
of involvement patients and carers have in the design of services, specifically in
relation to Minor Injury Units, End of Life Care and Childrens and Family services.
We have already begun a programme of monitoring of the outcomes of your Care
Quality Commission inspection, and are therefore pleased to see that the themes
highlighted in the inspection for improvement have been reflected in your quality
priorities for next year.
We would like to request, and look forward to receiving, the action plan that will be
drafted following the publication of your Quality Accounts, in order to ensure that the
priorities raised can be monitored, and progress against them can be reviewed. It
would be particularly helpful to understand how often you intend to measure the
progress of your 2015/16 quality improvement priorities, in order that we can review
your progress at timely intervals.
Please do not hesitate to contact me should you require any additional information
on my comments above.
Yours sincerely
Councillor Patricia Stallard
Chairman, Health and Adult Social Care Select Committee
Feedback from Southern Health Governors
Council of Governors - Southern Health NHS Foundation Trust
Comments on the Quality Report and Quality Account 2014/15 dated 18th May
2015
It is good to see that the Trust continues to place quality improvement as a high priority
and that improvement has been made in a number of important areas. The results from
the Care Quality Commission (CQC) mass inspection of Trust services in 2014 were
very encouraging; particularly with regard to their comments in respect of the Trust
having “ kind, caring, compassionate staff “, “ a strong recovery focus in mental health
services “, “innovative working in non-traditional settings” and “strong leadership and
development programmes“. At the same time we remain very concerned that the year
on year reduction in funding to the Trust, in the face of rising demand, will impact upon
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both the level and quality of services and thereby the Trust’s ability to reduce demand to
the acute sector. The priority focus of the Trust in the coming year on the improvement
of patient safety, clinical outcomes and patient experience, is greatly welcomed. We
also totally support proposals to improve customer feedback, and involve patients and
carers in the design of services and the co-design of the Trust’s restrictive practices
framework.
As stated in the report by Don Berwick `Improving the Safety of patients in England’,
2013, we are interested in the quality improvement programme being undertaken by the
Trust and how it links with the change of management culture. We would like to see this
culture of continuous improvement develop further. The involvement of staff and
customers in the provision of feedback to improve services and service quality should
always be sought and this initiative should be used to implement best practice. In
addition, the Trust should look at best practice from other NHS Trusts, international
sites and other sectors outside of the health sector to benchmark and learn from other
organisations, including the hospitality and leisure sectors.
The Trust has examples of providing leading edge thinking for service development and
the Trust's involvement in the Multi-Speciality Community Provider (NHSE Vanguard)
pilot projects is an example of leading edge and integrated work. The Trust has
identified co-production; service user and patient involvement; and service user, patient
and carer feedback as high priority. We have suggested ways to do this through
collaboration with GP surgeries, patient participation groups and joint interest group as
well as using voluntary sector organisations. We believe that information should
continue to be collected and used at different levels in the Trust, both at ward level and
corporately and that this information is acted upon as quickly as possible. We suggest
that patient feedback methods are further developed to capture patient experience
information post discharge to enable the learning to feed into the quality improvement
plans at a local level.
We hold regular meetings between the staff governors and the Executive Team which
enables staff Governors to act as a ‘temperature gauge’, and this is another opportunity
to provide the views of members directly to the Trust on proposed changes, the impact
on staff and on the quality of services. Through the Governor Focus sessions, open to
all governors, we are able to discuss individual services, any key pressures on the
services or teams and get a sense of what is working well or not so well, the plans for
the future and ways to improve quality. The Trust has also recently agreed that
governors will get the chance to attend Board committees, another route for ensuring
the voice of members can be communicated to the Board and assisting governors in
their duty to hold the non-executive directors to account.
We think it would be helpful if future quality reports included a summary by each service
which included patient feedback and outcomes, areas for service improvement
identified by both Clinical Commissioning Groups and staff, and the actions taken as
part of the quality improvement plan. This will help the Trust to continue to improve the
quality of services for the population we serve.
The Trust has identified co-production; service user and patient involvement; and
service user, patient and carer feedback as high priority
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Council of Governors May 2015
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:
board minutes and papers for the period April 2014 to April 2015;
papers relating to Quality reported to the board over the period April 2014 to April
2015;
feedback from West Hampshire CCG, Southampton CCG, North Hampshire CCG,
Fareham and Gosport CCG, South Eastern Hampshire CCG dated 08/05/2015;
North East Hampshire and Farnham CCG commissioners dated 14/05/2015;
Feedback form Chiltern and Aylesbury Vale CCG dated 20/05/2015;
feedback from governors dated 18/05/15;
feedback from Healthwatch Southampton dated 15/05/2015; Healthwatch
Buckinghamshire dated 18/05/2015; Healthwatch Oxfordshire dated 08/05/2015;
feedback from Southampton Health Overview and Scrutiny Panel dated 14/05/2015;
feedback from Oxfordshire Health Overview and Scrutiny Committee dated
13/05/2015;
feedback from Hampshire Health and Adult Social Care Select Committee dated
21/05/2015;
the trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated 18/05/2015;
the national patient survey dated 18/09/2014;
the national staff survey dated 24/02/2015;
the Head of Internal Audit’s annual opinion over the trust’s control environment
dated 20/04/2015;
CQC Intelligent Monitoring Report dated 20/11/2014.
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;
the data underpinning the measures of performance 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
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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
NB: sign and date in any colour except black
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Annex 3:
External Auditors’ Limited Assurance Report
Independent Auditors’ Limited Assurance Report to the Council of Governors of Southern Health
NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Southern Health NHS Foundation Trust to
perform an independent assurance engagement in respect of Southern Health NHS Foundation Trust’s
Quality Report for the year ended 31 March 2015 (the ‘Quality Report’) and specified performance
indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified indicators”)
marked with the symbol
mandated by Monitor:
in the Quality Report consist of the following national priority indicators as
Specified Indicators
100% enhanced Care Programme Approach (CPA)
patients receive follow up contact within seven
days of discharge from hospital
Admissions to inpatient services had access to
crisis resolution home treatment teams
Specified indicators criteria (exact page number
where criteria can be found)
105
105
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in accordance with
the specified indicators criteria referred to on pages of the Quality Report as listed above (the "Criteria").
The Directors are also responsible for the conformity of their Criteria with the assessment criteria set out
in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) and the “Detailed requirements for
quality reports 2014/15” issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything
has come to our attention that causes us to believe that:
•
•
•
The Quality Report does not incorporate the matters required to be reported on as specified in
Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2014/15”;
The Quality Report is not consistent in all material respects with the sources specified below; and
The specified indicators have not been prepared in all material respects in accordance with the
Criteria and the six dimensions of data quality set out in the “2014/15 Detailed guidance for
external assurance on quality reports”.
We read the Quality Report and consider whether it addresses the content requirements of the FT ARM
and the “Detailed requirements for quality reports 2014/15 and consider the implications for our report if
we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the following documents:
•
•
•
•
•
•
•
Board minutes for the financial year starting 1 April 2014 and up to April 2015 (the period);
Papers relating to quality report reported to the Board over the period April 2014 to the date of
signing this limited assurance report;
Feedback from West Hampshire CCG, Southampton CCG, North Hampshire CCG, Fareham and
Gosport CCG, South Eastern Hampshire CCG dated 08/05/2015;
Feedback from North East Hampshire and Farnham CCG commissioners dated 14/05/2015;
Feedback form Chiltern and Aylesbury Vale CCG dated 20/05/2015;
Feedback from governors dated May 2015;
Feedback from Healthwatch Southampton dated 15/05/2015; Healthwatch Buckinghamshire dated
18/05/2015; Healthwatch Oxfordshire dated 08/05/2015;
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•
•
•
•
•
•
Feedback from Southampton Health Overview and Scrutiny Panel dated 14/05/2015;
Feedback from Oxfordshire Health Overview and Scrutiny Committee dated 13/05/2015;
The Trust’s complaints report published under regulation 18 of the Local Authority Social Services
and NHS Complaints Regulations 2009, dated 18/05/2015;
The national patient survey 2014;
The national staff survey 2014;
The Head of Internal Audit’s annual opinion on the Trust’s control environment dated 20/04/2015; and
CQC Intelligent Monitoring Report dated November 2014.
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not
extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute of
Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our team comprised assurance
practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Southern
Health NHS Foundation Trust as a body, to assist the Council of Governors in reporting Southern Health
NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this
report within the Annual Report for the year ended 31 March 2015 to enable the Council of Governors to
demonstrate that they have discharged their governance responsibilities by commissioning an
independent assurance report in connection with the indicators. To the fullest extent permitted by law, we
do not accept or assume responsibility to anyone other than the Council of Governors as a body and
Southern Health NHS Foundation Trust for our work or this report save where terms are expressly agreed
and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical
Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’).
Our limited assurance procedures included:
•
•
•
•
•
•
•
•
reviewing the content of the Quality Report against the requirements of the FT ARM and
“Detailed requirements for quality reports 2014/15”;
reviewing the Quality Report for consistency against the documents specified above;
obtaining an understanding of the design and operation of the controls in place in relation to the
collation and reporting of the specified indicators, including controls over third party information (if
applicable) and performing walkthroughs to confirm our understanding;
based on our understanding, assessing the risks that the performance against the specified
indicators may be materially misstated and determining the nature, timing and extent of further
procedures;
making enquiries of relevant management, personnel and, where relevant, third parties;
considering significant judgements made by the NHS Foundation Trust in preparation of the
specified indicators;
performing limited testing, on a selective basis of evidence supporting the reported performance
indicators, and assessing the related disclosures; and
reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature,
timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited
relative to a reasonable assurance engagement.
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Limitations
Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different measurements
and can impact comparability. The precision of different measurement techniques may also vary.
Furthermore, the nature and methods used to determine such information, as well as the measurement
criteria and the precision thereof, may change over time. It is important to read the Quality Report in the
context of the assessment criteria set out in the FT ARM the “Detailed requirements for quality reports
2014/15 and the Criteria referred to above.
The nature, form and content required of Quality Reports are determined by Monitor. This may result in
the omission of information relevant to other users, for example for the purpose of comparing the results
of different NHS Foundation Trusts/organisations/entities.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators in the Quality Report, which have been determined locally by Southern Health NHS Foundation
Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that
for the year ended 31 March 2015:
• The Quality Report does not incorporate the matters required to be reported on as specified in
Annex 2 to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2014/15”;
• The Quality Report is not consistent in all material respects with the documents specified above;
and
• the specified indicators have not been prepared in all material respects in accordance with the
Criteria and the six dimensions of data quality set out in the “Detailed guidance for external
assurance on quality reports 2014/15”.
PricewaterhouseCoopers LLP
Southampton
27 May 2015
The maintenance and integrity of the Southern Health NHS Foundation Trust’s website is the responsibility of the
directors; the work carried out by the assurance providers does not involve consideration of these matters and,
accordingly, the assurance providers accept no responsibility for any changes that may have occurred to the reported
performance indicators or criteria since they were initially presented on the website.
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Annex 4: Data definitions
PwC tested the following indicators
100% enhanced Care Programme Approach (CPA) patients receive follow up
contact within seven days of discharge from hospital
Detailed descriptor
The percentage of patients on Care Programme Approach (CPA) who were followed up
within seven days after discharge from psychiatric inpatient care during the reporting
period.
Data definition
Numerator
The number of people under adult mental illness specialties on CPA who were followed
up (either by face-to-face contact or by phone discussion) within seven days of
discharge from psychiatric in-patient care during the reporting period.
Denominator
The total number of people under adult mental illness specialities on CPA who were
discharged form psychiatric in-patient care. All patients discharged from psychiatric inpatient wards are regarded as being on CPA during the reporting period.
Details of the indicator
All patients discharged to their usual place of residence, care home, residential
accommodation, or to non psychiatric must be followed up within seven days of
discharge. Where a patient has been transferred to prison, contact should be made via
the prison in-reach team. The seven-day period should be measured in days not hours
and should start on the day after the discharge.
Exemptions include patients who are re-admitted within seven days of discharge;
patients who die within seven days of discharge; patients where legal precedence has
forced the removal of the patient from the country; and patients transferred to an NHS
psychiatric inpatient ward.
All CAMHS (child and adolescent mental health services) patients are also excluded.
Accountability
Achieving at least a 95% rate of patients followed up after discharge each quarter.
More detail about this indicator and the data can be found within the Mental Health
Community teams Activity section of the NHS England website.
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Admissions to inpatient services had access to crisis resolution home treatment
teams
Detailed descriptor
The percentage of admissions to acute wards for which the Crisis Resolution Home
Treatment Team (CRHT) acted as a gatekeeper during the reporting period
Data definition
In order to prevent hospital admission and give support to informal carers, CRHT are
required to gatekeep all admission to psychiatric inpatient wards and facilitate early
discharge of service users.
Numerator
The number of admissions to the trust’s acute wards that were gatekept by the CRHT
during the reporting period.
Denominator
The total number of admissions to the trust’s acute wards.
Details of the indicator
An admission has been gatekept by a crisis resolution team if it has assessed the
service user before admission and was involved in the decision-making process which
resulted in an admission. An assessment should be recorded if there is direct contact
between a member of the CRHT team and the referred patient, irrespective of the
setting, and an assessment is made. The assessment may be made via a phone
conversation or by any face-to-face contact with the patient.
Exemptions include patients recalled on Community Treatment Order; patients
transferred from another NHS hospital for psychiatric treatment; internal transfers of
service users between wards in the trust for psychiatry treatment; patients on leave
under Section 17 of the Mental Health Act; and planned admissions for psychiatric care
form specialist units such as eating disorder units.
Partial exemption is available for admissions from out of the trust area where the patient
was seen by the local crisis team (out of area) and only admitted to this trust because
they had no available beds in the local area. Crisis resolution team should assure
themselves that gatekeeping was carried out. This can be recorded as gatekept by
crisis resolution teams.
This indicator applies to patients in the age bracket 16-65 years and only applies to
CAMHS patients where they have been admitted to an adult ward.
Accountability
Achieving at least 95% of patients in the quarter.
More detail about this indicator and the data can be found within the Mental Health
Community teams Activity section of the NHS England website.
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Local Indicator
Safety incidents involving severe harm or death
Indicator description
Patient safety incidents reported to the National Reporting and Learning Service
(NRLS), where degree of harm is recorded as ‘severe harm’ or ‘death’, as a percentage
of all patient safety incidents reported.
Indicator construction
Numerator: The number of patient safety incidents recorded as causing severe
harm/death as described above.
The ‘degree of harm’ for PSIs is defined as follows;
‘severe’ – the patient has been permanently harmed as a result of the PSI, and
‘death’ – the PSI has resulted in the death of the patient.
Denominator: The number of patient safety incidents reported to the National Reporting
and Learning Service (NRLS).
Indicator format: Standard percentage.