Quality Report 2012 - 2013
Cambridgeshire and Peterborough NHS Foundation
Trust
CONTENTS
INTRODUCTION TO THE QUALITY ACCOUNT
All NHS Trusts are required to produce an annual Quality Report. The purpose of this report is to
show how well we have performed in the past year and the areas where we feel we could make
further improvements. We aim for transparency and openness to provide you with accurate,
appropriate and sufficient information with which to assess our performance and the priorities we
have set for the future.
The key requirements of the Quality Report are set out in three sections below.
PART 1: STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
This is a statement from our Chief Executive, Dr. Attila Vegh, on behalf of the Board of
Directors setting out what quality means to us, what improvements we have made in
the past year and where we need to make further improvements, and our vision for
the future.
Chief Executive’s Statement
3
PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE
We present our strategic objectives that we believe will help us achieve our goal of
becoming a top 5 mental and community healthcare provider. We also review our
progress on quality priorities in 2012/13 identified in our 2011/12 Quality Report and in
previous years, and outline our quality improvement priorities for 2013/14.
The Statement of Assurance is a mandatory requirement and we confirm that the
Trust is able to meet all of the mandated requirements for the Trust.
Priorities for Improvement
6
Statements of Assurance
20
Mandatory Core Set of Quality Indicators
33
PART 3: OTHER INFORMATION
We report on performance against local quality performance indicators and key
national priorities.
Review of Performance Against Other CPFT Quality Indicators and Key
National Priorities
41
ANNEX
ANNEX 1
Our Quality Diamond Strategy
60
ANNEX 2
Definitions of Key National Quality Indicators
64
ANNEX 3
Statements from the Clinical Commissioning Board, the Local Healthwatch and
the Overview and Scrutiny Committees
67
ANNEX 4
Statement of Directors' Responsibilities in Respect of the Quality Report
70
ANNEX 5
External Audit Report
72
Page 2 of 74
PART ONE: A STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
Introduction
I am delighted to present our fourth Quality Report, and my second as Chief Executive of
Cambridgeshire and Peterborough NHS Foundation Trust (CPFT). Over the past year, we have
achieved many great things which I am very proud to present to you in this report.
What do we mean by quality?
Quality is at the core of everything we do, it is inherent within our values, our mission and our
vision. We view quality from the perspective of the people who experience it - our patients, their
families and carers, visitors to our premises and our staff – and this underpins our priorities for
quality which are outlined below.
Back in 2011 we developed a Quality Dashboard, mapped against the Care Quality Commission’s
Essential Standards of Quality and Safety, which sets out the key areas that we felt we could
reliably measure and that would tell us whether or not we are providing a good service. During the
year, this was translated into Divisional quality dashboards and embedded into our reporting and
governance framework.
For 2013/14, we will focus on our vision to become a top 5 mental and community healthcare
provider. To help us achieve this goal, we have developed four strategic objectives which are
outlined in our Quality Diamond Strategy. They cover the areas of patient safety, patient
experience, staff engagement and value for money. We have also reviewed our progress on
quality priorities identified in previous years and developed new priorities which are set around the
three domains of quality – patient experience, patient safety and clinical effectiveness. We believe
these quality objectives and priorities will further improve the care and outcomes for the people
who use our services, and also the experience and well being of our staff.
Our staff have helped us to identify these priorities through a series of Town Hall events organised
across the organisation to find out what their views were and what they thought was important. We
have also worked with our commissioners, governors and other key partners; and also reviewed
the range of data and other information that was available to us, including information from audits,
incidents, comments and complaints about our services, and the results of service reviews to help
us identify the areas that we need to focus on for improvement in 2013/14.
What have we done well this year?
Two years ago, CPFT was judged non-compliant in seven of the CQC standards of care and was
considered one of the worst performing Trusts in the East of England. I took up my post as Chief
Executive of the Trust in October 2011 and we began the difficult and challenging work of turning
the Trust around. Coming into 2012/13, we were faced with many difficult challenges. We were
still non-compliant in two of the CQC standards and had improvement actions required in two
more. Following an inspection in June 2012, we were found to be non-compliant in one other
standard around the management of medicines.
As we approached the end of 2012/13, we were declared fully compliant across the organisation.
This is a massive achievement and I believe the most important for CPFT to date and this is all
down to the phenomenal hard work and dedication shown by our staff. Without them, this wouldn’t
have been possible.
We also reviewed our governance and operational structures to further strengthen our systems
and processes and help us deliver on our objectives and priorities. In January 2013, we
implemented our new governance framework. Our Clinical Divisions were reduced from five to
three, and developed around diagnosis and needs as opposed to age groups. We believe that this
will enable us to deliver better care and outcomes for the people who use our services.
In terms of our Quality Accounts, we have met four out of nine quality priorities for 2012/13 and
partially met one, and six out of eight CQUIN goals for the year.
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But that is not all. Despite the areas of concern highlighted by the CQC, we have continued to
excel in our practice and service delivery. Some of the many achievements CPFT have made over
the past year are outlined below.
In June 2012 the Cambridgeshire Child and Adolescent Substance Use Service (CASUS)
won the Virgin Business Media and Guardian’s “innovation nation” award for collaboration.
CASUS is part of the AMBIT collaboration - a group of teams who are all working with
extremely vulnerable and high-risk youth who have multiple and complex problems.
CPFT’s Youth Offending Service was rated in the top 5 in the UK
CPFT’s Dementia Carers’ Support Service won a Cambridge News Community Award.
The opening a new dementia research facility at the refurbished Windsor House in Fulbourn.
The facility is the new home of the Dementia and Neurodegenerative Diseases Research
Network East Anglia.
The opening of Recovery College East, the first of its kind in the East of England. Courses
will be held at venues throughout Cambridgeshire and Peterborough, and will include
subjects such as helping people return to employment, staying well at work, getting the best
from mental health services and physical health and recovery.
CPFT was re-awarded the Ministry of Defence contract to provide local in-patient mental
health care for serving military personnel in the eastern region at The Cavell Centre in
Peterborough.
What do we need to do better?
We recognise that we have a lot do to rebuild staff morale in the coming year. Successfully
implementing a major turnaround programme required a lot of hard work and changes to our ways
of working and this has been reflected in our staff survey scores in 2012, both from the national
survey and our internal Pulse Surveys. Our commitment to our staff is embedded in our Quality
Diamond Strategy through the initiatives to become a top 5 community and mental health
organisation for staff engagement. Over the coming months, we will introduce a range of initiatives
to improve the experience of our staff.
We also need to focus on the areas in our quality priorities where we have not met the targets set
in 2011/12. This includes better compliance with our mandatory training programme and improving
staff satisfaction with the response times to IT requests. We have developed a range of actions to
help us do this, which is outlined in Part 2 of this report. In addition, we have identified other areas
where we need to do better particularly around provision of psychological therapies and physical
health outcomes for our patients. These are included in our priorities for 2013/14.
A huge thanks to our staff
All of the achievements we have made in the past year would not have been possible without the
hard work, dedication and commitment of our staff so I would like to take this opportunity to
formally thank them for everything that they have done which has brought us to where we are
today. I am very proud of every member of our staff and I know that together, we have the
capability and energy to continue to achieve many more great things in the years to come.
Some of the many initiatives we have started during the year to show our appreciation to our staff
include giving out the Quality Heroes and the Quality Champion awards. We also celebrated our
very first ever Staff Awards ceremony in February 2013, to recognise the achievements of
individuals in categories of patient experience, patient safety, staff engagement, productivity, good
governance and research innovation and education, among others. Over the coming months, we
will continue to think of ways to thank our staff and recognise their achievements.
What others think of us?
We welcome opportunities for external bodies to review our services to see how well we are
meeting the standards of quality and safety. During the year, the CQC assessed our services
against these standards on two occasions and they have judged us fully compliant against the
standards they examined. They also conducted specific visits to review our compliance with the
Page 4 of 74
Mental Health Act. I am proud to say that the feedback we have received has been extremely
positive.
We took part in a number of accreditation schemes during the year. For example, The Croft Child
and Family Centre was accredited by QNIC (Quality Network for Inpatient CAMHS) in October
2012, and our Adults and Learning Disability inpatient units are accredited under AIMS
(Accreditation for Inpatient Mental Health Services).
We also value the comments and learning that we get from PALS (Patient Advice and Liaison
Service) and Complaints and also from the results of our internal patient and staff survey as these
give us a very useful insight into the areas that we can and need to improve.
Statement of accuracy
I confirm that to the best of my knowledge the information in this document is accurate.
DR ATILLA VEGH
CHIEF EXECUTIVE
24 MAY 2013
Page 5 of 74
PART TWO: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF
ASSURANCE FROM THE BOARD
1.0
PRIORITIES FOR IMPROVEMENT
In this section we introduce our overarching strategy for quality which is embedded in our
Quality Diamond Strategy below. We also report on our performance in 2012/13 against
the quality priorities set in 2011/12.
It is important to show continuity when reviewing quality priorities between accounts
especially where priorities have changed over time. We therefore look back at our priorities
from previous years and provide an update on progress we have made during 2012/13 and
state how we will continue to measure, maintain and develop these priority areas.
Finally, we present our quality priorities for 2013/14.
1.1
QUALITY DIAMOND STRATEGY
2011/12 was a difficult and challenging year for the Trust due to the demands placed on the
organisation to consistently achieve all of the CQC essential standards of quality and
safety.
During 2012/13 we also developed our ambition to become a top 5 mental and community
healthcare provider which we have outlined over the following pages.
At the beginning of 2012/13, we started work to build on our successes and look forward to
2013/14. The second phase of the staff Town Hall events was held in June 2012 to identify
the key areas that everyone within the organisation wanted to prioritise in order to improve
the quality and experience of our services. Over 2,000 of our staff attended the events and
their ideas have helped us to formulate our strategic objectives for 2013/14.
These strategic objectives are
outlined within the Quality Diamond
which we published in December
2012, and are shown in the diagram
on this page. The four strategic
objectives are:
To become top 5 nationally for
patient safety
To become top 5 nationally for
patient experience
To become top 5 nationally for
engaged staff
To become top 5 nationally for
value for money
We have set out further details in
Annex 1. Our Quality Diamond
Strategy underlines our quality
priorities and quality dashboard for
2013/14.
We have already started implementing a number of these initiatives, and over the coming
months we will continue to roll out a series of actions and initiatives to support the
achievement of these objectives. We will publish regular reports on our progress against
the Quality Diamond priorities on our public website.
Page 6 of 74
A Review of Our Quality Priorities for Improvement
Patient Experience
2010/11
Priority 1 
Improvement in annual
Patient Survey
responses for overall
satisfaction rating
Priority 2 
Ensure 95% of patients
have a care plan
Patient Safety
Priority 3
Reduce all suicides by
patients in contact with
secondary mental health
services by 20% by 2013
Priority 4
Reduce the number of
physical assaults within
Trust services by 20% by
2013
Priority 1 
To develop routine patient
feedback mechanisms
across all care pathways
Priority 2 
To develop and
implement a Carer
Strategy
Priority 3
To establish with primary
care a Suicide Prevention
Strategy
Priority 4 
Reduce the risk of
absconsion through a
review of clinical risk
assessment observations,
access and therapeutic
programmes
Priority 5 
Significantly
strengthening patient
safety training in adult
safeguarding, clinical risk
assessment and physical
interventions
Priority 5 
Compliance with 18 week
referral to treatment
waiting time target
Clinical Effectiveness
2011/12
Priority 6
Ensure that 95% of CPA
patients have a HoNOS
outcome assessment in a
12 month period
Priority 6 
To develop and
implement a consistent
recovery outcome
measure which involves
service users directly in
planning their care
2012/13
2013/14
Priority 1 
To provide safe and
effective care which
provide excellent
customer services
1. Full compliance with
CQC standards
2. 95% of care plans
across the Trust will
sustainably achieve
7Cs standards
3. 80% inpatients and
74% community
patients will
recommend CPFT to
family & friends
Priority 1
To improve the
experience of our patients
and our staff
1. 65% of our patients
will be satisfied with
the quality of our
services and
recommend our
services to their
family and friends
2. 60 % of our staff will
recommend CPFT to
care for their friends
and family
3. 60% of our staff will
recommend CPFT to
friends and family as
a good place to work
Priority 2
To provide an estate and
IT infrastructure that is
safe, moderns and fit for
purpose.
1. All premises will
achieve at least 4
stars against our
environmental
standards 
2. 85% of our people will
describe IT response
times as good or very
good
Priority 2
To strengthen the culture
of safety in CPFT.
4. Our teams will
achieve a Trust wide
average InCA score of
95% by Qtr4 of
2013/14
5. 95% of our people will
complete
safeguarding adults
and safeguarding
children training
6. 65% of our people will
describe IT response
times as good or very
good
Priority 3
To provide services
through empowered staff
with the right skills,
attitudes and behaviour
1. 85% of our people will
state they are able to
make changes they
feel necessary for
excellent patient care
2. We will achieve
national upper 20% in
the number of our
people who state that
they will recommend
CPFT to their family
and friends as a place
to work
3. 95% of our people will
have completed all
their mandatory
training
4. No more than 5% of
our inpatient shifts will
have temporary staff
greater than 20% of
all staff at work
Priority 3
To improve outcomes of
care for our patients
1. 98% of relevant
admissions to our
acute wards gatekept
by Crisis Resolution
Home Treatment
Team
2. Achieve the 60%
national target in the
proportion of people
referred for
psychological therapy
who receive
psychological therapy
3. Improve physical
health outcomes for
our patients
Page 7 of 74
1.2
REVIEW OF QUALITY PRIORITIES 2012/13
We have reviewed our performance against the nine indicators within our quality priorities
for 2012/13. We have fully met four indicators, partially met one and not met four. This is
described below.
1.2.1
PRIORITY 1: PATIENT EXPERIENCE
2012/13 Priority
To provide safe and effective care which provide excellent customer experience.
Trust indicators
1.
Full compliance with the Care Quality Commission (CQC) Essential
Standards for Quality & Safety in any Trust registered location
2.
95% of care plans across the Trust will sustainably achieve the 7Cs
standards.
3.
80% of inpatients and 74% of community service users will recommend
CPFT to their family and friends
Performance
1. Full compliance with the Care Quality Commission
(CQC) Essential Standards for Quality & Safety in
any Trust registered location
As of March 2013, the current registration status
of CPFT with the CQC is ‘Registered Without
Conditions’.
Please refer to section 2.6 for further details on
our achievements in this area.
2. 95% of care plans across the Trust will
sustainably achieve the 7Cs standards.
The 7Cs standards were developed to help us
drive up the quality of our assessments and care
planning processes and documentation. The
7Cs assessment process was later incorporated
into the InCA (Integrated Compliance
Assessment) process.
7Cs scores are reported through our quality
dashboards.
Thresholds were set on an incremental basis
from 75% to 95%. The overall combined Trust
average score for Quarter 4 is 94% across all
participating teams.
It is worth noting that the results of our National
Community Patient Survey 2012 show
improvements in our scores overall, with the
biggest improvements in the questions around
care planning. Refer to section 3.1.3 for details.
Quality improvements
Care Planning Guidelines
booklet developed to
support the 7Cs standards
and to articulate the
standards around
involvement of patients and
carers in the assessment &
care planning process
Care Planning Policy was
reviewed and updated to
clarify required standards
of practice and incorporate
the 7Cs standards.
InCA was developed as an
Excel-based tool and later
converted into an iPad
application in September
2012. This is used to
assess and provide
assurance of compliance
with all 16 CQC Outcomes
on a monthly basis and
incorporates our 7Cs care
planning and 5 star
environmental standards.
Teams undertake self
assessments with quarterly
peer reviews.
Page 8 of 74
3. 80% of inpatients and 74% of community service users will recommend CPFT to their
friends and family
This target was originally set based on the results of the national patient surveys for
both inpatients and community services. During 2012/13, however, CPFT along with
many others in the East of England (EoE), decided, at the instigation of the EoE
Strategic Health Authority, to change the way that this indicator was calculated to one
based on the net promoter score (NPS) methodology. This resulted in the revisions to
the targets that are set out below.
The average score for the Trust and its constituent Divisions as at year end March 2013
are shown in Table 1 below.
Table 1: Friends & family test
Revised Target
Division
12/13
Acute Care Service
Community Service
Specialist Service
30%
30%
30%
Performance as of
March 2013
Total Trust average
score March 2013
26%
62%
34%
40.7%
Scores are collected from our internal patient surveys and are reported through our
quality dashboards (see sections 3.1.4 and 3.1.5).
Overall, the Trust has exceeded the targets for this indicator although recognising that
patient experience is variable across our different Divisions. In 2013/14 we have
agreed differential targets for patient experience to reflect the nature of the services we
provide.
This has been carried forward as our quality priority for 2013/14 with an ambition to see
substantial improvements across all three Divisions.
Page 9 of 74
1.2.2
PRIORITY 2: PATIENT SAFETY
2012/13 Priority
To provide an estate and IT infrastructure that is safe, modern and fit for purpose.
Trust Indicators
1. All premises will achieve at least 4 stars against our 5 star environmental
standards.
2.
85% of our people will describe IT response times as good or very good
Performance
1. All premises will achieve at least 4 stars against our
5 star environmental standards
The 5 star standards were developed to assess the
safety and suitability of our environment and
equipment. The 5 star standards incorporated
requirements around infection control, cleanliness,
privacy and dignity. Wards have to score 100% to
be awarded a ‘star’ against each of the five
domains. This was introduced in our wards in
January 2012 with varying results in the first three
months of roll out. The 5 star standards were later
incorporated into the InCA assessment process
(see notes in Priority 1.2.1).
Scores throughout the year, reported as part of our
quality dashboard, show that all of our 21 wards
have achieved at least 4 stars during the period.
We continue to monitor our performance on this
indicator regularly through our quality dashboards
to ensure that issues are identified and acted upon
in a timely manner. This shows our commitment to
maintaining the quality of our environment and
equipment to protect the safety of our patients,
visitors and staff.
Quality improvement
Environmental work was
undertaken in all of our
inpatient units throughout
the year particularly focusing
on the removal of ligature
points, reinforcing our doors
and windows, making our
wards compliant with Same
Sex Accommodation
standards and overall
redecoration and
refurbishment. Outside,
entrances to the wards were
improved, fences were
raised and benches
secured, among others.
Environmental work has now
been rolled out to our
community premises.
2. 85% of our people will describe IT response times as good or very good
This was a new indicator for the Trust and data was collected during the year through
our staff Pulse Surveys which appears on the computer screens when staff log on. As
of March 2013, the total average scores across the three Divisions show that only 43%
of staff rate IT response times as ‘good’ or ‘very good’.
Actions taken
Further work will be undertaken to determine the specific areas of performance that
staff are not happy about. Discussions are being held with SERCO, our IT service
provider, in order to address these areas and ensure improvement of staff satisfaction
scores around IT response time.
This has been carried forward as our quality priority for 2013/14.
Page 10 of 74
1.2.3
PRIORITY 3: CLINICAL EFFECTIVENESS
2012/13 Priority
To provide services through empowered staff with the right skills, attitudes and behaviours.
Trust Indicators
1. 85% of our people will state that they are able to make the changes that
they feel necessary for excellent patient care.
2.
We will achieve the national upper 20% in the number of our people who
state that they will recommend CPFT to family and friends as a place of
work.
3.
95% of our people will have completed all their mandatory training.
4.
No more than 5% of inpatient shifts will have temporary staff greater than
20% of all staff on that shift.
Performance
1. 85% of our people will state that they are able to make the changes that they feel
necessary for excellent patient care.
This was a new indicator for the Trust. Data is collected through our staff Pulse
Surveys and scores are reported through our quality dashboards. Trust scores for
2012/13 show that, on average, only 46% of staff stated that they are able to make
changes necessary for excellent patient care.
We are introducing a range of quality improvement initiatives to promote and support
staff engagement and involvement in matters that are important to patient care as part
of our ‘Big Conversation’ programme. These are outlined section 5 of this report
(Workforce Factors).
Actions for this indicator are linked to the Trust National Staff Survey action plan which
includes developing a Workforce Strategy in consultation with staff (see section 5).
2.
We will achieve the national upper 20% in the number of our people who state that they
will recommend CPFT to family and friends as a place of work.
The 2012 National NHS Staff Survey results show that CPFT is in the bottom quartile
when compared to similar Trusts for the percentage of our staff who would recommend
CPFT to family and friends as a place of work, scoring 33% (against the national
average of 53%) compared to 48% in 2011. Data from our own internal Pulse Surveys
is currently showing a much higher score of 48% as of March 2013.
We recognise that this is largely due to the challenges faced by our staff in the past
year as part of the quality turnaround programme. We are introducing a range of
improvement initiatives to improve the experience of our staff through our ‘Big
Conversation’ programme which is outlined in section 5 (Workforce Factors). However,
we acknowledge that we have a lot to do improve the way our staff feel about their
work and CPFT.
Actions for this indicator are linked to the Trust National Staff Survey action plan (see
section 5)
Our commitment to our staff is reflected in our Quality Diamond Strategy (Objective 2)
and this measure has been carried forward as our quality priority for 2013/14.
Page 11 of 74
3. 95% of our people will have completed all their mandatory training.
As of March 2013, overall mandatory training stands at 85%, as follows:
94% for mandatory gateway E-learning
82% for mandatory physical skills modules
80% for mandatory clinical skills modules
Performance against this indicator is reported through our quality dashboards.
Although falling short of the 95% target that we have set ourselves, this represents a
significant improvement over 68% in 2011/12.
Classroom-based training data is collected from ESR (Electronic Staff Records) while
e-learning data is collected from LMS (Learning Management Systems).
A Project Group was formed during the year to drive achievement of this target. This
has been continued in 2013/14 to ensure continued improvements.
4. No more than 5% of inpatient shifts will have temporary staff greater than 20% of all
staff on that shift.
Ensuring that our wards have the right staffing levels with the right skills is a priority of
the Trust, and our commitment to achieving this is embedded in Objective 2 of our
Quality Diamond Strategy.
This was a new indicator for the Trust. Data is collected from our electronic rostering
system (MAPS) and reported through our quality dashboard. During the year this
indicator was reviewed and revised and is now reported in our quality dashboard as the
percentage of bank and agency shifts used as a proportion of total shifts on the ward.
As of March 2013, this came to 24.70% which is significantly over our target of 5%
This remains a priority of the Trust and is monitored through our quality dashboards.
We have undertaken a major review of inpatient and community establishments during
2012 including the use of temporary staff through the PET Project (see below). The
implementation of the findings of this review will ensure that the use of temporary staff
will reduce to 5% by mid 2013/14
PET (Productivity, Establishment & Temporary Staff) Project
The PET project was established in January 2013 following a detailed review of
ward establishments and use of temporary staff in late 2012.
There are three key work streams in Phase 1 which is due to be completed in
September 2013:
Work stream 1: Delivering the new 333 staffing establishment model. This is
currently being rolled out in selected inpatient units in the Cambridge area.
Work stream 2: Making operational changes. This includes looking at shift
pattern changes, eradicating restrictive shift patterns, absence management and
looking at areas where productivity can be improved (e.g. administrative support
and introduction of the RiO electronic patients records system).
Work stream 3: This looks at the performance and effective sourcing of bank
staff and effective utilisation of MAPS, our electronic rostering system.
Phase 2 focuses on productivity and new ways of working and is planned to be
completed by March 2014
Page 12 of 74
REVIEW OF QUALITY PRIORITIES SET IN PREVIOUS YEARS
In this section, we look back at the priorities we set in 2010/11 and 2011/12 and provide an
update on progress made to March 2013. This allows us to show how we continue to
measure, maintain and develop these areas even when new priorities become the focus of
improvement.
Patient Safety
Patient Experience
2010/11
As of March 2013, we have met three out of six of our quality priorities and partially met
three from 2010/11, and we have met five out of six quality priorities and partially met one
from 2011/12. These are outlined below.
Clinical Effectiveness
1.3
Quality Priority
Priority 1 
Improvement in annual
Patient Survey
responses for overall
satisfaction rating
Priority 2 
Ensure 95% of
patients have a care
plan
Priority 3
Reduce all suicide by
patients in contact with
secondary mental
health services by
20% by 2013
Priority 4
Reduce the number of
physical assaults
within secondary
mental health services
by 20% by 2013
Priority 5 
Compliance with 18
week referral to
treatment waiting time
target
Priority 6
Ensure that 95% of
CPA patients have a
HoNOS outcome
assessment in a 12
month period
Update on Progress as of March 2012/13
Results of our annual National Community Patient Survey show an
overall improvement in our scores for 2012 and an improving trend
over time (see section 4.1.2 for further details).
This remains a Trust priority and is reported in Part 3 of this Quality
Report.
We have consistently achieved this target over the last three years.
In 2012/13, we changed the focus to improving the quality of our
care plans which we have also achieved (see sections 1.2.1 and
4.3.1 for further details).
This remains a Trust priority and is reported in Part 3 of this Quality
Report and monitored throughout the year through our quality
dashboard.
Data available as of March 2013 shows an 11% reduction between
2010/11 and 2012/13 in the total number of deaths with a verdict of
suicide and probable suicides, where the verdict was misadventure,
accidental death, cause unknown/unexpected, or cases where we
have not yet received a verdict from the coroner.
This remains a Trust priority, and we have commissioned an
independent review of inpatient Serious Incidents (SIs) by Professor
Louis Appleby from Manchester University to help us identify the
areas where we can make further improvements.
As of March 2013 there was an 11% reduction between 2010/11
and 2012/13 in the total number of physical assaults reported.
This remains a Trust priority and we have improved our training on
the assessment and management of violence and aggression. We
will continue to monitor this through our quality dashboard.
Although our children’s community services had breaches in two of
their services, the Trust’s overall average referral to treatment time
was 1.97 weeks as of March 2013 compared to 4.08 weeks in
2011/12.
This remains a Trust priority and is reported through our quality
dashboard.
As of March 2013, 85% of CPA patients had a HoNOS assessment.
This remains a Trust priority and we are addressing the issues
around the electronic Mental Health Clustering Tool (MHCT) and
our electronic Clinical Documents Library (CDL) system. This is
reported through our quality dashboards.
Page 13 of 74
2011/12
Patient Experience
Quality Priority
Priority 1 
To develop routine patient
feedback mechanisms across
all care pathways
Update on Progress as of March 2012/13
Meridian, the IT solution to collect patient experience
information, was rolled out to inpatient teams in January
2012 and community teams in April 2012. Routine patient
feedback is collected using an iPad every month and results
are reported as part of the quality dashboards.
This remains a Trust priority and is reported in Part 3 of our
Quality Report (see sections 4.1.3 & 4.1.4).
Priority 2 
To develop and implement a
Carer Strategy
The Partnerships Strategy 2013-2016 was developed during
the year and is due to be approved in May 2013. This will
drive forward our approach to develop and improve the way
we inform, consult, listen, involve and empower people
involved in our services.
This remains a Trust priority moving forward.
Patent Safety
Priority 3
To establish with primary
care a Suicide Prevention
Strategy
Priority 4 
Reduce the risk of
absconsion through a review
of clinical risk assessment,
observations, access and
therapeutic programmes
Within the region, Public Health England is leading on the
suicide prevention agenda and is in the process of
developing a regional Suicide Prevention Strategy. The
Trust is a member of the Joint Countywide Suicide
Prevention Group. CPFT is currently developing its own
Suicide Prevention Strategy, ensuring that this links with the
Public Health agenda and reflects the national strategy. This
is due to be ratified in May 2013.
This remains a Trust priority and will be reported in Part 3 of
the Patient Safety section of future Quality Reports.
We have put measures in place such as improving our
clinical risk assessment training, developing a policy and
improving arrangements around access to our wards,
carrying out environmental work, which includes reinforcing
doors and windows, raising the height of garden walls and
moving garden benches away from the garden walls, among
others. These measures have resulted in a 10% reduction in
the number of absconsions between 2011/12 and 2012/13.
This remains a Trust priority and is reported through our
quality dashboard.
Clinical Effectiveness
Priority 5 
Significantly strengthening
patient safety training in adult
safeguarding, clinical risk
assessments and physical
interventions
Priority 6 
To develop and implement a
consistent recovery outcome
measure which involves
service users directly in
planning their care
Although we have just missed the target of 95% as of March
2013, compliance rates in mandatory training is much
improved and we are only slightly below our agreed target.
This remains a Trust priority and is reported through our
quality dashboard.
We have introduced measures to support this objective, such
as the introduction of the HoNOS outcome scales,
strengthening collaborative care planning and the
involvement of patients and carers in planning their care
through the development of 7Cs standards.
We are now working with Clinical Divisions to help them
identify Patients Reported Outcome Measures (PROMs) that
are specific to their services and the needs of their patient
group. These will be incorporated into their Divisional quality
dashboards.
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1.4
QUALITY PRIORITIES FOR 2013/14
The priorities for quality improvement for 2013/14, outlined below, have been developed as
a result of the following:
We have listened to feedback from our patients and their families, our staff, our
commissioners, governors, regulators and other stakeholders.
We have reviewed information from various sources such as PALS and Complaints,
patient and staff surveys, serious incidents, incidents and near misses, clinical audits,
research, service development projects and external service reviews.
We commissioned external auditors to review our systems to support effective quality
governance within the Trust.
Please refer to the summary of our Quality Diamond Strategy in Annex 1 for additional
details on the improvement initiatives.
1.4.1
PATIENT EXPERIENCE
Priority 1: To improve the experience of our patients and our staff.
1 65% of our patients will be satisfied with the quality of our services and recommend our
services to their family and friends
2 60% of our staff will recommend CPFT to care for their friends and family
3 60% of our staff will recommend CPFT to friends and family as a good place to work
Rationale for Inclusion
We believe that a basic indicator of quality is when people state they are satisfied with
the quality of the services that we offer and are happy to recommend CPFT to their
family and friends. We also believe that there is a strong correlation between staff
satisfaction and patient satisfaction. If our staff believe that they are respected, valued
and supported, this will have a direct impact on the quality of their interaction with our
patients and the care that they provide.
We have chosen these indicators as our Net Promoter Scores (NPS), in conjunction
with the Department of Health (DH) guidance.
Measurement
Data for these indicators will be taken from our internal monthly patient satisfaction survey
and staff Pulse Survey.
Improvement initiatives
We are working with our commissioners to refine the questions around the quality of our
services in our patient and staff Pulse surveys.
Patient experience
Develop Care Pathway services
Implement year 1 action plan from
Engagement Strategy
Continue to roll out our Recovery
College East
Develop a new Social Care Strategy
Implement Big Conversation initiatives
Staff experience
Continue to roll out the CPFT Academy
To continue with the ‘Quality Heroes’
and ‘Team Champions’ initiative
Continue to strengthen staff
communication (e.g., Webex sessions,
Town Hall events& Diamond Talkback)
Implement Big Conversation initiatives
Monitoring and Reporting
Monthly quality dashboard reporting, Divisional Performance Review meetings and regular
reporting to Quality & Performance Committee and the Trust Board.
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1.4.2
PATIENT SAFETY
PRIORITY 2: To strengthen the culture of safety in CPFT
1
2
3
Our teams will achieve a Trust wide average InCA score of 95% by Qtr4 of 2013/14
95% of our people will complete safeguarding adults and safeguarding children training
65% of our people will describe IT response times as good or very good
Rationale for Inclusion
The quality of assessments, risk assessments and care planning have a direct impact
on the provision of safe and effective care. The standards around these are embedded
in InCA which is used to assess the performance of our clinical teams. InCA also
covers all 16 CQC outcomes which include standards around premises and equipment,
safeguarding and safety, cleanliness and infection control, among others. Compliance
with these standards will help us ensure the safety and wellbeing of our patients,
visitors and staff.
Providing quality service is dependent upon having staff with the right skills, knowledge
and experience, and providing them with appropriate systems and processes.
Safeguarding training is mandatory and as of March 2013, our compliance rates are
94% for safeguarding adults and 88% for safeguarding children. We need to improve
on these compliance rates to ensure that our staff know how to recognise and act
appropriately when they observe safeguarding incidents.
Finally, we need to ensure that our staff have the information that they need in a timely
manner to provide safe and effective care. This is dependent upon having IT systems
that are appropriate, responsive and fit for purpose.
Measurement
Data for these indicators will be taken from monthly InCA assessments, quality dashboards,
incident reporting and staff Pulse Surveys.
Improvement initiatives
Regular review of the InCA assessment tool and process, development of servicespecific standards and roll out to the rest of our community-based services.
Pilot the ‘No Force First’ initiative in selected inpatient services
Roll out of RiO, our electronic clinical records system, to the rest of the Trust.
Monitoring and Reporting
Monthly quality dashboard reporting, Modern Matrons meetings, Divisional Performance
Review meetings and regular reporting to the Clinical Executive, Quality & Performance
Committee and the Trust Board.
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1.4.3
CLINICAL EFFECTIVENESS
PRIORITY 3: To improve outcomes of care for our patients
1
2
3
98% of relevant admissions to our acute wards are gatekept by Crisis Resolution Home
Treatment Teams (CRHTT)
Achieve the 60% national target across all three IAPT services for the proportion of
people referred for psychological therapy who receive psychological therapy.
Improve the physical health outcomes for our patients
Rationale for Inclusion
Assessment by the CRHTT prior to admission into acute inpatient units ensures that
only patients who need inpatient care are admitted into our wards and that the patient
has the most appropriate plan of care agreed by all relevant parties, including the
patient. As of March 2013, our internal reports show that 95% of patients admitted to
CPFT inpatient units were assessed by CRHTT. Data reported by the Health and
Social Care Information Centre (HSCIC) as of December 2012 shows the national
average at 98% with 29% (n=18) of mental health Trusts achieving 100% compliance.
We need to improve on this performance.
NICE guidance and quality standards recommend the use of psychological therapies for
the treatment of psychological disorders either on its own or alongside traditional
medication. The Department of Health has promoted the use of psychological
therapies through the establishment of IAPT (Improving Access to Psychological
Therapies) services. As of March 2013, not all of our IAPT services met the national
60% target for the proportion of our patients referred for psychological therapy who
receive psychological therapy. We need to achieve this target across the Trust.
A high level scoping of physical health monitoring in CPFT shows that we need to
improve our arrangements in this area. This is supported by findings from national and
local audits. This is also a CQUIN target for 2013/14 covering inpatient services. .
Measurement
For priorities 1 and 2, data will be taken from the quality dashboards and contractual
performance reports. In regards to the physical health priority, we will
review the existing policies on physical health (inpatient and community) and develop
an inclusive Physical Health Policy.
develop a Physical Health dashboard. This will provide us with baseline information
from which we can set improvement targets for 2014/15.
Improvement Initiatives
Review and update the Psychological Therapies Strategy
Review the referral process and pathway into care across all three IAPT services to
streamline the process and achieve consistency across the Trust.
Trust wide review of Physical Health monitoring arrangements (new project) to identify
gaps and develop appropriate actions.
Develop Physical Health Policy, Physical Health dashboard and improve training
around physical health for frontline staff
Monitoring and Reporting
Monthly quality dashboard reporting, Divisional Performance Review meetings and regular
reporting to the Clinical Executive, Quality & Performance Committee and the Trust Board.
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1.5
HOW WE WILL MONITOR THESE PRIORITIES
We reviewed our governance structure based on recommendations from PwC to strengthen
the quality governance arrangements in the Trust. The new governance framework, which
will provide assurance that the Trust is meeting our strategic objectives and priorities, was
approved by our Board of Directors in February 2012.
1.5.1
ASSURANCE AT TRUST LEVEL
The governance committee structure responsible for monitoring our Trust’s objectives and
priorities is outlined below.
Board of Directors
Audit & Assurance Committee
Patient Safety, Risk &
Experience Group
Quality & Performance Committee
Executive
Management
Group
Performance & Risk
Executive
Clinical Effectiveness
Group
Finance Executive
Research & Development
Group
Mental Health Legislation
Group
Clinical Executive
Workforce Executive
Professional Development
& Education Group
The Audit & Assurance Committee and the Quality and Performance Committee have the
primary responsibility for obtaining assurance, on behalf of the Trust Board, that the Trust is
discharging its duties properly and that it is meeting its strategic objectives.
The Executive Management Group is chaired by the Chief Executive and has an
operational management responsibility for the Executive committees, which are responsible
for reviewing and making recommendations on the strategic direction of the Trust.
The Quality & Performance Committee is the main Board subcommittee responsible for
monitoring our compliance against the quality improvement priorities throughout the year
through position summaries on a regular basis. It will also inform the Board of our delivery
against these priorities alongside the regular reports on the Divisional quality dashboards to
provide assurance of continued improvements in the delivery of care across the Trust.
1.5.2
ASSURANCE AT OPERATIONAL LEVEL
Clinical and integrated governance has its foundations on having effective processes at
team level. We believe that patient and staff relationship lies at the heart of improving
quality. We therefore see governance as a pyramid based on the quality of interaction
between our staff and our patients. This is supported by robust governance processes and
a dynamic performance management framework at Divisional level.
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Within this governance framework, we have introduced a set of standards for team
governance which is known as ‘how are we doing?’ meetings. The standards are outlined
below.
Team Governance Framework
1
The purpose of team governance is to ensure and improve the quality of patient and
carer experience, patient safety and to identify, mitigate or escalate the risks to the
delivery of this.
2
Team governance will follow the five steps of governance process, from patient
experience through to monitoring progress.
3
Team governance should take place in a spirit of openness, constructive challenge
and willingness to reflect and learn. They shouldn’t be afraid to raise risks and
issues if they don’t believe they can manage this.
4
Teams must produce a governance report once a year.
5
Team governance meetings will take place at least monthly and can either be stand
alone meetings or form part of multi-disciplinary team meetings with protected time
for governance.
6
Team governance processes will be multi-disciplinary and include representatives of
all staff groups, this includes administrative and housekeepers as well as health and
social care professionals.
7
Teams will discuss and agree how patients and carers are involved in their
governance processes.
We will provide teams with the necessary training, support and practical tools to help them
undertake these meetings effectively. This will include:
provision of relevant and timely information to help them make decisions and develop
appropriate actions
self-assessment and peer review tools such as the InCA which provides teams with the
basis from which they can evaluate their compliance with the CQC essential standards
establishing a new process and system of risk management which will form the
backbone of governance within the organisation, through the development and
maintenance of team risk registers that will feed into the Divisional and Board
Assurance Framework (BAF).
Divisional Governance Framework
We have introduced ‘Divisional Accountability Governance Agreements’ (DAGA) which are
designed to clearly set out the expectations of the Board of Directors in regard to both
quality, safety and risk management arrangements as well as financial performance. This
will encompass the following processes:
Each Division will have monthly reviews through the Performance and Risk Executive
which considers all aspects of performance, risk management and service planning.
Divisions will be required to hold internal governance meetings to look at team
governance and specific safety, quality and effectiveness issues. This will include
reports about their compliance with the CQC essential standards through the InCA
process, risks identified at team level, incident reports and complaints.
Both team and Divisional governance frameworks will feed into and provide assurance to
the Trust Board that we are meeting our objectives and quality priorities.
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2.0
STATEMENTS OF ASSURANCE
We have reviewed the data available to us during the year covering the three dimensions of
quality – patient safety, clinical effectiveness and patient experience. There have not been
any significant concerns with the data that have impeded us in the preparation of this
Quality Report.
2.1
REVIEW OF SERVICES
Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) is a partnership
organisation providing mental health and specialist learning disability services across
Cambridgeshire and Peterborough, and also children's community services in
Peterborough.
We are a teaching Trust and work with the Department of Psychiatry at the University of
Cambridge. CPFT is also a member of Cambridge University Health Partners (CUHP), one
of only five Academic Health Science Centres in England.
The Trust provides the following:
Children’s mental health and community
services;
Adult mental health services;
Older people’s mental health services;
Primary care therapy and liaison psychiatry
services;
Forensic and specialist mental health services;
Substance misuse services; and
Specialist learning disability services.
We also provide some specialist services on a
regional and national basis. Full details of our
services are available on the Trust Website.
www.cpft.nhs.uk.
Community learning disability services are provided
by the Cambridgeshire Learning Disability
Partnership and the Peterborough Learning
Disability Partnership. Inpatient intensive
assessment and support services are provided by
the Trust in collaboration with the Learning Disability
Partnerships.
Around 2,000 staff working
across over 75 sites in
Cambridge, Huntingdon,
Peterborough, Fenland,
Mid Essex and Norfolk.
Three Clinical Divisions
o Acute Care Services
o Community Services
o Specialist Services
Our partners include:
o Cambridgeshire County
Council
o Peterborough City
Council
o NHS Cambridgeshire
o NHS Peterborough
Note: The new CCGs
(Clinical Commissioning
Groups) replaced NHS
Cambridgeshire and NHS
Peterborough in April 2013.
During 2012/13 CPFT provided and/or sub-contracted NHS services in seven relevant
health services (outlined above):
The Trust has reviewed all the data available to us on the quality of care in all seven of
these relevant health services. The income generated by the relevant health services
reviewed in 2012/13 represents 100% of the total income generated from the provision of
NHS services by CPFT for 2012/13.
2.2
PARTICIPATION IN CLINICAL AUDITS
During 2012/13, two national clinical audits and one national confidential enquiry covered
relevant health services that CPFT provides.
During 2012/13 CPFT participated in 100% national clinical audits and 100% national
confidential enquiries of the national clinical audits and national confidential enquiries
which it was eligible to participate in.
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The national clinical audits and national confidential enquiries that CPFT was eligible to
participate in during 2012/13 are as follows:
Prescribing Observatory for Mental Health (POMH)
National Confidential Inquiry (NCI) into Suicide and Homicide by People with
Mental illness (NCI/NCISH)
National Audit of Psychological Therapies (NAPT)
The national clinical audits and national confidential inquiries that CPFT participated in,
and for which data collection was completed during 2012/13, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or inquiry.
Table 2: National audits that CPFT participated in during 2012/13
Audit
% Cases submitted
University of Manchester
20 questionnaires sent by NCISH between April 2012
and March 2013, 20 completed and submitted by
National Confidential Inquiry into Suicide
CPFT (100%)
and Homicide by People with Mental
Illness (NCISH)
3 homicide questionnaires sent (2 in March 2013 so
not yet due at time of report) and 1 completed and
submitted by CPFT (100%)
National Programme of Prescribing Observatory for Mental Health (POMH)
POMH-UK 1f & 3f Prescribing high-dose
and combination antipsychotics:
7 participating teams
acute/PICU, rehabilitation/complex needs, 79 questionnaires submitted
and forensic psychiatric services.
POMH-UK 2f: Screening for metabolic
7 participating teams
side effects of antipsychotic drugs
105 questionnaires submitted
POMH-UK 11b: Prescribing antipsychotic
11 participating teams
medication for people with dementia
169 questionnaires submitted
POMH-UK 12a: Prescribing for people
13 participating teams
with personality disorder
77 questionnaires
Royal College of Physicians
74 Service user questionnaires returned, 82 case
National Audit of Psychological Therapies note audit cases submitted and 28 therapist
questionnaires returned.
The reports of six national clinical audits were reviewed by the provider in 2012/13. These
are:
a) Prescribing Observatory for Mental Health (POMH) audits
POMH-UK 1f: Prescribing high dose & combined antipsychotics in Adult in acute
adult inpatient or psychiatric intensive care wards
POMH-UK 2f: Screening for metabolic side effects of antipsychotic drugs
POMH-UK 3f: Prescribing high dose and combined antipsychotics in Forensic
wards
POMH-UK 11b: Prescribing antipsychotic medication for people with dementia
POMH-UK 12a: Prescribing for people with personality disorder
b) National Audit of Schizophrenia
and CPFT intends to take the following actions to improve the quality of healthcare
provided.
Page 21 of 74
Develop a Medication & Physical Health Dashboard to drive up standards in
prescribing and physical health monitoring
Review existing guidelines and procedures for poly pharmacy and prescribing over
BNF limits to ensure clarity of procedures and requirements.
Develop a Trust wide tool to record the history of prescribed interventions
(medication, psychological therapies and other interventions) , to include
documentation of side-effects and benefits
Add a standard line in the standard letter to the GP which is sent prior to a care
review requesting information about physical health investigations and most recent
list of prescribed medication.
Review the protocol about whether psychological treatments should be prioritised
for patients with treatment resistant schizophrenia as opposed to first episode or
both.
Develop a register to record all deaths in any age (to include age at death, ICD10
diagnoses, MH cluster. and causes of death) to create a data set that will inform
future service developments.
Disseminate results of the Shimme Project (Shared decision making in medicines
management) when completed and ensure that learning around shared decisionmaking in medicines management is shared and implemented in practice.
An identified Trust staff will link with Cambridge University Department of Public
Health to promote research on diabetes in people with mental disorder
The reports of 24 local clinical audits were reviewed by the provider in 2012/13 and CPFT
has taken/intends to take the following actions to improve the quality of healthcare
provided:
1. Standards and quality of documentation and record keeping
Form a Task & Finish Group to review and develop clear and specific guidance on
the practice and requirements around record keeping and documentation.
Review the Clinical Record Keeping Policy to clarify standards of practice and
procedures around competency assessments and countersigning delegation
Include the assessment of competence for record keeping in the Trust competency
framework for non-qualified staff
Compile all Trust approved forms and make these accessible on the Trust intranet
2. Medications management
Update the Medication Competency Workbook to include the need to document the
reason for administering the PRN (as required) medication and the outcome of the
PRN
Add information about what is a rapid tranquilisation and the monitoring
requirements following rapid tranquilisation in the Medication Competency
Workbook
Include examples of medicines reconciliation in the activity section of the medicines
management training for nurses
3. Review of policy and procedures
Review the Discharge Policy and clarify procedures around discharge planning and
documentation requirements
Review the Section 17 Policy and clarify the procedures particularly in relation to the
responsibility of the nurse in charge to ensure that a risk assessment is carried out
prior to allowing the patient to leave the ward for an agreed leave, reviewing
planned leave with the patient, and the required documentation regarding these
areas
Review the forms currently attached to the Falls Policy: (Falls screen, Falls
assessment, & Post-falls checklist) to clarify requirements for documentation
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Revise the ‘risk assessment’ section in the Safeguarding Adults Policy to include
agreed timescales for completion of investigation, emphasise requirement for
correct filing of documentation, and include requirement for the checklist to be
signed off.
Develop a pro-forma to guide doctors on the completion of In-patient and CTO
(Community Treatment Order) reports.
Develop a Trust DoL (Deprivation of Liberty) policy to replace the DoLs guidelines
and develop a robust implementation plan.
Review the Mental Capacity Act Policy and redesign the CPA capacity form
replacing text requirements with tick boxes where possible, and to reduce the length
of the form by replacing the legal language with plain English.
Revise Medicines Policy to include explicit requirement to document discussion
about side effects and benefits of medication
Develop a Trust policy on the procedures and standards for Advance Directives
Review and update the Continence Policy.
Following implementation of actions from audits completed in 2011/12, improvements were
made in the quality of our services in 2012/13. Examples include:
1. Medicines management
The action to develop and pilot a new form to record discussions about new
medication with patients and carers in Phoenix ward has been successful and is
reported to have improved engagement and information support for patients and
carers. (POMH10a: antipsychotic medicine in CAMH audit)
A Medication Competency Workbook was adapted from a London-based Trust and
attached to the Medicines Policy to provide clear guidance to nursing on medicines
administration, review and documentation. This has made demonstrable
improvements on medicines management practice in the wards (Omission of
Prescribed drugs audit).
The following actions were implemented following the POMH11b: prescribing
antipsychotic medication for people with dementia audit, and have resulted in
improved results for the 2012/13 round of the audit.
o Development of CPFT-specific guidelines which specifies that all letters to GPs
for patients with dementia with an antipsychotic medication initiated by the Trust
should have an instructions to GPs to review the medication within 6 weeks
o Development of joint guidelines on the use of antipsychotics for BPSD (Bipolar
Spectrum Disorder) across primary and secondary care which included
recommendations for appropriate documentations for appropriate
documentation and review dates of medication.
2. Practice improvement
Various improvements were implemented from findings of the Record Keeping
team-based monitoring audits. This included:
o In the Peterborough child health community services, making modifications to
Systm1 (electronic records system) to improve processes around countersigning
entries made by non-qualified staff, recording of ethnicity data and recording
diagnosis and needs at the point of referral.
o In the IAPT services, development of guidance around documentation practice
requirements and completion of risk assessments, among others.
CG45: Antenatal & postnatal mental health audit
o
A new specialist mental health midwife has been appointed in The Rosie
(maternity hospital in Addenbrookes) following results of the audit. Joint
planning meetings are held regularly with adult mental health services to
coordinate pre birth planning meetings for women
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3. Policy/guidance development
The ‘Use of Physical Interventions in the Management of Violence & Aggression
Within Mental Health & Learning Disability Policy’ was reviewed and updated to
clearly specify the requirement for documentation around physical restrain (NICE
CG25: Violence audit).
A Perinatal Standard Operating Procedure was developed to provide staff with
guidance on the safe management of women with serious mental illness (SMI) or at
significant risk of relapse of SMI in the perinatal period (CG45: Antenatal &
postnatal mental health audit)
Consent forms for Children’s services were revised and incorporated in the Consent
Policy (Children Act 1989 Consent to treatment audit in Phoenix ward) and
arrangements put in place to make copies of Consent forms easily accessible to
staff.
The Reading of Rights form was amended to evidence informing patients of their
rights to see an IMHA (Independent Mental Health Advocate Audit)
2.3
PARTICIPATION IN CLINICAL RESEARCH
2.3.1 RESEARCH AND DEVELOPMENT (R&D)
Participation in clinical research demonstrates the Trust’s commitment to improving the
quality of care we offer and to making our contribution to wider health improvement. CPFT
is the host for the National Institute for Health Research (NIHR) Mental Health Research
Network that supports well designed research studies adopted to the UK Clinical Research
Network (UKCRN) portfolio.
The number of patients receiving relevant health services provided or sub-contracted by
CPFT in 2012/13 that were recruited during that period to participate in research
approved by a research ethics committee was 1,029.
This surpasses the Trust’s target of 800 for the year which is positive progress. It is
expected that the results for the year will inform the Trust’s financial allocation from the
Comprehensive Local Research Network (CLRN) for 2013/14 enabling re-investment in
Trust research programmes.
As of March 2013, there were 105 active studies in the Trust of which 69 were adopted on
the NIHR portfolio. There were 10 portfolio studies in set up. A total of 37 studies were
approved in 2012/13, and there are a further 30 studies currently seeking Trust approval.
Examples of quality improvement actions relating from research include:
CRIS database: CPFT has ethical approval to establish a research database (Case
Registry Interactive Search) that will facilitate recruitment of participants into research
studies and pilot work is on going
DeNDRoN (Dementias and Neurodegenerative Diseases Research Network):
New team base and research facility has been launched in December in Windsor
House, Fulbourn
MHRN (Mental Health Research Network) A transition plan has been developed by
the Department of Health that will bring about key changes for the current set up of the
NIHR Clinical Research Network (CRN). By April 2014 the NIHR CRN will comprise of
15 Local Clinical Research Networks, each with a single host organisation. The
appropriate host organisations will be confirmed by Autumn 2013 through NHS
competition. The boundaries of the networks have yet to be decided but they will align
with the Academic Health Science Networks.
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2.3.2 CLAHRC CP
CPFT is also the lead NHS Trust for the NIHR Collaboration for Leadership in Applied
Health Research and Care for Cambridgeshire and Peterborough (CLAHRC CP), a centre
for mental health research that will accelerate health research into patient care.
As of March 2013, CLAHRC CP had over 100 projects on its portfolio, 23 of which were
classed as priority projects, across the five themes: Adults, Child and Adolescent, Old Age
and End of Life Care, Public Health and Design and Implementation.
Examples of CLAHRC studies that have led to improved outcomes of care include:
Transfer of Care at 17 pilot study
Strong collaborations and partnerships with NHS and social care partners have
ensured findings from this study, which focuses on the transition period from
adolescent to adulthood, have been incorporated into care pathways.
Dementia register
The Old Age theme has conducted a scoping exercise on the feasibility of
establishing a dementia register in Cambridgeshire and the project is being taken
forward by the NIHR Biomedical Research Centre (BRC).
Cognitive therapies
The East of England SHA has adopted the research outputs of an NIHR CLAHRC
CP project on the comparative effectiveness of cognitive therapies delivered face
to face and over the telephone in the Improving Access to Psychological
Therapies (IAPT) programme. The outcome of which is that regional training for
telephone sessions has been delivered.
The NIHR CLAHRC CP has continued to produce a successful Fellowship Scheme over
the past two years involving 3 cohorts, 33 professionals and 14 partner organisations.
Findings from several fellows’ projects have been translated into service change and
resulted in published journal articles. An example of service change is the introduction of
training for District Nurses in evidence-based end of life care in Peterborough.
2.3.3 SERVICE USER AND CARER ENGAGEMENT IN RESEARCH
Service User and Carer Involvement is a key priority area within the Trust’s R&D activities.
The R&D department runs a programme to support and strengthen meaningful involvement
of Experts by Experience in all stages of the research. This service is available to all
potential and established NHS researchers, service users and carers.
During 2012/13 we recruited and supported 18 service users and carers to be involved in
11 research activities as service user advisors or researchers. Advice and support was
provided to 15 researchers.
Key achievements during the year include:
Development of a pilot introductory research training for new members of our service
user and carer group in collaboration with CLAHRC CP. The programme provides a
basic introduction to research and involvement in research. Nine people attended the
first training course in March 2013 with very positive feedback.
Since September 2012 service user and carer involvement has become a step in the
process of obtaining CPFT R&D approval. As of March 2013, 80% of all locally
developed research projects that have gone through R&D approval have been reviewed
by members of our service user and carer research group to ensure that their project
has appropriate service user and carer involvement.
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2.4
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN) PAYMENT
FRAMEWORK
A proportion of CPFT’s income in 2012/13 was conditional upon achieving quality
improvement and innovation goals agreed between CPFT 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 2013/14 and for the following 12
month period are available online at: https://www.gov.uk/government/publications/using-thecommissioning-for-quality-and-innovation-cquin-payment-framework-guidance-on-new-nationalgoals-for-2012-13
The total value of the payment for completion of our quality goals in 2012/13 amounts to
£1,345,282 compared to £1,364,674 for our 2011/12 CQUIN.
The Trust’s Lead Commissioner is NHS Cambridgeshire with whom the Trust agreed a
number of quality goals for 2012/13. It is worth noting that the goals agreed at the
beginning of 2012/13 as reported in our Quality Report 2011/12 were further reviewed and
finalised in July 2012. These are outlined below:
Table 3: CQUIN performance against 2012/13 goals
CQUIN 2012/13 GOALS
Performance
Goal 1
The Trust has carried out monthly NHS
Safety Thermometer surveys of wards for
Theme: NHS Safety Thermometer
older people and learning disabilities.
Improve collection of data in relation to
Quarter 1: Achieved 97.6% harm free care
pressure ulcers, falls, urinary tract
Quarter 2: Achieved 98.8% harm free care
infection with a catheter, and VTE.
Quarter 3: Achieved 97.1% harm free care
Quarter 4: Achieved 98.2% harm free care
Goal 2
Indicator 1
Theme: Dementia
The Trust has, in collaboration with all
Improve awareness and diagnosis of
Acute Providers within the locality,
dementia by training staff in other local
developed and implemented over 70
NHS providers.
training sessions.
Indicator 1
Key outcomes:
Number of dementia training sessions
Feedback received shows that 95% of
delivered to each Provider Trust
participants learnt lot about the subject
highlighted above to enable these
as a result of the training
service Providers to deliver their
86% of participants reported a change
provider specific CQUIN schemes
in their attitude and approach to people
relating to dementia.
with dementia.
Indicator 2
Improve access to prompt advice and
support for people and their carers
recently diagnosed or identified as
potentially at risk of dementia following
screening in hospital or community
services.
Goal 3
Theme: Patient experience
Improve responsiveness to personal
needs of patients.
Indicator 1
To ensure that providers have real time
systems in place to monitor patient
experience.
Indicator 2
There is initial evidence to show that
referrals to Liaison Services within CUHFT
(Cambridge University Hospitals NHS
Foundation Trust) have increased as a
result of the training.
Indicator 1
CPFT has developed, with Meridian, a web
based patient survey system to routinely
collect real-time patient experience data
across all inpatient and community teams
using iPads. Results are discussed at our
monthly Divisional Performance Review
meetings with clear lines of accountability up
to the Trust Board
Page 26 of 74
Indicator 2
To demonstrate improvements in
patient experience using the Net
Promoter Score (NPS).
Indicator 2
The Trust’s overall average NPS score of
47% for the year. This shows a 13%
increase from the baseline figure in April
2012.
Goal 4
Theme: Making Every Experience
Count
Clinical Staff working in the agreed
areas have appropriate knowledge and
skills to make to make a “brief advice”
intervention for alcohol/smoking or both
and to signpost or refer as appropriate in
line with the ‘Making Every Contact
Count’ Initiative.
Goal 5
Theme: Measuring Outcomes
Routine reporting of outcome measures
for each of CAMH (IAPT), Adult
(Recovery Star) and OPMH CORE 10
and QALY AD.
We provide an e-learning training package
to our staff within the Rehabilitation and
Recovery Pathway to equip them with the
knowledge and skills to engage with their
patients around healthy lifestyle issues and
refer them on to the appropriate agency,
where required. We have not met the
target as of March 2013 The Trust will
continue to roll out the e-learning package
to the remainder of staff in early 13/14.
CAMH IAPT: Our staff have been trained in
undertaking the CYP-IAPT Outcomes
Measures during 12/13. We encountered a
number of challenges around putting the
technology in place but by Q4 the
necessary systems were in place to
support greater usage of outcomes
measures in 2013/14.
Adult: During 2012/13 we trained over
80% of our staff within the Rehabilitation
and Recovery Pathway to use the
Recovery Star which gets a patient to look
at recovery as a journey with different
stages. Using this approach has led to a
change in the culture, care delivered and
supporting documentation resulting in
better outcomes for the patient.
OPMH CORE 10/QALY AD: 70% of
service users in the specified pathways
have undertaken the specified outcome
measures.
As per the NICE Guidelines we give priority
access to perinatal patients with the
average waiting time across the locality
being 25 days during 2012/13.
Goal 6
Theme: Perinatal Mental Health
Delivery of NICE guidelines for priority
access to IAPT for pregnant and
postnatal women.
Goal 7
Theme: Learning disability
Improve access to mental health
services for people with learning
disability, based upon the annual selfassessment of progress that CPFT has
completed and reinforcing the
subsequent Action Plan.
Goal 8
Theme: ADHD
Training of core staff within Intake and
Treatment Teams in diagnosis and
advice on patient management for
ADHD.
The Trust has continued to deliver against
the Learning Disability Performance
Indicators Access to Healthcare Action
Plan.
CPFT staff have delivered ADHD training
to staff within the Department of Psychiatry
and the Intake and Treatment Team during
2012/13, based on training materials
developed through CPFT and the
University.
Page 27 of 74
2.5
CQUIN GOALS 2013/14
As part of our contractual agreement with NHS Cambridgeshire for 2013/14, the Trust will
work towards the achievement of a range of quality goals which will support further
improvements in patient experience, patient safety and clinical effectiveness. We will report
on our achievements in meeting these goals as part of next year’s quality report.
The proposed goals for 2013/14 which are still under discussion as of the date of this report
are outlined below.
Develop a service specification to improve the smooth transition and have a person
centred planning and flexible approach to the transition of children and adolescent
service users into the adult mental health services
To improve physical health outcomes for patients given the impact of physical morbidity
in mental health users and the mortality among those with mental illness
Patient Access - development of a Directory of Services for Choose and Book and selfreferral to the Advice Referral Centre
2.6
CARE QUALITY COMMISSION (CQC) REGISTRATION
The Care Quality Commission (CQC) is the independent regulator of all health and social
care services in England. Its primary role is to ensure that the care people receive meets
essential standards of quality and safety and to encourage on going improvements by
those who provide or commission care.
CPFT is required to register with the Care Quality Commission and its current registration
status is ‘Registered Without Conditions’.
The Care Quality Commission has not taken enforcement action against CPFT during
2012/13.
CPFT has participated in two investigations by the Care Quality Commission relating to
the areas outlined in the following page during 2012/13.
2.6.1
CQC INSPECTIONS
We had two conditions on our registration at the beginning of 2012/13 resulting from
investigations carried out in the previous year: minor concern on Outcome 16 (Assessing
and monitoring the quality of service provision), and moderate concern on Outcome 1
(Respecting and involving people who use services). A summary of the CQC inspections
and reviews during the year and the outcomes thereof is outlined in Table 4.
Improvement actions were also identified in our inpatient units on the following areas:
Fulbourn Hospital site: Outcome 10 (Safety and suitability of premises) around providing
better facilities that allow patients to access peaceful and private spaces or rooms
Cavell Centre site: Outcome 4 (Care & welfare or people who use the services) around
ensuring that care records provide clear information about any untoward event
experienced by patients, and Outcome 10 (Safety and suitability of premises) around
ensuring that patients have freer access to outside areas and this is managed according
to their assessed risk.
The inspection carried out in June 2012 in the Fulbourn Hospital site found us to be fully
compliant with Outcomes 1, 4 and 14. They identified concerns in Outcome 9
(Management of medicines), particularly in relation to recording of medicines administration
and the recording of medicines used on a discretionary basis (PRN) to control a person’s
challenging behaviour. The CQC also identified concerns against Outcome 16 (Assessing
and monitoring the quality of service provision) to fully strengthen and develop its Board of
Directors and to deliver a clear and effective strategy to improve, monitor and maintain the
quality of its services.
Page 28 of 74
The CQC carried out a table top review of evidence for Outcome 9 and 16, and an
inspection in the Cavell Centre site in December 2012. The report was published in
February 2013 which declared the Trust fully compliant in all areas covered by the review.
Table 4: Summary of investigations carried out during 2012/13
Fulbourn Hospital
Cavell Centre
Inspection
CQC
dates
CQC Outcomes
Judgement
Judgement
Outcomes

As of 31
March 2012
Outcome 10
Outcome 16
Outcome 4
Outcome 9
minor concern
Outcome 14
Outcome 16
December
2012 table
top review
minor concern


Outcome 1
June 2012
inspection

improvement actions
Outcome 4
Outcome 10
Outcome 16
minor concern
Outcome 1
moderate concern
moderate concern

Outcome 16

Outcome 18





Outcome 20

Outcome 1






Outcome 1
Outcome 7
December
2012
inspection
Outcome 13
Outcome 16
Outcome 4
As of 31
March 2013
Outcome 9
Outcome 10
Outcome 14
Outcome 16

improvement actions

Outcome 9
Outcome 1

improvement actions






Outcome 7
Outcome 13
Outcome 16
Outcome 18
Outcome 20
A number of actions were taken in 2012/13 that secured full compliance with the CQC
standards by the end of the year.
A summary of the key actions and excerpts from CQC reports are presented in the
following pages.
Page 29 of 74
Excerpts from CQC reports
July 2012 report
People told us that staff treated them respectfully and in a way that they liked. One person commented,
"Some staff are really good, really on the ball, quite sensitive to how you're feeling". Another person who
had been a patient previously told us, "It's so nice having my own room now. I sleep better and have
privacy to lie down for half an hour if I want". Another person commented, "I've recently started water
tablets so having the en suite toilet is a god send". (pg 8)
As part of our inspection we undertook a short SOFI (Short Observational Framework for Inspection) on
Willow Ward. SOFI is a tool which provides us with information about people's experiences of their care,
their general mood state and their engagement and interaction with those providing their care.
Throughout our observation we noted that people showed signs of well being and were calm, relaxed
and engaged in what was going on around them on the ward. The quality of interaction between people
and staff
was mostly very good, with staff showing respect and empathy to people. For example, we observed two
staff members assist one person to move between an armchair and a dining room chair. This was done
well with staff explaining to the person throughout the transfer what they were doing and also reassuring
them appropriately when they became agitated during the move. We saw a member of staff talk to one
person about his mother's Irish stew (which was on the menu that day), resulting in much laughter
between them. On another occasion we noted that one person's unusual request for what they wanted
for their lunch was fully respected by staff. We witnessed staff knocking on people's bedroom doors and
waiting for a response before they entered, and people (both staff and patients) being refused entry to
the ward's clinical room when treatment was being given to people. (pg 9)
January 2013 report
We inspected a ward for older people living with dementia. Staff on this ward were busy, but people's
needs were met in a calm, professional and unhurried manner. We spoke with relatives, one of whom
said, "The staff are beautiful, they're angels. They're all nice, there's not one nasty one. There are plenty
of staff." Another relative told us that all the staff are "…fine" but said there were times, when the ward
was full and in the evenings, when "…they could do with more staff." Senior staff on this ward told us
they had introduced a 'twilight shift' to improve the service offered in the evening and that there were
enough staff to meet people's needs. (pg 8)
Our inspection of February 2012 identified that there was an inconsistent approach to the way in which
people's dignity was upheld and maintained.
In their declaration of compliance with this regulation, the trust told us they had done a lot of work to turn
this around. They had introduced a number of measures to check that people had a positive experience
during their admission to the wards. One of these measures, REV (Respect, Empower, Value), involved
assessments and audits of each ward, carried out by a member of staff from another ward.
During our inspection on 12 December 2012 we saw improvements on Maple 1 in the way that staff
spoke with people, the way they treated people and the ways they now worked to promote people's
dignity. We spent some time on the ward observing the interactions between people on the ward and the
staff. Staff worked well as a team to support people. They spoke kindly and patiently to people, without
being patronising, and they listened when people wanted to talk with them. The staff noted when
someone was becoming agitated or behaving in a way that might upset someone else, and they
responded appropriately, distracting the person and calming them. Communication on the ward had also
improved. Senior staff told us that they had introduced and strengthened systems to ensure that
communication between staff, people on the ward and their relatives was as good as possible. Relatives
we spoke with told us that they were fully involved in the care their family member received. They felt
comfortable with speaking with staff at any time, could telephone the ward for information if they were not
able to visit and were confident that they would be communicated with when necessary. One relative told
us they had been invited to attend the doctor's round at the end of the week. A notice board on the ward
gave people information such as how to contact local support groups and advocacy services. (pg 6)
Page 30 of 74
Trust actions in response to CQC findings
1. Guiding Coalition and Satellite Team
The Guiding Coalition was formed in January 2012, consisting of 80 staff members from all
staff groups across the Trust, to develop solutions on the areas identified for improvement and
input directly into the turnaround board. A Satellite Team of around 94 staff was also formed
to support the Guiding Coalition to deliver change at local level. These two groups continued
into 2012/13 which made a significant impact on the success of our turnaround programme.
2. 7Cs standards of care planning
The 7Cs standards were developed to assess the quality of our assessments and care
planning process and documentation. Monthly peer assessments were carried out by senior
clinicians involving an examination of care records and interviews with patients and staff. 7Cs
was initially implemented in our inpatient units and later rolled out to community-based teams.
Scores were reported as part of the quality dashboards and shared on a Trust wide basis.
3. Environmental refurbishment and repairs
We started a wide ranging programme of refurbishment and repairs of all inpatient units in
December 2011 following a systematic and comprehensive review of our facilities. We
continued with this programme of improvement throughout 2012 and have extended the work
to cover our community-based services and corporate offices coming into 2013.
4. 5 star environmental standards
5 star environmental standards were developed in the last quarter of 2011/12 and initially
implemented in our inpatient units. This also involved monthly peer assessment carried out by
senior staff and clinicians and reported as part of the quality dashboards. The 5 star
assessments were piloted in our community-based teams in November 2012 – March 2013.
5. REV (Respect, Enable and Value) standards
REV was developed to address the concerns around Outcome 1, and implemented in our
inpatient units on a peer review basis. Teams were scored against the standards based on
observations made around patient-staff interactions. Scores were reported as part of the
quality dashboards. This has driven up the standards around patient-staff interactions.
6. InCA (Integrated Compliance Assessment)
InCA was developed to enable teams to assess their compliance with all 16 CQC Outcomes
on a monthly basis, and involved a self assessment and peer review process. It incorporates
the 7Cs and 5 star standards. InCA was implemented in our inpatient units in June 2012 and
piloted in selected community-based teams in March 2013. It will be rolled out to all
community-based teams by the end of 2013. This provides the Trust with assurance of our
compliance with the CQC Outcomes and enables us to focus our resources on areas that
require action in a timely manner.
7. Medicines management action plan
A set of actions were put in place to improve compliance with the standards around medicines
management. Specifically, this included increasing awareness amongst nursing staff of
medicines administration recording requirements and the implementation of a new ‘when
required’ medicines policy. Other general actions included ones identified from audit projects
and the annual medicines reviews, such as the development of the Medications Competency
Workbook, improving the training programme and regular monitoring of practice through the
InCA process and the audit programme
8. Performance management framework
Monthly triangulation meetings are undertaken with the aim of gathering all relevant
information from all sources. This enabled us to use information strategically and identify
possible reasons that give rise to problem areas. This information informed the Divisional
Performance Review meetings. This has strengthened Divisional accountability over
performance issues and ensured that appropriate actions are taken in a timely manner.
Page 31 of 74
2.6.2
MENTAL HEALTH ACT INSPECTIONS
Throughout the year, the CQC conducted a number of
reviews in respect of Trust services provided for
persons detained under the Mental Health Act
(MHA). The results are outlined on the right.
In total, 8 MHA visits were carried out, 7 of them
were unannounced. The one planned 2-day visit to
the Cavell Centre in Peterborough was carried out
by Commissioners accompanied by an ‘Expert by
Experience’, and included representatives from
Peterborough City Council and Cambridge County
Council. The visit focused on monitoring the
compliance with the “Assessment, application for
detention and admission under the MHA” process.
The Commissioners reported very positive feedback
from patients about their experience in the wards,
their involvement, care and their relationship with
staff. They found the relationship between the Trust
and external agencies to be effective and engaging
and reported good governance and procedural
arrangements.
They also found the Approved Mental Health
Professionals (AMHPs) assessment procedure to be
effective and were satisfied with the Mental Health
Act Administration, quality assurance processes,
and compliance with the Act’s legal requirements.
Minor concerns around the unit’s 136 suite
environment were raised (Section 136 -Place of
safety) and at the time of this report, the Trust still
awaits the formal CQC recommendations, which will
aide the current review of S136 functions across the
Trust.
Following their visits to other sites within the Trust,
the visiting commissioners were satisfied that
patients’ were detained by the Trust lawfully
their rights were read adequately and regularly
activity programmes were in place, were of a
good standard and individualised.
MHA inspections in 2012/13
7 unannounced visits
1 planned visit
12 units inspected
14 sets of case notes
scrutinised
Good practice noted.
Completion of previous
recommendations
Compliance with reading
and reminding patients of
their rights
Good patient involvement
in care planning
Good interaction and
engagement between
patient and staff
Access to advocacy
services
Clean and safe
environment
Good activity programmes
in place
Recommendations for S58
Improve practice around
recording of capacity to
consent treatment
assessments
Review recording process
of risk assessments
carried out prior to
authorising S17 leave
These findings were also
highlighted by our local
audits. Actions have been
developed to address these
areas.
The commissioners reported good staff patient interaction. The care plans inspected were
comprehensive and were reviewed regularly and patients’ involvement was evident. The
visiting commissioners also noted that the units visited were clean, well presented and safe.
The CQC were satisfied that most of their recommendations around ligature and
environmental improvements from previous visits were completed, or that there was a plan
in place to ensure their completion.
The CQC has not published the Mental Health Act annual statement for the review period
2012/13, as of the date of this report.
Page 32 of 74
2.7
DATA QUALITY AND INFORMATION GOVERNANCE
CPFT submitted records during 2012/13 to the Secondary Uses service for inclusion in
the Hospital Episode Statistics which are included in the latest published data.
The percentage of records in published data:
which included the patient’s valid NHS number was:
o 99% for admitted patient care
which included the patient’s valid General Practitioner Registration Code
o 99% for admitted patient care
CPFT’s Information Governance Assessment Report overall score for 2012/13 was 79%
and was graded GREEN
The Trust was not subject to the Payment by Results clinical coding audit during the
reporting period by the Audit Commission.
CPFT will be taking the following actions to improve data quality:
Rolling out RIO Electronic Care Record System across all Clinical Divisions and teams
Undertaking monthly non compliance audits of 7 day follow up and CRHT gatekeeping
indicators
Developing an automated system for the capture and reporting of Mental Health Act
compliance
A data cleansing exercise for ESR and an exercise to support the standardisation of
roles
Developing and rolling out InCA to record and report upon compliance with the 7Cs care
planning standards
Developing a protocol which outlines the calculation methodology for all performance
indicators on the Trust dashboard.
2.8
MANDATORY CORE SET OF QUALITY INDICATORS
From 2012/13, all Trusts are required to report against a core set of quality indicators using
data for the last two reporting periods provided by the Health and Social Care Information
Centre (HSCIC). The indicators that are relevant to CPFT are listed below.
Table 5: Mandatory core quality indicators for 2012/13
Prescribed information
1. The percentage of patients on Care Programme Approach who were followed up
within 7 days after discharge from psychiatric in-patient care.
2. The percentage of admissions to acute wards for which the Crisis Resolution Home
Treatment Team acted as a gatekeeper.
3. The percentage of staff employed by, or under contract to, the Trust who would
recommend the trust as a provider of care to their family or friends.
4. 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.
5. The number and, where available, rate of patient safety incidents reported within the
Trust, and the number and percentage of such patient safety incidents that resulted in
severe harm or death.
Where the data reported in the HSCIC indicator portal does not reflect the most current
data, we have provided current data available from the Trust.
Note: For a full definition of the quality indicators 1, 2 and 5 see page 64 in Annex 2.
Page 33 of 74
2.8.1 Patients on Care Programme Approach who were followed up within 7 days after discharge
from psychiatric inpatient care during the reporting period.
Table 6: Patients on CPA followed up within 7 days
CPFT considers that this data is as
described for the following reason:
Table 6 shows that CPFT is only two
points below the national average rate
of 97.60% in 2011/12, while four
Trusts achieved 100%.
Reporting
period
2012/13
(CPFT data)
CPFT
93.75%
Oct-Dec 2012
95.2%
(HSCIC data) (n=334/351)
Jul-Sept 2012
95.7%
(HSCIC data) (n=337/352)
England
average
Highest
rate
Lowest rate
Target
95%
Not yet available from HSCIC
(CPFT)
97.60%
100.00%
93.00%
97.20%
100.00%
89.80%
95%
(national)
Trust performance as of March 2013 is 93.75%, which is just under the target of 95% during
the period 2012/13.
Chart 1: Patients on CPA followed up within 7 days
CPFT intends to take/has taken the
following actions to improve this
93.75%, and so the quality of its
services, by:
reviewing our Discharge Policy and
procedures
continuing to monitor and report on
our performance against this
indicator through our quality
dashboards
2.8.2 Admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as
a gatekeeper during the reporting period.
Table 7: Admissions gatekept by CRHTT
CPFT considers that this data is as
described for the following reason:
Table 7 shows that CPFT had the
lowest rate nationally for the period
Oct-Dec 2012, with 18 Trusts
achieving 100%.
Reporting
CPFT
period
2012/13
93.17%
(CPFT data)
Oct-Dec 2012
90.7%
(HSCIC data) (n=390/430)
Jul-Sep 2012
91.7%
(HSCIC data) (n=409/446)
England
average
Highest
rate
Lowest rate
Target
95%
Not yet available from HSCIC
(CPFT)
98.40%
100%
90.70%
98.10%
100%
84.00%
no national
target
Trust figures as of March 2013 is 93.17% which is just under the target of 95% and shows
an improvement from 91.74% in 2011/12.
Chart 2: Admissions gatekept by CRHTT
CPFT intends to take/has taken the
following actions to improve this
95.24%, and so the quality of its
services, by:
redesign of our clinical services
monitoring performance through
our quality dashboards
making this our quality priority
under the Clinical Effectiveness
domain for 2013/14.
Page 34 of 74
2.8.3 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.
Table 8 below shows the proportion of our staff who would recommend CPFT as a provider
of care to their family and friends in 2011 and 2012, compared with the average, highest
and lowest scores for all mental health Trusts and all healthcare providers in England who
took part in the survey. In 2012, we scored the lowest among all mental health Trusts.
Table 8: Staff who would recommend CPFT as a provider of care to their family or friends.
Average rates
Reporting
period
2012
2011
Highest rates
Lowest rates
CPFT
Mental
Health
England
(all Trusts)
Mental
Health
England
(all Trusts)
Mental
Health
England
(all Trusts)
39%
50%
58%
58%
63%
60%
80%
83%
94%
96%
39%
43%
35%
22%
CPFT considers that this data is as
described for the following reason:
The major turnaround programme
implemented during the year affected
staff morale. This is discussed in more
detail in sections 1.2.3 and 5.2.
Chart 3: Staff who would recommend CPFT
CPFT intends to take/has taken the
following actions to improve this 39%,
and so the quality of its services, by:
talking to our staff to find out the
issues they are facing and what we
need to do to make it better.
developing an action plan to
address the issues that came out of
the National NHS Staff Survey.
developing a Workforce Strategy in consultation with our staff.
2.8.4 “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 weighted average of our scores for these questions is shown in Chart 4 below,
compared with the average, highest and lowest scores of all community mental healthcare
providers in England who took part in the survey.
Chart 4: Patient experience scores
This indicator uses the weighted
average for the following questions in
the CQC survey of community mental
health services:
Thinking about the last time you saw
this NHS health worker or social care
worker for your mental health
condition…
…Did the person listen carefully to
you?
…Did this person take your views
into account?
…Did you have trust and
confidence in this person?
…Did this person treat you with
respect and dignity?
Page 35 of 74
It is worth noting that our scores are higher than the national average for this indicator in
both years (see section 3.1.3 for further details on our national CQC Community Patient
Survey 2012).
We believe that the heart of a quality service lies in the relationship between a member of
staff and their patients. Quality comes when this relationship is based on values of trust,
respect, and mutual endeavour to improve the patient’s health, well being and quality of life.
All members of our staff are expected to uphold and promote these principles which are
embedded in our four key values outlined below:
CPFT’s Four Key Values
Patient first: we focus on the needs of the whole person, we aim to consistently
1 exceed the expectations of our patients and their carers by making every interaction
with them count
2
Only the best: we have high standards in all that we do, we are uncompromising in
our pursuit of excellence, we only do what is known to work, we evaluate everything
that we do and share the data with others to allow them to hold us to account.
3
Staff matter: we trust, value and develop each other, we build a great place to work
where people are inspired to be the best they can be, where they are engaged in
decisions that affect them and where they are empowered to deliver better and safer
services.
4
Together as one: we value our teams and our partners and believe we can achieve
more by working together for the benefit of the people we serve.
The graph below is taken from the 2012 CQC Community Patient Survey report. The black
diamond in the bar represents the score for CPFT while the green bar represents the
scores of the best performing Trusts in the country.
We are very pleased with these results and we are very proud of our staff for the
commitment and dedication that they have shown to their work and most importantly, their
patients.
CPFT considers that this data is as described for the following reason:
All the changes we have made in the past year around care planning, involvement and
other ways of working have had a positive impact on the experience of our patients.
CPFT has taken the following actions to improve this 89.32%, and so the quality of its
services, by:
sharing these results with our staff and developing a Trust action plan to address the
issues identified in the patient survey results
developing a Partnership Strategy 2013-2016
appointing a Head of Patient Experience and Engagement
Page 36 of 74
2.8.5 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 patient safety incidents
that resulted in severe harm or death.
The data reported in the HSCIC indicator portal, which is derived from the NRLS (National
Reporting and Learning System), are presented in six month periods up to March 2012.
For comparison purposes, we have only taken figures reported by mental heath providers
that have submitted six months worth of data per 1000 bed days.
It is worth noting that:
all mental health providers calculate their rates per 1000 bed days
12 PCTs also reported 6 months worth of data which were calculated per 1000 bed
days, these were excluded from the figures presented in this section. Within this group,
one PCT reported an incident rate of 157, two PCTs reported 118, and one of each
reported an incident rate of 95 and 77. The highest rate reported by a mental health
provider is 59.
Other healthcare providers (Acute Specialist, Ambulance, large Acute, medium Acute,
small Acute and PCTs with inpatient provision) that report data calculated per 100
admissions were excluded from the comparative figures as our data would not have
been comparable with the data reported by these healthcare providers.
We have also presented data for incidents reported in the Trust during 2012/13 that are not
yet reflected in the HSCIC indicator portal as of the date of this report in order to present
our most up to date performance data.
CPFT considers that the data presented in this section is as described for the following
reasons:
CPFT is in the highest quartile of 57 reporting mental health providers in the country.
Over the past two years, we have worked hard to improve our training programme and
raise awareness around patient safety incidents. Charts 7 and 8 show that we report
higher numbers of ‘no harm’ incidents which may explain the higher rates of patient
safety incidents reported by CPFT as compared to the national average.
The proportion of patient safety incidents that resulted in severe harm or death was only
around 1.6% of our total reported patient safety incidents in 2011/12, reducing to 1.3%
in 2012/13.
CPFT has taken the following actions to improve this 0.73 and 0.48 (rate of patient safety
incidents that resulted in severe harm or death), and so the quality of its services, by:
We have reviewed our Policy and Procedure for Reporting, Managing and Investigating
Incidents Including Serious Incidents (SIs). The revised version has been approved
and ratified.
We have started to deliver additional Root Cause Analysis (RCA) training
We have established a Serious Incident Group
We have appointed a Patient Safety Lead for the Trust who will lead and work with the
Clinical Divisions on the management of incidents and serious incidents in the Trust
We are working with our commissioners and with our partner organisations in the
development of an over arching Suicide Prevention Strategy for CPFT that links with
the national and regional strategy
We are monitoring all relevant data and information around incidents and serious
incidents through our quality dashboards reporting framework
We have commissioned Professor Louis Appleby to undertake a review of selected
serious incidents in order to identify further areas for improvement
We are undertaking a Trust wide Clinical Risk Assessment audit to investigate
compliance with our Clinical Risk Assessment and Care Planning Policies, planned in
2013/14
Page 37 of 74
1. Number of patient safety incidents
Data available from the HSCIC indicator portal during the reporting periods April –
September 2011 and October – March 2012 are presented below.
2012/13 data is not yet available from the HSCIC indicator portal. Trust data showing
figures for 2012/13 are shown in Table 9 in the following page.
Chart 5: Number of patient safety incidents
Data reported by NRLS shows
that CPFT is in the highest quartile
of 57 reporting mental health
providers in the country.
Chart 5 shows that the number of
patient safety incidents reported
by CPFT is comparable to the
average numbers reported by
other mental health providers.
2. Rate of patient safety incidents
Data available from the HSCIC indicator portal during the reporting periods April –
September 2011 and October – March 2012 are presented below.
Chart 6: Patient Safety Incidents per 1000 bed days
Chart 6 shows that CPFT’s rate of
patient safety incidents is higher
than the average for mental health
providers but much lower than the
highest rate reported.
Refer to item 4 for additional
information.
Note:
The Trust’s reporting of all incidents, including serious incidents, has been subject of
rigorous review by the CQC and as a consequence changes to our reporting processes
were put in place from 2010. Patient safety has been one of our main focuses in the
past couple of years. We have improved training and raised awareness of patient
safety incidents. We have worked with our Divisions and clinical teams in reviewing the
incident reporting process and procedures. We have processes in place to monitor,
through our governance arrangements, patient safety incidents. This has resulted in a
higher rate of reporting. According to NPSA, ‘Organisations that report more incidents
usually have a better and more effective safety culture’ (NRLS patient safety incidents
monthly reports for CPFT).
Page 38 of 74
Chart 7: Oct 11 – Mar 2012 (NRLS 2012)
Charts 7 and 8 show that a higher
proportion of our incidents result in
‘no harm’, as compared to other
mental health Trusts. This indicates
a good culture of reporting in CPFT.
However, a slightly higher
proportion of our reported incidents
result in moderate harm and death
which is reflected in the data
reported in item 4.
Data for the top 10 incident types
reported by NRLS (see Chart 9
below) shows that CPFT is
reporting higher rates of selfharming behaviour.
This may be explained by our
Complex Cases ward and our
Adolescent ward, which are part of
our Acute Care Service, and who
are reporting over half of the
incidents in the Trust. We are
reporting significantly lower rates of
incidents relating to patient
accidents and medication.
Chart 8: Apr - Sep 2012 (NRLS 2012)
Improving patient safety is a Trust
priority. We have adopted the ‘7
steps to patient safety in mental
health’ published by the National
Patient Safety Agency (NPSA) to
better support our staff to ensure
they manage risk effectively and
improve the safety of our patients.
Chart 9: Apr – Sep 2012 Top 10 incident types (NRLS 2012)
Page 39 of 74
3. Proportion of CPFT patient safety incidents that resulted in severe harm or death
Data available from the HSCIC indicator portal during the reporting periods April –
September 2011 and October – March 2012 are presented in Table 9 below, along with
CPFT data for the period 2012/13 as follows:
April – September 2012 submitted and reflected in the NRLS website
October 2012 – March 2013 submitted to the NRLS system but not yet final
Table 9: Incidents resulting in severe harm or death
Reporting
period
Oct 12-Mar 13
(CPFT data)
Apr 12-Sep 12
(NRLS data)
No. of
incidents
reported
Incidents
Total incidents
Incidents
resulting in
resulting in
resulting
severe
severe harm
in death
harm
or death
%
2282
12
23
35
1.5%
2268
9
17
26
1.1%
Oct 11-Mar 12
(HSCIC data)
2527
11
31
42
1.6%
Apr 11- Sep 11
(HSCIC data)
1981
4
26
30
1.5%
4. Rate of patient safety incidents that resulted in severe harm or death
Chart 10: Incidents resulting in severe harm or death
Data available from the
HSCIC indicator portal during
the reporting periods April –
September 2011 and October
– March 2012 are shown in
Chart 10 on the right.
Note: Data for 2012/13 is not yet available from HSCIC. However, Table 9 shows a
15% reduction in our incidents resulting in severe harm or death during 2012/13 (72 in
2011/12 to 61 in 2012/13). The proportion of incidents resulting in severe harm or
death is also slightly lower from 1.6% in 2011/12 to 1.3% in 2012/13.
During the year, we made significant improvements in our ward environments. This
includes removing all ligature points in our wards and any fixture that patients could use
to harm themselves or others. We also put measures in place to reduce the risk of
absconsions which includes reinforcing doors and windows, raising the height of garden
walls and moving garden benches away from the garden walls, among others. In
addition we developed a policy and improved arrangements around access to our
wards and improved clinical risk assessment training which showed increased levels of
attendance during the year. These measures appear to have made a positive impact
on our patient safety incidents during the year.
Moving forward, the review currently being undertaken by Professor Louis Appleby will
provide us with valuable learning in order to make improvements in this area.
Page 40 of 74
PART 3: OTHER INFORMATION
3.0
OTHER CPFT QUALITY PERFORMANCE INDICATORS 2012/13
The quality performance indicators presented in this section have been identified through
the following:
We discuss performance on our quality dashboard through the monthly Performance
and Risk meetings between our Executive team and Divisional managers; and regular
reports to the Trust Board on the outcome of these meetings.
We work closely with our commissioners and other appropriate stakeholders to review
our performance against quality indicators and the overall quality of our services.
During the year, we have also worked closely with the Adults Wellbeing and Health
Overview and Scrutiny Committees in Cambridgeshire and Peterborough around our
planned service improvements and to identify areas for further improvement. This is
reflected in their commentaries in Annex 3 of this report.
For 2012/13, we have reported on additional quality performance indicators not included in
the 2011/12 report, as follows:
We have improved the way we collect and monitor our performance on Reading of
Rights and this was added to our quality dashboard during the year
We have made significant improvements around MRSA screening during the year
following its inclusion in the Patient Safety Thermometer as part of our CQUIN goal 1
(see section 2.4).
We have presented data on breastfeeding to better reflect the diversity of the services
we provide. This has also been an area of concern for the Trust and is subject to on
going discussions with our commissioners.
We have included care planning as a separate item in this section in order to report on
the significant achievements we have made in this area in the past year.
3.1
PATIENT EXPERIENCE
3.1.1
Mental Health Act Compliance – Reading of Rights
Chart 11: Reading of Rights
Reading of Rights was added as a quality
indicator during the year and is the first
item in our quality dashboard. We have a
target of 100%. As of March 2013, the
total average compliance rate was 91%.
Prior to January 2012, compliance on this
indicator was audited based on a sample
of cases only. This explains why we only
have figures available for Q4 2011/12
(January – March 2012) as shown in
Chart 11.
From January 2012, data is collected by our MHA administration team on all patients
detained under the MHA and reported as part of our quality dashboard. This shows our
commitment to improving our performance in this area and ensuring that patients are given
information about their rights. From July 2013, we will be monitoring the completion of
capacity assessment for patients who lack capacity to understand their rights.
We are working with our Modern Matrons and Ward Managers to highlight the importance
of this statutory requirement. This is also monitored through our InCA process.
Page 41 of 74
3.1.2
Complaints and Patient Advice and Liaison (PALS)
There was a 37% reduction in the
number of complaints received
from 118 to 74 in 2012/13. This
figure is relatively small when
taken in the context of the total
number of episodes of care
(approximately 22,144 during
2012/13). Monthly trends are
shown in Chart 12.
Chart 12: Complaints during 2012/13
Greater engagement between
complainants and our staff,
together with the revised
complaints process and the
implementation of effective action
plans, has increased carer and
patient confidence in the process.
Actions taken that have contributed
to this improvement include:
Better engagement with
families
Early PALS involvement
Clear and timely information
with patients and carers
Working with Complaints
Advocacy
Chart 13: PALS contacts in 2012/13
There was a very small reduction in
PALS contacts from 538 in 2011/12
to 500 in 2012/13. The monthly
figures are shown in Chart 13.
Data is collected by our Complaints & PALS team and is monitored through the monthly
Quality and Safety reports to the Quality & Performance Committee and the Trust Board.
3.1.3
Mandatory CQC Community Patient Survey
Chart 14: CPFT scores for quality of care over time
(Quality Health 2012)
The results of our CQC Community
Patient Survey 2012 shows an
overall improvement in our scores
in 2012. This is largely due to the
work we have done around
improving the quality of our care
plans and the involvement of
patients and carers in planning
their care.
CPFT results on the overall
satisfaction rating have steadily
increased over time as shown in
Chart 14.
Page 42 of 74
It is worth noting that these results are supported by findings from the National Audit of
Schizophrenia 2012, whereby 81% of our patients reported a positive experience of our
service against the national average of 76%, while 84% reported positive outcomes of care
against a national average of 78%.
Our top 5 and bottom 5 scores are shown below. This shows that our patients are happy
with the quality of their relationship with our staff and their involvement in planning their
care. These scores are reflected in our internal patient surveys. Table 11 below also shows
that we have improved in three out of the five bottom scoring items in the survey.
Table 10: Top 5 scores
Questions
Did this person (health and social care worker) treat you with respect and
dignity?
Did this person listen carefully to you?
Did this person take your views into account?
Do you have trust and confidence in this person?
Were you given a chance to express your views?
2011
2012
9.2
9.4
8.8
8.6
8.2
8.1
9
8.7
8.6
8.6
2011
2012
5.2
5
4.4
5.1
4.9
5.2
5.2
5.3
5.4
5.4
Change
Table 11: Bottom 5 scores
Questions
In the last 12 months , have you received support in getting help with your
care responsibilities?
In the last 12 months , have you received support in getting help with finding
or keeping work?
Has anyone in the NHS mental health services ever asked you about your use
of non-prescription drugs?
In the last 12 months , have you received support in getting help with your
physical health needs?
Were you told about possible side effects of the medication?
3.1.4
Change
Trust Inpatient Survey
Inpatient survey data collection commenced on 26 January 2012. The inpatient survey
consists of 19 questions that are taken from the national patient survey. This is shown
below. At the end of March 2013, 2,655 questionnaires were completed with an overall
satisfaction rating of 82% (January 2012 – March 2013).
Trust inpatient survey questions
1
2.
3.
4.
5.
6.
7.
8.
9.
When you arrived on the ward did the staff
make you feel welcome?
Do you feel safe during your stay?
Do you have trust and confidence in our staff?
Do you feel you are treated with respect and
dignity by our staff?
Are you involved as much as you want to be
in decisions about your care and treatment?
Do you know who your care coordinator or
named nurse or lead professional is?
Do you have a care plan?
Do you understand what is in your care plan?
Have you had a care review meeting to
discuss your care?
10. Are the purposes of medication and treatments
explained in a way you can understand?
11. Are there enough activities available for you??
12. Do staff listen carefully to you?
13. How would you describe the food on the ward?
14. Have you been offered a choice of food at
mealtimes?
15. Have you been offered support in finding or
keeping accommodation?
16. Have you been offered support in finding or
keeping work?
17. Have you been offered support in seeking help
with financial advice or benefit?
18. How would you rate the care you receive?
19. How likely is it that you would recommend this
Trust to your friends and family
Page 43 of 74
Table 12: Top 5 scores
Questions
When you arrived on the ward did the staff make you feel welcome?
Do you have a care plan?
Have you been offered a choice of food at mealtimes?
Do you have trust and confidence in our staff?
Do you feel you are teated with respect and dignity by our staff?
Q1
Q2
Q3
Q4
Overall
2012/13
96
96
95
91
92
96
96
94
91
92
98
95
95
95
94
97
97
94
90
92
97
96
94
92
92
Three of our top scoring areas are around the quality of the staff relationship with our
patients which mirrors the results of our National Community Patient Survey. It is also worth
noting that patients report highly around having a copy of their care plan. Examples of
comments made by patients and carers are shown below.
“I am writing to express our thanks and appreciation to CPFT. I am a
mother of a 17 year old girl who has just been discharged from CPFT,
having spent 5 years being treated for anorexia and depression, both as an
outpatient and an inpatient. The care and support our daughter received
was truly outstanding.
We feel so fortunate to have received such support from dedicated
professionals with years of specific experience in treating adolescents with
eating disorders. We know from talking to parents of sufferers in other
parts of the country how this level of expertise and experience is not
common and yet it was vital to our daughter’s progress and to the wellbeing of the wider family. The critical factor in our daughter’s recovery has
been the wisdom, skill and kindness of the staff in teaching both her and
ourselves how to manage her condition.”
“Thank you for listening to me, talking and comforting me after my bad
dream yesterday. I would very much like to thank all of the nurses that have
been working here looking after me. (name of staff) saved my life not
directly but by talking to me and making himself approachable, like all staff
have. I felt comfortable to go to him and tell him the thoughts I was
having…I will always be grateful to the staff here for what they are doing for
me and for others. Without knowing it you save lives by instilling the belief
that we will get over our afflictions. I think when I am fully recovered and out
of the army I will try to help those in a similar position because I see that it is
a very important job that does not seem to get much recognition…
“I can’t believe how well my dad has come out of your ward (Older people’s
service). He was a very difficult patient and you have done wonders to put
him on the road to recovery. Take care all and keep up the good work. Dad
will miss you all.”
“I wanted to thank you for the kindness and understanding you have shown
(my son) who has had a lot of knockbacks in his life…His girlfriend and I are
already seeing the old (name) who is kind and very comical. I realise we
have such a long way to go, but you have made us very happy seeing
(name) like this and not upset and angry.”
Page 44 of 74
Comments received from (Meridian) patient surveys
Staff attitude
“The service from the team and the Trust has been fantastic and I cannot thank them enough for my care and
treatment in helping me get through a very difficult time. The facilities and activities available are far more that
I would have expected and I feel this is just as important or even more important in certain situations than the
use of only drugs.”
“The care staff have gone above and beyond anything that I could have expected, they are a very special kind
of people.”
Care planning
I’ve been involved in my treatment more than I expected. I’ve been allowed to voice my opinion without feeling
afraid or scared. I’ve been listened to and given very important advice for during and after treatment.”
“Every decision has been made clear and I am thankful for that.”
Food
“Good food and friendly staff.”
“High standards of food received whilst on the ward. Flexibility of visits by my family members.”
Table 13: Bottom 5 scores
Questions
How likely is it that you would recommend this Trust to your friends
and family?
How would you describe the food on your ward?
Have you been offered support in finding or keeping work?
Have you been offered support in seeking help with financial advice
or benefits?
How would you rate the care you receive?
Q1
Q2
Q3
Q4
Overall
2012/13
26
20
19
23
20
40
48
40
50
42
64
44
65
41
55
66
66
68
73
67
71
70
70
70
70
Table 13 above shows the specific areas that we need to focus on. It is worth noting that
while our patients are happy with the choice of food, we need to work on improving the
standard of the food on our wards. We have established a ‘Food Focus Group’ to drive up
the standards and quality of the food on our wards. We are also working with our provider
around improving the presentation of the food as well as the environments in which these
are being served.
We are also working on embedding recovery principles in our practice and services. The
Recovery College East which was opened in November 2012 will enable people who use or
have used secondary services from CPFT to develop new skills or increase their
understanding of the mental health challenges that they have.
Our Peer Support Worker programme also provides valuable support to our patients. We
are leading on this initiative and have the most number of PSWs among similarly sized
mental health Trusts.
Our lowest scoring item in this survey is the Friends and Family test with an overall average
score of 20%. This was our quality priority in 2012/13 and we are carrying this forward as
our quality priority for 2013/14.
Page 45 of 74
3.1.5
Trust Community Survey
Community survey data collection commenced in April 2012. A phased roll out across all
community teams was completed by the end of November. The survey consists of 14
questions which are shown below. 3,987 questionnaires were completed by the end of
March 2013. The overall satisfaction rating was 90%.
Trust community survey questions
1 Are staff polite and approachable?
2. Do you have trust and confidence in our staff?
3. Do you feel you are treated with respect and
dignity by our staff?
4. Do staff listen carefully to you?
5. Are you involved as much as you want to be
in decisions about your care and treatment?
6. Do you know who your care
coordinator/therapist/key worker or lead
professional is?
7. Do you have a plan of care/treatment/
therapy?
8. Do you understand what is in your plan of
care/treatment/therapy?
9. Have you had a care review meeting to discuss
your care/treatment/therapy?
10. Could you bring a friend, relative or advocate to
your care review meeting?
11. Are the purposes of medication and treatments
explained in a way you can understand?
12. Do you have the telephone number of someone
from the Trust that you can phone out of office
hours?
13. How would you rate the care/treatment/therapy/
activities you receive?
14. How likely is it that you would recommend this
Trust to your friends and family?
Table 14: Top 5 scores
Questions
Are staff polite and approachable?
Do you feel you are treated with respect and dignity by our team?
Do you have trust and confidence in our staff?
Do staff listen carefully to you?
Are you involved as much as you want to be in discussions about
your care?
Q1
Q2
Q3
Q4
Overall
2012/13
99
98
97
97
99
99
98
98
100
99
98
99
99
99
99
99
99
99
98
98
94
95
96
97
96
Examples of comments received from our community patients are shown below.
Comments received from (Meridian) patient surveys
Staff attitude
“There is always someone at the other end of the phone if we need them. All our questions, no matter how
silly we think they are, are always answered in a way that we understand. We are treated with respect. There
is always somebody available to do a home visit when needed.”
“Good rapport with support worker. Helpful and friendly advice.”
“They have taken the time to understand who I am and help me understand my condition.”
“Very helpful, friendly and understanding. Any concerns and necessary changes have been dealt with
immediately. I am treated like a human being.”
“Very good that I can talk to my care coordinator as though she is a friend and feel that I am treated as an
equal.”
“The consistency and professionalism of the service has made me feel valued and accepted and encouraged
me to live as fulfilling a life as possible given the limitations of my long term mental health issues.”
Care planning
“Always given advice on what is more favourable but given the choice of deciding what I personally feel will be
better. Very friendly and find it easy to talk to.”
“All consultations have been on a regular basis and all disciplines involved
Page 46 of 74
Table 15: Bottom 5 scores
Questions
How likely is it that you would recommend this Trust to your friends
and family?
Do you have the telephone number of someone from the Trust that
you can phone out of office hours?
How would you rate the care/treatment/therapy/activities you
receive?
Have you had a care review meeting to discuss your
care/treatment/therapy?
Could you bring a friend, relative or advocate to your care review
meeting?
Q1
Q2
Q3
Q4
Overall
2012/13
53
65
62
60
61
77
77
76
77
77
78
82
83
84
82
87
82
82
82
83
88
89
88
88
88
Four out of the five top scoring items refer to staff attitude and the quality of their
relationship with our patients, while the fifth one pertains to the quality of the patient’s
involvement in planning their care, treatment and support. These results mirror our national
and inpatient survey results and reflects the work that we have done around the 7Cs care
planning standards and the improvement in collaborative practice with patients in the care
planning process (see section 3.3.1).
Our bottom five scores also appear to mirror the results of our inpatient survey results. It is
worth noting however that the scores for the Friends and Family test are higher than the
Trust target of 30% (see quality priority 1 in section 1.2.1).
The introduction of the ARC (Advice and Referral Centre) will address the issue around out
of hours contact. Likewise, we expect that the restructuring of our community services and
development of Care Pathway teams will have a positive impact on the quality of care
provided.
Page 47 of 74
3.2
PATIENT SAFETY
Our performance in 2012/13 on patient safety quality indicators (i.e., suicide prevention,
physical assaults and absconsions, patient safety incidents and mandatory training
including safeguarding children and adults training) have been discussed in previous
sections of this Quality Report. Additional quality indicators are outlined below.
3.2.1
Reducing Healthcare Associated Infections (HCAIs)
The Trust remains committed to ensuring patients receive care in clean and safe
environments. During the year we continued to build on the measures put in place in order
to support good practice and reduce the risk of infection. Training figures are produced by
the Learning and Development team from ESR and LMS (see section 1.2.3), and are
reported through our quality dashboard.
The e-learning training
programme which runs
alongside the face-to-face
training helps to ensure
that staff maintain their
knowledge and skills in
the control and prevention
of infection. We have
made significant
improvements in training
as compared to the
previous year as shown in
Chart 15.
Chart 15: Infection Prevention & Control Training
HCAI incidents in 2012/13
1 incident of C Difficile in 2012/13 which is the same as the previous year. This was
investigated fully through our SI process
2 closures of wards due to diarrhoea and/or vomiting (3 closures in 2011/12). The
protocol was followed thereby ensuring the safest care for our patients and staff
One ward had two separate episodes of scabies (none in the previous year)
.
3.2.2
MRSA Screening
Assessing for MRSA screening is a national requirement for mental health providers since
2011. 100% of patients admitted into our wards need to be assessed for MRSA screening,
and those who fit into higher risk categories are offered swabs. We have made huge
improvements in 2012/13 and compliance level is much improved as shown in Chart 16.
This is monitored through the quarterly Patient Safety Thermometer returns (see CQUIN
goal 1, section 2.4) and reported through our quality dashboard.
Actions we have taken/are taking
to ensure consistent achievement
of the target include:
continued provision of Infection
control training
identification of Infection
Control leads/link workers in
each service
monthly reminders to ward
managers, link workers and
modern matrons
Chart 16: MRSA screening
Page 48 of 74
3.2.3
Pressure Ulcers (PUs)
Chart 17 shows the number of PUs reported in Datix, our electronic incident reporting
system, during the year. Of the four reported that were attributable to the Trust, two were
grade 2, one was grade 3 and another one was a grade 4 PU. The increase in cases
reported is most likely due to improved level of awareness regarding pressure ulcers and
care of the skin.
Other examples of good practice
Chart 17: Incidence of Pressure Ulcers reported via Datix
that are in place are listed below.
Modern Matron for Infection
Prevention & Control identified
as dedicated Trust lead for
PUs.
Use of NICE Guidance (CG29,
2005) and the European
Pressure Ulcer Advisory Panel
(EPUAP) guidance
Information resources available
on PU page on the Trust
intranet for staff
Use of the Waterlow
assessment tool as part of the
physical examination on admission
Reporting and investigation of all PUs through Datix, our incident reporting system. In
accordance with national guidance, any pressure ulcers of grades 3 or 4 are treated as
a Serious Incident. All actions resulting from investigations have been completed.
3.2.4
NHSLA
The NHS Litigation Authority handles negligence claims and works to improve risk
management practices in the NHS. The Trust achieved Level 2 accreditation in February
2011. The Level 3 assessment was originally scheduled in February 2014. This has been
moved to February 2015 by NHSLA following a review of their standards and assessment
process. An action plan is in place to help us prepare for the Level 3 assessment.
3.3
CLINICAL EFFECTIVENESS
3.3.1
Care Planning
Care planning is an on-going quality priority of the Trust. In 2010/11, our priority was to
ensure that 95% of our patients have a care plan and we consistently met this target over
the last three years (see section 1.3). In 2012/13, we shifted our focus on improving the
quality of our care plans (see section 1.2.1).
We developed the 7Cs standards, which are based on Outcome 4 and 6 of the CQC
standards, to clearly define the standards expected of our care plans and implemented a
process of monthly self and peer assessments. The scores are reported through our
quality dashboards and performance management framework.
The 7Cs standards are grouped under the following main headings:
Crisis/contingency
Comprehensive and cross-checked
Carried out
Collaborative
Carers and care for
Clear and concise
Choices
The standards are used to assess the quality of the care plans and include a section for
patients and/or their carers where appropriate to give feedback on their views about their
care plan and their involvement in planning and reviewing their care.
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Our work on improving the quality of our care plans contributed towards achieving
compliance with the CQC standards and improvement in our 2012 national patient survey
scores, with the section on ‘care plans’ showing the largest improvement. The results for
this section in the survey, taken from the CQC website and is presented below, shows we
scored higher than the national average around patients understanding their care plan.
This was acknowledged by our CQC assessors who praised the improvements we have
made in the quality of our care plans during the year. Comparative scores are also shown
in Table 16 below.
CQC, National Community Patient Survey 2012
Table 16: Comparative scores for care planning (CQC Community patient survey 2011 & 2012)
Questions
Do you understand what is in your NHS care plan?
Do you think your views were taken into account when deciding what was in
your NHS care plan?
Does your NHS care plan set our your goals?
Have the NHS mental health services helped you start achieving these goals?
Does your NHS care plan cover what you should do if you have a crisis?
Have you been given (or offered) a written or printed copy of your NHS care
plan?
2011
2012
6.6
7.7
6.8
7.5
6.0
6.6
6.6
6.8
6.6
6.7
6.9
7.8
Change
Actions for further improvement
We aim to further improve our practice and monitoring arrangements around care planning
in 2013/14. This includes:
reviewing the questions around care planning in our inpatient and community patient
surveys. We will adapt the questions around the specific needs and requirements of
individual services and patient groups.
reviewing our guidelines and policy around care planning to strengthen the links with
NICE guidelines and recovery principles.
rolling out a consistent care plan template through RiO, our electronic patients records
system.
Page 50 of 74
3.3.2
Breastfeeding
Our community children’s services were under their targets for breastfeeding at the end of
2012/13 as shown in Table 17. Data is collected though SystmOne (our electronic clinical
records system) and is monitored and reported though our quality dashboard.
Table 17: Breastfeeding targets and performance
Performance
Breast
Feeding
NI 53 (VSB 11) Prevalence of breastfeeding
(totally plus partially) at 6-8 weeks from birth
(%)
NI 53 (VSB 11) Percentage of infants for whom
breastfeeding status is recorded at 6-8 weeks
from birth (%)
Target
2011/12
Target
2012/13
March
2012
March
2013
48%
48%
44.5%
38.39%
No
target
set
95%
92.0%
93%
As a Trust we have strongly disputed the target which has been set in regard to breast
feeding prevalence within Peterborough. This is for two principal reasons, firstly the target
does not take account of the rapidly changing population and demographics of
Peterborough which would indicate reducing prevalence rates given that no new services
have been commissioned in this area. Equally, given the service we provide in this area
(Health Visiting), we have very limited scope to affect this performance given the
dependency that we have from other commissioned services such as community midwifery
and maternity services and in the absence of other support services such as baby cafes.
However, we remain committed to continually improving the effectiveness of our health
visiting services through active participation in a range of programmes such as UNICEF
(United Nations Children’s Fund) Baby Friendly Accreditation, but remain in active debate
with our commissioners to establish an appropriate measure to indicate the support we
provide to new mothers on breast feeding.
3.3.3
Participation in National Quality Improvement Programmes
National quality accreditation schemes provide a way of assessing the quality of our
services and comparing our performance with other Trusts across the country. They
provide assurance that our services are meeting the highest standards set by the
professional bodies, and also provides us with a framework for quality improvement.
During 2012/13, CPFT participated in the four accreditation schemes run by the Royal
College of Psychiatrists. This is shown in Table 18 in the following page.
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Table 18: Accreditation Schemes by CPFT
Accreditation
Services
Scheme
ECTAS
(ECT Accreditation
Service)
AIMS
(Accreditation for
Inpatient Mental
Health Services)
QNIC
(Quality Network for
Inpatient CAMH)
PLAN
(Psychiatric Liaison
Accreditation Network)
Current status
Addenbrookes ECT Clinic, Cambridge
Accredited
Cavell Centre, Peterborough
Accredited
Oak 2 Ward, Cavell Centre, Peterborough
(Adults unit)
Accredited
Oak 1 Ward, Cavell Centre, Peterborough
(Adults unit)
Accredited
Friends Ward, Fulbourn, Cambridge
(Adults unit)
Deferred (currently
closed for refurbishment
IASS, Ida Darwin, Cambridge
(Learning Disability unit)
Accredited
Hollies Ward, Cavell Centre, Peterborough
(Learning Disability unit)
Accredited
The Croft, Ida Darwin, Cambridge
(Children's unit)
Accredited
Darwin Centre, Ida Darwin, Cambridge
(Children's unit)
Accredited
Addenbrookes, Cambridge
Accredited
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4.0
PERFORMANCE AGAINST KEY NATIONAL PRIORITIES
The Trust is required to achieve a number of key national priorities as outlined within the
Department of Health Operating Framework. The Trust continues to perform well against
these targets in 2012/13 as shown below.
Table 19: Key national priorities
Target(%)
Target
2011/12
Target
2012/13
2011/12
2012/13
100%
100%
100%
95%
99.60%
95.99%
<= 7.5%
1.42%
2.30%
95%
100%
100%
97%
50%
99%
72%
98.81%
86.32%
LOCAL TARGET
Service users seen within 18 weeks (CPFT target)
100%
NATIONAL TARGETS
CPA patients having formal review within 12
95%
months
Minimising delayed transfers of care
<= 7.5%
Meeting commitment to serve new psychosis
95%
cases by early intervention teams
Data completeness: identifiers
99%
Data completeness: outcomes
50%
Data completeness: Community services referral to
treatment information
Referral information
Treatment activity information
Patient identifier information
Self-certification against compliance with
No
requirements regarding access to healthcare for
threshold
people with a learning disability
set
MRSA Infection rate (per 1000 bed days)
0.60
C.Difficile Infection Rate (per 1000 bed days)
0.70
Data has been sourced from the clinical records system
50%
100%
50%
50%
50%
No
threshold
set
0.00
0.00
98.9%
99.6%
97.6%
Met
Met
0.00
0.01
0.00
0.0001
Notes: Please note that data for the following have already been presented in section 2.8
under the mandatory core set of quality indicators for 2012/13:
Patients on Care Programme Approach who were followed up within 7 days following
discharge from psychiatric inpatient care during the reporting period
Admissions to acute wards for which the Crisis Resolution Home Treatment Team
acted as a gatekeeper during the reporting period.
.
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5.0
HIGH QUALITY WORKFORCE
5.1
Workforce Factors
Research evidence from the NHS has shown that higher levels of staff engagement are
linked to:
overall measures of financial effectiveness
lower levels of absence
improved levels of patient satisfaction
High quality patient care is therefore strongly associated with a highly skilled and motivated
workforce. As a consequence, the Trust’s Workforce Strategy is currently being developed
around four key themes that will enable effective staff engagement:
The four key themes and key performance indicators (KPI’s) for our workforce strategy are
as follows:
Theme
Definition
Target Outcome
Productivity
Maximising the
contribution of every
CPFT staff members to
patient care
75% of our substantive staff
productivity deployed at any one
time
Safe establishments on Ward and
Community Teams
engAgement
Every member of staff
will be involved with,
committed to and
satisfied with their work
for CPFT
60% staff to recommend CPFT to
family and friends
60% of staff state they have the
ability to make the changes
necessary for excellent patient care
Every CPFT staff
member will have the
knowledge, skills and
attitudes to perform to the
required performance
standards
Vacancy rates across CPFT are less
than 5%
95% of staff will receive appropriate
training relevant to their job role,
including Governance
All Band 7 and 8A’s will have
completed an appropriate leadership
Development Programme
95% of staff receiving appraisal and
competency review
Our key workforce
processes will be slick
and efficient
Recruitment ‘Time to Fill’ < 12 weeks
currently 16 weeks
Discipline Cycle Time < 63 days
currently 113 days
Sickness and Capability cycle time
will be reduced by 20%
Capability
Efficiency
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5.2
Staff Survey
The 2012 National Staff Survey was completed by 1185 members of staff between October
– December 2011, a sample of which (441) was used by the Department of Health to report
and directly compare our organisation to other Mental Health and Learning Disability
organisations. The findings for the 2012 National Staff Survey puts the Trust in the lowest
(worst) 20% for overall staff engagement when compared with Trusts of a similar type.
The areas the Trust performed well in and are the weakest areas are detailed in Tables 20
and 21 below.
Table 20: CPFT’s top 5 ranking scores
Key
Finding
Description
% of staff having equality and diversity
training in last 12 months
% of staff receiving health and safety
training in last 12 months
26
10
7
4
% of staff appraised in last 12 months
Effective team working
% of staff experiencing harassment,
bullying or abuse from patients, relatives
or the public in last 12 months
18
Threshold
2012
score
77%
Higher the
better
Lower the
better
84%
2011
score
National
Average for
MH & LD
Trusts
(2012)
59%
74%
73%
86%
91%
3.87
82%
3.94
87%
3.83
30%
n/a
30%
2012
score
2011
score
National
Average for
MH and LD
Trusts
(2012)
68%
70%
78%
3.34
3.37
3.52
3.06
3.30
3.54
52%
28%
41%
3.23
n/a
3.02
Table 21: CPFT’s top 5 ranking scores
Key
Finding
1
15
24
11
3
Description
% of staff feeling satisfied with the quality
of work and patient care they are able to
deliver
Fairness and effectiveness of incident
reporting procedures
Staff recommendation of the Trust as a
place to work of receive treatment
% of staff suffering work-related stress in
last 12 months
Work Pressure felt by staff
Threshold
Higher the
better
Lower the
better
The Trust will undertake the following actions in response to the survey findings:
Undertake a thorough analysis of questions as well as key findings.
Complete analysis for Divisions, Occupational Groups and Demographical Profile of
respondents.
Review against current objectives and priorities already in place as part of the Trust’s
Strategic Objectives.
Develop a communications plan around the results and engage with the Trust in
developing an action plan to improve staff experience. This phase is called the ‘Big
Conversation’.
Achieve feedback from the Executive Team around priority focus going forward.
Create an Action Plan involving representatives from the whole organisation.
Focus on staff engagement. Develop workforce strategy in liaison with staff.
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5.3
An Effective Healthcare Organisation
The Trust has robust workforce policies in place to ensure staff are safely recruited,
inducted, supervised and appraised and provide a minimum standard. The policies are
monitored to ensure managers and staff are compliant with these standards
Mandatory Training compliance is monitored on a monthly basis as well as being included
on the monthly Quality Dashboard which is reported corporately to demonstrate
compliance.
In 2012 the new Performance Management Framework Appraisal System was launched.
This includes a competency framework for staff performance, enabling a simpler and
consistent approach to individual assessment and a clearer overview of the overall
workforce performance. This rates staff performance on a ranking scale of between 1 and 5
and will feed into future Talent Management and Performance Management processes.
The system includes a validation process and appeals process, for consistency and
fairness. Feedback collected on the new system has enabled further development to take
place ready for the 2013 Appraisal launch in May.
The Trusts updated governance structure includes the Workforce Executive, which includes
Executive Directors and Divisional Managers and reports to the Board on a number of
workforce issues. A review of workforce data takes place on a monthly basis at high level
performance meetings. This workforce KPI’s are triangulated with patient safety and
experience KPI’s to highlight areas of concern for action.
Stop the line is an initiative which was launched in February 2013, and is where any
member of staff can raise an objection and literally stop something that is happening in
order to prevent a mistake from being made. It creates a safe environment for any member
of staff to report an unacceptable risk or when a harmful incident happens that seems to go
unnoticed or is not being taken seriously enough. From the report the Stop the Line Hub
alerts the Senior Manager and Executive Director to take action.
In response to the recommendations from the Francis Report (Report of the Mid
Staffordshire NHS Foundation Trust Public Inquiry, February 2013) all new job descriptions
will include a requirement for staff to be able to demonstrate care and compassion in their
work, and this will be monitored through our appraisal system and revised appraisal forms.
5.4
Planning and Developing the Workforce
A revised establishment control process has been implemented. Forms are completed,
including a risk assessment and final approval is required from Human Resources (HR)
before adverts are placed. In response to the recommendations from the Francis Report
(Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, February 2013) all
changes to nursing posts and clinical establishments must be signed off by the Director of
Nursing and Director of Finance for final approval. ,
A robust recruitment procedure is in place to ensure new staff are safe to work and this
complies with all the national recruitment standards which include appropriate pre
employment checks. A co-ordinated approach to filling vacancies is underway, to reduce
risks associated with vacant positions and also increase consistency across the Trust.
All staff are fully inducted corporately and locally when they commence and this includes
ensuring they complete the appropriate mandatory training to ensure they are safe to
practice. Robust monitoring is in place to ensure our compliance. Checks are in place to
ensure appropriate CRBs (Criminal Records Bureau) are in place and professional
registrations are up to date.
A robust workforce plan was developed to support the activity plans within the Trust
business plans for the last year. This included staff changes affected by service
transformation, changes to service provision and subsequent consultations. This will be
Page 56 of 74
reviewed annually to ensure it reflects changes to Trust plans and activities. A training
needs analysis (TNA) has been completed and this will inform future training plans. The
TNA was also commended by NHSLA (NHS Litigation Authority) at the last assessment as
an example of good practice nationally.
5.5
Staff Engagement
Feedback from All Staff Events supported the Trust in developing four Quality Priorities to
support the Trust in achieving our vision. Staff Engagement is one of the four priorities and
can be seen on the Quality Diamond Strategy in Section 1.1 and Annex 1.
Regular communications are provided to staff via weekly staff news emails and direct
emails from the Chief Executive. Staff have opportunities to directly feedback to the Chief
Executive and other Directors through the monthly Live ‘Webex’ chat and the ‘Back to the
Floor’ initiative. An excerpt from the CQC report below shows that staff value these
initiatives.
“Staff told us of the many changes that had taken place at the trust recently and of the extra
work that implementing the various quality initiatives to improve people's care had entailed.
However they clearly appreciated the many benefits this had brought to people and were keen
to continue the improvements and incorporate them into their everyday ward routines.
One staff member told us about the 'Ask Attila' initiative, whereby staff could email their
concerns and questions directly to the trust's chief executive (Attila Vegh) and that they had
done so and received a good response from him. Another staff member told us that visits to the
ward from the trust's directors had, as this staff member described, "been resurrected", making
the directors much more "visible and approachable" for staff. A number of staff told us they felt
that there was a lot more openness from senior managers in the trust and that lines of
communication with them had improved significantly within recent months. This had resulted in
staff feeling more confident that their concerns would be taken seriously. One staff member
commented, "There's shorter distance between here and the top" and another reported, "Things
get done a lot quicker now".
CQC report, July 2012 (pg 14/15))
The Trust’s Guiding Coalition forum which was set up in January 2012 comprised of 80
members of Trust staff from across all areas, bands and disciplines. Meetings on a regular
basis in 2012, the forum gathered feedback from staff on Trust direction, actions and plans
as well as led various projects around the Trust in improving the patient and staff
experience.
An increased number of staff responded to the 2012 Staff Survey (60.24%). Whilst the
challenges of turning the organisation around have affected staff engagement, with a lower
than average score of 3.48 (out of 5) it’s positive that an increased number of staff took the
time to feedback. The Trust takes the feedback from staff very seriously and feel strategic
action plans already in place will support in achieving increased staff engagement. Staff are
being invited to be part of the ‘Big Conversation’ which will look at the draft Workforce
Strategy and make improvements.
As part of the Trust performance reports we monitor sickness absence (the Trust’s KPI is
4.35%). In 2012, the Trust sickness rate has averaged at 4.17%.
Reward and recognition schemes have been developed through 2012, where staff can be
nominated and awarded monthly Quality Hero Awards for individuals and teams as well as
the annual Staff Awards. The first annual event was held in February 2013 and included 8
awards as well as the long service awards. All nominees and winners were invited to the
black tie celebration event.
Page 57 of 74
5.6
Health & Wellbeing
One of CPFT’s key values is “Our staff matter – we trust, value and develop each other. We
build a great place to work, where people are inspired to be the best they can be.” In
accordance with CPFT’s vision and values in all our policies and procedures, it is outlined
and acknowledged that staff wellbeing is of paramount importance. Wellbeing is an
important factor in the job satisfaction of our staff and is therefore a management issue for
the organisation.
Following feedback from staff at the Town Hall Events in June 2012 and the results of the
2011 Staff Survey, a Health and Wellbeing Strategy has been designed to bring existing
staff wellbeing issues to the forefront, whilst seeking to create an organisational culture
where negative wellbeing issues are identified, minimised and managed before they affect
the wellbeing of staff. We have a clear aim to promote the positive aspects and ideas
associated with health and wellbeing at work.
The CPFT Health and Wellbeing Strategy aims to embed a positive health and wellbeing
culture for all staff and that this is underpinned in the Trust’s policies and procedures,
including through appraisal, supervision and learning and development programmes. It
aims to:
Reduce sickness absence by improving the services available to staff for their mental
health
Reduce pressure felt by staff and effectively manage stress levels
Reduce the number incidents of staff affected by violence and bullying/harassment via
a Zero Tolerance Policy
Provide better access to health and wellbeing activities and facilities
We have also developed a ‘Mindfulness for the Health and Social Care’ course which is
based around the widely researched clinical approach to teaching mindfulness –
‘mindfulness based cognitive therapy’ (MBCT).
The Trust expect to achieve the East of England’s aSHAWed accreditation in Spring 2013.
They have also signed up to the National Responsibility Deal for Health and wellbeing in
the workplace.
5.7
Leadership
Following the previous changes to the Executive Leadership team and the Trust’s
turnaround agenda the leadership development for the Trust has been reviewed. A new
Leadership Development programme will be launched in the Summer 2013. As well as the
active engagement and hosting of the Festival of Leadership for the 3rd year in 2012, which
supported managers and clinical staff build their knowledge and skills around various
leadership qualities.
HR skills modules are in place to provide managers with the appropriate management skills
to support them in their roles and specific leadership and management competencies are
included in the performance management framework to support the development of
managers and leaders across the Trust.
As the Trust’s Academy is developed, further leadership development opportunities will be
available in Summer 2013.
5.8
Empowering Staff
The Trust’s Staff Consultative forum is the formal mechanism for consulting, liaising and
negotiating with staff side colleagues and trade unions. Consultations, staff developments
and employment policy development and changes are consulted on with staff side.
Page 58 of 74
In 2012 the Trust developed a Guiding Coalition which met regularly and provided a
mechanism for discussion and feedback with staff from across the Trust. The Trust also
continues to engage with staff and through the all staff meetings which take place biannually.
Fed-ex is a scheme which was launched in 2012 to support staff to make change happen,
by giving them a full day and £200 budget to work on an initiative which improves patient or
staff experience.
Much of the engagement strategy is built around empowering staff to make changes, be
heard and improve the services they provide.
Page 59 of 74
ANNEX 1 SUMMARY OF QUALITY DIAMOND STRATEGY
What we will do
Rationale
Culture of quality
We want a culture of quality that goes way beyond the
CQC essential standards where regular monitoring
against quality and safety standards becomes part of
our day to day practice. We will use new systems such
as the InCA tool to ensure we keep improving our
practice, our systems and process and the
environment. .
Achieving and maintaining full compliance
with the CQC and other quality standards will
help us to ensure that we continue to provide
the very best care possible that we will be
proud of and that we are happy for our friends
and family to receive.
Stop the line
This initiative was launched in February 2013 and will
enable CPFT staff to 'stop the line' whenever they see
something that poses a risk to patient or staff safety or
the quality of care. Immediate action will be taken and
reported upon when 'stop the line' incidents are raised.
Learning will be disseminated Trust wide and
unannounced inspections will take place to ensure
identified actions have been put in place.
We believe that most serious safety events
can be prevented if more decisive actions are
taken at the time of or leading up to the event.
This aims to create a safe environment for
any member of staff to report an unacceptable
risk or harmful incident they think is not being
taken seriously enough.
How are we doing?
Every clinical team will have a Quality Dashboard by
March 2013 to show how they are doing at giving
patients safe, effective treatment; at making sure their
experience is a good one, at looking after the needs of
staff and at using our resources sensibly. We will also
introduce 'risk cards' to report and manage risks openly
and efficiently.
Providing accurate, relevant, meaningful and
timely information about the quality of their
practice and service will enable staff and
teams to act in a timely manner to improve
services. It will also help them to demonstrate
how well they are doing as a service to their
patients, fellow staff, visitors and other
stakeholders.
No hotspots
OBJECTIVE 1: To be top 5 in patient safety
We will reduce the number and severity of adverse
events and serious incidents by noticing when there
are hotspots of risk, finding out why and putting thing
right. We will focus on areas of unacceptable risks and
harmful events and improve the process for
investigation of serious incidents and dissemination of
learning.
We acknowledge that there are still areas in
our service where risks to patient safety and
harmful incidents still exist. By identifying and
focusing on hotspots, we can focus our efforts
and resources to eradicate these in order to
improve the environment of safety in our
services.
Indicators
where available
95% compliance with
7Cs standards
95% compliance with
InCA standards
No conditions in our
CQC registration status
Agreed targets in the
Quality Dashboard.
reduction in adverse
events and serious
incidents
Children’s community
services will meet 18
week waiting time
targets
Clinical
Effectiveness


OBJECTIVE 2: To be top 5 in patient experience
Rationale
Put patients first
We will reorganise our services and develop diagnosis,
problem and need-based pathways that are based on the
evidence of best practice to be delivered by specialists in
that area. We will create a single point of access by
opening our Advice and Referral Centre (ARC) to all GPs,
patients and partners.
Diagnosis and needs-based services
ensures that patients don’t have to move
between services when they reach a
certain age and eliminates the risk of
falling between the gaps. Having staff with
the right skills also ensures that the best
and clinically effective care is provided
with the best possible outcomes of care.
Right staff for the
right amount of work
We will ensure that our staffing levels are based on
international research into patient care and staff
requirements. Work to determine safe and effective
staffing levels was concluded in December 2012, and will
take account of patient acuity and referral patterns. We
will reduce our bank and agency staff usage to less than
5%.
The delivery of good quality care is
dependent upon having the right number
of appropriately skilled staff. Ensuring
adequate staffing levels will help us
ensure we provide the best quality care for
our patients.
Reduce bank and agency
staff usage to less than
5%
In your shoes
We will use new ways to listen to our patients. Initiatives
include using iPads to collect feedback about our
services. Results will be published and combined with
other information to help us shape our services. We will
also link with social care and other partner organisations
to deliver seamless care.
We believe that listening to our patents
and their carers and giving them more
involvement in decision about their care
will help us to change and develop our
services. Collecting and sharing
meaningful qualitative information from
patient feedback in a timely manner will
also help teams to keep improving their
services.
Patient survey scores as
reported in Divisional
quality dashboards
Recovery &
integration
Indicators
where available
What we will do
We will continue to increase and strengthen the role of
peer support workers and maintain our national leading
position in this area. We opened our Recovery College
East in November 2012 – the first in the region - which
will deliver unique peer-led training in recovery. We will
deliver a new social care strategy and appoint a new
Director of Service Integration to improve the way we
provide support, recovery, education, employment and
financial advice to our patients.
We believe that giving our patients and
their carers more control over how their
care and treatment will be delivered will
help us to shape our services and deliver
responsive and personalised care. By
empowering them to express their choice
and preferences, we can help them to
direct their care, maintain their recovery
and promote their independence.
Clinical
Effectiveness


Page 61 of 74
Rationale
We will implement RiO to help make keeping electronic
records more efficient, use of iPads to help community
teams access and create patient records remotely,
develop standardised and service-specific templates to
deliver personalised care, review our record keeping
and records management processes to ensure we
support patient care in the most effective and efficient
way. We will train our staff to become IT literate.
Freeing up staff time spent on administrative
tasks will create more time to spend with
patients. Developing a fit for purpose electronic
record keeping system and streamlining our
processes around managing health records will
help create an efficient and effective service that
is aimed towards helping staff to spend more
time with patients.
Beyond the carrot &
CPFT Academy
stick
The CPFT Academy will provide our staff with decision
making and leadership skills to ensure that they have
the skills and competencies to do their job as best as
they can. It will help staff to deliver good quality care,
learn how to understand and investigate risks and
problems, plan new innovative services and measure
results and outcomes of care competently.
By developing our staff and providing them with
opportunities for personal and professional
development, we will make sure that they have
the right and up to date knowledge and are
capable of making the right decisions when it
comes to managing their teams and their
services.
We will recognise and reward good performance based
on their merits – initiatives include the ‘Quality Heroes’
and ‘Team Champions’. We celebrated our very first
Annual Staff Awards in February to recognise the
outstanding achievements of our staff. We will strive to
attain effective and meaningful staff appraisals that will
recognise good practice and also help staff improve
areas that need further development.
We believe that hard work and success need to
be acknowledged and rewarded fairly. This
helps to create a motivated and committed
workforce which contributes to the success of
our organisation. Hence we will reward staff
achievement and provide open and honest
feedback to developed engaged staff that will
help us to meet our objectives and priorities.
We will listen to our staff and give them the opportunity
to help shape our vision and direction as an
organisation. We will continue to have Town Hall
events to ensure staff are informed of new
developments and enabled to give feedback in a safe
environment. We will continue to support the Guiding
Coalition to deliver changes to our services. In 2012,
we introduced various initiatives to encourage open
communication between the management team and our
staff.
Sharing information with staff in an open and
timely manner and providing them with
opportunities to ask questions and express their
views in a safe environment will encourage
engagement and ownership, which are essential
ingredients of successful organisations.
More time with
patients
What we will do
Taking staff seriously
OBJECTIVE 3: To be top 5 in staff engagement
Indicators
where available
Clinical
Effectiveness
Page 62 of 74
OBJECTIVE 4: To be top 5 in value for money
Frontline first
Attack waste
Reducing the money spent on management
and non-clinical overheads will enable us to
increase the proportion of money spent on
clinical services that will lead to better care and
outcomes for the people who use our services.
We have reduced the money spent on management by
reducing our Clinical Divisions from five to three, and
the money spent on non-clinical overheads such as
finance, HR and performance. We also commit to
reducing the time for recruitment from 94 to 62 days,
and we will double the number of volunteers within the
Trust.
We will reduce the cost of business travel by £400,000
Reducing our overhead costs will mean that
a year and our legal fees by a further £100,000. We
we are able to spend more money on patient
will also reduce our printing costs and find other ways of
care and save jobs.
saving money.
Buy smarter
Rationale
We will get the best value for our money on products
and services and overall, work to save money in all the
areas where saving money does not make a negative
impact on patient care. We have started this work by
asking our suppliers to give us an initial 5% discount on
their current charges.
The same as above.
A workplace fir
for work
What we will do
We will ensure that all of our wards will meet the 5 star
environmental standards and ensure that maintenance
works are done quickly. We have launched our ‘warm
reception’ programme and will improve staff facilities.
We will also review and improve all our community
facilities and build a workplace that is fit for a top 5
Trust.
Improving the working environment will show
that we value our staff and our commitment to
their wellbeing which will, in turn, improve
morale, performance and productivity.
Indicators
where available
Clinical
Effectiveness
Reduce business
travel by £400,00
Reduce legal
fees by £100,000
Page 63 of 74
Annex 2
DEFINITIONS OF KEY NATIONAL QUALITY INDICATORS
1.
The proportion of those patients on Care Programme Approach (CPA) discharged
from inpatient care who are followed up within 7 days.
Data definition
‘Patients discharged’ includes all patients discharged to their place of residence, care home,
residential accommodation, or to non psychiatric care or to prison. All avenues need to be
exploited to ensure patients are followed up within 7 days of discharge. Where a patient has
been discharged to prison, contact should be made via the prison in-reach team.
CPFT adapted definition
The indicator excludes patients who are
readmitted within 7 days
transferred to other wards (patients transferred to NHS psychiatric inpatient ward when
discharged from inpatient care)
discharged to other hospitals
discharged to Alcohol Service/Bridge Alcohol Team/Drink Sense
discharged to GPs
discharged to Out of Area
Learning Difficulties
discharged to Community Alcohol Team CAT/Community Drug Team/Add Action.
of no fixed abode
discharged to the Prison Service
die within 7 days of discharge
patients removed from the country as a result of legal precedence: and
CAMHS (children and adolescent mental health services), i.e. patients aged under 18.
Those that are recorded as followed up receive face to face contact or a telephone conversation
(not text or phone messages). The 7 day period is measured in days not hours and starts on
the day after discharge
Accountability
Achieving at least 95% rate of patients followed up after discharge each quarter.
2.
The proportion of inpatient admissions gatekept by the crisis resolution home treatment
teams.
Data definition
Gatekeeping: 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. An admission has been gatekept by a crisis resolution team if they
have assessed the service user before admission and if the crisis resolution team was involved
in the decision making-process, which resulted in an admission.
CPFT adapted definition
The indicator is expressed as proportion of inpatient admissions gatekept by the crisis
resolution home treatment teams in the year ended 31 March 2013. The indicator is expressed
as a percentage of all admissions to psychiatric inpatient wards.
The following patients are excluded from the indicator:
patients recalled on Community Treatment Order,
patients transferred from another NHS hospital for psychiatric treatment,
Internal transfers of patients between wards in the Trust for psychiatric treatment,
patients on leave under Section 17 or come under section 136 of the Mental Health Act,
patients who are sections under s.2 or s.3 of the MHA
Ministry of Defense (MoD) patients,
planned admissions to detox beds, and
planned admission for psychiatric care from specialist units such as eating disorder unit.
An admission is reported as gatekept by a crisis resolution team where they have assessed* the
service user before admission and if the crisis resolution team were involved** in the decisionmaking process which resulted in an admission.
Notes:
1. An assessment should be recorded if there is direct contact between a member of the team
and the referred patient, irrespective of the setting, and an assessment made. The
assessment may be made via a phone conversation or by any face-to-face contact with the
patient.
2. Involvement is the assessment of all patients thought to be requiring admission other than
those detained under the Mental health Act., although seen out of hours between 10.00pm –
08.00am
3. Where the admission is from out of the Trust's area and 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 areas, the admission is recorded as gatekept if the CR team assure
themselves that gatekeeping was carried out.
3.
Patient safety incidents reported
Indicator description
Patient safety incidents (PSI), reported to the National Reporting and Learning Service
(NRLS), is defined as ‘any unintended or unexpected incident(s) that could or did lead to
harm for one of more person(s) receiving NHS funded healthcare’.
CPFT adapted definition
The Trust also uses the criteria of 'suffered long term harm' to classify an incident as
severe, as well as 'permanently harmed'.
Indicator construction
The number of incidents as described above.
Indicator format
Whole number.
4.
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.
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5.
The number of Delayed Transfers of Care per 100,000 population (all adults – aged 18
plus).
Data Definition
A delayed transfer of care occurs when a patient is ready for transfer from a hospital bed, but is
still occupying such a bed.
A patient is ready for transfer when:
a clinical decision has been made that the patient is ready for transfer AND
a multi-disciplinary team decision has been made that the patient is ready for transfer AND
the patient is safe to discharge/transfer.
To be effective, the measure must apply to acute beds, and to non-acute and mental health
beds. If one category of beds is excluded, the risk is that patients will be relocated to one of the
‘excluded’ beds rather than be discharged.
Accountability
The ambition is to maintain the lowest possible rate of delayed transfers of care.
Good performance is demonstrated by a consistently low rate over time, and/or by a decreasing
rate. Poor performance is characterised by a high rate, and/or by an increase in rate.
(Monitor 2012/13 Detailed Guidance for External Assurance for External Reports)
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Annex 3
STATEMENTS FROM CLINICAL COMMISSIONING GROUP, LOCAL
HEALTHWATCH and OVERVIEW AND SCRUTINY COMMITTEE
Statement for inclusion in 2012/13 Quality Account for CPFT
21 May 2013
Cambridgeshire and Peterborough Clinical Commissioning Group (the CCG) has reviewed the
Quality Account produced by Cambridgeshire and Peterborough NHS Foundation Trust (CPFT) for
2012/13.
The CCG and CPFT work closely together to review performance against quality indicators and
ensure any concerns are addressed. There is a structure of regular meetings in place between the
CCG, CPFT and other appropriate stakeholders to ensure the quality of CPFT services is reviewed
continuously with the commissioner throughout the year. In addition, the CCG has carried out
announced and unannounced visits to CPFT to observe practice and talk to staff and patients about
quality of care, feeding back any concerns and actions required by the Trust.
The Trust are required to develop annual Cost Improvement Plans (CIPs) focusing on service
redesign, whilst maintaining quality of services. The CCG look to review the CIPs so that a quality
impact evaluation of the potential effect on front-line service delivery can be made During 2012/13
the commissioners had to use a range of contract mechanisms to obtain information, and a similar
situation is now occurring for the 2013/14 CIPs. The lack of financial transparency as to future CIPs
and how they might impact on service quality remains a major concern for the CCG and will be
pursued through the range of channels available.
CPFT has safeguarding systems in place to ensure both children and vulnerable adults are
protected from harm. The CCG had concerns about the level of safeguarding training in the Trust in
2012/13, and has worked with all providers to develop a CCG Safeguarding Training Strategy which
makes explicit the framework required for safeguarding systems. The CCG will be seeking a higher
degree of clarity about safeguarding training delivered to staff in 2013/14 to ensure it is
commensurate with their role.
The CCG monitor all trusts’ Serious Incident investigation processes to ensure investigations are
carried out in a timely and robust way and learning is taken forward and embedded. CPFT has
reviewed how clinical risk assessments are undertaken as part of the care planning process and are
working through an action plan for improvement. Concerns in relation to understanding of physical
health issues and co-morbidities are also being addressed.
CPFT commissioned an external review of suicides by Professor Appleby from the Centre for
Suicide Prevention at the University of Manchester during 2012/13. The review is due to be
published in spring 2013. The Trust has been working with other agencies to develop a health
economy suicide prevention strategy, with terms of reference now finalised for the strategy group. A
task and finish multiagency group has looked at improving risk assessments in this area. The CCG
expect CPFT to play a major role in driving work and learning from thematic analysis forward across
the health economy in 2013/14.
The Care Quality Commission (CQC) is the national regulator of quality in the NHS and carries out
inspections across all health and social care organisations. The CQC inspected CPFT in June 2012
and reported a moderate concern relating to medicines management and a minor concern for
assessing and monitoring quality. The Trust addressed all issues raised and the CQC confirmed
these areas were no longer concerns after a follow-up review in January 2013. The Trust currently
has no CQC concerns. The Quality Account summarises both concerns and actions taken to
address these issues.
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The CQC also has a responsibility to inspect compliance with the Mental Health Act and carried out
a visit to CPFT in relation to this area in December 2012. The final report was received in March
2013 and a response is being submitted by CPFT. The report raised issues about advocacy
services, facilities, patients’ understanding of their rights and restriction of patients.
The Chief Executive reserves special praise for the staff at CPFT who have worked hard to turn the
Trust around following a period of significant CQC concerns. However, this pressure has had a
detrimental effect on staff morale with the both national and internal staff surveys reflecting the
stress staff feel. The percentage of staff who would recommend the Trust as a place to work to
family and friends was well below the national average for similar trusts. The Quality Account sets
out a range of measures that have been put in place to support and involve staff in decision making
and their own health and wellbeing. The CCG will monitor this work closely to ensure it is driving
improvement in staff morale.
With the emphasis of staff engagement in the Quality Account, the work relating to service user and
care experience and engagement has a lower profile. There is limited detail about service user
engagement, although the CCG is aware work is being carried out, with involvement in care
planning a priority. The CCG are concerned about the slow progress in developing and
implementing a Carers Strategy.
In 2012/13, all acute providers started to use the Net Promoter / Friends and Family question as part
of their patient experience surveys. The question asks ‘Would you recommend the trust to family
and friends?’ The requirement to use this question was not extended to Mental Health Trusts.
However, CPFT did collect some data and are working with other similar trusts nationally to
determine how to use the Friends and Family test for Mental Health providers.
Following a year when priorities for improvement for 2012/13 were driven by the improvements
required by the CQC, the priorities for 2013/14 reflect a more rounded approach with involvement of
all stakeholders, better use of data and information, and a focus on the initiatives in CPFT’s Quality
Diamond Strategy. Seven of the nine priorities cover the whole of CPFT, and so will support not only
the clinical mental health work of the organisation, but also cover social care and the physical health
of adults and children. The CCG expect to see CPFT improve working between the different parts of
the Trust in 2013/14.
The Quality Account gives detail of the Commissioning for Quality and Innovation (CQUIN) scheme,
which rewards trusts for developing and implementing innovative plans for improvement. The Trust
did well against most of the 2012/13 CQUIN goals. However, the project to promote public health
initiatives by giving advice to service users regarding smoking and alcohol did not progress well and
the CCG expect the Trust to ensure this work receives a higher priority in 2013/14.
The Quality Account is well set out and fairly easy for the public to understand, although there are
some sections which use NHS jargon The report is open about the areas where improvement is
needed, and looks at and links all quality priorities from the past three years with those chosen for
2013/14. The Quality Account includes all the nationally mandated sections including a list of
services and specialties provided by the Trust.
Healthwatch Cambridgeshire
17 May 2013
Healthwatch Cambridgeshire is new organisation and so at this point are not able to constructively
comment on the Trust's draft Quality Accounts for 2012/13.
Once fully established, Healthwatch Cambridgeshire will be delighted to work together with CPFT on
consultations and participation work on matters that are important to the health and social care
economy of Cambridgeshire
Page 68 of 74
Cambridgeshire Overview & Scrutiny Committee
16 May 2013
Statement from OSC Cambridgeshire Officer
As a result of the County Council elections, the Council's Committees were not determined at the
time that comments on the draft quality account were required. We are therefore not able to provide
a full Overview and Scrutiny Committee response on this occasion.
There has been on going liaison and communication between the Committee and the Trust
throughout the year
During 2012/13 the Adults Wellbeing and Health Overview and Scrutiny Committee
Highlighted the need for more timely access to and more co-ordinated provision of child and
adolescent mental health services, particularly for young people in the transitional age ranges,
including those who are referred for the first time when they are aged 16-18
Raised concerns about timely access to urgent inpatient mental health provision within the
County for working age adults and older people.
As part of a review of delayed discharge from acute hospitals used by Cambridgeshire residents,
identified a need for
o Ensuring prompt identification, referral and access to secondary mental health services
for patients with mental health problems
o Strengthening the provision of liaison psychiatry within the hospitals for working age
adults and older people
o Developing inter-agency strategies for supporting the discharge of people who have
alcohol problems, are homeless, or have other support needs.
The Committee worked with Peterborough City Council Scrutiny Commission for Health Issues to
follow up the implementation of the changes to CPFT services which were agreed in early 2012. A
particular area of focus is ensuring that the Advice and Referral Centre provides a high quality and
effective service when it is rolled out across the County.
Comments from Scrutiny Commission for Health Issues – Peterborough City Council
20 May 2013
Comment from the Chair
I would like to thank the Trust for all of the hard work that has been put into producing this
document. A lot of work has been put in to improve the service for patients and I fully support the
2013/14 priorities.
Comments from Members of the Commission
5 Star Standard.
It is encouraging to see that all 21 wards have achieved at least 4 stars and hope standards will
continue to improve so that we see mostly 5 stars in future.
I hope the IT response times will continue to improve and that discussions with Serco will address
these issues.
Priority 3: Clinical Effectiveness, Trust Indicators
Numbers 2 and 4 are red and we would look to see improvements in these areas in the future.
I was pleased to see that positive steps have been taken to improve patient safety overall.
It is reassuring to see that staff ratings have been taken seriously and that training and an
improvement in the patient satisfaction rate is expected to raise morale in this respect.
Congratulations are due for the phoenix-like rising from the ashes from the position two years ago. I
only hope the IT situation improves as this is also crucial in building staff morale in my experience.
It may be helpful to see what the position is regarding staffing at all levels in future reports but this
one was really easy to read so well done for that too.
Page 69 of 74
ANNEX 4
STATEMENT OF DIRECTOR’S RESPONSIBILITIES IN RESPECT OF THE
QUALITY REPORT
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 as amended 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 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 2012-13;
the content of the Quality Report is not inconsistent with internal and external sources of
information including:
o
o
o
o
o
o
o
o
o
o
o
Board minutes and papers for the period April 2012 to May 2013;
Papers relating to Quality reported to the Board over the period April 2012 to May
2013;
Feedback from the Commissioners Cambridgeshire Commissioning Group dated
21/05/2013;
Feedback from local Healthwatch organisation Healthwatch Cambridgeshire dated
17/05/2013;
Feedback from Cambridgeshire County Council Adults Wellbeing and Health
overview and Scrutiny Committee dated 16/05/2013;
Feedback from Peterborough City Council Scrutiny Commission for Health Issues
dated 20/05/13;
The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, presented in the PALS and
Complaints report to the Quality and Performance Committee in April 2013;
The 2012 national patient survey;
The 2012 national staff survey;
The Head of Internal Audit’s annual opinion over the Trust’s control environment for
the year ending 31 March 2013 dated 23/05/2013; and
CQC quality and risk profiles dated 02/04/13.
the Quality Report presents a balanced picture of the NHS foundation trust’s performance over
the period covered;
the performance information reported in the Quality Report is reliable and accurate;
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to confirm
that they are working effectively in practice;
the data underpinning the measures of performance reported in the Quality Report is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review; and
the Quality Report has been prepared in accordance with Monitor’s annual reporting guidance
(which incorporates the Quality Accounts regulations) (published at www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for the
preparation of the Quality Report (available at www.monitornhsft.gov.uk/annualreportingmanual)).
The directors confirm to the best of their knowledge and belief they have complied with the
Page 70 of 74
above requirements in preparing the Quality Report.
By order of the Board
NB: sign and date in any colour ink except black
................................................ Chairman
24th May 2013
................................................ Chief Executive
24th May 2013
Page 71 of 74
ANNEX 5
EXTERNAL AUDIT REPORT
Independent Auditor’s Limited Assurance Report to the Council of Governors of Cambridgeshire and
Peterborough NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Cambridgeshire and Peterborough NHS Foundation
Trust to perform an independent assurance engagement in respect of Cambridgeshire and Peterborough NHS
Foundation Trust’s Quality Report for the year ended 31 March 2013 (the ‘Quality Report’) and specified
performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2013 in the Quality Report that have been subject to limited
assurance consist of the following national priority indicators as mandated by Monitor:
100% enhanced CPA patients receiving follow-up contact within seven days of discharge from hospital
(“CPA patient follow-ups”) – page 34 of the Quality Report; and
Admissions to inpatient services had access to crisis resolution home treatment teams “Gate-keeping”
– page 34 of the Quality Report.
We refer to these national priority indicators collectively as the “specified indicators”.
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
assessment criteria referred to on page 70 of the Quality Report (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”) 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;
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.
We read the Quality Report and consider whether it addresses the content requirements of the FT ARM, 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 period April 2012 to the date of signing this limited assurance report (the period);
Papers relating to Quality reported to the Board over the period April 2012 to the date of signing this
limited assurance report;
Feedback from the Commissioners Cambridgeshire Commissioning Group dated 21 May 2013;
Feedback from local Healthwatch organisation Healthwatch Cambridgeshire dated 17 May 2013;
Feedback from the Cambridgeshire County Council Adults Wellbeing and Health Overview and Scrutiny
Committee dated 16 May 2013;
Feedback from Peterborough City Council Scrutiny Commission for Health Issues dated 20 May 2013;
Page 72 of 74
The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, presented in the PALS and Complaints report to the Quality and
Performance Committee in April 2013;
The CQC national inpatient survey 2011 and 2012;
The CQC survey of people who use community mental health services 2012;
The NHS national staff survey dated 2011 and 2012;
Care Quality Commission quality and risk profiles dated monthly from April 2012 to March 2013;
CQC Inspection Reports in respect of: The Cavell Centre - January 2012; and Fulbourn Hospital - January
2012;
CQC reviews of compliance in respect of Fulbourn Hospital - July 2012 and October 2012;
The Head of Internal Audit’s opinion over the Trust’s control environment for the year ending 31 March
2013 dated 23 May 2013;
Quality and Performance Committee minutes dated 13 December 2012, 14 March 2013 and 18 April
2013;
Trust Patient Experience Survey 2012, including data from the Trust’s internal inpatient and community
patient experience surveys;
Staff 'Pulse' survey results March 2013; and
Report of the National Audit of Schizophrenia (NAS) 2012.
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 Cambridge and
Peterborough NHS Foundation Trust as a body, to assist the Council of Governors in reporting Cambridge and
Peterborough 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 2013, to enable the Council of Governors to
demonstrate 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 Cambridge and
Peterborough 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:
Evaluating the design and implementation of the key processes and controls for managing and
reporting the indicators.
Making enquiries of management.
Limited testing, on a selective basis, of the data used to calculate the specified indicators back to
supporting documentation.
Comparing the content requirements of the FT ARM to the categories reported in the Quality Report.
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.
Page 73 of 74
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 and the Directors’ interpretation of the Criteria on page 70 of the
Quality Report.
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.
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 Cambridge and Peterborough NHS
Foundation Trust.
Basis for Disclaimer of Conclusion – CPA patient follow-ups and Gate-keeping indicators
The CPA patient follow-ups indicator, requires patients to be followed up within 7 days of discharge through
face to face contact or a phone call. For 3 patients that we tested out of a total of 35, patient files did not
contain evidence of the follow-up process performed. As a result, we were not able to conclude that a followup had been performed.
The Gate-keeping indicator requires in-patients to be assessed by the crisis resolution home treatment service
prior to admission (“gatekeeping”). We identified that the report produced from the Trust’s information systems
to calculate this indicator had not been programmed correctly. In our sample of 35 cases, there was
insufficient evidence on patient files in respect of 7 cases to substantiate that the patients, as reported by the
Trust, had been subject to gatekeeping. As a result, we were not able to conclude that the crisis resolution
home treatment service had assessed the patient prior to admission.
Conclusion (including disclaimer of conclusion on the specified indicators)
Because of the significance of the matters described in the Basis for Disclaimer of Conclusion paragraph, we
have not been able to form a conclusion on the specified indicators.
Based on the results of our procedures, nothing has come to our attention that causes us to believe that for
the year ended 31 March 2013,
The Quality 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 Quality Report is not consistent in all material respects with the documents specified above.
PricewaterhouseCoopers LLP Chartered Accountants
Cambridge
29th May 2013
The maintenance and integrity of the Cambridge and Peterborough 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.
Page 74 of 74