Sussex Partnership NHS Foundation Trust
Quality report 2014/15
Part 1 – A statement on quality from our Chief Executive
Part 2 – Priorities for improvement and statements of assurance from the board
Part 3 – Other Information
Annexes
1
Part 1 Statement on Quality from the chief executive of Sussex Partnership NHS
Foundation Trust
Our first goal is to deliver safe, effective and consistently high quality care. Over the last
year we have listened to people who have used our services, carers, commissioners and
other partners. We have also carefully considered the thorough, expert and independent
feedback we have received from organisations such as the Care Quality Commission.
This Quality Report helps us to look back over the last year and see where we have made
improvements for people using our services and for carers. It also helps us identify where
we have more to do. The report that follows is set out as mandated by Monitor, one of our
regulators. It incorporates our Quality Account and is formally reviewed by our auditors
(PwC). This is therefore an important statutory document that helps the people we serve
hold us to account. I hope this statement provides a useful overview. There will also be a
publicly available, and accessible, summary version of the full report.
Last year (2014/15)
Safety – we have used tools like the Mental Health Safety Thermometer and Patient Safety
Peer Reviews to find out how safe our services are and to then make improvements.
As a result of information collected via the Mental Health Safety Thermometer we have;
•
Made changes to the way that staff report on pressure ulcers
•
Launched a program to reduce the harm from falls which is currently being piloted
on 4 wards and has already significantly reduced the numbers of falls on these wards.
•
Improved reporting around the use of restraint and seclusion
The peer reviews are led by the Director of Nursing Standards & Safety and a team
comprising of the ward manager, matron, and other designated clinicians from the ward
along with a visiting ward manager. The team meet to discuss safety issues of the ward and
then attend focus groups of patients, staff and carers. Finally the team meet to feedback
what has been discussed on the day and agree 3 local actions to be completed in 3 months.
Going forward it is intended to include the Manchester Safety Tool in the review process as
an aid to discussion of ward safety.
20 (54%) wards have held a patient safety peer review to end of Q3. 59 actions have been
agreed, of these 47 (79%) have been completed.
Experience – we routinely ask people who use our services, and our staff, about their
experience using the Friends and Family Test across the Trust. We have also worked with
carers to implement the Triangle of Care. Thanks to this feedback we are making changes.
We have now established ‘You said – we did’ boards across many sites in the Trust. These
demonstrate that a) we are hearing the feedback being generated by the FFT and b) we are
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responding to it. Much of the feedback is simple quick wins, and a recent example from
Chalk Hill highlighted that the service users’ showers weren’t working properly and they
were quickly repaired in response.
Common developments linked to the Triangle of Care have been: the provision of carers
awareness training for staff, the development of carers support groups, the development of
specific information available for carers, better identification of carers and greater
involvement of carers in care planning, and improved links to carers support organisations.
Effectiveness – we have participated in every national clinical audit and confidential inquiry.
We have also conducted 32 local clinical audits. This systematic approach enables us to
identify good practice as evidence where we can improve.
When our patients were asked if they had blood tests in the last 12 months we were the
third highest scoring Trust in the country. However, we know that we need to improve the
monitoring of physical health, particularly for monitoring of Body Mass Index (height and
weight combined), blood glucose control, blood lipids, blood pressure, smoking, and alcohol
use.
An audit of letters showed that the majority of service users do not receive copies of their
clinic letters. There are some excellent examples of where a service user has opted in to
receive letters and subsequently has consistently been copied in to all correspondence.
These examples have been led by psychiatrists who have had clear discussions with both the
service user and their admin support team. The process is clear to all. During 2015-16 this
will be a Trust quality improvement priority. Systems and processes will be implemented for
improvements and subject to regular audit.
Compliance – we are required to register with the Care Quality Commission and our current
registration status is ‘without condition’. The Care Quality Commission has not taken
enforcement action against Sussex Partnership during 2014/2015.
The examples above illustrate some of the improvements we have made and the challenges
we still face. Our 2020 Vision sets out our ambitions for the next five years:
Our overall vision: outstanding care and treatment you can be confident in.
•
Provide the safest NHS mental health services in England.
•
Use recovery as a guiding principle, inspiring hope and supporting people to achieve
their goals and live meaningful lives.
•
Provide care and treatment based upon reliable evidence that it works and where its
impact on patients and their families is measured and published.
•
Enable patients and carers to access the services they need easily, encouraging them
to choose to receive their care from Sussex Partnership.
•
Develop and maintain a culture of openness, transparency and innovation that
values everyone’s contribution in delivering high quality patient care.
•
Have standard operating protocols across all our clinical services to help reduce and
eliminate variation in outcomes and the experience of the care we provide.
3
•
•
Provide services in clean, safe environments.
Always look after the physical health needs of people using our services.
The next section of this Quality Report (Part 2.1) gives some detail on how we will make
progress against these ambitions this year. For instance:
Sign up to safety – focus on reducing suicide and slips, trips and falls while being honest and
open when things go wrong so that we can learn
Patient experience – shining a light on two of the Friend and Family test questions that we
routinely ask: Have your care and treatment options been discussed with you? Were you
offered written information about your condition? We will be looking for consistent high
standards from every ward and team.
Carer experience – together with carers designing a survey and then working together to
make improvements
Effectiveness – improving physical health and reducing unnecessary readmissions to
hospital. Making sure the new Carenotes electronic system is properly implemented so that
it can measure outcomes for people using our services and support improved clinical
practice.
We need to challenge ourselves, be open to new ideas and have the conviction to put good
ideas into practice, evaluate outcomes and share learning where this will improve practice.
Putting into practice our quality improvement priorities will help us provide the kind of
services where you will feel confident about your friends and family being treated, and
where you would want to be treated yourself if you became unwell.
To the best of my knowledge the information in this report is accurate.
Colm Donaghy
Chief Executive
4
Part 2 Priorities for improvement and statements of assurance from the board
2.1 Quality improvement priorities for 2014/15 identified in 2013/14 and priorities for
improvement over the coming year (2015/16)
The Trust’s quality improvement priorities for 2014/15, identified in 2013/14, along with a
summary evaluation of performance are as follows:
Ref
1.1
Objective
Safe services
1.2
A positive
patient
experience
Target
To pilot the new Mental Health Safety
Thermometer
Summary evaluation
Piloting went well and
now adopted across all
wards.
To implement our programme of Patient
20 (54%) wards have held
Safety Peer Reviews
a patient safety peer
review to end of Q3. 59
actions have been agreed,
of these 47 (79%) have
been completed.
To embed and evaluate our Quality and
The results of the quality,
Safety Compliance Inspection Programme compliance and safety
inspections are fed
directly to the Trust
Quality Committee where
progress with action plans
is reported and monitored
Continue work to establish with each Care Emphasis on introducing
Group clear metrics that enable them to
the Friends and Family
monitor and improve the experience of
Test across the Trust. Over
those they serve
the coming year we will
examine the best outcome
indicators to adopt in each
care group.
Continue to implement the 15 Step
Use of this programme
Challenge programme across our
has helped identify
inpatient and residential units and extend needed changes. Will be
to all adult community mental health
used in the future to
services
follow up issues raised by
the Friends and Family
Test.
Implement the Triangle of Care
Developments have
programme across all services to support included: the provision of
delivery of essential changes in mental
carers awareness training
health services highlighted in the national for staff and the
Closing the Gap Report.
development of carers
support groups.
Develop a programme to ensure the
Successful programme in
implementation of feedback by patients
2014 resulting in full use
through the Mental Health Friends and
from January 2015
5
Ref
Objective
1.3
Effective
services
Target
Family Test by 2015
Ensure that our experience work is able to
reflect patient experience across the
protected characteristics and lead to
measurable improvement (Equality Act
2010).
Summary evaluation
onwards.
Piloted an additional
question for the Friends
and Family Test for people
with protected
characteristics. This has
enabled their specific
views to be captured and
used to improve services.
Measure and report our findings in clinical We completed all national
audit.
clinical audits, local safety
and effectiveness audits
prioritised in the clinical
audit forward plan 201415. In addition we
completed a range of
audits commissioned from
services as a result of high
risk, complaints and areas
of poor performance.
To deliver the 2014/15 clinical audit plan, A new tracker system has
ensuring that each audit has a direct
been developed to ensure
impact on improving patient experience
that the actions are
completed on time. This is
updated quarterly by each
service. Up to end
December 2014 75% of
actions had been
completed.
To provide evidence of effective
We have completed
interventions across the psychosis
various audits of physical
pathway and line with best practice and
health, prescribing
quality standards
practice, provision of
therapies and the
patient’s journey through
teams and services.
Full details on our performance against last year’s (2014/15) quality improvement priorities
can be found in part 3.1 of this report.
For the priorities for improvement over the coming year we have consulted with a range of
stakeholders:
 We have a continuous dialogue with commissioners on the quality of our services
and asked for their views on a draft set of priorities.
 Service user and care organisations. For example carers helped us draft the objective
for the coming year.
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



Local Healthwatch groups gave us their views in January 2015 which helped us
develop these priorities.
We meet regularly with local authority scrutiny committees and they were asked for
views on a set of draft quality improvement priorities.
Our governors gave us their views on the quality improvement priorities for 2015/16
at a joint meeting with the Board of Directors in February 2015.
The general public and out staff have given us a broad range of ideas on how we
should improve quality as part of the work to develop our new five year strategy
(Our 2020 Vision).
People have told us that we should improve quality in ways that make a noticeable, and
measurable, difference to the people using those services. We have also carefully
considered the thorough, expert and independent feedback we have received from
organisations such as the Care Quality Commission (Report published 27.5.15).
Making sure that our services are safe is the top priority. We have joined a growing number
of mental health trusts in the Sign up to Safety campaign. This builds on our improvement
work during 2014/15 (summarised in Part 1 and reported in detail in Part 3). For example
the mental health safety thermometer was piloted last year and will be fully implemented in
2015/16. Following feedback we have extended our safety work to include a specific
objective relating to our suicide prevention work.
The experiences of people who use our services, carers and our staff are critical to delivering
high quality services (quality improvement measures relating to staff experience are
included elsewhere in the Trust’s 2015/16 business plan). We have consulted on the
improvements that would make the most difference for people and these are specified
below. For example, last year we worked with carers on implementation of the Triangle of
Care. This work has progressed into 2015/16 with carers asking us to undertake a survey.
The Friends and Family Test was implemented in 2014/15 and over the next year will be
used to specifically measure how we are improving communication with people who use
our services. In particular we aim to see significant improvements in the way that people are
involved in their care and the way care is recorded through the introduction of the new
Carenotes system.
Last year our focus was to improve our capacity and capability in conducting robust and
effective clinical audit. In 2015/16 we aim to improve effectiveness by making sure that the
actions arising from audit work are implemented. Following feedback, we will also have
more specific objectives. People who use our services are significantly more likely than the
general population to die prematurely. We can begin to change this by making sure that
people using our services have good physical health care that promotes their health and
well-being. We have also been asked to have additional focus on crisis care. Last year we
completed a large number of clinical audits. Our stakeholders are keen for us to
demonstrate that we act on the findings and make a difference to service quality.
The following table shows our quality improvement priorities for 2015/16. These priorities
are now section one of the Trust’s 2015/16 Business Objectives. For each objective there are
7
clear deliverables and targets to be achieved. Progress against these objectives is reported
to the Board of Directors.
8
Ref
Objective
1.1
Delivering our 5
sign up to
safety pledges
1. Put safety
first
2. Continually
learn
3. Honesty
4.Collaborate
5. Support
Reporting
frequency
Quarterly
Lead
Deliverable
Target
EDNQ
Put Safety First
Publish safety improvement plan, which
will incorporate CQC feedback and
concerns from other stakeholders.
Develop a Trust wide suicide reduction
strategy by end Q1. [To include an
agreed methodology for reporting]
Mental Health Safety Thermometer in
active use in all wards & Community
settings
To reduce harm from trips, slips and falls
Continually Learn
Learning from Serious Incidents to be
shared with the team concerned.
Honesty
Compliance with duty of candour
regulations for all incidents of moderate
and severe harm and death.
Collaborate
Share learning from serious incident
reports with Commissioners
Support
See Learning into Action programme
Ensure that the team are debriefed
following a serious incident
9
Plan completed end May 2015
Strategy presented to Trust Board by end Q1
Monitoring by end Q2
Fully complete over next 12 months.
Number of incidents of harm from trips, slips
and falls to be reduced by 25% from the
2014/15 baseline.
Final Serious Incident report, learning and
actions to be shared with the team concerned
within 45 working days.
Report 100% compliance with the duty of
candour regulations including:1) Alert of incident and review process.
2) Shared learning with family and patient
as appropriate.
95% of SI reports completed and submitted to
commissioners in 60 working days.
Teams to be debriefed in the agreed timeframe.
1.2
Improving
experience for
people who use
services
Quarterly
SDSC
Patient Experience:
Monitor and show improvement in the
following questions, measured using the
Friends and Family test.
 Tell us if you have agreed with
someone from NHS Mental
Health Services what care you
will receive?”
Areas showing below average performance to
demonstrate improvement over the year.
Carers:
Carry out a survey to establish baseline
engagement and involvement in care for
Carers.
Develop an action plan based on Q1
survey.
Carry out a survey to demonstrate
improvement.
Survey complete in Q1
Action plan complete in Q2
10
Repeat survey in Q4
1.3
1.4
1.5
1.6
Achieve a
measurable
improvement in
physical health
for those using
our services
Continue to
improve the
crisis care
pathway
Quarterly
EMD
MEWS in place in all of our inpatient
services by 31 March 2016.
Increase use of MEWS (Modified Early Warning
Signs) across inpatient services
Quarterly
EMD
Reduction of 5% in unplanned
readmissions to hospital within 28 days
of discharge
Work closely with service users, carers, the
Police, Ambulance Trust, GPs and other
partners to improve the crisis care pathway, 24
hours a day, 7 days a week.
Making changes Quarterly
to the delivery
of care as a
result of
learning from
Clinical Audit
Successful
Quarterly
implementation
of Care Notes
CAD
To implement a tracing system to check
Quarterly reporting: 90% of actions are
that SMART actions following clinical
implemented by the agreed date.
audit agreed, owned and implemented
by a specified date. In this way we can be
sure that services learn and improve.
CAD
Carenotes (the new electronic patient
record system) rolled out to all services
by March 2016
EDNQ = Executive Director of Nursing and Quality
SDSC = Strategic Director of Social Care
EMD = Executive Medical Director
CAD = Clinical Academic Director
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CHYPS Services go live August 2015
Adults and other services by December 2015 All
Services by March 2016
We have been asked to include outcome indicators in our quality improvement priorities for
2015/16. The new electronic patient record system (Carenotes) will come on stream this
year and will enable us to do this. We will continue to consult on the most meaningful
indicators and set a quality improvement priority in this area next year.
Another area of concern for stakeholders is timely access to services and treatment,
especially for children and young people. We will continue to work with our commissioners
to make sure there is sufficient funding and that we provide an efficient and effective
service. An improvement indicator for Sussex Partnership alone would be unhelpful. We
can only improve access by working with our commissioners and all the other agencies
involved in providing care. We are committed to doing this.
The risks to successful delivery of these quality improvement priorities will be captured in
the Board Assurance Framework. Regular reports are made to the Board of Directors. The
key risks are:
o The pressure on our acute mental health beds, our community services and
the overall resilience of the local health and care system
o The need to use temporary staff in areas where it is hard to recruit
o The competing demands that our commissioners the CCGs have to balance
o Failure to continue improving our engagement with stakeholders, people
who use our services, carers and our staff.
o Difficulties with record keeping and reporting systems as Carenotes is
introduced (see section 2.1.11 for details of data quality improvement works
that will help mitigate this risk).
2.2 Statements of assurance from the board
1. Services provided.
During 2014/15 the Sussex Partnership NHS Foundation Trust provided and/or subcontracted 201 relevant health services. The Sussex Partnership NHS Foundation Trust has
reviewed all the data available to them on the quality of care in 201 of these relevant health
services. The income generated by the relevant health services reviewed in 2014/15
represents 100% of the total income generated from the provision of relevant health
services by Sussex Partnership NHS Foundation Trust for 2014/15.
2. Clinical audit
During 2014/15 six national clinical audits and one confidential enquiry covered relevant
health services that Sussex Partnership NHS Foundation Trust provides. During that period
Sussex Partnership NHS Foundation Trust participated in 100% national clinical audits and
100% national confidential enquiries of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Sussex Partnership NHS
Trust was eligible to participate in during 2014/15 are as follows:
National Audit of Memory Clinics
National Physical Health (CQUIN)
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National GP Communications (CQUIN)
Prescribing for Substance Misuse: Alcohol Detoxification (Prescribing Observatory for
Mental Health POMH)
Prescribing for people with personality disorder (POMH)
Antipsychotic prescribing for people with a learning disability (POMH)
National Confidential Inquiry into Suicide & Homicide by People with a Mental Illness
(NCISH)
The national clinical audits and national confidential enquiries that Sussex Partnership NHS
Trust participated in during 2014/15 are as follows:
National Audit of Memory Clinics
National Physical Health (CQUIN)
National GP Communications (CQUIN)
Prescribing for Substance Misuse: Alcohol Detoxification (Prescribing Observatory for
Mental Health POMH)
Prescribing for people with personality disorder (POMH)
Antipsychotic prescribing for people with a learning disability (POMH)
National Confidential Inquiry into Suicide & Homicide by People with a Mental Illness
(NCISH
The national clinical audits and national confidential enquiries that Sussex Partnership NHS
Foundation Trust participated in, and for which data collection was completed during
2014/15, are listed below alongside the number of cases submitted to each audit or enquiry
as a percentage of the number of registered cases required by the terms of that audit or
enquiry.
Audit title
Participation
% of cases submitted
National Audit of Memory Clinics
Yes
100
National Physical Health (CQUIN)
Yes
100
National GP Communications (CQUIN)
Yes
100
13
Prescribing for Substance Misuse: Alcohol
Detoxification (Prescribing Observatory for
Mental Health POMH)
Yes
1
Prescribing for people with personality disorder
(POMH)
Yes
100
Antipsychotic prescribing for people with a
learning disability (POMH)
National Confidential Inquiry into Suicide &
Homicide by People with a Mental Illness (NCISH
Yes
100
Yes
60
Actions arising from national audits
The reports of five national clinical audits were reviewed by the provider in 2014/15 and
Sussex Partnership NHS Foundation Trust intends to take the following actions to improve
the quality of healthcare provided (note – these are the national clinical audits that reported
in 2014/15, Sussex Partnership NHS Foundation Trust participated in data collection in the
preceding year 2013/14):
National audit of schizophrenia – We scored above average in access to family
interventions and an average level for Cognitive Behavioural Therapy (CBT). Consequently
we need to look at ways we can improve numbers of people having these treatments. A
current research study will help with this. The Uptake and Implementation (U&I) study will
explore some of the barriers to the offering and uptake of CBT for psychosis and promote
better implementation of CBT by clinicians and better uptake by patients.
Some aspects of our prescribing practice were below average. We are addressing these
concerns with the pharmacy team who are working with clinicians where there is a higher
proportion of patients receiving more than one antipsychotic and where a higher dose than
recommended is prescribed. We want to have confidence that if people are on more than
one antipsychotic medication, we know why and can confirm there are no alternatives with
a better evidence base such as clozapine. A good example is the setting up of a
multidisciplinary team which has already been working in one area to improve rates of
clozapine-prescribing there.
When our patients were asked if they had blood tests in the last 12 months we were the
third highest scoring Trust in the country (positive result). However, we know that we need
to improve the monitoring of physical health, particularly for monitoring of Body Mass Index
(height and weight combined), blood glucose control, blood lipids, blood pressure, smoking,
and alcohol use. We have worked with our commissioners to improve monitoring and
management of physical healthcare for people with mental health conditions, not just
schizophrenia. We have improved communications and clarified responsibilities and
developed training programmes for staff providing brief interventions. We have improved
links to with physical health Wellbeing Services, Smoking Cessation Services and third sector
providers such as Albion in the Community. We have Physical Health Champions in many
teams and have set up a Physical Health Forum. During 2014 the implementation of the
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Modified Early Warning System (MEWS) in all acute services ensures that inpatients receive
physical health monitoring and management to reduce risk of cancer, coronary heart
disease and diabetes during acute phase of illness.
In 2015 we are taking part in a research study called STEPWISE in collaboration with the
University of Sheffield which trials lifestyle (physical health) education to reduce the risk of
diabetes for people with schizophrenia.
Our full action plan will be published on the Trust website in May. This will include
additional actions for re-audit in the coming year which will focus on measuring
improvements made in prescribing and physical health monitoring and management.
Use of antipsychotic medication in CAMHs – We were pleased to see an improvement on
the previous two audits on almost all standards for this audit. This means that we have
made significant improvements ensuring there is a clear rationale for antipsychotic
prescribing, monitoring physical health factors and side effects of children and young people
prescribed antipsychotics. In order to sustain and make continued improvements the
specialist Trust pharmacist has worked with all teams with the aim that by the next audit all
patients will have a baseline physical health assessment and 6 monthly monitoring and all
patients will be assessed for a movement disorder.
Prescribing for people with a personality disorder – The final report publication was
delayed until February 2015. At present the report has been circulated to all clinicians and
action plans developed.
Prescribing for substance misuse: alcohol detoxification – Our level of participation in this
audit was low. In going forward we have reviewed the national findings and circulated
these to clinicians. We plan to use the same methodology for sampling patients used by a
neighbouring Trust in the re-audit (2016) and ensure improved participation.
Actions arising from local audits
The reports of 31 local clinical audits were reviewed by the provider in 2014/15 and Sussex
Partnership NHS Foundation Trust intends to take the following actions taken to improve
the quality of healthcare provided:
Use of Seclusion - The results of the audit suggest that improvements can be made in the
practice of seclusion events which will result in improvements to the quality of service user
experience. Trust staff report good knowledge in seclusion policy and procedures and give
many examples of how they apply this knowledge in practice. In particular this
demonstrates that the safety and wellbeing, human rights, privacy and dignity and cultural
needs of service users are maintained.
There is a wide variation across all wards and with each procedure for recording:
appropriateness and initiation of seclusion; monitoring and review of the secluded patient;
and termination of seclusion. Each ward should review these results and take action as
appropriate. In particular; ward managers should take action immediately to ensure that all
patients meet the criteria for seclusion, use of the seclusion audit tool is highly
15
recommended for this. Doctors should be informed at the onset of seclusion and should
attend for the initial multi-disciplinary team meeting and patients must be given the
opportunity to discuss the seclusion event and events leading up to it when they have been
returned to their room and given time to reflect.
Supervision - The audit demonstrates that a very good supervision system is in place in the
Trust and that good practice is maintained. An additional component to the audit this year
was the records audit. Improvements can be made to the record keeping of supervision and
the service action plans reflect this.
GP letters - It is clear from the psychiatrist survey and the Admin Team Leader interviews
that people believe letters are copied to service users in compliance with national
recommendations. In the majority of cases Admin Team Leaders and Psychiatrists believe
that there is a rigorous opt in/ out process, albeit one which varies by psychiatrist and or
location. In some cases this is communicated verbally and in others, service users are
provided with an information sheet and consent form at initial assessment. However, the
audit of letters shows that this is not the case and that the majority of service users do not
receive copies of the clinic letters. There are some excellent examples of where a service
user has opted in to receive letters and subsequently has consistently been copied in to all
correspondence. These examples have been led by psychiatrists who have had clear
discussions with both the service user and their admin support team. The process is clear to
all. During 2015-16 this will be a Trust quality objective. Systems and processes will be
implemented for improvements and subject to regular audit.
Medication adherence - This audit highlights the massive impact non-adherence can have
on some patients’ wellbeing. We often know what medication has worked well in the past
and allowed a patient to be discharged, but they fail to adhere post-discharge and find
themselves unwell again. Though we appear to record the adherence status of most
patients we need to be sure this information is used to get to the bottom of why some
patients are not adhering and practical steps taken to resolve issues where we can. We will
continue to roll out training to staff on how to minimize the barriers to non-adherence and
how best to explore the beliefs of patients who do not wish to adhere to their medication
regimen.
Monitoring the Need and Safety of Prescribing Melatonin/ Ramatonin in Children and
Young People - The result of this audit revealed that most of our aims have been met and
that the audit standards we have created under the guidelines provided by Sussex
Partnership NHS Foundation Trust for Melatonin have been satisfied. In particular, it is
evident from our audit that the majority of young people (84.6%) have been successfully
transferred from Melatonin to Ramatonin. Additionally, its effectiveness in each individual
person had been recorded most of the time (84.6%). However, our report also revealed that
possible side-effects being experienced by young people as a result of taking
Melatonin/Ramatonin are not necessarily being monitored and recorded, and no enquiries
were made to young people’s pubertal development despite this being an important aspect
in the Melatonin guideline.
The following recommendations have been made as a result of the audit:
16
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
All side-effects experienced by young people as a result of taking
Melatonin/Ramatonin should be recorded at each annual review.
Young people and their parents should be encouraged to fill out sleep diaries, both
on and off medication, to ensure that Melatonin/Ramatonin is still required.
Young people’s pubertal development should be monitored and recorded to screen
for any abnormalities that could have been caused by taking Melatonin/Ramatonin.
Administration and governance of an outpatient clinic – The findings of an initial audit
prompted the following changes in practice. In the re-audit all standards met 100%
 abolish paper feedback forms, instead write feedback (e.g. DNA/seen and when to
follow up on Outlook Calendar
 DNA Policy to be adhered fully, including not to ask administration staff to chase
patient if clinically inappropriate
 Bookings by the psychiatrist in clinic using Outlook Calendar after discussing with
patient
 Expand the Outpatient clinics to 6 a week instead of four, but with increased length
slots from 30minutes to 45 minutes for standard follow ups and 1.5 hour for New
Assessments.
 Job Plan/New timetable had strict provision for 17 follow up appointments and 5
New Assessments slots and no more.
 Clinical administration to be done strictly within the allocated time in Clinic and
separate Administration sessions abolished from Job Plan/ timetable
3. Research
The number of patients receiving relevant health services provided or sub-contracted by
Sussex Partnership NHS Foundation Trust in 2014/15 that were recruited during that period
to participate in research approved by a research ethics committee 1987.
4. Commissioning for Quality and Innovation
A proportion of Sussex Partnership NHS Foundation Trust income in 2014/15 was
conditional on achieving quality improvement and innovation goals agreed between Sussex
Partnership NHS Foundation Trust and any person or body they entered into a contract,
agreement or arrangement with for the provision of relevant health services, through the
Commissioning for Quality and Innovation payment framework. Further details of the
agreed goals for 2014/15 and for the following 12 month period are available electronically
at http://www.sussexpartnership.nhs.uk/board-meetings
Once the Commissioning for Quality and Innovation goals have been signed off by
commissioners as achieved an appendix to the performance report will be included in the
papers for a public Board meeting. Papers are available via the link above.
The monetary total for income in 2014/15 conditional upon achieving quality improvement
and innovation goals is £4,628,365. At the time of reporting Sussex Partnership NHS
Foundation Trust is confident of achieving close to, or all of this income because of
successful delivery of quality improvement and innovation goals.
In 2013/14 Sussex Partnership NHS Foundation Trust had a total monetary income from
achieving quality improvement and innovation goals of £4,006,422.
17
5. Registration with the Care Quality Commission (CQC)
Sussex Partnership NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is ‘without condition’. The Care Quality
Commission has not taken enforcement action against Sussex Partnership during
2014/2015.
6. Removed from the legislation by the 2011 amendments
7. Special reviews and investigations carried out by CQC
Sussex Partnership NHS Foundation Trust has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
Additional information
In the previous reporting year, 6 locations were inspected by the Care Quality
Commission. Three were found to be non-compliant with some of the essential standards
of quality and safety as described in the following table.
Location
Amberstone
Date
May 2013
Inspection
Response to
concerns
Judgement
2 minor compliance actions
against outcomes 14 and 10.
The Chichester Centre
August
2013
February
2014
Routine
2 minor compliance actions
against outcomes 13 and 14.
6 moderate and 1 minor concerns
against outcomes 1, 4,7,9,13,16
and 21.
Langley Green Hospital
Response to
concerns
The Chichester Centre had completed all actions that had been agreed to address issues of
non-compliance.
Amberstone Hospital is now compliant with regulation 15 but remains non-compliant with
regulation 23; supporting workers in relation to their responsibilities. This relates to staff
having access to relevant training. The Trust has introduced a new online training system
and, using this; training at Amberstone Hospital will be monitored and managed by
managers to ensure compliance and to signpost to attend all necessary training.
In October 2014 the Care Quality Commission conducted an unannounced inspection at
Langley Green Hospital. This was in response to concerns that one or more of the essential
standards were not being met. The inspection team focused on Outcome 4 – Care and
Welfare of people who use services. The judgment was that the service was not meeting
this standard and that this had a moderate impact on the people who used the service. The
service has a comprehensive improvement plan in place to meet unmet standards and this
is reviewed and reported to the Care Commissioning Group and the Care Quality
Commission on a monthly basis.
18
In the past the Regulators have completed follow up inspections to check that action has
been taken to meet the essential standards of quality and safety. However there have been
changes to the inspection processes and the Care Quality Commission now use Key Lines of
Enquiry to answer 5 questions of all services. Are they safe? Are they effective? Are they
caring? Are they responsive and are they well led?
The Care Quality Commission (CQC) conducted a planned inspection of our services in
January 2015 which was published on 27 May 2015. This rated Sussex Partnership overall as
an organisation which Requires Improvement.
The CQC’s report is based upon a thorough, independent assessment of what we do,
informed by the people who use our services, our staff and organisations we work with. It
highlights services where the level of caring is outstanding and where staff are
compassionate, kind and motivated to go the extra mile for the people they serve. Our
challenge is to achieve this consistently across all our services. The report also highlights the
need for us to be better at getting the basics right on issues like staff training and learning
from incidents.
We’ve addressed areas where the inspection team raised concerns about the patient
environment, improved the way we deliver staff training and have been talking with
patients, public and staff about the steps we need to take to improve patient care. Our 2020
Vision describes what we will do to achieve consistently outstanding care across all our
services.
In addition to the inspections undertaken by the Care Quality Commission, Sussex
Partnership NHS Foundation Trust have now embedded internal unannounced Quality,
Compliance and Safety inspections to support services to achieve high standards of care.
These identify any areas of concern that can be rectified and highlight areas of best practice
which can be disseminated across clinical areas.
There have been 19 internal inspections between April 2014 – March 2015. Following each
inspection a comprehensive report is written which evidences areas of good practice in
addition to identifying areas requiring improvement. Teams are asked to develop
improvement plans which address areas of non-compliance with the essential standards of
quality and safety. The Governance team monitor the improvement plans for a period of 9
months, which includes a follow up visit at the half way point. At the end of the 9 month
period it is expected that issues identified during the inspections will have been
addressed. Any outstanding issues are added to the services risks register. Teams are asked
to complete a short anonymous survey at the end of the 9 month period which is used to
help evaluate the effectiveness of the inspections.
The results of the quality, compliance and safety inspections are fed directly to the Trust
Quality Committee where progress with action plans is reported and monitored. These
reports are also shared with our Commissioners, the CQC and internally by our Strategic
Governance Groups.
19
8. Records submitted for inclusion in Hospital Episode Statistics
Sussex Partnership NHS Foundation Trust submitted records during 2014/15 to the
Secondary Users 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:
99.08% (5,916 out of 5,971) for admitted patient care
99.86% (81,906 out of 82,022) for outpatient care
-
Which included the patient’s valid General Practitioner Registration Code was:
100.0% (5,971 out of 5,971) for admitted patient care
100.0% (82,022 out of 82,022) for outpatient care
n/a for accident and emergency care
9. Information Governance
Sussex Partnership NHS Foundation Trust Information Governance Assessment report
overall score for 2014/15 was 91% and was graded green.
10. Payment by Results clinical coding
Sussex Partnership NHS Foundation Trust was not subject to the Payment by Results clinical
coding audit during 2014/15 by the Audit Commission.
Sussex Partnership NHS Foundation Trust was subject to the Payment by Results clinical
coding audit during the reporting period by Maxwell Stanley Consulting Ltd and the error
rates reported in the latest published audit for that period for diagnoses and treatment
coding (clinical coding) were:
 98% Correct Primary Diagnoses
 86.75% Secondary diagnoses correct
 100% Primary Procedure correct
 100% Secondary procedures correct
 0% unsafe to audit
The results should not be extrapolated further than the actual sample audited.
11. Action to improve data quality
Sussex Partnership NHS Foundation Trust will be taking the following actions to improve
data quality:
Data Quality Team
A new Data Quality Team was set up in July 2014 to work on cleaning poorly recorded data
as well as delivering the Data Quality message to all Services across the Trust. The team’s
20
main focus going forward will be working with front end users to ensure they are aware of
the importance of collecting good data quality. Training programs will be set up for teams as
well as individuals to increase the capture of good data. The team will also focus on making
sure processes are in place to reduce the amount of errors being made in the new clinical
information system (Carenotes) which will be implanted Trust wide in 2015.
RFT (Right First Time)
The purpose of the Right First Time project is to ensure the integrity and validity of the data
being entered into the Trusts systems is correct. All members of staff recording any patient
information have a responsibility to the NHS and to the patients to ensure that the data
held electronically or on paper is accurate, complete and captured in a timely manner.
Having accurate data allows for improved reporting, up to date statistics, correct invoicing
and improved decision making.
The Data Quality Team has:
 Worked closely with the Comms team to launch a number of campaigns aimed at
both staff and patients highlighting the importance of the Right Fist Time project.
There will be a bigger push on this project as staff are being trained on the new
Carenotes system.
 Set up a generic Data Quality email address has been set up. This will be
communicated out across the Trust alongside the Right First Time Project.
 Worked closely with all Services across the Trust highlighting the importance of Data
Quality. The Data Quality team have attended team meetings and Webinars where
we have listened to staff and the issues they face around collecting good data.
 Sent out weekly stats to all service leads to monitor data quality performance. The
stats show the quality of data captured for new registrations in Pims (the current
clinical information system).
2.3 Reporting against core indicators
The numbering below corresponds with the numbering of indicators in the Regulation 4
Schedule within the Quality Accounts Regulations.
No 13 - 7 Day follow up
The data made available to the trust by the Health and Social Information Centre with
regard to the percentage of patients on Care Programme Approach who were followed up
within 7 days after discharge from psychiatric in-patient care during the reporting period
(definition in Annex 4).
Graph: summary of percentage of adults followed up within 7 days of discharge from
hospital
21
100%
400
99.2%
97.7%
98.2%
97.4%
98.1%
97.6%
96.2%
96.2%
96.3%
95.7%
95%
350
94.7%
94.7%
301
90%
287
300
288
282
273
263
256
266
85%
250
241
242
234
231
80%
200
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
TRUST - % Followed-up
Oct-14
Nov-14
Target
Dec-14
Jan-15
Feb-15
Mar-15
TRUST - Discharged
Table: 7 day follow-ups, by locality, 2011-12 to 2014-15
% followed -up
West Sussex
East Sussex
Brighton & Hove
TRUST
2011-12
2012-13
2013-14
2014-15
Discharged
1,316
1,265
1,442
1,265
Followed-up
1,303
1,237
1,387
1,215
% followed -up
99.0%
97.8%
96.2%
96.0%
Discharged
1,145
1,128
1,137
1,159
Followed-up
1,119
1,106
1,122
1,137
% followed -up
97.7%
98.0%
98.7%
98.1%
Discharged
766
685
755
681
Followed-up
745
668
743
657
% followed -up
97.3%
97.5%
98.4%
96.5%
Discharged
3,227
3,078
3,334
3,105
Followed-up
3,167
3,011
3,252
3,009
% followed -up
98.1%
97.8%
97.5%
96.9%
Technical note:
The 7 day follow up indicator is built from figures collated monthly. They are based on
discharges up to, and including, the seventh day before the end of the month; this allows for
the full seven day follow up period to be included by month end, and hence, any breaches
be identified. The figures from the staggered month are reported nationally; for example,
22
for March 2015 the reporting period was February 21st to March 24th. The Trust has
reported this way for over five years.
For staggered months (2014/15); the numerator is 3,009 (followed-up) and the
denominator is 3,105 (discharges) = 96.9%. For the full calendar year (1 April – 31 March
2014/15): the numerator (followed-up) is 3,059 and the denominator is 3,150 (discharges) =
97.1%. For their review PwC have reconciled against the full calendar year figures
Table: Benchmarking 7 Day Follow-up, period Q1-Q4, 2014-15
Provider Organisation
Proportion of
patients on CPA
who were
followed up
within 7 days
after discharge
from psychiatric
inpatient care
England Average
97.2%
.
Trust
Ranking
(1 highest
58 lowest)
Sussex Partnership NHS Foundation Trust
96.9%
42
Solent NHS Trust
100.0%
1
North Staffordshire Combined Healthcare NHS Trust
99.8%
2
North Essex Partnership NHS Foundation Trust
99.5%
3
Worcestershire Health and Care NHS Trust
99.3%
4
Navigo
99.0%
5
Humber NHS Foundation Trust
99.0%
6
Nottinghamshire Healthcare NHS Trust
98.7%
7
North East London NHS Foundation Trust
98.7%
8
Norfolk and Suffolk NHS Foundation Trust
98.6%
9
Hertfordshire Partnership NHS Foundation Trust
98.6%
10
Barnet, Enfield and Haringey Mental Health NHS Trust
98.6%
11
Rotherham, Doncaster and South Humber NHS Foundation
Trust
Bradford District Care Trust
98.4%
12
98.4%
13
Cornwall Partnership NHS Foundation Trust
98.3%
14
Surrey and Borders Partnership NHS Foundation Trust
98.3%
15
Berkshire Healthcare NHS Foundation Trust
98.1%
16
Greater Manchester West Mental Health NHS Foundation
97.9%
17
23
Trust
Lincolnshire Partnership NHS Foundation Trust
97.9%
18
Cheshire and Wirral Partnership NHS Foundation Trust
97.8%
19
Tees, Esk and Wear Valleys NHS Foundation Trust
97.8%
20
Pennine Care NHS Foundation Trust
95.5%
55
Birmingham and Solihull Mental Health NHS Foundation
Trust
West London Mental Health NHS Trust
95.4%
56
95.2%
57
Leicestershire Partnership NHS Trust
94.9%
58
4 providers with less than 50 patients discharged have been excluded (highest only had 15)
The Sussex Partnership NHS Foundation Trust considers that this data is as described for the
following reasons:




Performance has been managed throughout the year through clear reporting
processes which include manual verification of data.
Performance is reviewed monthly with operational staff.
All staff receive training regarding this indicator and are set clear standards
The Sussex Partnership NHS Foundation Trust has taken the following actions to improve
this percentage, and so the quality of its services, by
 Monitoring trends in reported levels of performance and exceptions by team
 Ensuring all staff are aware of the targets and are supported to achieve the
standards
 Ensuring that the Trusts clinical standards are up to date and evidence based.
24
No 17 – Gatekeeping admissions to hospital
The data made available to the trust by the Health and Social Care Information Centre with
regard to the percentage of admissions to acute wards for which the Crisis Resolution Home
Treatment Team acted as a gatekeeper during the reporting period (definition in Annex 4).
Graph: summary of percentage of adults under 65 gate-kept prior to admission
300
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100%
99.5%
99.5%
98.9%
95%
250
90%
212
210
201
196
200
189
85%
191
191
188
188
188
184
183
80%
150
Apr-14
May-14
Jun-14
Jul-14
Aug-14
TRUST - % Gatekept
Sep-14
Oct-14
Target
25
Nov-14
Dec-14
Jan-15
TRUST - Admissions
Feb-15
Mar-15
Table: Admissions gate-kept, by locality, 2011-12 to 2014-15
% gatekept
2011-12
2012-13
2013-14
2014-15
Admissions
1,057
1,089
989
893
Gatekept
1,050
1,086
986
891
% gatekept
99.3%
99.7%
99.7%
99.8%
Admissions
846
844
788
842
Gatekept
840
844
785
842
% gatekept
99.3%
100.0%
99.6%
100.0%
Admissions
563
544
510
494
Gatekept
562
543
510
494
% gatekept
99.8%
99.8%
100.0%
100.0%
Admissions
2,466
2,477
2,287
2,229
Gatekept
2,452
2,473
2,281
2,227
% gatekept
99.4%
99.8%
99.7%
99.9%
Table: Benchmarking Crisis Team Gatekeeping, period Q1-Q4, 2014-15
Provider Organisation
Proportion of
admissions to
acute wards that
were gate kept
by the CRHT
teams
England
98.1%
Trust
Ranking
(1 highest
58 lowest)
Sussex Partnership NHS Foundation Trust
99.9%
11
Kent and Medway NHS and Social Care Partnership Trust
100.0%
1
Oxleas NHS Foundation Trust
100.0%
1
Dudley and Walsall Mental Health Partnership NHS Trust
100.0%
1
Black Country Partnership NHS Foundation Trust
100.0%
1
Devon Partnership NHS Trust
100.0%
1
Solent NHS Trust
100.0%
1
Humber NHS Foundation Trust
100.0%
1
Navigo
100.0%
1
Northumberland, Tyne and Wear NHS Foundation Trust
99.9%
9
South Essex Partnership University NHS Foundation Trust
99.9%
10
Coventry and Warwickshire Partnership NHS Trust
99.9%
12
West Sussex
East Sussex
Brighton & Hove
TRUST
26
Derbyshire Healthcare NHS Foundation Trust
99.9%
13
East London NHS Foundation Trust
99.9%
14
Sheffield Health and Social Care NHS Foundation Trust
99.8%
15
Hertfordshire Partnership NHS Foundation Trust
99.8%
16
North Staffordshire Combined Healthcare NHS Trust
99.7%
17
Cornwall Partnership NHS Foundation Trust
99.6%
18
2Gether NHS Foundation Trust
99.6%
19
South West Yorkshire Partnership NHS Foundation Trust
99.5%
20
Cambridgeshire and Peterborough NHS Foundation Trust
95.1%
54
Plymouth Community Healthcare (C.I.C)
94.9%
55
Avon and Wiltshire Mental Health Partnership NHS Trust
94.8%
56
South London and Maudsley NHS Foundation Trust
91.8%
57
Leicestershire Partnership NHS Trust
82.7%
58
4 providers with less than 50 admissions have been excluded (highest of four only had 3)
The Sussex Partnership NHS Foundation Trust considers that this data is as described for
the following reasons:




Performance has been managed throughout the year through clear reporting
processes which include manual verification of data.
Performance is reviewed monthly with operational staff.
All staff receive training regarding this indicator and are set clear standards
The Sussex Partnership NHS Foundation Trust has taken the following actions to improve
this percentage, and so the quality of its services, by
 Monitoring trends in reported levels of performance and exceptions by team
 Ensuring all staff are aware of the targets and are supported to achieve the
standards
 Ensuring that the Trusts clinical standards are up to date and evidence based.
No 19 Readmissions to hospital
The percentage of patients readmitted to a hospital which forms part of the trust within 28
days of being discharged from a hospital which forms part of the trust during the reporting
period. National data is not available from the Health and Social Care Information Centre.
27
25%
20%
15%
10%
5%
0%
Mar-14
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
AMHS <65 % Readmitted
Mar-14
Oct-14
Nov-14
Dec-14
Jan-15
Feb-15
Mar-15
AMHS 65+ % Readmitted
Apr-14 May-14 Jun-14
Jul-14
Aug-14 Sep-14 Oct-14 Nov-14 Dec-14
Jan-15
Feb-15 Mar-15
<65
18.1%
16.4%
13.7%
11.6%
13.4%
10.6%
14.7%
15.9%
13.6%
12.3%
15.0%
16.8%
12.0%
65+
3.8%
4.1%
6.3%
3.1%
2.9%
13.3%
11.8%
5.6%
7.9%
7.1%
6.4%
1.8%
3.8%
The above table is based on routinely collected data for adult mental health services (AMHS)
that was considered by the Board of Directors at their meeting in April 2015. The Sussex
Partnership NHS Foundation Trust considers that this data is as described for
the following reasons:




Performance has been managed throughout the year through clear reporting
processes which include manual verification of data.
Performance is reviewed monthly with operational staff.
All staff receive training regarding this indicator and are set clear standards
The Sussex Partnership NHS Foundation Trust has taken the following actions to improve
this percentage, and so the quality of its services, by
 Monitoring trends in reported levels of performance and exceptions by team
 Ensuring all staff are aware of the targets and are supported to achieve the
standards
 Ensuring that the Trusts clinical standards are up to date and evidence based.
No 22 Patient experience of community mental health services
The data made available to the trust by the Health and Social Care Information Centre with
regard to the trust’s “Patient experience of community mental health services” indicator
score with regard to a patient’s experience of contact with a health or social care worker
during the reporting period.
28
Sussex Partnership
score out of 10
Rating
Lowest
score
nationally
7.3
Highest
score
nationally
8.4
Overall
8.0
Listening
for the person or people
seen most recently listening
carefully to them
8.5
About the
same
About the
same
7.7
8.9
Time
for being given enough time
to discuss their needs and
treatment
Other areas of life
for the person or people
seen most recently
understanding how their
mental health needs affect
other areas of their life
8.1
About the
same
7.2
8.4
7.3
About the
same
6.4
8.1
Table: Patient Experience of Contact with a Health or Social Care Worker (Data source:
CQC 18 September 2014)
At the start of 2014, a questionnaire was sent to 850 people who received community
mental health services. Responses were received from 220 people (28% response rate
compared to 29% nationally) at Sussex Partnership NHS Foundation Trust. For each question
in the survey, people's responses are converted into scores, where the best possible score is
10/10. Each trust received a rating of Better, About the same or Worse on how it performs
for each question, compared with most other trusts. Comparisons with earlier years cannot
be readily made as the questions for 2014 were different to those used in 2013.
The Sussex Partnership NHS Foundation Trust considers that this data is as described for
the following reasons:




Performance has been managed throughout the year through clear reporting
processes which include manual verification of data.
Performance is reviewed monthly with operational staff.
All staff receive training regarding this indicator and are set clear standards
The Sussex Partnership NHS Foundation Trust has taken the following actions to improve
this percentage, and so the quality of its services, by
 Monitoring trends in reported levels of performance and exceptions by team
 Ensuring all staff are aware of the targets and are supported to achieve the
standards
 Ensuring that the Trusts clinical standards are up to date and evidence based.
29
No 25 Patient safety incidents
The data made available to the trust by the Health and Social Care Information Centre with
regard to the number and, where available, rate of patient safety incidents reported within
the trust during the reporting period, and the number and percentage of such patient safety
incidents that resulted in severe harm or death.
Trust data - Actual Impact April 2013 – March 2015
Actual Impact
2013/2014
2014/2015
1 – No Harm (No Injury – Insignificant)
1826
2041
2 – Low Harm (Minor Injury – Not Permanent)
824
952
3 – Moderate Harm (Significant Injury – Not Perm)
53
58
4 – Severe Harm (Significant Injury – Permanent)
1
3
102
65
5 – Death (Directly Attributable To The PSI)
6 – Near Miss Prevented Incident
1
Blank (awaiting grading)
74
Total
2807
3193
Please note the 2014/2015 data includes 177 forms that have yet to be validated and
subject to re-categorisation and therefore subject to amendment.
During the period 01 April 2014 – 31 March 2015 a total of 3193 patient safety incidents
were reported compared to 2807 the previous year. During this period a total of 65 deaths
were reported to the National Reporting Learning Service (NRLS). It is important to note that
this figure also includes service user deaths in the community. In the previous year a total of
102 deaths were reported. As a percentage of total incidents reported to the NRLS this
equates to 2.0% for the period April 14 – March 15 compared to 3.6% for the April 13 –
March 14 period.
A patient safety incident is any unintended or unexpected incident which could have or did
lead to harm for one or more patients receiving NHS care. The overall number includes all
deaths of those people receiving community treatment from Sussex Partnership and those
whom it is suspected have taken their own lives. This year (April 2014- March 2015), there
has been a 28% decrease in the number of people receiving treatment who have died as a
result of suspected suicide.
Reducing suicide and learning from patient safety incidents are two of our quality
improvement priorities for 2015/16 (see Part 2.1).
30
NRLS data - 01 April 2014 to 30 September 2014
Patient safety incidents are reported to the NRLS who publish reports every six months. The
most recent data published covers the first six months of 2014/15. The following tables are
drawn from the Health and Social Care Information Centre. The greater the overall number
of incidents of all levels of severity reported the ‘higher’ the Trust is judged to be
performing. The smaller the percentage of all incidents that resulted in severe harm or
death the ‘higher’ the Trust is judged to be performing.
In each table both the number of incidents and the rate or percentage are reported. For
comparison purposes it is the rate or percentage that should be studied (the second row in
each table).
National
SPFT
Highest
Lowest
Average
Performing
Performing
Trust by bed
Trust by bed
days
days
Number of incidents
2396
1481
1971
910
occurring
Rate per 1000 bed days
32.82
14.71
90.4
7.25
National
Average
SPFT
Number of severe harm
incidents occurring
8.3
1
Highest
Performing
Trust
0
Lowest
Performing
Trust
32
% of total incidents
N/A
0.07
0
2.9
National
Average
SPFT
Number of Death
incidents occurring
16
38
Highest
Performing
Trust
0
Lowest
Performing
Trust
33
% of total incidents
N/A
2.6
0
3
The Sussex Partnership NHS Foundation Trust considers that this data is as described for
the following reasons:



Performance has been managed throughout the year through clear reporting
processes which include manual verification of data.
Performance is reviewed monthly with operational staff.
31

All staff receive training regarding this indicator and are set clear standards
The Sussex Partnership NHS Foundation Trust has taken the following actions to improve
this percentage, and so the quality of its services, by
 Monitoring trends in reported levels of performance and exceptions by team
 Ensuring all staff are aware of the targets and are supported to achieve the
standards
 Ensuring that the Trusts clinical standards are up to date and evidence based.
Friends and Family Test
Implementation of the Friends and Family Test was a quality improvement priority for
2014/15. This is reported below in Part 3.1.
Part 3 other information
3.1 Overview of quality improvement during 2014/15
Note: The quality improvement priorities for last year (2014/15) were agreed locally,
following consultation with stakeholders. It has not been possible to make comparisons with
other mental health service providers as there was no common set of priorities or national
definition for the indicators. The objectives were also within year priorities and therefore
there is no historical trend comparison over more than one year.
A. Safe services
In last year’s Quality Report (2013/14) we said our objectives would be:
 To pilot the new Mental Health Safety Thermometer
 To implement our programme of Patient Safety Peer Reviews
 To embed and evaluate our Quality and Safety Compliance Inspection Programme
How did we do?
Mental Health Safety Thermometer
Sussex Partnership NHS Foundation Trust has been a pilot for wave 2 of the implementation
of the mental health safety thermometer. This is a national tool that has been designed to
measure commonly occurring harms in people that engage with mental health services. It
asks questions about five key harms.
1. Self-harm
2. Violence & Aggression
3. Psychological Safety
4. Medication Omissions
5a. Restraint (inpatients only)
5b. Discharge from hospital (community only).
32
A period of pilot testing and further development ran from the end of April 2014 to October
2014. The following services have participated in the pilot;
Langley Green wards and Crisis Resolution and Home Treatment (CRHT)
Meadowfield wards and CRHT
Selden Centre (Learning Disability)
Hazel Ward (Secure and Forensic).
As a result of information collected via the Mental Health Safety Thermometer the we have;
 Made changes to the way that staff report on pressure ulcers
 Launched a program to reduce the harm from falls which is currently being piloted on 4
wards and has already significantly reduced the numbers of falls on these wards.
 Improved reporting around the use of restraint and seclusion
The official launch of the Mental Health Safety Thermometer took place on the 23rd of
October 2014, which showcased the new Safety Thermometer website. The website enables
staff to benchmark against national, Trust and ward specific data.
Trustwide rollout will begin on 1st April 2015 (see quality improvement priorities for
2015/16).
Patient Safety Peer Reviews
Patient Safety Peer Reviews are one way of ensuring that senior clinicians and Trust
directors are informed first hand about the safety concerns of frontline staff, patients and
their carers. Patient Safety Peer Reviews provide a structure and process for directors and
senior clinicians from across the organisation to talk with patients, staff and carers about
safety issues in their clinical settings and show support for reporting incidents and near
misses.
The reviews are led by the Director of Nursing Standards & Safety and a team comprising of
the ward manager, matron, and other designated clinicians from the ward along with a
visiting ward manager. The team meet to discuss safety issues of the ward and then attend
focus groups of patients, staff and carers. Finally the team meet to feedback what has been
discussed on the day and agree 3 local actions to be completed in 3 months.
Going forward it is intended to include the Manchester Safety Tool in the review process as
an aid to discussion of ward safety.
20 (54%) wards have held a patient safety peer review to end of Q3. 59 actions have been
agreed, of these 47 (79%) have been completed.
Actions taken as a result of the Peer safety reviews are led by Clinicians, patients and carers
and are therefore generally individual to each ward. Some examples include;






Provision of lockable storage to help keep personal property safe
Improved provision of information for carers
Development of a carers drop in clinic
Environmental improvements / decoration (i.e. garden lighting, deep cleans, new
flooring)
A welcome board designed by young people using the service.
New garden furniture
33
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




Increased access to leisure activities (i.e. PS3, Wii, i-pad, afternoon tea group)
Wound management training for staff
Introduction of a local de-escalation protocol
Implementation of a patient booking system for ward rounds.
Revision of ward welcome pack in partnership with service users.
Reviewed Serious Incident reporting system to stop the need for duplication in the
process.
Quality and Safety Compliance Inspection Programme
In addition to the inspections undertaken by the Care Quality Commission, Sussex
Partnership NHS Foundation Trust has now embedded internal unannounced Quality,
Compliance and Safety inspections to support services to achieve high standards of care.
These identify any areas of concern that can be rectified and highlight areas of best practice
which can be disseminated across clinical areas.
There have been 19 internal inspections between April 2014 – March 2015. Following each
inspection a comprehensive report is written which evidences areas of good practice in
addition to identifying areas requiring improvement. Teams are asked to develop
improvement plans which address areas of non-compliance with the essential standards of
quality and safety. The Governance team monitor the improvement plans for a period of 9
months, which includes a follow up visit at the half way point. At the end of the 9 month
period it is expected that issues identified during the inspections will have been
addressed. Any outstanding issues are added to the services risks register. Teams are asked
to complete a short anonymous survey at the end of the 9 month period which is used to
help evaluate the effectiveness of the inspections.
The results of the quality, compliance and safety inspections are fed directly to the Trust
Quality Committee where progress with action plans is reported and monitored. These
reports are also shared with our Commissioners, the CQC and internally by our Strategic
Governance Groups.
Examples of some of the actions that have been taken as a result of the inspections include;



Changes in practice to ensure that when things go wrong these are shared and discussed
with teams and there is evidence that learning has taken place.
Managed ligature risks that have been identified following the inspections.
Improved systems to ensure that standards are being monitored, maintained and
addressed where problems have been identified including those relating too
- Environmental safety, cleanliness and infection control.
- Record keeping
- Use of restraint, seclusion and rapid tranquilisation
- Medication
- Management of Physical Health Care
- Provision of meaningful and therapeutic activity
- Mental Health Act
- Staff compliance with essential training, supervision, appraisal and personal
development plans.
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






Improved access to emergency equipment on wards
Improved provision of information for patients and carers.
Environmental / facility improvements (i.e. deep cleans, redecoration, new furniture,
improved outside spaces, improved signage, use of art work, equipment that meets
infection control requirements).
Improved patient involvement in care planning.
Implementation of daily community meetings to provide time and space for patients to
reflect and provide feedback on their experiences and identify ways in which the service
might be improved.
Introduction of ‘you said we did boards’ on some wards to provide feedback to people
who use services about what action staff have taken as a result of their comments.
Introduction of regular staff meetings to provide staff with the opportunity to discuss
issues relating to the essential standards of quality and safety and work together to
address any problems that are identified.
B. A positive patient experience
In last year’s Quality Report (2013/14) we said our objectives would be:
 Continue work to establish with each Care Group clear metrics that enable them to
monitor and improve the experience of those they serve
 Continue to implement the 15 Step Challenge programme across our inpatient and
residential units and extend to all adult community mental health services
 Implement the Triangle of Care programme across all services to support delivery of
essential changes in mental health services highlighted in the national Closing the
Gap Report.
 Develop a programme to ensure the implementation of feedback by patients
through the Mental Health Friends and Family Test by 2015
 Ensure that our experience work is able to reflect patient experience across the
protected characteristics and lead to measurable improvement (Equality Act 2010).
How did we do?
Care Group Metrics
On a Trust wide basis we have rolled out the ‘Friends and Family Test’ (FFT). The FFT has
been designed for use across abroad range of health settings and is now in use across
Sussex Partnership services (see below). Getting the FFT into everyday use has been the
priority. Over the next year we work with stakeholders, including people who use our
services and their carers to define what we mean by outcomes for people in each of our
care groups.
15 Step Challenge programme
We have completed '15 Steps Challenge' revisits to all our inpatient units and have visited 3
ATS sites since Christmas. Results so far have shown that the environment within which the
services are delivered has a significant impact on the experience of the service user and
their carer/s and all sites have been able to identify areas for improvement. Once all the ATS
sites have been visited we are proposing to target particular services based on feedback we
receive via a number of sources, including FFT, Complaints and staff survey results and
requests. Awareness of how all the protected characteristics are catered for at chosen sites
will be an integral part of each visit.
35
As a consequence of 15 Steps feedback, staff photo boards are now in place across all sites
visited. Additionally a new ‘customer services policy’ has been drafted and implemented
and we are currently piloting training specifically to improve the standards of customer
service across the Trust.
Triangle of Care
The Triangle of Care is a good practice guide developed by the Carers Trust that offers key
standards and guidance to support the involvement of carers in all aspects of care.
Our goal for 2014/15 was to introduce the Triangle of Care approach in all inpatient units
and in community services in adult mental health. The model we have followed is to
establish local Triangle of Care groups that involve staff and carers, and in some cases
service users, in using the Triangle of Care self assessment tool and from this identifying
actions to achieve local service improvement.
There has been a great deal of work across our local services and in the majority of areas in
adult mental health there are Triangle of Care groups in both inpatient and community
services. The model has also been successfully implemented in Secure and Forensic services
and is now being introduced into inpatient services for people with dementia.
The strength of this grassroots approach is that local partnerships with carers and carer
organisations are created, and that local initiatives are developed with the support of carers
and the local teams. The weakness has been that some areas have struggled to get a local
group established so that the developments are inconsistent across the Trust.
A Trust wide Triangle of Care advisory group is in place bringing together staff, carers and
carer organisations and this has proved important in providing a setting for shared learning
and support. Moving into 2015/16 it will be important to build on this to develop a more
systematic framework for development so that the progress achieved through Triangle of
Care can be more effectively measured.
Common developments linked to the Triangle of Care have been: the provision of carers
awareness training for staff, the development of carers support groups, the development of
specific information available for carers, better identification of carers and greater
involvement of carers in care planning, and improved links to carers support organisations.
Friends and Family Test implementation
In this report particular emphasis has been given to the Friends and Family Test as this
indicator was selected by the Council of Governors for review by our auditors (PWC). There
is also a growing ability to compare performance against other providers, and over time.
From January 1 2015, use of the Friends and Family Test (FFT) has become a national
requirement for NHS mental health trusts. FFT is a short survey, promoted to service users
and carers at key points on their pathway through services and is also available for
completion at any other time they choose.
The survey consists of two standard questions: Firstly: “How likely are you to recommend
our service/ ward to friends and family if they needed similar care or treatment?” on a 6
point scale from extremely likely to extremely unlikely. Secondly, they are then invited to
36
give in their own words a reason for their response. This free text response gives us
‘qualitative’ data and presents a real opportunity to develop our understanding of patient
experience at both a local and Trust wide level.
The FFT implementation was included in the 14/15 CQUIN programme. There is no specific
CQUIN target for 2015/16, on the basis that it is now part of the standard NHS contract.
To date NHS England has published headline results from January 2015 for 65 mental health
trusts in England. The table below indicates Sussex Partnership NHS Foundation Trust
compared to the national average, as published by NHS England.
January 2015
England NHS providers
Sussex Partnership
February 2015
England NHS providers
Sussex Partnership
March 2015
England NHS providers
Sussex Partnership
Recommend %
Not recommend %
86
91
5
4
84
88
5
6
87
86
5
3
No conclusions should be drawn from this data as publication has only recently commenced
and collection methods vary from provider to provider.
A detailed breakdown by service is available and the trust’s quality committee now receives
a report as shown below:
37
38
Respondents to the FFT are encouraged to include qualitative statements. These have proved
valuable. We have now established ‘You said – we did’ Boards across many sites in the Trust.
These demonstrate that a) we are hearing the feedback being generated by the FFT and b) we are
responding to it. Much of the feedback is simple quick wins, and a recent example from Chalk Hill
highlighted that the service users’ showers weren’t working properly and they were quickly
repaired in response.
Equality - Patient experience for people with protected characteristics
As part of the FFT we have piloted a specific question in relation to protected characteristics,
which asks the person completing the form that if they belong to any particular protected
characteristic group, what, if any impact this had upon the service they received? This has given
rise to 296 responses where the person has indicated that this had had an effect on their
experience. Going forward we will be looking to analyse these responses to identify any themes or
trends.
In addition we have a clear commitment to engaging with patients, carers and community
organisations across the protected characteristics and this is one of the key actions in our Equality
Performance Strategy. All of our equality reference groups have representation from the relevant
protected characteristic and in addition we have held and/or attended community events to
enable us to gain feedback in a variety of ways.
The Trusts LGBT focus group worked closely with the complaints manager and their feedback has
been taken forward to inform the revised complaints policy.
Some examples of feedback are as follow:
 The Trusts LGBT focus group worked closely with the complaints manager and their
feedback has been taken forward to inform the revised complaints policy.
 Feedback suggested that the Recovery College should be promoted in areas where we
know BME people are and will be – and as a result targeted promotional work was
undertaken with BME community organisations
 It was pointed out that the front page of all of our documents are written in English, which
means that if you do not speak at least a little English you will not know that our
documents can on request be translated into other languages. In order to address this we
commissioned the Sussex Interpreting Service to translate a statement ‘Would you like any
of our forms, policies or documents translated into another language? If so then please
contact the Equality and Diversity Team’ into our top 10 most frequently requested
languages. We will be producing an A5 poster containing these statements that will go up
in all our reception/waiting areas
C. Effective services
In last year’s Quality Report (2013/14) we said our objectives would be:
 Measure and report our findings in clinical audit.
 To deliver the 2014/15 clinical audit plan, ensuring that each audit has a direct impact on
improving patient experience
 To provide evidence of effective interventions across the psychosis pathway and line with
best practice and quality standards
39
How did we do?
Measure and report our findings in clinical audit
We completed all national clinical audits, local safety and effectiveness audits prioritised in the
clinical audit forward plan 2014-15 (examples in Part 2.2.2). In addition we completed a range of
audits commissioned from services as a result of high risk, complaints and areas of poor
performance. The findings from these were reported in accordance with the Trust clinical audit
assurance framework.
Improving patient experience through audit
Each audit initially identifies the proposed improvements to service user experience as a result of
the audit. On completion the results reflect the extent to which these are met and where not met,
an action plan is implemented to make improvements. During 2014 a new tracker system has
been developed to ensure that the actions are completed on time. This is updated quarterly by
each service. Up to end December 2014 75% of actions had been completed. Our aim for the
coming year is to ensure that 100% of actions for improvement are completed on time as a result
of audit findings.
Effective interventions across the psychosis pathway
We have completed various audits of physical health, prescribing practice, provision of therapies
and the patient’s journey through teams and services. The National Audit of Schizophrenia action
plan (Part 2.2.2 above gives details) incorporates learning from each of these audits and the focus
for improvement priorities for 2015-16. A continuous programme of audit will support
implementation.
Staff supervision
94% of staff had received supervision in the preceding 6 months of the audit carried out in
February. 2,077 (53%) clinical and non-clinical staff responded to the survey. We also saw an
improvement in the quality of support, learning and development and monitoring to ensure that
practice is safe in the supervision package. We will focus on sustained and continued
improvement in these areas for clinical staff and target some specific areas for improvement in
supervision for non-clinical staff.
40
3.2 Performance against Monitor’s Risk Assessment Framework
Area
ACCESS
MONITOR
Indicator
9
Description
Threshold
TRUST
Score
Result
Care Programme Approach:
patients receiving follow-up
contact within 7 days of
discharge (this indicator has
been reviewed by external
95%
96.9%
Achieved
auditors, PwC
See
technical note in Part
2.3.13)
9
Care Programme Approach:
patients having formal
review within 12 months
95%
95.5%
Achieved
10
Admissions to inpatient
services had access to Crisis
Resolution/Home
Treatment teams (this
indicator has been reviewed
by external auditors, PwC
)
95%
99.9%
Achieved
ACCESS
11
Meeting commitment to
serve new psychosis cases
by early intervention teams
95%
100%
Achieved
OUTCOMES
16
Minimising mental health
delayed transfers of care
≤7.5%
4.5%
Achieved
OUTCOMES
17
Mental health data
completeness: identifiers
97%
99.7%
Achieved
18
Mental health data
completeness: outcomes for
patients on CPA
50%
89.4%
Achieved
20
Certification against
compliance with
requirements regarding
access to healthcare for
N/A
N/A
Achieved
ACCESS
ACCESS
OUTCOMES
OUTCOMES
41
people with a learning
disability
Position after Q4 submission to MONITOR
Annex 1. Statements from commissioners, local Healthwatch organisations and Overview and
Scrutiny Committees
Coastal West Sussex Clinical Commissioning Group (lead commissioner)
Letter from Mona Walker, Interim Head of Quality Assurance
Thank you for giving the CCGs; Brighton and Hove, Crawley, Horsham and Mid-Sussex, High Weald
Lewes Havens, Eastbourne, Hailsham and Seaford, Hastings and Rother CCGs the opportunity to
comment on your Quality Account for 2014/15.
The Quality account appears to comply with Monitor requirements and the NHS England guidance
on the content of the Account.
The CCGs are pleased to see that the Quality Account priorities have taken into account both
national and local community priorities, and reflect concerns raised by the CQC, internal Trust
reviews into staff engagement, and the appropriateness of current organisational structures to
deliver better and safer clinical care.
There have been many challenges this year for SPFT, most notably the disappointing staff survey,
poor CQC inspection results in Langley Green hospital, staffing shortages, and the very tight
financial environment where continuous improvement demands fundamental changes in how
services are delivered.
The complexity of the Trust operating across a significant part of the south east of England
continues to challenge both the Trust and its local commissioners who seek to gain assurance of
the safety and quality of services with such a wide ranging brief.
It is pleasing therefore to see that the trust has responded with a proposed new care delivery
model called Care Delivery units. It is understood that these units are constructed in line with the
NHs England Forward View into Action paper, and take into account the outcome of the staff
engagement initiative 2020 Vision. By developing and supporting leadership in clinical teams, local
decision making and accountability is enhanced, with consequent improvement in care delivery.
Furthermore the Accreditation and risk rating of each delivery unit against the fundamental CQC
standards and the monitor framework gives staff the clarity and opportunity to embed best
clinical and operational practice.
The CCGs welcome the Sign Up to safety Campaign and will be working with the Trust to ensure
that the pledges in the five safety domains are achieved and sustained. The physical health of
mental health patients has been highlighted as both a national and local issue and the work to
embed early warning systems is welcome and an on-going priority over the coming year. The
42
introduction of the new care notes system is both an opportunity and a threat, as the possibility of
patients and carers being involved in care planning is to be commended, however the risk to
record keeping and continuity of care exists in the introduction of such a system. The CCGs would
expect the Trust to have robust contingency plans to address any problems which might arise from
its introduction. The continuation of the Safety Thermometer work is reassuring and provides
assurance that fundamental safety standards are maintained.
The CCGs agree that the key risks outlined in the Quality Account reflect the experience of CCG
monitoring and review over the past year and going forward. Key to the solution of many of the
issues are the staff engagement, recruitment and retention issues, better working relationships
with CCGs and key partners to address system resilience, and visible leadership from the SPFT
board in engaging the frontline in the many changes required to sustain safe and high quality
services.
The Trust has made significant improvements in key services and this is reflected in the recent
CQC review. Despite the many challenges the improvement in care and staffing at Langley Green
hospital is to be commended. Efforts to recruit and retain staff are noted, and the work with
Serious Incident reporting and learning is very welcome.
The CCGs look forward to working with SPFT over the coming year and will monitor and review
services in partnership with the Trust on a regular basis to this effect.
North East Hampshire & Farnham Clinical Commissioning Group
Email response from Jon Beresford, Quality Support Manager
In providing this response, the five Clinical Commissioning Groups (CCGs) for Hampshire (North
East Hampshire and Farnham CCG, North Hampshire CCG, West Hampshire CCG, South East
Hampshire CCG and Fareham and Gosport CCG), have taken the regular information and
assurance generated through the Clinical Quality Review Meetings for the Children’s and
Adolescents Mental Health Service (CAMHS) and other associated on-going quality assurance
processes into consideration.
Quality Account statement
The information contained within the Quality Account is reflective of both the challenges and
achievements within the Trust over the previous 12 month period. The Hampshire Clinical
Commissioning Groups are currently working with clinicians and managers from the Trust and with
local service users to continue to improve services to ensure quality, safety, clinical effectiveness
and good patient/care experience is delivered across the organisation; this includes reviewing
performance data collection and reporting. This Quality Account demonstrates the commitment of
the Trust to improve services.
Quality Account Priorities – progress review and looking forward
Quality Accounts Priorities for 2014/15 achievements are detailed and are to be congratulated. It
is encouraging to continue to see the breadth of work and achievement against existing quality
standards and initiatives across the three domains of patient safety, patient experience and
clinical effectiveness. However, highlighting CAMHs services, priorities and achievements in
Hampshire would have enabled a more detailed response considering the breadth of work the
service has developed over the past year.
43
Patient Experience
No specific data has been given around the CAMHS Friend and Family Test roll out across
Hampshire. The service has focused on the Patient Experience and reporting continues to evolve
as the Trust is moving away from the ‘Thumbs up, thumbs down’ approach. The Trusts aim is to
fully embed the Friends and Family Test as they want a more detailed analysis of patient feedback
to inform service improvements. To include this in the Quality Account would have been
welcomed to provide assurance that this would be a continued priority in the Hampshire area.
However, the CCGs will continue to support this development and monitor implementation and
improvement through the Clinical Quality Review Meetings.
The focus on Protective characteristics will be supported through the Clinical Quality Review
Meetings where trajectories will be put in place over the next financial year to improve reporting.
Patient Safety
Incident reporting for CAMHs has been a focus of the Clinical Quality Review Meetings over the
last financial year and it would have been helpful for this to be reflected within the Quality
Account as the trust has increased reporting significantly. Assurance that this would be a
continued focus over the next year would have been welcomed particularly to support a
Commissioning for Quality and Innovation (CQUiN) Scheme to reduce moderate to severe selfharm in Hampshire.
Patient Safety Peer Reviews were a success in the inpatient environment and would be interesting
to see how the trust will evolve this approach to include outpatient’s services.
The Hampshire CCGs have supported the Trust in the Quality and Safety compliance Inspection
Programme and the CCGs are in the process of developing a Quality Insight visit Schedule where
the role of the critical friend will be introduced; this is a co-production with the Trust.
Clinical Effectiveness
There is no guidance to what Clinical Audit was put in place for CAMHS, it would be helpful for
Clinical Audit priorities to lay out what they will do specifically to monitor effectiveness with in
CAMHS.
Areas for consideration
 Serious Incident reporting has increased from zero to 20 in the past 6 months through
detailed review of incidents through the Clinical Quality Review Meetings, but detail
regarding the continued focus to strengthen this work to sustain improvement in reporting
as a priority should be considered. This will provide assurance that the Trust continues to
be focussed on this area within Hampshire.
 It would be helpful to see detail regarding ‘Staff Survey’ results i.e. what was raised and
how the Trust listened and responded to its staff. This would provide a more balanced view
of how the organisation responds and acts upon feedback.
 Waiting times is an area of concern for both the Trust and commissioners and has been
briefly mentioned. An outline of the work that is currently underway to support this should
have been reflected including last year’s CQUiN and how the trust plans to embed this into
their business as usual processes.
 Details regarding recruitment priorities and risks would have been welcomed.
44
The Five Hampshire CCG’s are building strong working relationships with the Trust, supported by
good clinical leadership from both the provider and the CCG’s, which will be strengthened over
the coming year.
Commissioners will continue to hold the Trust to account for performance against their priorities
and improvement targets detailed in this Quality Account during 2015/16, through the existing
Quality Assurance processes.
West Sussex County Council Health and Adult Social Care Select Committee
Letter from Mrs Margaret Evans, Chairman
Thank you for offering the Health & Adult Social Care Select Committee (HASC) the opportunity to
comment on Sussex Partnership NHS Foundation Trust’s Quality Account for 2014-15.
There is useful performance data in your Quality Account, and the inclusion of case studies when
available, as suggested by HASC last year, will be useful to illustrate points to lay people. We are
also pleased to see that service users and other stakeholders have been involved in giving
feedback on your services e.g. through the Friends and Family test introduced in Summer of 2014.
The Quality Account sets out how you performed against key targets during 2014-15 and your
priorities for the future. We welcome your continued focus on safety through ‘Sign-up to Safety’,
experience of users, carers and staff and effectiveness through the ‘Parity of Esteem’ programme
for physical and mental health. We are also pleased that quality, which has improved over the last
year, is a top priority. HASC has been concerned over the level of support for people with
dementia (and their carers), and welcomes the fact that the ‘Triangle of Care’ approach is being
introduced into inpatient services for people with dementia and will be keen to see how this
works. HASC continues to be concerned as to whether appropriate mental health support is
available in A&E.
There has clearly been some good performance at the Trust during 2014-15. You have either
achieved or partially achieved all targets. However, HASC is concerned at the number of deaths
(51) directly attributable to patient safety incidents. HASC is also aware that there is still
considerable pressure on mental health services, with high demand for acute inpatient beds and
challenges in terms of capacity. Many of these pressures require a system-wide response (e.g. to
explore the rise in admissions and the impact of housing need in different parts of West Sussex,
particularly the availability of nursing homes). It was helpful to hear at our 12 March 2015
meeting what the Trust is doing to address these challenges, including how you are working with
the wider health and social care system across West Sussex. HASC will monitor progress on this
work in due course.
HASC was of course concerned at the situation at Langley Green hospital, but was reassured that it
was dealt with quickly with admissions starting again as soon as was possible but it is important to
keep up the momentum.
Finally, a priority for the future must be ensuring safe, high quality services that are sustainable
and deliverable for the future. This is not something you can achieve in isolation – it will require
the whole health and social care system to work together to meet the challenges of increasing
demand, pressure on services and financial constraints.
We welcome the continued open dialogue between SPFT and the HASC, and look forward to
working with you in 2015-16.
45
Medway Council Children and Young People Overview and Scrutiny Committee
Unable to comment due to local elections. Officer response: you are very welcome to make
reference to the discussion relating to CAMHS at the committee’s meeting on 25 March. This
weblink will direct you to the report and associated minute:
http://democracy.medway.gov.uk/ieListDocuments.aspx?CId=378&MId=2970&Ver=4
Kent County Council Health Overview and Scrutiny Committee
Letter from Mr Robert Brookbank, Chairman:
In recent weeks, the HOSC has received a number of draft Quality Accounts from Trusts providing
services in Kent, and may continue to receive more. I would like to take this opportunity to explain
to you the position of the Committee this year.
Given the large number of Trusts which will be looking to the HOSC at Kent County Council for a
response, and the standard window of 30 days allowed for responses, the Committee does not
intend to submit a statement for inclusion in any Quality Account this year.
Through the regular work programme of HOSC, and the activities of individual Members, we hope
that the scrutiny process continues to add value to the development of effective healthcare across
Kent and the decision not to submit a comment should not be interpreted as a negative comment
in any way.
As part of its ongoing overview function, the Committee would appreciate receiving a copy of your
finalised Quality Account for this year and hope to be able to become more fully engaged in next
year’s process.
Brighton and Hove City Council Health and Wellbeing Overview and Scrutiny Committee:
Email response from Councillor Sven Rufus, Chair
Brighton & Hove City Council's Health and Wellbeing Overview and Scrutiny Committee (HWOSC)
has worked closely with Sussex Partnership Foundation Trust (SPFT) for several years, particularly
in regard to their plans for community mental health services. We very much appreciate the open
and honest approach that SPFT has had with the HWOSC. Officers have been open when some
issues have proved more complex, and willing to listen to challenge from HWOSC members. The
Trust has always been willing to come to HWOSC when we have had a query or need some further
information. We appreciate the varied nature of the work that SPFT carries out for the residents
of Brighton and Hove, and for the wider Sussex region and look forward to continued discussion
and debate in the coming years.
Hampshire Health and Adult Social Care Select Committee
Letter from Councillor Patricia Stallard, Chairman
Thank you for sharing with the Hampshire Health and Adult Social Care Select Committee (HASC)
the draft 2014/15 Quality Report for Sussex Partnership NHS Foundation Trust.
I have circulated these priorities to Members of the HASC for their comments, and have received
general feedback which suggests that the Committee are supportive of the approach taken. We
therefore do not wish to recommend any additions to your draft document.
46
Please do not hesitate to contact me should you require any additional information on my
comments above.
East Sussex Health Overview and Scrutiny Committee
Email from officer to say they were unable to respond.
Healthwatch Brighton and Hove
Email response from Kerry Dowding, Intelligence and Projects Coordinator
There are some really positive stories in this year’s quality account which should be highlighted.
There has been an improvement in responding to complaints within 25 working days, which
means that patients receive timely interaction with the trust when they have shared experiences
and areas of improvement. The implementation of the Friends and Family Test is also to be
welcomed, where responses indicate positive feedback about SPFT services is above the target
amount. Looking forward, we are encouraged to hear that the trust would like to approach the
Quality Account in a more qualitative and outcomes focused way in future, to add to the more
proscriptive reporting which is required in the account.
Healthwatch Brighton and Hove hopes to contribute to the material in the Quality Account by
briefly discussing some key findings from our own intelligence and research over the financial year
2014 – 2015.
Involving patients, families and carers
We have collected a range of primary data on service user’s experiences of the trust in Brighton
and Hove over the last year. One particular theme we have seen emerging from this has been
around family and carer involvement, particularly on the topic of discharge from mental health
hospitals like Millview. When carers feel detached from the care of the service user, they are
commonly worried about the service user’s personal safety when discharged, and may not get an
opportunity to provide relevant information to the trust when making the decision to discharge.
For this reason, Healthwatch supports the carer’s element of the quality improvement priorities
for 2015/16, and would like to be kept informed about the outcomes from the initial carer’s
survey.
It is concerning that service users are not consistently receiving copies of clinical letters about
their care when they have requested to receive them. This sort of transparency is important in
building trust between people and the services they use, and can empower people to become
more involved in their own care. Healthwatch will monitor the trust’s progress on improving this
issue throughout this financial year to see what progress has been made.
Children and Adolescent Mental Health Services (CAMHS)1
In the last financial year, Healthwatch Brighton and Hove released a report on the service user and
carer journey through local CAMHS services. Through people’s experiences of the service we
highlighted issues with transition between children’s and adult’s mental health services, and with
parents and carer relationships with the service. We acknowledge that there is also a
commissioning dimension to the issue, but would have welcomed further discussion about the
service and the wider issues it highlights in the quality account. It is noted that following our
1
For the full report on CAMHS please click here
47
CAMHS report the trust sought reassurances from us that any safety issues for patients and carers
involved were managed effectively.
Care Quality Commission (CQC) Inspection
In preparation for the trust’s Care Quality Commission visit this financial year, we participated in a
mock inspection, and shared anonymised information with the CQC regarding services the trust
provides. Healthwatch Brighton and Hove looks forward to the release of the Care Quality
Commission report on the trust, and will review the details through key meetings over the next
few months.
Healthwatch East Sussex
Email response from Julie Fitzgerald
Sussex Partnership NHS Foundation Trust as a NHS Foundation Trust is accountable to local
people.
Healthwatch East Sussex has viewed this account with interest. This response reflects the
interactions and involvement with the Trust on behalf of local people.
The account acknowledges Healthwatch as a stakeholder, however there is little reference to the
relationship the Trust is building with its local Healthwatch organisations.
In East Sussex, we welcome the opportunity to meet with staff at senior and executive level to
discuss the challenges within our area and how this impacts on the Trust.
We also welcome the opportunity to be involved as a key partner in the Patient Led Assessments
of the Care Environment (PLACE) Audits. This is another opportunity for local people who have
used the Trust’s services to give feedback on how the environment affects the patient experience.
We believe it is an opportunity missed to report the progress that has been made and the benefits
achieved through building excellent relationships with our Healthwatch.
We are pleased to see during 2015/16 there is an additional focus placed on crisis care. This is also
a priority in East Sussex (based on what people have told us) for adults and young people. We will
hold the Trust to account when our reports looking into this area are published, to act on the
findings and make a difference to service quality where identified.
From the Trusts Business Objective for 2015/6
Put Safety First (1.1) as a stakeholder we would welcome input into this priority
Patient Experience (1.4) as a stakeholder we would welcome input into this priority
The new electronic patient record system (Carenotes) we would welcome the opportunity to be
involved.
Timely Access to services – we welcome a joined up approach and would want to see the Trust
respond to external reports where evidence suggests areas for improvement.
Administration and governance of an outpatient clinic
We welcome the commitment to expand the number of Outpatient clinics and the increased
appointments times. We also look forward to receiving information on the difference this makes
to patient experience.
48
Reporting against indicators:
7 Day Follow Up – further information is required to understand the drop in this trend.
Patient experiences of community mental health services – we acknowledge the rating is about
the same however a priority to look at improving patient experiences would be beneficial to
include.
Patient Safety Peer reviews; on visits to units in East Sussex, Healthwatch learned about peer
reviews and the success they were beginning to achieve. This is a welcome inclusion and we would
wish to see this extended across more services.
Quality and Safety Compliance Inspection Programme
Healthwatch would like to see more commitment to embedding learning into practice i.e. staff can
demonstrate in supervision where they have changed their practice to take on board learning,
especially when things go wrong.
To conclude: we welcome the open and transparent approach the Trust adopts in working with
Healthwatch and look forward to strengthening the relationship in the coming year.
Healthwatch West Sussex
Email response from Katrina Broadhill.
Introduction
Sussex Partnership Foundation Trust has made considerable effort to engage with HealthWatch
West Sussex (HWWSx) in the development of their Quality Account 2015/16. The Trust has
engaged with HWWSx volunteers on a number of occasions through meetings and presentations
when we were pleased to see transparency in reporting actions following national and local
clinical audits.
Our primary source for commentary is drawn from patient experience as recorded in our Client
Relationship Management (CRM) system, feedback from HWWSx liaison work and national Trust
monitoring.
Mental health services across West Sussex continue to be a significant area of concern for people
who contacted HWWSx and reflect those expressed in the previous year. Most commonly
reported issues in our CRM include:
 Lack of support
 Inability to cope with complex or serious condition
 Poor communication
 Continuity of staff
 Insufficient staffing levels
Concerns have been raised nationally about the provision of Child and Adolescent mental health
services (CAMHS). The provision of some elements of the care pathway are the responsibility of
the Trust. Additionally there is concern nationally around the provision of mental health beds
under the Section 136 of the Mental Health particular for under 18 year olds. Most areas across
England and Wales experience difficulties in this provision. However, Sussex has been identified as
an area which requires the greatest change in securing mental health beds as a place of safety for
49
individuals rather than a police custody. HWWSx therefore would expect these issues to be
reflected in the Trust’s quality measures 2015/16.
The process for selection of quality measures to be monitored during 2015/16 is commended,
including as it does organisational and mandated priorities under the headings of safety,
effectiveness and patient experience.
Patient safety
Reported improvement 2014/15
HWWSx recognises that the Trust has been involved in the pilot for the Mental Health Safety
Thermometer and service change has already been put in place. It is expected that further service
improvement will be in place as a results of national reporting and benchmarking using the Safety
Thermometer which is now implemented across all mental health services.
The Peer review has resulted in actions which meet the concerns raised through HWWSx CRM of
poor communication.
Use of Quality and Safety Compliance Inspection completed by clinicians is welcomed and
supports HWWSx wish for transparency even on negative situations. It also goes some way
towards outcome focus services.
Priorities for 2015/16
The proposal to place additional focus on crisis care as a result of audit findings clearly
demonstrates the Trusts willingness to respond to audit finding which we hope will continue given
the extension audit programme for 2015/16. HWWSx welcomes the Trust proposal to focus on
transparency and a willingness to learn from mistakes. We would however, wish to be able to drill
down on each objective to understand what they would mean for service users and their carers.
Contact from service users and their carers across West Sussex has strongly identified concerns
over staffing which we would urge the Trust to consider in finalising their priorities for 2015/16.
Effectiveness
Reported improvement 2014/15
The Trust’s extensive clinical audit programme both nationally mandated and internally generated
with the aim of improving service user experience is strongly welcomed by HWWSx.
Priorities for 2015/16
The implementation of a tracking system with measurable targets can only result in improvement
of service user experience Although HWWSx appreciates that services for children are delivered
by a number of agencies we see little emphasis on the part played by the Trust We would urge
that these services and partnership with other agencies are prioritised over 2015/16.
Patient experience
Reported improvement 2014/15
HWWSx welcomes the changes made to services through the implementation of the 15 Step
Challenge and the Triangle of Care initiatives across all services. It is clear that the Trust are
increasingly listening and engaging service users and their carers and other stakeholders.
Priorities for 2015/16
50
The inclusion of in depth analysis of feedback from Friends and Family Test to identify trends and
improve services is welcomed particularly as the test is site specific. The consequence is direct and
timely improvement for users of each element of the service.
We welcome priorities to meaningfully involve service users in their care and the way it is
recorded through the introduction of a new Casenotes system which we hope will address the
concern of poor communication identified through HWWSx CRM.
A further area of concern expressed to us was the lack of aftercare in community. We would
therefore urge the Trust to consider this in the final set of priorities for 2015/16.
Conclusions from the service user perspective
As an organisation representing the service user interest, viewing evidence of service
improvement is of primary importance to us.
Trust wide reporting makes it difficult to form an assessment of performance improvement within
West Sussex. However, the Trust has clearly demonstrated their positive moves towards
evidencing outcomes from initiatives which are transparent. We welcome positive year on year
changes in measurable outcomes affecting service users but would expect the Trust to continue to
focus on outcomes and reflect this is subsequent Quality Accounts.
We acknowledge the particularly challenges especially in safety of service which, on occasions,
are posed to the Trust by the specialised nature of the service delivered and welcome the stated
primary aim by the Trust chief executive to deliver a safe service. The Trust has evidenced its
efforts to engage service users and their carers wherever possible to be inclusive of people with
protected characteristics.
It is anticipated that the Trust will continue to strive to work to improve those areas of concern
identified internally and by service users with particular reference to partnership working around
CAMHS and the use of Section 136 of the Mental Health Act. It is expected that the introduction of
Casenotes system will improve data quality over 2015/16.
HWWSx looks forward to building on an open, transparent and mutually respectful relationship
with the Trust to work in partnership for continuously improve performance for all service users
and their carers.
Healthwatch Kent
Email response from Robbie Goatham
As the independent champion for the views of patients and social care users in Kent we have read
the Quality Accounts with great interest.
Our role is to help patients and the public to get the best out of their local health and social care
services and the Quality Account report is a key tool for enabling the public to understand how
their services are being improved. With this in mind, we enlisted members of the public and
Healthwatch staff and volunteers to read, digest and comment on your Quality Account to ensure
we have a full and balanced commentary which represents the view of the public.
51
On reading the Account, our initial feedback is that whilst this is the shortest Quality report we
have read (by some distance) it would still benefit from an additional summary document to be
produced to make the information more accessible to the public reading it. Having said this, in the
majority of the document there is a structure and flow that means it is mostly easy to follow. Of
particular note is the way information on quality from the previous year, aims and achievements
are signposted with areas which haven’t been achieved highlighted as clear priorities going
forward.
It must be acknowledged that a lot of acronyms or jargon used within this document have been
explained including names of various stakeholders. Despite this, it can still be hard for a reader to
completely understand or follow the meaning of such terms particularly with a lot of the focus on
new projects within the NHS which a lay person may not know about.
The report evidences several ways the Trust have engaged with patients and stakeholders to
influence their progress and discuss how recommendations may be implemented. It appears as
though there has been a genuine attempt to listen to many groups including the use of a
translation service for those who need help with communicating. However, we are keen to
understand the other ways in which the Trust has engaged with the public and tried to reach as
many people as possible. There is also mention of 20 out of 27 interactions with organisations
involving those with “protected characteristics”. We would welcome more details on this and
further information on how seldom heard groups are being engaged with.
In summary, we would like to see more detail about how you involve patients and the public from
all seldom heard communities in decisions about the provision, development and quality of the
services you provide. We hope to continue and develop our relationship with the Trust to ensure
we can help you with this.
Sussex Partnership NHS Foundation Trust Council of Governors
Additional responses received following formal consideration of the draft report.
Response A
1. Carer and Family training for all staff as other trusts do which is a two day training rather
than on line would be a good move. I feel it really needs this sort of commitment to move
Family and Carer things forward as well as a Carer lead for the trust and carer notes.
2. As stated prescribing for detox needs addressing and this is where people like CRI get in an
nab services. They are so geared up.
3. Concerned about supervision as its states good practice is maintained but to my knowledge
I'm not sure this is the case. I may be wrong but I'm pretty sure people wait a long time for
supervisions and reviews and how regular are they. When I got to the end of the quality
report it stated that in the last six months a certain percentage had received supervision. I
have some concerns re this as most staff should be supervised every four to eight
weeks. How is this going be reflected. The stats look good but in reality are they? Im
concerned re the quality of this rather than the stats.
4. GP letter I think is bigging it up as we know this is not great in the trust but it appears to
have leant towards the ‘excellent examples’ when in reality few people are included.
52
5. With data quality I would have liked a commitment to get rid of paper not full stop as some
units still have computer and written notes which puts us behind many trusts. Some
places have been paperless for ages.
6. With gatekeeping stats it may be worth pointing out these are all informal admissions as to
my knowledge sectioned patients are not included in gatekeeping and Im not sure
transfers either (with my crisis hat on)
7. I feel with readmissions to hospital there needs to be a commitment to come up with some
figures. This could be done by crisis or liaison as all readmissions should by virtue of
gatekeeping go through them. the figures should really be able to be pulled through
current stats and not need anything new.
8. Was there going to be added statement about move to improve incident reporting as from
past governor meetings I seem to remember we were on the downturn of reporting and
were not sure why or what this was about although could have been due to new incident
reporting methods.
Response B
I think this is much better - and I particularly like the specifics and measures compared to
previous.
On the ’base-lining care for carers’ objective though - I would also like to see Triangle of Care
mentioned specifically as a longer term, universal model to achieve across services. I recall Vincent
said last Thursday that this quest had not been dropped. Without a longer term specific objective
in relation to Triangle of Care as well (i.e. beyond Q1, possibly a year) I think the danger might be
that we do a baseline survey, lose focus and leave it there perhaps.
Response C
I have now read through the draft quality account - and as far as I can see it is very thorough and
presumably covers the necessary criteria. Perhaps right at the beginning there should be a full
definition of "quality" or is this already a statutory definition. I see later on the paper there is
some reference to other bodies with whom we work. Is it possible to emphasise further our
increased working in partnership or that not relevant in this account
53
Annex 2. Statement of directors’ responsibilities for the quality report
The directors are required under the Health Act 2009 and the National Health Service (Quality
Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual
quality reports (which incorporate the above legal requirements) and on the arrangements that
NHS foundation trust boards should put in place to support the data quality for the preparation of
the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2014/15 and supporting guidance

the content of the Quality Report is not inconsistent with internal and external sources of
information including:
o board minutes and papers for the period April 2014 to 27 May 2015
o papers relating to Quality reported to the board over the period April 2014 to 27 May
2015
o feedback from commissioners dated 11+14/05/2015 (two responses received)
Coastal West Sussex Clinical Commissioning Group (lead commissioner), letter from Mona
Walker, Interim Head of Quality Assurance (11/05/2015).
North East Hampshire & Farnham Clinical Commissioning Group, email response from Jon
Beresford, Quality Support Manager (14/05/2015).
o feedback from governors dated 23/04/2015 (date of Council of Governors meeting;
further feedback received from three governors via Peter Lee, head of Corporate
Governance, Sussex Partnership NHS Foundation Trust, email (14/05/15).
o feedback from local Healthwatch organisations dated 10+11+12+19/05/2015 (four
responses received)
Healthwatch Brighton and Hove, email response from Kerry Dowding, Intelligence and Projects
Coordinator (11/05/2015).
Healthwatch East Sussex, email response from Julie Fitzgerald (11/05/2015).
Healthwatch West Sussex, email response from Katrina Broadhill, (12/05/2015).
Healthwatch Kent, email response from Robbie Goatham (18/05/2015).
54
o feedback from Overview and Scrutiny Committee dated 20+23+29/04/2015 and
06+12/05/2015 (five responses received)
West Sussex County Council Health and Adult Social Care Select Committee, letter from Mrs
Margaret Evans, Chairman (06/05/2015).
Medway Council Children and Young People Overview and Scrutiny Committee. Officer response
by email (23/04/2015).
Kent County Council Health Overview and Scrutiny Committee, letter from Mr Robert Brookbank,
Chairman (20/04/2015).
Brighton and Hove City Council Health and Wellbeing Overview and Scrutiny Committee, email
response from Councillor Sven Rufus, Chair (29/04/2015).
Hampshire Health and Adult Social Care Select Committee, letter from Councillor Patricia
Stallard, Chairman (12/05/2015).
o the trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, dated 25/01/2015 (Quality Committee, a
sub-committee of the Board of Directors)
o the 2014 national patient survey 18/09/2014
o the 2014 national staff survey 24/02/2015
o the Head of Internal Audit’s annual opinion over the trust’s control environment dated
18/05/2015
o CQC Intelligent Monitoring Report dated 20/11/2014





the Quality Report presents a balanced picture of the NHS foundation trust’s performance
over the period covered
the performance information reported in the Quality Report is reliable and accurate
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Report, and these controls are subject to review to
confirm that they are working effectively in practice
the data underpinning the measures of performance reported in the Quality Report is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review and
the Quality Report has been prepared in accordance with Monitor’s annual reporting
guidance (which incorporates the Quality Accounts regulations) (published at
www.monitor.gov.uk/annualreportingmanual) as well as the standards to support data
quality for the preparation of the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Report.
55
By order of the board
NB: sign and date in any colour ink except black
..............................Date.............................................................Chairman
..............................Date.............................................................Chief Executive
56
Annex 3
External Assurance on this Quality Report from PWC
Independent Auditors’ Limited Assurance Report to the Council of Governors of Sussex
Partnership NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Sussex Partnership NHS Foundation Trust to perform
an independent assurance engagement in respect of Sussex Partnership NHS Foundation Trust’s Quality
Report for the year ended 31 March 2015 (the ‘Quality Report’) and specified performance indicators
contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified indicators”)
marked with the symbol
mandated by Monitor:
in the Quality Report, consist of the following national priority indicators as
Specified Indicators
100% enhanced Care Programme
Approach (CPA) patients receive follow
up contact within seven days of discharge
from hospital
Admissions to inpatient services had
access to crisis resolution home
treatment teams
Specified indicators criteria (exact page number
where criteria can be found)
130
130
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in accordance with
the specified indicators criteria referred to on pages of the Quality Report as listed above (the "Criteria").
The Directors are also responsible for the conformity of their Criteria with the assessment criteria set out in
the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) and the “Detailed requirements for quality
reports 2014/15” issued by the Independent Regulator of NHS Foundation Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:



The Quality Report does not incorporate the matters required to be reported on as specified in Annex 2
to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2014/15”;
The Quality Report is not consistent in all material respects with the sources specified below; and
The specified indicators have not been prepared in all material respects in accordance with the Criteria
and the six dimensions of data quality set out in the “2014/15 Detailed guidance for external assurance
on quality reports”.
We read the Quality Report and consider whether it addresses the content requirements of the FT ARM and
the “Detailed requirements for quality reports 2014/15” and consider the implications for our report if we
become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the following documents:



Board minutes and papers for the period April 2014 to 27 May 2015
Papers relating to Quality reported to the board over the period April 2014 to 27 May 2015
Feedback from commissioners dated 11+14/05/2015 (two responses received)
o Coastal West Sussex Clinical Commissioning Group (lead commissioner), letter from Mona Walker,
Interim Head of Quality Assurance (11/05/2015).
o North East Hampshire & Farnham Clinical Commissioning Group, email response from Jon
Beresford, Quality Support Manager (14/05/2015).
57








Feedback from governors dated 23/04/2015 (date of Council of Governors meeting; further feedback
received from three governors via Peter Lee, head of Corporate Governance, Sussex Partnership NHS
Foundation Trust, email (14/05/15).
Feedback from local Healthwatch organisations dated 10+11+12+19/05/2015 (four responses received)
o Healthwatch Brighton and Hove, email response from Kerry Dowding, Intelligence and Projects
Coordinator (11/05/2015).
o Healthwatch East Sussex, email response from Julie Fitzgerald (11/05/2015).
o Healthwatch West Sussex, email response from Katrina Broadhill, (12/05/2015).
o Healthwatch Kent, email response from Robbie Goatham (18/05/2015).
Feedback from Overview and Scrutiny Committee dated 20+23+29/04/2015 and 06+12/05/2015 (five
responses received)
o West Sussex County Council Health and Adult Social Care Select Committee, letter from Mrs
Margaret Evans, Chairman (06/05/2015).
o Medway Council Children and Young People Overview and Scrutiny Committee. Officer response by
email (23/04/2015).
o Kent County Council Health Overview and Scrutiny Committee, letter from Mr Robert Brookbank,
Chairman (20/04/2015).
o Brighton and Hove City Council Health and Wellbeing Overview and Scrutiny Committee, email
response from Councillor Sven Rufus, Chair (29/04/2015).
o Hampshire Health and Adult Social Care Select Committee, letter from Councillor Patricia Stallard,
Chairman (12/05/2015).
The trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, dated 25/01/2015 (Quality Committee, a sub-committee of the
Board of Directors)
The 2014 national patient survey 18/09/2014
The 2014 national staff survey 24/02/2015
The Head of Internal Audit’s annual opinion over the trust’s control environment dated 18/05/2015
CQC Intelligent Monitoring Report dated 20/11/2014
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with those documents (collectively, the “documents”). Our responsibilities do not extend to
any other information.
We are in compliance with the applicable independence and competency requirements of the Institute of
Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our team comprised assurance
practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Sussex
Partnership NHS Foundation Trust as a body, to assist the Council of Governors in reporting Sussex
Partnership NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of
this report within the Annual Report for the year ended 31 March 2015 to enable the Council of Governors to
demonstrate that they have discharged their governance responsibilities by commissioning an independent
assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept
or assume responsibility to anyone other than the Council of Governors as a body and Sussex Partnership
NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior
consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on Assurance
Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical Financial
Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our
limited assurance procedures included:



reviewing the content of the Quality Report against the requirements of the FT ARM and “Detailed
requirements for quality reports 2014/15”;
reviewing the Quality Report for consistency against the documents specified above;
obtaining an understanding of the design and operation of the controls in place in relation to the
collation and reporting of the specified indicators, including controls over third party information (if
applicable) and performing walkthroughs to confirm our understanding;
58





based on our understanding, assessing the risks that the performance against the specified indicators
may be materially misstated and determining the nature, timing and extent of further procedures;
making enquiries of relevant management, personnel and, where relevant, third parties;
considering significant judgements made by the NHS Foundation Trust in preparation of the
specified indicators;
performing limited testing, on a selective basis of evidence supporting the reported performance
indicators, and assessing the related disclosures; and
reading the documents.
A limited assurance engagement is less in scope than a reasonable assurance engagement. The nature, timing
and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a
reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of different
but acceptable measurement techniques which can result in materially different measurements and can
impact comparability. The precision of different measurement techniques may also vary. Furthermore, the
nature and methods used to determine such information, as well as the measurement criteria and the
precision thereof, may change over time. It is important to read the Quality Report in the context of the
assessment criteria set out in the FT ARM the “Detailed requirements for quality reports 2014/15” and the
Criteria referred to above.
The nature, form and content required of Quality Reports are determined by Monitor. This may result in the
omission of information relevant to other users, for example for the purpose of comparing the results of
different NHS Foundation Trusts/organisations/entities.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators in the Quality Report, which have been determined locally by Sussex Partnership NHS Foundation
Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that for
the year ended 31 March 2015:
 The Quality Report does not incorporate the matters required to be reported on as specified in Annex
2 to Chapter 7 of the FT ARM and the “Detailed requirements for quality reports 2014/15”;
 The Quality Report is not consistent in all material respects with the documents specified above; and
 the specified indicators have not been prepared in all material respects in accordance with the
Criteria and the six dimensions of data quality set out in the “Detailed guidance for external
assurance on quality reports 2014/15”.
PricewaterhouseCoopers LLP
Southampton
29 May 2015
The maintenance and integrity of the Sussex Partnership NHS Foundation Trust’s website is the responsibility of the directors; the
work carried out by the assurance providers does not involve consideration of these matters and, accordingly, the assurance
providers accept no responsibility for any changes that may have occurred to the reported performance indicators or criteria since
they were initially presented on the website.
59
Annex 4
Detailed definitions of indicators reported in Part 2.3 and subject to review by PwC
100% enhanced Care Programme Approach (CPA) patients receive follow up contact within
seven days of discharge from hospital
Detailed descriptor
The percentage of patients on Care Programme Approach (CPA) who were followed up within
seven days after discharge from psychiatric inpatient care during the reporting period.
Data definition
Numerator
The number of people under adult mental illness specialties on CPA who were followed up (either
by face-to-face contact or by phone discussion) within seven days of discharge from psychiatric inpatient care during the reporting period.
Denominator
The total number of people under adult mental illness specialities on CPA who were discharged
form psychiatric in-patient care. All patients discharged from psychiatric in-patient wards are
regarded as being on CPA during the reporting period.
Details of the indicator
All patients discharged to their usual place of residence, care home, residential accommodation,
or to non psychiatric must be followed up within seven days of discharge. Where a patient has
been transferred to prison, contact should be made via the prison in-reach team. The seven-day
period should be measured in days not hours and should start on the day after the discharge.
Exemptions include patients who are re-admitted within seven days of discharge; patients who die
within seven days of discharge; patients where legal precedence has forced the removal of the
patient from the country; and patients transferred to an NHS psychiatric inpatient ward.
All CAMHS (child and adolescent mental health services) patients are also excluded.
Accountability
Achieving at least a 95% rate of patients followed up after discharge each quarter.
More detail about this indicator and the data can be found within the Mental Health Community
teams Activity section of the NHS England website.
Admissions to inpatient services had access to crisis resolution home treatment teams
Detailed descriptor
The percentage of admissions to acute wards for which the Crisis Resolution Home Treatment
Team (CRHT) acted as a gatekeeper during the reporting period
Data definition
In order to prevent hospital admission and give support to informal carers, CRHT are required to
gatekeep all admission to psychiatric inpatient wards and facilitate early discharge of service
60
users.
Numerator
The number of admissions to the trust’s acute wards that were gatekept by the CRHT during the
reporting period.
Denominator
The total number of admissions to the trust’s acute wards.
Details of the indicator
An admission has been gatekept by a crisis resolution team if it has assessed the service user
before admission and was involved in the decision-making process which resulted in an admission.
An assessment should be recorded if there is direct contact between a member of the CRHT team
and the referred patient, irrespective of the setting, and an assessment is made. The assessment
may be made via a phone conversation or by any face-to-face contact with the patient.
Exemptions include patients recalled on Community Treatment Order; patients transferred from
another NHS hospital for psychiatric treatment; internal transfers of service users between wards
in the trust for psychiatry treatment; patients on leave under Section 17 of the Mental Health Act;
and planned admissions for psychiatric care form specialist units such as eating disorder units.
Partial exemption is available for admissions from out of the trust area where the patient was
seen by the local crisis team (out of area) and only admitted to this trust because they had no
available beds in the local area. Crisis resolution team should assure themselves that gatekeeping
was carried out. This can be recorded as gatekept by crisis resolution teams.
This indicator applies to patients in the age bracket 16-65 years and only applies to CAMHS
patients where they have been admitted to an adult ward.
Accountability
Achieving at least 95% of patients in the quarter.
More detail about this indicator and the data can be found within the Mental Health Community
teams Activity section of the NHS England website.
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