Quality Report
2012 - 2013
The Fifth Quality Account of
Somerset Partnership NHS Foundation Trust
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
A report on the quality of the care we offer
and how we are seeking to improve
SOMERSET PARTNERSHIP NHS FOUNDATION TRUST
QUALITY ACCOUNT
2012/13
CONTENTS
Page
Part 1
Statement on Quality
Statement on Quality from the Chief Executive
Part 2
1
Priorities for Improvement and Statements of
Assurance from the Board
Priorities for Improvement
Priorities for Improvement for 2012/13
3
Priorities for Improvement 2013/14
17
Statements of Assurance from the Board
Part 3
Clinical Audit/Research Activity
24
Local Quality Improvement Plans
30
Commissioning for Quality and Innovation
35
Registration with the Care Quality Commission and
periodic/special reviews
35
Data Quality
40
Progress and evaluation of performance against
national and local indicators
41
Review of Quality Performance
Patient Safety
47
Staff Wellbeing and Development
49
Patient Experience
50
i
APPENDICES
APPENDIX 1
Statements from External Agencies
53
APPENDIX 2
Statement of Directors‟ responsibilities in respect of the
quality report
56
APPENDIX 3
Performance Indicators Subject to External Audit
58
ii
PART ONE: STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
I am pleased to present the Somerset Partnership NHS Foundation Trust‟s fifth
annual Quality Report and our first full year report as a provider of both mental
health and social care and community health services. The provision of safe quality
services and the best possible experience for patients, staff and the public remains
central to the work of the Trust and we have made great strides in terms of our focus
on improving quality during the year, and I am grateful once again for the
contribution that staff and key stakeholders have made to that success.
In 2012 we introduced new clinical governance arrangements to monitor standards
and address areas of concern more effectively across the Trust. We now report
monthly to the public Board meeting on Quality issues and publish this information
on our website.
There are a number of national targets set each year by the Department of Health
and locally, against which we monitor the quality of the services we provide. Through
these Quality Accounts we aim to provide you with information on how effective our
services are, how they are measured and where we aim to make improvements.
In February 2012 the Trust approved a Quality Strategy for 2012-15 which describes
the structures and processes developed to underpin the Trust Board‟s strategic
responsibility for quality, sets out clear commitments to the quality of care that will be
delivered, defines the process for reporting progress and identifies priorities for
quality improvement in the coming years.
During 2012/13 we have moved forward significantly in delivering the aims of the
Strategy, in particular the integration of clinical policies, clinical audit and patient
safety programmes, rolling out the Trust‟s Quality Effectiveness and Safety Trigger
Tool to mental health services, improving our uptake of mandatory training and
strengthening our arrangements for appraisal of medical practitioners.
We have also further developed our patient and public involvement approach,
integrating our governors into our Patient and Public Involvement Group and
providing quarterly reports to the public meetings of our Council of Governors and
the Board on all aspects of patient feedback and public engagement. In 2013 we will
launch our revised Patient and Public Involvement Strategy which will set out 13 key
standards we have agreed with our staff, governors and patient representative
groups.
We have continued to work with colleagues from the Learning Disabilities
Partnership in Somerset and have rolled out the programme of Patient Passports to
help people who have a learning disability understand their care and treatment, an
initiative that has now been taken up by other NHS Trusts across the country.
People with learning disabilities will continue to work with us over the next year to let
us know about the quality of our services through a programme of joint audits.
As will be seen from the information set out in this report, the Trust has continued
actively to undertake clinical audit across both the community health and the mental
health and social care directorates. This process has been supported by the
1
Somerset Partnership Integrated Clinical Effectiveness (SPICE) conferences, the
work of our Medical Audit Group and the clinical audit work of the Professional Nurse
Advisory Group. In the last year the Trust has again maintained its progress in its
research work, with mental health services participating in all of the national clinical
audits and national confidential enquiries in which it was eligible to participate.
The Trust has continued to bring quality and performance together, through reporting
and monitoring within the Trust‟s performance dashboard. The Trust has also
worked in partnership with NHS Somerset, our main commissioner of services, to
develop a set of quality measures to be used to monitor our contract to provide
community and mental health services.
The Trust has again consulted widely on the quality improvement areas for 2013/14
with staff, governors and patient representative groups, based on a „long list‟ of
priorities drawn from the Trust‟s own review of its quality performance and the
identification of areas for improvement. The Trust agreed as part of this process that
it would have as its overarching theme for 2013/14 improving patient experience and
patient and carer involvement in care.
The priority areas we have identified for this year are:
personalised care planning (including promoting self-care/personal independence)
avoidable pressure ulcers
recognising physical deterioration (including hydration)
recruiting for care and compassion
screening for dementia
medicines administration
These priorities have been included in our Quality Improvement Plans developed by
all our services and teams for 2013/14.
I hope that you will find this report informative and you will agree that we have made
excellent progress with the quality agenda over the last year. In February 2013, Sir
Robert Francis QC published the report of his inquiry into Mid Staffordshire NHS
Foundation Trust and the government has now issued its initial response “Putting
Patients First and Foremost”. We believe that the areas we have identified as
priorities this year, particularly our focus on involving patients and carers and
recruiting for compassion, support the findings and recommendations of the inquiry.
We will continue our focus on quality over the next twelve months, which will be
measured through our own Ward to Board quality performance reporting and
national quality measures such National Patient Safety Agency and National Institute
of Health and Care Excellence compliance, and will build upon the excellent care
which our patients have come to expect from us, and to raise standards yet further.
To the best of my knowledge, the information in this document is accurate.
EDWARD COLGAN
Chief Executive
2
PART TWO: PRIORITIES FOR IMPROVEMENT AND STATEMENT OF
ASSURANCE FROM THE BOARD
PRIORITIES FOR IMPROVEMENT 2012/13
In this section we review how we performed against the key priorities we set
ourselves last year.
During 2012 the Trust introduced new governance and Quality reporting
arrangements to ensure that we sharpened our focus on all aspects of quality across
the Trust.
While our aim is always to achieve the continuous quality improvement of all our
services, each year we focus on a number of particularly key issues where we think
improved quality would make the most difference to our patients.
We then agree ways to measure how we have improved these aspects of our care
delivery and we ask teams, wards and services to develop two local Service Quality
Improvement Plans - which draw on at least one of these priorities – and report at
the end of the year how they have made a difference locally in this area.
In 2012/13, the Trust produced its first integrated quality account. Staff, Governors
and stakeholders identified the following priorities:
Patient Safety Thermometer (harm free care)
-
Pressure ulcers
-
Falls
-
Catheter acquired infections
-
Venous Thromboembolism (VTE)
care planning
nutrition
dementia
Learning Disabilities.
Here is how we have done.
3
PERSONALISED CARE PLANNING
In the last twelve months the Trust has set up a Personalised Care Planning
Working group comprising clinicians and operational managers. The group reviewed
the Trust policy and procedures relating to personalised care planning benchmarking
them against national standards and Care Quality Commission (CQC) outcomes.
This resulted in the development of a set of key principles for Personalised Care
Planning for both inpatient and community settings. The principles have been
cascaded to all front line teams together with practical guidance on the care planning
process using local workshops.
Following a period of implementation, two audits of personalised care planning have
been completed, one for inpatients and one for patients cared for in a community
setting.
These audits measured compliance against the agreed principles and have been
used as a benchmark. Where there are areas of non-compliance, teams have been
asked to develop improvement plans and these are being monitored through the
relevant best practice groups via Clinical and Social Care Effectiveness group.
The results of the audits for inpatient wards and community settings are set out
below. We recognise that there is more work to be done and we have kept care
planning as a key priority for next year‟s Quality Account to make sure we further
embed this key quality measure in the services we provide.
4
REF
NO
COMPLIANCE
(%)
STANDARD
1
All patients should have one plan of care which outlines the current care/treatment
being provided
94%
2
The plan of care should clearly reflect the individual needs and goals of a patient
identified as a result of the assessment process
83%
3
In addition to the identified needs, the plan of care should also record the
individual preferences of the patient which are to be taken into account during the
in-patient stay
61%
4a
4b
An interim plan of care should be recorded within 4 hours of admission.
As a minimum, the interim care plan should detail the patient and/or health
professionals understanding of the following:
1. reason for admission;
2. admission objectives; and
3. key risks to be managed.
48%
1: 70%
2: 61%
3: 83%
5
The working care plan should be in place within 24 hours of admission to a
Community Health inpatient setting or within 72 hours of admission to a Mental
Health inpatient setting.
83%
6
The plan of care should focus on strengths and needs, seek to promote recovery
and be drawn up in consultation with the patient (and carer where appropriate)
54%
7
Care plans should be written to the patient, avoiding jargon and using plain
English which can be easily understood by the patient (and carer where
appropriate).
55%
8
A current copy of the plan of care should be offered or made available to each
patient.
88%
9
The plan of care should be updated when a new care need is identified or the care
needs have changed
61%
10
There should be a review of the care plan with the patient/carer at least weekly
and the care plan updated accordingly.
Review: 44%
CP updated:89%
11
All changes to the care plan must be made by and/or agreed with a qualified
professional.
98%
12
The progress/evaluation records must reflect the care needs in the care plan and
not replace them
86%
13
Where a review of patients‟ progress highlights and/or identifies a change to the
plan of care, the care plan is updated.
The current care plan should ONLY include current care needs.
5
79%
81%
REF
NO
14
COMPLIANCE
(%)
STANDARD
Care Plans should be written in a manner that is: Specific, Measurable,
Achievable, Realistic and Timely.
42%
Community Services
COMPLIANCE
(%)
STANDARD
1
All patients should have one plan of care which outlines the current care/treatment
agreed
Exceptions: Patients only being assessed
91%
2
The plan of care should clearly reflect the individual needs and goals of a patient
identified as a result of the assessment process
84%
3
In addition to the identified needs, the plan of care should also record the individual
treatment/care preferences of the patient which are to be taken into account
74%
4
The plan of care should focus on the patient‟s strengths and needs, seek to
promote recovery and be agreed in consultation with the patient (and carer
where appropriate)
Exceptions: Where patients lack capacity, consultation will be proportionate to
their capacity
80%
5
Care plans should be written to the patient, avoiding jargon and using plain English
which can be easily understood by the patient (and carer where appropriate)
65%
6
A current copy of the plan of care should be offered to each patient
52%
7
The plan of care should be considered (and updated if applicable) at each contact
67%
8
There should be a review of the care plan with the patient/carer at least annually
and the care plan updated accordingly
79%
9
All changes to the care plan must be made by and/or agreed with a registered
professional.
95%
6
10
The progress/evaluation records must reflect the care needs in the care plan and
not replace them
87%
11
Where a review of patients‟ progress highlights and/or identifies a change to the
plan of care, the care plan is updated.
The care plan should ONLY include current care needs/plans.
94%
12
Care Plans should be written in a manner that is: Specific, Measurable,
Achievable, Realistic and Timely
66%
For the purposes of providing a benchmarking tool in which standards can be grouped into non-compliant, partially compliant,
and compliant, to aid improvement, the follow “RAG” Red, Amber & Green score has been developed.
00% - 44%: Non – Compliant
45% - 79%: Partially Compliant
80% - 100%: Compliant
The intention of this RAG rating is to provide a simple visual indication of compliance, which provides focus to those standards
specifically highlighted in this audit as requiring improvement. However, the actual percentage results are also shown to give
exact compliance rates.
Recommendations and the resulting action plans arising from these audits will be
monitored through the Trust‟s Best Practice Groups and Care Planning Group.
PATIENT SAFETY THERMOMETER
Pressure Ulcers
Figure 1 illustrates the monthly total numbers of pressure ulcers (grade 2 and above)
reported to be present 72 hours post admission or transfer to the Trust‟s community
health and mental health inpatient wards.
Figure 1 - Number of pressure ulcers (Grade 2 and above) occurring 72 hours
post admission/ transfer
8
7
7
7
6
6
5
5
5
5
5
5
4
4
4
3
3
3
Number of Press ure Ulcers
2
2
1
0
Mar-12
Apr -12
May-12
Jun-12
Jul-12
Aug -12
Sep -12
7
Oct -12
Nov-12
Dec -12
Jan-13
Feb -13
Mar-13
Figure 1 shows that the monthly number of pressure ulcers meeting these criteria
reported in the Trust‟s inpatient wards ranged from two in May 2012, to seven in
April and September 2012. The average monthly number across the reporting
period was five. In March 2013, five such pressure ulcers were reported in
community hospital inpatient wards, and none in mental health wards.
Slips, Trips and Falls
Figure 2 below sets out the monthly numbers of cases of slips, trips and falls
occurring on the Trust‟s inpatient wards, and the percentage of these resulting in
injury during the period from 1 March 2012 to 31 March 2013.
Figure 2 - Incidents Involving Slips, Trips and Falls on Inpatient Wards, and the
Percentage of these Resulting in Injury
180
45%
Incidents Involving slips, trips and fall on inpatient
wards
160
154
Percentage of total slips, trips and falls resulting in
injury
40%
152
149
140
35%
128
122
120
117
117
30%
111
105
103
101
103
100
25%
87
80
20%
60
15%
40
10%
20
5%
0
0%
Mar-12
Apr -12
May-12
Jun-12
Jul-12
Aug -12
Sep -12
Oct -12
Nov-12
Dec -12
Jan-13
Feb -13
Mar-13
The monthly number of slips, trips and falls reported across the year ranged from 87
in August 2012, to 154 in December 2012, with a monthly average of 119. The
percentage of all slips, trips and falls resulting in injury across the period was 27%.
Figure 3 illustrates the monthly numbers of slips, trips and falls on inpatient wards
resulting in injury. Figure 3 shows that the average monthly number of slips, trips
and falls resulting in injury during the reporting period was 33.
8
Figure 3- Number of Incidents Involving Slips, Trips and Falls on Inpatient
Wards Resulting in Injury
50
45
45
45
42
39
40
35
35
34
33
31
30
28
28
25
25
20
20
18
15
Number of Inci de nts Resulti ng in I njury
10
5
0
Mar-12
Apr -12
May-12
Jun-12
Jul-12
Aug-12
Sep -12
Oct -12
Nov-12
Dec -12
Jan-13
Feb -13
Mar-13
The year saw an increase in the number of complex patients with cognitive
impairment or dementia, falling on multiple occasions. These patients have reduced
awareness of safety and require close supervision and frequent checking, in order to
minimise their risk of falling. The increase in the numbers of these complex patients
coincided with high level of bed occupancy in a number of community hospitals,
leading to a situation of multiple high-dependency, high-risk patients on the ward at
the same time presenting challenges for staff to provide the close supervision
required for every at risk patient.
The total number of slips, trips and falls reported during the period 1 April 2010 to 31
March 2011 was 1,309. The total number reported between 1 April 2012 and 31
March 2013 was 1,004, a reduction of 23%
The average number of slips, trips and falls per average occupied bed reported
during the period 1 April 2010 to 31 March 2011 was 4.958. The average for the
period 1 April 2012 and 31 March 2013 was 3.804
Infection Control
The Trust has robust systems and processes in place to manage the risk associated
with the prevention and management of infections within our services.
The Trust has performed very well against the targets set nationally and locally. In
the last year the Trust had a commissioner-set trajectory of no more than ten cases
of Clostridium difficile infections attributable to the Trust. The Trust reported a total of
just five cases as at 31 March 2013 (an improvement of five cases on the previous
year).
9
In terms of Meticillin Resistant Staphylococcus Aureus (MRSA), the Trust did not
have a national target but set an internal trajectory for 2012/13 of zero. In the last
year the Trust reported no cases of MRSA bacteraemia bloodstream Infection. The
last Trust attributable case was reported in July 2009, pre-acquisition.
Hands are the most common cause of transporting micro-organisms and Somerset
Partnership NHS Foundation Trust operates a zero tolerance policy towards noncompliance with the Hand Hygiene Policy. Local hand hygiene audits are a valuable
source of compliance and these are validated by the Infection Prevention and
Control team on a quarterly basis. The validated scores to date have ranged from
97% to 100%.
Evidence demonstrates that 2.5% of hospital inpatients acquire a urinary tract
infection (UTI) during admission. This can lead to an increased length of
hospitalisation (average 5-6 days), additional pain and discomfort experienced by
patients, and can lead to complicated upper UTI infections and bacteraemia. The
major predisposing factor is the presence of an indwelling urinary catheter. Evidence
suggests that an average of 26% of patients are catheterised and the risk of
acquiring a catheter associated urinary tract infection is 1-2% per procedure.
The 2012/13 NHS Operating Framework announced the extension to the collection
of data using the NHS Patient Safety Thermometer. This included the collection of
the prevalence of catheter associated infections as part of the Commissioning for
Quality and Innovation (CQUIN) payment programme. This data has been collected
on a monthly basis across all Somerset Partnership managed community hospitals
and older peoples mental health units, and since December 2012, across all
community nursing services.
To enable the Trust to provide sufficient assurance in relation to the management of
urinary catheterised patients the Trust Continence and Infection Prevention and
Control Leads have undertaken a pilot to promote a urinary catheter free inpatient
service, leading to a reduction in the risk of patients acquiring urinary tract infections
linked to the indwelling device. This was undertaken at Burnham on Sea Community
Hospital.
The results of this pilot have demonstrated reassuringly positive results for Burnham
on Sea inpatients and provide tangible evidence that staff that are well informed and
enabled to make robust clinical assessments in relation to indwelling devices can
positively influence patient outcomes. The Continence Link Practitioner has reported
increased staff awareness in relation to urinary catheterised patients being admitted
to Burnham on Sea Community Hospital. Nursing staff are now leading the
professional challenge in relation to the continued requirement for this type of
indwelling device and are actively implementing a trial without catheter when not
clinically indicated.
The next challenge for the organisation is to roll this initiative out across all of the
Somerset Partnership managed inpatient services. It is planned to initially roll the
pilot out across the four South Somerset based Community Hospitals
(Chard/Crewkerne/Wincanton and South Petherton), and the Infection Prevention
10
and Control/Continence Leads are planning to meet with the Matrons of these four
inpatient areas to identify key personnel to be involved.
The Catheter Acquired UTI pilot has been shortlisted for a National Patient Safety
Award, the results of which are to be announced in July 2013.
Venous Thromboembolism (VTE) Assessments
As set out in the table below, the Trust has met and exceeded its CQUIN targets for
VTE assessments in every month from April 2012 to March 2013.
11
Objective
Measure
Percentage of all
adult inpatients
who have had a
VTE risk
assessment on
admission to
hospital
Improve Quality
of Care for
Patients
Ensure that
patients receive
timely
assessment and
treatment for
venous
thromboembolism
Percentage of
audited adult
inpatients where
appropriate
prophylaxis is
used for patients
assessed as at
risk of VTE
Number of
inpatients
diagnosed with
hospital acquired
venous
thromboembolism
where no root
cause analysis
has been done
May12
Jun12
Sep12
Dec12
Jan13
Feb13
Mar13
>=90% in
every
month
95.8%
97.3% 99.1% 96.9% 96.5% 97.7% 97.6% 97.8% 97.8% 97.8% 97.7% 98.7%
>=90% in
every
month
Not
collected
96.2% 97.5% 97.4% 99.0% 97.3% 96.7% 95.7% 97.8% 98.3% 97.8% 99.6%
0
0
0
0
12
0
0
Oct-12
Nov12
Apr-12
0
Jul-12
Aug12
Target
0
0
0
0
0
0
Nutrition
The Trust seeks to deliver the highest standards of nutritional care to patients. During 2012/13 we have met and exceeded our
CQUIN targets for nutritional assessments, using the validated “MUST” tool in every month from April 2012 to March 2013.
Objective
Improve
Quality of
Care for
Patients
Ensure that
patients
receive
timely
assessment
for nutrition
Measure
C6a.
Percentage of
all adult
inpatients
who have had
nutrition
screening
using a
validated tool,
such a MUST,
within 24
hours of
admission to
hospital
Percentage of
all identified
inpatients at
risk who have
a plan within
24 hours of
admission to
hospital
Percentage of
all full
compliance of
the
recommended
management
care plan
Target
Apr-12
May-12
Jun-12
Jul-12
Aug-12
Sep-12
Oct-12
Nov-12
Dec-12
Jan-13
Feb-13
Mar-13
>=90%
97.8%
96.9%
98.9%
98.3%
98.3%
94.8%
96.2%
95.4%
97.3%
96.4%
97.1%
94.7%
>=90%
Not
collect
ed
95.5%
96.1%
95.8%
98.9%
95.0%
96.2%
96.6%
95.9%
94.4%
93.3%
93.4%
100%
100 %
96.3%
100%
100 %
96.6%
>=90
Specific clinical audits of
selected patient records
undertaken confirmed
100% compliance
Clinical audits showing
100% compliance
13
Dementia
The Trust has worked during the year to achieve the level one standards of the South West Dementia Partnership: Improving Care
for People with dementia or mild cognitive impairment whilst in hospital and to meet eight level two standards. A dementia audit
was undertaken in the year and the information will be used during 2013/14 to drive forward further improvements.
The Trust has met its CQUIN targets for dementia screening1, risk assessment and referral for diagnosis.
We have also continued to work with the wider health and social care community to promote good practice in the treatment of
behavioural and psychological symptoms of dementia.
Objective
Measure
Dementia
screening
Ensure
appropriate
identification
and support
for patients
with
dementia in
order to
provide
appropriate
management.
Percentage
of patients
aged 75 and
over who
have been
asked the
dementia
screening
question
within 72
hours
following
admission
to hospital
Percentage
of patients
aged 75 and
over
screened as
at possible
risk of
dementia
who have
May12
Jun12
Jul-12
Aug12
Sep12
Dec12
Jan13
Feb13
Mar13
Apr-12
>=90%
Not
collected
76.8% 96.8% 99.6% 98.6% 97.3%
97.9%
98.2% 98.9% 98.9% 98.3% 98.3%
>=90%
Not
collected
58.3% 78.4% 87.3% 78.3% 85.0%
95.0%
97.3% 98.4% 98.6% 97.8% 97.5%
14
Oct-12
Nov12
Thresholds
had a
dementia
risk
assessment
during the
admission
stay
Percentage
of patients
aged 75 and
over,
identified
as at risk of
having
dementia (
>=90%
Not
collected
38.1% 81.3% 90.0% 88.1% 86.2% 100.0% 97.7% 97.1% 97.6% 91.9% 93.5%
1
Under the Commissioning for Quality and Innovation (CQUIN) payment framework - Guidance on new national goals for 2012-13
“Payment for indicator one will be based on the achievement of 90% or above for a consecutive three month period. Payment for indicators two and three can only be achieved
if indicator one is above 90% and the target of 90% for these two indicators is achieved for three consecutive months…This means that the provider will need to ensure that
systems are in place by 31st December at the very latest to be able to earn the full 100% CQUIN payment during the 2012/13 contract year, as no payment will be awarded for
indicators two and three if indicator 1 is below 90%.”
15
Somerset Partnership NHS Foundation Trust has continued to develop its services
for people with Learning Disabilities (LD) in response to the key drivers set out in
„Healthcare for All‟. These are to:
1.
empower integrated and accessible healthcare for people with LD:
empowering access and empowering services to be accessible
2.
ensure healthcare is safe and effective
3.
develop a culture of Reasonably Adjusted NHS care
4.
develop services that people their carers and families want
5.
ensure all health staff are trained to support people with LD
Steps we have taken this year include:
Inclusion
All LD developments are discussed through the Learning Disabilities Partnership
Board which includes user and carer representation. We hold a “Better Health
Check Up” day annually where we report on our services to the LDPB and we are
looking to include LD representation in our new Patient and Public Involvement
Group.
Primary Care
All GP practices are linked to an LD Primary Care Liaison Nurse and identifiable
through GP registers. Somerset has a Direct Enhanced Service in place for Annual
Health Checks and, uniquely, we have set up a Better Health Team to support this
process which also includes bespoke Health Facilitators and Language Facilitators.
Acute Care
We have Acute Liaison Nurses in post across Yeovil District Hospital and Musgrove
Park Hospital and have rolled out Hospital Passports for those with LD.
Mental Health Care
People with LD have full access to mental health services in Somerset as required
with Community LD Nurses acting as liaison, fully supported by the Rapid
Intervention Team (designed along LD Intensive Support Team model).
Training
Somerset Partnership‟s LD service provides training, bespoke to complex needs, to
the Local Authority and to all other LD providers. Courses include:
Challenging Behaviour and Behavioural Support Plans
ICE (Inclusive Communication Environments)
16
Epilepsy Management
Dysphagia
Reasonable Adjustments
The Trust has included LD as its tenth „Protected Characteristic‟ within our Equality
and Diversity Policy. We have also developed and put in place a range of innovative
and effective accessible signage at Holford ward, Rydon ward and in the planning for
the new Bridgwater Hospital and Frome Dental Access Centre.
PRIORITIES FOR IMPROVEMENT 2013/14
This section sets out how we decided our priorities for improvement for 2013/14.
During 2012 we consulted with staff, governors, patients and commissioners on our
proposals for priorities for quality improvement for 2013/14, based on a „long list‟ of
priorities drawn from the Trust‟s own review of its quality performance and the
identification of areas for improvement. The Trust agreed as part of this process that
it would have as its overarching theme for 2013/14 improving patient experience and
patient and carer involvement in care.
The „long list‟ of potential priorities was as follows:
personalised care planning;
avoidable pressure ulcers;
recognising physical deterioration;
recruiting for care and compassion;
hydration;
dementia;
preventing suicide;
medicines administration;
promoting self-care/personal independence.
Other areas for consideration were a focus on better recording of risk assessment
and issues around consent and capacity.
Following the consultation exercise, the general feedback was supportive of all
aspects of the overarching approach and of all the identified priorities.
All of the priorities will be taken forward. The final list of priorities to be included in
Service Quality Improvement Plans, together with the rationale and the proposed
performance measures and monitoring arrangements are set out in Table 1 below.
With regard to the area of preventing suicide, following feedback from recent serious
untoward events, the Trust is developing its own strategy during 2013 – to
17
complement the countywide Suicide Prevention Strategy. It is felt that a focus on the
implementation of this would best form part of the Quality Account priorities for
2014/15 and work this year should focus on the development and publication of the
strategy itself.
Monitoring of risk assessment recording – again an issue which has been highlighted
in investigations of serious untoward incidents – will continue to be monitored as a
local quality indicator.
The Trust has established a working group to look at issues around assessment of
capacity and consent and a programme for improvement in these areas will be
developed during the year and monitored through the Mental Health Act Group, as
appropriate.
The Trust will monitor performance against these priorities through its Quality report
and other reports to the Board and Council of Governors and through the Integrated
Governance Committee, the Clinical Governance Group and the Patient and Public
Involvement Group.
18
QUALITY ACCOUNT PRIORITIES 2013/14
Overarching Theme
Rationale
Improving Patient Experience and In line with the provisions of the NHS
Patient and Carer Involvement
Mandate, the revised NHS
Constitution and the development of
the Trust‟s own integrated Patient and
Public Involvement Strategy, the Trust
aims to develop local ward and
service level improvement plans
alongside organisational initiatives to
improve patient and carer involvement
in care and deliver measurably better
patient experiences in all services
19
Performance Improvement
Measures
Friends and Family Test –
levels of response; increased
positive responses
Monitoring
Monthly reports from April
2013
CQUIN performance measures
CQUINs monitored
quarterly through Clinical
Governance Group
Achievement against Local
Quality Improvement Plan
outcomes
Monitored quarterly
through Clinical
Governance Group
Patient Survey results and
outcomes
Quarterly reports to
Patient and Public
Involvement (PPI) Group,
Board and Council of
Governors
Priority Area
1
2
Personalised Care Planning
(including promoting self care and
personal independence)
Avoidable Pressure Ulcers
Rationale
In line with national initiatives “No
Decision About Me Without Me” and
the overarching theme, this also
remains the area that those individuals
and organisations consulted on felt
most strongly about. The Trust
continues to monitor the number of
patients with care plans and those
whose care has been reviewed
through a dedicated Best Practice
Group. Care planning remains a core
task carried out to support the delivery
of effective care. It applies to all
services, although the actual plan
developed with patients may vary in
design and style, depending on
circumstances
In line with the roll out of the Patient
Safety Thermometer and the revised
programme for Harm Free Care, the
Trust has been a leader in
implementing new reporting and
monitoring pressure ulcers. This has
led to an increased level of reporting
and serious untoward incident
reviews. The Trust is looking to
prioritise this work to ensure that it is
fully embedded in all inpatient and
community services
20
Performance Improvement
Measures
Monthly monitoring of numbers
of patients with care plans (for
mental health services these
will be measured in line with
the Recovery Care
Programme Approach).
Monitoring
Monitored quarterly
through Clinical
Governance Group
Audits of care plans across
services
Monitored quarterly
through Clinical
Governance Group
Patient survey results on
involvement in care planning
and decision-making
Annual reports to PPI
Group, Board and Council
of Governors
Number of reported Grade 2, 3
and 4 pressure ulcers
Grade 3 and 4 incidents
monitored monthly
through SIRI Review
Group and reported
monthly to the Board.
Grade 2 incidents
monitored monthly
through Clinical
Governance Group
CQUIN performance measures
Monitored quarterly
through Clinical
Governance Group
3
4
5
Priority Area
Rationale
Recognising Physical Deterioration
(including hydration)
Reflecting national initiatives and Trust
priority programmes to ensure that
physical deterioration in patients is
monitored actively and acted upon
promptly as part of the Trust‟s Quality
Strategy and patient safety
programme. The Trust has identified
a particular theme of hydration, linked
to national patient experience and
local concerns raised and reported
through complaints and PALS
Recruiting for Care and
Compassion
Screening for Dementia
Performance Improvement
Measures
Physical Assault Reporting
System (PARS) reporting of
incidents
Hydration levels and
availability of water/fluids
monitored through
unannounced inspection
programme
Monitoring
Monitored quarterly
through Clinical
Governance Group
Monitored quarterly
through Clinical
Governance Group
To reinforce the principles of the Chief
Nursing Officer‟s “6 Cs” campaign and
the Trust‟s own Quality Strategy, the
Trust is looking to ensure that all staff
acknowledge the need for care and
compassion as core attributes in
delivering high quality health services.
The Trust will review all its job
descriptions to ensure they have these
attributes as essential parts of the
personal specification and will
incorporate „tests‟ into
recruitment/interview and appraisal
processes
Percentage of job descriptions
reviewed to include revised
person specification
Appraisal records
Monitored quarterly
through Workforce
Governance Group
The Trust will look to continue its work
on realising the benefits of integrated
community and mental health care in
screening and providing care for
patients with dementia in line with the
government‟s high priority for
CQUIN performance measures
Monitored quarterly
through Clinical
Governance Group
21
New posts recruited with
compassion „test‟
Monitored quarterly
through Workforce
Governance Group and
Professional Nursing
Advisory Group
Monitored quarterly
through Human
Resources Report to the
Board
Priority Area
Rationale
Performance Improvement
Measures
Monitoring
management of this disease and the
countywide Dementia Strategy.
6
Medicines Administration
In response to incident reports and
training needs analysis – and in line
with the Trust‟s review of medicines
management arrangements, the Trust
is looking to focus on reinforcing
competency training of all staff
involved in medicines administration
22
Percentage of relevant staff
who have successfully
undertaken mandatory training
and competency assessment
in medicines administration
Monitored quarterly
through Workforce
Governance Group
STATEMENTS OF ASSURANCE FROM THE BOARD
In this following section we report on statements relating to the quality of NHS
services provided as stipulated in the regulations.
The content is common to all providers so that the accounts can be
comparable between organisations and provides assurance that Somerset
Partnership NHS Foundation Trust Board has reviewed and engaged in
national initiatives which link strongly to quality improvement.
The Board has received monthly information on quality indicators as part of
the Patient Safety, Quality and Activity Report and from September 2012
through the Quality Report and the Finance and Performance Report. In
addition, the Board has received reports on patient experience. The Board is
satisfied with the assurances it has received.
The Board has discussed the priorities for 2013/14 and has agreed those
described above.
Services provided by the Trust
During 2012/13 Somerset Partnership NHS Foundation Trust provided and/or
sub-contracted 83 relevant services, including the following:
Acute services (including community hospitals; minor injury units;
surgical operations; diagnostics, termination of pregnancy clinics;
psychiatric liaison)
Long-term conditions services
Inpatient services for people with mental health needs, learning
disabilities and problems with substance misuse
Prison healthcare services
Rehabilitation services
Community healthcare services (e.g. district nursing; integrated
therapy services; health visiting; school health nurses; family planning
and sexual health services)
Dental services
Community learning disability services including rapid intervention
and speech and language services.
Community mental health services including community mental
health teams; assertive outreach; early intervention teams; court
assessment services; crisis resolution home treatment teams.
The Somerset Partnership NHS Foundation Trust Board has reviewed all the
data available on the quality of care in all 83 of these relevant health services.
23
The income generated by the NHS services reviewed in 2012/13 represents
100% of the total income generated from the provision of relevant health
services by the Somerset Partnership NHS Foundation Trust for 2012/13.
The data reviewed aimed to cover the three dimensions of quality – patient
safety, clinical effectiveness and patient experience. The types of data
reviewed included targeted measures and patient experience. The Trust
considers that the amount of data did not impede these objectives.
CLINICAL AUDIT/RESEARCH
During 2012/2013 five national clinical audits and one national confidential
enquiry covered relevant health services that Somerset Partnership NHS
Foundation Trust provides.
During 2012/13 the Trust participated in 100% of national clinical audits and
100% of national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that the Trust
was eligible to participate in during 2012/13 are as follows (listed with the
number of cases submitted as a percentage of the number of registered cases
required by the terms of that audit):
1. National Audit of Schizophrenia 100%
2. National Audit of Psychological Therapies 100%
3. Intermediate Care 100%
4. Stroke Improvement National Audit Project (SINAP) (ongoing, 5 years)
100%
5. Prescribing Observatory for Mental Health – UK:
-
Prescribing high dose and combined antipsychotics on adult acute
and psychiatric intensive care wards Topic 1f 100%
-
Prescribing for people with Personality Disorders 100%
-
Screening for metabolic side effects of antipsychotic drugs 100%
-
Prescribing antipsychotics for people with dementia 100%
-
ADHD (data collection/input ongoing)
6. National Confidential Inquiry into Suicide and Homicide by People with
Mental Illness 100%
There were a total of 34 audits on the Trust Clinical Audit Plan for 2012/13.
The status of these is as follows:
Fully
completed
Awaiting
finalised report
National, ongoing
into 2013/2014
Postponed
19
10
3
2
24
Total
34
In addition to this, there are a large number of audit projects outside the
2012/13 Trust Clinical Audit Plan, being carried out by individual
clinicians/teams, or carried over and completed during this period from the
previous audit plan:
Fully completed
Ongoing
Total
26
16
42
The number of patients receiving relevant health services provided or subcontracted by Somerset Partnership NHS Foundation Trust in 2012/13 that
were recruited during 2012 to participate in research approved by a research
ethics committee was 174 -129 into national portfolio studies and 45 into own
account studies. Examples of actions to improve the quality of healthcare
provided as a result of clinical audits include:
25
Audit 41: Personalised Care Planning, Inpatient Services (both community and mental health hospitals)
Objective: To assess compliance with standards for Personalised Care Planning
Sample: The audit included all community hospitals and mental health wards in Somerset Partnership. 5 sets of notes were randomly selected
from each hospital/ward, with the inclusion criteria of the patient being admitted to hospital for a minimum of 5 days. Total sample = 145 from
29 wards
Recommendation (community hospitals):
Report to be discussed at Community Hospital (CH) Best Practice
1
Group
All CH to use the new care planning documentation to ensure
2
consistency across all CH
Actions required (community hospitals):
Send electronic copies and obtain feedback
New documents to be printed and circulated
Staff orientation with new documentation fully in use
All Sisters to review a minimum of 2 care plans per ward per week
initially, and review after 6 months.
Devise an agreed checklist which is consistent across all hospitals
Invite MH Ward Manager to CH BP group to talk through process
Implement a “peer review” system of care plan review, which will
include updating plans where required, and feeding results into
3
individuals supervision to enable learning
This peer review should cover all standards taken from this audit
4
All nurses to bring a care plan to their supervision sessions, in addition
to those being reviewed as part of the peer review
Included within supervision as a standing item
Recommendations (mental health wards):
Report to be discussed at Ward Managers/Inpatient Quality Indicators
1
(IQIS) Best Practice Group
Implement a “peer review” system of care plan review across all wards,
which will include updating plans where required, and feeding results
2
into individuals‟ supervision to enable learning. This peer review should
cover all standards taken from this audit
3
All nurses to have a care plan reviewed in their supervision sessions, in
addition to those being reviewed as part of the peer review
Action required (mental health wards):
Discuss and agree recommendations
Ward Managers to review a minimum of 2 care plans per ward per
week initially, and review after 6 months.
Devise an agreed checklist which is consistent across all wards.
To be included within supervision as a standing item
Devise an agreed checklist which is consistent across all wards
Review the existing peer support work identified through the Patient
Safety Programme considers the findings from this audit
Work with all the acute wards to ensure this happens and explore
possible recording of exceptions to this
4 Ensure patients are fully involved in their care planning
5 All patients should have an interim care plan within 4 hours
26
Recommendations (both community and mental health hospitals):
Action required
Re-audit for both Community Hospitals and Mental Health Wards in 12 months, to include:
Clarity to be provided on the scope and purpose of the audit i.e. an audit of Care Plans, or an
audit of Care Planning?
Standards to reflect the scope and purpose
Standards to be clear and precise, allowing for clear understanding of what is being asked
Clinical Audit team to be involved in designing the re-audit and standards
Pilot of standards and audit tool
Clear guidance given for auditors
Recommendation to be passed to Care
Planning Group to include in re-audit planning
process
Results of audit to be circulated across all inpatient staff
Results to be discussed in Hospital/Ward
meetings
Publish in SPICE News
Audit 13: Dementia Care for patients within Community Hospitals
Objectives:
1.
2.
3.
4.
Improving the patient and carer experience when accessing the Trust for dementia services
To identify gaps in practice and put in place action plans to address these
Embed and move forwards with the South West Hospital Standards in Dementia Care
Strengthen workforce knowledge and skills in dementia care
Sample: All patients admitted to a community hospital between 1 September 2012 – 1 December 2012 requiring a dementia screen were
included, total sample = 56.
Recommendation
Action required
Report to be discussed at the Dementia and Community Hospital Best
Practice Groups, and the Dementia Champions Group
Put on agenda for discussion
All patients with dementia and suspected dementia should have their
records clearly identified
To reinvigorate the use of the butterfly symbol both in patient rooms and
handover sheets Ensure all members of the multidisciplinary team are
aware of the relevance of that symbol
27
Continued focus on ensuring all patients in our community hospitals
suspected of dementia have appropriate risk assessments and
ongoing referral to specialist services
Individual hospitals continue to value the importance of the dementia
champion role to support both staff and patients
Share audit results with Clinical Commissioning Group (CCG) as
outlined in 2012/2013 CQUIN framework
Further communications to all teams to ensure appropriate assessments
are undertaken on admission and during the patient pathway
Profile to be raised at various Best Practice Meetings
Guidance to be reissued to Ward Sisters in relation to the Dementia
Champion role
Dementia Champions to have regular meetings with their Ward Sisters to
discuss local issues and feedback at Dementia Champions meetings
Audit results will be shared at next Quality Review Meeting (after
finalisation of this report)
Audit 2: Improved Planning for End of Life Care
1. To provide a baseline compliance with the Quality Standard for End of Life Care
2. To identify any gaps in practice and put an action plan in place to address these
3. To provide evidence of compliance with the CQUIN Target 8 – Improved Planning for End of Life
Sample: 65 patients who had died in Community Hospitals, plus 28 from the District Nursing localities. Total sample = 93.
Recommendation
1
2
3
4
Action required
Report to be discussed at End of Life, Community Hospital and Community
Nursing Best Practice Groups
Heighten awareness of the Electronic Palliative Care Coordination Systems
(EPaCCS) and its usage within Community Hospitals
Develop an enhanced training framework building on the successes from
the last year including:
Launch of the revised health community Advanced Care Planning Policy
Outcome of national review of Liverpool Care Pathway (LCP)
Results of this audit
Provide a consistent and standardised approach to written information in the
event of death
28
Put on agenda for discussion
Arrange a schedule of visits to each Community Hospital with
relevant Lead from Commissioning Group
Workforce Group to carry out a training needs analysis and
consider participation in wider multidisciplinary training within the
GP Federations
Devise an organisation bereavement pack
All patients approaching End of Life should receive a full holistic assessment
of all needs, which should be an ongoing process
Organisational wide recording required with regards to LCP, including
6
responsible clinician/service
5
7 Share audit results with CCG as outlined in 2012/2013 CQUIN framework
Ensure all staff are aware of the Personalised Care Planning
Strategy (and audit results) and its implications in clinical practice
Review current practice and reporting templates to provide
assurance
Audit results will be shared at next Quality Review Meeting (after
finalisation of this report)
Audit 1: Prescribing and review of antipsychotic medication for those people diagnosed with dementia
Audit objectives: To ensure that all people who are diagnosed with dementia, and who are prescribed antipsychotic medication,
have had their medication reviewed at least once over the previous 12 months (Bannerjee 2009)
Sample: All current patients with a recorded diagnosis of dementia were included in this audit. Questionnaires sent to staff to
complete, 1905 forms returned (89%).
Recommendation
Action required
1 Disseminate via SPICE News
Post on intranet and send to the Head of Clinical Effectiveness and Research
2
Ensure information is given to patients and/or carers with
regards to risks/benefits of antipsychotics
3
Establish clear responsibility between Somerset Partnership
and GPs re medication reviews etc.
Request POMH-UK to ascertain if they will be producing a specific information
leaflet for this patient group
Consider devising shared care protocol, which could develop into change of
priority/funding for the partnership to conduct medical reviews on patients who
are more severely ill (and prescribed antipsychotics). Any protocol/agreement
should be drawn up with the input of SOAP (an acronym for subjective,
objective, assessment, and plan)
4 Take part in supplementary audit with POMH-UK
Add to clinical audit programme when dates available
Standard 4 should focus on what is included in a medication
5
review, rather than how on RiO it is recorded.
Focus of standard 4 to be altered for any future audit, although best practice
may indicate recording medication reviews as a Care Programme Approach
(CPA) review
29
LOCAL QUALITY IMPROVEMENT PLANS
In 2012 the Quality Improvement Plan requirement was for each team to
demonstrate two areas of improvement, one of which was to align with one of the
priorities for improvement detailed within the integrated Quality Account, and the
second could be an area for improvement of the team‟s choice.
A total of 81 quality improvement plans were undertaken during 2012.
Teams were given the option to select a „key area‟ which was to be measured by an
audit based on one of the following five Trust Quality Account priority areas for
2011/12:
Patient Safety Thermometer
Care Planning
Nutrition
Dementia
Learning Disabilities
The second key area could be a topic of the team‟s choice and measured in any way
they wished. The graph below demonstrates the range of topics selected from the
mandated selection (key area 1) and also service specific topic choice / uptake
across the Trust.
30
Two examples of quality improvements made during 2012 are provided below:
INTEGRATED THERAPY SERVICE (ITS), COMMUNITY HEALTH
The Integrated Therapy Service (ITS) was directly commissioned in October 2009 to
provide a local, community therapy service for children and young people aged 0 19 years in Somerset who have physical, occupational, speech and language and
feeding difficulties. The service is mainly delivered within community settings such
as schools, pre-schools, children's centres, patients' own homes and ITS Clinics as
well as through in-reach provision to the wards and outpatient clinics at the two
acute hospitals in Somerset.
Integrated Therapy Service (ITS) chose to improve the quality of Care Planning.
This topic was chosen because it was an on-going development for the service and
the team felt it was an essential component of high quality, clinical delivery to meet
Care Quality Commission (CQC) Outcome 4 – Care and Welfare of People who use
Services.
The group used the principles of Care Aims and the requirement of Care Planning as
set out by the CQC and the Trust Record Keeping Standards to develop the ITS
care planning process and paper work.
Measures used to monitor progress and the final outcome were audits of quality and
the percentage of care plans completed
Three audits were completed:
Audit 1 was completed in May and June 2012 which was to gather baseline
data.
Audit 2 was completed in September 2012 which measured progress and
provided data which was submitted to the Quality Improvement team through
the QIP process.
Audit 3 was completed in January 2013 and provided the data for the team‟s
final yearend QIP report.
A RAG scoring system was used to indicate level / degree of compliance
00- 54% Red 55 – 84% Amber 85 – 100% Green
The team looked at and measured 2 elements within care planning.
To ensure that all patients on the active caseload have an appropriate Care Plan for
each therapy involved.
Results:
Base line = 62%, Target was set at 95%, year end result 84% leaving a variance of 11%; however these figures demonstrate an improvement of 22%
31
To ensure the ITS care plans meet ITS & CQC Standards of Care Plans and Record
Keeping.
Results: Areas that made the
most progress are as follows:
Baseline %
Re-Audit
Increase
Presence of a relevant long-term
goal
81%
94%
13% increase
Baseline adequately descriptive
of current ability
43%
70%
27% increase
Specific goals
50%
67%
17% increase
Achievable goals
19%
48%
29% increase
Realistic goals
19%
48%
29% increase
Timed goals
34%
48%
14% increase
Care plan signed
54%
71%
17% increase
Following assessment of the audit results the team concluded that where the desired
target had not been met the team would use the information gained and through
reflection roll the Quality Improvement Plan over to the following year, adapting the
actions to ensure the desired outcome is met in the coming year (2013).
Areas for priority improvement:
Others areas for improvement:
Measurable goals
Achievable goals
Realistic goals
Timed goals
Review boxes completed at care
plan review
Evidence that the plan has been
drawn up with child or parent
Baseline adequately descriptive of
current ability
Baseline neutral or positive in style
Next contact with service recorded
Signed in appropriate box
Outcome boxes completed at care
plan review
SOMERSET TEAM FOR EARLY PSYCHOSIS (STEP), MENTAL HEALTH
The Somerset Team for Early Psychosis (STEP) is a specialised service for young
adults (14-35 years) experiencing, or at high risk of developing, a first episode
psychosis (FEP). As a service, STEP embraces diagnostic uncertainty, emphasises
symptom management rather than diagnosis, and provides interventions in the least
stigmatising setting.
The service operates according to the following referral criteria:
32
Individual to be aged between 14-35 years
Individual to be either „at risk‟ of, or experiencing, their first episode of
psychosis
STEP should be involved from the point of first referral to mental health
services
First psychotic symptoms to have commenced within a year of referral date if
client is already engaged with another mental health team
STEP carries a caseload of approximately 175 clients, with an additional 15-20
clients undergoing assessment at any point.
The STEP Team considered results of the previous STEP annual reviews when
selecting their topics for 2012 and consequently decided to consider whether clients
who were prescribed antipsychotic medication were receiving a comprehensive
package of interventions. This included monitoring the positive and negative (side)
effects of medication through discussion with clients.
Progress against this aim was measured by using the electronic care plans on RiO
for all clients who are prescribed antipsychotic medication. The team also requested
a monthly list of STEP clients, the date at which each client had completed the
Glasgow Antipsychotic Side effects Scale (GASS) and the date at which their BMI
had been recorded from the RiO Information Team.
Information was gathered for all STEP clients. An information request reflecting the
identified standards was sent to the RiO Information team in January. Monthly data
was then sent by the RiO Information team to the Assistant Psychologist who
audited the data against the agreed standards. Data was not available from the
Information Team until April 2012. The results of the audit were forwarded to all
members of the STEP team as a means of feeding back progress in achieving these
aims and highlighting where standards were not being met. Progress was also
discussed in the STEP monthly team meetings.
The table below details the audit standards and results.
Aim of the Improvement
What you trying to
accomplish?
To ensure that all STEP clients who are prescribed antipsychotic
medication receive appropriate monitoring of their physical health
and experience of any side effects of their medication
Measures
1
All clients prescribed
antipsychotic medication to have
an entry in their care plan
regarding the monitoring of
antipsychotic medication
Baseline %
Target %
Year end
result %
Variance
between
Yearend
and target
%
14%
100%
77%
23%
33
2
3
All clients prescribed
antipsychotic medication to be
administered the Glasgow
Antipsychotic Side Effect Scale
(GASS)
All clients prescribed
antipsychotic medication to have
at least 2 Body Mass Indices
(BMIs) recorded on RiO- one at
baseline and one within 3 months
of the baseline
(For clients accepted onto the
STEP caseload after April 2012)
18%
Baseline
BMI- 0%
Follow up
BMI- none
yet due
100%
61%
39%
100%
Baseline
BMI- 83%
Follow up
BMI- 70%
Baseline
BMI- 17%
Follow up
BMI- 30%
Standard 1 - The data indicate a significant improvement in the percentage of clients
who did have an entry in their care plans regarding the monitoring of antipsychotic
medication from 14% in April to 77% in October.
Standard 2 - There was a significant improvement in the proportion of clients who
were administered the GASS to monitor side effects from 18% in April to 61% in
October.
Standard 3 - The recording of BMI at baseline also improved. In October 10 out of 12
of new clients taken on by STEP had a baseline Body Mass Index (BMI) completed.
There was also a small improvement in completion of follow up BMIs. In October
baseline BMIs for 10 clients should have been available and 7 had been completed.
The results suggest that STEP had improved in the monitoring of antipsychotic
medication, although they felt there was still room for improvement. In particular
administering the GASS and completing three month follow up BMI measurements.
The improvements had been facilitated by monthly feedback about progress towards
targets and regular demonstrations by the teams RiO expert during team meetings.
]
After consideration within the team, the team concluded that although it would be
preferable for 100 % of clients taking antipsychotic medication to have all of these
areas completed in full was perhaps unachievable due to the nature of the STEP
service, its reduction in contact with clients over time and the difficulties in
ascertaining current medication status. The team agreed they had set the target of
100 % too high for this client group.
An audit of Quality Improvement plans by RSM Tenon was conducted in August
2012 which looked at the number of plans submitted, the topics covered, the quality
of the information provided and the return rates. Recommendations made following
the audit have been incorporated into the design of the new documentation template
to ensure the areas that required improvement are met in the coming year.
The recommendations included:
timely completion and return of Service Quality Improvement Plans – set clear
deadlines for submission
34
Service Quality Improvement Plans to be reviewed by Quality Improvement
Manager on submission
teams to consider previous years Quality Improvement Plans and provide
assurance that all aims were achieved before new ones are set
where aims were not achieved, teams should be prepared to carry these aims
forward into the coming year
all quality improvements should be SMART
Head of Quality Improvement and Quality Improvement Manager to carry out
verification exercise for a sample of teams Service Quality Improvement Plans
the Trust requires all teams to carry out a Service Quality improvement Plan
which feeds into the Quality Account and identifies a minimum of two areas for
improvement
the process for completing a Service Quality Improvement Plan is to be
cascaded/shared by managers through team meetings
teams to provide a six month progress update to the Quality Improvement
Manager
at the year end teams are to submit a report to evidence improvements made
These recommendations are being implemented as part of the Trust‟s Service
Quality Improvement Plan programme for 2013.
COMMISSIONING FOR QUALITY AND INNOVATION (CQUIN)
A proportion of Somerset Partnership NHS Foundation Trust income in 2012/13 was
conditional upon achieving quality improvement and innovation goals agreed
between Somerset Partnership NHS Foundation Trust and any person or body they
entered into a contract, agreement or arrangement with for the provision of NHS
services, through the Commissioning for Quality and Innovation (CQUIN) payment
framework. In this case the CQUIN goals were agreed with Somerset Clinical
Commissioning Group, acting with delegated authority from NHS Somerset. Further
details of the agreed goals for 2012/13 and for the following 12 months period are
available online at: http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275
In 2012/13, Somerset Partnership NHS Foundation Trust received £3,043,000 in
income for achieving the CQUIN goals set by NHS Somerset and Somerset Clinical
Commissioning Group. In 2011/12 the Trust received £729,000.
REGISTRATION WITH THE CARE QUALITY COMMISSION AND
PERIODIC/SPECIAL REVIEWS
Somerset Partnership NHS Foundation Trust is required to register with the Care
Quality Commission and its current registration status is compliant. Somerset
Partnership NHS Foundation Trust has no conditions on its registration.
35
The Care Quality Commission has not taken enforcement action against Somerset
Partnership NHS Foundation Trust during 2012/13.
Somerset Partnership NHS Foundation Trust has participated in the following
reviews and inspections undertaken by the Care Quality Commission relating to the
following areas during 2012/13:
Joint Care Quality Commission/OFSTED Review of Safeguarding and Looked
After Children’s Services
Between 23 April and 4 May 2012, the Care Quality Commission and OFSTED
conducted a joint inspection of Safeguarding and Looked After Children‟s Services
within Somerset.
This inspection was conducted by the Care Quality Commission alongside the
Ofsted-led programme of children‟s services inspections, focusing on safeguarding
and the care of looked after children within the local authority. The two-week
inspection process comprised a range of methods for gathering information –
document reviews, interviews, focus groups (including where possible with children
and young people) and visits – in order to develop a corroborated set of evidence.
The findings of the inspection are set out in the table below:
Somerset County Council
Safeguarding Inspection Outcome
Overall effectiveness of the safeguarding services
Capacity for improvement
The contribution of health agencies to keeping
children and young people safe
Looked After Children Inspection Outcome
Overall effectiveness of services for looked after
children and young people
Capacity for improvement of the council and its
partners
Being Healthy
Aggregated inspection
finding
ADEQUATE
ADEQUATE
GOOD
Aggregated inspection
finding
ADEQUATE
ADEQUATE
INADEQUATE
The report made the following recommendations:
Immediately
NHS Somerset, Taunton and Somerset NHS Foundation Trust, Yeovil District
Hospital NHS Foundation and Somerset Partnership NHS Foundation Trust and
the council should ensure that all looked after children have access to timely,
comprehensive health assessments leading to quality assured health care.
(Ofsted June 2012)
NHS Somerset and Somerset Partnership NHS Foundation Trust and the
council should ensure that looked after children and care leavers are fully
36
engaged in the development and delivery of the Being Healthy agenda and
health elements of the Pledge. (Ofsted June 2012)
Within three months (from report)
NHS Somerset and Somerset Partnership NHS Foundation Trust and the
council should ensure that looked after children and care leavers have prompt
access to specialist health care services including mental health and substance
misuse services as required (Ofsted June 2012)
NHS Somerset and Somerset Partnership NHS Foundation Trust and the
council should review thresholds for prioritising timely interventions for children
with emotional and mental health difficulties by the CAMHS. (Ofsted June 2012)
The local safeguarding children‟s board (LSCB) and NHS Somerset should
ensure that general practitioners (GPs), dentists and all appropriate health
practitioners are fully engaged in safeguarding arrangements and have regular
developmental opportunities for practice reflection and learning. (Ofsted June
2012)
NHS Somerset and Somerset Partnership NHS Foundation Trust should ensure
the optimum use of strengths and difficulties questionnaires in the provision of
the health and wellbeing of looked after children, including their use by young
people as appropriate.
NHS Somerset and Somerset Partnership NHS Foundation Trust should ensure
that health case records are kept to a satisfactory standard and subject to
routine quality assurance audit.
NHS Somerset and Somerset Partnership NHS Foundation Trust should ensure
that parental consent for health assessment and treatment for looked after
children are recorded appropriately and compliance with national guidance is
demonstrated.
NHS Somerset, Taunton and Somerset NHS Foundation Trust, Yeovil District
Hospital NHS Foundation and Somerset Partnership NHS Foundation Trust
developed an action plan in response to the recommendations made in the report
which has been fully implemented and agreed by the regulators.
Care Quality Commission Review - Chard Community Hospital
On 19 June 2012 the Care Quality Commission visited Chard Community Hospital
as part of its routine schedule of planned reviews.
During the course of the visits, observations were undertaken to assess how people
were being cared for and patients were spoken to on the ward, in the
outpatients department and in the minor injuries unit. The review looked to assess
compliance with the following essential standards:
Outcome 1: People should be treated with respect, involved in discussions
about their care and treatment and able to influence how the service is run;
Outcome 4: People should get safe and appropriate care that meets their
needs and supports their rights;
37
Outcome 7: People should be protected from abuse and staff should respect
their human rights;
Outcome 13: There should be enough members of staff to keep people safe
and meet their health and welfare needs; and
Outcome 16: The service should have quality checking systems to manage
risks and assure the health, welfare and safety of people who receive care.
The findings of the review were published in July 2012 and concluded that Chard
Community Hospital was found to be meeting all of the essential standards
assessed.
The report identified that “People told us that they were always treated properly they
said "The staff are very courteous", "They are always very kind and thoughtful" and
"They are very respectful of my privacy and treat me the way I like to be treated".
People said that staff were very good at communicating with them both in terms of
their treatment and if there were any delays in minor injuries or outpatient clinics. A
patient's family member told us that "We are kept well informed about our relative's
treatment and what the doctor has said".
Care Quality Commission Visit – St Andrew’s Ward, Wells
On 4 December 2012 the Care Quality Commission visited St Andrew‟s Ward, Wells
as part of its routine schedule of planned reviews.
The inspector reviewed compliance with:
Outcome 1: People should be treated with respect, involved in discussions
about their care and treatment and able to influence how the service is run;
Outcome 4: People should get safe and appropriate care that meets their
needs and supports their rights;
Outcome 7: People should be protected from abuse and staff should respect
their human rights;
Outcome 13: There should be enough members of staff to keep people safe
and meet their health and welfare needs; and
Outcome 16: The service should have quality checking systems to manage
risks and assure the health, welfare and safety of people who receive care
The final report of the visit was received from the Care Quality Commission on
7 December 2012. The report indicates that St Andrews Ward was meeting all the
essential standards of quality and safety.
The report identified that people the inspectors spoke with said “they felt safe on the
ward. We observed that staff spoke with people in a friendly and respectful manner.
One person said "staff are lovely, they respect privacy and they respect us." People
were very complimentary about the staff on the ward. Comments included "staff
are all very kind," and "they are very nice and have helped me a lot."
38
QUALITY RISK PROFILE (QRP)
The QRP is a tool used by the Care Quality Commission to gather together key
information about the Trust to support monitoring of compliance with the essential
standards of quality and safety. The QRP is updated and published nine times a
year. The QRP analyses a range of qualitative and quantitative data sources
including, but not limited to:
regulatory bodies – for example the National Patient Safety Agency;
the NHS Litigation Authority;
routine data collections – for example Hospital Episode Statistics (HES) and
Estates Return Information Collection (ERIC);
other CQC regulatory activity – for example monitoring of compliance with
the regulation on cleanliness and infection control;
national clinical audit datasets; and
information from people using services – for example NHS Choices and
feedback from Local Involvement Networks (LINks).
The QRP published in February 2013 was the first „integrated‟ publication; taking
account of data sets available for Community Health services monitors the Trust‟s
compliance with the Essential Standards of Quality and Safety through the work of
inspectors.
The QRP assesses 1,466 data items (40 qualitative, 1,426 quantitative) and
provides an estimate of risk of non-compliance against each of the 16 essential
standards of quality and safety. It also provides also a summary of the risk
estimates from the six most recent QRP refreshes. For Somerset Partnership NHS
Foundation Trust the QRP indicates a low risk assessment for the Trust against all
the standards considered and no areas of significant deteriorating performance.
39
DATA QUALITY
Somerset Partnership NHS Foundation Trust recognises the important role of data
quality in providing confidence in the accuracy of information used to inform
decisions relating to service improvement. Data quality indicators relating to the
timeliness and accuracy of coding are routinely reported to the Trust‟s Finance and
Performance and Audit Committees. Additional measures which permit the regular
monitoring of data quality include:
the use of the NHS number
the clinical coding error rate
the use of GP medical practice
the Information Quality and Records Management score
Somerset Partnership submitted records during 2012/13 to the Secondary Uses
Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data. The percentage of complete records for data submitted for
community health services which included the patient‟s valid NHS number was:
99.8% for admitted patient care
100% for outpatient care
97.9% for accident and emergency care.
The percentage of records which included the patient‟s valid General Medical
Practice Code was:
100% for admitted patient care
100% for outpatient care
100% for accident and emergency care
The Somerset Partnership NHS Foundation Trust Information Governance
Assessment Report overall score for 2012/13 was 72% and was graded as GREEN.
The Trust achieved a minimum of level 2 compliance against all criteria.
Somerset Partnership will be taking the following actions to improve data quality in
2013/14:
continuing with the automation of data collection and information analysis,
focusing on any community based services which operate manual or paperbased data collection systems
ensuring that the data for these services is accessible by the central
information team for Somerset Partnership NHS Foundation Trust, in order
that it may be subject to rigorous data quality checks and validation processes
continuing to undertake targeted and supportive work with services, to
understand the reasons behind any adverse variances in respect of data
completeness or accuracy
40
Somerset Partnership NHS Foundation Trust was not subject to the Payment by
Results clinical coding audit during the reporting period by the Audit Commission.
Somerset Partnership NHS Foundation Trust utilised the Terminology Referencedata Update Distribution Service (TRUD) to ensure the local Electronic Patient
Record contains update reference data which has led to the improvement in General
Practitioner Registration Code data completeness rates.
PROGRESS AND EVALUATION OF PERFORMANCE AGAINST NATIONAL AND
LOCAL INDICATORS
This section demonstrates how the Trust performed in 2012/13 against indicators
specified by Monitor, (the NHS Foundation Trust regulator), the Operating
Framework for the NHS in England for 2012/13, and against those indicators that the
Trust has identified as quality priorities in previous years.
The Trust met, and in the majority of cases routinely exceeded, all Monitor
Compliance Framework targets in 2012/13.
Mental health
Target
Threshold
Q1
Performance
Q2
Q3
Q4
Care Programme Approach (patients
receiving follow-up contact within
seven days of discharge.
95%
97%
96%
97%
96%
Care Programme Approach patients
having formal review within 12 months.
95%
95.7%
95.0%
95.4%
95.0%
<7.5%
2.8%
3.7%
4.0%
4.1%
95%
96.3%
98.3%
96.7%
98%
165
177
177
183
178
97%
99.7%
99.7%
99.7%
99.7%
50%
72.1%
73.2%
74.4%
75.6%
Minimising delayed transfers of care
(delays as a percentage of all
discharges)
Admissions to inpatients services had
access to crisis resolution/ home
treatment teams
Meeting commitment to serve new
psychosis cases by early intervention
teams
(Current agreement is for a caseload
of 174 cases)
Achieve targets for patient identity data
completeness metrics
Achieve target for data completeness:
outcomes (for patients on CPA)
41
Community Health
Target
Threshold
Q1
Referral to treatment waiting times –
admitted
Referral to treatment waiting times –
non-admitted
Referral to treatment waiting times –
incomplete pathways
90% of
patients inside
of 18 weeks
95% of
patients inside
of 18 weeks
92% of
patients inside
of 18 weeks
Accident and Emergency maximum
waiting time of four hours from arrival
to admission/ transfer/ discharge
95%
Performance
Q2
Q3
Q4
100%
100%
97.4%
100%
100%
100%
99.5%
99.1%
100%
100%
99.9%
99.6%
99.6%
99.6%
99.7%
99.7%
Performance Indicators
Definition
2009-10
2010-11
2011-12
2012-13
2012-13
(NHS
Portal
figure)
National
(target
95%)
97%
97%
97%
96%
N/A
97.6%
95.8%
97.4%
96.8%*
97.7%
N/A
Not available
2
National
551
521
446
1,432
~
N/A
Not available
3
National
New
indicator
New
indicator
New
indicator
3,693
1,328
Not available
5
National
New
indicator
New
indicator
New
indicator
1%
1%
Benchmark
(where
available)
Patient Safety
1. Seven day follow up
Percentage of people
receiving face to face or
telephone contact within
7 days of inpatient
discharge
2. Recording of risk
Percentage of clients
under our care who
have had a formal
assessment of risk and
safety recorded
3. Hospital falls
Number of falls of
patients reported by staff
4. Patient Safety
Incidents Reported
Patient safety incidents
reported to the National
Reporting and Learning
Services (NRLS)
5. Safety Incidents
involving severe harm
or death
Percentage of patient
safety incidents reported
to the NRLS where
degree of harm is
recorded as „severe
harm‟ or „death‟
Local
(target
95%)
Clinical Effectiveness
42
4
1%
4
1
2012-13
(NHS
Portal
figure)
Benchmark
(where
available)
Definition
2009-10
2010-11
2011-12
2012-13
6. Delayed transfers of
care.
Percentage of inpatient
days where a person‟s
transfer from inpatient
care is delayed
National
(target
less than
or equal
to 7.5%)
3.2%
3.7%
4.3%
3.7%
3.6%
7. Care plans
Percentage of clients on
the care programme
approach with a
Recovery Care Plan
National
97.5%
98.3%
98.3%
98.6%
Not available
8. Gatekept
Admissions
Admissions to inpatient
services had access to
crisis resolution home
treatment teams
National
(95%)
95%
97%
95%
97%
98.4%
Local
4.4%
4.0%
4.3%
10. Complaints
Number of complaints
received by the Trust
National
62
48
80
11. Patient Advice and
Liaison Service (PALS)
Number of enquiries
received by the Trust
Patient Advice and
Liaison
Service Officer
National
611
609
988
12. Compliments
Number of compliments
received by the Trust
National
198
237
2954
Patient Safety
1
6
1
Patient Experience
9. Cancelled
appointments
Percentage of first
appointments cancelled
by the Trust
1.
+
3.5%
Not available
2
~
Not available
7
~
Not available
6
~
Not available
2
139
+
+
1219
5263
2012-13 Q3 Department of Health website
Local target not collated nationally or regionally
3.
Information on the number of falls is not collated nationally or regionally but data on falls resulting in harm is
collected through the HSCIC Patient Safety Thermometer Report at http://www.hscic.gov.uk/thermometer
4.
NHS Commissioning Board Special Health Authority Organisation Patient Safety Incident Report March 2013
5.
Information on number of incidents is not collated nationally or regionally but the Commissioning Board Special
Health Authority Organisation Patient Safety Incident Report March 2013 benchmarks the reporting rate of
incidents per 1,000 bed days. Somerset Partnership NHS Foundation Trust has a reporting rate of 24.9 incidents
per 1,000 bed days compared to a median of 23.8
6.
Information not collated nationally or regionally
7.
Information not collated nationally or regionally but The NHS Benchmarking Network is including areas of
patient safety and service quality as part of its benchmarked information in the 2013-14 programmes. This will
cover complaints.
2.
43
* change of definition to include those care managed by others
+ includes Somerset Community Health figures from 1 August 2011
~ figure for the integrated Trust for the full year. Previous years‟ reports relate only to mental health inpatient
services)
1. Seven day follow up Somerset Partnership considers that this data is as described for the
following reasons: This is defined in the Monitor 2012/3Compliance Framework and data is sourced from the
electronic patient record. Performance is monitored monthly through a balanced scorecard presented to
the Trust's Senior Managers‟ Business Meeting which identifies discharges and follow ups, and
enables our Heads of Service to alert clinicians and take focused, informed action. There is a CPA
Policy to support this operationally, and the business rules are published and shared across the Trust
to ensure we are acting on and recording this information correctly.
The Trust has taken these actions to improve this percentage, and so the quality of its services: by
continuing the level of monitoring at service and locality level through the coming year.
2. Recording of Risk Somerset Partnership considers that this data is as described for the following
reasons: This is defined locally as the percentage of clients who have a risk assessment recorded in the
electronic patient record as a proportion of those over 18, open to services, and placed on a CPA level. The
Trust policy sets a higher standard of recording a risk assessment annually. All relevant records are checked
each month as part of an automated report. This process has been subject to a previous internal
audit review. A clear record of an assessment of risk is an important component in the process of
managing risk and of communicating patient safety factors in a structured, easy to find, manner.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services: by monthly reporting on performance in this area and notifying individual health care
professionals of cases requiring a record of the risk assessment when performance falls below a
threshold in that service area.
3. Hospital Falls Somerset Partnership considers that this data is as described for the following
reasons: The total number of falls recorded is exported directly from the Trust‟s Risk Management
System, DATIX. All untoward events, including falls, are reviewed daily by the Risk Management
Team. This centralised function enables the team to accurately record patient safety incidents that
require reporting onto the NRLS. Falls are reported routinely to the Board as part of the monthly
Quality Report and analysed by the Falls Best Practice Group.
The Trust has taken the following actions to improve this number, and so the quality of its
services: by developing and implementing action plans through the Best Practice Group to address
issues identified from incidents. Information on falls will be analysed at ward level and reported as
part of the monthly Quality Report.
4. Patient Safety Incidents Reported Somerset Partnership NHS Foundation Trust considers that
this data is as described for the following reasons: the total number of patient safety incidents is
exported directly from the Trust‟s Risk Management System, DATIX to the National Reporting and
Learning System (NRLS). All untoward events, including patient safety incidents, are reviewed daily
by the Risk Management Team. This centralised function enables the team to accurately record
patient safety incidents that require reporting onto the NRLS.
The Trust has taken the following actions to improve this number, and so the quality of its services: by
promoting risk management within the organisation. This is a cultural shift which started with Board
and Directorates embracing risk registers in order to record risks. In order to sustain the accuracy of
all untoward events including patient safety incidents and encourage active and prompt investigation;
the Corporate Governance Directorate has created a performance score card. This score
card includes the monitoring of the closure of all untoward events, including patient safety incidents.
5. Patient Safety Incidents involving Severe Harm or Death Somerset Partnership NHS
Foundation Trust considers that this data is as described for the following reasons: the percentage of
patient safety incidents recorded as major or catastrophic consisted of Somerset Acquired pressure
ulcers graded 3 or 4, sudden unexpected deaths and other reportable Serious Incidents Requiring
Investigation (SIRI). Within this 1% are also significant incidents where a full Root Cause Analysis
44
(RCA) was not required from the Commissioner. The Trust receives a bi-annual report from the NHS
Commissioning Board Special Health Authority which uses data submitted to the NRLS to benchmark
Somerset Partnership NHS Foundation Trust against similar neighbouring NHS Trusts. Within these
th
reports Somerset Partnership NHS Foundation Trust is within the 50 percentile of reporters. The
report suggests that 0.5 % of incidents reported by the Trust resulted in severe harm (major) and
0.8% of incidents reported by the Trust resulted in death (catastrophic), which was the same as the
figure collectively for other organisations.
The Trust has taken the following actions to improve this percentage and so the quality of its services:
by developing strategies to reduce significant harm to patients and actively learning from
experiences. The Pressure Ulcer Best Practice Group has created and disseminated a pressure
ulcer Root Cause Analysis (RCA) toolkit, to aid staff in the investigations and recommendations
following related untoward events. A Pressure Ulcer Launch Event took place on 13 March 2013. All
incidents are reviewed by the risk management team. Significant incidents are followed up by a 72
hour review which, if necessary will inform the level of RCA investigation required. SIRIs and other
significant incidents are reviewed at the SIRI review group, where full investigations are considered,
and learning outcomes and action plans are monitored.
6. Delayed Transfers of Care Somerset Partnership NHS Foundation Trust considers that this data
is as described for the following reasons: all delayed days are reported directly from the electronic
patient record and ward staff are asked to confirm on a weekly basis that new delays have been
registered.
The Trust has taken the following actions to improve this number, and so the quality of its
services: by reporting to the service manager any wards with delays that breach the performance
threshold and by monitoring performance at monthly Senior Managers Business Meetings.
7. Care Plans Somerset Partnership considers that the recording of a structured care plan is as
described for the following reasons. All relevant records are checked each month as part of an
automated report. This process has been subject to a previous internal audit review. A structured
Recovery Care Plan for those on CPA is a vital element of peoples care.
The Trust has taken the following actions to improve this percentage, and so the quality of its
services, by monthly reporting on performance in this area, provision of reporting tools within the
electronic patient record to check when people on CPA last had their Recovery Care Plan updated
and by notifying individual health care professionals of cases requiring a Recovery Care Plan.
8. Gate-kept admissions Somerset Partnership considers that these percentages are as described
for the following reasons: This is defined in the Monitor 2012/13 Compliance Framework and includes for the
Trust gatekept admissions via Psychiatric Liaison Teams as part of Crisis Services as recorded in the electronic
patient record. Performance is monitored monthly through a balanced scorecard presented to the
Trust's Senior Managers‟ Business Meeting which identifies admissions and gate‐keeping which
informs actions as required. The Crisis Resolution Team policy and business rules are published and
shared with all staff via our intranet to ensure we are acting on and recording this information
correctly.
The Trust has taken the following actions to improve this number, and so the quality of its
Services: by reviewing the Crisis Resolution Team policy, as well as providing weekly reports to local
business managers for action planning. This is also reviewed at Senior Managers‟ Business
Meetings.
9. Cancelled Appointments Somerset Partnership considers that these percentages are as
described for the following reasons: are cancellations are reported directly from the electronic patient
record and categorised by cancellation type.
The Trust has taken the following actions to improve this number, and so the quality of its
services: by reporting cancellation rate each month in the relevant directorate dashboard.
45
10. Complaints Somerset Partnership considers that these percentages are as described for the
following reasons: complaints are recorded on the Trust‟s Risk Management System, DATIX and
reported monthly to the Trust‟s Clinical Governance Group for review. The number of complaints,
information on response times and analysis of themes, lessons learned and actions taken are
reported quarterly to the Patient and Public Involvement Group and as part of the Trust‟s Quality
Report to the Board. The report is also presented in the public meetings of the Council of Governors.
An annual return on complaints (K041a) is submitted to the Department of Health and validated as
part of the national reporting system.
The Trust has taken the following actions to improve this number, and so the quality of its
services: by reviewing its Complaints and PALS policy and systems and introducing monthly
monitoring of response times. Introducing structured systems for feedback of lessons learned across
the Trust and participating in a peer review project working with the Patients‟ Association and
neighbouring healthcare organisations.
11. PALS Somerset Partnership considers that these percentages are as described for the following
reasons: PALS enquiries are recorded on the Trust‟s Risk Management System, DATIX and reported
monthly to the Trust‟s Clinical Governance Group for review. The number of PALS enquiries,
analysis of themes, lessons learned and actions taken are reported quarterly to the Patient and Public
Involvement Group and as part of the Trust‟s Quality Report to the Board.
The Trust has taken the following actions to improve this number, and so the quality of its
services: by reviewing its Complaints and PALS policy and systems and introducing monthly
monitoring of response times. Introducing structured systems for feedback of lessons learned across
the Trust. The PALS team will also be the lead to follow up issues identified from the introduction of
the Friends and Family Test in community hospitals and Minor Injury Units.
12. Compliments Somerset Partnership considers that these percentages are as described for the
following reasons: Compliments are collected from all Trust sites and services and reported monthly
to the Trust‟s Clinical Governance Group for review. The number of compliments and areas of best
practice are reported quarterly to the Patient and Public Involvement Group and as part of the Trust‟s
Quality Report to the Board.
The Trust has taken the following actions to improve this number, and so the quality of its
services: by establishing a Patient and Public Involvement Best Practice Group which will look at best
practice identified through compliments and ways to disseminate these. Compliments will also be
followed up by PALS from the introduction of the Friends and Family Test in community hospitals and
Minor Injury Units.
As part of its programme for external assurance, the Trust identified three
performance indicators for detailed audit by our external auditors. The indicators are
100% enhanced Care Programme Approach patients receiving follow up
contact within 7 days of discharge from hospital.
admissions to inpatient services had access to Crisis Resolution Home
Treatment Teams
patient safety incidents reported
46
PART THREE: REVIEW OF QUALITY PERFORMANCE
The NHS (Quality Accounts) Amendment Regulations 2012 requires Trusts to
identify three performance indicators against each of the quality criteria:
patient safety
clinical effectiveness
patient experience
We have set these out in Part Two (see pages 45 – 46) together with the additional
key indicators that we have identified as priorities for the Trust. We also continue to
improve quality across other essential areas of our services. Some examples
include:
PATIENT SAFETY
Safeguarding Children
Somerset Partnership NHS Foundation Trust has a statutory duty, under Section 11
of the Children Act 2004, to protect children from harm as part of the wider work of
safeguarding and promoting their welfare.
Somerset Partnership NHS Foundation Trust takes its responsibility for safeguarding
children and young people very seriously and takes all the necessary steps to
ensure that consistent best practice is adhered to across the organisation.
The Trust has a team of Safeguarding Nurses who are committed to ensuring the
current service is of a consistent high quality across the whole of the organisation.
There is an internal safeguarding forum and a senior representative attends the
Local Safeguarding Children‟s Board.
The Trust has well established relationships across agencies which facilitate a
partnership approach to safeguarding children. Following integration systems,
structures and processes for safeguarding children have been reviewed and a
number of steps have been taken to strengthen guidance and improve practice to
implement lessons learnt from Serious Case or Health Reviews. Child protection
processes have become more transparent and are subject to regular assessment
and scrutiny.
Safeguarding Vulnerable Adults
The Trust is committed to protecting vulnerable adults from abuse, ill-treatment and
exploitation. There is a Lead for Safeguarding Vulnerable Adults, an internal
safeguarding forum and senior representation at the multi-agency Safeguarding
Vulnerable Adults Board.
An agreed Somerset Multi-Agency Safeguarding Adults Policy is available to all
staff. A training strategy has been written and additional training sessions have been
developed in order to meet the training requirements for all staff. The training
focuses on Safeguarding Vulnerable Adults, The Mental Capacity Act and the
47
Deprivation of Liberty Safeguards and includes lessons learnt from Serious Case
Reviews and incidents.
Medical Revalidation
Systems and policies needed for medical revalidation, which came into effect on 3
December 2012, have been established. The creation and operation of these
systems has been overseen by the Medical Appraisal Steering Group, with
accountability to the Trust Board provided through the Medical Director and
Responsible Officer, who submitted an Annual Board Report on Medical Appraisal
and Revalidation in May 2012.
Regular self-assessment using the Organisational Readiness Self-Assessment
(ORSA) tool has shown full compliance with the requirements set by the NHS
Revalidation Support Team. Systems have also been independently scrutinised
through a peer review process, which resulted in positive feedback and minimal
recommendations that consisted of suggestions for future versions of some relevant
policies.
All doctors with a prescribed connection to the Trust had an appraisal in accordance
with the Appraisal Policy for Medical staff during 2012/13. Information required by
the GMC was provided on time, which meant that all relevant doctors have been
allocated a revalidation date within the next three years.
Learning for the Future
The Francis Report into failings at Mid Staffordshire Trust, which was released on
the 6 February 2013, revealed how devastating the consequences of poor
management and patient care can be for patients and their families.
Somerset Partnership NHS Foundation Trust wholly endorses Robert Francis‟
comments that “patients are entitled to be the first and foremost consideration of the
system and all those who work in it.”
We pride ourselves on our track record of, and commitment to, delivering high
quality care to each and every one of our patients. The Trust had no never events
during 2012/13. We do, however, recognise that in exceptional circumstances
mistakes are made, in some cases tragically for patients and their families, for whom
the care and support we provided did not reach the high standards that we aim to
provide.
We always acknowledge our mistakes, and our apology to those affected is
supported by assurances that we will examine critically what went wrong so we can
learn from our mistakes, sharing the learning across the Trust to ensure that
they are not repeated in the future. In addition, we actively aim to ensure that our
findings and actions are shared with the people affected.
All complaints and serious untoward incidents are reported to the Board and all
serious incidents requiring investigation are subject to a root cause analysis so that
we can find out what went wrong and why it happened – and make sure we improve
our services to prevent such things happening again.
48
In February 2012 a patient died in our care as a result of an overdose of medication.
The incident was the subject of a police investigation and as a Trust we have also
conducted a comprehensive investigation of the events, including an independently
chaired review of our governance processes. We have already taken significant
actions with the learning from this serious incident, including a review of our
medicines management governance processes; reviewed drug administration and
drug calculation training for all staff; and we have made medicines administration
one of our key priorities for the Quality Account next year so that we can further
embed the learning from this incident.
We have also worked with our commissioners to undertake a review of inpatient
suicides that have occurred during the year to see if there are any lessons we can
learn from these tragic events to improve the quality and safety of our services.
STAFF WELLBEING AND DEVELOPMENT
The 2012 staff survey was completed in October and November 2012 with a 55%
response rate. Although above the national average, this response rate is less than
the 58% for the previous year.
Overall Staff Engagement
Overall staff engagement has been maintained since the previous year with a slight
rise from 3.65 to 3.69 out of a maximum of 5 for the staff engagement measure. Of
the 28 key findings in the survey, 14 were either better than average on in the best
20% compared to the national average.
Top Four Ranking Key Findings
The top four ranking key findings which ranked the Trust in the best 20% of Trust‟s
are:
Key finding 6: Percentage of staff receiving job-relevant training, learning or
development in the last 12 months. The Trust scored 87% compared to a national
average of 82% and represented the highest scoring Trust.
Key finding 7: Percentage of staff appraised in the last 12 months. The Trust scored
95% compared to the national average of 87% and represented the highest scoring
Trust.
Key finding 27: Percentage of staff believing the Trust provides equal opportunities
for career progression or promotion. The Trust scored 93% compared to the national
average of 90%.
Key Finding 28: Percentage of staff experiencing discrimination at work in the last 12
months. The Trust scored 8% compared to the national average of 13% and a
significant improvement from 12% the previous year.
Bottom Four Ranking Key Findings
The bottom four ranking key findings are:
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Key finding 5: Percentage of staff working extra hours. The Trust scored 75%
compared to a national average of 70%.
Key finding 3: Work pressure felt by staff. The Trust scored 3.12 out of a maximum
of 5 compared to the national average of 3.02.
Key finding 22: Percentage of staff able to contribute towards improvements at work.
The Trust scored 68% compared to the national average of 71%
Key finding 1: Percentage of staff feeling satisfied with the quality of work and patient
care they are able to deliver. The Trust scored 73% compared to the national
average of 78%.
Notable Improvements
The notable key areas of improvements since the previous staff survey were the
increase from 86% to 95% of staff saying they have received an appraisal. This
represents the highest of all comparator Trusts. The increase in number is matched
with improvements in the quality and structure of appraisals with an increase from
35% to 42% of staff reporting well-structured appraisals.
Other notable good improvements since the previous year are the increase from
58% to 68% of staff saying that they are able to contribute towards improvements at
work. Whilst this remains in the worst 20% compared to other Trusts, it is significant
improvement in the right direction and represents an encouraging cultural
improvement in light of the Francis report.
PATIENT EXPERIENCE
Somerset Partnership values the views of patients, carers, and service users, and
takes very seriously comments and complaints about the services which it provides.
The Trust welcomes feedback from people who use its services, and their families
and carers, in order to address any shortfalls and issues and build improvements
into Trust policies, processes, and procedures.
During 2012/13, Somerset Partnership set up new arrangements for evaluating and
reporting patient experience through its Patient and Public Involvement Group. This
group comprises Trust managers, governors, voluntary sector representatives and
during 2012/13 representatives from Somerset LINk.
The group considers a variety of forms of feedback on patient experience, including:
complaints and PALS;
patient surveys and patient satisfaction surveys;
patient feedback from the Trust‟s and other websites (e.g. Patient Opinion,
NHS Choices;
patient and public and carer engagement events (e.g. carers groups,
Listening Events, Health Forums);
public consultations;
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Members‟ Council constituency and other events;
media activity.
The Trust has a mixed approach to assessing patient experience. For mental
health services there is a national patient survey conducted each year. In 2012
the survey focused on community mental health services. The Trust also
commissioned its own tracker survey in respect of inpatient services. The results
of the survey were presented at an open event on 18 July 2012. Action plans
relating to the findings were presented to the Patient and Public Involvement
Group in February 2013.
In community health services, the Trust undertakes monthly generic patient
satisfaction questionnaires of all community hospital inpatients and regular (at least
annual) surveys of all other community services. This relates to a quality target
(CQUIN) under the contract the Trust holds with NHS Somerset.
During the year the Trust consistently met the overall patient satisfaction target for all
criteria (over 90% positive response rates) with high rates of satisfaction particularly
in relation to privacy and dignity, although response rates have fallen and work is
being done to address this.
The Trust is renewing its programme of patient surveys for 2013 and from next year
will introduce the national “Friends and Family Test” question into its surveys of adult
community hospital inpatients and Minor Injury Units.
Responding promptly and honestly to complaints and concerns is an important
element of the Trust‟s Being Open Policy. All complainants are provided with
detailed feedback and a summary of all actions taken as a result of the complaint.
Face to face conciliation meetings will continue to remain an important part of the
complaints resolution process where appropriate.
In April 2013 the Trust published its Patient and Public Involvement Strategy which
seeks to embed further the Trust‟s commitment to involving patients, families and
carers in all stages of the development and delivery of its services and support the
further development of the Quality Account.
Involvement within the Trust should be a continuous process rather than a one-off
activity. Evaluation is a crucial aspect of the involvement process and for this
strategy to be effective we will put in place regular reporting and ongoing evaluation.
A mapping exercise was undertaken in early 2012 to obtain an understanding of the
range of involvement activity undertaken, and which revealed an encouragingly high
level of participation by clinical teams. The results also indicated that whilst there are
some similarities within service clusters, there is a limited level of consistency across
services, which makes realistic assessment of patient experience difficult.
We will monitor personalised care planning through the Personalised Care Planning
Best Practice Group and through our CQC compliance mapping.
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In order to deliver operational level involvement, from 2013/14 each team will submit,
as part of its annual Service Quality Improvement Plan, a proposal relating to patient
experience or involvement. Each service should also be able to demonstrate how
they have involved patients and carers in team processes such as recruitment and
staff training, through reports to the Patient and Public Involvement Best Practice
Group. This Group will report to the Patient and Public Involvement Group on both
these activities and innovative ways of engaging with and involving patients and
carers.
At organisational level, the PPI group will report quarterly to the Council of
Governors and the Trust will receive a quarterly Patient Experience Report, as part
of its regular Quality Report and the Trust will continue to engage actively with the
new Healthwatch organisation and with local Health Forums.
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Statements from External Agencies
[HEALTHWATCH]
53
Wynford House
Lufton Way
Lufton
Yeovil
Somerset
BA22 8HR
Our Ref: LW/jy/commser/QA/2013
24 May 2013
Phil Brice Director of Corporate Governance
Somerset Partnership NHS Foundation Trust
Mallard Court
Express Park
Bridgwater
Somerset
TA6 4RN
Tel: 01935 384000
Fax: 01935 384079
enquiries@somersetccg.nhs.uk
Dear Phil
Somerset Partnership NHS Foundation Trust Quality Account 2012/13
As lead commissioner, Somerset Clinical Commissioning Group (and previously
NHS Somerset) has monitored the safety, effectiveness and patient experience
of health services at Somerset Partnership NHS Foundation Trust (the Trust)
during 2012 -13. The Trust‟s engagement in the quality contract monitoring
process provides the basis for commissioners to comment on the quality account
including performance against quality improvement priorities and the quality of
the data included.
We have reviewed the achievements against the National Performance Indicators as
outlined in the account and can confirm that the reported position is accurate.
We have reviewed the identified Quality Improvement priorities included in the
Quality Accounts for 2012 - 13 and would comment as follows:
Quality
Ensuring that we put patients first in all that we do is essential for patients to receive
care that meets their needs, and is provided by caring and compassionate staff. The
publication in February 2013 of the Mid Staffordshire NHS Foundation Trust Public
Inquiry (Francis Inquiry) has emphasised that the NHS must put patients at the heart
of decision making and ensure that the fundamental standards of care are met for all
patients. Somerset Clinical Commissioning Group has agreed a number of quality
standards in the Somerset Partnership NHS Foundation Trust to implement the
relevant recommendations from the Francis report where staffing levels reflect
patient needs, there is promotion of an open culture where staff can raise concerns
and all patients have a good experience of care.
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The Somerset Clinical Commissioning Group (CCG) acknowledges the
achievements of the Trust in implementing their Quality Strategy in 2012-13,
integrating community and mental health services and producing the first integrated
quality account, defining priorities for quality improvement and including the roll out
of the safety thermometer and introduction of the Friends and Family Test in
community hospitals.
The CCG can confirm that the Trust regularly reviews the quality and safety of its
services using a variety of quality indicators and these are reported to the CCG at
quarterly clinical quality review meetings. The CCG welcomes the priorities identified
by the Trust to focus on improving patient experience and patient and carer
involvement in care, putting patients first in improving services.
Patient Safety
Patient Safety Thermometer (Harm Free Care) and Infection Control
The CCG confirms that the Trust has participated as a member of the Somerset
Harm Free Care Collaborative to develop a consistent approach to reducing
pressure ulcers through use evidenced based tools. The Trust reported an average
of five, Grade 2 or above, community hospital or mental health inpatient ward
acquired pressure ulcers per month in 2012/13. In recognition of the need for the
continued focus and reduction of incidence of pressure ulcers and improved care
and outcomes for patients, the Trust will continue to focus on the reduction in
pressure ulcer development and to achieve a zero tolerance culture to the
development of pressure ulcers.
The CCG has set the Trust a challenging target of 40% reduction in avoidable
hospital acquired cases and a 15% reduction in avoidable pressure ulcers acquired
within a community setting for patients on a District Nurse caseload as part of the
CQUIN framework for 2013 - 14.
The Trust has made good progress on reducing the incidence of patient falls within
community hospitals with a 23% reduction in reported slips, trips and falls during
2012/13 compared to the previous year, despite the increasing complexity of
patients and a high level of bed occupancy. The CCG has closely reviewed the
number of falls with the Trust and the learning from serious incidents where patients
have fallen resulting in harm, and can confirm that the Trust is implementing a range
of interventions to reduce falls including intentional rounding in community hospitals
to proactively offer care to patients.
The CCG notes the successful outcome of the pilot in Burnham on Sea Hospital to
promote a urinary catheter free environment, demonstrating positive outcomes with
the challenge to roll out the leaning across all Trust inpatient services and district
nursing.
The Trust is commended for consistently achieving greater than 90% of all adult
inpatients having a risk assessment for Venous Thrombo-embolism and receiving
appropriate prophylaxis when assessed as being at risk across every month in
2012/13.
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Somerset CCG confirms the data for healthcare acquired infections for 2012 -13 as
correct. The Trust met the local trajectory of zero MRSA bloodstream infections and
is commended for achieving the commissioner set trajectory of no more than ten
cases of C difficile acquired after 72 hours of admission, with an overall year end
position of 5 cases. Somerset CCG notes the commitment from the Trust to continue
to focus of the reduction of healthcare associated infections in 2013 -14.
Care Planning
The CCG recognises the emphasis the Trust places on the importance of
Personalised Care Planning the the progress made in developing key principles for
inpatient and community settings and cascading these, along with guidance for
implementation to frontline staff, and the audit programme undertaken to benchmark
progress. The CCG notes the continued focus on this aspect of patient care by
including it as a key priority for the 2013/14 Quality Account and would encourage
the Trust to link this priority with the introduction of personal health budgets for
patients in receipt of continuing care funding.
Nutrition
Ensuring early identification of patients at risk of not receiving adequate nutrition is
an essential element of patient care. Somerset CCG commends the Trust for the
consistently exceeding the target of greater than 90% of nutritional risk assessments
using the „MUST‟ tool for all inpatients within 24 hours of admission, with more than
90% of patients identified as „at risk‟ having a care plan to support their needs.
Dementia
Both the number and proportion of people in Somerset aged over 65 with dementia
is set to increase. It is important that this vulnerable group of patients are identified
early so that they can receive appropriate care and treatment. The Trust met their
CQUIN targets for dementia screening, risk assessment and referral for diagnosis
and is committed to continue with improvements during 2013 -14 to maintain
achievement of the Level 1 and Level 2 standards of the South West Dementia
Partnership: Improving Care for People with dementia or mild cognitive impairment
in hospital.
Learning Disabilities
Somerset CCG recognises the range of steps undertaken by the Trust in respect of
provision of services for people with Learning Disabilities (LD). The implementation
of health passports for all people with a learning disability as part of the CQUIN
framework for 2012 – 13 has been a significant achievement to assist in improving
health outcomes for patients with a learning disability.
Serious Incidents requiring Investigation (SIRIs)
The CCG confirms the ongoing commitment of the Trust to learn from serious
incidents. Representatives from the Nursing and Patient Safety Directorate of NHS
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Somerset have attended the Trust SIRI review group. The Trust reported five Grade
2 serious incidents that require investigation during 2012 – 13. These included four
inpatient deaths on mental health wards or for patients on leave from the ward and
one patient who died as a result of an overdose of medication at home. In discussion
with the commissioner, the Trust commissioned an external thematic review of these
Grade 2 incidents which indicated that this was not a cluster of incidents and
identified good practice in risk assessment and care of these patients. The report
made recommendations for improvements in discharge planning for patients and risk
assessment and care planning for patients taking leave from the ward. The CCG will
continue to monitor the implementations of these recommendations with the Trust.
A further recommendation from the external review was that the Trust should
develop its own suicide prevention strategy and the CCG welcomes the Trusts work
to develop a whole mental health service approach to this to ensure safe care for
mental health patients.
Clinical Effectiveness
The Trust has participated in a range of relevant national clinical audits and the
national confidential enquiry into suicide and homicide by people with mental illness.
The Trust has also completed the National Patient Safety Agency Suicide Prevention
Audit for the third time. This demonstrates improved progress in meeting each of the
eight standards for maintaining the safety of patients on inpatient mental health
wards. Key recommendations are for improvements in documenting leave from the
ward, management of medication and involving carers in assessments of patients.
These are recurrent themes from serious untoward incidents and the Trust identified
quality priorities for 2013 – 14 will support work in these areas
Patient Experience
The CCG notes the variety of approaches taken by the Trust to assessing patient
experience and acknowledges the values the Trust places on the views of patients,
carers and service users. The Trust is commended on the high rates of patient
satisfaction reported via local surveys with over 90% being positive responses, with
plans in place to address overall response rates. The Trust is well placed to start
reporting against the Friends and Family Test in 2013 in Community Hospital
settings and Minor Injury Units.
Patient experience of community mental health services
The national survey for mental health services in 2012 concentrated on community
mental health services. The CCG acknowledges that the Trust have developed an
action plan as a result of the „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‟ to the Patient and Public Involvement Group in February 2013.
Staff experience
The national NHS staff survey demonstrates that staff engagement has had a slight
increase on the previous year‟s data from 3.65 to 3.69. The CCG notes the
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improvements in staff who have had an appraisal and a well - structured appraisal.
This is an important aspect of ensuring staff access appropriate continuing
professional development and training. The CCG notes the Trust was in the lower
ranking Trusts for staff working extra hours and feeling pressured at work and this
will be a key area for focus in 2012 – 13. The Trust was within the average range for
staff recommendation of the Trust as a place to work or receive treatment.
Joint Care Quality Commission (CQC)/OFSTED Review of Safeguarding and
Looked After Children‟s Services
During 23 April and 4 May 2012 the CQC and OFSTED conducted a joint inspection
of Safeguarding and Looked After Children‟s Services in Somerset with a judgment
of inadequate for health of looked after children. The CCG acknowledges the
immediate response by the Trust to improve systems and process for children
looked after to receive timely health assessments and the improvements made to
record keeping to track the journey of the child through health services. The
appointment of a nurse practitioner for children looked after commissioned by the
CCG will enable the Trust to redesign the service to be focused around the needs of
children and young people in 2013 – 14.
Data Quality
The Trust acknowledges the importance of data quality in providing confidence in the
accuracy of information used to inform decisions in respect of service improvement.
The Governance Assessment report for 2012/13 was graded as „satisfactory‟ and
the CCG notes the actions being taken to improve data quality.
Quality Improvement Priorities for 2013/14
Somerset CCG supports the quality improvement priorities identified by the Trust for
the coming year. In the light of the publication of the Francis Inquiry the overarching
theme of improving patient experience and patient and carer involvement is
increasingly important and will be delivered through the priority areas of:
Personalised Care Planning
Avoidable Pressure Ulcers
Recognising Physical Deterioration
Recruiting for Care and Compassion
Screening for Dementia
Medicine Administration
The Commissioning for Quality and Innovation (CQUIN) framework that the CCG
have agreed with the Trust will also support the priorities and drive quality
improvement.
We can confirm that the Quality Account provides a balanced view of the Trusts‟
achievements and as such is an accurate reflection of the quality of services
provided. Somerset Partnership NHS Foundation Trust has made significant
achievements in improving the quality of the services provided during 2013 -14 and
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we look forward to continuing to work with them to improve the safety, clinical
effectiveness and patient experience of the services provided by the Trust.
Please contact me at the above address if you wish to discuss any of the above
comments further.
Yours sincerely
Lucy Watson
Director of Quality and Patient Safety
Copy:
Copy:
Copy:
Copy:
Dr David Rooke, Somerset Clinical Commissioning Group
David Slack, Managing Director, Somerset Clinical Commissioning Group
Ann Andrerson, Director of Clinical Commissioning Development,
Somerset Clinical Commissioning Group
Lynn Street, Deputy Director of Quality and Patient Safety, Somerset
Clinical Commissioning Group
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[HEALTH SCRUTINY COMMITTEE]
60
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 2010 to prepare Quality Accounts for each
financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and
content of annual quality reports (which incorporate the above legal requirements)
and on the arrangements that foundation trust boards should put in place to support
the data quality for the preparation of the Quality Report.
In preparing the quality report, directors are required to take steps to satisfy
themselves that:
the content of the Quality Report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual 2012-13
the content of the Quality Report is not inconsistent with internal and external
sources of information including:
-
Board minutes and papers for the period April 2012 to June 2013
-
papers relating to quality reported to the Board over the period April 2012
to June 2013
-
feedback from the commissioners dated 24 May 2013
-
feedback from governors
-
feedback from Healthwatch dated [xx May 2013]
-
feedback from Health Scrutiny Committee dated [xx May 2013]
-
the Trust‟s complaints report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009
-
the National Patient Survey September 2012
-
the 2012 National Staff Survey
-
the Head of Internal Audit‟s annual opinion over the Trust‟s control
environment presented at the Trust Audit Committee on 28 May 2013
-
CQC quality and risk profile dated March 2013
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;
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the data underpinning the measures of performance reported in the Quality
Report is robust and reliable, conforms to specified data quality standards
and prescribed definitions, is subject to appropriate scrutiny and review; and
the Quality Report has been prepared in accordance with Monitor‟s annual
reporting guidance (which incorporates the Quality Accounts regulations)
(published at www.monitornhsft.gov.uk/annualreportingmanual) as well as
the standards to support data quality for the preparation of the Quality Report
(available at www.monitornhsft. gov.uk/annualreportingmanual).
The Directors confirm to the best of their knowledge and belief they have complied
with the above requirements in preparing the Quality Report.
By order of the Board
28 May 2013
Chairman
Chief Executive
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Performance Indicators Subject to External Audit
All information is taken from the Trust Electronic Patient Record.
Seven day follow up
Percentage of people receiving face to face or telephone contact within 7 days of
inpatient discharge.
Numerator: the number of people under adult mental illness specialties on Care
Programme Approach who were followed up (either by face-to-face contact or by
phone discussion) within seven days of discharge from psychiatric inpatient care.
Denominator: the total number of people under adult mental illness specialties on
Care Programme Approach who were discharged from psychiatric inpatient care.
Contact can include face-to-face or telephone contact. Guidance on what should and
should not be counted when calculating the achievement of this target can be found
on Unify2.
All patients discharged to their place of residence, care home, residential
accommodation, or to non-psychiatric care must be followed up within seven days of
discharge. Where a patient has been transferred to prison, contact should be made
via the prison in-reach team.
Exemptions from both the numerator and the denominator of the indicator include:
patients who die within seven days of discharge;
where legal precedence has forced the removal of a patient from the country;
or
patients discharged to another NHS psychiatric inpatient ward.
Recording of Risk: Percentage of clients under our care who have had a formal
assessment of risk and safety recorded.
Numerator: the number of people over 18 open to services and placed on a CPA
level (new CPA, standard care, remaining under the care of the Local Authority or
GP) who have had a risk assessment recorded.
Denominator: the total number of people over 18 open to services and placed on a
CPA level (new CPA, standard care, remaining under the care of the Local Authority
or GP)
The Trust policy sets a higher standard than that reported. The Trust policy standard
is that there is a risk assessment recorded at least annually.
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Gatekept Admissions: Admissions to inpatient services had access to crisis
resolution home treatment teams.
This indicator applies only to admissions to the NHS foundation trust‟s mental health
psychiatric inpatient care. The following cases can be excluded:
admissions to psychiatric intensive care units;
internal transfers of service users between wards in a trust and transfers from
other trusts;
patients recalled on Community Treatment Orders; or
patients on leave under Section 17 of the Mental Health Act 1983.
An admission has been gate-kept by a crisis resolution team if they have assessed
the service user before admission and if they were involved in the decision-making
process which resulted in admission.
For full details of the features of gate-keeping, please see Guidance Statement on
Fidelity and Best Practice for Crisis Services on the Department of Health‟s website.
As set out in Guidance Statement on Fidelity and Best Practice for Crisis Services
the crisis resolution home treatment team should:
a)
provide a mobile 24 hour, seven day a week response to requests for
assessments;
b)
be actively involved in all requests for admission: for the avoidance of doubt,
„actively involved‟ requires face to face contact unless it can be demonstrated
that face-to-face contact was not appropriate or possible. For each case
where face-to-face contact is deemed inappropriate, a declaration that the
face-to-face contact was not the most appropriate action from a clinical
perspective will be required;
c)
be notified of all pending Mental Health Act assessments;
d)
be assessing all these cases before admission happens; and
e)
be central to the decision making process in conjunction with the rest of the
multidisciplinary team.
With the agreement of Monitor, the Trust includes gatekept admissions via
Psychiatric Liaison Teams as part of Crisis Services.
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Patient Safety Incidents reported
Indicator description
Patient safety incidents reported to the National Reporting and Learning Service
(NRLS).
Indicator construction
The number of incidents as described above.
A patient safety incident (PSI) is defined as „any unintended or unexpected
incident(s) that could or did lead to harm for one or more person(s) receiving NHS
funded healthcare‟
Indicator format
Whole number
Safety Incidents involving severe harm or death
Indicator description
Patient safety incidents reported to the NRLS where degree of harm is recorded as
„severe harm‟ or „death‟, as a percentage of all patients safety incidents (PSIs)
reported
Indicator construction
Numerator: The number of patient safety incidents recorded as causing severe
harm/death as described above
The degree of harm for PSIs is defined as follows:
„severe‟ – the patient has been permanently harmed as a result of the PSI, and
„death‟ – the PSI has resulted in the death of the patient
Denominator: The number of patient safety incidents reported to the NRLS
Indicator format
Standard percentage
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