Quality Account 2014/15
Open up possibilities
North East London NHS Foundation Trust I Quality Account 2014/15
Page 1
Page 2
North East London NHS Foundation Trust I Quality Account 2014/15
Contents
Foreword from the chief executive
4
2.7. Participation in clinical audits
27
Statement from the chief nurse and
executive director of integrated care (Essex)
6
2.8. Participation in clinical research
32
2.9. Commissioning for Quality and Innovation
(CQUIN) targets 2014/15
33
42
Introduction to the Quality Account
What is a Quality Account and why is it important?
8
2.10. Registration with the Care Quality
Commission (CQC)
Development of our quality priorities for 2014/15
8
2.11. Data quality
45
Quality Account governance arrangements
8
46
How to provide feedback
9
2.12. NHS number and general medical practice
code validity
Part three
Looking back –
Review of our quality performance in 2013/1447
Part one
Introduction to NELFT
1.
Description of our services
10
3.1. Priority 1
50
1.1. Our strategic direction
11
3.2. Priority 2
58
1.2.Engagement
11
3.3. Priority 3
60
1.3. NELFT management structure
12
3.4. Serious incidents and complaints feedback
60
1.4. Equality and diversity
12
3.5.Safeguarding
63
1.5
14
3.6.Benchmarking
63
Barking and Dagenham, Havering and Redbridge
localities
14
3.7. Monitor risk assessment framework
64
3.8. Monitor core indicators
66
Waltham Forest locality
15
3.9. Department of Health compliance targets
76
Basildon, Brentwood and Thurrock localities
16
3.10. Governors selected local indicators
78
3.11. Commissioning for Quality and Innovation
(CQUINS) payment 2013/14
79
Highlights from 2015/15
Part two
Looking forward –
Priorities for improvement 2014/15
2.1. Improvement priority 1
18
Appendix 1 – Quality Account governance85
structure
2.2. Improvement priority 2
20
Appendix 2 – Third party statements86
2.3. Improvement priority 3
23
Appendix 3 – 2014/15 Statement of directors97
responsibilities
2.4. Feedback from service users that influenced 24
our priorities
Appendix 4 – Auditors limited assurance report98
2.5. Patient surveys
26
Glossary100
2.6. Statement of assurance from the board
27
Useful contact numbers103
North East London NHS Foundation Trust I Quality Account 2014/15
Page 3
Foreword
This is the seventh year we have
published a Quality Account
and looking back it is easy to
see how progress has been
made year on year. This year
is no exception and it would
be difficult to look back and
not experience some sense of
pride in what our staff and
stakeholders have delivered year
on year.
In reality we have to acknowledge
that nothing comes without cost.
The media coverage of the NHS
stories over the year clearly identify
pressures and hotspots with staff
struggling to deliver the services
expected by patients and carers
across the country.
Staff availability is no longer
assumed, with national shortages
across many clinical groups causing
real difficulty for their peers
struggling to maintain services and
the continuous improvement that
we have come to expect from the
NHS. Staff now frequently tell us
Page 4
that the demand for compliance with
systems and the need to maintain
volume in services is threatening
quality. No one can afford to ignore
our staff, they are the clinicians
and as such they are the patient
advocates and the experts.
These challenges are recognised
and they are clearly reflected in
discussions with commissioners and
our own investment decisions to
support and develop staff for the
challenging times ahead.
Staff morale in the NHS is
frequently headlined in the media
and – since this is a major marker
for quality - we are investing some
of our resources in addressing that
and their health and wellbeing. This
will be an important quality marker
for NELFT in the time ahead.
Whilst the NHS may be
challenged it has not dampened
the enthusiasm and energy of
NELFT staff, we have seen many
nominations, and indeed winners,
from amongst our services for
North East London NHS Foundation Trust I Quality Account 2014/15
national and regional awards. Our
reputation continues to grow and
that is clearly evidenced in our
commissioners commitment to new
services and supporting our models
of care that seek to create truly
integrated services for the people
we serve. Integration is and will
continue to be one of the quality
markers so that increasingly we will
be able to bring patients to a single
point of access where all of their
clinical needs can be met.
The real measure of our quality is
the reported experiences of our
patients. To date, we have seen
high levels of satisfaction with a
trend of continuous achievement.
The initiatives and programmes in
this report will offer some insight
into this process and share some
of the initiatives in place to build
on that achievement over the time
ahead.
Peter Wignall
Acting chair
John Brouder
Chief executive
To the best of our knowledge the information presented to you in
this account is accurate and provides a fair representation of the
quality within our organisation.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 5
Statement from the chief
nurse and executive director of
integrated care (Essex)
At NELFT our ambition is to
provide patients, relatives and
carers with high quality care and
the best possible experience.
People deserve the safest and
most compassionate care we can
provide and in doing this it is also
important to acknowledge our
mistakes and learn from them.
As chief nurse, I am proud of what
we have achieved this year and of
the challenging agenda we have set
for ourselves in the year ahead. The
Quality Account sets out a number
of areas that we need to focus on.
These have been influenced and
identified by our patients, staff and
partner organisations; by listening
to their views and comparing
ourselves with others we ensure
we focus on what matters to the
people we serve.
The Quality Account is a vital
snapshot of our achievements and
whilst it shows areas where we
have progressed – there are clearly
areas where further improvement is
needed.
Key to our success and achievement
are our people, particularly as
we continuously respond to the
changing needs of the health of our
communities, the remarkable and
welcome improvement in the life
expectancy of older people along
with a changing social and financial
landscape. As a trust, we believe
that patient experience is inextricably
linked to staff experience.
Page 6
By investing in the wellbeing and
professional development of staff,
we invest in improving the patient
experience and achieving our
ambition of providing high quality,
safe, compassionate care.
Since the largest proportion of our
workforce are our nursing staff
and we know that safe nursing
levels on our wards will mean
good standards of care, we have
highlighted improvements in our
substantive workforce as a priority
in this year’s Quality Account.
2015/16, we will strive to further
reduce the overall number of
harms we cause such as falls and
avoidable pressure ulcers.
We remain committed to getting
the basics of care right, learning
from patient and carer experience
and ensuring national best practice
is the norm.
We hope that you find that this
Quality Account for 2014/15
describes our achievements to date
and that you recognise our plans
for the future.
Feedback from our staff has told
us that we need to improve their
employment experience and this
is why we set out to make our
organisation a great place to
work and ensure that we are an
engaging and listening organisation
to work for. Through our valuesbased recruitment we aim to recruit
and keep people who believe and
live our values, to ensure that
patients receive and experience
the best care. We aim not only to
employ an engaged, enabled and
empowered workforce but also
to develop great leaders who put
patients first.
We know that providing healthcare
is not without risk and that there
have been occasions where patients
have been harmed whilst in our
care. Our intention is to always
advise you of any harm we have
caused and to say ‘sorry’ and learn
from our mistakes. As a priority for
North East London NHS Foundation Trust I Quality Account 2014/15
Stephanie Dawe
Chief nurse and executive director
of integrated care (Essex)
North East London NHS Foundation Trust I Quality Account 2014/15
Page 7
Introduction
What is a Quality Account and
why is it important?
Our Quality Account provides
a continuous process for us to
engage with patients, stakeholders
and staff in an open, transparent
way in order to scrutinise our
processes. By doing this, we seek to
improve the quality of services we
provide year on year and to embed
those improvements in to our
everyday practise.
Our Quality Account is an annual
report split in to three sections:
• an introduction to NELFT, our
services and our commitment to
quality (Part 1)
• looking forward and setting our
priorities for the coming year –
2015/16 (Part 2)
• our progress on last year’s
priorities (Part 3)
Development of our quality
priorities for 2014/15
Improving quality is always a high
Page 8
priority for NELFT and we seek
to develop meaningful quality
indicators that can be monitored,
reported and scrutinised by all.
The Quality Account provides a
framework where improvement
priorities can be developed which
reflect local need, but that can also
be adopted at a NELFT-wide level.
We have again consulted widely
with stakeholders and invited much
participation in our stakeholder
consultation for setting quality
priorities for 2015/16.
This year saw a rise in responses by
58 per cent of which 12 per cent
of responses were from people
who considered themselves carers,
a significant rise from last year. Six
per cent of responses were received
from young people aged 18 years
and under – the first time we have
had such positive engagement
from this age group.
We still would like much more
feedback from representatives
across ethnicities, and are working
North East London NHS Foundation Trust I Quality Account 2014/15
with members of the NELFT
strategic patient experience
partnership group (PEP) to achieve
this. In addition to patients and
carers, a good cross section of
feedback was received from
commissioners, Healthwatch, GP’s,
staff, members and governors.
The collated results from the
consultation indicated that NELFT
should focus in the coming year on:
• Working together for service
users and patients
• Commitment to quality of care
•Compassion
Quality Account governance
arrangements
The chief nurse and executive
director of integrated care (Essex)
is the lead executive director
with responsibility for the Quality
Account. Production of the Quality
Account is the responsibility of the
acting director of performance and
business intelligence.
Clinical locality leads are engaged
to produce the content of the
Quality Account by working with
clinical staff to shape improvement
indicators in line with the priorities
identified by stakeholders through
the quality questionnaire. Progress
reports on each of the quality
improvement priorities are reported
to each clinical localities quality and
patient safety group bi-monthly
and to the quality and safety
committee (chaired by a nonexecutive director) half yearly.
The chief nurse group oversees the
Quality Account process where it
is formally reported quarterly and
in turn, reports to the executive
management team, which then
report to the NELFT Board.
Data quality is assured through
NELFT's data quaity group and
through audit processes (both
internal and external).
How to provide feedback on this
Quality Account
We hope you find this report
informative. We welcome your
feedback on how we can improve
our Quality Account next year.
If you would like to give us
feedback on our Quality Account
2014/15, please contact:
Julie Price, acting director of
performance and business
intelligence.
Email: julie.price@nelft.nhs.uk
Tel: 0300 555 1201 ext. 64700
Address: North East London NHS
Foundation Trust,
Suite 1B, Phoenix House,
Christopher Martin Road,
Basildon, Essex SS14 3EZ.
See appendix 1 for our Quality
Account (QA) governance
structure.
NELFT provides services
to more than
1,500,000 people
North East London NHS Foundation Trust I Quality Account 2014/15
Page 9
Part one
NELFT is a growing
organisation serving over 1.5
million of the population in
north east London and south
west Essex.
In 2008, NELFT achieved
foundation trust status, and a
year later acquired Barking and
Dagenham community health
services. In 2011, South West
Essex Community Health Services
(SWECS) and outer North East
London community services
(ONEL) joined the trust to work
towards our aim to become a fully
integrated healthcare provider
offering a complete care pathway
of mental and physical health. We
now employ over 5,750 staff and
have an annual turnover in excess
of £340 million.
Our shared organisational values are:
• People first
• Prioritising quality
• Progressive, innovative and
continually improving
• Professional and honest
• Promoting what is possible –
independence, opportunity and
choice
Page 10
1. Description of our services
NELFT provides mental health and
community services for people
living in the London boroughs of
Barking and Dagenham, Havering,
Redbridge and Waltham Forest;
and community health services
in the south west Essex areas of
Basildon, Brentwood and Thurrock.
We provide these services in a
range of settings including health
centres, community hospitals and
people’s own homes. We work
closely with local authorities, clinical
commissioning groups (CCGs) and
voluntary organisations.
NELFT provide community services
in north east London and south
west Essex including:
• Care and support for people
living with long term conditions
such as diabetes
• Speech and language therapy
• Health visiting, district and
school nursing
• Community dental services
• Many services that in other areas
may be provided in hospital,
such as blood testing, foot care
and children’s audiology
NELFT provides mental health
services in north east London
including:
NELFT provides added quality/
value through service developments
including:
• Services for people experiencing
acute mental illness
• Mental health input into
long term physical conditions
such as diabetes, stroke, lung
disease etc.
• Help for children and young
people with emotional,
behavioural or mental health
difficulties
• Care for people with dementia
• Support for people with
problems associated with drug
and alcohol misuse
• Specialist services for people
with a learning disability
• Physical health of people with
mental problems
• Providing treatment at home
and in the community
• Reducing demands on hospital
services
• Innovative transformation of
health services
North East London NHS Foundation Trust I Quality Account 2014/15
1.1 Our strategic direction
delivery and morale, whilst reducing
our estate overheads.
NELFT has a sound track record
in both financial and business
management. Our strategy sets
out our plan to maintain the
established position of strong
financial ratings over the next five
years, whilst providing high quality
clinical experiences for patients
and our investment in cultural and
behavioural change reflects this
ambition.
Over the next five years, we will
continue to work closely with other
providers and commissioners to
play a key role in providing more
care out of hospital and will aim
to take on some existing primary
care services or developing new
business in this area. We are
committed to expanding into new
areas of operation in our existing
geographical footprint and we
expect to expand the latter to
include the delivery of new services,
notably in Essex.
The technological demands of the
future will grow exponentially and
we will transform our workforce,
their agility and our estates portfolio
to reflect this radical shift. We are
undertaking a large initiative to
support agile working, which will
allow our staff to provide services in
a more flexible manner, improving
productivity, flexibility of service
We have committed to a wider
programme of development
designed to create a partnership
for the broader good of our
community called Care City. This
initiative will significantly grow
our research and development
portfolio and its contribution to
the organisation. It will create
additional education partnerships
and workforce opportunities such
as apprenticeships as well as bring
technology partnerships together
creating a test bed for new products
and healthcare solutions.
1.2 Engagement
NELFT works closely with governors.
We hold a monthly forum which
provides governors with the
opportunity to meet with our NELFT
chair and chief executive to discuss
key strategic issues. Governors meet
with the chairs of the board sub
committees to better understand
the role and work of committees
in continually reviewing the quality
of the service we provide. We also
hold a joint workshop with board
members and governors once a year
to discuss forward planning.
and also to meet with staff and
patient users to hear about their
experiences first hand. Governors are
also involved in mock Care Quality
Commission (CQC) inspections and
patient-led assessment of the care
environment (PLACE) visits, which
gives them the opportunity to have
a conversation with patients about
their experience.
NELFT communicates with our local
population via our website and
through pro-active and re-active
communications and media relations
work. NELFT has profiles on social
media platforms including Twitter,
Facebook and LinkedIn, which
provide a forum for engagement
and discussion as well as a means of
providing information. A range of
public activities and events are open
to patients, service users, carers and
the local community throughout
the year. Printed patient literature
is available at all sites providing
information about services.
Non-executive directors, who chair
the board sub committees, regularly
visit clinical services to better
understand the service provision,
North East London NHS Foundation Trust I Quality Account 2014/15
Page 11
Strategic patient experience
partnership group
Quarterly patient experience
partnership groups (PEP) and
an overarching strategic patient
experience partnership group have
been established to monitor the
quality of patient/service user/carer
experiences of services.
Following a consultation with
members these are now being
reconfigured to align with the
integrated care directorates. The
chair and vice chair of the PEPs are
patient members, with integrated
care directors and directors of
nursing in attendance.
well as external stakeholders and
partners. It also facilitates the ability
of teams to better integrate mental
health and community health
services in our London boroughs
and provides a good foundation
to be responsive to the differing
needs within the diverse population
served in Essex. It is expected that
this will further enhance the patient
experience and allow teams to work
more effectively for the patient.
The locality directorates are:
• Barking and Dagenham
• Havering
• Redbridge
• Waltham Forest
Key agenda items:
• Basildon and Brentwood
• Patient experience strategy
action plan
• Thurrock
• Francis Report priorities
1.4 Equality and diversity
• Quality Accounts
Equality and diversity remains a
priority in everything we do. We
endeavour to be fair, open and
transparent in service provision, our
workforce and whatever systems and
structures NELFT develops.
• Survey reporting and friends and
family test
• Care Connect
• Complaints process and duty of
candour
• Business unit PEP updates
• NELFT organisational restructure
• PEP consultation
1.3NELFT management
structure
Our operational structure has
been formulated according to
local authority and Care Quality
Commission (CCG) boundaries.
This allows the locality directorates
to establish close working links
with the communities they serve as
Page 12
The strategic equality and diversity
group is led by the interim
director of human resources and
organisational development. The
group aims to help identify steps to
improve performance in the area
of equality and diversity, which are
then addressed and embedded via
the Essex and London equality and
diversity groups prospectively. The
aims of the groups are to ensure
that services are designed to meet
the needs of all communities we
serve and:
• Ensure our patients, carers,
partners and stakeholders are
effectively engaged in service
provision
• Ensure that our workforce reflects
the communities we serve
• That our workforce is free
from discrimination, bullying,
harassment and victimisation
• Ensure all staff have the skills and
abilities to work with the diverse
communities it serves
• Everyone feels assured that the
trust is fair to all and values its staff
As a public sector organisation we
are expected to comply with the
Equality Act 2010, the public sector
duty, which includes publishing
four key objectives and monitoring
processes in place:
• Improve the quality and
completeness of data on the
nine protected characteristics
across all services in NELFT,
including all patient electronic
systems, i.e. RIO and SystemOne
by 50 per cent by February
2015. (The report highlighted
gaps in data, particularly for
transgender, sexuality, religion,
disability and pregnancy/
maternity).
• Implement the ethnic minority
staff strategy to help break the
‘glass ceiling affect’ and reduce
the number of staff bullying
and harassment cases, focusing
on our interview processes,
mentoring, coaching, training of
anti-discriminatory practices and
training for middle managers.
• Work in partnership with
human resources workforce
team to develop a framework
that ensures the development,
North East London NHS Foundation Trust I Quality Account 2014/15
progression and promotion of
staff and ensures that equality
of opportunities is embedded in
every process.
• Develop of a lesbian, gay,
bisexual, transgender (LGBT)
and disability staff network to
increase confidence for these
groups and to improve both
access and workforce issues.
In addition to these four key
objectives, NELFT will also
concentrate on the following five:
The NHS Equality and Diversity
Council have this year announced
the implementation of the
Workforce Race Equality Standards.
All NHS organisations will be
expected to demonstrate progress
against six key indicators of
workforce equality, including a
specific one to address the low
levels of black and ethnic minority
staff at board level.
Alongside the Workforce Race
Equality Standards, the Equality
Delivery System (2) (EDS2), will
be made mandatory for all public
sector organisations to comply
with. The EDS2 is a toolkit which
aims to help organisations improve
the service they provide for the
local community and provide better
working environments for staff.
These standards will be mandatory
from April 2015.
• Increase the number of equality
impact assessments (EQIA).
There is agreement that to
improve data collections, all
services across NELFT will
undertake a service provision
EQIA. These will involve
consultation with patients,
carers and stakeholders and in
particular with Healthwatch.
It has been agreed that a
minimum of 30 EQIAs will take
place every year.
An action plan to implement the
standards will be the main focus of
the equality and diversity groups
across NELFT, which will be agreed
and signed-off for implementation
from 1 April 2015.
• Development of cultural
guidance to support staff
working with diverse
communities. Our priorities are:
gypsy communities and eastern
European communities.
Further information on the work
plan for equality and diversity is
available at www.nelft.nhs.uk
• Count Me In Census – Repeat
the Count Me In Census to
support developing systems
that reduce the number of
admissions of black and ethnic
minority groups in mental health
inpatient services.
• Implementation of the equality
delivery system.
• Implementation of the
workforce race equality
standards.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 13
1.5Highlights from 2014/15
Barking and Dagenham,
Havering and Redbridge
localities (BHR)
The redesign of the intermediate
care offer in the BHR clinical
commissioning groups (CCGs)
has meant that we have reduced
our intermediate care bed base
through improved efficiency and
the resource released has been
reinvested into two community
teams to meet patients’ needs at
home, these being the community
treatment team (CTT) and the
intensive rehabilitation service (IRS).
The concept of the CTT is to
avoid emergency department
presentations that lead to short
term admission of less than
five days where a community
alternative was not in place.
This multidisciplinary team of
geriatricians, nurses, therapists and
social workers support patients
at home to avoid emergency
department attendance and
can access ‘step up’ community
inpatient beds. The CTT has
been hugely successful and has
demonstrated change in patient
and carer behaviour as they can
self-refer to the service rather than
attend the emergency department
or dial 999. The success has now
led to a new pilot scheme to work
jointly with the London Ambulance
Service to support 999 callers who
have had a fall.
Success of the service is
demonstrated through our patient
surveys where 9.4 out of 10
patients/carers were satisfied with
Page 14
the service and further evidence
highlights that where patients
have used the service once by
professional referral on the second
occasion they self-refer and avoid
the emergency department. The
CTT service manages to keep 95
per cent of all patients assessed
safely at home or supported in the
community with a direct pathway
to the IRS service or a community
bed through ‘step up’ if required.
The average length of stay with
the CTT is three days, highlighting
the team are working with the
appropriate patient group with the
correct level of acuity.
NELFT in partnership with our CCG
colleagues has completed a lengthy
and comprehensive period of
patient engagement working with
Healthwatch, patient groups and
carers. Feedback gained through
this process from stakeholders such
as our patients and carers being
able to self-refer was used to assist
with the service design for the
implementation on these new CTT
and IRS services to work alongside
our existing intermediate care beds.
In Havering, NELFT has worked in
partnership with CCGs to develop
and embed a co-ordinated approach
to care through integrated case
management (ICM). ICM is a
partnership approach to managing
patients with long term conditions
at high risk of hospital admission.
NELFT co-ordinates the care though
community matrons and integrated
care liaison officers who work in
partnership with social care and
primary care, such as GPs, the
system supported by the CCGs
identified those patients at high risk.
All staff employed in the community
health and social care services
(CHSCS) and other intermediate
care services always consider
whether a patient may benefit from
case co-coordination through ICM.
The overall impact of this
transformational work has seen
the number of patients treated in
intermediate care beds over the
course of 12 months rise from
1,324 patients having intermediate
care admission to 10,118 patients
being treated in year across the
three services.
The ICM model has been well
received locally, however NELFT has
worked with BHR CCGs to take
integration one step further for the
clusters. NELFT identified the lack
of co-ordinated resource to support
the ICM model, as historically other
adult community services have been
not been provided in an integrated
way across nursing, therapies and
mental health. As a result, NELFT
developed, in partnership with
CCGs and social care, the concept
of the CHSCS. The aim was to
simplify community provision which
had become complex and difficult
to navigate for health and social
care colleagues as well as patients
and carers.
The changes were significant and
recognised by commissioners who
submitted a nomination for the
Health Service Journal (HSJ) award
and were subsequently shortlisted
from 60 applicants.
The CHSCS is a multidisciplinary
team of nurses, therapists, support
workers, a mental health link
worker and administrative support
staff delivered at a locality level
supporting a group of GP practices.
North East London NHS Foundation Trust I Quality Account 2014/15
There are 16 community health and
social care services across Barking
and Dagenham, Havering and
Redbridge clinical commissioning
groups, one for each locality based
on population size and current ICM
locality and delivered at a locality
level. There will be a physical base
in each locality where possible
to facilitate, access and improve
efficiency in communication and
joint working. These teams have
been remodelled out of existing
resource and reprofiled to the
localities by size of population
and health need. The service
with continue to deliver the
existing provision of community
nursing and therapies but will be
consolidated into one team with
the ICM team and a link mental
health worker to create the CHSCS.
• Phase one – Integration of
community health teams
including ICM and social care
associated
Any patient referred to the
community health and social care
services has a named healthcare
professional. This person will
be responsible for ensuring the
patients care is appropriately
co-ordinated for their needs. The
named healthcare professional will
be allocated to the patient based
on the level/type of need agreed
at the time of referral, triage and
assessment.
Waltham Forest locality
NELFT implemented the new model
across the BHR CCGs in 2014.
Havering CCG was the first to go
‘live’ and all GP practices were
visited as part of the launch and
a comprehensive communication
plan accompanied the role with
other stakeholders, patient and
carer groups. The roll out was over
seen using project management
principles and the roll-out was
designed in two phases:
• Phase two – Integration with
adult social care
The next phase of integration
is working with social care
to progress to full social care
integration. By building strong
relationships with the local
authorities, Havering will be
the first to go live with the full
integration of adult social care
into the locality teams. The project
which has already delivered phase
one is progressing to phase two
in Havering with a timeline to
integrate with adult social care by
September 2015.
Significant work has been
undertaken over the last year to
improve the mental health crisis
care pathway in the emergency
department at Whipps Cross
hospital. Service users, carers and
acute colleagues at Whipps Cross
hospital had expressed considerable
concern about the numbers of
waiting time breaches in the
emergency department and the
unacceptable length of stay in
many cases. A joint NELFT/Barts
Health improvement plan was
devised and implemented and this
has seen a significant improvement
in the percentage of mental health
breaches.
service availability over the past
year. Extended opening hours were
introduced in October 2014 which
meant the service is now available
until 8pm on weekdays and on
Saturday mornings. Response
times for initial assessment have
improved significantly. 80 per cent
of all routine referrals were seen
within 14 days in December 2014
compared to only 28 per cent in
quarter one.
Improving access to psychological
therapies (IAPT) is a primary
care talking therapy service for
people experiencing anxiety and
depression. The Waltham Forest
service has expanded considerably
in the last year and has seen an
increase in the numbers entering
treatment from 83 per month in
April 2014 to 320 per month in
March 2015. The service has also
delivered significantly above the
national and London averages for
service outcomes.
The mental health access and
assessment team in Waltham
Forest has also demonstrated
considerable improvements in
North East London NHS Foundation Trust I Quality Account 2014/15
Page 15
New wound clinics have been
launched in Waltham Forest during
2014 in three health centres across
the borough. The clinics are staffed
by district nurses and provide a
dressing service for mobile patients
to avoid hospital attendances and
to fill a gap in service provision in
primary care. The clinics have been
well attended and a useful local
resource.
Health staff became fully integrated
into the multi-agency children’s
safeguarding hub (MASH) earlier
in 2014. Numerous technical IT
problems have been successfully
overcome to ensure that NELFT
staff can work effectively in the
multi-agency team receiving
safeguarding referrals in the
borough. Specialist targeted
children’s services in Waltham
Forest have also created a single
point of entry system for referrals.
It is anticipated that this will
promote children, young people
and their families receiving the
right service at the right time and
be a simpler system for referrers to
navigate.
Basildon, Brentwood and
Thurrock localities (BB&T)
Over the past year we have been
piloting a local community based
dementia crisis support team
(DCST) in BB&T localities. The
purpose of the team is to deliver
care to people with dementia in
a timely manner in their place of
residence. The DCST provides a
rapid response and a specialist
multidisciplinary intervention
and assessment for those with
Page 16
dementia and suspected dementia
in a crisis situation.
The service provides short term
intensive input to patients for
up to six weeks, with an aim
to discharge, where clinically
appropriate, in three weeks with
onward referrals and links to other
care pathways as needed. We have
also been working with colleagues
in community teams to increase
the knowledge regarding the early
identification of dementia and the
pathway, to ensure an early offer
of support is in place and accessible
on a seven day a week basis.
This approach has contributed to
the reduction on overall hospital
admissions as well as ensuring
the people with dementia, their
families and carers are able to
access specialist care in the most
appropriate setting.
This year, we have been officially
accredited as UNICEF Baby
Friendly – achieving the stage 3
accreditation. Staff have worked
hard to ensure that we achieved
stage 3 over the last year.
of equipment to meet the needs of
patients. Tighter controls and audits
of clinical reasoning have resulted
in significant cost improvements
against a budget that was set to
become substantially overspent.
NELFT continues to loan an ever
increasing number of devices but at
reduced unit costs and improving
recovery and reuse rates.
We continue to work with our
community teams, patients and
carers to raise the profile of
pressure ulcer prevention and to
increase the tools available to aid
prevention. Areas of particular note
in 2014/15 include:
• Pressure ulcer day,
21 November 2014
• Issuing of a new prevention
leaflet
• Issuing of prevention boxes to
all areas to support the Heels Up
campaign
• Updated prevention policy and
associated standard operating
procedures for each locality
We decided to join forces with
UNICEF UK’s Baby Friendly initiative
to increase breastfeeding rates
and improve care for all mothers.
Mothers can be confident that their
health visitors will provide high
standards of care and support them
to continue breast feeding.
We have been working with Essex
health and social care partners
to strengthen the provision of
equipment to patients. We have
reviewed our current systems and
processes and revised the catalogue
to ensure the provision of a range
North East London NHS Foundation Trust I Quality Account 2014/15
North East London NHS Foundation Trust I Quality Account 2014/15
Page 17
Part two
In part two of our Quality
Account we outline our
planned improvement
priorities for 2015/16,
including those improvement
priorities agreed with our
commissioners. Our priorities
are organised under the three
areas of quality identified
through our stakeholder
engagement process.
Priorities for improvement
2015/16
2.1 Priority 1: Working
together for patients
NELFT has consulted widely
with stakeholders, through the
Quality Account survey run from
September 2014 to November
2014, in order to inform our
quality priorities for the coming
year. We have also taken account
of progress against last year’s
priorities, and whilst most of
these are now embedded as
day to day business, others may
require continued focus and so will
remain as priorities. Themes from
complaints and compliments, as
well as patient and service user and
staff questionnaires, are also rich
sources of feedback and these have
been considered when setting our
quality priorities.
Why we have chosen this priority
The core principle of our patient
experience strategy is that service
users/patients and carers should be
central to decision making about
the care and treatment that is
provided, especially when changes
are made to the way this care is
delivered.
The result of our Quality Account
survey indicated that our
stakeholders wanted us to focus
on three improvement priorities:
working together for patients,
commitment to quality and care
and compassion. Each priority
has been considered by clinical
staff and the chief nurse group
and specific areas of quality
improvement have been identified.
Page 18
What are we trying to improve?
We want to ensure that everyone
who we see feels that they have
been involved in making decisions
about their care. We have,
therefore, decided to include the
question ‘do you feel you were
involved in your care as much as
you would have liked?’ in all of our
patient experience surveys. This will
enable us to measure whether we
are achieving the principles set out
in the patient experience strategy
and to take action if we are not.
North East London NHS Foundation Trust I Quality Account 2014/15
Quality goal: Working together with patients
Quality
improvement goal
for 2015/16
Area
What do we expect
applicable to to achieve
How progress
How progress
will be measured will be
monitored and
reported
Produce and
distribute
throughout all NELFT
services a patient
survey to ask patients
and service users ‘do
you feel you were
involved in your
care as much as you
would have liked?’
NELFT-wide
Qtr 1
Gather baseline data
Collation and
analysis of survey
results
Quarterly report
to board and
at the strategic
patient experience
partnership group
Continue to seek
improvement and
maintain high levels
of engagement with
our patients and
service uses on their
care.
NELFT-wide
Qtr 2
If baseline data < 50% - seek
improvement of 20% by qtr 4
If baseline data = 50%-70% - seek
improvement of 15% by qtr 4
If baseline data = 70%-80% - seek
improvement of 10% by qtr 4
If baseline data = 81%-90% - seek
improvement of 5% by qtr 4
If baseline data > 90% - seek to
maintain
Collation and
analysis of survey
results
Quarterly report to
chief nurse group
and strategic
patient partnership
group
Qtr 3
Resurvey to review continuous
improvement (so that qtr 4 goals are
achieved)
Qtr 4
Survey results to be reviewed to assess
if targets (set in qtr 2) have been
achieved
2,605,300
Service users contacts a year
North East London NHS Foundation Trust I Quality Account 2014/15
Page 19
2.2 Priority 2: Commitment to quality and care
Why we have chosen this
priority
The quality and care of our
patients/service users is paramount
to us at NELFT. To demonstrate our
continuing commitment to provide
the best quality and care, this year
we will concentrate on three key
areas: NHS Safety Thermometer,
safer staffing and the continuation
of our induction programme to
train and assess our health care
support workers (HCSW) against
the Skills for Health/Skills for Care
minimum training standards.
NHS Safety Thermometer
The NHS Safety Thermometer
0.4
records the presence or absence of
four harms: pressure ulcers, falls,
urinary tract infections (UTI’s) in0.2
patients with a catheter and new
venous thromboembolisms
(VTE).
Q2 - 2014/15
Q3 - 2014/15
We have chosen to focus on these
four areas of harm to demonstrate
our commitment to our patients
and their harm free care.
1.2
Safer
staffing
1
With
around 2,100 shifts occurring
0.8
in the average0.6month on our 0.7
0.6
inpatient
wards, we continue to
work
0.4 hard to ensure these shifts
achieve
the levels of care that we
0.2
demand for our patients. We plan
0
Q2 - 2014/15
Q3 - 2014/15
ahead to ensure that anticipated
staff absences for holidays or
training courses are covered. We
are committed to ensuring all our
inpatients/services users are in
wards which provide appropriate
levels of staffing.
Healthcare support workers
induction programme
Building on our success from last
year, we will continue to deliver
the trust’s three year programme
to ensure our health care support
workers (HCSW) are competent
to deliver safe patient care. Our
programme will continue to see
our new and existing HCSW
trained against the Skills for Health/
Skills for Care minimum training
standards.
0.5
Leading on from this, 2015/160.4
will see the launch of the Care
Certificate award in April 2015.
The Care Certificate provides
clear evidence
to employers,
Q4 - 2014/15
Q1 - 2015/16
patients and people who receive
care that our health or social care
workers have been trained to a
specific set of standards. It gives
everyone the confidence that the
HCSWs have the skills, knowledge
0.9
and behaviours
to provide
0.8
compassionate and high quality
care and support.
In quarter two of 2014/15, NELFT
commissioned London South Bank
University to develop a two day
Q4 - 2014/15
training programme which will
map across to the Care Certificate
when it is introduced in April 2015.
Staff will be required to complete
the two day programme and will
subsequently be assessed against
the care certificate competencies.
Once completed, along with their
statutory and mandatory training
they will be entered onto the
internal register.
What are we trying to improve?
NHS Safety Thermometer
In 2014, we saw the introduction
of the ‘pain assessment tool’ as
part of the pressure ulcer policy.
During 2015/16 we will ensure
the use ofUCL
this
tool is embedded in
(0.8)
practice with
audits
taking place
+ 2 SD
quarterly to
ensure teams which
Measurement
report new
pressure
ulcers are
Mean
(0.4)
2 SD pain assessment
using the -new
LCL (0.0)
tool.
The definition of a ‘fall’ and any
subsequent level of harm is an
area that staff find challenging to
record on computer systems, i.e.
differentiation of categories of harm.
2015/16 will see us continue to raise
awareness of the varying categories
UCL (1.1)
of harm for falls in the community
+ 2 SD
rehabilitation
wards leading to the
Measurement
improvement
of data quality and
Mean (0.7)
reporting and
- 2 SD subsequently ensuring
patients receive
LCL (0.3) the appropriate
pathway of care.
Q1 - 2015/16
Baseline falls data
Falls (patient numbers) with harm:
60
50
UCL (49.9)
40
30
+ 2 SD
28
26
Measurement
Mean (17.8)
20
9
10
8
0
Q2 - 2014/15
Page 20
Q3 - 2014/15
Q4 - 2014/15
Q1 - 2015/16
North East London NHS Foundation Trust I Quality Account 2014/15
- 2 SD
LCL (0.0)
60
Falls (percentage) with harm:
50
UCL (49.9)
40
20
0.5
0.4
9
Q2 - 2014/15
0.2
Q3 - 2014/15
10
+ 2 SD
28
26
30
0
Q2 - 2014/15
Q4 - 2014/15
Q3 - 2014/15
Q4 - 2014/15
80.4
Q1 - 2015/16
Measurement
UCL (0.8)
Mean (17.8)
+ 2 SD
- 2 SD
Measurement
LCL (0.0)
Mean (0.4)
- 2 SD
LCL (0.0)
Q1 - 2015/16
Falls (patient numbers) with no harm:
80
70 1.2
60
50
1
40 0.8
0.5 46
0.8
0.4
35
30 0.6
20
0.4
10
0 0.2
0
37
0.7
0.6
0.9
0.4
0.2
Q2 - 2014/15
Q2 - 2014/15
Q2 - 2014/15
17
Q3 - 2014/15
Q3 - 2014/15
Q3 - 2014/15
Q4 - 2014/15
Q4 - 2014/15
Q1 - 2015/16
Q1 - 2015/16
Q4 - 2014/15
(70.2)
UCLUCL
(0.8)
+
2
SD
+ 2 SD
UCL (1.1)
Measurement
Measurement
+ 2 SD
Mean
(33.8)
Mean
(0.4)
Measurement
2
SD
- 2 SD
Mean (0.7)
(0.0)
LCLLCL
-(0.0)
2 SD
LCL (0.3)
Q1 - 2015/16
Falls (percentage) with no harm:
1.2
1
0.8
60
0.8
50
0.6
40
0.4
30
0.2
20
0
10
0.6
0.9
UCL (1.1)
+ 2 SD
0.7
Measurement
UCL (49.9)
Mean (0.7)
+ 2 SD
- 2 SD
Measurement
LCL (0.3)
Mean (17.8)
28
26
Q2 - 2014/15
9
Q3 - 2014/15
Q2 - 2014/15
Q3 - 2014/15
Q4 - 2014/15
8
Q1 - 2015/16
Q4 - 2014/15
Q1 - 2015/16
- 2 SD
LCL (0.0)
0
People living at home with a
urinary catheter continue to have
the support of a district nurse.
60
However their independence and
50
safe management could be further
40 enhanced
80
by the development
70
30 of patient26information regarding
60 to care for a catheter. During
how
20
50
2015/16
the members of the 9NELFT
10 40
35
catheter association
urinary tract37
30
0 infection
group will work across all
20
- 2014/15
Q2 - 2014/15
services
to further developQ3patient
10
information
which will have a
0
positive impact on reducing the
Q3 - 2014/15
Q2 - 2014/15
number of urinary tract infections.
Patients admitted to the older
80people’s mental health wards require
70
60
50
a VTE (venous thromboembolism)
risk assessment as part of the
physical heath monitoring. In
2015/16 NELFT will ensure that
risk assessment is embedded into
general practice on our three older
28
adult mental
health wards and all
patients admitted to these wards will
46 risk assessment.
receive a VTE
8
Safer staffing
Q4 - 2014/15
17
Q1 - 2015/16
There are, of course, times when we
will have emergency absences due
to illnessQ4or- 2014/15
other circumstances,
but
Q1 - 2015/16
every effort is made to ensure this
does not impact on patient care.
We have systems in place to obtain
additional nursing support at short
notice. Very occasionally we are
unable to find emergency cover. At
these times an assessment is carried
out andUCL
this(49.9)
will be reported as a
potential+ 2risk
SD incident on our risk
management
system Datix under the
Measurement
UCL (70.2)
(17.8)
categoryMean
‘adverse
events that affect
+ 2 SD
2 SD
staffing -levels’.
Measurement
LCL (0.0)
Mean (33.8)
Healthcare
support workers
- 2 SD
(0.0)
inductionLCLprogramme
To ensure all HCSW’s are competent
to deliver safe patient care and
thereby providing the trust with
a pipeline for qualified staff to
undertake professional training.
UCL (70.2)
2 SD
North East London
NHS Foundation Trust I Quality+Account
2014/15
46
Measurement
Page 21
Quality goal - Commitment to quality and care
Quality
improvement goal
for 2015/16
Area
What do we expect
applicable to to achieve
How progress will
be measured
How progress
will be monitored
and reported
NHS Safety
Thermometer pressure ulcers
Introduction of
the use of the
pressure ulcer pain
assessment tool
NELFT-wide
Pain assessment tool is
embedded in nursing practice
Copy of pain
assessment tool (as
per trust policy) in
the patient records
Quarterly audits
Audit of top five
teams reporting
the highest number
of new pressure
ulcers as identified
by the NHS Safety
Thermometer
NHS Safety
Thermometer - VTE
Introduction of a
VTE risk assessment
to patients admitted
to the older peoples
mental health wards
MHS inpatients
All patients on the older adult
mental health wards receive
a VTE risk assessment and
associated treatment
Introduction of assessment to the
wards by qtr 1 with:
25% compliance by qtr 2
50% compliance by qtr 3
100% compliance by end of qtr 4
Monthly NHS Safety
Thermometer audit
NHS Safety
Thermometer
results via IPAD and
quarterly director
of nurses harm free
care paper
NHS Safety
Thermometer - UTI’s
Development of a
patient information
leaflet for people
with an indwelling
urinary catheter
NELFT-wide
Patients with an indwelling
urinary catheter receive written
information in suitable format
Agreement of leaflet details
for indwelling urinary catheter,
suprapubic catheter by qtr 1
Agreement of trial without
catheter, intermittent
catherisation leaflet by qtr 2
Agreement of easy read formats
for all information by qtr 3
Launch of leaflets to clinical staff
by end of qtr 4
Production of patient
information
Catheter associated
urinary tract
infection (CAUTI)
group
NHS Safety
Thermometer - falls
Improve staff
understanding of
the definition of falls
and harm categories
as identified by
the NHS Safety
Thermometer
Inpatient
rehabilitation
community
hospital areas
Accurate reporting of severity of
harm and associated action
Using the PIP quality
assurance process
Quarterly audit
reported to the falls
group showing a
reduction in the
number of changes
to falls grading
NHS Safety
Thermometer - falls
Ensure the falls
leaflet is being
provided and
ascertain it’s use to
patients
Inpatient
rehabilitation
community
hospital areas
All patients receive the ‘reducing
your risk of falls while in
hospital’ leaflet
Introduce a survey to a selected
number of patients per month,
per ward to evaluate the
effectiveness of the leaflet
Collation of survey
results
Quarterly audit
reported to the falls
group
Safe staffing
All inpatient
wards
<1% of shifts will be reported
as an ‘adverse events that affect
staffing level’ on Datix
Monthly Datix audit
report
Monthly board
report
Page 22
North East London NHS Foundation Trust I Quality Account 2014/15
Quality
improvement goal
for 2015/16
Area
What do we expect
applicable to to achieve
How progress will
be measured
How progress will
be monitored and
reported
Safe staffing
All inpatient
wards
100% of those ‘adverse events
that affect staffing level’ logged
on Datix will be reported as
‘no harm’
Monthly Datix audit
report
Monthly board
report
HCSW certificate
programme
NELFT-wide
Qtr 1: Launch programme via
NELFT Communication
Data from in-house
AT-Learning records
Quarterly via chief
nurse group
Data from in-house
AT-Learning records
Quarterly via chief
nurse group
Qtr 2 - qtr 4:
1. 90% of all newly recruited
HCSW’s to be trained within
12 weeks of joining the trust
2. 100 existing HCSW’s to be
trained per quarter
HCSW certificate
programme
NELFT-wide
2.3 Priority 3: Compassion
Why we have chosen this priority
Dignity, respect and empathy for
one another are central to how
we care for people. Showing
compassion for one another is
integral to providing high quality
care and achieving health and wellbeing outcomes.
NELFT has chosen this priority
which underpins its own values and
the values and behaviours of the
NHS and public health.
We aim to highlight compassion
and develop a supportive
framework to implement this
further within NELFT to improve
outcomes for the people
we care for and ensure that
compassionate care is delivered
with professionalism and a positive
friendly attitude, putting patients at
the heart of all we do.
What are we trying to improve?
To continually promote and
instil the value of compassion
Qtr 1:
1. Set-up HCSW’s certificate register
Qtr 2 - qtr 4:
2. Maintain register
throughout our workforce, to
enable all NELFT staff both clinical
and non-clinical to fully understand,
embrace and share with others
their individual responsibility to
show and act with compassion at
all times of patient care.
Importantly, before registering an
interest the potential care maker
will be required to provide evidence
of how to be an ambassador
for the 6Cs - care, compassion,
competence, communication,
courage and commitment.
To help us continue the promotion
of ‘compassion’ within our
organisation, during 2015/16
NELFT will develop and introduce
a care makers programme. Care
makers will be volunteers made
up of colleagues throughout
our services; both clinical and
corporate. Those volunteering can
range from our care assistants,
student nurses, physiotherapists
through to directors, medical staff
and board members.
The aim of the care maker is to
inspire and deliver person centred
care. They will encourage others
to emulate their best practice by
embodying the essence of the 6Cs
in their everyday work. Having
care makers in our organisation
will ensure focus on compassion
in practice and the 6Cs and will
be fundamental in the delivery
of quality patient care. The key
principle of the care makers
programme is being able to
always remember the needs of
our patients/service users come
first, and for each member of the
organisation to be aware of their
own individual role they play in
showing compassion.
The NELFT care makers
programme will involve creating
an interest to become a care
maker and becoming involved in
a programme of activities across
NELFT. Explaining the role and
expectations of a care maker
will be given through training.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 23
Quality goal: Compassion
Quality
improvement goal
for 2015/16
Area
What do we expect
applicable to to achieve
How progress will
be measured
How progress will
be monitored and
reported
Introduce care
makers concept to
the chief nurses
group (CNG) and
at the nurses day
conference on
13 May 2015
NELFT-wide
Raise awareness throughout the
organisation in qtr 1
Attendance at the
chief nurse group
meetings, nurses day
and focus groups
Evaluation of event
Produce and launch
an online survey
asking staff ‘what
does compassion
mean to the trust?’
NELFT-wide
Understand the staff’s initial
perception of what compassion
means to NELFT as an organisation
by end of qtr 2
Use the findings as a starting point
to aid the plan and development
of the care makers programme by
end qtr 2
Quantity and quality
of response
Results and analysis of
survey
‘Summary of findings’
document produced
by the patient
experience team
Patient survey asking
‘were you treated
with compassion
today?’
NELFT-wide
To receive data and understand
current position on how patients
feel
Qtr 2 - utilise
findings to progress
improvements and
share good practice
Qtr 3 - embed
learning
Qtr 4 - include in
survey results by
patient experience
team
Through patient
experience report via
the cycle of business
reporting and via
associated action plans
Plan and develop
the care makers
programme
NELFT-wide
A holistic approach to embed
the 6Cs in practise by end qtr 3
Regular ‘task and
finish’ group to
address actions
Regular ‘task and
finish’ group using
PDSA cycle of
evaluation
Roll-out the care
makers programme
throughout the
organisation
NELFT-wide
Embed care makers concept by
end qtr 4
Staff fully understand the concept
of compassion and use it in
everyday language by end qtr 4
Less complaints,
more compliments
about compassion
Evaluations of care
makers programme
Re-run initial survey
Summarise reporting
Annual report
Improvement in survey
results
2.4 Feedback from service
users that influenced our
priorities for 2015/16
Feedback from our service users is
vital to help us understand what
we are doing well and what we
Page 24
should improve. Patient/service user
surveys are extensively used across
NELFT and continue to be a rich
insight to our service delivery.
The table overleaf shows a few
comments received from those who
use our services.
North East London NHS Foundation Trust I Quality Account 2014/15
Feedback from service users
Patient comment
Our response
Linked to quality
priority
“I have been very pleased with the way the staff
have treated me with respect and dignity while I
was staying at the ward and during visits. Thank
you for being so caring”
Compassion
“This is an outstanding brilliant service. What you
have done in 21 days is unbelievable. My mum was
in hospital for 13 weeks and was nowhere near
where she is today with her walking. My mum is
now able to walk which I never thought would
happen. Also I would like to say that mum was on
8 pain relief medication tablets, since having this
service she now only needs 2”
Commitment to
quality and care
“Staff shortage. Staff didn’t have time for all the
patients”
Maintaining safe staffing levels can be challenging
at times due to unplanned staff absence and
vacancies. We will always endeavour to manage
the situation safely with matrons and senior ward
sisters across all units reviewing staffing levels and
where possible staff will be transferred to work in
areas where any risk to patient safety is identified. We look to prioritise care so that the most
important needs for our patients are addressed.
Longer term plans include recruitment to vacancies
and supporting our staff where sickness may be
the cause of their absence
“Found the staff very helpful optimistic about
things which has given me more confidence in
myself. All the staff have been very supportive and
caring“
Commitment to
quality and care
Working together
for patients
“The nurses just connect the pump and do not
assess what the needs are. Very task orientated”
When a concern is raised by patients or their
families or carers, we ensure that these are
responded to in a caring and collaborative
approach with whoever has raised the concern. We
also ensure that lessons are learnt and actions are
addressed with the individual or teams involved, as
well as with other services across the organisation
where appropriate
Compassion
“There was a delay in being seen for more
therapy as staff member of sick and there was
no cover. I felt my child was doing well but then
went back a bit due to the break in therapy”
We try to ensure that our service focuses on
quality of care, but it can be difficult to manage
staff vacancies. We try to support parents/carers
and children with practical activities that they can
work with and hope that parents/carers are able
to contact us with their concerns, which we take
seriously. We try to prioritise children and offer
further activities to help them to progress through
advice and discussion with their parents/carers and
their educational setting
Commitment to
quality and care
“Most of the staff are very good. A few try to voice
their opinion and will not listen”
When patients raise a concern about their care we
endeavour to address these concerns in a caring
and compassionate manner. NELFT’s values for
service users continue to be highlighted to our staff
and addressed through our customer care training
Working together for
patients
North East London NHS Foundation Trust I Quality Account 2014/15
Page 25
2.5 Patient surveys
London MHS feedback
Inpatient survey
All inpatients in our community
hospitals complete a questionnaire
at the point of discharge. This
compares our performance against
the 2012 national inpatient survey.
We are scoring above the national
average in all areas assessed.
High levels of satisfaction, over
75 per cent, were achieved for:
• Being made to feel welcome by
staff
• Having tests regarding physical
health
MHS wards are scoring 20 per cent
above the national average in:
• Care taken of physical health
problems
• Staff knew about you and any
previous care you received
70 per cent of inpatients are
either extremely likely or likely to
recommend our wards to friends
and family should they need similar
care or treatment.
Home treatment team survey
Everyone under the care of the
home treatment team is asked to
complete a questionnaire at the
point of discharge.
Particularly high levels of satisfaction,
over 90 per cent, were achieved for:
• Being given information about
the service
• Being treated with dignity and
respect
Page 26
• Being given an emergency
contact number
92 per cent of patients are
either extremely likely or likely to
recommend our home treatment
team to friends and family should
they need similar care or treatment
London CHS feedback
A survey was run for the integrated
rehabilitation service and
community treatment team.
99 per cent of patients are
either extremely likely or likely to
recommend our services to friends
and family should they need similar
care or treatment.
Basildon and Brentwood
and Thurrock CHS feedback
Patients were asked to complete
a questionnaire on the quality
of treatment and care they had
received and how likely they are to
recommend our service to friends
and family.
Community services
Particularly high levels of
satisfaction were reported in the
following areas:
• Did you find it easy to access
this service? 92 per cent
• Did staff introduce themselves
to you? 94 per cent
• Did staff explain what they
could or couldn’t do for you?
92 per cent
• Did the service you received
meet your expectations?
94 per cent
96 per cent of patients are
extremely likely or likely to
recommend our services to friends
and family should they need similar
care or treatment.
Inpatient services
Particularly high levels of
satisfaction, over 96 per cent, were
reported in the following areas:
• Being made to feel welcome
• Having confidentiality respected
• Being treated with dignity and
respect
• Being listened to
• Feeling safe on the ward
• Having home situation taken
into account at discharge
96 per cent of patients are extremely
likely or likely to recommend our
services to friends and family should
they need similar care or treatment.
Lower scores, below 80 per cent,
were received from patients in the
following areas:
• Quality of the food
Nationally required
information
2.6 Statement of assurance
from the board regarding
the review of services
During 2014/15 NELFT provided
and/or subcontracted 157 relevant
health services. NELFT has reviewed
all the data available to them on
the quality of care in all of these
relevant health services.
The income generated by the
relevant health services reviewed in
2014/15 represents 100 per cent
North East London NHS Foundation Trust I Quality Account 2014/15
of the total income generated from
the provision of relevant health
services by NELFT for 2014/15.
All the data received ensures the
delivery of high quality care, covers
the three dimensions of quality:
patient safety, clinical effectiveness
and patient experience. Quality
assurance data is collated and
received in the quality and safety
committee dashboard and the
performance executive dashboard.
This level of monitoring takes place
through the quality governance
structure within the trust which
includes integrated care directorate
(ICD) locality performance, quality
and safety groups and the subgroups, directorate performance,
quality and safety groups.
Risks are reported on the trustwide risk register and high level risk
registers (containing risks scoring
15 and above) are monitored via
the ICD directorate performance,
quality and safety groups and
quality and safety committee.
Strategic risks which prevent
NELFT from achieving corporate
objectives are recorded on the
board assurance framework which
is reported at board.
To date, data availability has not
impeded our objectives. However,
we continually strive to improve
and extend our data capture and
the quality of data.
2.7 Participation in clinical
audits
NELFT has a responsibility to
delivering continuous progression
in clinical audit with the aim of
providing better quality care for
patients. NELFT is responsible for
conducting clinical audit in order
to demonstrate assurance that
the services it provides are of the
highest standard and patients
receive the most appropriate
standards of care according to the
best available evidence.
national clinical audits and 100 per
cent national confidential inquiries
of the national clinical audits and
national confidential inquires which
it was eligible to participate in.
Clinical audit is integral to the
delivery of the quality agenda and
by helping to ensure adherence
to agreed guidelines/protocols/
policies, measuring outcomes and
taking action where issues are
identified. This ensures high quality
care and continued improvement
for patients.
Clinical audit is “A quality
improvement cycle that involves
measurement of the effectiveness
of healthcare against agreed and
proven standards for high quality,
and taking action to bring practice
in line with these standards so as
to improve the quality of care and
health outcomes.” (NICE, 2002)
National clinical audit
During 2014/15, eight national
clinical audits and one confidential
inquiry covered relevant health
services that NELFT provides.
During that period NELFT
participated in 100 per cent
21,188
new birth visits carried out
within 14 days of birth
North East London NHS Foundation Trust I Quality Account 2014/15
Page 27
National audit/inquiry
Cases submitted
POMH 10c – Use of antipsychotic medication in CAMHS
11 cases
POMH 14a – Prescribing for substance misuse, alcohol
detoxification
21 cases
POMH 12b – Prescribing for people with personality disorder
29 cases (TBC)
National epilepsy audit
N/A – no minimum data set
National audit of intermediate care
100%
National audit of schizophrenia
200 patients were selected randomly for the audit (out of a
total of 1243)
National Parkinsons audit
Due to commence February 2015 – completion date
30/06/2015
National chronic obstructive pulmonary disease
Due to commence January 2015 Completion date
30/06/2015
National confidential inquiries
National confidential inquiry into suicide and homicide
100%
The reports of eight national clinical audits which included one national
confidential enquiry were reviewed by the provider in 2014/15 and NELFT
intends to take the following actions, set out in the table below, to improve
the quality of healthcare provided:
Clinical service unit
Audit title
Reviewed Action to improve quality of care
Children’s services
POMH 10c
– Use of
antipsychotic
medication in
CAMHS
N/A
• The audit aim is to help mental health services improve
prescribing practice in discrete areas
• The audit undertaken is a quality improvement programme
which addresses the use of antipsychotic medication in children
and adolescents
• A review of therapeutic response and side-effects of
antipsychotic medication will be documented at least once every
six months. This review will include compliance against NICE
Guidance CG155 recommendation 1.3.18)
• Final report received from Prescribing Observatory for Mental
Health (POMH). NELFT currently reviewing the findings and are in
the process of developing recommendations and an action plan
Mental health
services
POMH 14a
– Prescribing
for substance
misuse, alcohol
detoxification
N/A
• Baseline national audit undertaken to demonstrate compliance
to NICE clinical guidelines on alcohol-use disorders (NICE CG100,
2010 and CG115, 2011)
• The audit presents data on prescribing practice for alcohol
detoxification conducted in acute psychiatric inpatient settings
• Final report has been received from POMH. NELFT currently
reviewing the findings and are in the process of developing
recommendations and an action plan
Page 28
North East London NHS Foundation Trust I Quality Account 2014/15
Clinical service unit
Audit title
Reviewed Action to improve quality of care
Mental health
services
POMH 12b –
prescribing for
people with
personality
disorder
N/A
• This national audit is undertaken to demonstrate adherence to
NICE guidelines on borderline personality disorder (CG78, 2009)
• Final report has been received from POMH. NELFT currently
reviewing the findings and are in the process of developing
recommendations and an action plan
Children’s services
National
epilepsy audit
N/A
• The audit will facilitate health providers and commissioners to
measure and improve quality of care for children and young
people with seizures and epilepsies
• To contribute to the continuing improvement of outcomes for
those children, young people and their families
• Round two of reporting has been received and NELFT currently
reviewing the findings and are in the process of developing
recommendations and an action plan
Intermediate care
services
National audit
of intermediate
care
N/A
• To develop quality standards for key metrics within the
intermediate care audit based on published Department of
Health best practice guidance and the standards used in the pilot
audits
• Data is in the process of being reviewed and action plans and
recommendations will be developed as a result of the findings
Mental health
services
National
audit of
schizophrenia
N/A
• The audit will assess practice in the prescribing of antipsychotic
drugs and will help evaluate the quality of physical health
monitoring and interventions offered to people with
schizophrenia
• Final report received from the national body. NELFT is currently
reviewing the findings and is in the process of developing
recommendations and an action plan
Parkinsons services
National
Parkinsons
audit
N/A
• Adherence to NICE clinical guideline 35, 2006, Parkinson’s
disease – Diagnosis and management in primary and secondary
care
• Audit to be registered in February 2015
COPD services
National
chronic
obstructive
pulmonary
disease (COPD)
N/A
• The audit seeks to improve the quality of care provided to NELFT
service users by supporting health professionals, policy makers
and service managers with evidence and recommendations they
require to implement change
• An on-going audit. Currently data for quarter three has been
submitted. A report will be produced after the final submission
of quarter four data
N/A
• The audit seeks to improve the quality of care provided to NELFT
service users by supporting health professionals, policy makers and
service managers with evidence and recommendations they require to
implement change
• An on-going audit. Currently data for quarter three has been
submitted. A report will be produced after the final submission of
quarter four data
National confidential inquiries
Mental health
services
National
confidential
inquiry into
suicide and
homicide
North East London NHS Foundation Trust I Quality Account 2014/15
Page 29
Corporate clinical audit
During 2014/15, NELFT undertook
a review into the clinical audit
processes. The outcome of which
included making improvements in
the processes that support staff
and services in undertaking clinical
audit, so as to present a balanced
view of clinical audit activity during
2014/15.
In 2014/15, there were at least
three clinical audit areas which
were directly related to NELFT
quality priorities as shown in the
table below, which focused primary
on improving the quality of care
provided to service users, best
practice and ensuring information
is communicated effectively across
NELFT.
Objective
Quality priorities
Supporting corporate audit activity
Improve
communications
between staff
and service users
Improve staff supervision rate
Target compliance rate of 80%
Supervision audit
Improve best practice and national guidance to prevent and
manage the spread of infection for staff and service users
Essential steps to safe clean care audit
Promoting good clinical practice, maintaining the quality of
records, reducing risk and safeguarding patients in effective
clinical care across the trust
Improve compliance to confidentiality and Data Protection Act
Annual record keeping audit
Complaints audit
Improve engagement with carers
Patient surveys
Improved communication regarding safe clean care across
the trust for both staff and service users
Supporting CQC intelligence
monitoring
Essential steps to safe clean care audit
Improve management and information sharing regarding
incidents and complaints
Review the risk management, handling and reporting
processes
Serious incidents audit
Complaints audit
Domestic violence
Supporting CQC intelligence
monitoring
Reduce any potential delay in supply of medicines and
ensuring the availability of medicines for patient use
Pharmaceutical waste audit
Improving the safe and secure storage and handling
of controlled drugs in NELFT and improve medicines
management practices
Controlled drugs audit
Medicines management audit
Promote high standards of clinical and non - practice
Quality of child protection supervision
Improving the assessment process, reducing pressure ulcers
and improving patient care
Monthly SSKIN bundle audit
Quality assurance systems embedded for safer patient care
Improving information sharing practices for patients
prescribed lithium
Medicines management audit
Monitoring of patients prescribed
lithium
Improve compliance with the NELFT physical health policy
and ensure recording of baseline observations for all new
patients in MHS are on-going
Improve level of care and patient safety with any
deteriorating patients being easily identified
Physical health monitoring compliance
Improve practice in the prescribing of antipsychotic
medications and equip staff with appropriate skills
National audit of schizophrenia
Improve the correct management and treatment in relation
to the diagnosis of mental health conditions
POMH-UK Topic 4b: prescribing antidementia drugs
Improving quality
Meeting mental
health needs of
service users
Page 30
North East London NHS Foundation Trust I Quality Account 2014/15
Local clinical audit
The reports of five local clinical
audits were reviewed by NELFT in
2014/15 and NELFT intends to take
the following actions to improve
the quality of healthcare provided.
Clinical service unit
Audit title
Reviewed
Action to improve quality of care
Mental health
services
Audit on
physical health
monitoring
across all
inpatient wards
(IPAD)
Yes
• Systems embedded, guiding doctors on how to ensure the
correct process for documents being signed off
• Guidance for junior doctors to be developed as to what is
expected of them in relation to the documentation process for
physical health monitoring
• Six monthly inductions with junior doctors in IPAD to take place
to discuss expectations in terms of the physical heath monitoring
of patients on the wards
Long term conditions
Head and neck
audit
Yes
• Re-audit planned to ensure regular monitoring is adhered to and
measure compliance
Mental health
services
Audit on clinical
documentation
standards
across all
inpatient wards
(IPAD)
Yes
• Audit demonstrated further improvements in diagnostic services,
delivering timely and comprehensive assessments for children
with autism spectrum disorder (ASD)
• Access to RiO has shown improvement to assist clinicians to
comply with electronic documentation
Dietetics service
Re-audit of
completion
of MUST tool
in community
inpatient
hospitals
Yes
• Staff to use the malnutrition universal screening tool (MUST)users
guide (yellow book) to convert imperial measures to metric
• Staff to write MUST scores into medical notes each time they are
calculated
• Workshops run by dieticians to be arranged with matrons of
community hospitals at a mutually convenient time
Children and
adolescent mental
health service
(CAMHS)
Evaluation of
the referral,
assessment
and diagnosis
of children and
young people
on the autism
spectrum in our
service
Yes
• Duty doctors to be provided access to RiO electronic record
management system, in a medical capacity and a structure to be
implemented to ensure the processes are effective
• Inductions with junior doctors in progress ensuring they are
updated with regards to documentation standards
• Further resources for autism services to be implemented to reduce
waiting times for follow up appointment
North East London NHS Foundation Trust I Quality Account 2014/15
Page 31
2.8 Participation in clinical
research
Participation in clinical research
demonstrates NELFT’s commitment
to improving the quality of the care
that we offer and to making our
contribution to health improvement
is demonstrated by our
participation in clinical research.
Active participation in research at
NELFT contributes to successful
patient outcomes. Similarly we
ensure that clinical staff stay
abreast of the latest possible
treatments. Our engagement with
clinical research also demonstrates
NELFT’s commitment to testing
and offering the latest medical
treatments and techniques.
A commitment to clinical research
leads to better treatments for
patients and this is demonstrated
by the improvement in patient
health outcomes in NELFT mental
health and community services. Our
involvement in National Institute
for Health Research (NIHR) research
has resulted in 106 publications
over the last three years. This
illustrates our commitment to
transparency and desire to improve
patient outcomes and experience
across the NHS.
In 2014/15 the number of patients
receiving NHS services provided or
sub-contracted by NELFT mental
health services recruited during
that period to participate in NIHR
portfolio studies approved by a
research ethics committee was 334.
The number of patients receiving
NHS services provided or subcontracted by NELFT community
health services recruited during
that period to participate in NIHR
Page 32
portfolio studies approved by a
research ethics committee was 168.
NELFT mental health services were
involved in conducting 27 NIHR
clinical research studies in mental
health during April 2014 to March
2015, and involved in conducting
23 local clinical research studies
during the same period.
NELFT community health services
were involved in conducting 11
NIHR clinical research studies
during April 2014 to March 2015
and involved in conducting seven
local clinical research studies during
the same period. A total of 38 NIHR
portfolio research studies were
active across NELFT’s business units
between April 2014 and March
2015, of which eight were newly
adopted studies during this period.
NELFT has been participating in
an EU telehealth research project
for heart failure patients. This is
a three year research programme
and is being led by Brainport in the
Netherlands. NELFT participates in
Hub 3, working with partners in
health enterprise east (Cambridge)
and KU Leuven university in
Belgium. There are three aspects to
the research:
• Leuven university are detailing
the clinical patterns emerging
from the anonymised data sets
provided by NELFT (as approved
via an ethics committee)
• Leuven University are expecting
to detail what further indications
are needed in order to model a
fully working decision support
tool (e.g. also use GP data sets
to complement the community
data and introduce a control
group) so that this can help
inform any following research
project into developing and
designing clinical decision
support systems in the future
• NELFT decided to use two
distinct telehealth equipment
types – one ‘stand alone’
device with no educational
video streaming to patients;
the other an integrated device
with the patient television,
enabling video streaming of
educational information. An
evaluation questionnaire was
introduced to all patients taking
part in the trial with NELFT to
assess the two systems and
whether they have benefited the
patient in terms of both better
understanding their condition,
and in better coping with the
symptoms
The research information from
NELFT will be fed back into the
overall EU project so that a better
understanding of telehealth in
heart failure patients is developed.
2.9 Commissioning for Quality and Innovation (CQUIN) targets 2015/16
What is Commissioning for
Quality and Innovation (CQUIN)?
The CQUIN payment framework
enables commissioners to reward
excellence by linking a proportion
of the income they give to provider
organisations such as NELFT to
the achievement of national and
local quality improvement goals.
proportion of the NELFT income
in 2014/15 was conditional on
achieving quality improvement and
innovation goals agreed between
North East London NHS Foundation Trust I Quality Account 2014/15
NELFT and our commissioners
through the CQUIN payment
framework. Full outcome of the
achievements of the agreed goals
for 2014/15 can be found from
page 50. Further details of these
goals and goals for the following
12 month period are available on
request from:
Julie Price, acting director of
performance and business
intelligence.
Email: julie.price@nelft.nhs.uk
Tel: 0300 555 1201 ext. 64700
Address: North East London NHS
Foundation Trust,
Suite 1B, Phoenix House,
Christopher Martin Road,
Basildon, Essex SS14 3EZ.
The total amount of income
in 2014/15 conditional upon
achieving quality improvement and
innovation goals was £5,653k.
The CQUIN targets for 2015/16
outlined below build on, and are
consistent with, both local and
national strategy.
Essex community health services
Not available as time of print
168,018
people did not attend (DNA)
their booked appointment with
our services this year
North East London NHS Foundation Trust I Quality Account 2014/15
Page 33
London community health service
Goal
number
Goal name
1
Inreach
Page 34
Indicator Indicator name
number
1.1
Patient discharge - (80% of available CQUIN).
Qtr 1
a) Establish the number of patients whose discharge was contributed
to by a NELFT intervention and define a minimum level of patient
discharge baseline
1.12
b) Finalise data reporting mechanism to track onward discharge
pathway to include as a minimum: ICM Follow up, ICM - not
previously known to NELFT, CTT follow up, community health service
referral, IRS referral and other. This level of reporting will be required
for qtr 1
1.2
Qtr 2
a) Minimum number of discharged patients baseline as defined in
qtr 1 to increase by 5%
1.21
b) Review of qtr 1 baseline information to inform an agreement of
any trajectory increase for qrt’s 3 and 4
1.22
c) Partial payment mechanism/levels of incentive to be agreed (to be
informed by the confirmed baseline set in qtr 1). This will apply for
qtr 2
1.23
d) Delivery of bi-annual audit (to be completed at qrt's 2 and 4) - an
audit would be undertaken on 10% of all patients, this would
support commissioners and provider analysis of pathway factors
influencing the achievement of an improved discharge process,
reasons for delay and opportunities for improvements
1.3
Qtr 3
Potential % increase to qtr 2 baseline to be determined by qtr 2 review.
Minimum baseline would remain at qtr 2 level if increase not agreed
1.4
Qtr 4
Potential per cent increase to qtr 2 baseline to be determined by qtr 2
review. Minimum baseline would remain at qtr 2 level if increase not
agreed
1.41
Qtr 4
Delivery of bi-annual audit (to be completed at qtr 2 and 4) - an audit
would be undertaken on 10% of all patients, this would support
commissioners and provider analysis of pathway factors influencing the
achievement of an improved discharge process, reasons for delay and
opportunities for improvements
North East London NHS Foundation Trust I Quality Account 2014/15
Indicator
weighting
(% of
CQUIN
scheme)
30%
Goal
number
Goal name
2
Patient
experience
and
satisfaction
surveys
Indicator Indicator name
number
2.1
Indicator
weighting
(% of
CQUIN
scheme)
5x5 survey provided monthly to a sample of patients in IRS/CTT/
community beds on exit, with follow up via phone call within seven
days by a patient engagement officer for non respondents (five
questions to five patients per month, per service, per borough).
Results to be seperated by the individual service and borough
Baseline level of satisfaction:
Qtr 1 to qtr 4
a) IRS: 90% b) CTT: 90% c) Community beds 80%
Barking and Dagenham
IRS
CTT
Community beds
CTT
Community beds
CTT
Community beds
20%
Havering
IRS
Redbridge
IRS
2.2
Qtr 4
a) Report on general themes identified throughout the year, identify
areas requiring improvement and relevant actions taken to seek
improvement
North East London NHS Foundation Trust I Quality Account 2014/15
Page 35
London community health service
Goal
number
Goal name
3
Dementia
Page 36
Indicator
number
Indicator name
3.1
FAIR: targeted at 75+ :
National CQUIN: Based on national guidance
Qtr 1 - qtr 4
(1) FAIRI -Find, Assess, Investigate, Refer, and Inform (60% of available CQUIN)
a) The proportion of patients aged 75 years and over to whom
case finding is applied following an episode of emergency,
unplanned care to either hospital or community services;
- Quarterly target - 90%
3.12
b) The proportion of those identified as potentially having
dementia or delirium who are appropriately assessed;
- Quarterly target - 90%
3.13
c) The proportion of those identified, assessed and referred for
further diagnostic advice in, who have a written care plan on
discharge which is shared with the patient’s GP.
- Quarterly Target - 90%
3.14
Qtr 1
a) Relationships beween acute/non acute to be defined - CSU/
CCG
b) ED pathway to be reviewed, with recommendations to be
made by the end of qtr 1 as to whether this is a requirement
of NELFT or acute
Indicator
weighting
(% of
CQUIN
scheme)
3.2
Qtr 1 - qtr Q4
Staff training - (10% of available CQUIN)
a) To ensure that appropriate dementia training is available
to all relevant qualified staff through a locally determined
training programme
- Number of relevant staff who have completed training to be
reported quarterly
- Quarterly target - 80% of overall relevant qualified staff who
have received training
3.3
Qtr 3 - qtr 4
Supporting carers - (30% of available CQUIN)
The 5x5 surveys will be reported at qtr’s 3 and 4. The data
captured will be two quarters behind (qtr 3 report will relate
to qtr1, qtr 4 will relate to qtr 2) and will allow sufficient time
from a positive screening and referral to being seen through the
memory service
a) Carer survey (5x5) - Surveying carers of people with
dementia and delirium using the 5x5 survey. The survey
will be applicable to the cohort of patients who have been
appropriately assessed and referred for further diagnostic
advice. The findings of the survey to presented biannually to
the provider board.
North East London NHS Foundation Trust I Quality Account 2014/15
20%
Goal
number
Goal name
4
Reducing the
proportion
of avoidable
emergency
admissions
to hospital
- frequent
attenders
Indicator
number
Indicator name
4.1
Frequent attenders
Qtr 1
a) Identify & agree definition of frequent attender with NELFT/
BHRUT/CCG
b) Agree data source and reporting of attendee from BHRUT
c) Establish NELFT recording system via EMHLS and CTT
d) Evidence via qtr 1 - close report
4.2
Qtr 2
a) Collect data on frequent attenders based on definition
b) Establish diagnosis and presenting criteria
c) Establish joint forum with BHRUT to discuss cases
d) Establish baseline of frequent attenders cohort where an
investigation of engagement with ICM or MH services would
support reduced attendance
e) Establish the sharing of data to CCG pills
4.3
Qtr 3
a) Reduce attendance rates of those established as benefiting
from intervention by 10% (evidence via RiO)
4.4
Qtr 4
a) Reduce the attendance rates of those established as
benefiting from intervention by ICM or MH by 20% (evidence
via RiO)
Indicator
weighting
(% of
CQUIN
scheme)
30%
99.98%
of patients were treated within
four hours of arriving at our minor
injury units and walk-in centres
North East London NHS Foundation Trust I Quality Account 2014/15
Page 37
London mental health service
Goal
1
2
3
Page 38
Goal name
Cardio metabolic
assessment and
treatment for
patients with
psychoses
Communication
with general
practitioners
Ensuring patients
on CPA with
diabetes, CHD
and COPD,
hypertension
and obesity have
either completed
a physical health
check or that
there is recorded
evidence of an
outreach attempt
to facilitate it
Indicator Indicator name
number
1.1
Indicator
weighting
(% of
CQUIN
scheme)
Qtr 1 - (20% of CQUIN) Implementation plan covering:
• Board commitment sign-up
• Identified clinical leadership
• Detailed project plan
• Planning for training for all clinical staff
• Systematic feedback process for individual clinical teams
• Planning for implementation of electronic healthcare records
data collection of physical health assessment and measurable
outcomes with a view to going live in 16/17 (assessed locally
by commissioners)
25%
1.12
Qtr 2 - No milestone
25%
1.13
Qtr 3 - (20% of CQUIN) clinical staff training plan fully
implemented (assessed locally by commissioners)
Electronic recording of outcomes fully implemented
25%
1.14
Qtr 4 - (60% of CQUIN) Results of national Royal College audit separate samples for:
• Inpatients (broken down as 30%)
• Community early intervention patients (broken down as 20%)
(See sliding scales below for payment details)
Evidence of systematic feedback on performance to clinical teams
(assessed locally by commissioners) (broken down as 10%)
2.1
3.1
Qtr 2 audit demonstrates that, for 90% of patients audited
during the period, the provider has provided to the GP an
up-to-date copy of the patient’s care plan or a comprehensive
discharge summary for patients with no CPA initiated.
Qtr 2 audit demonstrates that, for 90% of patients audited
during the period, the provider has provided to the GP an up-todate copy of the patient’s care plan, which sets out appropriate
details of all of the following:
• NHS number
• All primary and secondary mental and physical health diagnosis,
including ICD codes
• Medications prescribed and monitoring requirements; an
• Physical health condition and ongoing monitoring and treatment
needs
• Recovery focussed healthy lifestyle plans
25%
100%
No. of patients on CPA (who are registered with a GP)
identified as having Diabetes, CHD, COPD, hypertension and/or
obesity with either a completed health check or recorded
evidence of an attempt to facilitate it
North East London NHS Foundation Trust I Quality Account 2014/15
100%
Goal
number
Goal name
4
Crisis care
Indicator Indicator name
number
3.1
3.12
3.13
3.14
Indicator
weighting
(% of CQUIN
scheme)
Qtr 1
1) Reducing ED attendances:
• Agree with CHS, BHRUT, LAS, police and commissioners:
• Definition of people with mental health problems at risk of being
taken to ED (at minimum to include psychosis and self-poisoning)
• Definition of “mental health frequent attendees”
• Agree data source. This may be derived from BHRUT and/or from
NELFT’s liaison service
• Analysis/audit plan, with timescales, of those cases brought to
A&E by police/LAS to identify themes and broader opportunities
for diversion, including any recommended service development to
reduce the numbers of people with specific MH disorders attending
ED
• Baseline data report on ED use by people with mental health issues
brought to ED by LAS and/or police
2) Crisis pilots:
Agree with commissioners:
• Review/audit plan to quantify the impact of crisis pilot projects,
including enhanced MH Direct clinical inputs, extended access, street
triage, and CAMHS in-reach into ED.
• Baseline numbers of people using the elements of the pilot projects.
• Trajectory to increase numbers using the service.
25%
Qtr 2
1) Reducing ED attendances:
• Undertake and report analysis/audit agreed in qtr 1
• Agree with commissioners actions arising from findings of review/audit
2) Crisis pilots:
• Undertake and report on review/audit agreed in qtr 1
• Agree with commissioners actions arising from findings of review/
audit
• Deliver achievement against trajectory agreed in qtr 1 to increase
numbers using the service
25%
Qtr 3 1) Reducing ED attendances:
• Report progress on actions agreed in qtr 2 arising from findings of
review/audit
2) Crisis pilots:
• Report progress on actions agreed in qtr 2 arising from findings of
review/audit
• Deliver achievement against trajectory agreed in qtr 1 to increase
numbers using the service
• Survey of police and LAS of satisfaction with the service pilot
services with anonymised vignette case examples of benefits from
each pilot element
25%
Qtr 4
1) Reducing ED attendances:
• Report progress on actions agreed in qtr 2 arising from findings of
review/audit
• Report progress against trajectory as agreed in qtr 2
2) Crisis pilots:
• Report progress on actions agreed in qtr 2 arising from findings of
review/audit
• Deliver achievement against trajectory agreed in qtr 1 to increase
numbers using the service
25%
North East London NHS Foundation Trust I Quality Account 2014/15
Page 39
London mental health service
Goal
number
Goal name
5
Dementia
Indicator Indicator name
number
4.1
Havering
Redbridge
ii) Higher numbers of referrals will benefit from improved time from
start of assessment to dementia diagnosis/results of tests.
Barking and Dagenham
Havering
Redbridge
4.12
NELFT to report on (and agree with commissioners):
• Scope of review
• Project plan
• Engagement to date (including at least one meeting) with
stakeholders including each BHR CCG clinical lead
4.2
i) Higher numbers of referrals will benefit from improved time from
referral to assessment
Barking and Dagenham
4.21
Havering
Havering
NELFT to report on:
• Review findings on existing dementia pathway, problems identified
and possible improvements
• Stakeholder engagement
4.3
i) Higher numbers of referrals will benefit from improved time from
referral to assessment
4.31
Redbridge
ii) Higher numbers of referrals will benefit from improved time from
start of assessment to dementia diagnosis/results of tests
Barking and Dagenham
4.32
Havering
20%
Redbridge
4.22
Barking and Dagenham
15%
Redbridge
ii) Higher numbers of referrals will benefit from improved time from
start of assessment to dementia diagnosis/results of tests
Barking and Dagenham
Page 40
(% of
CQUIN
scheme)
i) Higher numbers of referrals will benefit from improved time from
referral to assessment.
Barking and Dagenham
4.11
Indicator
weighting
Havering
Redbridge
Qtr 3:
NELFT to report on:
Description of revised dementia pathways including:
• All potential routes into and out of the services
• Services offered by NELFT memory services, OP CMHT and any
other relevant service for people with dementia
• Arrangements for diagnostic tests
• Arrangements for YP dementia
• Evidence that the dementia pathway has been developed and
agreed collaboratively with stakeholders including, as a minimum,
CCG clinical leads, BHRUT, local authorities and relevant third
sector organisations
• Description of how and when the dementia pathway will be
communicated to stakeholders by end of qtr 4 including any
written and/or on-line information that will be available for GPs,
patients, carers and wider stakeholders
North East London NHS Foundation Trust I Quality Account 2014/15
25%
Goal
number
Goal name
5
Dementia
Indicator Indicator name
number
4.4
4.41
Havering
Redbridge
ii) Higher numbers of referrals will benefit from improved time
from start of assessment to dementia diagnosis/results of tests
Barking and Dagenham
To oversee the
implementation
of the Crisis Care
Concordation
Action Plan,
completing
all NELFT led
actions
(% of
CQUIN
scheme)
i) Higher numbers of referrals will benefit from improved time
from referral to assessment
Barking and Dagenham
6
Indicator
weighting
Havering
Redbridge
4.42
Qtr 4: NELFT to report on:
• Description of the revised dementia pathways with any further
modifications
• The briefings and communication to stakeholders, including
minimum 85% of GPs
• Written and/or online information that is available for GPs,
patients, carers and wider stakeholders
1.1
Qtr 1 - Improvements to MH direct – the 24 hour mental health
crisis line:
a) Produce an evaluation report detailing the recommendations
from the review of the algorithm and functionality of the current
MHD system and improvements to MH direct, including the
additional clinical input
b) Implement improvements to MHD software and hardware in line
with recommendations (subject to affordability)
Produce a qtr 1 report on progress in the triage and CAMHs
schemes
Street Triage
i. Implement the police liaison (Street Triage) pilot – where mental
health staff work with the police to triage 999 calls and respond
to incidents where appropriate
CAMHS
ii. Extending the hospital based and CAMHS based support for
children and young people at high risk
Crisis care concordant action plan: Produce a quarterly progress
report against NELFT actions in the WF crisis care concordant action
plan
1.2
1.3
1.4
40%
25%
Qtr 2 - Implement outcome of MHD business case:
Evaluate triage and CAMHS schemes and produce business case
Crisis care concordant action plan:
Produce a quarterly progress report against NELFT actions in the
WF crisis care concordant action plan
25%
Implement outcome of business cases for Street triage and
CAMHS scheme
Crisis care concordant action plan:
Produce a quarterly progress report against NELFT actions in the
WF Crisis care concordant action plan
25%
Crisis care concordant action plan
25%
North East London NHS Foundation Trust I Quality Account 2014/15
Page 41
London mental health service
Goal
number
Goal name
7
Supporting
the NELFT
services to
meet the
psychosis
access
standards by
end 2016
Indicator Indicator name
number
2.1
2.2
2.3
2.4
Qtr 1 (Audit)
a) Working towards compliance with 2015-16 access standards
for the psychosis pathway: 50% people of all ages experiencing
first episode psychosis treated with Nice approved care package
within two weeks of referral:
Undertake an audit in April of the current psychosis pathway
from access point to psychosis care pathway in EIP, CRS and
CAMHS. Audit how many people experiencing first episode
psychosis were referred for:
• Compulsory treatment in 2014/15
• How many people with first episode psychosis committed suicide
in 2014/15
• Number of people with first episode psychosis in employment at
the time of referral in 2014/15
NELFT is required to register with
the CQC and its current registration
status is that it is registered to
carry out the following regulated
activities:
• Assessment or medical
treatment of people detained
under the Mental Health Act
• Diagnostic and screening
procedures
• Treatment of disease, disorder
or injury
• Family planning
Page 42
(% of
CQUIN
scheme)
25%
Recruitment in line with agreed investment based on the outcome
of business case to start in June 2015 and complete in three
months by 30 August 2015
25%
The new staff to be established and start working towards meeting
the new target gradually from qtr 3 with the aim of fully meeting it
from qtr 4 (subject to full funding agreed)
Develop reporting systems provide quarterly progress report on
implementation of the service development
25%
Re-audit RTT to establish level of improvement delivered and to
review resources in place in order to establish case for recurrent
funding in 16/17 and business case to be submitted to CCG. Agree
KPI for 2016/17
25%
Essex community health services not available at time of print
2.10 Registration with the
Care Quality
Commission (CQC)
Indicator
weighting
• Maternity and midwifery
• Surgical
The CQC has not taken
enforcement action against NELFT
during 2014/15. NELFT has not
participated in any special reviews
or investigations by the CQC during
the reporting period.
During the year, the CQC
have carried out a total of five
inspections across NELFT, consisting
of:
• One essential standards
inspection
• Four Mental Health Act
inspections
North East London NHS Foundation Trust I Quality Account 2014/15
Essential standards inspections
Date
Unit inspected
Outcome
05/12/14
All wards,
Sunflowers Court
Final inspection report received
Mental Health Act inspections
Date
Unit inspected
Outcome
05/12/14
Hepworth ward,
Sunflowers Court
Measures to be put in place to:
• Reduce noise and promote rest and sleep
• Promote peoples sense of safety and reduce stress
• Increase staff-patient interaction
• Reduce bullying amongst patients and the safeguarding processes followed
• Debrief patients following incidents and the ongoing management of victims and
perpetrators to prevent incidents from occurring
• Confirm of what procedures are put in place following the submission of an
incident report via Datix
• Demonstrate that patients are involved in drawing up their care plans and
discharge arrangements
• Demonstrate that patients know who their primary nurse is
In addition some patients raised specific issues regarding their care, treatment and
human rights
21/10/14
Morris ward,
Sunflowers Court
Measures to be put in place to:
• Confirm that copies of the relevant detention documents are also kept on the ward
and available for scrutiny on the ward
• Ensure that the documents are filled in such a way as to ease the finding of the
chronology of various documents related to the detention of patients
• Confirm that all patients have a current forms T2 or T3 to authorise all the
treatments that they are currently receiving
• Ensure that patients are regularly reminded of how the Act applies to them and
what rights they may be able to exercise whilst being detained
• Ensure that the patients feel that they are being listened to, their needs are being
addressed and that they are being helped to achieve the abilities necessary to be
discharged and live in the community
• Ensure that patients’ wellbeing and recovery is promoted through the provision of
adequate staffing levels
• Confirm what arrangements are finalised to ensure that patients are facilitated to
both take part in the activities and have the opportunity to use PPT
In addition some patients raised specific issues regarding their care, treatment and
human rights.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 43
Mental Health Act inspections
Date
Unit inspected
Outcome
24/10/14
Monet ward,
Sunflowers Court
Measures to be put in place to:
• Ensure that all care plans are reviewed and updated regularly
• Ensure that the explanation of rights is repeated in accordance with chapter 2 of
the CoP and that this is documented appropriately
• Ensure that statutory consultees make a record of their consultation with the
second opinion approved doctor (SOAD) and add this to the patient’s notes in line
with paragraph 24.54 of the CoP which states: “Consultees should ensure that
they make a record of their consultation with the SOAD, which is then placed in
the patient’s notes”
In addition some patients raised specific issues regarding their care, treatment and
human rights
13/11/14
Cook ward,
Sunflowers Court
Measures to be put in place to:
• Ensure that all relevant forms for each patient are completed soon after their arrival
on the ward and are systematically filed so that there is no confusion as to the
status of patients and sufficient information is available to plan the right treatment
• Ensure that confidentiality of patients is maintained and that mistakes in the care
and treatment of patients do not occur due to documents being filed under the
wrong names
• Ensure that all risks faced or posed by patients are accurately identified and
management plans are put in place to address these risks
• Ensure that, as a matter of good practice, every detained patient has an assessment
of capacity and consent at the time of detention
• Ensure that the authorisations for medication and other treatments are kept with
the documents which authorise the patient’s detention
• Confirm which sets of records are followed by ward staff as there were both paper
and electronic systems, and a number of documents which were not available in
either format
• Ensure that forms have a space to indicate that copies are given to the patient and
other relevant parties
• Ensure that ward staff are able to ascertain what leave each patient is currently
entitled to
• Ensure that the social circumstance reports of all detained patients are available on
the ward
• Ensure that the information contained in these reports comes form the basis of the
patients’ care plans, taking into consideration the needs expressed by the patients
and those observed by the staff
• How the trust will make sure that all detained patients are given an explanation
of their rights at detention using appropriate methods and that this is repeated at
frequent intervals
• Confirm that this patient was given ECT under lawful authorisation of the RC and/
or a SOAD
In addition some patients raised specific issues regarding their care, treatment and
human rights
Thematic review – Mental health in crisis
Date
Unit inspected
Outcome
10/12/14
Mental health
acute inpatients
wards
Findings will be published in national report
Page 44
North East London NHS Foundation Trust I Quality Account 2014/15
Internal audit –
areas for improvement
2.11 Data quality
All NELFT staff receive training on
how to collect, record and report
information correctly. The uptake
of data quality and health record
system training is monitored and
reported to the data quality action
group (DQAG) quarterly. Staff are
provided with data quality guidance
prior to attending training on the
electronic patient record (EPR)
systems including access to the trust
policy on records management.
The NELFT record keeping policy
has been updated and is in the
process of being agreed. Record
keeping training has been updated
to include data quality aspects and
more guidance regarding use of
electronic records. A data quality
intranet site has been established
to provide guidance to staff and a
data quality section is now included
within the corporate e-learning
training module. A joint data
quality and information governance
module has been developed to add
to the NELFT mandatory training
programme. A variety of data
quality reports are made available
to managers an on-line IT tool
developed by NELFT called MIDAS.
This allows staff to monitor a
number of data quality issues, such
as missing NHS numbers, equalities
data and appointments data – and
the information is ‘refreshed’ daily
to allow managers to monitor
progress an improvements in data
quality every day.
Data quality issues and updates
are discussed with clinical teams
at monthly performance meetings
alongside business managers
who support the clinical staff in
understanding and resolving data
quality errors. The head of data
quality also attends local team
meetings to discuss specific issues
and provide support and advice.
NELFT undertakes an annual health
records audit to assess data quality
standards in electronic clinical
records systems, as well as paper
records, and this informs an action
plan for improving data quality
across the whole organisation.
DQAG is led by an executive director
and meets monthly to provide
strategic direction and oversee
the improvement of clinical and
non-clinical data quality in NELFT.
Together with the head of data
quality, this group is developing the
trust’s data quality strategy. DQAG
oversees the implementation of
information assurance frameworks
(IAF) for all key targets, which
includes an annual spot check of
the data. Operational services are
also requesting IAF assessments to
ensure that their data recording and
reporting processes are robust. Data
quality is a standing agenda item
on all performance group meetings,
where data quality, standardisation
of recording, codes and new forms
are discussed. In addition to the
above.
NELFT will be taking the following
actions to improve data quality:
• Improve and monitor the quality
and capture of information for
the community information data
set (CIDS)
• Improve and monitor the quality
and capture of information for
the secondary uses service data
set (SUS)
• Improve and monitor the quality
and capture of equalities data
• Monitor and maintain the
quality and accuracy of the
information recorded for mental
health minimum data set
(MHMDS)
• Audit and monitor the accuracy
and quality of data recorded
for mental health payment by
results
• Provide training on data quality
and accuracy for mental health
payments by results to all
eligible clinicians
• Produce quarterly data quality
briefing paper informing staff
of the importance of good data
quality and highlighting good
practice
• Agree and implement the data
quality strategy
• Monitor the quality of data
recorded for the trust’s IAF and
identify actions required to
improve data quality via the IAF
audit cycle
2.12 NHS number and
general medical practice
code validity
NELFT submitted records during
2014/15 to the secondary uses
service for inclusion in the hospital
episode statistics which are
included in the latest published
data.
The percentage of records in the
published data, which included the
patient’s valid NHS number was:
• 100 per cent for admitted
patient care
• 100 per cent for outpatient care
The percentage of records in the
data which included the patient’s
valid general medical practice code:
• 100 per cent for admitted care
• 99.9 per cent for outpatient care
Information governance
assessment report
The NELFT information governance
toolkit version 12 current
submission report overall score
for 2014/15 is currently at 68 per
cent, and has met the Department
of Health satisfactory level two
target on all requirements and is
graded as green (satisfactory on all
requirements).
Clinical coding error rate
The MHS business unit was not
subject to the payment by results
clinical coding audit during
2014/15 by the audit commission.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 45
Page 46
North East London NHS Foundation Trust I Quality Account 2014/15
Part three
Review of our quality performance in 2013/14
This year has seen the further
embedding of team integration
across community and mental
health, with clinical teams now fully
established in each of the localities.
The quality indicators chosen last
year were adopted across the
organisation and therefore able
to have a real trust focus that was
driven by the chief nurse through
her weekly chief nurse groups
attended by directors of nursing
from across the localities.
Progress against quality indicators
was reported and monitored
via monthly dashboards and
information cascaded via
directorate quality sub groups to
each clinical team.
This has afforded much more
ownership of the priorities and a
greater focus and understanding
for each of the clinical teams.
Ensuring consistently good quality
in all that we do across such a
board spectrum of services and
localities will always present
challenges. But having a consistent
message and approach for staff
and our patients ensures that we
retain our focus, always striving to
improve and aim to provide the
best possible care.
We have committed to the same
approach this year; NELFT-wide
challenging targets that are
meaningful across all our services.
We are proud of the improvements
we have achieved in the last
12 months and aim to be high
achievers throughout this coming
year.
The table overleaf provides a
summary of progress to date.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 47
Priority 1: Communication
Goal
Achievement target
What we achieved
Staff friends and
family test
10% year on year improvement in staff recommending
their service from April 2014 baseline
63% qtr 1
63% qtr 2
56% qtr 3
60% qtr 4
Named
professionals
100% of patients on an inpatient ward (both community
hospitals and mental health units) will be allocated a
named nurse and doctor
London CHS & MHS - 100%
Essex CHS - 83% rising to 99%
following two half yearly spot-checks
Introduction
of feedback
loop following
complaints and
consultations
100% of patients will receive responses to their complaints
100% of themes arising from complaints will be shared
with staff individually (where they are involved in the
complaint) and through team meetings and via the learning
lessons workstream to inform changes in practice and
organisational learning (Linkages also with Care Connect)
100%
Data available early 2015/16
Good practice around communicating consultations and
consultation outcomes adhered to eg, consultations are
timely, accessible, communicated and transparent
92%
Continue to build on current performance against the
appraisal target of 85%
Barking and Dagenham
MHS
Havering MHS
Redbridge MHS
Waltham Forest MHS
Waltham Forest
psychological therapies
Improve uptake
of appraisals for
staff of NELFT
mental health
services
72.15%
76.11%
64.13%
75.63%
79.45%
Priority 2: Zero tolerance to pressure ulcers
Goal
Achievement target
What we achieved
NELFT-wide policy
to be in place
A consistent organisational approach to the prevention and
management of pressure ulcers
Policy was ratified by qtr 3
Standing
operating
procedures
(SOP) for each
directorate to be
in place
Localised implementation of policy ensuring consistent
approach to improve patient care
Essex SOPs are in place for Essex
boroughs.
The London SOPs have been developed
and agreed by the tissue viability nurse
specialists for the London boroughs
of Havering, Redbridge, Barking and
Dagenham, and Waltham Forest.
They are currently going through the
leadership team ratification process to
ensure governance and equality and
diversity. There expected completion
date is July 2015
Scheduled audit
plan to be in
place
Increase knowledge of staff and improve patient outcomes
SSKIN (a five step model for pressure
ulcer prevention) audits are in place
and analysis produced throughout the
year
Page 48
North East London NHS Foundation Trust I Quality Account 2014/15
Priority 3: Staff competence - delivering patient care
Goal
Achievement target
What we achieved
All new health
care support
workers (bands 1
to 4) recruited to
the trust will be
assessed against
the Skills for
Health/Skills for
Care minimum
training standards
The band 1 – 4 programme is measured against the
NHS Skills for Health/Skills for Care code of conduct and
minimum training standards, plus competencies set by
NELFT which are relevant to each care setting. Achievement
of these standards and competencies will allow staff to be
entered onto the NELFT internal register for unqualified
staff
Two day LSBU programme attended by
24% of new HCSWs
Training existing
health care
support workers.
Project will be
rolled out to each
borough starting
with Waltham
Forest. Additional
competencies
will be added
to the minimum
standards
including the
6Cs of nursing
and dignity and
respect
We currently have 994 clinical health care support workers
so we estimate that it will take two years to roll out.
However, for new staff the programme will be part of their
induction. Pilot to be implemented by June 2014
Programme paused due to launch
of the national HCSWs certificate
programme
The trust will also
create an internal
register for health
care support
workers
The register will record levels of competency
An internal register has not been
introduced. The launch of the register
for NELFT healthcare support workers
will now take place in 2015/16 in
conjunction with the launch of the Care
Certificate Programme in April 2015 1,700
More than
written compliments
were received by staff from
service users
North East London NHS Foundation Trust I Quality Account 2014/15
Page 49
Progress against
each of our 2014/15
priorities
Considerable progress has been
achieved against the targets
NELFT set for 2014/15 and our
achievements are demonstrated
below. Whilst we did not meet
all the targets that we set for
ourselves, we are proud of
the improvements made to
date, and the commitment to
quality from all our staff. We
will continue to implement our
programmes of work and ensure
processes are embedded.
The NELFT competency induction
for health care support workers has
been over taken by the introduction
of a national certification
programme. NELFT, therefore,
decided to pause its programme
and will instead adopt the national
competency programme in the
coming year.
3.1 Priority 1: Communication (includes four target areas)
NELFT achieved the requirement
to implement the NHS staff friends
and family test from April 2014 and
the results table below provides
baseline data for the trust going
forward.
Aim 1: A 10 per cent year on year improvement in staff
recommending their service from the April 2014 baseline using the
staff friends and family test.
Quarter
Recommend for
treatment
Recommend as place
of work
Qtr 1
63%
54%
Qtr 2
63%
52%
Qtr 3
56%
45%
Qtr 4
60%
48%
Page 50
We continue to invest in studies
and analysis of staff satisfaction and
morale as well as action planning to
address areas of concern.
In an environment where NELFT
consistently benchmarks very highly
for the quality of its services as well
as its performance both in relation
to commissioners’ and regulators’
requirements, there is no doubt
that the workforce remains
committed and dedicated.
Disappointingly, the
recommendations for NELFT as a
place to work have declined and
this is consistent with the annual
staff survey results. NELFT places
enormous value in its reputation
both with its staff and its service
users. A key priority for 2015/16
is to further raise the profile of
staff engagement and continue
to dedicate resources and
investment in further measures to
effectively engage with the whole
workforce and taking positive
steps to improve morale and the
working lives of our staff. Such
measures feature strongly in the
trust’s proposed approach to
developing a new organisational
development strategy to ensure
that the workforce is not only
fit for purpose, but well-led and
shows consistently higher levels of
job satisfaction.
North East London NHS Foundation Trust I Quality Account 2014/15
North East London NHS Foundation Trust I Quality Account 2014/15
Page 51
Aim 2: 100 per cent of patients on an inpatient ward (both
community hospitals and mental health units) will be allocated a
named nurse and doctor.
Goal
Area
What we expect
to achieve
How progress
Measure
will be measured
Target
Apr 14 May 14
Named
professionals
Community
hospitals
and mental
health units
100% of patients
on an inpatient
ward (both
community
hospitals and
mental health
units) will be
allocated a named
nurse and doctor
Reports to be run
from RiO and PAS
London CHS
100%
Guidance
completed,
circulated to
inpatient units April
and May 2014
London
MHS
100%
100%
Essex CHS
100%
System data
unavailable
NELFT London inpatient beds have
had in place the named nurse for a
sustained period but this was not
captured on the electronic clinical
records system. The capture of this
on the electronic clinical records
system commenced in June 2014.
Initial implementation was patchy
but this has now been embedded
across London inpatient sites as
evidenced by the green RAG rating.
During the last year, the ward staff
on the NELFT Essex inpatient wards
have worked hard to improve the
use of the named nurse to support
partnership working with patients
and carers. Currently, there is
no electronic system in place to
audit this. Two spot audits were
Aim 3: Introduction of feedback loop following complaints and consultations.
What we expect to achieve
How progress
Measure
will be measured
Target
100% of patients will receive responses to their
complaints
DATIX
DATIX
100%
Audit of team
meeting minutes
and learning
lessons reports
(responses)
100% of themes arising from complaints will be
shared with staff individually (where they are involved
in the complaint) and through team meetings and via
the learning lessons work stream to inform changes in
practice and organisational learning (linkages also with
Care Connect)
Complaints narrative:
Feeding back to staff individually is
part of the trust’s complaints policy;
managers are required to feedback
to staff involved in complaints.
Additionally, this can be evidenced
in some complaints action plans
Page 52
100%
Reports
from leads
following investigations. However,
the complaints team do not have a
robust data monitoring mechanism
for this indicator and rely on
periodic audit. This has been
discussed in the quality and patient
safety team and potential recording
solutions are being reviewed.
North East London NHS Foundation Trust I Quality Account 2014/15
100%
Jun 14
Jul 14
Aug 14
Sep 14 Oct 14 Nov 14
Dec 14 Jan 15 Feb 15 Mar 15
7%
66.96%
100%
100%
100%
100%
100%
100%
100%
88.10%
91.39%
100%
100%
100%
100%
100%
100%
100%
86%
System data unavailable
completed, one in June 2014 with
the second taking place in March
2015, with the later audit showing
the named nurse being displayed
at 99 per cent of bedsides. To
further improve this, a patient and
Apr 14 May 14
100%
Jun 14
Jul 14
99%
carer information leaflet is being
produced and the named nurse
policy is under review.
Aug 14
Sep 14 Oct 14 Nov 14
100%
100%
An audit of team meeting minutes is planned for early
February 2015 and results will be reported by 28/02/15
Dec 14 Jan 15 Feb 15 Mar 15
100%
Data relating to qtr 3 and qtr 4 will be reported and
validated via the quality and safety committee after
31/03/15
North East London NHS Foundation Trust I Quality Account 2014/15
Page 53
Consultations
Goal
Area
What we expect
to achieve
How progress will
be measured
April 2014 – March 2015
Introduction
of feedback
loop
following
consultations
All
NELFT
services
Good practice
around
communication
consultations
and consultation
outcomes
adhered to egg,
consultations are
timely, accessible,
communicated and
transparent
Consultations will
be evaluated by the
consultation lead/
project group
24 consultation underway
London - 18 consultations
Essex - 6 consultations
Feedback reports will be
submitted
once consultations are
complete
All leads have been contacted
and reporting process
established
YTD
92% of
consultations
achieved target
Essex
Name of consultation
Did we demonstrate good practice
when conducting our consultation?
Proposal of TUPE transfer of staff from the stop smoking service to a new
alternative service provider
Yes
Proposal of TUPE transfer of staff from the weight managment service to a
new alternative service provider
Yes
Proposal of TUPE transfer of staff from the NHS checks service to a new
alternative service provider
Yes
Proposal of TUPE transfer of staff from the sexual reproductive health
service to a new alternative service provider
Yes
Proposal of TUPE transfer of staff from the 5-19 years children’s school
nursing service to a new alternative service provider
Yes
Internal staffing restructure of the specialist children’s service
Yes
Page 54
North East London NHS Foundation Trust I Quality Account 2014/15
London
Name of consultation
Did we demonstrate good practice
when conducting our consultation?
Integration of the Barking and Dagenham integrated care team with the existing
localities team
Yes
Service redesign - walk-in centre, Barking
Yes
Proposal of TUPE transfer of three domestic staff transferring to the private sector
‘Initial Health’
Yes
Unqualified occupational therapy role being made into a rotational occupational
therapy role
Yes
Improving access to psychological therapy (IAPT), Havering. Ensure clinical staff
are appropriately trained and qualified
No
Proposed structure to reate integrated leadership for children’s targeted services
within London localities
No
Role change of two looked after children’s nurses - one in Waltham Forest and
one in Barking and Dagenham
Yes
Proposal of bed reconfiguration of Waltham Forest older adults mental health
inpatient services
Yes
Restructure of podiatry service, the future management and skill mix - London
localities
Yes
Proposed management changes to podiatry and MSK (musculo skeletal) services London localities
Yes
Possible closure of Hawkwell Court - mental health rehabilitation unit
Yes
Consultation of a 24 hour, seven days a week psychiatric liaison service in
Waltham Forest
Yes
Communications team - office relocation move from Wigham House, Barking to
Goodmayes hospital
Yes
Performance and contracts team - Office relocation from Wigham House, Barking
to Barking community hospital
Yes
Health and safety team - Office relacation move from Wigham House to Barking &
Dagenham and Waltham Forest community then to Barking Community Hospital
Yes
Safeguarding children’s team - Office relocation from Wigham House, Barking to
Maggie Lilley Suite, Goodmayes hospital
Yes
Senior operational management cover to mental health services (MHS) out of
hours acute services - MHS inpatient ward manager change of working pattern
Yes
Barking and Dagenham senior leadership team - office relocation from Wigham
House, Barking to Barking Town Hall
Yes
NELFT consulted with staff on 24 consultations which took place
due to changes in contracts and delivery of services. Communication
with individual staff has been key to ensure that the consultations
are meaningful and all viewpoints considered in line with the trust's
organisation change policy.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 55
Aim 4: Improve uptake of appraisals for staff of NELFT mental health services
Goal
Area
What we expect How
to achieve
progress
will be
measured
Measure
Target Status Apr 14
May 14
Improve
uptake of
appraisals
for staff
of NELFT
mental
health
services
NELFT
mental
health
services
Continue to
build on current
performance
against the
appraisal target of
85%
Barking and
Dagenham MHS
85%
•
61.63%
59.52%
Havering MHS
85%
68.5%
70.49%
Redbridge MHS
85%
52.11%
51.6%
Waltham Forest
MHS
85%
•
•
•
55.29%
63.47%
Waltham Forest
psychological
therapy services
85%
•
79.15%
81.69%
Monitored
monthly on
performance
dashboard.
Rolling 12
months
Some progress has been made
towards achieving the challenging
85 per cent compliance rate for
staff appraisal in the trust’s mental
health services and improvements
have been made in all localities
apart from Redbridge.
NELFT mental health services
continue to benchmark highly for
quality and performance, yet in the
context of high vacancy rates and
stretched resources, further efforts
to improve on the recent success
feature in the new year’s plans.
Redbridge acknowledge that the
rounded figure for completed
appraisals of 64 per cent is
disappointing. There is evidence of
appraisals being booked and it is
expected that this figure will rise
quickly. The mental health services
have experienced issues with a
number of staff who are responsible
for completing appraisals leaving
the service and a high level of new
appointments being made to the
teams. Senior staff who will be
completing appraisals are now in
post and we are confident of an
improved position in the first quarter
of the coming year.
The introduction of a new web
based appraisal system that is
values based and more user
friendly will make the process more
meaningful for all parties as well as
less time consuming and allow for
real time reporting of activity.
Page 56
North East London NHS Foundation Trust I Quality Account 2014/15
Jun 14
Jul 14
Aug 14
Sep 14
Oct 14
Nov 14
Dec 14
Jan 15
Feb 15
Mar 15
YTD
65.85%
75%
80.72%
79.76%
85.71%
80.49%
80%
80.25%
78.75%
72.15%
72.15%
76.67%
81.20%
88.98%
85%
80.99%
80.99%
82.91%
78.45%
77.48%
78.76%
76.11%
0%
68.13%
73.13%
71.17%
70.12%
69.33%
56.28%
51.55%
53.01%
61.41%
64.13%
64.02%
76.07%
76.13%
80%
83.65%
83.44%
83.85%
85%
81.82%
75.63%
75.63%
78.14%
76.89%
78.77%
71.96%
72.12%
71.79%
73.39%
85.52%
76.03%
76.60%
79.45%
North East London NHS Foundation Trust I Quality Account 2014/15
Page 57
Priority 2: Care - Zero tolerance to pressure ulcers
Goal
Area
What we expect to
achieve
How progress
Measure
will be measured
Target
NELFT-wide
policy to be in
place
NELFT adult
service
A consistent organisational
approach to the prevention
and management of
pressure ulcers
Policy in place
Report from
lead
Policy in place and
implemented by end
of qtr 2
Standing
operating
procedures
(SOP) for each
directorate to
be in place
NELFT adult
services
Localised implementation of
policy ensuring consistent
approach to improve
patient care
Standing operating
procedures (SOP)
in place by end of
year
Report from
lead
Standing operating
procedures (SOP) in
place by end of year.
Two in qtr 2, two in
qtr 3 and two in qtr 4
Scheduled
audit plan to
be in place
NELFT adult
services
Increase knowledge of
staff and improve patient
outcomes
One audit per
month, 12 in total
Report from
lead
One audit per month
Page 58
North East London NHS Foundation Trust I Quality Account 2014/15
Apr 14 May 14 Jun 14 Jul 14 Aug 14
Pressure ulcer policy agreed by all leadership teams
Sep 14 Oct 14
Nov 14
Dec 14 Jan 15 Feb 15
Mar 15 YTD
Policy ratified for staff
Essex SOPs completed and implemented
London SOPs have been developed and agreed by the tissue viability nurse specialist for the
London boroughs of Havering, Redbridge, Barking and Dagenham and Waltham Forest.
Summary received
SSKIN audits in place and analysis produced
3.2 Priority 2: Care - Zero tolerance to pressure ulcers
Aim: Scheduled audit plan to be
in place
Aim: NELFT-wide policy to be in
place
NELFT pressure ulcers (prevention,
assessment and management)
policy was ratified for staff use on
17 November 2014.
Aim: Standing operating
procedures for each directorate
to be in place
Standard operating procedures
are in place for Thurrock, Basildon
and Brentwood integrated care
directorate. The London SOPs have
been developed and agreed by
the tissue viability nurse specialists
for the London boroughs of
Havering, Redbridge, Barking and
Dagenham and Waltham Forest.
They are currently going through
the leadership team ratification
process to ensure governance and
equality and diversity. The expected
completion date is July 2015.
An audit process for the Quality
Account initiative relating to
pressure ulcer prevention has
been introduced across NELFT
inpatient units (CHS) Woodbury,
Stage and Cook (MHS) and
community nursing teams (district
nursing). A SNAP audit measures
compliance against the East of
England SSKIN (a five step model
for pressure ulcer prevention) and
will support targeted improvement
initiatives to be delivered by the
practice improvement team in
collaboration with operation and
tissue viability teams. The practice
improvement team is working with
the performance team to develop a
strategic, ICD and local team report
using the data.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 59
Priority 3: Competence - Assurance that all health care support
workers are competent to deliver safe patient care
Goal
Area
What we expect to achieve How progress will be
measured
All new health
care support
workers (bands
1 – 4) recruited to
the trust will be
assessed against
the Skills for
Health/Skills for
Care minimum
training standards
and the recently
published Care
Certificate
All new
health care
support
workers
(bands
1 – 4)
The band 1 – 4 programme
is measured against the NHS
Skills for Health/Skills for Care
code of conduct and minimum
training standards and the
Care Certificate and plus
competencies set by NELFT
which are relevant to each care
setting. Achievement of these
standards and competencies
will allow staff to be entered
onto the NELFT internal
register for unqualified staff
Progress will be measured
against the project plan
which is monitored by the
chief nurses group and by
the number of staff being
entered onto the register
Two day London South
Bank University (LSBU)
programme attended
by 24% of new HCSWs
Training existing
health care
support workers.
Project will be
rolled out to each
locality starting
with Waltham
Forest. Additional
competencies
will be added
to the minimum
standards
including the 6Cs
of nursing and
dignity and respect
Existing
health care
support
workers
(bands
1 – 4)
We currently have 994 clinical
health care support workers
so we estimate that it will take
two years to roll out. However,
for new staff the programme
will be part of their induction
Evaluation through a precourse questionnaire which
will create a baseline for all
participants followed up by
a post course evaluation
of the programme.
Further evaluation will
be provided through
supervision, patient
experience, complaints and
participants demonstrating
competence and
confidence in carrying out
their role
Programme paused
due to the launch of
the national HCSWs
certificate programme
The trust will also
create an internal
register for health
care support
workers
All health
care
support
workers
(bands
1 – 4)
The register will record levels
of competency
The register will be updated
on a regular basis
An internal register has
not been introduced.
The launch of the
register for NELFT
health care support
workers will now take
place in 2015/16 in
conjunction with the
launch of NELFT’s Care
Certificate programme
in April 2015
3.3 Priority 3: Competence - Assurance that all health care support workers are competent to deliver safe patient care
Aim: All new health care
support workers (bands 1 –
4) recruited to NELFT will be
assessed against the Skills for
Health/Skills for Care minimum
training standards.
Page 60
Two day London South Bank
University (LSBU) programme was
attended by 24 per cent of new
HCSWs. HCSWs will continue to be
trained during 2015/16 following
the launch of certificate programme
in April 2015 – see priority 2.
Aim: Training existing health
care support workers. Project will
be rolled out to each borough
starting with Waltham Forest.
Qtr
1
Qtr Qtr
2
3
Qtr
4
Additional competencies will be
added to the minimum standards
including the 6Cs of nursing and
dignity and respect.
Although some HCSW’s were
trained the programme was paused
due to the launch if the national
HCSWs certificate programme
which NELFT will adopt in 2015/16
- see priority 2.
North East London NHS Foundation Trust I Quality Account 2014/15
Aim: NELFT will also create an
internal register for health care
support workers.
An internal register has not been
introduced. The launch of the
register for NELFT HCSWs will
now take place in 2015/16 in
conjunction with the launch of
NELFT’s Care Certificate Programme
in April 2015.
3.4 Priority 3: Serious incidents and complaints feedback
Serious incidents
Serious incidents in healthcare
are rare, but when they do occur,
everyone must make sure that there
are systematic measures in place
to respond to them. In NELFT, our
serious incident policy adopts a
‘systems improvement approach’ to
safety, as promoted by the National
Patient Safety Agency. As such,
it acknowledges that the causes
of incidents are not usually simply
linked to the actions of individual
staff members. The policy employs
a system-wide perspective for the
notification, management and
learning from serious incidents.
NELFT has a dedicated team of
trained investigators who use key
skills to find the root causes of
serious incidents to help minimise
the chances of a similar incident
re-occurring. All staff apply the
principles of ‘being open’ with
services users, carers and family
members when things go wrong.
This includes saying sorry, keeping
everyone informed as to the progress
of any investigation and sharing the
findings of the investigation report
with everyone involved.
Over the past year, NELFT has
shown a considerable improvement
in completing its investigations
within the timescales set by our
commissioners. Not only does this
mean that people involved in a
serious incident do not have to wait
so long to find out what happened
but also the action plans that are
created can be started earlier. We
have adapted the templates we
use to capture all the information
we need, particularly this year this
has been because of the duty of
candour requirements.
Complaints
NELFT received 247 complaints
during 2014/15 (compared to 215 in
2013/14) that were dealt with under
the formal trust complaints process.
This excludes cases withdrawn by
complainants, where consent was
not received or that came into the
trust via an MP and were not related
to clinical care. This figure reflects
the reportable complaints that were
submitted to the Department of
Health via the KO41a annual return.
NELFT has been proactive in
seeking both positive and negative
feedback from patients, service
users, their families and carers
and offering informal resolution.
Care Connect has been available
throughout the year enabling
patients, service users, their
families and carers to inform the
trust of a concern 24/7 (ceasing
March 2015). An intensive review
was undertaken into complaints
handling and management in
October 2014 as a result of
some delays in the processing of
complaints and an action plan is
being developed.
Key findings 2014/15
Measure
Outcome
Overview
Increased activity of 15% on previous year.
Complaints policy has been reviewed and the trust
is consulting with stakeholders on the revised policy.
Feedback leaflets including children and young people
and easy read have been review and will be sent to
stakeholders for consultation
Complaints received
The highest number of complaints were received by
Waltham Forest integrated care directorate
Highest category of
complaints
Highest number of complaints was received from
family, friend or carer compared with last year which
the highest number of complaints were received from
patients/service users
Acknowledging
complaints within
three working days
98% of complaints were acknowledged to within
three working days which shows an improvement
from last year at 94%
Completion of first
responses
53% of complaints were responded to within agreed
timescale, which is the same as reported last year’s.
However, further analysis showed that 42% of
complaint responses missed the deadline by less than
one week
Complaints dealt
with informally
21% of complaints received were dealt with informally
Compliments
A total of 1474 compliments were recorded onto Datix
following its implementation in July 2014
Complaints
handling
Improved following implementation of complaints
handling management system. An audit was
undertaken by Mazars in April 2014 which provided
a ‘substantial’ assurance that the complaints process
was basically a sound system for internal control
North East London NHS Foundation Trust I Quality Account 2014/15
Page 61
Complaints received 2014/15
Locality
2014/15
Barking and
Dagenham
Basildon and
Brentwood
Corporate
Havering
Mental
Health IPAD
Redbridge
No.
% of
total
No.
% of
total
No.
% of
total
No.
% of
total
No.
% of
total
No.
% of total
25
10.1%
30
12.1%
2
0.8%
52
21.0%
27
10.9%
36
14.6%
Complaints received 2010/11 - 2013/14
SWECS
NELCS
MHS
Total
Completion of
first responses
Acknowledging
complaints within
3 working days
No.
% of
total
No.
% of
total
No.
% of
total
2013/14
43
20%
69
32%
103
48%
215
53%
94%
2012/13
34
20%
59
35%
76
45%
169
Data not
available
85%
2011/12
20
12%
57
34%
92
54%
169
38%
97%
2010/11
0
0%
25
20%
98
80%
123
Data not
available
Data not available
The table shows that the trust
received 247 complaints during
2014/15 which represents an
increase of 15 per cent on the
previous year. The highest number
of complaints received related
to the Waltham Forest locality
which represents 22.2 per cent
of the total received. 53 per cent
of complaints were responded
to within the agreed timescales,
however, further analysis shows
that 42 per cent of complaints
missed the deadline by less than
one week.
The following table shows the
source of the complaint, e.g. the
patient or service user directly or
their family, carer or friend (with
written consent from the patient/
service user). Family/carers and
friends were the main source of
a complaint. In some cases, the
complaint may have been lodged
through an advocacy service or
local MP.
Complaints received 2014/15
Who was the complaint made by
Total
% of total
Patient/service user
108
44%
Family/carer/friend
117
47%
Advocate/MP
22
9%
Total
247
100%
Page 62
North East London NHS Foundation Trust I Quality Account 2014/15
Thurrock
Waltham
Forest
No.
% of
total
No.
% of
total
20
8.1%
55
22.2%
Total
Completion of
first responses
Acknowledging complaints
within three working days
247
53%
98%
An analysis of complaints during
2014/15 shows that the top areas
of complaints are as follows:
2014/15 Top three areas of complaint
2014/15 Improvement priorities
Clinical care
Working together for patients
Staff attitude
Commitment to quality and care
Communication
Compassion
3.5Safeguarding
The NELFT safeguarding team
have shared learning events/
dissemination of learning regarding
outcomes of local/national serious
case reviews dated 29/4/2014 and
09/10/2014. The safeguarding
annual report is submitted by the
associate director of safeguarding
looked after children (LAC)
detailing learning from serious case
reviews (SCR) across NELFT.
There are monthly directorate
safeguarding adults/children
meetings at which all SCR/multi
agency risk assessment conference
(MARAC) and social care institute
for excellence (SCIE) reviews are
discussed and learning identified.
These are also discussed at
directorate quality and safety
meetings.
The safeguarding teams contribute
to the annual audit programme
which covers the quality of
safeguarding record keeping and
supervision in addition to the
organisations response to domestic
violence.
3.6 Benchmarking
Themed benchmarking
Bespoke benchmarking
NELFT publishes benchmarked
information on our website on
a quarterly basis. This allows
stakeholders to review NELFT
performance against local and
national indicators. These can be
found at: www.nelft.nhs.uk/
about_us/performance
NELFT is a member of the NHS
Benchmarking Network and
undertakes themed benchmarking
throughout the year across
community and mental health
services. NELFT has provided
information to the network for
OATs (out of area treatments) and
use of restraint in MHS. NELFT
participated in the MHS inpatients
and community benchmarking.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 63
Performance targets
3.7 Monitor risk assessment framework
Monitor, the regulator of foundation trusts, requires foundation trusts to
report a set of quality indicators known as the risk assessment framework
which are set out in the table below:
CHS
Goal
Goal name
number
Measure
Target
Status
1
A&E - 4 hour waiting time
Percentage
95%
2
Data completeness - Referral to treatment
Percentage
50%
3
Data completeness - Referral information
Percentage
50%
4
Data completeness - Treatment activity information
Percentage
50%
5
Patient Identifier information
Percentage
50%
6
Patients peferred place of death
Percentage
50%
•
•
•
•
•
•
Goal
Goal name
number
Measure
Target
Status
7
Care Programme Approach (CPA) - F/U within 7 days of
discharge
Percentage
95%
8
Care Programme Approach (CPA) - Formal review within 12
months
Percentage
95%
9
Admissions to inpatients services had access to Crisis/Home
Treatment Teams
Percentage
95%
10
New psychosis cases by early intervention teams
Percentage
95%
11
Minimising delayed transfers of care
Percentage
<7.5%
12
MH data completeness: identifiers
Percentage
97%
13
MH data completeness: outcomes for patients on CPA
Percentage
50%
•
•
•
•
•
•
•
Measure
Target
Status
MHS
NELFT-wide
Goal
Goal name
number
14
Certification against compliance with requirements regarding Percentage
access to healthcare for people with a learning disability
N/A
N/A
15
Maximum time of 18 weeks from point of referral to
treatment in aggregate – complete pathways (non-admitted)
Percentage
95%
16
Maximum time of 18 weeks from point of referral to
Percentage
treatment in aggregate – patients on an incomplete pathway
92%
•
•
Page 64
North East London NHS Foundation Trust I Quality Account 2014/15
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
99.96%
100%
99.97%
100%
100%
100%
100%
100%
87%
88%
88%
88%
88.7%
88.9%
94%
94%
94%
94%
94%
100%
100%
100%
100%
93.8%
93.8%
94.1%
59.4%
65.71% 80.13%
Apr
14
May
14
Jun
14
100%
98.4% 98%
Feb
15
Mar
15
99.98% 100%
100%
100%
87.7% 87.7%
87.6%
88%
94.9% 87.7%
99.4%
94.1% 93%
93.4%
93.4%
94%
93.2%
100%
100%
100%
100%
100%
100%
100%
93.5%
92.7%
93.9%
93.5% 94.1%
94%
93.7%
93.8% 94.1%
71.13%
74.34% 77.3%
69.2% 89.1%
86.6%
81.7%
76.6% 86.6%
100%
Jan
15
Year
(cumalative)
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Year
(cumalative)
100%
100%
100%
98%
96.7%
98%
97.5%
97.2%
98.2%
98.7%
96.1%
95.4% 95.16% 95.8%
95.7%
96.8%
95.9%
95.5%
95.9% 95.01%
95.2%
96.4%
98.7%
100%
99.6%
98.9%
99.5%
99%
99%
97.6%
98%
97.8%
97.6%
95.5%
129%
106%
116%
122.6% 117.4% 110.8% 113.4% 108.9%
113%
112%
108.5%
106.5%
0.6%
1.36% 1.65%
1.45%
1.34%
1.54%
2.75%
4.5%
5.37% 5.38%
4.73%
3.81%
99.7%
99.7% 99.7%
99.7%
99.7%
99.7%
99.8%
99.8%
99.7% 99.7%
99.7%
99.8%
97.1%
94.7% 95.2%
96.7%
94.6%
96%
89.4%
93.7%
97%
94%
97.4%
97.6%
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
97.1% 96.1% 85.8%
92.5%
99.3%
99.4%
98.1%
100%
100%
100%
100%
100%
96.7% 96%
98.7%
98.4%
100%
99.7%
98.8%
98.9%
98.9%
100%
99.8%
83.6%
North East London NHS Foundation Trust I Quality Account 2014/15
98.3%
3.06%
Year
(cumalative)
Page 65
Legionella reporting
Legionella incidences
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
Total
0
1
0
0
1
0
0
0
0
0
0
0
2
There have been two incidents of
elevated levels of legionella since
1 April 2014 reported across the
trust, both of which were in nonNELFT buildings where NELFT lease
areas within the building. The
first incident was at St Andrews
in Billericay (Basildon, Thurrock
university hospital - BTUH) and the
second at the GUM Clinic in Orsett
(BTUH). Both incidents related to
WC sink taps within patient areas
and were identified through routine
monitoring. Outlets were isolated
Page 66
and immediate remedial action
taken (other outlets were available
for use). There were no reported
cases of infection affecting staff or
patients. No further incidents have
been reported across the trust.
3.8 Monitor core indicators
Monitor also requires foundation
trusts to report performance
against a core set of quality
indicators using data made
available by the health and social
care information centre (HSCIC).
These mandated indicators are
summarised below with each
indicator given detailed analysis in
the following pages:
* Merger of NELFT with the
London community services
occurred mid-year during
2011/12 therefore data not fully
representative of all business units
at this time
North East London NHS Foundation Trust I Quality Account 2014/15
Monitor performance framework
Core Indicators
Measure
*2011/12 2012/13
2013/14 2014/15
1
The percentage of admissions to acute wards for
which the crisis resolution home treatment team
acted as a gatekeeper
Adults
95.5%
98.5%
99.1%
98.3%
2
The percentage of patients on care programme
approach who were followed up within seven days
after discharge from psychiatric in-patient care
during the reporting period
Adults
97.4%
98%
97.7%
98.7%
3
The percentage of patients aged:
(i) 0 to 15 and
(ii) 16 or over
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
London CHS
1.6%
2.1%
1.2%
0.9%
Essex > 16 years
2.6%
2.6%
2.2%
1.9%
London MHS
8.1%
7.6%
7.3%
7.5%
4
The percentage of staff employed by, or under
contract to the trust, who would recommend the
trust as a provider of care to their family or friends.
Essex >16 years
52.7%
59.5%
56.0%
60%
5
‘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
Response rate
8.5
8.4
8.4
6.9
6
The percentage of patients who were admitted to
hospital and were risk assessed for VTE
Percentage
N/A
96.7%
99.1%
97.8%
7
Cases of c.difficile infection amongst patients aged
two or over
All cases
N/A
8
11
3
Rate per 100,000
beds days
N/A
5.0
7.6
2.2
Number
3834
5022
7782
9226
Rate per 100,000
population
276.2
361.8
560.7
664
Number
N/A
N/A
19
12**
Percentage
N/A
N/A
0.49%
0.28%**
North East London NHS Foundation Trust I Quality Account 2014/15
Page 67
8
9
Patient safety incidents
Patient safety incidents that resulted in severe harm
or death
**data based only on qtr’s 1 and 2
1. Admissions to acute wards for
when home treatment teams
(HTT) acted as gatekeeper
The local home treatment teams
(HTT) provide intensive support
for people in a mental health crisis
in their own home or community
setting. They are designed to
provide prompt and effective
home treatment, including the
administration and monitoring of
medication, in order to prevent
hospital admissions and give
support to informal carers.
discharge from an inpatient ward
who may be able to continue their
treatment at home. We want to
ensure that as many people as
possible are treated at home used
appropriately and safely, HTT brings
clinical benefits, increased patient
satisfaction and reduces pressure
on hospital beds.
Gatekeeping means assessing
everyone who is referred for
admission into hospital and also
those that may be suitable for
Admissions to acute wards for when home treatment teams
(HTT) acted as gatekeeper 2011/12-2014/15
NELFT
Qtr 1
2011/12
Qtr 2
2011/12
Qtr 3
2011/12
Qtr 4
2011/12
Qtr 1
2012/13
Qtr 2
2012/13
Qtr 3
2012/13
Qtr 4
2012/13
Qtr 1
2013/14
97.8%
92.9%
96.4%
96.9%
98.1%
97.8%
99.3%
98.9%
100%
National
target
95%
2. Patients on care programme
approach (CPA) followed up
within seven days
The care programme approach
(CPA) is a framework designed to
promote the effective co-ordination
of care of people suffering from
complex mental health issues and
are being treated within secondary
mental health services such as those
provided by NELFT. Service users
on CPA who are discharged from
inpatient care must be followed up
by a mental health professional,
preferably face to face but may be
Patients on care programme approach followed up within seven days
2011/12-2014/15
NELFT
Qtr 1
2011/12
Qtr 2
2011/12
Qtr 3
2011/12
Qtr 4
2011/12
Qtr 1
2012/13
Qtr 2
2012/13
Qtr 3
2012/13
Qtr 4
2012/13
Qtr 1
2013/14
97.7%
97.1%
97.6%
97.5%
99.2%
99.1%
100%
99.2%
98.3%
National
target
3.
95%
30 - day emergency
re-admission rate
NELFT considers this data is as
described for the following reason:
Target
NELFT London CHS
<5%
NELFT Essex CHS
<5%
NELFT MHS
<9%
Page 68
figures are taken from our electronic
patient management systems. The
figures represent patients readmitted
to one of our inpatient wards within
30 days of being discharged.
Rating
•
•
•
2011/12
2012/13
2013/14
2014/15
VAR
1.6%
2.1%
1.2%
0.9%
-0.7%
2.6%
2.6%
2.2%
1.9%
-0.7%
8.1%
7.6%
7.3%
7.5%
-0.6%
North East London NHS Foundation Trust I Quality Account 2014/15
NELFT considers that this data is as
described for the following reason:
both internal and external audits
have taken place on a regular basis
over the year and no significant
issues have been found. NELFT will
continue to monitor this indicator
closely to maintain the high level of
performance and the quality of its
services.
Qtr 2
2013/14
Qtr 3
2013/14
Qtr 4
2013/14
Qtr 1
2014/15
Qtr 2
2014/15
Qtr 3
2014/15
Qtr 4
2014/15
2011
/12
2012
/13
2013
/14
2014
/15
98.4%
98.9%
100.0%
99.5%
100%
98%
95.5%
95.5%
98.5%
99.3%
98.3%
95%
95%
by telephone contact directly with
the service user within a maximum
of seven days from discharge.
both internal and external audits
have taken place on a regular basis
over the year and no significant
issues have been found. NELFT will
continue to monitor this indicator
NELFT considers that this data is as
described for the following reason:
closely to maintain the high level of
performance and the quality of its
services.
Qtr 2
2013/14
Qtr 3
2013/14
Qtr 4
2013/14
Qtr 1
2014/15
Qtr 2
2014/15
Qtr 3
2014/15
Qtr 4
2014/15
2011
/12
2012
/13
2013
/14
2014
/15
95.5%
99.2%
100%
98%
100%
98.4%
98.2%
97.4%
98%
98.1%
98.7%
95%
95%
Apr
14
May
14
Jun
14
Jul
14
Aug
14
Sep
14
Oct
14
Nov
14
Dec
14
Jan
15
Feb
15
Mar
15
NELFT Essex CHS
0%
5.2%
0%
1%
1.9%
1.1%
0.9%
3.2%
1%
1%
5.4%
3.4%
NELFT London CHS
0.7%
0%
1.4%
1.3%
0.8%
1%
0.8%
1.9
0.8%
1.2%
1.4%
0%
NELFT MHS
8.8%
7.6%
5.8%
5.8%
7.3%
7.8%
9.6%
9.2%
10.7%
4%
11.1%
3.2%
North East London NHS Foundation Trust I Quality Account 2014/15
Page 69
Whilst there is an improvement
in the re-admissions rates across
the inpatient units for NELFT, the
following actions will be taken to
progress further improvement:
• Work closely with the
commissioners and other
partners to improve patient
pathways around frailty and
increase the effectiveness of
patient flow through the health
and social care system
• Increased levels of nursing staff
in line with safer staffing to
support clinical quality and safety
• Review the medical support
offer across the units to
support effective and efficient
use of medical resource to
ensure quality patient care
and appropriate medical
management
• Robust and strengthened
leadership across all units to
support clinical safety of patients
ensuring patients discharge
planning is managed in such
a way that meets the needs of
patients and reduces the risk
of readmission to acute and
community hospital settings
• Assertive recruitment to all
vacancies across the teams,
working with human resources
as part of the national
recruitment campaign to
stimulate recruitment pool
• Focus on planning patient
care and discharge with an
integrated approach to care,
working with partner agencies
including acute and community
colleagues and social care
• Improving ease of access to all
community services for both
physical and mental health
• Work and learning emanating
from the frailty academy/
communities of practice
• Utilising intermediate care audit
and subsequent action plans to
improve patient care
• Effective multi-disciplinary
working focusing on working
systems around the patient,
including social services,
pharmacy, occupational
therapists, medical staff
and other agencies (dental,
optometrists and podiatry)
• Ensuring pharmacological
needs meet tailoring medication
•
•
•
•
•
•
appropriately and working in
partnership with pharmacy
colleagues
Reviewing positive patient
experience and learning from
success, understanding gaps in
the service where discharges
could have improved
Actively engaging with carers
Patient and staff feedback
Working with voluntary agencies
to support patient discharge
Using evidence-based and
nationally recognised screening
tools to detect at the earliest
stage conditions such as
dementia so that patients can
access services that will support
independence
Screening patients for falls
– to ensure treatments and
preventative work is enabled to
support independence
NELFT considers that this data is as described for the following reason:
figures are taken from national NHS staff surveys.
Staff recommendation of NELFT as a provider of care
2014/15
NELFT
60%
4. Staff recommendation of the
trust to a friend or relative as a
provider of care
NELFT intends to take the following
actions to improve this percentage,
and so the quality of its services, by
the following:
NELFT continues to explore ways
of supplementing the information
provided by the staff survey results
in identifying areas of concern.
Page 70
Patient satisfaction levels remain
good, yet the staff survey result
for satisfaction with the quality of
work and patient care they are able
to deliver is slightly lower than last
year. Analysis of results by staff
group and directorate however has
revealed no significant changes in
opinions or confidence in particular
areas. NELFT is showing significant
year on year increases in demand
with either the same or less
resources and cost improvement
aspirations remain challenging.
Commissioner funding across
the NELFT localities recognises
demographic changes and it is
important that this continues to
be recognised by commissioners
in setting contract prices. We
have now gained the support of
commissioners in specific areas to
review recruitment activities and
implement targeted actions to
improve applicant attraction and
conversion rates.
North East London NHS Foundation Trust I Quality Account 2014/15
Since engagement of staff is critical
to improving quality and has a
strong link to recommendation for
treatment NELFT is developing a
strategic approach to organisational
development and investing in
resources to improve engagement.
Action plans from the staff survey
and the engagement agenda in
general, are overseen by NELFT
clinical executive, joint negotiation
and consultation committee and
strategic staff health and wellbeing
group. Actions emerging from
plans will be widely communicated
throughout the trust via a range
of media, to ensure that staff
recognise the commitment of the
organisation to value their opinions
and input to improving the high
standards of care to which they
aspire.
5. Patient experience of
community mental health
NELFT considers that this data is as
described for the following reason:
the results of the community
mental health service user survey
were released in September 2014.
This was compulsory for all trusts.
people who received community
mental health services. Responses
were received from 237 people
at NELFT. A score of 10 would
represent the most positive possible
reported service user experience.
NB. This year brought change to some
of the survey questions and therefore
the overall score of 6.9 does not
provide a true like for like comparison
to the previous three years.
At the start of 2014, a
questionnaire was sent to 850
Patient’s experience of contact with a health or
social care worker
2011/12
2012/13
2013/14
2014/15
NELFT score
8.5
8.4
8.4
6.9
Patient’s experience of contact with a health or social
care worker
2011/12
2012/13
2013/14
2014/15
Overall score
8.5
8.4
8.4
6.9
Listening carefully to them
8.7
8.7
8.4
8.6
Taking their views into account
8.3
8.2
8.1
N/A
Having trust and confidence in the health or social care worker
8.2
8.1
8.0
N/A
Treated with respect and dignity
9.1
9.2
9.3
8.4
Being given enough time to discuss their condition or treatment
8.1
7.9
7.9
7.7
NELFT has taken the following actions
to improve this rate, and so the
quality of its services:
Annual
change
6
5
6
6
finding or keeping accommodation
and supporting patients in taking part
in a local activity, if they so wanted.
Following on from the results of the
survey, NELFT recognises the need
to focus on improving the overall
results and, in particular, that focus
and improvement is required in the
category ‘other areas of life’ which
provided a disappointing result of 5.1.
This area of improvement includes,
for example, giving information
about getting support from others
with experiences of the same mental
health, help finding support for
North East London NHS Foundation Trust I Quality Account 2014/15
Page 71
6. Rate of admissions assessed for VTE
NELFT considers that this data is as described for the following reason: data is
as reported on the NHS Safety Thermometer. The data for NELFT represents
community inpatient wards and does not include mental health inpatient
wards.
Qtr 1
12/13
Qtr 2
12/13
Qtr 3
12/13
Qtr 4
12/13
Qtr 1
13/14
Qtr 2
13/14
Qtr 3
13/14
Qtr 4
13/14
Qtr 1
14/15
Qtr 2
14/15
Qtr 3
14/15
Qtr 4
14/15
NELFT
97.1%
93.5%
96.3%
96.6%
99.8%
96.8%
99.6%
100%
99.02%
95.95%
97%
99.24%
England
93.4%
93.9%
94.2%
94.3%
95.5%
95.7%
95.8%
96%
96.1%
96%
96%
TBA*
Norfolk
Community
Health &
Care Trust
90.4%
90.4%
90.4%
96.1%
98.3%
97.8%
97.4%
95%
97.3%
98.2%
97%
TBA*
NHS Target
92%
92%
92%
92%
95%
95%
95%
95%
95%
95%
95%
95%
*Data not available at time of print
NELFT has taken the following actions to improve the percentage of
completed VTE risk assessments on admission to the ward, and so the
quality of its services, by:
• Agreement of the venous thrombosis policy to support staff in practice
• Development of the guideline/protocol for the prevention and
management of VTE (venous thromboembolism)
100%
99%
98%
97%
96%
95%
94%
93%
92%
91%
90%
Q1
12/13
Q2
12/13
NELFT
Page 72
Q3
12/13
Q4
12/13
England
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
Norfolk Community Health & Care Trust
North East London NHS Foundation Trust I Quality Account 2014/15
Q2
14/15
Q3
14/15
Q4
14/15
NHS Target
7. Clostridium difficile rates
Rate of clostridium difficile (C.diff) infection in patients aged two years and
over reported within NELFT are as follows. NELFT have a target of nil cases
which we achieved for 2014/15 as all cases investigated were unavoidable
and non-attributable to NELFT. This means that these patients had underlying
contributing factors that were not evident/communicated to NELFT at the time
of referral/dormant at the time of referral subsequently there was a relapse
in symptoms having been treated previously and when investigated proved
positive to C.diff.
NB. There is currently one case pending investigation which NELFT is awaiting
the outcome of an appeal. The result is expected by June 2015.
2014/15
C.difficile rates
Target
2012/13
2013/14
Number
Incidences
0
8
11
3
Rate per 100,000 bed days
5.0
7.6
2.2
National rate
27.7
25
N/A
Unavoidable and
How we
non-attributed to NELFT have done
0
•
NELFT considers that this data is as described for the following reason: data is
taken from a positive sample.
NELFT has taken the following actions to improve this rate, and so the quality
of its services, by:
•
•
•
•
•
•
•
•
•
•
Treating all cases of positive C.diff as per the national guidance
Reviewing positive cases
C.diff leaflet has been printed and distributed to all services
NELFT has developed a C.diff strategy and will continue to work with
the wider health economy for implementation
Undertaking root cause analysis to determine how the incidence
occurred
Continue to provide training for frontline staff on C.diff management
and root cause analysis
12 month trend analysis to analyse the rate where NELFT will look
at salient themes with continuing development of a C.diff reduction
strategy underpinned by the 12 month data
Flowchart has been produced aligned to acute trusts for antibiotic
prescribing
Working with NELFT pharmacy to implement the anti-microbial
stewardship
Undertaking policy reviews
North East London NHS Foundation Trust I Quality Account 2014/15
Page 73
8. Patient safety incidents
NELFT considers that this data is as described for the following reason:
data is taken from National Reporting and Learning System (NRLS) when
benchmarking with other trusts and from the local risk management system
(Datix) for 2014/15.
Patient safety incidents
2011/12
NELFT
2012/13
2013/14
2014/15
N
Rate
N
Rate
N
Rate
N
Rate
3834
276.2
5022
361.8
3878
279.0
9226
664.7
Trust
2011/12
2012/13
2013/14
2014/15
N
Rate
N
Rate
N
Rate
N
Rate
Oxleas NHS Foundation Trust
2420
322.7
4859
647.9
3638
485.1
4231
564.1
Central & NW London NHS Foundation Trust
4788
233.4
5420
264.2
3660
178.4
4189
204.2
East London NHS Foundation Trust
2364
292.4
2406
297.6
2348
290.5
1706
211
NELFT patient safety incident rates 2012/13-2014/15
200
181.4
180
140
120
159.4
155.8
160
128
126.1
134.4
134.4
159.9
164
144.3
126.1
113.8
100
80
60
40
20
0
Page 74
Q1
12/13
Q2
12/13
Q3
12/13
Q4
12/13
Q1
13/14
Q2
13/14
Q3
13/14
Q4
13/14
Q1
14/15
North East London NHS Foundation Trust I Quality Account 2014/15
Q2
14/15
Q3
14/15
Q4
14/15
By reporting incidents, staff are
contributing to patient safety and
quality of care. An increase in
the number of incidents does not
mean things are getting worse
but more that NELFT is a learning
organisation where staff feel
supported in reporting when things
do not go as intended. NELFT
continues to report more low and
no-harm incidents than moderate,
severe and incidents of death.
needlestick injuries to see if
these recommendations make a
difference.
9. Patient safety incidents that
resulted in severe harm or
death
NELFT considers that this data
is as described for the following
reason: data is taken from National
Reporting and Learning System
(NRLS).
NELFT has taken the following
actions to improve the quality
of incident reporting and so the
quality of its services, by:
• Commissioning an e-learning
training package with Datix
• Rolling out the use of the risk
module so risks and incidents
can be linked
• Updating user guides on the
NELFT staff intranet
• Informing reporters when the
incident they reported has been
reviewed by their manager
• Local analysis of incident
reporting and findings fed
back to appropriate senior
management
• Supporting managers to review
and approve their incidents
One recent example where incident
reporting and investigations
have led to quality improvement
is regarding needlestick injuries
sustained by staff. The health and
safety and quality improvement
group met and an audit of the
injuries was carried out. The
recommendations of this audit
included the policy for safe
handling and disposal of sharps
policy be available for staff at
induction, an insulin needle
remover becoming standard part of
nurse equipment and team leaders
making it clear to all their staff
the importance of not resheathing
needles at team meetings. We
continue to monitor the reported
North East London NHS Foundation Trust I Quality Account 2014/15
Page 75
Patient safety incidents 2013/14 – 2014/15 (Source: NRLS)
Paitent safety incidents
2013/14
Severe harm
No
%
Death
No
%
Total
2014/15
(Qtr’s 1 & 2 only)
NELFT
3873
0
0%
19
0.49%
0.49%
4323
Average mental health trust
2209
16
0.73%
36
1.63%
2.36%
2396
Oxleas NHS Foundation Trust
7508
11
0.15%
37
0.49%
0.64%
4231
Central & NW London NHS Foundation Trust
7462
26
0.35%
17
0.23%
0.58%
4189
East London NHS Foundation Trust
3484
23
0.66%
97
2.78%
3.44%
1706
Benchmarking with trusts comparable to NELFT
*NRLS data for qtr’s 3 and 4 not available at time of print
3.9 Department of Health compliance targets
NELFT is also required to monitor and report on the performance indicators
as set by the Department of Health. These are set out below.
Department of Health performance framework
Target
Description
Milestone 2012/13
1
Patient safety incidents, per
100,000 population
Number of patient safety incidents reported to the
National Reporting and Learning Service (NRLS) by
provider organisations in England per 100,000 population
N/A
361.8
2
Safety incidents involving
severe harm or death
Patient safety incidents reported to the National Reporting
and Learning Service per 100,000 population
N/A
N/A
3
Incidence of healthcarerelated venous
thromboembolism (VTE)
Patients with VTE, during their period of admission (as
percentage of total admissions)
<5%
0.80%
4
Incidence of MRSA
bacteraemia
Overall number of cases of MRSA bacteraemia
0
1
5
Incidence of C. difficile
Overall number of cases of C. difficile
<5%
7.5%
6
Incidence of newlyacquired category 2, 3 and
4 pressure ulcers
Patients with any pressure ulcer during the care of the
facility (NHS Safety Thermometer: 1 day snapshot)
N/A
0.10
7
Incidence of medication
errors causing serious harm
The number of medication error incidents recorded as
causing severe harm/death, per 100,000 population
N/A
0.10
Page 76
North East London NHS Foundation Trust I Quality Account 2014/15
Severe harm
No
%
Death
No
Total
%
8
0.19%
4
0.09%
0.28%
8
0.33%
16
0.67%
1%
13
0.31%
24
0.57%
0.87%
18
0.43%
6
0.14%
0.57%
15
0.88%
18
1.06%
1.93%
2013/14
2014/15 How are we doing
560.7
664.7
N/A
N/A
19
12*
N/A
N/A
0.10%
0.28%
•
We are achieving
to date
0
0
•
All non
attributable to
NELFT
0.90%
0.16%
•
We are achieving
to date
0
0.07
N/A
We are achieving
to date
0
0.07
N/A
N/A
NELFT is required to report all incidents graded as causing
severe harm or death to the NRLS within 48 hours. To
improve the timeliness of our reporting, we have allocated
additional staff who have received specific training. Incidents
of this type are managed by a dedicated team and are
investigated thoroughly and learned from to prevent the
likelihood of similar incidents happening again.
33,710
mandatory training
courses undertaken by
our staff in the last year
North East London NHS Foundation Trust I Quality Account 2014/15
Page 77
3.10 Our workforce
The highest and lowest ranking
scores in the 2014 national staff
survey were as follows:
Top five ranking scores
• In the last three months had not
felt pressure from the manager
to attend work when they had
not felt well enough to perform
their duties
• Staff stating that in an average
week they have not worked
additional paid hours over and
above the hours for which they
are contracted
• Staff have never personally
experienced physical violence
from the public in the last 12
months
• Agreed that senior managers act
on staff feedback
• In the last three months had not
felt pressure from colleagues
to attend work when they had
not felt well enough to perform
their duties
Bottom five ranking scores
• Received equality and diversity
training in the last 12 months
• Received health and safety
training in the last 12 months
• Agreed that they would
recommend their organisation as
a place to work
• Appraisal helped staff to improve
how they did their job
• Agreed that they are satisfied
with the quality of care they give
Planning and developing the
workforce
The NHS Constitution sets a clear
expectation that staff are provided
with training, development and
learning. NELFT has always had a
good record in this area in staff
Page 78
surveys and yet in the 2014 national
survey NELFT is below average for
access to job relevant training and
development in the last 12 months.
This is contrary to monthly reports
that show that NELFT consistently
achieves more than the 85 per cent
compliance target and that the trust
benchmarked 4th overall amongst
32 London trusts for mandatory
training compliance. NELFT has had
difficulty in increasing the amount
of appraisal activity significantly
across the organisation and this
remains below target overall.
The 2014 staff survey, however,
evidenced that 86 per cent of
respondents had been appraised
within the last 12 months. Action
plans are in place to support
managers and staff to ensure that
appraisal take place and a new
technological solution has been
implemented to accurately record
and report on activity consistently
across the whole of NELFT.
Medical revalidation which brings
together information about doctors
from a range of sources to help
provide them with a complete
picture of their practice continues
across the trust and maintains full
assurance in audit reports.
One area where NELFT is particularly
active is in improving the systems
and processes around recruitment,
specifically around attracting health
care professionals. A national
advertising campaign has been
launched to build on the programme
'A Call to Action', the national
initiative to fill 4,200 additional
funded health visiting posts. NELFT
continues to explore both pay and
non-pay related benefits to attract
and retain such vital staff as well
as increases in the range of staff
benefits in general. NELFT continues
to work with higher education
providers to promote long term
employment prospects for students
placed with us.
Staff engagement and
empowering staff
NELFT has continued with the
strong commitment to more
actively engage with all staff,
through a range of formal and
informal forums. Whereas staff
morale had been improving
following the restructuring last
year, both staff engagement and
job satisfaction have suffered
placing NELFT below the average
when benchmarked nationally.
The findings of the staff survey
show a reduction in satisfaction
levels relating to staff feeling able
to contribute to improvements at
work and motivation at work.
Recognising that this lowering
of morale, whilst currently not
impacting on organisational
performance, is not sustainable
as it does impact on retention
and turnover. NELFT has invested
in further programmes of work
and specific roles dedicated to
improving morale and developing a
more positive culture.
Health and wellbeing
The health and wellbeing agenda
continues to grow, as well as
other networks that focus on
the diversity of the workforce.
NELFT held another successful
sports and wellbeing event in
summer 2014, which was well
received and attended by staff
from all services. Further ambitions
include participating in the global
Corporate Challenge.
Leadership and workforce
development
The Leadership Academy
Programme continues to develop
and, in association with the Care
City programme, aims to manage
the talent of the workforce and
develop the leaders of the future.
Work continues with local partners
as well as Health Education England
North East London NHS Foundation Trust I Quality Account 2014/15
in providing a comprehensive range
of programmes in the field of
leadership development.
Recognising the need for
management skills development
referred to in relation to staff
engagement, ‘Forward Focus’ a
programme for team and deputy
team Leaders has been run
effectively as has a new programme
to equip first line managers with
people management skills.
The development programme for
non-professionally qualified staff in
bands 1 – 4 progressed at a pace
and will be augmented by the Care
Certificate programme from the
new financial year.
innovation goals agreed with our
commissioners through CQUIN
payment framework. The targets
agreed were consistent with
the delivery of NELFT’s strategic
objectives and are delivery driven
at the team, directorate and board
level. Clinical teams monitor their
own performance against each
CQUIN. This occurs via a number
of local forums and through staff
supervision. The monetary total for
achievement of goals in 2014/15
was £5,653k and the monetary
total for achievement of goals in
2013/14 was £5,206k.
The central panel to approve
funding for CPD, processed
applications from 214 staff and
allocated £180,000 worth of
training funds. Further programmes
include continuing coaching
master classes for managers and
the 'unlocking potential' coaching
programme to help staff from BME
backgrounds develop their career
potential.
Workforce diversity
NELFT goes from strength
to strength in this area, with
significant progress in developing
networks for BME staff, staff with
disabilities and LGBT staff. A highly
successful BME conference was
held and NELFT has been requested
to showcase its excellent work
on equality and diversity at local
and regional events as well as in
national publications.
3.11 Commissioning for Quality and Innovation (CQUIN) payment 2014/15
A proportion of NELFT’s income
in 2014/15 was conditional on
achieving quality improvement and
93,171
the total annual number
of mental health and
community health service
occupied inpatient bed days
North East London NHS Foundation Trust I Quality Account 2014/15
Page 79
Essex community health service
End of life
Dementia
Pressure ulcers
Friends and
family test
Indicator description
Page 80
2014/15
Actions to meet
achievement the CQUIN
Maintain full compliance with patient experience questionnaire to ‘5x5’
(five questions to five patients per month per team)
a
None required
Evidence of learning from detractors. Summary report, actions taken to
learn from negative responses and summary of learning used to improve
patient experience
a
None required
Reduction in category 2, 3 and 4 pressure ulcers (old or new):
Baseline: Median of six consecutive monthly data points up to 31 March
2014 (due 15 April)
Reduction:
- median of six month period April to Sept being below baseline
- median of six month period Oct to March being below baseline
a
None required
Quarterly report on actions and measures taken to reduce all grade
pressure ulcers old and new
a
None required
Implement the care home project supporting pressure ulcer reduction.
Quarterly report on roll out of implementation. To include evidence of
harm free days by setting
a
None required
Training to support early identification of people with dementia from
the integrated community team case load by registered nurse. Training
schedule broken down by staff groups relevant to work stream. Progress
against training schedule to be reported
a
None required
Onward referral to ensure diagnosis. Number of referrals to primary care.
Review quarterly in partnership with commissioners pathway
a
None required
Strengthen advance care planning, increased use/awareness of DNAR
(where appropriate) for conditions not just cancers, improved access to
medication and delivery of a service model that provides 24/7 access to
specialist advice to reduce unnecessary emergency admission at end of
life or for symptom management.Summary report on lessons to include
lessons learnt to be escalated through the SWEL group
a
None required
Increase size of end of life (EOL) register
Increase from 13/14 out-turn: Qtr 1:10%, qtr 2: 20%, qtr 3: 30%, qtr 4:
40%.
Based on EOL register as at Dec 13 (596) these percentages would increase
the register as follows: Qtr 1: 655, qtr 2: 715, qtr 3: 775, qtr 4: 834
834 is 0.19% of total population. Best guidance estimates 1% of
population on EOL register. For SW Essex population of 433,635 (as at Jan
14) this would be 4,336
a
None required
Increase proportion of total patients (not just new) on EOL register offered
an advance care plan within three months
Qtr 1: 75%, qtr 2: 100%, qtr 3 – maintain, qtr 4 – maintain
a
None required
North East London NHS Foundation Trust I Quality Account 2014/15
COPD
Indicator description
2014/15
Actions to meet
achievement the CQUIN
Evidence of COPD training (spirometer and complex management of) for
primary health care professionals to facilitate early diagnosis, primary care
management and delivery against quality outcome framework indicators.
One training session to be offered for GP Time To Learn at Thurrock CCG
and BB CCG. Three additional training sessions to be delivered to support
practice nurses for each CCG. Evidence of training in a summary report
a
None required
All South West Essex CCG patients with an MRC 3 or above exacerbation
of COPD admitted to Basildon Hospital or NELFT community beds are
reviewed within two weeks of discharge within the patients community
settings. NELFT to be notified of BTUH discharges via the COPD care
bundles data. Data set defined to be provided as evidence. NELFT will not
be responsible for failure to deliver the CQUIN requirements if they have
made reasonable attempts to get the necessary discharge information
from BTUH but have not been provided with said information
a
None required
Data to support this high impact pathway will be collected monthly
a
None required
Develop education programme which will be given post patient discharge
to support this pathway in the community setting to include primary care,
education setting and child and family. Summarise in a report quantity of
education sessions given
a
None required
NELFT to undertake a retrospective audit of current asthma caseload.
Retrospective audit on readmission rates for those known to the CCN
caseload six months post joining the caseload.
10% reduction in acute admissions for those on the asthma pathway
a
None required
Quarterly summary report to highlight community equipment pressures
within the SW Essex system
a
None required
Share with commissioners baselines for qtr 1. For qtr's 2-4 share with
commissioners increase activity
a
None required
Population
growth
scheme
Community
equipment
Children and young people
People with COPD have a comprehensive clinical and psychosocial
assessment, at least once a year or more frequently if indicated, which
includes degree of breathlessness, validated measures of health status and
prognosis, presence of hypoxemia and comorbidities
NELFT to undertake a retrospective audit of current asthma caseload.
Retrospective audit on readmission rates for those known to the CCN
caseload six months post joining the caseload.
10% reduction in acute admissions for those on the asthma pathway
North East London NHS Foundation Trust I Quality Account 2014/15
Page 81
London community health service
Indicator description
Percentage reduction against baseline of 6.5 pressure ulcers per month for
new grade 2, 3 or 4 pressure ulcers which were avoidable by the trust
2014/15
Actions to meet
achievement the CQUIN
a
None required
Attendance at provider to provider meetings to review data collection
Pressure ulcers
Trust to submit draft improvement plan to commissioners by end of qtr 1
Attendance at joint meeting with acute and community provider to discuss
and agree an improvement plan on how providers will to work together to
reduce system wide pressure ulcer prevalence
Trust to be given one month to write up and finalise improvement plans. Plan to contain as a minimum: Identification of the areas to be targeted. Details of how the provider intends to improve. Clear and measurable
outcomes that enables the provider to know and demonstrate their input
has led to a reduction in pressure ulcers. Measurement of healing rates for
patients admitted to the Trust with a pressure ulcer present on admission
None required
Improvement plan implemented and rolled out to identified areas
Intergated care management acute bed reduction
Friends and family test
Trust to provide evidence that delivery of improvement plan actions has led
to a reduction in the prevalence of grade 3 and 4 pressure ulcers
Page 82
To undertake the friends and family test survey asking staff about their
recent experience of working in NELFT. How likely are you to recommend
NELFT to friends and family if they needed care or treatment?
a
None required
To undertake the friends and family test survey asking staff about your
recent experience of working in NELFT. How likely are you to recommend
NELFT to friends and family as a place to work?
a
None required
Number of responses received via mode of collection
a
None required
Report in qtr 4 on the progress of ICM LOS reduction plan
a
None required
Audit of 10% of patients to be undertaken
a
None required
300 patients to be reviewed with a reduction of 300 predicted discharge days
r
The 300 predicted
dicharge days
target was
narrowly missed
in qtr 4. NELFT
achieved 257
days, this led to
a small financial
consequence
North East London NHS Foundation Trust I Quality Account 2014/15
Wound care
Falls
Dementia
screening
Indicator description
2014/15
Actions to meet
achievement the CQUIN
Patients aged 65 years and over referred to ICM, IRS and community
inpatients screened for dementia
a
None required
Proportion of people with a positive dementia screening result who are
referred directly to memory clinics for specialist assessment
a
None required
Agreement with key stakeholders of falls pathway in respect of service
users with particular focus on ICM cohort (expected stakeholders: acute
and primary care, social services, CCG commissioners, voluntary sector
groups including carer representatives, LAS)
a
None required
NELFT to take key lead role jointly with NHS commissioners
a
None required
NELFT to identify a key senior manager lead for falls and clinical champion
a
None required
Falls pathway in place by end of qtr 1
a
None required
Adoption of a falls risk assessment tool
a
None required
Implementation within the teams working to the ICM and DN caseload
(linked with primary care diagnosis of osteoporosis)
a
None required
40% of ICM and DN qualified staff trained up to use risk assessment tool
a
None required
Provide twice weekly wound/ suture clinics one each in Comely Bank and
Chingford health centres per week
a
None required
To provide promotions information to GPs describing service and how to
access the service
a
None required
To review feasibility of 3rd clinic base for south of borough to commence
early qtr 2
a
None required
To audit activity of clinics against capacity and by GP practice in monthly
report. Capacity for qtr 1 is 400 and 600 for qtr 2, qtr 3 and qtr 4 patient
contact episodes
a
None required
To provide third weekly clinic in base in south of borough or 3rd clinic in
Comely bank if not viable
a
None required
To audit activity of clinics against capacity and by GP practice in monthly
report
a
None required
To undertake a satisfaction survey of GPs regarding the service and report
on findings
a
None required
Produce a final report on recommendations for mainstreaming impact of
service to include all activity and surveys and costings
a
None required
To audit activity of clinics against capacity and by GP practice in monthly
report
a
None required
To undertake a satisfaction survey of patients using the survey and report
on findings
a
None required
North East London NHS Foundation Trust I Quality Account 2014/15
Page 83
London mental health services
Dementia
Improving and
extending access to
access assessment
teams (AAT) (BHR)
Cardiometabolic
assessment for patients
with schizophrenia
Falls
Friends and
family test
Indicator description
Implementation of staff friends and family test (FFT) as per national
guidance
a
None required
Full delivery of FFT across all services delivered by the provider as outlined
in national guidance
a
None required
Full delivery of the nationally set milestones
a
None required
To improve clinical practice in identifying patients at risk of falls
a
None required
To demonstrate, through a national audit process similar to the national
audit of schizophrenia, full implementation of appropriate processes for
assessing, documenting and acting on cardio metabolic risk factors in
patients with schizophrenia
a
None required
Ensure that 75% of service users on care plan approach with diabetes,
coronary heart disease and COPD, hypertension and obesity have either
completed a physical health check with their GP or that there is recorded
evidence of an outreach attempt to facilitate it
a
None required
Extending access hours from 5pm to 8pm
a
None required
Improving access to AAT to meet GPs’ requirements
a
None required
Improving dementia diagnosis rates
a
None required
Develop and implement programmes of cognitive stimulation therapy
a
None required
Improve time for assessment to dementia diagnosis/results of tests
a
None required
NELFT employs
more than
5,750 people
Page 84
2014/15
Actions to meet
achievement the CQUIN
North East London NHS Foundation Trust I Quality Account 2014/15
Appendix 1
Quality Account governance structure
NELFT board/EMT
Reports to NELFT board
( Half yearly – Stephanie Dawe)
Quality and safety committee
(Half yearly – Stephanie Dawe)
Data quality group
Chief nurse meeting
(Quarterly – Julie Price)
Basildon
and
Brentwood
LPQSG*
Thurrock
LPQSG
(Integrated care
director)
(Integrated care
director)
Basildon
and
Brentwood
DPQSG**
Barking
and
Dagenham
LPQSG
Havering
LPQSG
(Integrated care
director)
Redbridge
LPQSG
(Integrated care
director)
(Integrated care
director)
Thurrock
DPQSG
Barking and
Dagenham
DPQSG
Havering
DPQSG
Redbridge
DPQSG
Waltham
Forest
LPQSG
(Integrated care
director)
Waltham
Forest
DPQSG
Inpatient
Acute
Directorate
LPQSG
(Integrated care
director)
Inpatient
Acute
Directorate
DPQSG
(Monthly – assistant
(Monthly – assistant (Monthly – assistant
service director)
service director)
service director)
(Monthly – assistant
(Monthly – assistant
service
director)
service director)
(Monthly – assistant
(Monthly – assistant
service director)
service director)
Local Improvement priorities/leads
Patient and service user involvement
* LPQSG - Locality performance and quality safety group
** DPQSG - Directorate performance and quality safety group
North East London NHS Foundation Trust I Quality Account 2014/15
Page 85
Appendix 2
Third party statements
Quality Account distributed for comment to:
Healthwatch
Local authority
•
•
•
•
•
•
•
•
•
•
•
•
Barking and Dagenham
Basildon
Havering
Redbridge
Thurrock
Waltham Forest
Health and wellbeing boards
•
•
•
•
•
•
Barking and Dagenham
Basildon
Havering
Redbridge
Thurrock
Waltham Forest
Page 86
Barking and Dagenham
Basildon
Havering
Redbridge
Thurrock
Waltham Forest
Local authority health and
overview scrutiny committees
•
•
•
•
•
•
Barking and Dagenham
Essex
Havering
Redbridge
Thurrock
Waltham Forest
Clinical commissioning chair
groups
•
•
•
•
•
•
Barking and Dagenham
Basildon
Havering
Redbridge
Thurrock
Waltham Forest
NELFT
• Staff
• NELFT board members
North East London NHS Foundation Trust I Quality Account 2014/15
Statement from Waltham Forest CCG
Waltham Forest CCG welcomed
the opportunity to review
the NELFT Quality accounts.
The Quality account has been
reviewed by:
• Helen Davenport:
Director of nursing and quality
• Lorraine Smailes:
Deputy director of quality
and Safeguarding Adults
• Deirdre Malone:
Deputy director of
integrated governance
• Nyasha Mapuranga:
Quality assurance manager
WELC Collaborative
Comments regarding the
Quality Account
The Quality Account is very well
written. It has been written with
the reader (patients/ public)
in mind. It is clear and easy to
follow. NELFT has been very
transparent about the clinical
quality safety issues and the
mitigation that they have put in
place.
The CCG agrees with all the
three priorities. However, Priority
3 (Compassion) regarding the
care makers programme is
not clear. The document does
not clearly explain what the
role entails and how it would
influence the 6Cs.
Some suggestions:
• The safeguarding section is
a little light. There appears
no mention of the SCR and
learning from Waltham Forest
perspective
• Whilst OFSTED is a review
of LA processes, should it
be mentioned within the
document as NELFT was a key
player when reviewed within
Waltham Forest? i.e. MASH
service, looked after children
and safeguarding children?
• No mention of prevent. NELFT
has undertaken a great deal
of work in this area. Waltham
Forest remains one of the top
eleven in London
• Also the collaborative work
NELFT is involved in within
Waltham Forest regarding
child sexual exploitation
project
• It might be worth mentioning
that there is now a local
NELFT CQRM for Waltham
Forest
• Duty of candour is listed as
something NELFT discuss.
NELFT has undertaken a great
deal of work on this but it is
not reflected in their quality
accounts
• Where area of poor patient
experience has been identified
it needs to explain what
NELFT has done to address
and improve the patient
experience and outcomes
• NELFT should consider
including a line on the
collaborative working with
regards to quality assurance
visits
• Serious incidents (page 48):
this section is too generic.
NELFT has not described
how learning from serious
incidents has been embedded
• We would have preferred
a report with a completed
complaints section. The Trust
should consider including
the number of complaints
supported by the Health
Service Ombudsman (HSO) to
show how HSO has supported
their investigated complaints
• Glossary page is missing
MUST score and a few other
abbreviations used under
Clinical Audit
We hope the above comments
will help in completing the
Quality account. As stated
above, it a clear, reader-friendly
document.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 87
Page 88
North East London NHS Foundation Trust I Quality Account 2014/15
North East London NHS Foundation Trust I Quality Account 2014/15
Page 89
NHS Thurrock CCG commentary on
North East London NHS Foundation Trust 2014/15
NHS Thurrock CCG welcomes the opportunity to comment on the annual Quality Account
prepared by North East London NHS Foundation Trust (NELFT) as the primary commissioner of
the Trust’s South West Essex Community Services.
To the best of NHS Thurrock CCG’s knowledge, the information contained in the Account is
accurate and reflects a true and balanced description of the quality of provision of services.
The CCG is pleased to note that the Trust has used patient feedback to influence the priorities
for 2015/16:
Working together for Patients
The CCG supports the decision to include the question ‘Do you feel you were involved in your
care as much as you would have liked?’ in all patient experience surveys, which will enable the
measurement of compliance with the Trust’s Patient Experience Strategy.
Commitment to quality and care
The CCG is pleased to note that this priority includes the collection of NHS Patient Safety
Thermometer data, monitoring of safer staffing levels in line with NICE guidance and the
implementation of the healthcare support workers induction programme. This will lead to staff
successfully professionally developing to hold a Care Certificate.
Compassion
This builds on the Compassion in Practice national initiative to ensure that patients in their care
are treated with dignity, respect and empathy.
The CCG is pleased to note within this section the sharing of outcomes from compliments and
concerns, demonstrates an open culture and opportunity to learn and working with partners
across the whole patient pathway.
Whilst the Basildon, Brentwood & Thurrock locality patient survey results demonstrate
positive outcomes for community and in-patients services, it is noted that one area for further
improvement related to the quality of food.
The report provides a detailed account of the corporate, clinical audit and research
programmes, including measures to improve the quality of care. It would be useful in future
reports to include percentage compliance rates within the outcomes.
The CQC carried out a total of 5 inspections across the whole of NELFT and no enforcement
action was undertaken. However, it is noted that there were no inspections to this locality.
The internal audit of standards is detailed, including the 100% compliance with the use of the
NHS numbers for in-patient and out-patient care and a robust compliance with the general
medical practice code.
The CCG notes the NELFT Information Governance Assessment Report for which they have
achieved 68% which is deemed green rated and satisfactory.
Progress against 2014/15 priorities is reported within the Account and detailed below.
Page 90
North East London NHS Foundation Trust I Quality Account 2014/15
Communication
• It is disappointing that the staff FFT results for ‘recommendations for NELFT as a place
to work’ have declined. This outcome is also reflected in the annual staff survey results. The 2015/16 priority is to raise the profile of staff involvement and to engage the whole
workforce to optimise morale. The CCG actively support NELFT with this initiative.
• The allocation of named professionals for individual patients. The CCG notes from the
Account that the named nurse is being displayed at 99% of bed spaces. However,
named consultant is not included within this data. The CCG would be interested to
know when the rollout of electronic monitoring of this standard will be undertaken for
the Essex locality.
• Introduction of a robust feedback loop following complaints and consultations. The
formatting of information within this section is difficult to read due to the size of the font
Care
• Zero tolerance for pressure ulcers programme. The CCG will be working with NELFT to
support is reduction programme
Competence
• Skills for Health training standards for all new health care workers. The CCG will be
seeking clarity during 2015/16 on the data and progress on outcomes.
• The CCG notes that the internal register has yet to be produced and this will be
monitored through 2015/16. creation of an internal register for health care support
workers
Dementia care
The CCG have supported NELFT piloting a local community based Dementia Crisis Support
Team (DCST) in BB&T localities. The purpose of the team has been to deliver care to people
with dementia in a timely manner in their place of residence. The DCST provides a rapid
response and a specialist multidisciplinary intervention and assessment for those with dementia
and suspected dementia in a crisis situation. This approach has contributed to the reduction
on overall hospital admissions as well as ensuring the people with dementia, their families and
carers are able to access specialist care in the most appropriate setting.
Breast feeding - Baby Friendly Care
The CCG congratulates the Trust on its achievement on being accredited as a UNICEF Baby
Friendly service. It is recognised that the NELFT staff have worked hard to ensure Stage 3 was
achieved over the last year. This has resulted in increased breastfeeding rates improving care for
all mothers and babies. The CCG agree that mothers can be confident that their health visitors
will provide high standards of care and support them to continue breast feeding.
Infection Control
The Infection Control data identifies that there have been no cases of C difficile reported
through NELFT which is a positive achievement.
CQUINS
The CCG is pleased to note the successful achievement of the 2014/15 CQUINS which are
positive initiatives for improving quality and patient experience.
NHS Thurrock CCG is fully supportive of all the priorities identified by NELFT in taking forward
the patient safety, effectiveness, experience and involvement agenda and looks forward to
working in partnership with the Trust in the forthcoming year.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 91
Statement from Healthwatch Waltham Forest
Page 92
North East London NHS Foundation Trust I Quality Account 2014/15
Statement from Healthwatch Havering
Thank you for asking us to comment on the Quality Account proposals for 2014/2015, below are some
comments and suggestions as requested.
A substantial part of the work that Healthwatch has undertaken with NELFT has been the work with the Positive
Parents group and the wider agenda for Learning Disabilities. This work has required NELFT to have a high degree
of compassion, the ability of working together for patients and a complete commitment to quality and care.
During 2014/2015 we have seen the development of this approach from the NELFT team and we are delighted
that these three themes are now being taken forward as the three Priorities for 2015/2016.
Priority 1 - Working together for patients
For the parents of children with Learning Disabilities it is often the experience of the parent/carer that can be most
crucial in establishing the long term relationship that is needed to sustain the child and the family with the NELFT staff.
Your decision to include the question ‘Do you feel you were involved in your care as much as you would have
liked?’ in all of your patient experience surveys, is an excellent approach.
Suggestion: Is it possible to extend this positive question to the parents and carers of children.
Priority 2 Commitment to Quality and Care - Safer Staffing
Earlier in the year Healthwatch undertook an Enter and View to Ogura Ward, this was at the request of the
parents of two young men who were patients on the ward. These concerns were about the poor quality of the
environment and the lack of interesting and stimulating activities.
Our Healthwatch volunteers visited the ward and requested that urgent consideration be given to increasing
staffing levels to enable staff to offer more input to stimulating activities. The overall environment was noted as
extremely poor.
The proposal that NELFT increase the number of nursing staff is going to be a challenge particularly in north east
London.
Suggestion: The increase in staff includes the creation and designing of new roles which would support the
patients in their wider need for stimulating activities and their overall health and wellbeing, rather than the more
traditional nursing roles.
Priority 3 - Compassion
This is a key component in providing care as it is so closely linked to dignity and respect, it requires a nurturing
and supportive approach.
NELFT’s concept of developing and introducing a Care Makers Programme made up of colleagues throughout
your services; both clinical and corporate, volunteers ranging from care assistants, student nurses, physiotherapists
through to directors, medical staff and board members, is forward thinking and innovative.
The three priorities for this year address some really key issues and build on the feedback from patients which is
essential to service improvement. We wish you every success and look forward to working with you during the year.
Anne-Marie Dean - Chairman Healthwatch Havering
12/05/2015
North East London NHS Foundation Trust I Quality Account 2014/15
Page 93
Statement from Royal College of Psychiatrists
Mr John Brouder
Chief Executive
North East London NHS Foundation Trust
Trust Head Office, Goodmayes Hospital
157 Barley Lane
Ilford
IG3 8XJ
Dear Mr Brouder
I enclose a summary of your Trust’s participation in our national quality improvement
programmes over the last 12 months. This should assist you in preparing your Trust’s
Quality Account for 2014/15.
We have listed the national clinical audits that your Trust took part in, together with the
services that have been accredited or participated in quality improvement networks.
Following a request from the Care Quality Commission, we are providing information
about participation in accreditation programmes and results from the National Audit
of Schizophrenia. These will be used in their Intelligent Monitoring of Trusts and in
data packs that help inspectors prepare for hospital visits.
The CQC recognise the value that participation in accreditation and quality improvement networks has for assuring the quality of care Trusts provide. Participation
demonstrates that staff members are actively in engaged in quality improvement and
take pride in the quality of care they deliver.
If you have any queries about service accreditation, please contact Francesca
Brightey-Gibbons on fgibbons@rcpsych.ac.uk. Yours sincerely
Professor Mike Crawford
Director, College Centre for Quality Improvement
Page 94
North East London NHS Foundation Trust I Quality Account 2014/15
Participation in National Quality Improvement Programmes
From 01 April 2014 – 31 March 2015
Trust Participation
National Participation
Service Accreditation Programmes and Quality Improvement Networks
Eating Disorder Inpatient Wards
0 wards
36 wards
Forensic Mental Health Units
1 service
110 units
Inpatient Child and Adolescent Wards
1 ward
120 wards
Inpatient Rehabilitation Units
0 wards
45 wards
Learning Disability Inpatient Wards
0 wards
20 wards
N/A Units
15 units
Older Peoples’ Inpatient Wards
0 wards
54 wards
Psychiatric Intensive Care Wards
0 wards
37 wards
Working Age Inpatient Wards
0 wards
163 wards
Child and Adolescent Community Mental Health Teams
0 teams
56 teams
Crisis Resolution and Home Treatment Teams
0 teams
36 teams
Electroconvulsive Therapy Clinics
1 clinic
82 clinics
Memory Clinics
4 clinics
91 clinics
Perinatal Community Mental Health Teams
1 teams
20 teams
Psychiatric Liaison Teams
0 teams
57 teams
Mother and Baby Units
NELFT participation in the Prescribing Observatory for Mental Health (POMH-UK)
Topic
Trust participation
National participation
Teams
Submissions
Teams
Submissions
Topic 14a: Prescribing
for Substance Misuse
(Alcohol Detoxification)
6
21
174
1197
Topic 12b: Prescribing
for Personality Disorder
5
29
522
4014
Topic 9c: Prescribing for
People with a Learning
Disability
TBA
TBA
TBC
TBC
North East London NHS Foundation Trust I Quality Account 2014/15
Page 95
National Audit of Schizophrenia
Monitoring of BMI
The below figure shows the percentage of service users in each Trust who
had their BMI monitored and recorded at least once in the previous 12
months. There is a wide range across Trusts, from 5 per cent to 92 per cent
being recorded as monitored in NAS2, with a TNS average of 52 per cent. In
NAS1 the range was 27 per cent to 87 per cent with a TNS of 51 per cent.
NAS ID: 47 (NELFT)
The data for this figure area taken from Q34 of the audit of practice tool
The number of cases included in this analysis is 5,608.
Data collected Autumn 2013
Page 96
North East London NHS Foundation Trust I Quality Account 2014/15
Appendix 3
2014/15 Statement of directors’ responsibilities in respect of the quality report
The directors are required under
the Health Act 2009 and the
National Health Service (Quality
Accounts) Regulations to prepare
Quality Accounts for each financial
year.
Monitor has issued guidance to
NHS foundation trust boards on
the form and content of annual
quality reports (which incorporate
the above legal requirements) and
on the arrangements that NHS
foundation trust boards should put
in place to support the data quality
for the preparation of the quality
report.
In preparing the Quality Report,
directors are required to take steps
to satisfy themselves that:
• The content of the Quality
Report meets the requirements
set out in the NHS Foundation
Trust Annual Reporting Manual
2014/15 and supporting
guidance
• The content of the Quality
Report is not inconsistent with
internal and external sources of
information including:
• Board minutes and papers for
the period April 2014 to 26 May
2015
• Papers relating to Quality
reported to the board over the
period April 2014 to 26 May
2015
• Feedback from commissioners
dated between 21 April and
26 May 2015
• Feedback from governors dated
17 February 2015
• Feedback from local
Healthwatch organisations
dated between 21 April and
26 May 2015
• Feedback from Overview and
Scrutiny Committee – still
awaited (NELFT draft Quality
Report was emailed to them on
21 April 2015)
• The trust’s complaints report
published under regulation 18
of the Local Authority Social
Services and NHS Complaints
Regulations 2009, dated
05/05/2014
• The [latest] national patient
survey 26 October 2014
• The [latest] national staff survey
24 March 2015
• The Head of Internal Audit’s
annual opinion over the trust’s
control environment dated
26 May 2015
• CQC Intelligent Monitoring
Report dated 30/11/2014
• 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
• The Quality Report has been
prepared in accordance with
Monitor’s annual reporting
guidance (which incorporates
the Quality Accounts
regulations) (published
at www.monitor.gov.uk/
annualreportingmanual) as well
as the standards to support
data quality for the preparation
of the Quality Report (available
at www.monitor.gov.uk/
annualreportingmanual).
The directors confirm to the best
of their knowledge and belief they
have complied with the above
requirements in preparing the
Quality Report.
By order of the Board
Peter Wignall
Acting Chair
27 May 2015
John Brouder
Chief Executive
27 May 2015
North East London NHS Foundation Trust I Quality Account 2014/15
Page 97
Appendix 4
Auditor’s limited assurance report
We have been engaged by the
Council of Governors of North East
London NHS Foundation Trust to
perform an independent assurance
engagement in respect of North
East London NHS Foundation
Trust’s Quality Report for the
year ended 31 March 2015 (the
“Quality Report”) and certain
performance indicators contained
therein.
Scope and subject matter
The indicators for the year ended
31 March 2015 subject to limited
assurance consist of the national
priority indicators as mandated by
Monitor:
• Percentage of patients on
enhanced Care Programme
Approach (CPA) followed up
within seven days of discharge
from hospital; and
• Percentage of admissions to
acute wards gate kept by
the Crisis Resolution Home
Treatment Team (CRHT);.
We refer to these national priority
indicators collectively as the
“indicators”.
Respective responsibilities of the
Directors and auditors
The Directors are responsible for
the content and the preparation of
the Quality Report in accordance
with the criteria set out in the NHS
Foundation Trust Annual Reporting
Manual issued by 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:
Page 98
• the Quality Report is not
prepared in all material respects
in line with the criteria set out
in the NHS Foundation Trust
Annual Reporting Manual;
• the Quality Report is not
consistent in all material respects
with the sources - specified
in the Detailed Guidance for
External Assurance on Quality
Reports (‘the Guidance’); and.
• the indicators in the Quality
Report identified as having been
the subject of limited assurance
in the Quality Report are not
reasonably stated in all material
respects in accordance with the
NHS Foundation Trust Annual
Reporting Manual and the six
dimensions of data quality set
out in the Detailed Guidance
for External Assurance on
Quality Reports.
We read the Quality Report and
consider whether it addresses
the content requirements of the
NHS Foundation Trust Annual
Reporting Manual, 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:
• Board minutes for the period
April 2014 to April 2015;
• Papers relating to Quality
reported to the Board over the
period April 2014 to May 2014;
• Feedback from Commissioners
dated 21 April and 26 May
2015;
• Feedback from governers dated
17 February 2015;
• Feedback from local
Healthwatch organisations,
dated 21 April and 26 May
2015,
• the trusts complaints report
published under regulation 18
of the Local Authority Social
Services and NHS Complaints
Regulations 2009, dated 5 May
2014;
• the national patient survey,
dated 26 October 2014;
• the national staff survey, dated
24 March 2015;
• Care Quality Commission
intelligent Monitoring Report
dated 31/11/14; and
• the Head of Internal Audit’s
annual opinion over the trust’s
control environment, dated 26
May 2015.
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 North East London NHS
Foundation Trust as a body, to
assist the Council of Governors in
reporting North East London NHS
Foundation Trust’s quality agenda,
North East London NHS Foundation Trust I Quality Account 2014/15
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 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 North
East London 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 (Revised) ‘Assurance Engagements other
than Audits or Reviews of Historical
Financial Information’ issued by
the International Auditing and
Assurance Standards Board (‘ISAE
3000’). Our limited assurance
procedures included:
• Evaluating the design and
implementation of the key
processes and controls for
managing and reporting the
indicators.
• Making enquiries of
management.
• Testing key management
controls.
• Limited testing, on a selective
basis, of the data used to
calculate the indicator back to
supporting documentation.
• Comparing the content
requirements of the NHS
Foundation Trust Annual
Reporting Manual to the
categories reported in the
Quality Report.
• Reading the documents.
A limited assurance engagement is
smaller 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 criteria set out in the NHS
Foundation Trust Annual Reporting
Manual.
The scope of our assurance work
has not included governance over
quality or non ­mandated indicators
which have been determined
locally by North East London 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 is not
prepared in all material respects
in line with the criteria set out
in the NHS Foundation Trust
Annual Reporting Manual;
• the Quality Report is not
consistent in all material respects
with the sources specified in the
Guidance; and
• the indicators in the Quality
Report subject to limited
assurance have not been
reasonably stated in all material
respects in accordance with the
NHS Foundation Trust Annual
Reporting Manual.
KPMG LLP, Statutory Auditor
15 Canada Square Canary Wharf
London E14 5GL
27 May 2015
North East London NHS Foundation Trust I Quality Account 2014/15
Page 99
Glossary
6Cs of nursing
These are care, compassion, competence, communication, courage and
commitment which are the centre point of the national Compassion in
Practice strategy – embraced by all NHS staff.
Agile working
To empower staff by giving more flexibility and reducing constraints,
enabling the organisation to optimise performance and service.
Audit Commission
Local spending watchdog. The Commission’s primary objective is to
appoint auditors to a range of local public bodies in England, set the
standards for auditors and oversee their work.
Care programme approach (CPA)
The term ‘Care programme approach’ describes the framework for
supporting and coordinating effective mental health care for people with
severe mental health problems in secondary mental health services.
Care Quality Commission (CQC)
The Care Quality Commission is the health and social care regulator for
England. It looks at the joined up picture of health and social care. Their
aim is to ensure better care for everyone in hospital, in a care home and at
home. They provide the Essential Standards for Quality and Safety against
which organisations must demonstrate compliance.
Child and adolescent mental health
services (CAMHS)
CAMHS are specialist NHS services who offer assessment and treatment
when children and young people have emotional, behavioural or mental
health difficulties.
Clinical audit
Clinical audit is a process that has been defined as a quality improvement
process that seeks to improve patient care and outcomes through
systematic review of care against explicit criteria and the implementation of
change.
Clinical commissioning groups
(CCGs)
CCGs commission the majority of health services, including emergency
care, elective hospital care, maternity services, and community and mental
health services, since the implementation of the Health and Social Care Act
2012 on 1st April 2013. There are 211 CCGs, each commissioning care for
an average of 226,000 people.
Commissioning for Quality and
Innovation (CQUIN)
The CQUIN payment framework was introduced in 2009 to make
a proportion of providers’ income conditional on demonstrating
improvements in quality and innovation in specified areas of care.
The framework helps make quality part of the commissioner-provider
discussion everywhere. The framework has been designed based on
feedback from partners in the NHS.
Page 100
North East London NHS Foundation Trust I Quality Account 2014/15
DATIX
DATIX is a patient safety and risk management software application that
enables users to spot trends as incidents/adverse events occur and reduce
future harm by prioritising risks and putting in place corrective actions.
Francis Report
The final report of the Mid Staffordshire NHS Foundation Trust Public
Inquiry was published on 6 February 2013. Robert Francis’ report outlines
failures by individuals, tiers of management and regulators. Following
recommendations, NHS England has led many significant improvements to
address the concerns raised in this landmark report (www.england.nhs.uk).
Integrated governance
Integrated governance is the process of “systems, processes and
behaviours by which NHS trusts providing services for the National Health
Service in the United Kingdom lead direct and control their functions in
order to achieve organisational objectives, safety and quality of service
and in which they relate to patients and carers, the wider community and
partner organisations”.
MHS
Mental health services.
Monitor
Monitor is the sector regulator for health services in England. Our job is to
protect and promote the interests of patients by ensuring that the whole
sector works for their benefit. They exercise a range of powers granted by
Parliament which include setting and enforcing a framework of rules for
providers and commissioners, implemented in part through licences we
issue to NHS-funded providers.
NELCS
North East London Community Services.
NELFT (North East London NHS
Foundation Trust)
NELFT – a community and mental health services trust serving the health
needs of residents in south west Essex (community only), Havering,
Redbridge, Waltham Forest and Barking & Dagenham.
National Institute of Clinical
Excellence (NICE)
NICE is an independent organisation responsible for providing national
guidance on promoting good health and preventing and treating ill health.
National Reporting and Learning
System (NRLS)
NRLS is a central database of patient safety incident reports. Since the
NRLS was set up in 2003, over four million incident reports have been
submitted. All information submitted is analysed to identify hazards, risks
and opportunities to continuously improve the safety of patient care.
North East London NHS Foundation Trust I Quality Account 2014/15
Page 101
Glossary (continued)
Payment by Results (PbR)
The aim of PbR is to provide a transparent, rules-based system for paying
trusts. It rewards efficiency, supports patient choice and diversity and
encourages activity for sustainable waiting time reductions. Payment is
linked to activity and adjusted for casemix. Importantly, this system ensures
a fair and consistent basis for hospital funding rather than being reliant
principally on historic budgets and the negotiating skills of individual
managers.
NHS Safety Thermometer
The NHS Safety Thermometer provides a ‘temperature check’ on harm,
such as pressure sores and Urinary Tract Infections (UTIs), that can be
used alongside other measures of harm to measure local and system
improvement. The NHS Safety Thermometer allows teams to measure
harm and the proportion of patients that are ‘harm free’ during their
working day, for example at shift handover or during ward rounds.
Serious case reviews (SCR)
Serious case reviews take place after a child dies or is seriously injured and
abuse or neglect is known or suspected. The aim is to help agencies learn
lessons about how they can work better together to protect children from
serious abuse.
Social Care Institute for Excellence
(SCIE)
An independent charity working with adults, families and children’s social
care, social work services, health care and housing - improving the lives of
people who use care services by sharing knowledge about what works.
Staff friends and family test
(Staff FFT)
Staff FFT is a feedback tool for staff, predominantly for local improvement
work; consisting of two questions (with options to give free text feedback
for each) through which organisations can take a temperature check of how
staff are feeling. It is a quicker feedback mechanism than the existing NHS
annual staff survey, and at its best will enable staff to voice their concerns
(on a regular basis if they wish to) and for organisations to respond.
TUPE
Transfer of undertakings (protection of employment) regulations 2006.
Page 102
North East London NHS Foundation Trust I Quality Account 2014/15
Useful contact numbers
Borough/Directorate
Name
Extension
Val Ayres
01268 244600 ext. 4600
Barking and Dagenham
Emma Harrington
0300 555 1201 ext. 65066
Havering
Samantha Darby
0300 555 1201 ext. 65048
Redbridge
Alison Wood
0208 822 4254 ext. 74254
Jan Murray
0300 555 1201 ext. 68496
Helena Corny
0300 555 7233 ext. 67233
Basildon, Brentwood and Thurrock
Waltham Forest
In-patient & acute directorate (IPAD)
Trust secretary
Trust Head Office
Goodmayes Hospital
Barley Lane
Ilford
Essex IG3 8XJ
Email: helen.essex@nelft.nhs.uk
Tel: 0300 555 1200
Trust membership
Members get information on local
health services and shape how
these develop. Members can also
stand as governors and take part in
key activities. Membership is free.
For more information contact North
East London NHS Foundation Trust
on 0800 694 0699
Patient advice
If you require information, support
or advice, please contact us on:
Tel: 0300 555 1200
Accessibility
If you require this report in another
language or in a different format,
eg. large print, easy read, braille or
audio, please contact:
Harjit Bansal
NELFT equalities and diversity
manager
Email: harjit.bansal@nelft.nhs.uk
Tel: 0300 555 1201 ext 64231
Careers
For the latest information on
vacancies at NELFT please visit our
website at www.nelft.nhs.uk
You can follow us for news and
upcoming events for our users and
members:
on twitter.com/NELFT
on www.facebook.com/NELFTNHS
on LinkedIn www.linkedin.com/
company/north-east-london-nhsfoundation-trust
North East London NHS Foundation
Trust (NELFT) provides community
and mental health services
for people of all ages in the
London boroughs of Barking and
Dagenham, Havering, Redbridge
and Waltham Forest and
community health services in the
south west Essex areas of Basildon,
Brentwood and Thurrock.
North East London NHS
Foundation Trust
Trust Head Office
Goodmayes Hospital
Barley Lane
Ilford
Essex IG3 8XJ
Tel: 0300 555 1200
©2015 North East London NHS Foundation Trust
North East London NHS Foundation Trust I Quality Account 2014/15
Page 103
www.nelft.nhs.uk
Page 104
North East London NHS Foundation Trust I Quality Account 2014/15