ENTS
1
PART 1: CHIEF EXECUTIVE’S STATEMENT ............................................................................................................ 2
2
PART 2: PRIORITIES FOR IMPROVEMENT & STATEMENTS OF ASSURANCE FROM THE BOARD ........................... 4
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
3
PRIORITIES FOR IMPROVEMENT ................................................................................................................................. 4
OUR PRIORITIES FOR 2015/16................................................................................................................................. 4
STATEMENTS OF ASSURANCE .................................................................................................................................... 7
REVIEWING THE QUALITY OF TRUST SERVICES .............................................................................................................. 8
CLINICAL AUDIT ..................................................................................................................................................... 8
CLINICAL RESEARCH .............................................................................................................................................. 12
GOALS AGREED WITH COMMISSIONERS (COMMISSIONING FOR QUALITY AND INNOVATION - CQUIN) ................................. 13
WHAT OTHERS SAY ABOUT THE TRUST..................................................................................................................... 15
DATA QUALITY .................................................................................................................................................... 16
NHS NUMBER AND GENERAL PRACTICE CODE VALIDITY .............................................................................................. 17
PART 3: REVIEW OF QUALITY PERFORMANCE...................................................................................................20
3.1
3.2
3.3
3.4
PART 3A: DEPARTMENT OF HEALTH MANDATORY INDICATORS ..................................................................................... 20
PART 3B: PERFORMANCE AGAINST QUALITY IMPROVEMENT PRIORITIES 2014/15 ........................................................... 29
PART 3C: TRUST PERFORMANCE AGAINST ADDITIONAL QUALITY PERFORMANCE INDICATORS ............................................. 35
PART 3D: STATEMENT FROM THE TRUST’S KEY STAKEHOLDERS...................................................................................... 44
4
CONCLUSION .....................................................................................................................................................48
5
HOW TO PROVIDE FEEDBACK ............................................................................................................................48
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 1 of 55
1 Part 1: Chief Executive’s Statement
2014/15 has been another challenging year for the whole healthcare system, with the ongoing
implementation of NHS reforms and ensuring quality remains at the heart of services.
Within this context, Dudley and Walsall Mental Health Partnership NHS Trust (the Trust) has had
another productive year with a continuing high focus on quality, led by the Executive Director of
Operations and Nursing and the Joint Medical Directors, supported by rigorous and regular
reporting to provide assurance to the Board.
The Board’s Governance and Quality Sub–Committee meets monthly to review and maintain
effective systems for integrated governance, risk management and internal control across all of the
Trust’s activities, both clinical and non-clinical. More broadly the Trust also uses the Monitor Board
Quality Governance Framework, on a quarterly basis, as a live mechanism to self-monitor and
assure the Board of the robustness of its Quality Governance systems and processes.
We therefore welcome the opportunity to present the annual Quality Account to demonstrate our
continued commitment to delivering high quality care and ensuring quality is at the heart of the
organisation. It is particularly pleasing to be able to confirm that the Trust has continued to achieve
targets set nationally for Mental Health Trusts in 2014/15, delivered the Commissioning for Quality
and Innovation (CQUIN) schemes, and retained ‘registration without conditions’ with the Care
Quality Commission. More detail is provided in the key quality improvements delivered by the
Trust in 2014/15 and the quality challenges we have set for ourselves for 2015/16.
On a practical level, the Trust firmly believes that the delivery of high quality services is an integral
part of everyday practice and is “everyone’s business”. In support of this, during the last year the
Trust has:
 Achieved a gold star award from the National Triangle of Care programme in recognition for
our commitment for working in partnership with service user, their carer and the
professionals involved.
 Maintained Royal College of Psychiatrists Centre for Quality Improvement (CCQI)
Accreditations.
 Strengthened clinical audit within the Trust and alignment to Trust’s Quality Improvement
Strategy.
 Further developed the role of ‘Experts by Experience’ to strengthen the service user and
carer voice with regards to quality of care.
 Implemented a local action plan in response to the Francis Report to ensure lessons
learned are embedded.
 Achieved encouragingly positive results from our Community and Inpatient Surveys.
 Trust voted ‘Top 100 places to work in the NHS by the health Service Journal.
 Continued to invest in leadership development for senior staff and clinicians.
 Continued to develop an integrated performance dashboard, including quality indicators to
ensure that the monitoring of quality is embedded.
 Continued to use the Trust’s embedding lessons framework to ensure that there is an
accountable process whereby recommendations result in actions to improve quality.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 2 of 55
As Chief Executive of the Trust, I can confirm that, to the best of my knowledge, the information
contained in this Quality Account is accurate. The Statement of Directors responsibilities
summarises the steps taken to develop this Quality Account and external assurance is provided in
the form of statements from our commissioners. The report of an external audit undertaken by
Grant Thornton UK LLP is included in the quality account.
Gary Graham
Chief Executive
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 3 of 55
2 Part 2: Priorities for improvement & statements of assurance from
the Board
2.1
Priorities for Improvement
This is the forward-looking section of the Quality Account. It details the improvements planned for
the next year and explains why the priorities have been chosen. When identifying the 2015/16
priorities, consideration were taken against progress made since the last Quality Account which is
detailed in Section 3 of this report.
During 2014/15, the Trust embraced an ambitious agenda for quality improvement which has been
delivered through the Quality Improvement Strategy. The Trust will continue this journey during
2015/16, and has identified 8 quality improvement priorities through a process of reviewing
services and working with stakeholders, and by looking at the Trust’s performance against national
and local quality indicators.
These quality priorities are especially pertinent as barometers for service quality as they:







Reflect the vision and current priorities for the organisation
are distributed across the CQC domains Caring, Responsive, Effective, Well-led, Safe
represent both local and national agendas
include priorities that are important to our service users and their carers
Include priorities that are important to our staff
include priorities important to stakeholders and partners
Are a mixture of new areas and those which build on key priorities from 2014/15 and are
applicable to services being developed as part of the Trust’s Service Transformation work.
For each of the quality priorities a delivery strategy has been developed to track the performance
against improvement initiatives at all levels from Ward to Board. Progress against these priorities
will take place through quarterly integrated ‘Quality Reports’ presented to the Quality and Safety
Committee and Trust Board.
2.2
Our Priorities for 2015/16
Quality Goal 1: Enhance care and compassion through the introduction of ‘My Name Is’
initiative Trust wide
Rationale for Inclusion
The Trust is committed to ensuring staff are deliver compassionate care.’ My Name Is’ initiative is a
National Campaign to remind healthcare staff about the importance of introductions in the delivery
of care. It is about the beginning of a therapeutic relationship and building trust and supports the
delivery of compassionate care. The Trust wants to embrace this National initiative to further
develop and embed the 6 C’s – caring, compassion, communication, courage, competence,
commitment.
Improvement Initiatives
To sign up as a Trust to the national initiative and implement a local delivery plan.
Measurement
Satisfaction levels of service users and carers that feel staff introduce themselves
Progress against a locally agreed action plan to support the implementation of the ‘My Name Is’
campaign’
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 4 of 55
Quality Goal 2: Improve Trust processes for managing Did Not Attends (DNAs)
Rationale for Inclusion
The Trust has identified the need to improve the management and processes for DNAs this has
been identified through a number of sources including coroners recommendations, embedding
lessons from incidents, service user and carer feedback. The aim of the initiative is to improve
patient safety and the efficiency and responsiveness of clinical processes.
Improvement Initiatives
To develop and implement a revised policy and underpins clinical process for the management of
DNAs including quality metrics.
Measurement
Clinical Audit to measure compliance with policy
Monitoring of DNA rates through internal quality key performance indicator
Quality Goal 3: Improve the quality of dementia care through dementia mapping
Rationale for Inclusion
During 2014/15 the Trust focussed on ensuring best practice guidelines are being delivered within
our dementia services. This has included taking on board the recommendation from the Care
Quality Commission Inspection visit to the Trust in February 2014. Dementia care will continue to
be a priority for the Trust in coming year with a focus on introducing ‘Dementia Care Mapping
that has been recommended by the National Institute for Health and Clinical Excellence, the Social
Care Institute for Excellence, the Audit Commission and the Commission for Health Improvement
as a method for improving care practice for people with dementia and promoting person centred
care.
Improvement initiative
To introduce Dementia Care Mapping programme across our inpatient dementia services that
results in local improvement plans and benchmarking of practice.
Measurement
Dementia care mapping results for each participating ward and improvement plans
Quality Goal 4: To improve the quality of clinical supervision and appraisals to support
care delivery and practice
Rationale for Inclusion
The Trust has identified though embedding lessons from serious case reviews, Care Quality
Commission recommendations and staff feedback the requirement to further improve and embed
the quality of supervision and appraisal processes
The Trust views supervision as a critical element in ensuring the provision of high quality mental
health care and treatment across its services. Supervision is viewed as fundamental to the
safeguarding of standards of performance and practice by providing a framework within which line
management accountability is discharged, decision making and risk management takes place,
expertise is developed and where effective delivery of quality care for all services users is placed
at the heart of the process.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 5 of 55
Improvement Initiatives
Implementation of revised Supervision and Appraisal Policy including quality monitoring
Measurement
Clinical Audit to measure compliance against policy
Quality Goal 5: To demystify care pathways to ensure transparency and ease of
understanding for services users, carers and stakeholders about our services
Rationale for Inclusion
Following feedback from our service users, carers and commissioners the Trust is committed to
undertaking a quality improvement initiative to further demystifying our care pathways. This will
enable greater transparency and ease of understanding of the services we deliver and how they
interface.
Improvement Initiative
To produce maps of our clinical pathways in a format that is clear, accessible, and transparent to
enable stakeholders to navigate our services.
Measurement
Monitoring of complaints
Incident reporting
Stakeholder survey
Quality Goal 6: To improve the management and monitoring of long term physical
conditions
Rationale for Inclusion
The Trust has identified the requirement to further improve the quality of managing long term
physical health conditions. This is underpinned by National publications ‘Living well for Longer, No
Health Without Mental Health, Closing the Gap and the National Audit of Schizophrenia which
promote the improvement in the early detection, monitoring and effective management of long term
conditions for people long term mental health conditions.
Improvement initiative
To develop in partnership with key stakeholders and implement a local plan across the Trust
services for the management and monitoring of long term physical health conditions.
Measurement
Clinical Audit to measure practice against clinical standards and pathways.
Quality Goal 7: To improve patient and staff experience relating to the impact of
incidents and the management in relation to their perceptions and feelings of safety
Rationale for Inclusion
During 2014/15 the Trust focussed on ensuring best practice guidelines are being delivered in the
management of violence and aggression including least restrictive practice principles. Feedback
from both and patient surveys have identified further work the Trust needs to undertake to improve
patient and staff experience relating to the impact of incidents and their perceptions and feelings of
safety.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 6 of 55
Improvement initiative
To introduce an improvement plan informed by staff and service user feedback
Measurement
Post incident analysis of patient and staff experience
Quality Goal 8: To improve access to psychological therapies through the implementation
of a therapeutic hub
Rationale for Inclusion
During 2014/15 the Trust focused on improving inpatient activities which was informed by service
user, Commissioners and Care Quality Commission feedback. To ensure the Trust has a
sustainable, person centred and evidence based approach to the delivery of therapeutic
interventions and activities the Trust is in the process of developing a therapeutic hub. This will
enhance the progress made during 2014/15.
Improvement Initiatives
The Therapeutic Hub will draw together all of the multidisciplinary psychological skills under one
virtual roof. By moving towards a more unified approach to planning and delivering psychological
care in the Trust will clearly demonstrate effectiveness through specific psychological performance
measures
It will ensure that expertise only available in one part of the service will become accessible across
the Locality.
Measurement
Compliance against local psychological therapies performance metrics
Dudley and Walsall Recovery Outcome measure
How will we review and monitor these priorities?
Each quality improvement priority identified for 2015/16 will be delivered through the framework
identified in the Trust Quality Improvement Strategy. Progress will be monitored through the Trust
quality governance framework and overseen by the Governance and Quality Committee. The
Governance and Quality Committee and Trust Board will receive quarterly updates on progress
and also any required exception reports.
2.3
Statements of Assurance
The aim of the following sections (2.4 - 2.10) is to provide information to the public which will be
common across all Quality Accounts, thereby enabling people to gain a more informed and
transparent view about what different healthcare organisations have reported.
The statements in this section offer assurance from the Trust Board to the public that the Trust is: Performing to essential standards
 Measuring our clinical processes and performance
 Involved in national projects and initiatives aimed at improving quality
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 7 of 55
2.4
Reviewing the Quality of Trust Services
During 2014/15, the Trust provided NHS services through five service lines: 




Acute Services
Older Adults Services
Recovery Services
Early Intervention Services
Community Services
The Trust has reviewed the data available to them on the quality of care in all five of these
services.
The income generated by the NHS services reviewed in 2014/15 represents 100% of the total
income generated from the provision of NHS services by the NHS Trust for the reporting period
2014/15.
2.5
Clinical Audit
Clinical Audit is a quality improvement cycle that involves measurement of the effectiveness of
healthcare against agreed and proven standards for high quality, and taking action to bring practice
in line with these standards so as to improve the quality of care and health outcomes. (HQIP ‘New
Principles for Best Practice in Clinical Audit’ - Radcliffe Publishing, 2011).
As part of the Clinical Governance Agenda, the Trust has a comprehensive Clinical Audit
programme that is delivered as part of the annual audit programme. This is monitored by the
Clinical Governance and Quality Committee on behalf of the NHS Trust Board. The Audit
Committee may also request specific clinical audit reports as appropriate
2.5.1
National Clinical Audits and Confidential Enquiries
During April 2014 to March 2015, six National Clinical Audits and one National Confidential Enquiry
covered NHS services that Dudley & Walsall Mental Health Partnership Trust provides.
During that period Dudley & Walsall Mental Health Partnership NHS Trust participated in 100% of
National Clinical Audits and 100% of National Confidential Enquiries of the National Clinical Audits
and National Confidential Enquiries which it was eligible to participate in
The National Clinical Audits and National Confidential Enquiries that Dudley & Walsall Mental
Health Partnership NHS Trust was eligible to participate in during April 2014 to March 2015 are as
follows:
 Prescribing Observatory for Mental Health (POMH) Prescribing for People With Personality
Disorders
 National Audit of Schizophrenia (NAS) round 2
 Commissioning For Quality and Innovation (CQUIN) Cardio Metabolic Assessment for
Patients with Schizophrenia Physical Health Part 1
 Commissioning For Quality and Innovation (CQUIN) Cardio Metabolic Assessment for
Patients with Schizophrenia Physical Health Part 2
 Safeguarding Children Section 11 Audit
 National association of psychological therapies (NAPT)
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 8 of 55
The national clinical audits and national confidential enquiries that Dudley & Walsall Mental Health
Partnership Trust participated in during April 2014 to March 2015 are as follows:
 Prescribing Observatory for Mental Health (POMH) Prescribing for People with
Personality Disorders
 National Audit of Schizophrenia (NAS) round 2
 Commissioning For Quality and Innovation (CQUIN) Cardio Metabolic Assessment for
Patients with Schizophrenia Physical Health Part 1
 Commissioning For Quality and Innovation (CQUIN) Cardio Metabolic Assessment for
Patients with Schizophrenia Physical Health Part 2
 Safeguarding Children Section 11 Audit
 National association of psychological therapies (NAPT)
 National Confidential Enquiry into Homicide and Suicide
The national clinical audits that Dudley & Walsall Mental Health Partnership NHS Trust participated
in, and for which data collection was completed during April 2014 to March 2015, are listed below
alongside the number of cases submitted to each audit or enquiry as a percentage of the number
of registered cases required by the terms of that audit or enquiry.
The National Clinical Audits
Figure 1: National Clinical Audits
Audit Title
Participation
POMH Prescribing for people with personality disorders
Yes
National audit of Schizophrenia 2 (NAS2)
Yes
Commissioning for quality and Innovation (CQUIN) cardio
metabolic assessment for patients with schizophrenia physical
health part 1
Commissioning for quality and Innovation (CQUIN) cardio
metabolic assessment for patients with schizophrenia physical
health part 2
Safeguarding children section 11 audit
National association of psychological therapies (NAPT)
National Confidential Enquiry into Suicide and Homicide
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
% cases submitted
42 were submitted
(target number was 42)
97 were submitted
(target number was 100)
Yes
100 were submitted
(target number was 100)
Yes
86 were submitted
(target was 100)
Yes
Not applicable. This was a
national audit of Trust
processes
Yes
Yes
100 were submitted
(target number was 100)
Minimum data set
exceeded
Page 9 of 55
2.5.2
Local Clinical Audits
The Trust own Quality priority audits for 2014-2015 were derived from a number of key sources
including trend analysis of incidents, complaints, commissioner requests, National best Practice
Guidelines (I.e. NICE) and to gain assurance with regards to newly embed processes and to
ensure embedded quality processes were safe and effective. The audits commissioned to support
these processes and the key findings or recommendations arising from these audits are detailed in
the table below:
Figure 2: Trust Priority Local Clinical Audits
Title of audit
Summary of actions/recommendations
Fall Prevention
As part of the Trust Falls Prevention Strategy, an audit against National guidance
and Trust policy was commissioned to occur in 2014/15.
The aim of the audit was to review practice in relation to falls risk assessments,
provision of falls risk mitigating equipment and staff skills and knowledge.
The audit highlighted some areas of good practice, but also identified some areas
where further improvements were required to ensure best practice is maintained.
Following the completion of the audit, and following analysis of outcome of incident
investigations the Trust identified the need to assess a patient’s fear of falling as part
of a patient’s risk assessment. This was especially important for older adults where
risk of falls is more prevalent and falling can affect the persons overall wellbeing and
mobility.
In addition, the audit also highlighted a need for the medication that service users
are currently prescribed to be assessed by medical staff to ensure that they are
suitable, not contra indicated and where possible reduces the risk of medication
induced falls.
Another important identified need was for Families and/or carers (where agreed by
the patient) to always either be included in the assessments or informed of the
results of any assessment. This is in line with one of the Trusts key quality
improvement successes: The Triangle of Care project which emphasise the need for
the patient, the family and/or carer and the NHS staff to work collaboratively for an
effective outcome.
Care Programme
Approach
The Trust Care Programme Approach Audit (CPA) is conducted on an annual basis
and is a key feature of the Trusts audit activity.
Care Planning is a fundamental part of the majority of patients care and it is
therefore essential that the Trust is assured that the practices and care provided is in
line with National Best Practice to maximise the effectiveness of care delivery.
Whilst year on year improvements have been noted. The Trust has modified its
Clinical Audit tool to reflect the changes to best practice and to ensure improvements
are being implemented appropriately.
The two key recommendations arising from the 2014-2015 CPA audit are
summarised below.
 In support of the Trust’s Triangle of Care project, there will be additional work to
further ensure the involvement of carers and families in the assessment of a
patients risk and risk management planning (where appropriate).
 In support of the above recommendation there is also a recognised need to
continue to improve documentation in relation to recording when families and
carers have been involved in the development of service user care plans and
also when families and carers have been involved in the review of a patients
care and associated care plan.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 10 of 55
The 2015/16 audit will aim to build on the results of this audit and will be reviewing
the quality of the care plans and risk assessments to ensure they are outcome
focussed and effective.
Violence
Aggression
and
This audit was commissioned to explore how staff were managing incidents of
violence and aggression following a noted increase in reported incidents and a
subsequent request for assurance from the Trust Commissioners in relation to the
safety of patients and staff.
Following the recent Winterbourne review and similar high profile incidents, there
has been a National driver to eliminate the use of face down restrain. The Trust is
fully assured that it does not utilise this practice and has an excellent reporting
culture which would highlight any concerns.
To further assure itself, this Clinical Audit was then commissioned to review the
knowledge and practice of staff with regards to the use of physical intervention skills.
The key findings that were identified from the audit are summarised below;
 There is a need to be aware of and to fully involve the Local Security
Management specialist in the review of incidents. A clear communication
strategy has been developed so that all staff members are aware of how contact
can be made and the support that can be provided from this key role.
 The audit validated the need for the Trust to continue to teach specialist skills to
staff members working in older adults when a physical intervention is required.
The Trusts lead MAPA trainer for this will be working with the Learning and
Development Department and Ward Managers to ensure all nursing staff have
received appropriate training
 The Trust has commissioned a further audit to examine trends and themes
arising from incidents of violence and aggression reported by the Trust incident
reporting systems.
Triangle Of Care
The implementation of the Triangle of Care project and the subsequent Trust
accreditation was a key Quality Improvement priority for the Trust for 2014/15. This
audit aimed to support the project and provide key evidence in support of the
implementation of the project.
The outcome of the audit fully endorsed and supported the Trust in its application for
accreditation but also highlighted a few minor areas for improvement as listed below:
 Improving the recording of status of consent of service users to share
information with carers or relatives.
 To improve the recording of capacity and best interests assessments
 To continue to improve information given to carers regarding what support is
available for carers from key services such as the Carers Support Network
In 2015/16 the Triangle of Care audit will be extended to include Trust Community
based teams and services.
Electronic Record
Keeping
A newly commissioned annual audit and a key component of the Information
Governance Toolkit evidence portfolio, this audit was undertaken to examine
electronic record keeping and to test the validity of the current audit tool.
Key recommendations from the audit included.
 Reviewing and refreshing the current audit tool to ensure it appropriately
captures key findings and is in line with the current patient administration system
utilised by the Trust (Oasis)
 Reminding staff of the need to avoid the use of abbreviations where possible and
to use approved abbreviations in the clinical record
 To undertake a Re-audit of electronic records in 2015-2016 to ensure high levels
of compliance are maintained and improvements embedded.
Service User
The Trust is fully committed to ensuring that the experience of service users is as
positive as possible and to fully engage Expert By Experience service users to
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 11 of 55
Experiences Surveys
directly influence the strategic visions and direction of the Trust.
To help facilitate this, service experience surveys were included as part of the
2014/15 audit priority plan. Key findings from the survey were as follows.

To undertake a review of patient information and to fully involve key staff such as
the Communication Team and the Trust Experts by Experience Team to assist
with the redesign of some patient information and to ensure that it is concise,
factual and supportive of the patients, carers and relative’s needs.

To work with staff to promote the Triangle of Care and give a better
understanding of the programme and the importance of involving carers and to
ensure all staff are carer aware.

To identify carers leads and champions on the wards and increase knowledge of
carers support services and rights.

To promote the work of the Carers Support Team
The report of one national clinical audit was reviewed by the provider in April 2014 to March 2015
and Dudley & Walsall Mental Health Partnership NHS Trust intends to take the following actions to
improve the quality of healthcare provided:
 Increase the sharing of information about prescribed medicines with service users
 Improved monitoring of 5 cardio metabolic risk factors (blood pressure, smoking status,
alcohol consumption, BMI, blood glucose)
 Improved pathways to prescribing clozapine for service users with a diagnosis of
schizophrenia
 Improve support offered to service uses who are seeking employment
 Improve service users knowledge of how to get help in a crisis
2.6
Clinical Research
During 2014/15 the Trust has participated in 8 portfolio based research projects
The number of patients receiving NHS services provided or sub- contracted by Dudley and Walsall
Partnership NHS Trust in the period 1st April 2014 to 31st March 2015 that were recruited during
that period to participate in research approved by a research and ethics committee was 143
(against a target of 130)
The Research & Development (R&D) team has grown over the past year, with the commencement
of a Research Champion (Consultant Level) who joined in April 2014 and a Research Nurse who
joined in January 2015. Both of these posts provide additional capacity to further enhance the
Trusts research capability. Furthermore, the Trust received funding £30,000 from the ‘NIHR
Clinical Research Network: West Midlands’ to set up a Clinical Trials Unit (CTU).
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 12 of 55
Figure 3: Portfolio research studies at Dudley & Walsall Mental Health Partnership NHS Trust (2014/2015)
Research Study Title
Topic
Service Line
Status
DPIM Schizophrenia – DNA Polymorphism in Mental
Health illness
Schizophrenia
Adult Mental
Health
Open
E Sibling – Exploratory randomised controlled trial of
an online multi-component psycho educational
intervention for siblings of individuals with firstepisode psychosis
First Episode
Psychosis
Adult Mental
Health
Open
NCISH – National confidential enquiry into suicide
and homicide
Suicide
Adult Mental
Health
Open
COFI – Comparing integrated and functional systems
of mental health care
ReQoL – Recovering Quality of Life
Service Delivery
Adult Mental
Health
Open
Service Delivery
Adult Mental
Health
Open
FemNAT - Understanding sex differences in
disruptive behavior in children and teenagers
Conduct Disorder
Child &
Adolescent Mental
Health
Open
CIRCLE – Randomised controlled trial of the clinical
and cost-effectiveness of a contingency management
intervention for reduction of cannabis use and of
relapse in early psychosis
SUD – Sudden death in psychiatric inpatients and the
relationship with psychotropic drugs
First Episode
Psychosis
Adult
Health
Mental
Open
Not set
Adult
Health
Mental
Open
2.7
Goals Agreed with Commissioners (Commissioning for Quality and Innovation
- CQUIN)
A proportion of Dudley and Walsall Mental Health Partnership NHS Trust’s income in 2014/15 was
conditional on achieving quality improvement and innovation goals agreed between the Dudley and
Walsall Mental Health Partnership NHS Trust and the commissioners through the Commissioning
for Quality and Innovation (CQUIN) framework. CQUIN is a national initiative which aims to embed
demonstrable quality improvements within the commissioning cycle for NHS healthcare.
Further details for 2014/15 and the following 12 month period are available electronically at
http://www.dwmh.nhs.uk/publications/
The CQUIN scheme indicators, financial values and performance for the past 3 years are
summarised below.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 13 of 55
Figure 4: Historical CQUIN Performance 2012–2015
2012/13
CQUIN
Schemes
7 schemes:
1. Patient Experience
2. Medicines Management
3. Safety Thermometer
4. Making Every Contact
Count
5. Effective Care Planning
in CAMHS
6. Reduce Average Length
of Stay
7. Reduction in referral to
treatment to Community
Recovery Service
2013/14
6
1.
2.
3.
schemes:
NHS Safety Thermometer
NET Promoter (FFT)
Making Every Contact
Count
4. Medicines Management
5. Reducing Falls in Older
People Mental Health
6. Undertake Agency for
Healthcare Research and
Quality’s (AHRQ) Patient
Safety Culture
2014/15
1.
2.
3.
4.
5.
6.
7.
7 schemes:
Friends & Family Test
Safety Thermometer
Physical Health Check
Medicines Management
Recording Duration of
Untreated Psychosis
CAMHS Transition
Protocol
Improving Diagnosis
Recording
Outcome
99.5% Achieved
100% Achieved
96% Achieved
Financial
value
Value £1,410,249
Achievement: £1,403,197
Value: £1,368,634
Achieved: £1,368,634
Value: £1.38m
Achieved: £1.325m
CQUIN Schemes 2015/16
For 2015/16, the Trust has agreed six CQUIN schemes (see below) with a total value of
£1,395,621. The schemes cover a range of services including the four quality domains of Patient
Experience, Safety, Effectiveness and Innovation.
Figure 5: Agreed CQUIN Schemes for 2015/2016
2015/16
CQUIN
CQUIN Details
Value
1
Improving Physical Healthcare for Patients with severe mental
illness (smi)
Cardio Metabolic Assessment & treatment for patients with psychoses
2
£139,562
Family, Carers & relevant others support
Identify, support & provide advice & guidance to carers who have relatives
with mental health problems
£139,562
3
Implementation of DWMH Recovery Outcome Measure
Clinical outcome measures within CRS & EI
£348,905
4
Pain Management
£348,905
Introduction of the Abbey Pain Scale
5
UEC Menu
£279,124
Improving diagnosis & re-attendance
6
Medication Safety Thermometer Year 2/2 & Improving Use of
Medicines
Improving the use of medicines & assurance that hospital pharmacy
standards are in place so that patients receive a high quality pharmacy
service
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 14 of 55
£139,562
Further details and the agreed goals for the reporting period and the following twelve months can
be obtained from communications@dwmh.nhs.uk
2.8
What Others Say About the Trust
As a provider of NHS services, the Trust is monitored and regulated by a variety of external bodies
and arrangements. This regulatory framework helps to ensure that the Trust provides services
which are of the highest quality, well-managed and make appropriate use of resources.
Statements from the Care Quality Commission (CQC)
Dudley and Walsall Mental Health Partnership NHS Trust is required to register with the Care
Quality Commission and the Trust has no conditions attached to its registration. Through the
Trust’s quality governance processes the Trust identifies guidance issued by the Secretary of State
which relates to chapter 2 ‘ Registration in Respect of Provision of Health and Social Care ‘of the
Health Act 2009, and act and acting upon it appropriately. As such Dudley and Walsall Mental
Health Partnership NHS Trust have no conditions attached to their registration.
The Trust was a pilot site for the first wave of the new CQC Mental Health Chief Inspector of
Hospitals inspection visits during February 2014. The CQC inspection report was published on
16th May 2014 and identified many areas of good practice, these were:
There was good practice in the leadership of the trust; the non-executive directors and the Chair
were particularly strong.
 The Trust’s quality and governance systems were seen as robust and ran through the trust at
every level. The leadership of governance and quality was outstanding.
 Learning from incidents and the embedding lessons programme meant that changes in practice
in the inpatient areas and community teams were evident, and staff understood why.
 Safeguarding processes were embedded across all of the teams in the trust and the application
of the Mental Health Act across the services was good. People were lawfully detained and had
their rights read to them at the appropriate times.
 Experts by experience were introduced and used at all levels in the Trust
 The trust worked well with other local stakeholders, such as the local authorities and the clinical
commissioning groups.
 The Trust has a robust approach to learning from incidents and ensuring this was embedded in
practice across all levels.
CQC did identify 3 areas where essential standards of quality and safety were not being met and
the Trust were requested to take action. These were:
1. There were some issues raised in respect to privacy and dignity in respect to the promotion of
independence and routine.
2. It was noted that there were some changes required in respect to the built environment and as a
result individual patient preferences were sometimes not met.
3. It was documented that there was not deemed to be an effective call system in place and there
were some issues around managing patients in relation to least restrictive principles.
As a result of the above actions, the Trust took immediate action to address these and as such the
Trust is able to confirm that areas of non-compliance had been resolved. The Trust has also
developed a robust action plan against other actions the Trust could and should to and this action
plan is monitored on an on-going basis by the Trusts Governance and Quality Committee.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 15 of 55
During 2014/15 the Trust also reviewed a copy of the CQCs place of safety survey into 136 suites
entitled “A safer place to be”. The report was the outcome of data submitted by Trusts and
providers of 136 (place of safety) suites nationally. The results submitted by the Trust showed a
good level of compliance against the emerging themes and recommendations outlined within the
report and highlighted no areas of material concern. An action plan has been complied against the
report through which the Trust is currently working.
During 2014/15 the Trust has also received a number of CQC MHA visits. The Trust has returned
provider action statements in relation to these visits and has developed robust action plans to
ensure that issues are resolved.
Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations
During 2014/15 the Trust has continued to participate in CCQI National Quality Improvement
projects managed by the Royal College of Psychiatrists. This is a voluntary national improvement
and development programme which aims to raise standards of care in mental health services.
CCQI accreditation is a nationally recognised indicator of high quality services which support
continuous quality improvement.
The Trust has achieved CCQI accreditation for: all of its working age adult inpatient wards via the Accreditation for Inpatient Mental Health
Services programme
 both of its Electro-Convulsive Treatment (ECT) Services via the Electro-Convulsive Therapy
Accreditation Scheme
 three of the four older peoples’ inpatient wards via the Accreditation for Inpatient Mental Health
Services – Older People and its memory service via the Memory Services National
Accreditation Programme
The figure below shows the number of CCQI accredited services in the Trust.
Figure 6: Number of CCQI Accredited Services in the Trust
CCQI Programme
Participation by the Trust
ECT Clinics
2 ECT clinics (100%)
Working Age Adult Wards
5 wards (100%)
Older People’s Mental Health Wards
3 wards (75%)
Memory Services
1 service (100%)
2.9
Data Quality
Good quality information underpins the effective delivery of care and is essential for measuring and
monitoring improvements in quality and performance. The Trust has made significant
improvements to its performance management and reporting framework, and has taken a number
of actions to improve data quality.
In 2010/11 the Trust developed the Contract Activity Review Meeting (CARM). This meeting is held
at the start of each month to discuss and review the previous month’s data, before it is presented
to the Finance and Performance Committee, to Commissioners at the Contract Review, Clinical
Quality Review Meetings and then at Board. CARM is now an established governance mechanism
for the Trust that involves operational and information staff.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 16 of 55
The function of CARM has been further developed during 2014/15 to help raise the profile of
information in the Trust and to drive data quality improvements. In particular, this forum has been
extended and is now used to:
 Monitor progress against the Data Quality Improvement Plan
 Review all submitted reports to monitor performance against target
 Co-ordinate Exception reports and remedial action plans to achieve operational service
compliance
 Authorise submission of performance related data to any external organisations
 Standardise data definitions
 Explore emerging performance challenges
 Commission work covering more detailed analysis and forecasting
 Help managers understand the financial impact and implications of changes in the level of
activity.
In 2014/15 the Trust refreshed its Data Quality Improvement Plan (DQUIP) which aims to ensure
that all strategic, operational and clinical decisions are made on the basis of good information
drawn from robust data.
The DQIP was endorsed by Management Executive Team and the Finance and Performance
Committee, and implementation has continued throughout 2014/15 with an internal audit being
undertaken in March 2015. This has included the establishing of weekly operational data quality
and exception reports, together with progress monitoring reports, within the data warehouse
desktop dashboards.
New processes have been put in place to track and monitor all data quality checks and
exercises. The scope and purpose of each data quality process is agreed centrally and the results
are documented to ensure that a clear audit trail of checks and changes is maintained.
The Performance Department monitor other Data Quality Reports. These include Blank Team
Referrals, Floating Referrals, Duplicate Referrals, Appointments with no Outcomes, Daily
Demographic checks, Monthly Batch Trace files cross referencing GP Practices and Deceased
Records.
2.10 NHS Number and General Practice Code Validity
The Trust submitted records during 2014/15 to the Secondary Uses service for inclusion in the
Hospital Episode Statistics which are included in the latest published data. The percentage of
records in the published data which included the patient’s valid NHS number was:


99.8% for Admitted Patient Care (national 99.2%)
100 % for Outpatient Care (national 99.3%)
The percentage of records in the published data which included the patient’s valid General Practice
medical code:
 100% for Admitted Patient Care (national 99.9%)
 99.8% for Outpatient Care (national 99.9%)
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 17 of 55
2.10.1 Information Governance Toolkit Attainment Levels
Information Governance (IG) refers to the systems and processes the Trust has in place to safely
and effectively manage all types of information. The HSCIC / NHS England’s IG Toolkit (IGT) is an
online system which allows NHS organisations and partners to assess themselves against
Department of Health Information Governance policies and standards. It also allows members of
the public to view participating organisations. Trusts are required to assess themselves annually
against the standards in the toolkit. By March 2015 the Trust attained 81% compliance against the
toolkit.
Dudley and Walsall Mental Health Partnership NHS Trust Information Governance Assessment
Report score overall score for 2014/15 was 81% and was graded green. 95% of all staff received
IG training and the Trust’s internal IGT audit gave a result of ‘Significant Assurance’.
2.10.2 Clinical Coding Error Rate
Clinical Coding compliance applies to inpatient records to ensure that diagnosis and procedures
are coded correctly and consistently across the Trust. Clinical Coding is part of the Information
Governance (IG) Toolkit requirements where the accuracy of coding must be maintained at a given
level to achieve level 2 or 3 within the Toolkit.
The Trust was not subject to Payment by Results clinical coding audit during 2014/15 by the Audit
Commission. No audits took place in 2014 – the audit was arranged for December 2014 which was
then rearranged to January 2015.
The Trust has completed several external clinical coding audits. The table below shows positive
progress against compliance with the IG toolkit over the last 3 years:
Figure 7:
Progress against IG Toolkit Compliance
Outcome
December 2012
Achieved level 2 compliance
Information Governance Requirement 10-508 – Clinical/care staff are involved
in validating information derived from the recording of clinical/care activity.
The Trust has therefore not achieved attainment level 1
Information Governance Requirement 10-514 - An audit of clinical coding,
based on national standards, has been undertaken by NHS Classifications
Service approved clinical coding auditor within the last 12 months.
The Trust has therefore achieved attainment level 2
Information Governance Requirement 10-516 - Training programmes for
clinical coding staff entering coded clinical data are comprehensive and
conform to national standards.
The Trust has therefore achieved attainment level 2.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 18 of 55
December 2013
Achieved
Information Governance Requirement 11-514 - An audit of clinical coding,
based on national standards, has been undertaken by NHS Classifications
Service approved clinical coding auditor within the last 12 months
Attainment level – 3
Information Governance Requirement 11-516 - Training programmes for
clinical coding staff entering coded clinical data are comprehensive and
conform to national standards
Attainment level 3
January 2015
Information Governance Requirement 12-514 - An audit of clinical coding,
based on national standards, has been undertaken by a Clinical Classifications
Service (CCS) approved clinical coding auditor within the last 12 months.
The Trust has therefore achieved attainment level- 3
Information Governance Requirement 12-516 - Training programmes for
clinical coding staff entering coded clinical data are comprehensive and
conform to national clinical coding standards.
The Trust has therefore achieved attainment level 3
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 19 of 55
3 Part 3: Review of Quality Performance
This section provides information related to the quality performance of the Trust’s services.
External sources of data have been used to provide the public with as much benchmarking
information as possible.
This part of the Quality Account is presented in four sections
1. Part 3A – Performance against Department of Health (DOH) Mandatory Indicators, which Trusts
are required to report against in their Quality Accounts for 2014/15.
2. Part 3B – Performance against 2014/15 Quality Improvement Priorities
3. Part 3C - Performance against additional Quality Performance Indicators chosen by the Trust
including National and Contractual KPIs
4. Part 3D - Statement from the Trust’s key stakeholders.
3.1
Part 3A: Department of Health Mandatory Indicators
The NHS (Quality Account) Amendments regulations (2012) defined a set of core quality
indicators, which Trusts are required to report against for their Quality Accounts from 2013/14
onwards. The Trust’s position against ALL relevant indicators for the last two years is shown
below:
The data made available with regard to the Percentage of Service Users Discharged from Inpatient
Care Followed Up Within 7 Days
Preventing People from Dying Prematurely – 7 Day Follow-up
 The Trust has utilised the information available from the Information centre and the Trust
considers that the data is as described for the following reasons:
 Staff are aware of their responsibilities regarding data quality through regular
communications and team meetings. In addition, all national, local and internal quality
indicators are reviewed and data validated at the Contracted Activity Reporting meeting
with representation from all Trust areas.
 Robust data quality monitoring and validation processes and procedures are in place and
embedded along with clear guidance on the requirements to record data accurately.
 The Trust has taken the following actions to improve this percentage, and the quality of its
services, by:
 holding a series of awareness sessions,
 Issuing daily specific exception reports to operational managers.
 Strong leadership provided by senior operational staff to ensure that the clinical
importance of this indicator was understood.
This continued to be an important area for the Trust in 2014/15.
The Trust has performed strongly throughout 2014/15 and managed to achieve 97%.
The table below provides the percentage achievement for the last two years in addition to a
comparison to the national position (latest published figures for seven day follow-up relate to
Quarter 3 (Q3) 2014/15).
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 20 of 55
Figure 8: 7 Day Follow Up
Indicator
7 Day Follow Up
Target
Full Year
2013/14
Full Year
2014/15
Q3 2014/15
National
Average
Q3 2014/15
Lowest Trust
Q3 2014/15
Highest Trust
95%
99%
97%
97.5%
77.2%
100%
The graph below provides the monthly percentage achievement in 2014/15.
Figure 9: Seven Day Follow Up in 2014/15
3.1.1
Enhancing the Quality of Life for People with Long Term Conditions - Gate keeping
All Admissions to Acute Inpatient Services will have had Access to Crisis Resolution/Home
Treatment (CRHT) Team
The Trust has utilised the information available from the Information centre and the Trust considers
that the data is as described for the following reasons:
 Staff are aware of their responsibilities regarding data quality through regular
communications and team meetings. In addition, all national, local and internal quality
indicators are reviewed and data validated at the Contracted Activity Reporting meeting
with representation from all Trust areas.
 Robust data quality monitoring and validation processes and procedures are in place and
embedded along with clear guidance on the requirements to record data accurately.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services, by:
 Issuing daily exception reports to operational staff.
 Strong leadership provided by senior operational staff to ensure that the clinical importance
of this indicator was understood. This continued to be an important area for the Trust in
2014/15.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 21 of 55
The information provided by the Information Centre showed numerators, denominators and
percentages for all admissions to acute inpatient services and how many were gate-kept by CRHT
Team, by Trust, as at Q3 2014/15.
This has been an area of consistent strong performance throughout 2014/15 with 100% Inpatient
Admissions being gate-kept in 2014/15.
The table below provides the percentage achievement for the last two years in addition to a
comparison to the national position (latest published figures for Crisis Gate Keeping relate to Q3
2014/15).
Figure 10: Crisis Gatekeeping
Indicator
Target
2013/14
2014/15
Q3 2014/15
National
Average
Gate keeping of
Inpatient Admissions by
CRHT
95%
100%
100%
98.6%
Q3 2014/15 Q3 2014/15
Lowest
Highest
Trust
Trust
85.5%
100%
The graph below provides the monthly percentage achievement 2014/15.
Figure 11: Gatekeeping Achievement Rates
3.1.2
Ensuring that People have a positive Experience of Care – Staff Survey
The percentage of staff employed by, or under contract to, the Trust during the reporting period who
would recommend the Trust as a provider of care to their family and friends
The Trust has utilised the information made available by the Information Centre with regard to the
results based on a sample of the workforce surveyed as part of the 2011, 2012 and 2013 staff
surveys, (the 2013 Trust response rate was 56%, i.e. 329 respondents from sample of 588).
The Trust’s performance against this question was as follows:
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 22 of 55
Figure 12: Staff Survey
Survey
Year
Trust
MH/LD Trust
Average
2011
Question 22b - ‘If a friend or relative needed treatment I
would be happy with the standard of care provided by this
Trust’
55%
59%
2012
Question 12d - ‘If a friend or relative needed treatment, I
would be happy with the standard of care provided by this
organisation’
60%
60%
2013
Question 12d - ‘If a friend or relative needed treatment I
would be happy with the standard of care provided by this
organisation’
60%
59%
2014
Question 12d - ‘If a friend or relative needed treatment I
would be happy with the standard of care provided by this
organisation’
62%
60%
The Trust considers that these percentages are as described for the following reason:
 As previously recommended, the Trust used an independent approved contractor to run the
staff survey on behalf of the Trust in 2011-2013. Approved contractors provide external
assurance of the process.
 In 2014, the Trust has continued to use the same independent approved contractor to run
the staff survey.
 We also employed an independent contractor as a Staff Engagement Lead since April 2014
who focused energy promoting the staff survey as well as leading the Staff Friends and
Family Test.
 For the first time in 2014 all eligible staff were offered the survey rather than a sample, as
per previous years, which met the requirements
The Trust has taken the following actions to improve this percentage, and so the quality of the
services provided:
 The Trust has held focus groups and staff engagement sessions, using an independent
contractor, involving variety of staff from various locations and services to help understand
any issues, and to seek staff feedback on possible solutions/remedies.
 Senior Management continue to attend areas outside of their usual remit, to improve the
visibility to staff on the ground and to enhance engagement and communication Trust-wide.
 An action plan was developed that encompasses recommendations from the staff survey,
CQC inspection and focus groups. This will ensure an overarching approach and support
pan-trust implementation, as appropriate.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 23 of 55
The Trust will be taking the following actions to improve this percentage, and so the quality of the
services provided:
 Outputs/recommendations from the focus groups and staff engagement sessions have
been included in the action plan, as appropriate.
 The Trust launched the Staff Friends and Family Test via its intranet, in May 2014, and
have monitored these throughout the year, drilling down into the free text comments as to
why people answered the way they did.
3.1.3
Helping people to recover from episodes of ill health during injury – readmissions within 28
days of being discharged from hospital
The percentage of patients readmitted to hospital which forms part of the Trust within 28 days of being
discharged from a hospital which forms part of the Trust during the reporting period.
Readmission Rates
The Trust has utilised information made available from the Trust’s information system OASIS as
the information was not accessible from the Information Centre to enable meaningful comparison.
The Trust considers that the data is as described for the following reasons:
 Staff are aware of their responsibilities regarding data quality through regular
communications and team meetings. In addition, all national, local and internal quality
indicators are reviewed and data validated at the Contracted Activity Reporting meeting
with representation from all Trust areas.
 Robust data quality monitoring and validation processes and procedures are in place and
embedded along with clear guidance on the requirements to record data accurately.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services, by:
 Developing processes and procedures, to agreed parameters, with clinical staff to ensure
validated readmissions figures were reported internally and externally.
 Establishing robust reporting through the Trusts data warehouse dashboard to enable
services to view the level of readmissions.
 Strong leadership provided by senior operational staff to ensure that the clinical importance
of this indicator was understood.
The Trust has closely monitored this Indicator and year end results shows a compliance rate at
8.9% against a aspirational Trust target of 10%.
The table below provides the percentage achievement for the last two reporting periods: (note, no
national benchmarking data available at time of writing this document).
This KPI is no longer a national requirement. The Trust has agreed with commissioners to provide
a detailed quarterly report in 2014/15.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 24 of 55
Figure 13: Readmission Rates
Indicator
Target
2013/14
2014/15
Readmission Rate
<10%
6.6%
8.9%
Direction of travel
(14/15 compared
to 13/14)
The graph below provides the monthly percentage achievement 2014/15.
Figure 14: Trust Readmission Rate in 2014/15
3.1.4
Ensuring People have a positive Experience of Care – Patient Survey
The Trust’s patient experience of community mental health services indicator with regards to a
patient’s experience of contact with a health or social care worker
The Trust has utilised the information available from the Information Centre in relation to the 2012
and 2013 Community Patient Survey. To determine the Trusts performance against this indicator,
the mean score achieved against the following three questions has been calculated from the 2014
survey of people who use community mental health services:
Extract from Survey – Section Health and Social Care Workers:
1. Did the person or people you saw listen carefully to you?
2. Were you given enough time to discuss your needs and treatment?
3. Did the person or people you saw understand how your mental health needs affect other
areas of life?
The 2014 survey questionnaire was substantially redeveloped and updated in order to reflect
changes in policy, best practice and patterns of service. This means that the results from the 2014
survey are ‘not comparable’ with results from previous years.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 25 of 55
Figure 15: Patient experience
Experience of Care*
Performance
2014
DWMH
8.0
Figure 16: Survey Overall Experience
Figure 17: Benchmarking against other Trusts
Based on patients’
responses to the survey,
this trust scored
How this score compares with other Trusts
8.5/10
8.1/10
7.4/10
Listening
for the person or people seen most recently listening carefully to
them
About the same
Time
for being given enough time to discuss their needs and treatment
About the same
Other areas of life
for the person or people seen most recently understanding how their
mental health needs affect other areas of their life
About the same
The overall score is the average of the domain scores, which is taken as the experience of care
score.
We consider the percentages are as described for the following reasons:
 The Trust used an independent approved contractor to run the Community Patient Survey
on behalf of the Trust in 2011, 2012, 2013 and 2014
 2014 figures for the lowest and highest scoring Trust are provided by the CQC
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 26 of 55
We have taken the following actions to improve this score further, and the quality of the services:



Improved the visibility of our Service Experience Desk (PALS and Complaints) to better
support service uses, carers and staff
Patient Reported Experience Measures (PREMS) survey will be deployed across all teams.
The survey has been developed for benchmarking teams and service lines against CREWS
standards. PREMS are used to understand patients’ views on their experience while receiving
care.
In response to the Francis inquiry into the failings of Mid Staffs NHS Foundation Trust, the
PHSO, LGO and Health watch England committed to developing a user-led “vision” of the
complaints system and produced a report entitled “My Expectations for Raising Concerns”.
This report presents the vision/framework that was created and the findings of the primary
research with patients, service users, frontline staff and stakeholders that lay behind it. There
are five main areas to the framework which the Trust aims to follow and achieve which has
been incorporated into the SED induction programme.
The Trust Development Authority (TDA) has issued a new toolkit that allows Trusts’ to measure
patient experience consistently. It comprises of a Patient Experience Development Framework,
which is a self-assessment tool, and a Patient Experience Headline Tool, and together these have
been designed to enable Trusts to benchmark performance against service lines, as well as
promoting discussion at a senior level to improve patient experience.
The Department of Health have recently issued a new toolkit that allows Trusts’ to measure patient
experience consistently. This is described in more detail along with the Trust’s results in section
3.3.5.
3.1.5
Treating and Caring for People in a Safe Environment and protecting them from Avoidable
Harm – Patient Safety Incidents.
NRLS – Patient Safety Related incidents
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 Trust has obtained data from the Information Centre which utilises data from the National
Reporting and Learning System (NRLS) from which national benchmarking data is scrutinised by
the Trust to monitor performance.
The figures below are taken from the last 4 half yearly feedback reports from the NRLS who collect
information regarding all Patient safety related incidents within the Trust and offer a comparison
against similar organisations, As a Mental Health Provider we are placed into a cluster group
alongside 55 other Mental Health Organisations.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 27 of 55
Figure 18: Serious Incidents
Number of
Incidents per
1000 bed days
st
st
1 October 2012 – 31 March 2013
st
th
1 April 2013 – 30 September 2013
st
st
1 October 2013 - 31 March 2014
st
th
1 April 2014 – 30 September 2014
Median – per
1000 bed days
Percentile of 55 other
reporters within mental
health cluster
25.01
25.3
Middle 50%
26.56
26.37
Middle 50%
29.35
26.71
Middle 50%
24.51
32.82
Middle 50%
Figure 19: Level of Patient Safety Related incidents Submitted to the NRLS, for the last 4 reporting periods.
1st October 2012 – 31st March 2013
1st April 2013 – 30th September 2013
1st October 2013 - 31st March 2014
1st April 2014 – 30th September 2014
None
Low
Moderate
Severe
Death
343
272
63
4
16
9.03%
0.57%
2.29%
49.14% 38.97%
330
266
41
5
13
50.4%
40.6%
6.3%
0.8%
2%
366
309
35
2
12
50.6%
42.7%
4.8%
0.3%
1.7%
405
272
40
2
7
55.8%
37.5%
5.5%
0.3%
1.0%
Total
698
655
724
726
The Trust considers that this data is as described for the following reasons:
 Incident reporting is a central component to risk management within Dudley and Walsall
Mental Health Partnership NHS Trust and all incidents have been managed according to
the Trusts ‘Incident, Near Miss and Serious Incident Reporting Policy
 All incidents are recorded on ‘Safeguard’ which is the Trust’s Integrated Risk Management
System, for which staff receive training and on-going support
 The Trust is considered to have a good reporting culture and that all incidents are reported
in a timely manner, with regular training provided to all staff and managers.
The organisation also recognises the importance of having robust process for the investigation of
Incidents, Complaints and Claims. This is done through the use of Root Cause Analysis
Techniques that can be used to identify any key areas of learning for the organisation and
identifies any systems failures, key events, human errors and areas for improvement.
The Trust submits its Governance Exception report to the Commissioner Quality Review meeting
on a monthly basis for external scrutiny. This process acts as an independent scrutiny check and
would highlight any issues such as underreporting or trends in respect to the quality of services
provided.
The Trust has taken the following actions to improve this:
 Embedding lessons – The Trust has a comprehensive embedding lessons system which is
led by the Trust Governance Team and the Heads of Service. It has been reviewed by the
CQC and NHSLA who complimented the processes and systems employed. In addition the
Trust is participating in a commissioner sponsored SI/Embedding Lessons Research and
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 28 of 55
Development project which aims to compare local Trusts’ SI and embedding lessons
procedures and make recommendations for improved practice and shared learning.
 Duty of Candour – The Trust has ensured that the Duty of Candour is embedded within the
Trusts serious incident processes and has ensured wherever possible that service users
and carers are involved in the process and outcome.
3.2
Part 3B: Performance against Quality Improvement Priorities 2014/15
This section of the Quality Account demonstrates the significant improvements made against the
nine Quality Improvement Priorities for 2014/15. This is a demonstration of progress since the
publication of the Trusts Quality Account 2013/14.
The progress against the priorities and the associated action plans were monitored by the
Governance and Quality Committee and the Trust Board, and the need and opportunity for further
improvements were identified during the development of priorities for the coming year. They will
roll over to 2014/15 and the other priorities will continue to be monitored as part of the Trust’s
quality agenda.
3.2.1
Progress against 2014/15 Priorities
Quality Goal 1: Providing meaningful and effective inpatient activities
Rationale for Inclusion
The Trust has identified this as a priority following feedback from a number of sources including,
Experts by Experience Reports and Care Quality Commission feedback. Furthermore acute
inpatient services and older adult services are undergoing service transformation and it is timely to
revisit inpatient activities to ensure they are meaningful and effective.
Improvement Initiatives

Undertake a full review of inpatient activities

To develop and implement Trust wide standards based on national and locally defined best
practice
Measurement
Clinical audit will be undertaken to measure concordance against Trust defined standards. This will
include:

Baseline scoping audit

Service user feedback

Observational audit
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 29 of 55
Progress 2014/2015
The Trust undertook a scoping audit and worked with Experts by Experience to obtain service users
feedback. As a result of the audit the following actions have been taken

A revised programme for in patient therapeutic/ diversional activities

An activity monitoring tool has been introduced to monitor the level of activity

Education for in patient nursing staff has been developed in relation to therapeutic activities

Supervision of staff delivering inpatient activities has been strengthened.

Environmental review of hospital sites has been completed to increase space to deliver activities and
interventions
The Trust is now embarking on consolidating existing therapies and activities into a central point to enable
flexibility across the service. This will be achieved through the development of a ‘Therapeutic Hub’ To ensure
a continued focus therapeutic activities will remain a trust Quality Improvement priority for 2015/16.
Quality Goal 2: Embedding the ‘Think Family’ model across Child and Adolescent Services
and Adult Mental health services.
Rationale for Inclusion
Following the Trusts involvement in a thematic CQC / Ofsted inspection and the subsequent
publication of a national report ‘What about the Children’ the Trust has emphasised the importance
of a ‘think family’ approach within the services delivered. The Trust has also received feedback
from Serious Case reviews and Domestic homicide reviews which have highlighted the need for
further integration of think family processes between adult and child mental health services
including addressing domestic violence.
Improvement Initiatives

Development of joint protocols and pathways between Adult and Child mental health
services to support ‘think family approach’

Further development of electronic clinical processes to ensure families are identified

To incorporate parental mental health in Trusts safeguarding training programme
Measurement

Clinical audit including documentation, clinical pathways and peer review

Training compliance
Progress 2014/2015
During 2014/15 the Trust has undertaken a considerable amount of work in relation to promoting a ‘think
family’ model across all our services this has included the

Development and implementation of a joint working protocol between our Child and Adolescent Mental
Health Services and Adult Mental Health Services to emphasise the importance of a ‘think family’
approach.

Introduction of roles and responsibilities training for clinical managers and leaders
Compliance will continue to be monitored through the Trusts annual programme of clinical audit for
safeguarding.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 30 of 55
Quality Goal 3: Management of Disruptive and Aggressive behaviour
Rationale for Inclusion
Disruptive and aggressive behaviour is one of the Trusts highest reported categories of incidents
and therefore the Trust needs to ensure it is maintaining best practice guidelines and taking on
board learning from national reports such as Winterbourne View 2012. This includes the Trust
approach to restraint reduction planning.
Improvement initiative
 Undertake review of Trust guidance against best practice and review supporting policies
 To incorporate the principles of restraint reduction planning
 Enhance training to up skill staff in de-escalation techniques
Measurement
 Disruptive and aggressive behaviour incidents
 Clinical Audit against best practice standards
Progress 2014/2015
During 2014/15 the Trust has continued to monitor reported incidents of disruptive and aggressive
behaviour through our clinical governance processes. To ensure best practice is being maintained the
following actions have been taken

Revision of Trusts clinical policy for the Management of Actual and potential Aggression (MAPA) in
line with national best practice standards

Introduction of a clinical model to enable the development of more effective behavioural support care
plans for service users

Piloted a new model for debriefing of staff and service users following an incident. This includes
working partnership with Experts by Experience.

Completed an audit of staff values in relation to violence and aggression which concluded staff had a
clear understanding of the importance concepts fundamental to good practice.
Quality Goal 4: Focussing on dementia care
Rationale for Inclusion
The Trust has identified dementia care as a quality improvement priority. This is to ensure that the
trust is following best practice guidelines and has been identified as an area for improvement
through the Trusts internal clinical governance processes and feedback from the Care Quality
Commission Review. It is also timely as older adult services in the trust are part of the Trusts
service transformation programme during 2014/15. This will be informed by the national dementia
care strategy.
Improvement Initiatives
 To undertake a review of staff competency and training and introduce revised skills based
training programme
 To ensure the inpatient environment is conducive to best practice guidance and standards
 To revisit local standards based on best practice for behaviours which challenge in
dementia inpatient services and person centred care
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 31 of 55
Measurement
 Training compliance
 Environmental audit
 Observational audits of dementia care, including family and carer feedback
Progress 2014/2015
During 2014/15 the Trust has maintained a focus on providing best practice in relation to dementia care. This
has included

A training needs analysis of our staff working on our dementia wards which has resulted in the delivery
of skills based training in dementia care to all appropriate inpatient nursing staff

Introduction of a dementia care inpatient learning package

Introduction of a dementia care workbook for staff which includes a competency framework for staff

The completion of an environmental audit which included input from a specialist architect. This has
resulted in significant improvements in ensuring the environments are ‘dementia friendly’
High quality dementia services will remain a focus for the Trust for 2015/16. The Trust has agreed that a
quality improvement priority for the coming year will be to introduce a Dementia Care Mapping programme.
This will enable on-going monitoring of the quality of care provided and support future quality improvements.
Quality Goal 5: Health Care Assistant development programme – Fundamentals of Care.
Rationale for Inclusion
Following the publication of the Francis Report the Trust identified lessons to be learnt which
included the development of a bespoke Heath Care Assistant development programme. This was
piloted in 2013/14 and was successful in terms of increasing knowledge, confidence, and
engagement and in changing behaviours. This programme will be rolled out during 2014/15.
Improvement Initiative
 Implementation of Health Care Assistant development programme
Measurement
 Training compliance
 Programme evaluation
Progress 2014/2015
During 2014/15 the Trust has continued to deliver a robust Health Care Assistant development programme
for care staff. Achievements include
 Over 52% of the Trusts care staff have completed or are undertaking the course with a full roll out
timetable agreed for remaining staff.
 Evaluation of the course indicates an improvement in both confidence and competence of care staff to
deliver high quality care for service users
 Work is in progress to map the course against the recommendations contained in the recent national
publication Shaping for Caring – A Review of the Future of Registered Nurses and Care Assistants
(Health Education England 2015) This recommends the introduction of a fundamentals of care certificate
for care staff. It is anticipated that the Trust course will be a firm platform to take this forward and all
newly recruited care staff will be required to complete during their induction period.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 32 of 55
Quality Goal 6: My Care Plan
Rationale for Inclusion
During 2013/14 the Trust focussed on ensuring that service users were actively involved in the
development of care plans and received copies. The Trust has decided to maintain care plans as a
quality priority for 2014/215 with emphasis this year on ensuring that the quality of the care plan is
recovery and outcome focussed.
Improvement initiative
 Revision of the Care Programme Approach (CPA)/Non-CPA training on outcome focussed
and service user lead care planning
 Revision of the Trust wide clinical standards for care planning
 Revision of Trust CPA policy to further align to clinical pathways
Measurement
 CPA Audit
 Peer and Expert by Experience review of care plans
Progress 2014/2015
During 2014/15 the Trust has continued to ensure service users and carers are actively involved in the
development of care plans and received copies. Emphasis has been on the quality of care plans and
ensuring they promote recover and are outcome focussed. The following actions have been taken during the
year

Adopted the Care Programme Association national best practice standards for care planning

Worked with Experts by Experience to obtain feedback from service users about the quality of care plans

Delivered Care Programme Approach training

Completed a CPA audit. Key findings from the sample group show :

Does the care plan clearly show well defined outcomes and goals - 88% compliance

Does the care plan clearly show a description of the intervention/action to be taken and by whom - 86%
compliance

Does the care plan clearly describe the need – 89% compliance

Is there evidence that the service user has been involved in the development of the care plan – 86%
compliance
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 33 of 55
Quality Goal 7: Ensuring and enabling effective engagement with family and carer
involvement
Rationale for Inclusion
Over the last year, the Trust focussed on implementing the Triangle of Care model across inpatient
and community services. To ensure this is fully embedded and monitored the Trust has agreed this
will remain a priority for 2014/15 with emphasis on community services.
Improvement Initiatives
 Continued Implementation of Triangle of Care Model across Adult Services through four
work streams:

Policies, protocols and procedures

Carers support/information

Training

Documentation and record keeping
Measurement
 Accreditation by Triangle of Care
 Family and carer satisfaction
 Number of staff trained in carer awareness
 Clinical audit to measure Compliance with carers pathway standards
Progress 2014/2015
During 2014/15 the Trust has focussed on fully embedding the Triangle of Care model across in- patient and
community service. A key achievement for the Trust is the receipt of a gold star award from the national
Triangle of Care programme which demonstrates the progress made in implementing the national standards
within inpatient services and recognises the Trust commitment to working in partnership with service users
and carers. Trust initiatives include

Unannounced Expert by Experience to clinical services to obtain real time feedback from service users
and carers

Triangle of Care awareness sessions for clinicians

Commencement of Carer Awareness training

Triangle of Care standards incorporated into clinical pathways

Improved carer/support information
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 34 of 55
3.3
Part 3C: Trust Performance against additional Quality Performance Indicators
This section of the Quality Account aims to provide a selection of indicators chosen by the Trust to
demonstrate a holistic view of quality across the services provided. The Trust has included
contractual and national key quality indicators and a selection of quality indicators the Trust uses to
monitor the quality of the services provided.
3.3.1
Contractual Quality Requirement Goals agreed with Commissioners
For 2014/15 the Trust agreed 15 Contractual Quality Requirements with its commissioners, which
were reported on a Monthly basis as KPI’s. 8 of these Quality Requirements are also existing
National Measures from the Operating Framework & Monitor Governance Risk Rating. The Trust
achieved 14 of the 15 KPI’s at Trust level which demonstrates that the Trust has sustained
significant high performance for the past 2 years.
Figure 20: Contractual KPIs in 2013/14 and 2014/15
2013/14
15 of 16 contractual KPIs met (94%)
2014/15
14 of 15 contractual KPIs met (93%)
Figure 21: Contractual KPI’s Performance in 2014/15
Contractual KPIs
1
2
3
4
5
6
7
8
9
9
10
11
12
13
14
15
Number of new cases accepted to Early Intervention
Admissions gate kept by CRHT
7 day follow up on Inpatient Admissions
Delayed Transfers of Care (All Reasons)
Average Length of Stay
Copies of Care Plans (CPA caseload)
Number of Home Treatment episodes by Crisis Teams
Inappropriate under 18 Admissions
Referral to Treatment Time – Complete
Referral to Treatment Time – Incomplete
Physical Health Checks (for inpatients more than 12
months)
Completion of NHS Number on MHMDS
Completion of Ethnicity Code on MHMDS
Improved Access to Psychological Therapies – People
who receive psychological therapies – attending one
session only
IAPT – people who have successfully completed
treatment
IAPT – completion of outcome data PHQ9 and GAD7
Target
Achieved
89
95%
95%
<7.5%
<64 days
98
100%
97%
1.6%
47
95%
1187
0
95%
92%
100%
94.8%
1691
0
99%
95%
100%
99%
90%
10585 (Dudley4825 Walsall5760)
50.5%
99.9%
92.0%
12393
(Dudley - 5758
Walsall – 6635)
Dudley - 52.1%
Walsall - 54.3%
97.6%
90%
The Trust’s overall performance against the commissioners’ KPIs is very positive and has
improved throughout the year.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 35 of 55
Significant improvements have been made in data quality and the Trust meets regularly with
commissioners to discuss performance and quality.
The Trust is fully aware of areas it needs to improve and is working closely with commissioners to
achieve this. The CPA caseload is a point in time indicator drawn at 1st April 2015.
Figure 22: Contractual KPI Performance in 2014/15
Contractual KPI
Trust Achievement
Number of new cases accepted to Early
Intervention
7 day follow up on Inpatient Admissions
98
(Target 89)
97%
(Target 95%)
94.8%
(Target 95%)
1691
(Target 1187)
Copies of Care Plans (CPA Caseload)
Number of Home Treatment episodes by
Crisis Teams
3.3.2
Dudley
Walsall
50
(Target 43)
96%
48
(Target 46)
98%
94.8%
94.8%
907
(Target 579)
784
(Target 608)
Monitor – Access targets and outcomes objectives
The Trust routinely reports performance against the national outcome framework and Monitor’s
access targets and outcomes (a single integrated measure of service quality and performance) to
the Management Executive Committee, Finance and Performance Committee and Trust Board
each month. The report summarises previous, current and target GRR ratings and highlights any
risk areas.
The Trust has improved or maintained performance in all areas against the National metrics in
2014/15 (as shown below).
Figure 23: National Indicators 2012 – 2015
National Indicators
2012/13
2013/14
2014/15
7 Days Follow Up
Target = 95%
Achieved = 98%
Target = 95%
Achieved = 98%
Target = 95%
Achieved = 97%
Minimising Delayed Transfers of
Care
(NHS reasons)
Target < 7.5%
Achieved = 5.4%
Target < 7.5%
Achieved = 3.2%
Target < 7.5%
Achieved = 1.6%
Gate keeping of Inpatient
Admissions by CRHT
Target = 95%
Achieved = 100%
Target = 95%
Achieved = 100%
Target = 95%
Achieved = 100%
Number of new cases accepted
to Early Intervention (against
contract)
Target = 95%
Achieved = 101%
Target = 95%
Achieved = 124%
Target = 95%
Achieved = 110%
Target = 95%
Completed = 98%
Target = 92%
Completed = 95%
Target = 97%
Achieved = 99%
Target = 50%
Achieved = 57%
Target = 95%
Completed = 99%
Target = 92%
Completed = 98%
Target = 97%
Achieved = 99.7%
Target = 50%
Achieved = 95.6%
Target = 95%
Completed = 99%
Target = 92%
Completed = 95%
Target = 97%
Achieved = 99.8%
Target = 50%
Achieved = 96.2%
Referral to Treatment –
Complete
Referral to Treatment Incomplete
Data Completeness Identifiers
Data Completeness Outcomes
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 36 of 55
3.3.3
Patient Environment
According to NHS England, “Good environments matter”. The expectation is that every NHS
patient should be cared for with compassion and dignity in a clean and safe environment and that if
patients believe that standards fall short then they should be able to hold the service and its
management to account.
The annual Patient Led Assessment of the Care Environment (PLACE) was introduced in early
2013 and replaced PEAT (Patient Environment Action Team)
The PLACE 2013 assessment was completed at Bushey Fields Hospital, Dorothy Pattison Hospital
and Bloxwich Hospital between April and June 2013 and the results were published in September.
On average the Trust out-performed the NHS national average in three of the four domains as
detailed in the table and graph below. The environment score, representing the physical condition
of the estate portfolio, was identified as needing improvement.
Figure 24: PLACE Results
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 37 of 55
3.3.4
NHSLA
“At its last formal assessment, the Trust was accredited with level 1 compliance against the
NHSLA’s risk management standards for Trust providing Acute, Community, Mental Health and
Learning Disability services. Following a change in approach the NHSLA confirmed there were to
be no further standards based assessments after March 2014 however the Trust is still committed
to demonstrating compliance with these standards as they show an on-going commitment to the
proactive management of risk within the organisation. Compliance with these standards and
ensuring the on-going suitability of policies pertaining to NHSLA standards continues to be
overseen by both the Trusts Policies and Procedures Focus Group and the Trust’s Governance
and Quality Committee.”
Patient Experience
Understanding Patient Experience is important to the Trust in order to ensure that our services are
developed and improved to meet service users’ needs through listening to peoples’ experiences
and views, responding comprehensively to feedback and demonstrating what has been improved
as a result. The following are a selection of indicators chosen by the Trust as important measures
of patient experience.
Friends and family test – net promoter
Introduced in April 2013, the Friends and Family Test (FFT) asks patients whether they would
recommend the NHS service they have received to friends and family who need similar treatment
or care. This means every patient in our wards and departments is able to give feedback on the
quality of the care they receive, giving hospitals a better understanding of the needs of their
patients and enabling improvements.
The Trust implemented this test in 2012 as part of its CQUIN schemes. People being discharged
from community services were asked “How likely is it that you would recommend this service?”
We are pleased to report that 78% of the 1729 people asked, responded with ‘likely’ or ‘extremely’
likely, response rate maintained since 2012. The full results are shown below.
Figure 25: Friends and Family Test Data
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 38 of 55
Community Mental Health Survey 2014 overall satisfaction score
The Annual Community Mental Health Survey 2014 was conducted independently for the Trust by
Quality Health and a questionnaire was sent out to around 850 people who received community
mental health services. The response rate was 36% (303 usable responses received from a basic
sample of 850), which is higher than the Quality Health National Response Rate of 29%.
The results were positive and a good indication of the levels of satisfaction of our service users,
with our Trust scoring higher than the national average in many areas, in particular, around
organising and planning care, reviewing care and treatment, patients feeling that they were treated
with dignity and respect and feeling that were listened to carefully. The Trust is among the top 20%
of Trusts surveyed by Quality Health for many questions.
Service users were asked how they would rate their experience of our services overall and the
results show that the Trust scored higher than the national average, with 72% of respondents
rating their experience as ‘good’ or ‘very good’, scoring in the top 20% of Trusts.
Areas for action focus on maintaining the positive feedback and in addressing some areas for
improvement - triangulating findings with other patient experience methods to identify key themes.
In response to the findings the Trust have highlighted 4 main themes to be more fully investigated
and managed, such as communication and information which spans most of the recommendations,
crisis care – considering the role of the service, expectations, pathways and urgent care links,
changes in who people see and support and understanding with other areas of life. We will
examine the scores on overall experience and drill down data to look for areas of care which are
scored low and for any pockets of poor ratings from different groups or locations.
Compliments and Complaints 2014/15
In addition to our focus on quality, we recognise that sometimes people’s experience of our
services is not always as positive as we would hope. In October 2007, the Health Service
Ombudsman published ‘Principles for Remedy’ as an overall good practice guide for public bodies
in dealing with complaints. Our complaints policy is based around these principles which are:






Getting it right
Being customer focused
Being open and accountable
Acting fairly and proportionately
Putting things right
Seeking continuous improvement
In response to the Francis inquiry into the failings of Mid Staffs NHS Foundation Trust, the PHSO,
LGO and Healthwatch England committed to developing a user-led “vision” of the complaints
system and produced a report entitled “My Expectations for Raising Concerns”. This report
presents the vision/framework that was created and the findings of the primary research with
patients, service users, frontline staff and stakeholders that lay behind it. There are five main
areas to the framework which the Trust aims to follow and achieve and has been incorporated into
the SED induction programme.
During the period April 2014 to March 2015, we received a total of 127 formal complaints, 30 of
which were withdrawn or closed. We responded to 45 cases within the target timescale; 21 cases
remain open, 15 of which were still within target at the time of writing.
Service users were asked how they would rate their experience of our services overall and the
results show that the Trust scored higher than the national average, with 72% of respondents
rating their experience as ‘good’ or ‘very good’, scoring in the top 20% of Trusts.
Areas for action focus on maintaining the positive feedback and in addressing some areas for
improvement - triangulating findings with other patient experience methods to identify key themes.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 39 of 55
In response to the findings the Trust have highlighted 4 main themes to be more fully investigated
and managed, such as communication and information which spans most of the recommendations,
crisis care – considering the role of the service, expectations, pathways and urgent care links,
changes in who people see and support and understanding with other areas of life. We will
examine the scores on overall experience and drill down data to look for areas of care which are
scored low and for any pockets of poor ratings from different groups or locations.
Figure 26 Compliments and Complaints data
There were 127 formal complaints and 375 compliments received during April 2014 to March 2015.
The number of complaints received is relatively small compared to the
number of patients we see and treat each year.
Over the last twelve months we are pleased to say we have also received
375 written compliments from people who have accessed our services,
highlighting cases where the quality of our services has been recognised
and appreciated. The Service Experience Desk (SED) feature “On a
Happy Note” highlights the positive comments made by service users
about their care by posting a selection of experiences from service users
on the Trust Intranet every month.
Some examples of what people have said about our services are demonstrated below:
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 40 of 55
I have found the service and its employees; helpful, dedicated, supportive, understanding, reliable,
conscientious and devoted to doing a thoroughly good job for the service.
I thought I was going mad and I couldn't cope with daily things, I felt I was having a mini meltdown, me the
office manager, how could this happen to me but it did. I am a normal level headed woman and upon
meeting you I thought you were so young, what did you know about life, but when I cried, you comforted
me, you put me at ease you were compassionate and very understanding. You put everything into
perspective and made me realise step by step at a time I could return to normality, so a very big thank you.
We want to thank you so much for your kindness to our Son you have helped him more than you will ever
know; we now have our son back (so to speak). Our son thinks the world of you and so do all of our family,
you have shown us such kindness throughout his visits to you. You are a lovely kind professional and once
again we owe so much to you.
I cannot leave Bushey Fields Hospital without writing to thank you and the staff for the excellent care I
received at Bushey fields Hospital for the past four months. In particular, I must say thank you for the
kindness shown to me. As I told your staff, I have had a difficult life and never have experienced so much
kindness as I did at your hospital. I will never forget you all.
I started work as a bus driver, after such a long process didn't think I would ever start but after 10 days of
training, I am fully qualified. I couldn't have done it without you we are all really grateful - thank you.
I won't forget what you and all the other people that were involved in me getting my mind back and being
able to live as normal a life as possible. I had really given up before I met you and the others.
Wonderful services wouldn't be able to function without it. All staff are friendly, welcoming, understanding
and not judgemental. Please keep up the good work without you I wouldn't be here today writing this.
I wish to compliment the Eating Disorder Specialist at Canalside for probably saving my daughter’s life. The
support has been an absolute life line.
Thank you for all the support and information you have given me through the years with my mom. I know if
I had any concerns or complaints for my mom I could count on the Support Nurse to be able to give me the
right information to deal with my concerns. I am glad for this service and would tell anyone who is a Carer
to use this service it has been so helpful to me and my family. I will say gain thank you from the bottom of
my heart for people like you.
I would like to thank you so much for all you've done. Thank you for all the support and information you
have given me through the years with my mom. I know if I had any concerns or complaints for my mom I
could count on the Support Nurse to be able to give me the right information to deal with my concerns. I am
glad for this service and would tell anyone who is a Carer to use this service it has been so helpful to me and
my family. I will say gain thank you from the bottom of my heart for people like you.
I would like to thank you so much for all you've done. For your kindness, thoughtfulness and helping us to
cope with his illness. You have talked him through his bad times with compassion and made him feel a lot
better; you have given him trust and hope for the future which means a lot to him.
Feedback from Service Users and Carers
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 41 of 55
Over the past twelve months our 10 Experts by Experience (EBEs) have been significantly
involved in raising awareness of Trust activities and gaining valuable feedback from service users
and carers. We have also gained essential and valuable feedback via informal concerns and
comments from the Service Experience Desk, patient surveys and the electronic patient
experience trackers.
Here are just a few of the selected actions that have been carried out as a result of feedback from
those who use our services, their relatives and carers.
Figure 27: You Said - We Did
You Said:
We did:
Patients complained that they could hear what was
being said in the consultancy room at Outpatients
department at Dorothy Pattison Hospital
We changed the flooring In order to improve sound
proofing/confidentiality
There were no religious or cultural resources in the
open space area at the Henry Lautch Centre
We put prayer mats and prayer books in the open
space area at Henry Lautch to consider our
patients religious and cultural needs
At a recent Trust Policy & Procedures Focus Group,
the EBEs reported that our “DNA (Did not attend)”
policy was “aspirational” and an untrue reflection of
what often happens. The policy placed responsibility
on the service user to contact staff when they were
unable to attend
The policy has been changed so that at the point of
DNA occurrence the service user is contacted to
ascertain the situation and appropriate action
taken, such as immediate clinical intervention.
Feedback from Staff
The Trust has once again encouraged its staff to participate in the annual staff survey as it values
the opinions of its staff. There was a 53% return with 494 staff completing a survey. This was
significantly better than the national average response rate of 42% . In addition to this a Staff
Engagement Lead was recruited externally who has agreed a detailed Action Plan with the Board
following 26 staff engagement focus groups. The topics of the focus groups were key areas within
the 2013 staff survey. The Staff Engagement Lead has linked in with high performing Trusts for
2013 Staff Survey to learn from what has made them successful and incorporated this along with
the staff feedback and external business experience he brought with him.
The Staff Engagement Lead has agreed a number of actions to allow staff the opportunity to be
heard such as the imminent introduction of Staff Engagement Champions (whose role will be to the
communication channel between staff feedback generally and to provide views on new initiatives)
and Workplace Advisors (whose role will be to provide staff a place to go if they have any concerns
around bullying and harassment or whistleblowing, where they might prefer not to go through
current channels). The 2014 Staff survey showed an improvement in many areas from the previous
year as shown below.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 42 of 55
Figure 28: Staff Survey Data
Areas showing improvement from the previous year:
85% staff have had an appraisal/review in the last 12 months (up from 81%)
50% said their appraisal was well structured (not only was this an improvement from 42% in 2013 but the
Trust was in the top 20% performing MHTs as the national average for MHTs was 41%)
81% of staff said they were feeling satisfied with the quality of work and patient care they are able to
deliver (the national average for MHTs was 76%)
16% of staff said they had experienced bullying, harassment or abuse by another member of staff (this
placed the Trust in top 20%. This was an improvement on 2013 and is better than the national average
of 21% for MHTs)
74% staff said they were able to contribute towards improvements at work (this was an improvement
from 72% in 2013)
However, the results also highlighted some areas where improvement could be made as shown in
the table below.
Figure 29: Staff Survey Improvements
Key areas for improvement within the 2013 staff survey:
Staff said that team working was not as effective as in previous years
Staff said they had experienced physical violence by another member of staff (this was 5%
and above the national average for MHTs at 3%)
These results form part of the Action Plan that will be addressed throughout 2015/16.
Staff Health and Wellbeing
The wellbeing of our staff continues to be of paramount importance to us as we recognise that this
has a direct impact on clinical outcomes and the experience of patients. It is therefore important
that our staff are energised, motivated and healthy.
We have refreshed our Health and Wellbeing Programme by introducing a senior - led committee
to include champions from across the Trust, which also presents another opportunity to engage
with staff over an issue which is important to them. This Committee will lead the refreshment of the
Health and Wellbeing Strategy due this year. Health and wellbeing programmes include activities
linked to our health priorities such as resilience, eye sight tests for headaches and physiotherapy
for musculo-skeletal issues but more importantly they are supposed to be fun so we have included
activities such as Pilates, laughing yoga and Mindful meditation. All of the activities in the
programme are linked in some way to our sickness reasons and also national priorities such as
smoking and obesity.
This year one of the key areas of focus has been assisting staff and managers to get staff back
into the workplace, particularly in the instance of long term sickness, by providing extra help and
support of a Health and Wellbeing co-ordinator supported by the health and wellbeing programme.
Staff health and wellbeing is also a wonderful mechanism for staff engagement as it is easily
accessible and understanding and most of all, fun.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 43 of 55
3.4
Part 3D: Statement from the Trust’s key stakeholders.
We approached the following stakeholders to comment on the Quality Account:
 Dudley CCG
 Walsall CCG
 Dudley Healthwatch
 Walsall Healthwatch
 Dudley Health and Wellbeing Board
 Walsall Health and Wellbeing Board
 Dudley Health Overview and Scrutiny Committee
 Walsall Health Overview and Scrutiny Committee
The Trust is pleased to have received the following commissioner feedback responses
 Dudley CCG
 Walsall CCG
The Trust will endeavour to incorporate the comments into on-going quality improvements and
welcomes opportunities for continued partnership working. The full responses are detailed below
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 44 of 55
2nd Floor,
Brierley Hill Health & Social Care Centre
Venture Way
Brierley Hill
DY5 1RU
Tel: 01384 321847
Email: paul.maubach@dudleyccg.nhs.uk
28 May 2015
RESPONSE TO DUDLEY AND WALSALL MENTAL HEALTH PARTNERSHIP TRUST QUALITY ACCOUNT REPORT 2014/15
The CCG welcomes the Dudley & Walsall Mental Health Partnership Trust quality account
report for 2014/15. Over the last 12 months we have worked closely with the Trust on
issues relating to quality and we are pleased to note the strong focus on quality of care
continuing.
This report is written from a pan wide perspective and so some of the references do not
apply to the patients of Dudley and may be more specific to Walsall. During CQRM, we are
keen to gain greater clarity to understand what the services for patients of Dudley look like
and are working closely with Trust colleagues to achieve parity.
We recognise the themes of the priorities introduced in the last financial year throughout
the document as outlined on page 5 to include:
•
The introduction of the ‘ my name is initiative is to be commended, to include the
embedding of the 6c’s
•
The Dementia Care pathway which has improved the experience for patients and
their carer’s. The CCG is pleased that the Living well for longer agenda has been
embraced in order to improve the management of long term physical conditions
•
Recognition that the trust has some way to go to ensure that all staff is able to
access quality supervision and annual appraisals
•
The CCG is pleased to support the work undertaken by DWMHT to promote
transparent and effective pathways, this can only improve the experience of patients
who are experiencing crisis and at critical point in their lives
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 45 of 55
•
The trust has participated in a number of audits which further demonstrates a
willingness to review the quality of services offered.
The trust has outlined some of the challenges to include the achievement of CQUIN
targets, this year further challenging areas of quality innovation have been agreed with the
aspiration to achieve further quality improvements. The trust is demonstrating that they
are looking more broadly at the service and taking bold steps to develop. This will include
changes in delivery and a move to greater innovation.
It is pleasing to note that the CQC inspection carried out in February 2014 reported that
there were no conditions attached to the Trust’s registration, however, three areas were
identified for further scrutiny and the trust has taken immediate action to address these
areas.
The CCG supports the statement that the trust has a good reporting culture for serious
incidents and we are pleased to note that the trust has demonstrated a commitment to
improve the management and analysis of incidents to support the sharing and embedding
of lessons learnt across the organisation.
There have been consistent issues nationally with obtaining timely access to Child &
Adolescent Mental Health Tier 4 beds for admission of young people under the age of 18
years, which the Trust has been dealing with during the year. This service is
commissioned by NHS England specialised service commissioning teams and the CCG is
aware that strenuous efforts are being made to resolve the problems being experienced.
The introduction of the ‘experts by experience’ is a positive step; the CCG would welcome
more of this reflective, person centred feedback to support change and improvement for
service users.
The CCG has heard much about the introduction of the ‘Triangle of Care’ model and we
look forward to hearing how this approach triangulates the family / carer, provider and
service user going forward.
The CCG is satisfied that the Trust is operating a rigorous and thorough complaints
process and has received examples of this throughout the year.
The CCG welcomes the steps and plans for engagements that have been put in place to
support the staff employed by the trust. We are particularly pleased to note that the
wellbeing of staff has been identified as a key area of priority an aspect of concern from
the 2014 Care Quality Commission staff survey report published in March 2015.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 46 of 55
Commissioner’s feedback on Dudley and Walsall Mental Healthcare NHS Trust Draft
Quality Report 2014-15
Walsall Clinical Commissioning Group (CCG) Safety Quality and Performance Committee
has reviewed the Quality Account (QA) for the year 2014/15 for Dudley and Walsall Mental
Healthcare NHS Trust.
Review of Quality Priorities for 2014/15
As clinical commissioners we note that the Trust has again worked hard to meet a range of
quality outcomes this year. The Trust has consistently performed well over the last 12
months and the report fairly reflects all of the achievement to date.
The trust has achieved all of the national contractual targets and has again delivered all of
the Commissioning for Quality and Innovation (CQUIN) schemes for this year. The CCG
would particularly like to praise the achievement of a gold star award from the National
Triangle of Care programme in recognition for commitment to working in partnership with
service user, their carer and the professionals involved.
Of particular note are the good staff survey results received recently and the on-going
work with regards Safeguarding and the Care Act preparedness undertaken for statutory
duties by the trust which will undoubtedly better support Mental Health patients going
forward.
The CCG is looking forward to continuing to work closely with the trust over the next
twelve months and will be working closely in partnership with the trust, primary care and
college to support the expected outcomes determined in goal six.
The CCG has identified some particular areas for further emphasis and improvement for
2015/16:



Readmissions: The CCG supports further emphasis on the work undertaken with
regards re-admission rates and the underlying causes for readmissions.
Clinical Supervision: The CCG notes the goal to ‘Improve the quality of clinical
supervision and appraisals to support care delivery and practice.’ The CCG
recognises this requirement to improve supervision across the trust; however, the
CCG is keen to regard this goal as ‘mandatory’ as soon as possible and therefore
suggests this goal is time limited to an immediate short piece of work.
Care Pathways: The CCG supports the addition of goal five and would also
suggest that pathways are developed electronically, specifically with regards those
accessed by Primary Care.
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 47 of 55
4 Conclusion
This is the Trusts fifth Quality Account and it is designed to present an open and transparent view
of the quality of service provided by the Trust. It describes the progress we have made in relation
to our Quality Improvement Priorities and sets out further local quality improvement priorities for
2015/16.
The Trust is extremely grateful for the input and continued support of key stakeholders and
partners in developing this document. We are fully committed to maintaining and strengthening this
dialogue through the coming year.
5 How to provide feedback
Thank you for taking the time to read the Trust’s Quality Account for 2013/14. If you have any
comments or would like to provide feedback about the contents of this document, please contact
the Trust in any of the following ways:
Phone:
0300 555 0262
Email:
communications@dwmh.nhs.uk
Post:
Trust Headquarters
Trafalgar House
47-49 King Street
Dudley
West Midlands
DY2 8PS
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 48 of 55
Statement of directors’ responsibilities in respect of the Quality
Account
The directors are required under the Health Act 2009 to prepare a Quality Account for each
financial year. The Department of Health has issued guidance on the form and content of
annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009
and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the
National Health Service (Quality Accounts) Amendment Regulations 2011).
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
• The Quality Accounts presents a balanced picture of the trust’s performance over the period
covered;
• The performance information reported in the Quality Account is reliable and accurate;
• There are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
• The data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed definitions,
and is subject to appropriate scrutiny and review; and
• The Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
NB: sign and date in any colour ink except black
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 49 of 55
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 50 of 55
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 51 of 55
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 52 of 55
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 53 of 55
Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2014/15
Page 54 of 55