Quality Report
1 April 2013 – 31 March 2014
Page 1 of 69
Quality Report
Part 1: Statement on Quality from
the Chief Executive
This is our sixth anniversary as a Foundation Trust. Over this time we are pleased to have
made significant improvements and developments in the way we organise and provide our
services.
Connecting well is at the heart of our clinical strategy: connecting mind and body; and an
individual within their family, community, and environment. What's really important to us
is people – the people we serve, their carers and families and our staff. We find our
strength in doing all things in partnership with others and our approach is underpinned by
our Values with our commitment to equality and human rights at their heart. They guide
the way we do things and how we want our relationships and connections with people and
communities to be. We aim to be best at working with people, organisations and systems
to help with prevention, early intervention, diagnosis and, when necessary, treatment.
We want people to have the best experience possible when using our services every time.
We know that to achieve this we have to work hard at every level for continued
improvement. We must be constantly alert and listen carefully to others so that we can
spot the early warning signs of things not being as we would want them to be and act
quickly to put things right.
This year the Berwick Report was published following on from the Francis Inquiry about
the appalling care at Mid Staffordshire Hospital. In our response to the Report we tested
the measures we have in place to ensure we are not complacent and that we are doing
everything we can to make sure such failures could never happen in our services. Our
response aims to enable us all to build on best practice and strive to be the safest and best
health and social care enterprise in England, which is an ambitious claim but one that I
know we can achieve by working together.
In learning from elsewhere we have also reviewed our incident reporting in the light of the
findings from what went wrong at Morecombe Bay NHS Trust where important things
were missed. We know it is important we remain vigilant and continue to focus on
improving safety, experience and outcomes of and for people who use services; whilst
improving the value for money of our services and organisation.
During the year many of our services were inspected by the Care Quality Commission. In
total, 26 final reports from inspections have been received across our currently registered
locations during 2013/14. We want all of our services to be fully compliant with CQC’s
standards every day. That’s why, whilst we were pleased that CQC identified only minor
and moderate impact concerns through their inspections to date and with the many
positive comments within their reports from people who use our services and carers, we
Page 2 of 69
have been working hard to implement a range of actions across our services to learn from
their feedback to us and improve our services so that they are fully compliant.
Our staff are key to making sure this happens; we know making sure they are supported
and led well underpins their ability to do this. So this year I launched my competition for
staff to propose a word which would help us all to remember our passion and ambition
and do the right thing every time, every day. As a result of the What’s Your Word?
competition staff chose CARE Communicate | Aspire | Respond | Engage as our word. I
will be working with a group of staff over the next year to see how we can use CARE to
support all staff in our everyday practice.
One important part of doing this is speaking up and talking about difficult things so we can
learn and improve, such as untoward incidents and complaints. We actively encourage
everyone to report all incidents and near misses so that we can continue to improve the
quality of our services. Maintaining a rigorous focus on quality and safety can be really
hard to do in a world where there is so much turbulence, but we know we know it is the
most important thing we must do. The increase in incident reporting figures within this
report reflects that staff are embracing this. However, we still have an overall low rate of
incident reporting and know there is more for us to do so that we know what is really
going on for people who use our services and staff.
Our ambition is to improve the experience people have of our services and for this to be
reflected in both the community and inpatient national surveys. Both survey results for
2013 showed positive improvements for our Trust with strong response rates. The
inpatient survey showed an improvement in reducing the number of areas where we fell in
the lowest 20% of Trusts and there was also an increase in the number of areas we were in
the highest 20% of Trusts. However we were disappointed that the Community survey
national comparison showed we were mostly the “same as other Trusts” in the majority of
the over-arching standards but worse in three areas. We are working hard to improve this
and have a number of initiatives with the aim of achieving sustained improvements over a
longer period of time. These include the implementation of a real time experience system
‘Your Views Matter’ which we launched this year.
Our ‘Your Views Matter’ real time experience trackers are starting to help us to listen
better and more quickly to what people tell us about their experiences. It is already helping
us to gain feedback from far more people than our previous paper based approach. The
feedback allows each service to monitor and act upon any concerns raised in a timely
manner which, in turn, improves the satisfaction for people using services and their carers.
This system helps us gain a rounded view of services by seeing things through the eyes of
people who use our services and their carers’ perspectives.
Mind’s report on the use of physical restraint in mental health services brought into sharp
relief for me the importance of our absolute focus on equality and human rights in what
we do every day. Last year we signed up to the Challenging Behaviour Charter for people
with learning disabilities which focuses on making sure we support people to change their
behaviour, rather than seeing the behaviour as the problem. We are charged with looking
after people when they are at their most vulnerable. It is testimony to our staff’s skills and
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care, particularly those working within our most challenging 24/7 settings in mental health
and learning disabilities, that our figures show de-escalation is followed and physical
restraint is our last resort.
We know environments can play an important role in people’s health and wellbeing. In
2013/14 we have been delighted to achieve two landmark milestones in our ambitious
estates programme to provide truly therapeutic environments for the most vulnerable
people in our care. In July our Board approved the business case for the development of
our new hospital at Farnham Road in Guildford and construction work has commenced. In
March we opened our new Oakwood unit for people with learning disabilities. We have
also invested c£5m in 2013/14 to improve our other facilities across our services and know
how important it is for us to make sure we keep improving and respond more quickly to
maintaining all our facilities so they provide environments that are respectful and
encourage recovery.
Supporting and leading our staff well is essential to our achievement of our ambitions for
the people and communities we serve. Feedback from our staff in our latest Staff Survey
has given us the best results we have had so far, continuing the year-on-year improvement
in how we connect and support each other to do a good job. We are now amongst the best
mental health and learning disability trusts in the country for how we engage, involve and
support our staff. All of this is testimony to hard work; increasing openness in feeding
back; and to our leaders, at every level, paying more attention to the right things.
Improvements in recruitment activity, a reduction in staff turnover and the fact that we
have recruited to 97 additional posts this year has helped greatly increase staff
satisfaction. Further, as this report identifies, our sickness absence level is averaging at 3.8
percent which is better than most comparable trusts.
However, we have a long way to go as I think being the best amongst our NHS peers is just
the start to realising our ambitions for the people we serve. There is so much more we
could be doing to support our staff and create great outcomes and experience for the
people we serve. We want to be a great employer compared to any sector to achieve this
ambition.
One area where we know we need to continue to improve is on our ability to collect and
report on the work we do and the outcomes we help people to achieve. Improving the
quality of our data capture and reporting and our rigorous use of information as a tool for
improvement therefore remains a priority for us. Our use of benchmarking and systematic
approach to using data is getting better. Our efforts to do this will be further aided by our
Patient Safety Collaborative membership and our associated hub work in the coming year.
I have experienced first-hand the current pressures, challenges and improvements all of
our staff are working on in our 24/7 services with some of the most vulnerable people who
use services. I have seen strong evidence of improvements being made in areas identified
in the Care Quality Commission inspections, such as care planning and involving people
who use services in these. There is however still much to do to make improvements and
best practice consistently evident across all of our services all of the time.
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It has recently been confirmed that we will be inspected by CQC in the next phase of the
programme using their new inspection regime. The inspection, due in the summer, will
provide us with a good opportunity to benefit from their external assessment of how well
our services are doing in terms of being Caring, Responsive, Well Led, Innovative and Safe
and learn what else we could be doing to further improve.
By placing the quality and safety of care for people using our services above all other aims
and fostering the growth and development of our staff we will be able to improve on
current best practice and strive to be the safest and best health and social care enterprise
in England.
To the best of my knowledge the information in this document is accurate.
Signed
Fiona Edwards
Chief Executive
23 May 2014
Page 5 of 69
Part 2
Quality Improvement Priorities for 2013/14
The information below outlines the Trust’s quality improvement priorities for 2013/14:
Clinical Quality Priorities
Experience
To improve ‘year on year’ the
experiences for people who use our
services, their carers and families
and staff
To be a top performing Trust in
national community survey in
relation to “overall, how would you
rate the care you have received
from the NHS mental health services
in the last 12 months” by 2015/16
Improve the Trust’s performance in
the three areas of feeling safe, being
included in decisions about their
care and activities through the
inpatient people experience tracker
To be a top performing Trust in
national staff survey to recommend
the Trust as a place to work and a
service for friends and family by
2015/16
Effectiveness / Outcomes
To provide evidence to
commissioners and individuals of
the effectiveness of our services and
the outcomes they help people
achieve
1.
Targets / Measures for 2013/2014
Achieve by Q4 a return rate equivalent to 15% of people who
use our services providing feedback through the People
Experience Trackers using real time devices to establish a
baseline for the "Friends and Family Test"
2.
Increase the feedback from Carers Experience Trackers using
real time devices to establish the number of carers offered a
Carers Assessment
3.
Improve the Trust’s performance within the national staff
survey with particular focus on the percentage of staff that
would recommend the Trust as a service to friends or family
who need care, and as a place to work, and achieve a return
rate in the top three nationally of mental health and learning
disability trusts
1. Use Health of the Nation Outcome Scales (HoNOS) reporting as
a clinical outcome measure to monitor recovery progress for
people who use services. Measure that the second HoNOS
score is being completed and report outcomes achieved
2. Continue to reduce actual staff sickness absence rates to 3.75%
from 4% achieved in 2011/12
3. Each division has a targeted plan to improve access to services
for people who are currently significantly under-represented
and implement at least one pilot project within each division
4. 95% of people who use our services will receive physical
health care checks
Safety
To demonstrate the safety of our
services and the care, treatment
and support they provide
1. Attain compliance of 100% of all staff being up to date with
their statutory training and at least 75% of all staff being
compliant with their mandatory training (using new measure
of % of staff across each division and each training programme)
Page 6 of 69
2. Reduce the rate of patient safety incidents and percentage
resulting in severe harm or death from the number in 2011/12
of which 5% resulted in severe harm or death
3. Demonstrate an increased willingness by staff to report
experiences of discriminatory abuse with a 20% increase in the
number of incidents reported by staff citing discrimination. The
outcome will aim to ensure that staff that experience
discrimination in the workplace have confidence in the support
available from the Trust
Page 7 of 69
Performance against 2013/14 Quality Improvement Priorities
The following is an outline of the progress made for each of the ten quality improvement
priorities under the three dimensions of quality – experience, effectiveness and safety.
Experience
1. Achieve by Q4 a return rate equivalent to 15% of people who use our services
providing feedback through the People Experience Trackers using real time devices
to establish a baseline for the "Friends and Family Test"
Progress
The real time experience trackers is a concept that provides an end-to-end solution for the
capture, analysis and reporting of People’s Experience. The system has the capability of
gathering questionnaire based feedback through an integrated approach across multiple
potential channels. People who use our services are able to provide meaningful feedback
on important aspects of their experience to the people who care for them. The reporting
of data is in real-time which is aggregated and informs quality improvement measures and
gives us the ability to respond locally and quickly to feedback.
We initiated the ‘Your Views Matter’ programme with the roll out of handheld devices in
the working age adult services. There has been a significant increase in responses over the
year, which we are very pleased about. During quarter 4 there have been 550 surveys
completed which represents 3.1% of the people seen in the quarter. However if you
calculated this purely on people seen by working age adult services this would represent
8% of the people seen.
Children’s and young people’s services have begun to receive feedback and easy read
surveys for people with learning disabilities are being tested. We continue to use paper
surveys in our older adult services whilst we roll out the ‘Your Views Matter’ programme
to ensure people using our services always have an opportunity to give us feedback on the
care they receive. In addition our older people’s mental health services have participated
in the EQ programme where people’s experiences were gathered. Our Trust will continue
to prioritise this area to meet the planned trajectory and have identified it as a quality
indicator for 2014-15.
Page 8 of 69
16.0%
14.0%
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
0.0%
2013/14
Trajectory
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
0.0%
0.2%
3.6%
3.1%
2%
5%
10%
15%
Friends and Family
The following depicts the feedback received to form the baseline for the Friends and family
test in the future.
Inpatient Services
Sample of 365 questionnaires
Based on your experience how likely are you to recommend our ward or
unit to your friends and family if they needed similar care or treatment?
Don't know
4%
Extremely
Unlikely
16%
Unlikely
10%
Neither likely or
unlikely
6%
Extremely Likely
32%
Likely
32%
Page 9 of 69
Community Services
Sample of 750 questionnaires
Based on your experience how likely are you to recommend our ward or
unit to your friends and family if they needed similar care or treatment?
Don't know
4%
Extremely Unlikely
3%
Unlikely
2%
Neither likely or
unlikely
7%
Extremely Likely
45%
Likely
39%
Our overarching ambition is to improve experience and for this to be reflected in the
national community survey and inpatient surveys. The following is a heat map we use to
track the feedback we have received from the ‘Your Views Matter’ surveys. The areas
below were identified from the national inpatients survey as requiring more improvement.
The ‘Your Views Matter’ programme has already started to change the responsiveness of
our services allowing teams to have a clear picture of what is working well and to act on
concerns in a timely way. It also allows services to clearly demonstrate change in practice.
Improve the Trust’s performance in the three areas of feeling safe, being included in decisions about
their care and activities through the inpatient people experience tracker.
Question Text
During the daytime are there sufficient
activities to take part
in?
During the evening are there sufficient
activities to take part
in?
Apr May Jun Jul
13 13 13 13
-
-
-
-
-
-
-
-
Aug Sep Oct Nov Dec Jan Feb Mar
Benchmark
13
13 13 13 13 14 14 14
50
0
60
45
Page 10 of 69
53
42
63
45
65
46
57
39
60
39
80
< 50
< 75
<=
100
60
< 50
< 75
<=
100
At weekends - are
there sufficient
activities to take part
in?
-
Did you feel involved
as much as you would
like to be, in decisions
about your care and
treatment?
-
-
Did you feel safe
during your stay on
the ward?
-
-
-
-
-
-
-
-
-
0
50
100
40
55
63
36
58
68
35
69
79
32
66
74
33
59
72
36
57
64
46
< 50
< 75
<=
100
67
< 50
< 75
<=
100
83
< 50
< 75
<=
100
Improve performance in three areas needing most improvement in the national community survey.
Question Text
Do you think your
views were taken
into account in
deciding which
medication to
take?
Can you contact
your Care Coordinator /
Keyworker (or lead
professional) if you
have a problem?
How well does your
Care Co-ordinator /
Keyworker (or lead
professional)
organise the care
and services you
need?
Apr May Jun Jul
13
13
13 13
-
-
-
-
-
-
-
-
-
-
-
-
Aug Sep Oct Nov Dec Jan Feb Mar
Benchmark
13 13 13 13
13 14 14
14
75
75
67
75
96
74
80
84
83
76
85
81
77
84
85
78
85
78
77
80
82
79
< 50
< 75
<=
100
83
< 50
< 75
<=
100
78
< 50
< 75
<=
100
Data source: Internal data collection.
This information is reported quarterly to the Executive Board, Trust Board and Council of
Governors through the Key Performance Indicators report. This information is not
Page 11 of 69
governed by standard national definitions. It has been chosen for the Quality Accounts
because it is an example of how our Trust works to ensure that people using our services
are supported and involved in their care. This is a new quality priority for 2013-2014 and
consequently there is no comparative data available.
2. Increase the feedback from Carers Experience Trackers using real time devices to
establish the number of carers offered a Carers Assessment
Progress
The contribution of carers is significant in many people’s care and support. Understanding
and improving their experience is essential. In addition to that which is discussed above
the real time experience trackers programme has also been designed to provide a
mechanism for people who are carers to feedback their experience of our services. This
means carers are able to provide meaningful feedback on important aspects of their
experience of the care provided to the people they care for and the support offered to
them as a carer and we are able to make improvements locally and in a timely way.
In keeping with our organisation’s drive to meaningfully involve carers our survey includes
a series of questions on the Carers Assessment. This is to not only establish the numbers
being completed but also understand how effective they are and if there are any variations
across our Trust.
As of end quarter four there have been 50 surveys completed by carers. The launch of the
hand held devices as a means of gathering carer feedback has been phased in to run
alongside the existing paper version. The completion of the real time experience trackers
has been low at this implementation stage. To improve the response rates more direct
feedback will be sought via existing Carer Groups to improve completion and all services
have been encouraged to ask for carer feedback at all opportunities. The targeted
communication undertaken to date is now beginning to increase responses via online and
tablet devices.
Our Trust will continue to prioritise this area and it has been identified as a quality
indicator for 2014-15.
Page 12 of 69
180
160
140
120
100
80
60
40
20
0
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
2013/14
0
1
18
50
Trajectory
15
40
100
160
Data source: This information is reported quarterly to the Executive Board, Trust Board
and Council of Governors through the Key Performance Indicators report. This information
is not governed by standard national definitions. It has been chosen for the Quality
Accounts because it is an example of how our Trust works to ensure that carers are
supported and aware of and involved in the care of people who use our services. This is a
new quality priority for 2013-2014 and consequently there is no comparative data
available.
3. Improve the Trust’s performance within the national staff survey with particular
focus on the percentage of staff that would recommend the Trust as a service to
friends or family who need care, and as a place to work, and achieve a return rate in
the top three nationally of mental health & learning disability trusts
Progress
481 of our staff took part in the 2013 staff survey. This was a response rate of 62% which
was in the second highest in England, and compares with our response rate of 64% in the
2012 survey.
Our 2013 results compare very favourably with the 2012 results and, when compared to
our neighbouring Trusts both in mental health and acute sectors, we demonstrate a high
staff satisfaction rate. We were the fifth highest nationally in the Mental Health and
Learning Disability Sector for our results. We have 12 results in the top 20% of Trusts and
zero results in the lowest 20% of Trusts. We are delighted that we have achieved such
positive feedback this year.
Regarding the percentage of staff that would recommend our Trust as a service to friends
or family who need care, and as a place to work, we can show a steady improvement over
the last three years. Staff recommendation of our Trust as a place to work or receive
treatment has increased from 3.28 in 2011 to 3.54 in 2013. When staff were asked if a
friend or relative needed treatment, would they be happy with the standard of care
provided by our organisation, it increased from 53% in 2011 to 59% in 2013. This puts our
Trust equal to the national average and shows a continuous improvement towards our
ambition to be top rated in this area by 2015-16.
Page 13 of 69
The following tables demonstrate our performance within the national staff survey with
particular focus on the percentage/scale of staff that would recommend the provider to
friends or family needing care. There are two questions within the survey that focus on this
area.
Table 1
Staff recommendation of the trust as
a place to work or receive treatment
2011
2012
2013
Trust score
3.28
3.46
3.54
National
average
3.42
3.54
3.55
Lowest National
score
3.07
3.06
3.01
Highest
National score
3.94
4.06
4.04
Note: Please note the data relating to this data is presented as scale summary scores which are calculated
by converting staff responses to particular questions into scores. For each of these scale summary scores,
the minimum score is always 1 and the maximum score is 5.
Staff recommendation of the Trust as a place to work or
receive treatment
3.6
3.55
3.5
3.45
3.4
3.35
3.3
3.25
3.2
2011
2012
2013
SABP
3.28
3.46
3.54
National
3.42
3.54
3.55
Table 2
"If a friend or relative needed
treatment, I would be happy
with the standard of care
provided by this organisation"
Trust score
2011
53%
Trust score
2012
54%
Trust score
2013
59%
Average (median) for
mental health
Trusts 2013
59%
Data source: This is national survey data governed by standard national definitions and the
indicator has been chosen for the quality accounts because it provides information that
allows for effective national benchmarking. Currently it is not mandatory for Mental Health
Trusts to report on the Friends and Family test.
Page 14 of 69
Effectiveness
1. Use Health of the Nation Outcome Scales (HoNOS) reporting as a clinical outcome
measure to monitor recovery progress for people who use services. Measure that the
second HoNOS score is being completed and report outcomes achieved
Progress
The facility to routinely collect HoNOS scores became available at the end of 2010 with the
roll-out of our Trust’s single electronic patient record system, RiO. Therefore we are able
to benchmark performance over four years. Surrey and Borders has made steady progress
over the four years, increasing the number of people who use services who have a HoNOS
score recorded on RiO. The overall percentage rate has risen from 79% in 2010/11 to
94.6% in 2013/14.
We implemented a HoNOS measure at the beginning of the year which provided the
following: A random selection of 20 people and followed them each month to check if
they have had a cluster review interval after the mandatory period of four weeks. The data
has shown that these clusters are not routinely being reviewed after the mandatory period
of four weeks (see table 5).
Even if the mandated period was being achieved we have subsequently identified that
using HoNOS in this way would not provide us with reliable clinically reported outcome
data because it is complex in as far as it is not possible to extrapolate the before and after
treatment scores to indicate whether a service or cluster is improving outcomes for
people, which is why we have not achieved this indicator. However we have alternative
sources of outcome scores being measured such as CORE-OM in arts therapy and the
Warwick-Edinburgh Mental Well-being Scale (WEMWBS) is being piloted.
The number of people who use our working age adult, older people’s and specialist
services (excluding Drug and Alcohol and Learning Disability Services) and children and
young people’s services with a completed recent HoNOS score for 2010-2014 is identified
in the tables below. The table for 2010/11 excludes data for children and young people’s
services.
Table1
Service
2010 – 2011
Total No of people
using services
Adult Mental Health
7861
No and % of people
using services with
HoNOS
6297 (80%)
Older People’s Mental Health
6230
4847 (78%)
1383 (22%)
Specialist
Services
TOTAL
1198
998 (83%)
211 (17%)
15289
12142 (79%)
3158 (21%)
Page 15 of 69
No and % of people
using services
without HoNOS
1564 (20%)
Table 2
Service
2011 – 2012
Total No of people
using services
Adult Mental Health
6985
No and % of people
using services with
HoNOS
6463 (93%)
Older People’s Mental Health
6923
6539 (94%)
384 (6%)
Specialist
28
25 (89%)
3 (11%)
Children and Young People’s
645
501 (78%)
144 (22%)
14581
13528 (93%)
1053 (7%)
TOTAL
No and % of people
using without
HoNOS
522 (7%)
Table 3
2012/2013
Service
Adult Mental Health
Children and Young People
Older People Mental Health
Specialist
TOTAL
Total No of people
using services
6466
546
8327
29
15368
No and % of people
using services with
HoNOS
6161 (95%)
529 (97%)
7808 (94%)
27 (93%)
14525 (95%)
No and % of
people using
without HoNOS
305 (5%)
17 (3%)
519 (6%)
2 (7%)
843 (5%)
No and % of people
using services with
HoNOS
5,966 (94.3%)
504 (94.9%)
8,671 (94.7%)
26 (86.7%)
15,167 (94.6%)
No and % of
people using
without HoNOS
359 (5.7%)
27 (5.1%)
481 (5.3%)
4 (13.3%)
871 (5.4%)
Table 4
2013/2014
Service
Adult Mental Health
Children and Young People
Older People Mental Health
Specialist
TOTAL
Total No of people
using services
6,325
531
9,152
30
16,038
Page 16 of 69
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
2013/14
3%
2%
2%
0%
Trajectory
98%
98%
98%
98%
Data source: A random selection of 20 records were tracked each month to check if they
have had a cluster review interval after the mandatory period of four weeks through RiO
electronic patient records data and reported to the Executive Board, Trust Board and
Council of Governors through the Key Performance Indicators report. This is locally
collected data and is not governed by a standard national definition and has been selected
as an effective tool to measure progress against this indicator. This is a new quality priority
measure for 2013-2014 and consequently there is no comparative data available.
2. Continue to reduce actual staff sickness absence rates to 3.75% from 4% achieved in
2011/12
Progress
Our sickness absence rates have been maintained below the national average for the NHS
and other mental health and learning disability trusts which is 4.24%. Our actual absence
rate in 2013/4 has remained consistent, finishing the year at 3.81% in March 2014. This is a
reduction compared to March 2012 which was 3.85% and the same as March 2013.
We have improved our audit results from two years ago following the NICE public health
guidance for the workplace across all aspects of workforce management namely:
 Increase physical exercise
 Reduce obesity
 Facilitate smoking cessation
 Improve mental health and well-being
 Reduce long term sickness absence
Our employees actively engaged with Trust-wide physical challenges during the summer of
2013 when we recorded via our intranet the distance travelled through all forms of
physical activity in order to meet a combined 10,500 mile target which was the distance of
Page 17 of 69
the Ashes and Lions’ Tour to Australia. Employees are keen for a similar initiative in
2014/15 which we will link to Rio de Janeiro plus we will embark on a Team Weight Loss
Challenge.
3.95%
3.90%
3.85%
3.80%
3.75%
3.70%
3.65%
2013/14
Trajectory
Mar- Apr- May- JunAug- Sep- Oct- Nov- Dec- Jan- Feb- MarJul-13
13
13
13
13
13
13
13
13
13
14
14
14
3.77% 3.80% 3.83% 3.88% 3.90% 3.85% 3.87% 3.86% 3.86% 3.86% 3.86% 3.84% 3.81%
3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75% 3.75%
Data source: Sickness rates are calculated by days absent divided by work days available in
a 12 month period. This information is reported to the Executive Board, Trust Board and
Council of Governors via the Key Performance Indicators report. This is locally collected
data not governed by standard national definitions and it has been chosen for the Quality
Accounts because it is a core priority outlined in the 2013/14 Quality Accounts.
3. Each division has a targeted plan to improve access to services for people who are
currently significantly under-represented and implement at least one pilot project
within each division
Progress
As part of our Equality Objectives, each Service Division has produced a targeted plan to
improve access to services for people who are currently significantly under-represented
and implemented pilot projects (see tables below). All actions have been implemented.
Children and young people’s services focused on looked-after children and young people
to further develop the cultural competence of the staff in the services. The divisions for
people with learning disabilities and working age adults worked together in the Improving
Access to Psychological Therapies (IAPT) to improve access for people with learning
disabilities. The Older People’s Mental Health Service has improved the support provided
to carers of people recently diagnosed with dementia.
Children and Young People’s Services
Outcome
To improve the cultural
competence of 3C’s staff
helping them in their
formulations and how they
role model this to the rest
Action
Q1 – develop a full diversity data baseline
information
Q2 – develop a training plan/master class
in collaboration with the BME network lead
Q3 – roll out cultural competence training
Page 18 of 69
Review and Progress
The review undertaken
highlighted that there is a full
set of diversity data in the main
– which positively
demonstrated the increase
of the looked after system
thereby supporting access
and understanding to this
group
to 3C’s team
Q4 – review of evidence in the team of
increased expertise (care pans, records,
consultations with Children’s Services
attention and skill in this area.
Additional training has been
delivered and lessons learned
from this programme will be
shared across the division
Services for People with Learning Disabilities and Working Age Adults
Outcome
To improve access to IAPT
services for people with
learning disabilities
Action
Q1 Gain agreement to participate in
research project led by the Foundation for
People with Learning Disabilities and King’s
College
Q2 Undertake the facilitated stakeholder
event between IAPT and CTPLD to identify
what works well / what doesn’t work well
and barriers for people with LD accessing
IAPT in Surrey
Q3 Two staff each from IAPT and CTPLD
attend the two day residential action
learning sets and identify an area to work
together to improve access
Q4 Two staff each from IAPT and CTPLD
attend the two day residential action
learning sets and continue to work
together to improve access
Review and Progress
Work has continued on
developing a “reasonably
adjusted” IAPT model
Staff attended the second of the
two day Action Learning Set on
IAPT and Learning Disabilities
which focused on addressing
the needs of people with
learning disabilities and those
with literacy and numeracy
issues
A further meeting of the IAPT
and Learning Disabilities
Reference Group is being held
with the Commissioners present
to plan the next steps for this
project
Older People’s Mental Health Services
Outcome
To improve access to
support for carers of
people with dementia
Action
Q1 Develop group protocol covering
essential aspects of dementia
Q2 Engage multidisciplinary professionals
across the Trust to deliver three groups for
carers (one in each Trust sector)
Q3 High level of attendance at each of the
three groups
Q3 Utilise pre and post group outcomes
measures exploring carers’ objective levels
of knowledge about various topics related
to dementia
Q4 Revise group based on participant
feedback
Review and Progress
COMPLETE
Three groups have been run
across the North West, Mid and
South West sectors of the
directorate – with plans to run a
group in the East. Analysis of
this project has demonstrated
significant increases in people’s
self-reported awareness of
dementia as a result of the
group work
Data source: Targeted plan - developed, piloted, reviewed and spread considered. This
information is reported to the Executive Board, Trust Board and Council of Governors via
the Key Performance Indicators report. This is locally collected data not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
Page 19 of 69
a core priority outlined in the 2013/14 Quality Accounts. This is a new quality priority for
2013-2014 and consequently there is no comparative data available.
4. 95% of people who use our services will receive physical health care checks
Progress
During the reporting year the percentage of people using services receiving a physical
health check who is supported by Care Programme Approach has ranged from 47% to 60%.
The March 2014 figure was 60%. This total is a combined figure for working age and older
people’s services. In March 2014 the figure for adult mental health was 68%. The figure for
older people mental health in March 2014 was 48%.
Research shows that physical health is a key determinant on people’s mental health and so
it is essential that people are cared for holistically. This is an essential component of our
clinical strategy and we are taking positive steps to increase the number of physical health
care checks and health action plans offered. Data quality is key to improving our
performance so weekly monitoring for individual, team and service performance has been
introduced and divisional dashboards have been developed.
The physical health lead is helping the divisional teams to form an action plan to address
the obstacles to meeting this target. Nurses in working age adult mental health are
undertaking tailored training to run a new physical health clinic in mid Surrey and if this
new service is successful the expectation is to run similar clinics across other parts of our
Trust.
To ensure we continue to prioritise this area we will include this indicator in the 2014-15
quality indicators.
100%
80%
60%
40%
20%
0%
Mar-13 Apr-13 May-13 Jun-13
2013/14
Trajectory
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Mar- Apr- May- JunAug- Sep- Oct- Nov- Dec- Jan- Feb- MarJul-13
13
13
13
13
13
13
13
13
13
14
14
14
61.0% 60% 55% 54% 55% 47% 58% 54% 62% 58% 64% 57% 60%
95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
Data source: The above data is based on the number of people who have had a Physical
Health Assessment in the 12 months before their CPA Review. This is reported to Executive
Board, Trust Board and Council of Governors through the Key Performance Indicators
Page 20 of 69
report. This is locally collected data and is not governed by a standard national definition
and has been selected as an effective tool to measure progress against this indicator. This
is a new quality priority for 2013/14 and consequently there is no comparative data
available.
Safety
1. a) Attain compliance of 100% of all staff being up to date with their statutory training
Progress
Excluding staff where training was not applicable, compliance ranged from 48% in quarter
1 to 60% in quarter 4 when the Electronic Staff Record (ESR) has been introduced to
monitor and report on compliance. Compliance with specific statutory subjects varied
according to the type of training.
Therefore we did not achieve 100% of staff being up to date with their statutory training.
To help support staff with this important task we have reviewed in the year all training and
their delivery modes to try and ensure maximisation of resources and reduce down time
for training to be completed by clinical staff in particular. This now includes more elearning
options and less frequent but safe updating requirements where not legally specified.
In quarter 4 the data source changed to be received from the Electronic Staff Record for
the second time. The roll-out of Manager Self-Service was not fully compliant with
amalgamating all training records from a variety of legacy systems during the year. The
competence requirements requiring validation by managers in ESR Manager Self Service is
currently being undertaken. While data from ESR indicates we have not achieved this
indicator, using ESR will give us much more transparency and clarity in the future and
provide staff with visible means of managing their compliance with training, flagging in
advance that their training requires updating and reporting this to their manager. We can
demonstrate an improvement in the quarter 4 position and expect to see this
improvement continue as we complete the self-service ESR programme in July 2014.
100%
80%
60%
40%
20%
0%
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
2013/14
48%
51%
45%
60%
Trajectory
75%
80%
90%
100%
Page 21 of 69
1. b) At least 75% of all staff being compliant with their mandatory training
Progress
Excluding staff where training was not applicable compliance ranged from 42% in quarter 1
to 53% in quarter 4 (in quarters 3 and 4 this was reported through the Electronic Staff
Record). Compliance with mandatory training varies according to the type of training. In
order for mandatory training to be accurately reported in ESR further work was required to
identify and validate competence requirements by managers in ESR Manager Self Service.
As improvement in levels of compliance can be demonstrated in quarter 4, the goal of 75%
of staff being up to date was not achieved. More work is required to ensure more staff are
compliant with training requirements as well as more detailed work to enable the accurate
reporting of compliance with mandatory training. To help support staff with this important
task we have reviewed in the year all training and their delivery modes to try and ensure
maximisation of resources and reduce down time for training to be completed by clinical
staff in particular. This now includes more elearning options and less frequent but safe
updating requirements where not legally specified.
80%
70%
60%
50%
40%
30%
20%
10%
0%
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
2013/14
42%
50%
42%
53%
Trajectory
55%
60%
70%
75%
Data source: The above information is based on the % of relevant staff from each division
(including corporate staff) who are compliant with each statutory and relevant mandatory
training programme (excluding from the calculation those staff where the training is not
applicable). This is reported quarterly to the Executive Board, Trust Board and Council of
Governors through the Key Performance Indicators report. This is locally collected data not
governed by standard national definitions and it has been chosen for the Quality Accounts
because it is a core priority outlined in the 2013/14 Quality Accounts.
2. Reduce the rate of patient safety incidents and percentage resulting in severe harm
or death from the number in 2011/12 of which 5% resulted in severe harm or death
Progress
Over the 12 month period April 2013 - March 2014 our Trust has continued to reduce the
percentage of incidents that were reported via the DATIX system that resulted in severe or
Page 22 of 69
extreme harm compared to the overall number of patient safety incidents reported (see
graph below). The 2012 – 2013 percentage for the year was 4.16% (see table 1). As of
28.02.14 the percentage was 3.52% (see table 2). This reduction is a combination of an
increased number of patient safety incidents reported on Datix during this period and the
number of severe harm or death incidents decreasing to 68 from 70 last year. It should be
noted that this figure includes deaths that occurred from natural causes during this period.
Our Trust works closely with our stakeholders and commissioners to scrutinise and learn
from such incidents and has a robust internal incident investigation and scrutiny process
that allows us to ensure root causes from such incidents are identified and robust actions
implemented to prevent reoccurrence and aid learning. We are also actively participating
in the South of England Improving Safety in Mental Health Collaborative, which we
anticipate will help further improve the robustness of our safety processes that will lead to
improved outcomes for all people using our services. The aim of the Collaborative is to
reduce harm to people using our mental health services by focusing improvement efforts
on the following:
 Senior leadership for safety
 Safe and reliable delivery of mental health care
 Getting medicines right
 Improving the physical care of patients
 Delivering person and family centred care
 Communication and team work
Plans are currently being developed to create a virtual Safety and Experience Hub across
our Trust that would improve the ability of our Trust to implement safety improvements
and tackle indicators of increased risk more quickly which will help to coordinate and
progress the work of the Patient Safety Collaborative.
No.
Reduce the number of patient safety incidents resulting in severe harm or
death in 2011/12
10
9
8
7
6
5
4
3
2
1
0
April
May
June
July
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Total
2011-2012
6
6
6
6
6
6
6
6
6
6
6
7
73
2012-2013
5
8
5
4
8
6
5
6
8
4
5
6
70
2013-2014
6
8
4
2
9
5
6
6
7
8
4
3
68
Page 23 of 69
Data source: STEIS (Strategic Executive Information System) is managed by the
Department of Health. This information is reported to the Executive Board, Trust Board
and Council of Governors through the Key Performance Indicators report. This information
is governed by standard national definitions and it has been chosen for the Quality
Accounts because it provides important information on the rates of levels of severe and
extreme harm incidents compared to the overall number of serious incidents reported for
a given month. We are working to ensure there is a continued reduction in the number of
severe harm or death incidents below the 73 patient safety serious incidents resulting in
severe harm or death that occurred in 2011/12.
Table 1
Reduce the percentage of patient safety incidents resulting in severe harm or death in 2011-2012
from 5% (2012-13)
April
2012
3.62%
May
2012
4.39%
June
2012
5.26%
Jul
2012
3.89%
Aug
2012
4.24%
Sept
2012
4.85%
Oct
2012
4.49%
Nov
2012
4.37%
Dec
2012
4.37%
Jan
2013
4.15%
Feb
2013
4.12%
Mar
2013
4.16%
Table 2
Reduce the percentage of patient safety incidents resulting in severe harm or death in 2011-2012
from 5% (2013-14)
April
2013
0.92%
May
2013
3.14%
June
2013
2.68%
Jul
2013
2.14%
Aug
2013
2.60%
Sept
2013
2.45%
Oct
2013
2.95%
Nov
2013
3.11%
Dec
2013
3.53%
Jan
2014
3.66%
Feb
2014
3.52%
Mar
2014
3.47%
Data source: This information is reported to the Executive Board, Trust Board and Council
of Governors through the Key Performance Indicators report. This information is not
governed by standard national definition as it is locally calculated data using information
from patient safety incidents reported in our Trust that are submitted to the NRLS. It has
been chosen for the Quality Accounts because it provides important information on the
rates of levels of severe and extreme harm incidents compared to the overall number of
incidents reported for a given month. We are working to ensure there is a continued
reduction in the number of severe and extreme harm incidents below the 5% baseline
figure for 2011/12.
3. Demonstrate an increased willingness by staff to report experiences of discriminatory
abuse with a 20% increase in the number of incidents reported by staff citing
discrimination. The outcome will aim to ensure that staff that experience
discrimination in the workplace have confidence in the support available from the
Trust
Progress
As part of our Equality Objectives we have introduced the RESPECT programme to find new
Page 24 of 69
ways of addressing discriminatory abuse staff experience whilst caring for people who use
services. During the reporting year we can demonstrate a steady increase in the
willingness by staff to report experiences of discriminatory abuse. In the 4th quarter a total
of five incidents have been reported: accumulatively across the year 47 incidents have
been reported where the reporter has "ticked" the question "Does this incident relate to
discriminatory behaviour?" This represents an increase from last year’s base rate of nine
incidents (for the total year) of 522%. This is the first year we have reported on this
indicator.
600%
500%
400%
300%
200%
100%
0%
2013/14
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
167%
278%
478%
522%
Data source: The data above is based on the number of incidents reported on the DATIX
incident system where the reporter has "ticked" the question "Does this incident relate to
discriminatory behaviour?" This question was added to DATIX in June 2012. The base line
figure of nine incidents was based on incidents reported during 01.04.12 and 31.03.13 (one
regarding disability, seven regarding race, one regarding gender / sexuality). This is
reported quarterly to the Executive Board, Trust Board and Council of Governors through
the Key Performance Indicators report. This is locally collected data not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
a core priority outlined in the 2013/14 Quality Accounts. This is a new quality priority for
2013/14 and consequently there is no comparative data available.
Page 25 of 69
Quality Improvement Priorities 2014/15
The following outlines our Trust’s Quality Improvement Priorities going forward for the
year 2014 to 2015. These targets have been developed by the Board and Council of
Governors building on our learning through the year in talking with people who use
services, carers, commissioners, our clinical leaders, staff and other stakeholders and
regulators. They have also been identified through our existing performance monitoring
results, our Equality Objectives, our plans to implement our real time experience
monitoring system, together with results from previous national surveys and by mandated
indicators.
Our progress against these targets will be reported to our Trust Board and Council of
Governors throughout the year by the Director of Quality (Nurse Director). These targets
are core to our Trust’s Annual Plan and as such will form part of our quarterly performance
reporting to the regulator, Monitor, on our delivery. These targets will form our quality
(KPI) report for 2014/15. Our progress on delivering these will be reported publicly
throughout the year. At the end of the year we will publish this progress in our Quality
Account 2014/15.
Clinical Quality Priorities
Experience
To be the best for the experiences for people
who use our services, their carers and families
and staff
Benchmarked by:
a) Achieving top quartile scores in the national
community survey in relation to “overall, how
would you rate the care you have received
from the NHS mental health services in the last
12 months” by 2016
b) Achieving top quartile scores in the national
staff survey to recommend the Trust as a place
to work and a service for friends and family by
2016
Effectiveness / Outcomes
For people to have outstanding care plans that
they were both involved in writing and that
they have a recognised and accessible copy
Benchmarked by:
a) Achieving top quartile scores in the national
community survey in relation to “have you
been given a written or printed copy of your
care plan” by 2017
Targets / Measures for 2014/2015
1. To increase the percentage of people, reported
through ‘Your Views Matter’, who would
recommend our services to friends and family
members (from baseline of 68% (based on
responses between Sept 13- Jan 14))
2. To increase from the baseline of 41% of carers
(based on responses between Sept 13- Jan 14) the
percentage offered a carers assessment
3. Improve the Trust’s performance within the
national staff survey with particular focus on the
percentage of staff that would recommend the
Trust as a service to friends or family who need
care, and as a place to work, and sustain a return
rate in the top three nationally of mental health &
learning disability trusts
4. To attain 85% scored in ‘Your Views Matter’
question – “Do you think your views were taken
into account when deciding what was in your care
plan?”
5. 90% of people who use our services will have a
person centred care plan (excludes assessment and
advisory services)
6. 90% of people who use services have a health check
Page 26 of 69
b) Achieving an increase in the number of
community contacts from 2013/14 activity
baseline
7. Each division has a targeted plan to improve access
to services for people who are currently significantly
under-represented and implement at least two
further projects within each division
Safety
8. Achieve compliance of 95% of all staff being up to
date with their statutory training and at least 80% of
all staff being compliant with their mandatory
training
To provide the safest care, treatment and
support for people
9. Reduce the rate of patient safety incidents and
percentage resulting in severe harm or death from
the number in 2011/12 of which 5% resulted in
severe harm or death
10. Demonstrate an increased willingness by staff to
report experiences of discriminatory abuse with a
20% increase from 2013/14 in the number of
incidents reported by staff citing discrimination
Page 27 of 69
Statements of Assurance from the Board
Review of Services
During 2013/14 Surrey and Borders Partnership NHS Foundation Trust provided 147
relevant health services.
Surrey and Borders Partnership NHS Foundation Trust has reviewed all the data available
on the quality of care in 73 of these relevant health services through the periodic service
review process.
The income generated by the relevant health services reviewed in 2013/14 represents
100% of the total income generated from the provision of services by Surrey and Borders
Partnership NHS Foundation Trust for 2013/14.
The data reviewed through the Periodic Service Review process covers the dimensions of
quality – patient safety, clinical effectiveness and people’s experience. The number of
services and how these are configured and clustered changes over time.
Participation in Clinical Audits
During 2013/14 two national clinical audits and one national confidential enquiry covered
relevant health services that Surrey and Borders Partnership NHS Foundation Trust
provides.
During that period Surrey and Borders Partnership NHS Foundation Trust participated in
100% of national clinical audits and 100% of national confidential enquiries of the national
clinical audits and national confidential enquires which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Surrey and Borders
Partnership NHS Foundation Trust was eligible to participate in during 2013/14 are as
follows:
 National Audit of Schizophrenia
 Prescribing Observatory for Mental Health
 National confidential inquiries into suicide and homicide for people with severe and
enduring mental illness
The national clinical audits and national confidential enquiries that Surrey and Borders
Partnership NHS Foundation Trust participated in during 2013/14 are as follows:
 National Audit of Schizophrenia
 Prescribing Observatory for Mental Health
 National confidential inquiries into suicide and homicide for people with severe and
enduring mental illness
Page 28 of 69
The national clinical audits and national confidential enquiries that Surrey and Borders
Partnership NHS Foundation Trust participated in, and for which data collection was
completed during 2013/14, are listed below alongside the number of cases submitted to
each audit or enquiry as a percentage of the number of registered cases required by the
terms of that audit or enquiry.
National Clinical Audits
Number of Cases
Submitted
National Audit of Schizophrenia (NAS)
 Audit of practice
 Service user survey
 Carer survey
Prescribing Observatory for Mental Health
 Prescribing for ADHD
 Monitoring of patients prescribed lithium
 Prescribing anti-dementia drugs
 Use of antipsychotic medication in
CAMHS
Note: The final numbers for the NAS are in the last stages of data cleaning
% of Registered
Cases
95
31
13
100%
100%
100%
148
160
189
21
100%
100%
100%
100%
The report of one national clinical audit was reviewed by the provider in 2013/14 and
Surrey and Borders Partnership NHS Foundation Trust intends to take the following actions
to improve the quality of healthcare provided:
All clinical audits carried out within the Trust have recommendations, which are
implemented through detailed action plans. These will be monitored through various
governance committees and locally to ensure the Trust delivers quality services.
The reports of eight local clinical audits were reviewed by the provider in 2013/14 and
Surrey and Borders Partnership NHS Foundation Trust intends to take the following actions
to improve the quality of healthcare provided:
Recommendations have been borne out of the results of the audits, which are
implemented through detailed action plans, further recommendations and re-audit.
These are monitored through various governance committees and individual services
to ensure the Trust delivers quality services.
Participation in Clinical Research
The number of patients receiving relevant health services provided or sub contracted by
Surrey and Borders Partnership NHS Foundation Trust in 2013/14 that were recruited
during that period to participate in research approved by a Research Ethics Committee was
312.
The R&D Office promotes and encourages a wide range of research projects with practical,
hands-on support and involvement from our Clinical Studies Officers and positive
cooperation from all our services across our Trust. Positive and meaningful involvement in
research from people using our services, their carers and the public has increased over
2013/14, showing real transformative benefits for services. Research offering new
opportunities for our stakeholders is described below:
Page 29 of 69
A trial of antipsychotic treatment for very late-onset schizophrenia-like psychosis.
Participant feedback indicates improvements in both mood and mental state and a
willingness to continue on this medication.
A randomised controlled trial of the clinical and cost effectiveness of a contingency
management intervention for reduction of cannabis use and relapse in early psychosis. A
participant reported being able to effectively use the strategies taught through a psychoeducation programme to avoid cannabis use in a social situation with friends. Another
participant reported consistent abstinence for nine weeks and as a result the frequency of
the voices he hears has greatly reduced and it is no longer as distressing as it was when he
first entered the trial. He also reports feeling more motivated and positive about his future
now he is no longer using cannabis.
Hypertension: Treatment and outcomes in people with dementia. People using services
enjoy the social contact, especially carers as they feel somebody is listening to them. They
are also keen to engage with researchers as they feel studies in dementia are very
important to finding a future cure for the disease.
A double-blind randomised, placebo-controlled, parallel group study of adjunctive therapy
in the first line treatment of schizophrenia or related psychotic disorders. We are the first
trust in England to recruit into this international, multi-site study. A participant was quoted
as saying they “found the study interesting and enjoyed partaking in cognitive tests.”
Use of the Commissioning for Quality & Innovation (CQUIN) Payment Framework 2013/14
A proportion of Surrey and Borders Partnership NHS Foundation Trust’s income in 2013/14
was conditional on achieving quality improvement and innovation goals agreed between
Surrey and Borders Partnership NHS Foundation Trust and any person or body it entered
into a contract, agreement or arrangement with for the provision of NHS services, through
the Commissioning for Quality and Innovation payment framework (CQUIN). Further
details of the agreed goals for 2013/14 and for the following 12 month period are available
electronically at:
http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTK
File.php?id=3275
Page 30 of 69
Goals and Indicators 2013/14
The table below identifies the Trust’s CQUINs for 2013/14. Some CQUINs are improvement
goals and some are system-wide goals aimed at achieving wider improvements through
working in partnership with the local acute trusts.
Goal No
Goal 1
Indicator 1
Goal 2
Indicator 2
Goal 3
Indicator 3
Goal 3
Indicator 4
Goal 3
Indicator 5
Goal 3
Indicator 6
Goal 3
Indicator 7
Goal 4
Indicator 9
Goal Name
NHS Safety Thermometer
Mental Health Safety Thermometer (not yet available)
Refocusing the MA Acute Care Pathway
Refocusing the MA Acute Care Pathway - Suicide Prevention – NPSA Toolkit
Refocusing the MA Acute Care Pathway - Safe Places for Assessment outside
of A&E
Refocusing the MA Acute Care Pathway – Improved Care Planning &
Management
Refocusing the MA Acute Care Pathway – Positive Patient Experience –
Customer Journey Mapping
Young Onset Dementia – Awareness Training
The monetary total for the amount of income in 2013/14 conditional upon achieving
quality improvement and innovation goals is £1,555,180 against a target of £1,875,550.
The monetary total for the amount of income in 2012/13 was £2,340,809 against a target
of £2,272,005.
Registration with Care Quality Commission
Surrey and Borders Partnership NHS Foundation Trust is required to register with the Care
Quality Commission and its current registration status is registered without conditions.
The Care Quality Commission has not taken enforcement action against Surrey and
Borders Partnership NHS Foundation Trust during 2013/14.
Surrey and Borders Partnership NHS Foundation Trust has not participated in any special
reviews or investigations by the Care Quality Commission during the reporting period.
Quality of Data
Surrey and Borders Partnership NHS Foundation Trust submitted records during 2013/14
to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are
included in the latest published data. The percentage of records in the latest published
data:
 Which included the patient’s valid NHS Number was: 99.55 % for admitted patient
care and 99.87% for outpatient care
Page 31 of 69
 Which included the patient’s valid General Practitioner Registration Code was:
100% for admitted patient care and 100% for outpatient care
Surrey and Borders Partnership NHS Foundation Trust’s Information Governance
Assessment Report overall score for 2013/14 was 82% and was graded green.
Surrey and Borders Partnership NHS Foundation Trust will be taking the following actions
to improve data quality:
During 2014-15 we will continue to maintain and improve upon our ‘satisfactory’ status
with the IG Toolkit. We can demonstrate a 5% increase from last year’s result. We now
have weekly information reporting via our system analysis team and a Data Quality Forum
to ensure all information governance issues are addressed and good practice
implemented.
Surrey and Borders Partnership NHS Foundation Trust was not subject to the Payment by
Results Clinical Coding Audit during the reporting period by the Audit Commission.
Page 32 of 69
CORE SET OF QUALITY INDICATORS
1. Care Programme Approach who were followed up within seven days after discharge from psychiatric in-patient care during the
reporting period
The Surrey and Borders Partnership NHS Foundation Trust considers that this data is as described for the following reasons: an accurate
three year comparison against national data.
The Surrey and Borders Partnership NHS Foundation Trust has taken the following actions to maintain this high percentage, and so the
quality of its services, by continuing to monitor and ensure it provides high quality, efficient and effective services whilst striving to
improve further.
Quality Indicator
The percentage
of patients on
Care
Programme
Approach who
were followed
up within seven
days after
discharge from
psychiatric inpatient care
during the
reporting
period
2011-2012
2012-2013
2013-2014
Qu.1
Qu. 2
Qu.3
Qu. 4
Qu.1
Qu. 2
Qu.3
Qu. 4
Qu.1
Qu. 2
Qu.3
Qu. 4
SABP
99%
98%
99%
99%
96%
98%
98%
98%
99.5%
97.7%
97.3%
93.3%
National
96.7%
97.3%
97.4%
97.6%
97.5%
97.2%
97.6%
97.3%
97.4%
97.5%
96.7%
TBC
*Note: Please note these figures are for Qu. 3 only as the national data for Qu. 4 is not yet available.
Page 33 of 69
Lowest
National
Highest
National
*77.2%
*100.0%
2. Admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting
period
The Surrey and Borders Partnership NHS Foundation Trust considers that this data is as described for the following reasons: an accurate
three year comparison against national data.
The Surrey and Borders Partnership NHS Foundation Trust has taken the following actions to improve this percentage, and so the quality
of its services, by continuing to monitor and ensure it provides high quality, efficient and effective services whilst striving to improve
further.
Quality Indicator
Percentage of
admissions to
acute wards for
which the Crisis
Resolution
Home
Treatment
Team acted as
a gatekeeper
during the
reporting
period
2011-2012
2012-2013
2013-2014
Qu.1
Qu. 2
Qu.3
Qu. 4
Qu.1
Qu. 2
Qu.3
Qu. 4
Qu.1
Qu. 2
Qu.3
Qu. 4
SABP
97%
96%
98%
95%
99.7%
99%
98%
99%
98%
97.2%
97.8%
98.5%
National
97.0%
97.3%
97.7%
97.7%
98.0%
98.1%
98.4%
98.7%
97.7%
98.7%
98.6%
TBC
Lowest
National
Highest
National
*85.5%
*100.0%
*Note: Please note these figures are for Qu. 3 only as the National data for Qu. 4 is not yet available.
3. The percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as
a provider of care to their family or friends
The Surrey and Borders Partnership NHS Foundation Trust considers that this data is as described for the following reasons: an accurate
three year comparison against national data.
Page 34 of 69
The Surrey and Borders Partnership NHS Foundation Trust will be taking the following actions to improve this percentage, and so the quality
of its services, by formulating action plans and will be working with staff and their representatives to target actions according to the
shortfall within individual teams.
Staff recommendation of the Trust as a place to work or receive
treatment
(the extent to which staff think care of patients/service users is the
Trust’s top priority, would recommend their Trust to others as a
place to work, and would be happy with the standard of care
provided by the Trust if a friend or relative needed treatment.)
2011
2012
2013
SABP score
National average
Lowest National
score
Highest National score
3.28
3.46
3.54
3.42
3.54
3.55
3.07
3.06
3.01
3.94
4.06
4.04
Note: Please note the data is presented as scale summary scores which are calculated by converting staff responses into scores. For each of these scale summary
scores, the minimum score is always 1 and the maximum score is 5.
"If a friend or relative needed
treatment, I would be happy with the
standard of care provided by this
organisation"
SABP score 2011
SABP score 2012
SABP score 2013
53%
54%
59%
Average (median) for mental
health trusts 2013
59%
4. Patient experience of community mental health services indicator score with regard to a patient’s experience of contact with a health
or social care worker during the reporting period
The Surrey and Borders Partnership NHS Foundation Trust considers that this data is as described for the following reasons: an accurate
four year comparison against national data.
The Surrey and Borders Partnership NHS Foundation Trust has taken the following actions to improve this percentage, and so the quality of
its services, by building on the 2012 action plan which focuses on the key areas for development. This includes introducing the Real Time
People Experience Trackers. This system provides people using services with a continuous opportunity to feedback their experiences and
Page 35 of 69
allows the Trust to respond in a timely and efficient way. This improves the experience for people using services and in turn the results of
the national survey.
2010
Health and Social Care workers
Did this person listen carefully to you?
Did this person take your views into account?
Did you have trust and confidence in this person?
Did this person treat you with respect and dignity
Were you given enough time to discuss your condition and
treatment?
Trust score
Threshold
for highest
20% of
trusts
90
87
85
94
Highest
score
achieved
No. of
respondents
88
84
82
92
Threshold
for lowest
scoring 20%
of trusts
87
83
81
91
92
90
89
96
218
210
221
220
83
81
85
89
219
Trust score
Threshold
for highest
20% of
trusts
89
87
85
94
Highest
score
achieved
No. of
respondents
87
84
82
93
Threshold
for lowest
scoring 20%
of trusts
86
83
81
91
93
89
89
95
308
305
308
305
82
80
85
88
306
Trust score
Lowest trust
score
8.2
7.9
Highest
trust score
9.3
9.0
2011
Health and Social Care workers
Did this person listen carefully to you?
Did this person take your views into account?
Did you have trust and confidence in this person?
Did this person treat you with respect and dignity
Were you given enough time to discuss your condition and
treatment?
2012
Health and Social Care workers
Did this person listen carefully to you?
Did this person take your views into account?
8.6
8.3
Page 36 of 69
No. of
respondents
287
251
Did you have trust and confidence in this person?
Did this person treat you with respect and dignity
Were you given enough time to discuss your condition and
treatment?
7.9
9.0
7.6
8.8
9.0
9.7
286
289
7.9
7.7
8.7
281
Trust score
8.7
8.4
8.0
9.2
Lowest trust
score
8.2
7.9
7.5
8.6
Highest
trust score
9.2
8.9
8.7
9.5
No. of
respondents
265
259
266
268
8.0
7.4
8.8
262
2013
Health and Social Care workers
Did this person listen carefully to you?
Did this person take your views into account?
Did you have trust and confidence in this person?
Did this person treat you with respect and dignity
Were you given enough time to discuss your condition and
treatment?
Note: Please note the Care Quality Commission data for the 2012 survey was analysed and therefore categorised differently to the previous reports, using a more
robust statistical technique called the ‘expected range’, rather than identifying the top and bottom 20% of trust scores. Further in 2013 there was a sampling error and
as a result the 2013 data cannot be compared to previous years.
5. The number and rate of patient safety incidents reported within the Trust during the reporting period, and the number and
percentage of such patient safety incidents that resulted in severe harm or death
The Surrey and Borders Partnership NHS Foundation Trust considers that this data is as described for the following reasons: an accurate
three year record of patient safety incidents and percentage that resulted in severe harm or death.
The Surrey and Borders Partnership NHS Foundation Trust has taken the following actions to improve this percentage, and so the quality of
its services, by working closely with our stakeholders and commissioners to scrutinise and learn from such incidents and having a robust
internal incident investigation and scrutiny process that allows us to ensure root causes from such incidents are identified and robust
actions are implemented to prevent reoccurrence and aid learning. As the data in this table indicates, we have increased the total number
of patient safety incidents reported to the NRLS from the previous half year, a trend which continues into 2013 and beyond. This has helped
to reflect a more accurate picture of the percentage of incidents that occur which result in severe harm or death.
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However whilst it is encouraging to see that the number of deaths reported by our Trust have reduced (comparing time period to time
period for 2011 -2012) work continues to further reduce this overall percentage and the overall number of such incidents. This is critical to
bring our organisation in line with other mental health organisations as captured in the NRLS comparison reports. The median percentage of
deaths from mental health trusts compared to the total number of incidents reported to the NRLS has remained relatively stable across
from October 2011 at approximately 0.8%. Our percentage remains significantly higher than this at 2.2% but has reduced from the following
half year when it was 3.4%. We are very good at reporting serious incidents due to robust internal scrutiny in this regard and these include
incidents that may have led to a death.
Our ratio of reported deaths to number of reported incidents is high because our reporting of general incidents is much lower than other
trusts, as shown by our very low incident rate per bed days below. This coupled with the relatively low number of incidents we report
compared to other mental health trusts suggests that we should continue to focus effort in encouraging the contemporaneous reporting
and reviewing of all patient safety incidents.
The Suicide Prevention Action group (SPA) has worked to raise awareness of the issues surrounding suicide and plans are currently being
developed to create a virtual Safety Hub across our Trust that would improve the ability of our Trust to implement safety improvements and
tackle indicators of increased risk more quickly.
The figures used to populate this table for the period April 2011 – Sep 2013 were taken from the NRLS public website. This is the latest
information NLRS have currently released comparing our organisation against other similar mental health trusts.
Page 38 of 69
Incidents
Number of incidents logged by the
Trust
Number resulting in severe harm or
death
Number of Trust deaths
Percentage of Trust deaths
compared to total number of
incidents reported to NRLS
Median percentage of deaths from
mental health trusts compared to
total number of incidents reported
to NRLS
*Median number of incidents
reported by mental health trusts
(incidents per bed 1000 bed days)
*Median number of incidents
reported by mental health trusts
(incidents per bed 1000 bed days)
for lowest performing trust
*Median number of incidents
reported by mental health trusts
(incidents per bed 1000 bed days)
for highest performing trust
SABP reporting rate per 1000 bed
days
April 2011 –
Sep 2011
Oct 2011 March 2012
April 2012 –
Sep 2012
Oct 2012 –
March 2013
April 2013 –
Sep 2013
Oct 2013 –
March 2014
473
822
654
864
1,170
945
36 (7.6%)
37(4.5%)
36 (5.5%)
34 (3.9%)
29 (2.47%)
28
40
26
30
26
5.9%
4.9%
4.0%
3.4%
2.2%
0.4%
0.8%
0.8%
0.79%
0.9%
21.1
19.9
23.8
25
26.37
3.06
4.51
5.44
5.5
8.49
86.22
86.89
70.29
99.8
67.06
3.1
5.3
8.1
10.6
15.81
Page 39 of 69
Note: The number of incidents resulting in severe harm or death data set is the number that remained on STEIS after some had been closed because they were not
actually serious incidents (ie the cause of death was later determined to be as a result of natural causes or the incident was duplicated or initial investigation
determined that the incident did not meet serious incident criteria.) The externally reported number of deaths was accurate at the time of reporting.
Caveats to this Declaration
This indicator is being published for the first time which is subject to reliance on staff reporting all incidents and includes an element of local
clinical judgement in the reported figure. There is a completeness risk at every Trust relating to the data collected for total incidents
(regardless of their severity) as it relies on every incident being reported (as the denominator). This requires all staff to be aware of
processes to follow and ensure that every incident is reported. We have provided training and there are various policies and processes in
place relating to incident reporting to support this process, but this does not provide sufficient assurance that could be subject to audit to
ensure that all incidents are being reported. This is in line with all other trusts.
There is also clinical judgement in the classification of an incident as ‘severe harm’ as it requires moderation and judgement against subject
criteria and processes. This can be evidenced as classifications can change once they are reviewed (as outlined in the note above).
Page 40 of 69
Part 3
Other Information
Performance
The following is an overview of the care offered by Surrey and Borders Partnership NHS
Foundation Trust based on performance in 2013/14 against indicators selected by the
board in consultation with stakeholders, with an explanation of the underlying reason for
selection.
Patient Safety
1. Care Programme Approach (CPA) 7-Day follow up
This is the percentage of people being treated by mental health services on enhanced CPA
who were seen/contacted within seven days of discharge from inpatient care.
100
90
80
70
60
50
40
30
20
10
0
CPA 7 day follow-up
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual 2010/11
98
98
98
98
98
98
98
98
98
98
98
98
Actual 2011/12
100
99
99
99
98
98
99
99
99
99
99
99
Actual 2012/13
100
100
96
97
97
97
97
97
97
98
97
98
Actual 2013/14
100
98
100
96
98
98
96
99
97
96
89
94
Threshold
95
95
95
95
95
95
95
95
95
95
95
95
Data source: Internal monthly collection. Reported to Executive Board through the Quality
standards report. This information is governed by standard national definitions and it has
been chosen for the Quality Accounts because it is part of our Trust’s Vision and Values to
treat people well.
2. Percentage of staff with an up-to-date appraisal
This is the % number of staff appraised against total headcount.
Page 41 of 69
100%
95%
90%
85%
80%
75%
Mar-13 Apr-13 May-13 Jun-13
2013/14
Jul-13 Aug-13 Sep-13 Oct-13 Nov-13 Dec-13 Jan-14 Feb-14 Mar-14
Mar- Apr- May- JunAug- Sep- Oct- Nov- Dec- Jan- Feb- MarJul-13
13
13
13
13
13
13
13
13
13
14
14
14
84% 90% 93% 93% 87% 91% 92% 95% 91% 93% 92% 90% 91%
Trajectory
90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
Data source: This is reported to the Executive Board, Trust Board and Council of Governors
through Key Performance Indicators report. This information is not governed by standard
national definitions and it has been chosen because it provides key performance data for
staff in our organisation. The trajectory is 90% of staff with an appraisal held at year end.
This is a new performance data for the Quality Report for 2013-2014 and consequently
there is no comparative data available.
3. Serious Incidents
NUMBER OF SERIOUS INCIDENTS
15
13
11
9
7
5
3
1
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual 2010/11
6
9
6
6
8
2
5
9
5
9
6
8
Actual 2011/12
4
8
4
7
7
12
7
5
4
15
8
7
Actual 2012/13
4
9
5
4
8
6
5
7
11
3
7
6
Actual 2013/14
8
10
6
2
11
7
6
6
7
13
5
6
Threshold
5
5
5
5
5
5
5
5
5
5
5
5
Total
79
88
75
87
Note: The 2013-2014 data set is the number that remained on STEIS after some had been closed because
they were not actually serious incidents (ie the cause of death was later determined to be as a result of
natural causes or the incident was duplicated or initial investigation determined that the incident did not
meet serious incident criteria.)
Page 42 of 69
Data source: Strategic Executive Information System (STEIS) is managed by the
Department of Health. This information is reported to the Executive Board, Trust Board
and Council of Governors through the Key Performance Indicators report. This information
is governed by standard national definitions and it has been chosen for the Quality
Accounts because it provides important information on the rates of serious incidents
reported on STEIS in the organisation.
4. 136 Monitoring
Number of S136 to each place of safety
Place of
Safety
Apr
May
Jun
Jul
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Total
MSATU
17
17
27
34
22
15
14
20
17
20
14
13
230
ACU
21
22
24
30
19
19
26
19
17
16
15
19
247
Ridgewood
23
15
7
-
5
15
15
4
6
10
14
6
120
Total 11/12
54
67
56
58
64
43
61
49
58
47
54
64
675
Total 12/13
49
66
50
74
59
48
34
49
57
44
35
52
617
Total 13/14
61
54
58
64
46
49
55
43
40
46
43
38
597
Invalid
Total
Total outcomes of S136s
Not
Admitted
Admitted
Informally
S2
S3
MSATU
130
64
32
4
ACU
163
51
25
6
Ridgewood
86
24
9
1
Total
379
139
66
11
1
1
63.5%
23%
11%
2%
0.25%
0.25%
Ward
Total as %
Recall CTO
S44
Trans
230
1
1
247
120
597
Data source: This is reported to and monitored by the Mental Health Act Committee and
the Police Liaison Committee. This information is not governed by standard national
definitions and it has been chosen because it provides important intelligence as to the use
of section 136 in our organisation. This is new performance data for 2013-2014 Quality
accounts.
Page 43 of 69
Clinical Effectiveness
1. Assertive Outreach
Number of people receiving Assertive Outreach Services
ASSERTIVE OUTREACH
350
300
250
200
150
100
50
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual 2010/11
319
315
312
307
312
315
314
322
319
319
320
316
Actual 2011/12
317
302
305
303
309
312
306
299
299
302
298
297
Actual 20012/13
303
300
300
301
301
298
297
302
300
300
308
311
Actual 2013/14
259
251
251
241
236
229
218
212
205
197
192
170
Threshold
306
306
306
306
306
306
306
306
306
306
306
306
Data source: Internal data collection. This information is reported to the Executive Board
through the Quality Standards Report. This information is not governed by standard
national definitions and it has been chosen for the Quality Accounts because it is an
example of how our Trust works to ensure patients have access to effective treatment.
2. Early Intervention in Psychosis
Number of new cases referred to the Early Intervention in Psychosis Services.
200
180
160
140
120
100
80
60
40
20
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual 2010/11
10
26
38
51
68
81
97
114
130
147
161
172
Actual 2011/12
9
36
54
70
86
104
119
135
149
159
171
181
Actual 2012/13
15
30
47
65
77
88
103
114
133
150
165
180
Actual 2013/14
24
39
53
65
77
94
105
119
132
140
154
163
Threshold
11
24
35
48
60
72
84
96
108
121
132
145
Page 44 of 69
Data source: Internal data collection. This information is reported to the Executive Board
through the Quality Standards Report. This information is not governed by standard
national definitions and it has been chosen for the Quality Accounts because it is an
example of how our Trust works to ensure that patients have access to effective
treatment. These are cumulative (year to date) figures over 12 month periods for the past
four financial years.
3.
Reduce the Duration of Untreated Psychosis
To reduce the duration of untreated psychosis of people entering our Early Intervention
Programme for first time
100
90
80
70
60
50
40
30
20
10
0
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
2013/14
14
22
20
15
Threshold
90
90
90
90
Data source: This is reported to the Executive Board, Trust Board and Council of Governors
through the Key Performance Indicators report. This information is not governed by
standard national definitions and it has been chosen because it provides key clinical
performance data. The target covers clients on EIIP caseload who have Duration of
Untreated Psychosis (DUP) recorded. Each person on EIIP caseload should have a DUP
recorded at some point up to six months after referral to the Trust. This is new
performance data for the 2013-2014 Quality Accounts and consequently there is no
comparative data available.
Page 45 of 69
4. Home Treatment Team
Number of home treatment episodes.
2000
1800
1600
1400
1200
1000
800
600
400
200
0
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Actual 2010/11
172
310
464
655
810
978
1098
1265
1383
1566
1724
1917
Actual 2011/12
164
326
474
638
824
974
1152
1311
1482
1657
1850
2038
Actual 2012/13
182
351
532
715
869
1029
1182
1333
1486
1650
1773
1944
Actual 2013/14
154
304
443
586
734
867
1027
1191
1343
1505
1635
1759
Threshold
129
269
423
581
739
897
1055
1213
1371
1517
1646
1777
Data source: Internal data collection. This information is reported to the Executive Board
through the Quality Standards Report. This information is not governed by standard
national definitions and it has been chosen for the Quality Accounts because it is an
example of how our Trust works to ensure patients have access to effective treatment.
These are cumulative (year to date) figures over a 12 month period for the last four
financial years.
Patient Experience
%
1. All service users on CPA to be given a copy of their care plan
100
90
80
70
60
50
40
30
20
10
0
Data source: Internal data collection. This information is reported quarterly to the
Executive Board through the Quality Standards Report. This information is not governed by
standard national definitions and it has been chosen for the Quality Accounts because it is
an example of how our Trust works to ensure that patients are aware of and involved in
their care and have access to their care plans. The 2013/14 figures include only service
teams that are covered by the Quality Standards.
Page 46 of 69
2. Number of compliments and complaints
180
160
140
No.
120
100
80
60
40
20
0
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Compliments 2011 - 2012
65
110
88
119
Compliments 2012-2013
117
141
161
104
Compliments 2013-2014
135
117
156
118
70
60
No.
50
40
30
20
10
0
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Complaints 2011 - 2012
34
39
33
59
Complaints 2012-2013
47
26
22
37
Complaints 2013-2014
31
32
35
21
Data source: Internal data collection. This information is reported to the Executive Board
Quality Report to Board and Expert Report to Board and Council of Governors. This
information is governed by standard national definitions and it has been chosen for the
Quality Accounts because it is an example of how our Trust works to ensure people who
use our services are being listened to.
Page 47 of 69
3. Visions and Values in our Periodic Service Review
Periodic Service Reviews are our Trust’s quality assurance system whereby services need
to achieve 85% to meet the standards. Areas where the teams score below the required
levels are immediately addressed and then reassessed within three months.
Our Vision and Values are central to high quality delivery of services and these high scores
indicate that our clinical teams are continuing to improve.
Vision and Values
100
98
96
%
94
92
90
88
86
Community
Teams for
People with
Learning
Disabilities
and Older
Persons
Mental
Health
Community
Teams for
Working age
Adults
Specialist
Services and
Psychologica
l Services
Children and
Young
People's
Services
24/7
Services
Active
Support and
Treatment/R
egistered
Social Care
2010
93
93
93
94
93
95
2011
95
95
94
96
96
94
2012
96
95
96
98
96
96
2013
94
90
94
97
94
95
Data source: Internal Periodic Service Review. This is locally collected data and not
governed by standard national definitions as it is based on local priorities. The indicator
has been chosen for the Quality Accounts because it provides information based on our
Trust’s internal audit tool, which is acknowledged by the Care Quality Commission, to
allow for effective internal cross-service benchmarking. PSR reported also in our Expert
Report to Council of Governors and key stakeholders such as commissioner, Healthwatch
and our Forum of Carers and people who Use our Services.
Page 48 of 69
4. Social Media
Increased public engagement and intentional promotion through increased use and
responses through social media - Twitter and Facebook.
600
500
400
300
200
100
0
2013/14
Trajectory
Mar-13
Q1 2013/14
Q2 2013/14
Q3 2013/14
Q4 2013/14
142
220
312
439
538
163
187
215
247
Data source: This is reported to the Executive Board, Trust Board and Council of Governors
through the Key Performance Indicators report. This information is not governed by
standard national definitions and it has been chosen because it provides key performance
data on engagement. This is also a key strategic priority to reach more people through the
resources we have available. The trajectory is to increase the number of followers on
Twitter by 15% each quarter. This is new performance data for the 2013/14 Quality
Accounts and consequently there is no comparative data available.
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Performance against Key National Priorities
The following gives an overview of performance in 2013/14 against the key national priorities from the Department of Health’s Operating
Framework. This includes performance against the relevant indicators and performance thresholds set out in Appendix A of Monitor’s
Risk Assessment Framework.
Measure
Care Programme
Approach (CPA)
patients receiving
follow-up contact
within seven days of
discharge
Care Programme
Approach (CPA)
patients having
formal review within
12 months
Definition/Notes
Numerator: the number of people under
adult mental illness specialties on CPA
who were followed up (either by face-toface 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 CPA who were discharged
from psychiatric inpatient care
Numerator: the number of adults in the
denominator who have had at least one
formal review in the last 12 months
Denominator: the total number of adults
who have received secondary mental
health services during the reporting
period (quarter) who had spent at least
12 months on CPA (by the end of the
reporting period OR when their time on
CPA ended)
For full details of the changes to the CPA
process, please see the implementation
guidance Refocusing the Care Programme
Approach on the Department of Health’s
website
2013/2014
Q2
Q3
Issues
Data
Period
Target
No Change
Q - Actual
95%
99.5%
97.7%
97.3%
93.3%
No Change
Q - Actual
95%
95.4%
95.9%
96.7%
96.3%
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Q1
Q4
Minimising delayed
transfers of care
Admissions of
people to inpatients
services had access
to Crisis Resolution
Home Treatment
Team
Meeting
commitment to
serve new psychosis
cases by Early
Intervention Team
Numerator: the number of non-acute
patients (aged 18 and over on admission)
per day under consultant and nonconsultant-led care whose transfer of
care was delayed during the quarter. For
example, one patient delayed for five
days counts as five
Denominator: the total number of
occupied bed days (consultant-led and
non-consultant-led) during the quarter.
Delayed transfers of care attributable to
social care services are included
Count is now occupied bed
days, not patients.
Average no longer
reported.
Social Care now included
which will increase delayed
transfers.
Q - Actual
< = 7.5%
4.7%
5.7%
5.0%
2.1%
Numerator: The number of admissions to
the Trust's acute wards (excluding
admissions to psychiatric intensive care
units) that were gate kept by the Crisis
Resolution Home Treatment Teams.
Denominator: The total number of
admissions to the Trust's acute wards
(excluding admissions to psychiatric
intensive care units)
Target has now been
increased from 90% to
95%.
Q - Actual
90%
98.0%
97.2%
97.8%
98.5%
Quarterly performance against
commissioner contract. Threshold
represents a minimum level of
performance against contract
performance, rounded down
No Change
Q - Actual
95%
53
94
132
163
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Data completeness:
identifiers
The reports show all those services
currently submitted in the mental health
minimum data set for adults and older
people. It does not cover activity related
to Learning Disabilities, CAMHS or
Substance Misuse services
Completed Numerator: count of valid
entries (Valid, Other, Default)
Denominator: total number of entries
Target has been reduced
from 99% to 97%.
Date of Birth
Patient's Current Gender
Patient's NHS Number
Organisation Code of Patient’s
Registered GP
Postcode of Patient's normal residence
Organisation Code of Commissioner
Data completeness:
outcomes for
patients on CPA
Definition is for those adult patients on a
CPA with a HoNOS, Employment Status,
Settled Accommodation data.
Completed %
Numerator: count of valid entries (Valid,
Other, Default)
Denominator: total number of entries
Q - Actual
Q - Actual
Q - Actual
Q - Actual
Q - Actual
No Change
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99%
99%
99%
99.9%
99.9%
99.9%
99.9%
99.66%
99.8%
100.0%
99.8%
99.9%
100.0%
99.9%
99.9%
100.0%
99.8%
99.9%
100.0%
99.8%
Q - Actual
Q - Actual
99.99%
99.87%
100.00%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
100.0%
Q - Actual
50.00%
85.2%
86.4%
86.7%
86.2%
Self-certification
against compliance
with requirements
regarding access to
healthcare for
people with a
learning disability
Weighting: 0.5
Q - Actual
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N/A
Green
Green
Green
Green
Equality and Human Rights
We are now in the second year of the implementation of our Equality Objectives – which
we developed from our review using the Equality Delivery System. These are:
 To improve the access to services for people with protected characteristics for all
our services where they are currently under-represented; reducing their health
inequality
 Staff report that they are free from discrimination and abuse in the workplace
 To improve the representation of people with protected characteristics in senior
leadership roles across the Trust (proportionate when compared with overall
workforce profile)
 The Trust has strong partnerships with groups representing people with protected
characteristics at a local and national level
We have been implementing new data quality checks to help focus improvements on the
recording of key diversity information about the protected characteristics of the people
who use our services. We see this as an important tool to help our staff make effective
assessments which take account of the importance of these characteristics.
This year each service division has undertaken a pilot project aimed at improving access
and representation of people in our services. Details are outlined below:
 Children & Young People - to improve the cultural competence of 3C’s staff helping
them in their formulations and how they role model this to the rest of the looked
after system thereby supporting access and understanding to this group
 Services for Working Age Adults with Mental Health Needs and Services for People
with Learning Disabilities - to improve access to IAPT services for people with
learning disabilities
 Services for Older Adults with Mental Health Needs - to improve access to support
for carers of people with dementia
Our Respect Programme continues to be piloted – this aims to ensure that where staff
experience discriminatory abuse, there is clear support and mechanisms in place on how
to respond. We continue to see an increase in the reporting of these incidents (which is
what we anticipated) as awareness grows and staff feel more confident to report these
incidents – this in turn helps us to respond more effectively and to monitor and respond to
patterns of incidents.
We have also received feedback from Stonewall following our participation in the
Workforce Equality Index (a tool to help measure how well we are supporting our staff
who are lesbian, gay or bisexual. This also provides a benchmark against other
organisations using the same tool. This is the second consecutive year we have used this
approach and this year we successfully improved our ranking by 98 places – to 150th in the
national Stonewall WEI.
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Our annual Equality Information Report (including details on access to our services and
workforce data) was published in January with extended information for all protected
characteristics. Our equality data is supporting our work with individuals and groups of
people to ensure that equality and human rights remain a central consideration in
designing and delivering services that can respond to the differing needs of our local
communities and a workplace that is free of discrimination.
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Annex to the Quality Account
The Quality Account has been designed and written following discussions regarding the
quality of our services throughout the year with our Board, the clinical teams and key
stakeholders. These include representation of carers and people who use services, our
Foundation Trust Governors and the Care Quality Commission.
Response by the NHS Commissioning Board
North East Hampshire and Farnham, Surrey Heath, East Surrey, North West Surrey,
Guildford and Waverley and Surrey Downs Clinical Commissioning Groups response to
the Surrey and Borders Partnership NHS Foundation Trust Quality Account 2013/14
North East Hampshire and Farnham, Surrey Heath, East Surrey, North West Surrey,
Guildford and Waverley and Surrey Downs Clinical Commissioning Groups have reviewed
Surrey and Borders Partnership NHS Foundation Trust’s Quality Account.
Overall Surrey and Borders Partnership NHS Foundation Trust has continued to achieve
well compared to the national operating framework requirements. The Trust has identified
a number of the local quality requirements challenging this year. This has been reported to
be mainly due to the quality of the data. The Surrey CCGs are disappointed with the speed
and progress of the data quality and Payment by Result (PbR) cluster information
development that the Trust has shown and look to a higher priority and greater support
being given to this area in 2014/15.
It was disappointing to see the results of the National Service User Survey this year for
Surrey and Borders Partnership NHS Foundation Trust. Commissioners have welcomed the
introduction of the real time capture of patient experience initiatives such as: ‘Your Views
Matter’. These show a significant increase in the response rate from service users and
carers throughout the year. Commissioners are encouraged by the Trust’s commitment to
identify and implement appropriate improvement actions arising from feedback received
this way.
The Trust’s compliance to staff mandatory and statutory training has improved throughout
the year but remains disappointing. There is an expectation for further improvement
during the coming months.
The CQC inspection visits over 2013/14 have been a valuable learning opportunity for the
Trust. Significant progress against the actions and improvements identified has been made
with Surrey and Borders Partnership demonstrating an openness to work with
commissioners to ensure learning is optimised and continuous sustained improvement
results.
The number of serious incidents that result in death or serious injury remains an area that
is being monitored closely. Following a review of the serious incidents reported and the
management process of them, commissioners supported the findings of the open
reporting culture and the Trust’s compliance to national guidance. Over the past six
months, progress has been made in learning lessons from serious incidents, and the review
Page 56 of 69
and closure of serious incidents to meet the national timeframes. The commissioners will
continue to work with the Trust to enable consistent meeting of the expected standards
and shared learning to further improve the quality of the services.
The 2014/15 Quality Account priorities are consistent in improving service users and staff
experience, reducing preventable harm, improving clinical outcomes and staff training. The
Surrey CCGs are pleased to see that the Trust has made physical health checks as one of its
priorities for next year.
This Quality Account provides a comprehensive overview of the quality of care that is
provided within the Trust and its aspirations to consistently improve the quality and safety
of that care. The Clinical Commissioning Groups look forward to continuing to work with
the Trust to meet the quality aspirations of patients, carers, members of the public,
stakeholders, partners and staff.
21 May 2014
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Response by Healthwatch Surrey
During the transition year from Surrey Link to Healthwatch Surrey, Healthwatch Surrey’s
lead representative for Learning Disability services was JO.
JO is a long standing volunteer who previously chaired the Surrey LINK Learning Disability
group and has an in depth knowledge and understanding of the learning disability services
provided by the Trust.
The brief for mental health services was held by the Mental Health Group co-ordinated by
Surrey Coalition of Disabled People. This group includes many of the LINK volunteers who
have experiences and understanding of Surrey & Borders Partnership mental health
services.
Healthwatch Surrey would like to acknowledge and thank the work done by JO and CP in
putting together this response on behalf of Healthwatch Surrey.
MENTAL HEALTH SERVICES
1.
INTRODUCTION
Healthwatch representatives have received the quarterly Expert Reports during 2013/14
and have reviewed these at quarterly meetings with the Trust’s Director of Quality. This
has been the primary means by which Healthwatch has monitored the quality of services
provided by the Trust during the past year as, due to organisational changes through the
transition from Surrey LINK to Surrey Healthwatch, no Enter and View visits have been
undertaken to check on the quality of services from observation of practice.
However, the CQC inspections of Trust services undertaken during 2013 identified a wide
range of issues and concerns which Healthwatch representatives have discussed with the
CQC Inspectors, as their reports reinforced concerns raised through Enter and View visits
undertaken in 2012/13. We hope that the Trust will be able to demonstrate considerable
improvement in these areas when CQC undertakes an inspection of all the Trust’s services
and premises in June/July 2014.
2.
COMMENTS ON PERFORMANCE AGAINST THE QUALITY IMPROVEMENT PRIORITIES
FOR 2013/14 (PART 2)
2.1
Experience
We commend the introduction of portable devices to collect real time feedback from
people using services, but the measure for future years needs to demonstrate an
improvement in patients’ experience, not just an increase in the number of people who
give their views. We therefore look forward to seeing trend analyses from quality reports
which show ‘year on year’ improvements in the experiences of people using the Trust’s
services and carers.
There is, for example, room for improvement in the percentage of people who would
recommend the Trust’s services to friends and family, particularly in inpatient services.
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The ‘Your Views Matter’ means of collecting real time feedback from people using services
and carers will also help inform the Trust’s performance in improving in the three areas of
feeling safe, being included in decisions about their care and activities for inpatients.
These three areas were highlighted in the 2012/13 Quality Accounts, and it is difficult to
assess from the data provided whether there has been any improvement or not. From the
data provided in the 2013/14 Quality Account it would seem that:
 Less than 45% of people feel there are insufficient activities to take part in during
the evenings, and only about 15% more felt there were enough activities in the
daytime
 More people said they felt involved in decisions about their care and treatment,
particularly in decisions about medication, but there is still room for considerably
more improvement
 Even more people said they felt safe whilst in hospital, although on average 25 to
30% still reported that they do not feel safe. Again, we would hope to see
improvements in this area over the coming year.
Regarding carers’ surveys, we agree that the Trust must prioritise improving the response
rate from carers, and acting upon the views given.
2.2 Effectiveness
Although the Trust recognises that physical health is a key determinant of people’s
mental health, it is disappointing to note that by the end of March 2014 only 60% of
people had received a physical health check, compared to the Trust’s target of 95%.
2.3 Safety
Again, it was noted that between only 48 and 60% of staff were up to date with
mandatory training, against the standard of 100%. This raises considerable concern for
patient safety which must be addressed.
2.4 Quality improvement priorities for 2014/15
We would support the priorities identified by the Trust for 2014/15, but would point out
that a target “to be the best” means achieving more than just scoring in the top quartile
in national surveys.
We note however that the Trust proposes to reduce the target for people receiving
physical health checks from 95% to 90%, but does not explain why. We feel that the
higher target should remain in place.
We also think that the Trust should retain the priority to improve their performance in
the three areas of feeling safe, being included in decisions and providing activities in the
evenings and at weekends, where no significant improvement has yet been
demonstrated over recent years.
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3. COMMENTS ON TRUST PERFORMANCE (PART 3)
The following comments are made on the indicators selected by the Trust. Trends and
comparisons were however difficult to assess because annual totals were rarely given. We
hope the Trust will address this in the next Quality Accounts.
3.1 Patients’ safety
Whilst the Trust continues to exceed the national threshold of 95% of people being seen or
followed up within seven days of discharge, it should be noted that the percentage
achieved in 2013/14 is lower than three years previously. To improve patient safety we
would wish 100% of people to be contacted within seven days.
It was disappointing to note that the number of serious incidents increased again during
2013/14 to 2011/12 levels.
3.2 Clinical Effectiveness
It is disappointing to see that the number of home treatment episodes has not increased,
and is indeed lower than the number achieved three to four years ago. This service is
highly valued by service users as an alternative to hospital admission, and we would hope
to see an increase in the number of people supported at home when in crisis or at the
point of admission.
3.3 Patient experience
It is good to note the increase in the percentage of people recorded as being given a copy
of their care plan, but the average of 94% is still short of the target of 100%. This
achievement is not however corroborated by the feedback from people using services in
the Quarter 3 Expert Report (latest version received, dated February 2014), where only
52% of people said they had a copy of their care plan. This difference may be due to
people’s understanding of what a care plan is, but this is an issue in itself which the Trust
needs to address.
3.4 Equality and Human Rights
It was acknowledged by the Trust in their Expert Report for Quarter 3 that little progress
had been made in delivering the four Equality Objectives. This however is not reflected in
the Quality Accounts, and we hope to see progress towards achieving these in 2014/15. In
particular, the Trust has been continually challenged to improve access to services for
people with different impairments, such as text numbers for people who are deaf or hard
of hearing, so that they are able to communicate with the different Trust services.
4. CONCLUDING COMMENTS
Healthwatch Surrey welcomes the initiatives taken by the Trust to seek people’s views on
their experiences of the services (Real time tablets) but would hope to see the Trust
responding more to people’s views and improving their performance in delivering high
quality services. The CQC Inspection due in June/July 2014 will provide more insight into
the extent of compliance, and Healthwatch plans to follow up on both the CQC
recommendations and the Trust’s performance in delivering on their 2014/15 Quality
Improvement Priorities through ‘Enter and View’ visits later in the year.
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LEARNING DISABILITY SERVICES
Healthwatch have received the Quarterly Expert Report, and subsequently met the
Director of Quality at Surrey and Borders Partnership. There have been no ‘Enter and View’
visits in the last 12 months, but three units for People with LD that were closing were
visited during this period (Old School House, Tattenham House and Birchgrove young
persons’ registered residential service). We also reviewed the CQC visits to Surrey and
Borders Partnership and the resulting action plans.
General Comments:
 The data received demonstrates an improvement in some areas but some need
further attention to improve quality of care.
 The initiative of Real Time Experience Trackers we hope will drive up quality and we
welcome this with the inclusion of accessible formats for PLD. We hope support for
PLD will be available for those who require it.

Carers’ opinions are being sought using Real Time Devices and the number of carers
offered an assessment is being monitored and this initiative is vital for carers for MH
and LD clients.
 We commend the initiative for IAPT services to be extended to improve access to
services for PLD to meet their specific needs. Through this initiative we hope it will
also be extended to those diagnosed as having an Autistic Spectrum Disorder.
 Health Action Plans for every client with a Learning Disability still remain an
ambition. When in place they still require regular updating on an annual basis at
minimum.

We were disappointed that there had been slippage on the essential statutory and
mandatory training updates for staff to ensure the safe delivery of services.
 We hope lessons learnt from the CQC reports will continue to be taken on board to
improve quality, safety and environmental issues.
 We note that the Clinical Quality Priorities for the Council of Governors was
produced in an accessible format and we hope other areas will continue to follow
their example.
All the closures of units for PLD proved to be complex. We commended the positive
approach demonstrated by staff to ensure clients’ person centred needs were met for
each individual and choice offered in their new placement. Robust transition plans
were created. Their families and advocates, where appropriate, were kept informed
and involved in the process.
2 May 2014
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Response by Governors
The Board of Governors are pleased to have had the opportunity to review and to provide
a response on the Trust’s Quality Accounts. The Governors find the report to be an
accurate reflection of the Trust’s performance over the year based on the information
reviewed during that time.
The Trust’s Expert Report which is provided to all Governors throughout the year allows us
to follow the Trust’s progress on its performance. Governors have also been issued with an
easy read version of the Trust’s Quality Priorities which has helped to give an accessible
version of progress made. We would welcome similar easy read versions of other
documents.
From our review of the Quality Accounts report we can see that there are areas where the
Trust is doing well such as the early intervention in psychosis, but there are still some areas
where further progress is needed. In particular, the quarter 4 position for CPA follow-up.
We hope that ongoing work will continue to improve this position over the coming year.
We have seen significant improvement in the engagement of people through the ’Your
Views Matter’ programme. We are particularly pleased to see that carers are included as it
has sometimes felt in the past that work with carers has been reactive instead of proactive.
We also welcome the involvement of people with learning disabilities in this programme.
Receiving the feedback from people using the services and carers will assist Governors in
measuring quality of care.
We are delighted that the Trust listened to us and changed the reporting target for
Statutory Training even though it hasn’t managed to achieve it. However, this has been
included again in the 2014-15 targets, which shows a continued focus on this important
area.
We feel some of the targets set for the indicators might have been too high, for example,
staff sickness levels which do not reflect how well the Trust has done in this area and some
are set too low, making it difficult to assess performance. However, we understand that
some of the targets are aimed at a longer time period so it will be interesting to review the
progress for these in a year’s time.
We have noted a positive shift in the narrative used by staff using the term “Our Trust”
instead of “The Trust” which reflects ownership of the organisation and a change in
culture.
We welcome the introduction this year of Governors’ involvement in the Board
workarounds as it has provided us with a first-hand view of the care and treatment
offered, and will assist us in our focus on quality of care and services.
The Deepdive work has been important for the Governors to allow a closer focus into the
quality of service provision. We look forward to further Deepdives in the future and more
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opportunity to look at the performance of the Trust in more detail. This will support the
assurance we require when reviewing the Quality Accounts.
Response by Health Overview and Scrutiny Committee
The Health Scrutiny Committee is pleased to be offered the opportunity to comment on
Surrey and Borders Partnership NHS Foundation Trust Quality Account for 2013/14. The
Trust is thanked for its working with the Health Scrutiny Committee over the last year. The
committee recognises the improvements made by the Trust and endorses the quality
account for 2013/14 and the priorities for 2014/15 with the following comments:
Experience
1. Despite not achieving this target the committee notes the increase in responses and
the value in gathering more feedback and welcomes the continuing focus on this area
in 2014/15
2. Commends the attempts to reach more carers despite the low response rate in
2013/14. We support this priority
3. Commends the Trust's performance.
Effectiveness/Outcomes
1. Supports the decision taken to alter the method for this priority and the amendments
for reporting in 2014/15
2. Commends the low levels of staff sickness absence achieved despite missing the target
set for this year
3. Supports the continuing work to target under-represented groups and acknowledges
the difficulty this presents
4. Recognises the need to reduce the target from 95 per cent and the steps taken by the
Trust to improve. The committee trusts that the reduced target will enable improved
results in 2014/15.
Safety
1. The committee would like to stress the importance of meeting this target and expects
to see rapid improvement in 2014/15 through the use of the ESR to improve training
compliance and will monitor closely
2. Recognises the difficulty in tackling this issue and notes the year-on-year improvements
achieved by the Trust
3. Supports the focus on staff wellbeing and encourages reporting of discriminatory
abuse.
23 April 2014
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Statement of Directors’
Responsibilities in Respect of
the Quality Report
The Directors are required under the Health Act 2009, National Health Service (Quality
Accounts) Regulations 2010 as amended to prepare Quality Accounts for the 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 2013 to June 2014
- Papers relating to quality reported to the Board over the period April 2013 to
March 2014
- Feedback for the commissioners dated 21/05/14
- Feedback from local Healthwatch dated 02/05/14
- Feedback from Governors dated 23/04/14
- Feedback from Health Overview and Scrutiny Committee 02/05/14
- The Trust’s Complaints Report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009 dated May 2014
- The 2013 national patient survey dated August 2013
- The 2013 national staff survey dated March 2013
- The Head of Internal Audit’s annual opinion over the Trust’s control environment
for 2013/14
 CQC quality and risk profiles dated 28/02/14 and 08/04/14;
 The Quality Accounts presents a balanced picture of the Trust’s performance over
the period covered;
 The performance information reported in the Quality Account is reliable and
accurate;
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 There are proper internal controls over the collection and reporting of the measures
of performance included in the Quality Report, and these controls are subject to
review to confirm that they are working effectively in practice;
 The data underpinning the measures of performance reported in the Quality Report
is robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review; and
 The Quality Report has been prepared in accordance with Monitor’s annual
reporting guidance (which incorporates the Quality Accounts regulations) as well as
the standards to support data quality for the preparation of the Quality Report.
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
Date: 23 May 2014
Signed:
Chairman
Date: 23 May 2014
Signed:
Chief Executive
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Independent Auditors’ Report
Independent Auditor’s Report to the Council of Governors of Surrey and Borders
Partnership NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of Surrey and Borders Partnership NHS
Foundation Trust to perform an independent assurance engagement in respect of Surrey
and Borders Partnership NHS Foundation Trust’s Quality Report for the year ended 31
March 2014 (the “Quality Report”) and certain performance indicators contained therein.
Scope and Subject Matter
The indicators for the year ended 31 March 2014 subject to limited assurance consist of
the national priority indicators as mandated by Monitor:
• 100% enhanced Care Programme Approach patients receiving follow-up contact within
seven days of discharge from hospital; and
• Admissions to inpatients services had access to crisis resolution home treatment teams
We refer to these national priority indicators collectively as the “indicators”.
Respective Responsibilities of the Directors and Auditors
The Directors are responsible for the content and the preparation of the Quality Report in
accordance with the criteria set out in the NHS Foundation Trust Annual Reporting Manual
issued by Monitor.
Our responsibility is to form a conclusion, based on limited assurance procedures, on
whether anything has come to our attention that causes us to believe that:
• The Quality Report is not prepared in all material respects in line with the criteria set
out in the NHS Foundation Trust Annual Reporting Manual;
• The Quality Report is not consistent in all material respects with the sources specified in
the Detailed Guidance for External Assurance on Quality Reports; and
• The indicators in the Quality Report identified as having been the subject of limited
assurance in the Quality Report are not reasonably stated in all material respects in
accordance with the NHS Foundation Trust Annual Reporting Manual and the six
dimensions of data quality set out in the Detailed Guidance for External Assurance on
Quality Reports.
We read the Quality Report and consider whether it addresses the content requirements
of the NHS Foundation Trust Annual Reporting Manual, and consider the implications for
our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is
materially inconsistent with:
• Board minutes for the period April 2013 to April 2014;
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• Papers relating to Quality reported to the Board over the period April 2013 to May
2014;
• Feedback from the Commissioners dated May 2014;
• Feedback from local Healthwatch organisations dated May 2014;
• The Trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, 2013/14;
• The 2013/14 national patient survey;
• The 2013/14 national staff survey;
• Care Quality Commission quality and risk profiles/intelligent monitoring reports
2013/14; and
• The 2013/14 Head of Internal Audit’s annual opinion over the Trust’s control
environment.
We consider the implications for our report if we become aware of any apparent
misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of
the Institute of Chartered Accountants in England and Wales (ICAEW) Code of Ethics. Our
team comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of
Governors of Surrey and Borders Partnership NHS Foundation Trust as a body, to assist the
Council of Governors in reporting Surrey and Borders Partnership NHS Foundation Trust’s
quality agenda, performance and activities. We permit the disclosure of this report within
the Annual Report for the year ended 31 March 2014, to enable the Council of Governors
to demonstrate they have discharged their governance responsibilities by commissioning
an independent assurance report in connection with the indicators. To the fullest extent
permitted by law, we do not accept or assume responsibility to anyone other than the
Council of Governors as a body and Surrey and Borders Partnership NHS Foundation Trust
for our work or this report save where terms are expressly agreed and with our prior
consent in writing.
Assurance Work Performed
We conducted this limited assurance engagement in accordance with International
Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other than
Audits or Reviews of Historical Financial Information’ issued by the International Auditing
and Assurance Standards Board (‘ISAE 3000’). Our limited assurance procedures included:
• Evaluating the design and implementation of the key processes and controls for
managing and reporting the indicators;
• Making enquiries of management;
• Testing key management controls;
• Limited testing, on a selective basis, of the data used to calculate the indicator back to
supporting documentation;
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• Comparing the content requirements of the NHS Foundation Trust Annual Reporting
Manual to the categories reported in the Quality Report; and
• Reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance
engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance
engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than
financial information, given the characteristics of the subject matter and the methods used
for determining such information.
The absence of a significant body of established practice on which to draw allows for the
selection of different but acceptable measurement techniques which can result in
materially different measurements and can impact comparability. The precision of
different measurement techniques may also vary. Furthermore, the nature and methods
used to determine such information, as well as the measurement criteria and the precision
thereof, may change over time. It is important to read the Quality Report in the context of
the criteria set out in the NHS Foundation Trust Annual Reporting Manual.
The scope of our assurance work has not included governance over quality or nonmandated indicators which have been determined locally by Surrey and Borders
Partnership NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us
to believe that, for the year ended 31 March 2014:
• The Quality Report is not prepared in all material respects in line with the criteria set
out in the NHS Foundation Trust Annual Reporting Manual;
• The Quality Report is not consistent in all material respects with the sources specified
above; and
• The indicators in the Quality Report subject to limited assurance have not been
reasonably stated in all material respects in accordance with the NHS Foundation Trust
Annual Reporting Manual.
KPMG LLP, Statutory Auditor
Chartered Accountants
15 Canada Square
London E14 5GL
29 May 2014
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Surrey and Borders Partnership NHS Foundation Trust
18 Mole Business Park
Leatherhead
Surrey KT22 7AD
Tel: 0300 55 55 222
Textphone: 020 8964 6326
Email: communications@sabp.nhs.uk
www.sabp.nhs.uk
If you require this document in another format please call the
Communications Department on 01372 216285
Publication date: June 2014