Berkshire Healthcare
NHS Foundation Trust
Quality Account
2015
What is a
Quality Account?
A Quality Account is an annual report
about the quality of services provided by
an NHS healthcare organisation. Quality
Accounts aim to increase public
accountability
and
drive
quality
improvements in the NHS. Our Quality
Account looks back on how well we have
done in the past year at achieving our
goals. It also looks forward to the year
ahead and defines what our priorities for
quality improvements will be and how we
expect to achieve and monitor them.
About the Trust
Berkshire Healthcare NHS Foundation
Trust provides specialist mental health
and community health services to a
population of around 900,000 within
Berkshire. We operate from more than
100 sites across the county including our
community hospitals, Prospect Park
Hospital, clinics and GP Practices. We also
provide health care and therapy to people
in their own homes.
The vast majority of the people we care
for are supported in their own homes. We
have 171 mental health inpatient beds
and almost 200 community hospital beds
in five locations and we employ more than
4,000 staff.
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Table of Contents
Section
Content
Page
Quality Account Highlights 2014
3
4
Appendix A
Statement on Quality by the Chief Executive of Berkshire Healthcare
Foundation Trust
Priorities for Improvement and Statements of Assurance from the Board
2.1 Priorities for improvement 2014/15
2.2 Priorities for improvement 2015/16
2.3 Statements of Assurance from the Board
2.4 Clinical Audit
2.5 Research
2.6 CQUIN Framework
2.7 Care Quality Commission
2.8 Data Quality and Information Governance
Review of Performance
3.1 Performance Assurance Framework 2014/15
3.2 Monitor Authorisation
3.3 Statement of directors’ responsibilities in respect of the Quality Account
Quality Strategy
Appendix B
National Clinical Audits: Actions to Improve Quality
42
Appendix C
Local Clinical Audits: Actions to Improve Quality
45
Appendix D
Patient Safety Thermometer
58
Appendix E
CQUIN Achievement 2014/15
60
Appendix F
CQUIN 2015/16
62
Appendix G
Statements from Governors, Clinical Commissioning Groups, Healthwatch,
Health and Wellbeing Boards, and Health Overview & scrutiny
Committees.
Independent auditor’s report to the council of governors of Berkshire
Healthcare NHS Foundation Trust on the quality report
64
Part 1
Part 2
Part 3
Appendix H
5
22
23
24
26
26
26
27
28
35
40
41
76
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Quality Account Highlights 2015
The Trust was in the top 20% for staff
engagement.
This
includes
staff
motivation at work, staff recommending
the Trust as a place to work and receive
treatment and the ability to contribute
towards improvements at work.
62% of staff agree or strongly agree that
they would recommend the organisation
as a place to work (54% nationally).
71% of staff would agree or strongly agree
that they would be happy with the
standard of care for a friend or family
member. This compares with 60% for
similar Trusts nationally
91% of community mental health and
physical
health
patients
would
recommend the service for a friend or
family member who needed it, which is an
improvement on last year (86%).
83% of mental health inpatients rate their
care as good or very good. This has
improved from 75% last year.
During 2014/15 the trust has publicly
declared that ward staffing levels have
been safe.
53% of care pathways (Community Mental
Health) clients, at the end of the year,
have been offered psychological support.
66 extra health visitors have been
recruited over the last 2 years, exceeding
the Trust’s target (62).
4 out of 7 inpatient wards achieved the
target of over 90 days without a
developed grade 2, 3 or 4 pressure ulcers.
2 wards have achieved over a year and 1
of these is currently over 500 days.
The Trust is implementing its plan to be
smoke free by the end of 2015/16.
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1. Statement on Quality
The Trust continues to deliver high quality care for the
vast majority of patients and their families. Standards
are continuing to rise despite significant financial
pressures.
Where lapses in best care occur there is an
increasingly robust governance and incident reporting
system to highlight areas for improvement and foster
learning across the organisation. We continue to
strive to improve these processes further.
Available evidence demonstrates high levels of staff
engagement. We recognise that our staff are working
extremely hard, often over and above the
requirements of their job plans, to deliver high quality
care for patients with ever increasing demands. We
do not take this dedication for granted and are very
grateful to all our employees who strive every day to
provide the best possible care.
This year we have particularly focussed on patient
engagement and involvement in improving services.
The Listening into Action methodology, which has
been helping us to involve staff in removing obstacles
to high quality care, has been applied successfully to
patients and carers. This has included involvement of
people with learning disabilities. One of the key
messages concerns the value of friendly and
courteous interactions and thoughtfulness when
working with patients in addition to good clinical
skills. This has led to our SHINE campaign – Stop, Hear,
Interested, Notice, and Engage – to help all employees
remember that the most important person at any
time is the person in front of them.
There has been an emphasis on children’s mental
health services during the year, working with health
commissioners and local authorities across the health
and social care system to provide better joined up
care from the community, home and school to
specialist inpatient care. There is much work still to be
done in this area, but a great deal of progress has
been made in identifying what needs to change and
securing additional investment to address this.
We have taken an opportunity to expand our
involvement in primary care by taking over the
running of a GP practice in Circuit Lane, Reading. This
builds on our existing expertise in Out of Hours GP
services and walk in centre provision. We are
interested in taking on more GP services where we
are best placed to improve services for patients and
provide sound financial and quality governance
management. This model is very much in line with the
type of organisational structure being developed
through the NHS Forward View.
The Trust is implementing its plan to go smoke free
across all sites in 2015. This will have a major impact
in promoting a positive message on illness prevention
and, in particular, will help to tackle the major
discrepancy in physical health outcomes for people
with long term mental health problems.
The Trust’s values - caring, committed and working
together - remain key underlying principles which
drive the pursuit of high quality care. These are
embedded within the Trust appraisal system for all
staff. The principle of working together extends
beyond the organisation with respect to work with
others to find innovative solutions to the wider health
and social care challenges in Berkshire and beyond.
There has been very promising collaboration in the
West of Berkshire across providers and local
authorities to improve care pathways for older people
and with respect to urgent care. We very much
welcome the involvement of Frimley Health
Foundation Trust in driving improvements in the acute
hospital services in East Berkshire. We are active
participants in the Oxford Academic Health Science
Network and the Thames Valley Strategic Clinical
Network with a view to learning from each other,
contributing to research and service development and
resolving unwarranted variation in care quality.
There is much more that can be done to ensure that
the people of Berkshire receive amongst the best care
in the country for physical and mental health
problems. At Berkshire Healthcare NHS Foundation
Trust we are determined to play our part in making
sure that this is the case.
This quality account is a vital tool in helping to support
the delivery of high quality care. The information
provided in this report is, to the best of my
knowledge, accurate and gives a fair representation of
the current services provided.
Julian Emms CEO
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2.1 Priorities for Improvement 2014/15
This section of the Quality Account details Trust achievements against the 2014/15 priorities and information on the
quality of services provided during 2014/15. The priorities support the Trust’s quality strategy (Appendix A) to
provide accessible, safe, and clinically effective community and mental health services that improve patient
experience and outcomes of care through the following six elements:
1.
2.
3.
4.
5.
Clinical Effectiveness – Providing services based on best practice
Safety – To avoid harm from care that is intended to help
Efficient – To provide care at the right time, way and place
Organisation culture –Patients to be satisfied and staff to be motivated
Patient experience and involvement – For patients to have a positive experience of our service and receive
respectful, responsive personal care
6. Equitable – To provide equal care regardless of personal characteristics, gender, ethnicity, location and
socio-economic status.
2.1.1 Patient Experience
The Trust’s aim was to continue to ensure patients
and carers have a positive experience of care and are
treated with dignity and respect. This has been
measured in a number of ways, through the ‘Friends
and Family Test‘ where patients and staff are asked
whether they would recommend the service they
have received to a friend or family member if required
and through learning from compliments and
complaints.
Improving patient participation and involvement has
been a key theme for the Trust during 2014/15. There
have been a number of initiatives in this area,
including:
1. ‘Listening into Action’ events with staff to identify
the best ways to remove barriers to better patient
and carer involvement in their clinical areas.
2. ‘Listening into Action’ events with patient and carer
groups to improve care.
There has been a particular focus on enhancing
patient, family and referrer experience in key areas
and services. For example, in child and adolescent
mental health services an independent review has
been undertaken to understand better how to
improve care pathways and reduce waiting lists.
Percentage
Figure 1. Percentage of Patients Extremely likely or very likely to recommend the service to a friend or family member
100
90
80
70
60
50
40
30
20
10
0
Community Services
(Mental and Physical
Health combined)
Mental Health
Inpatients
2012/13 Average
84
66
2013/14 Average
86
74
2014/15 Average
91
62
Note: MH figures for 2014/15 are for Nov 2014-March 2015 due to the change in national methodology. 33/53 mental health
inpatients and 9426/10317 community services responded to the survey.
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Figure 1 shows that our community services in both physical and mental health are highly valued with 91% of people
surveyed likely to recommend the services. For our mental health inpatients, the percentage who would recommend
the services has reduced although other measures of satisfaction have improved (see figure 3).
Figure 2 Percentage who would recommend to a friend or family member.
100
90
98
92
94
Percentage
80
60
40
20
0
Community Hospital Inpatients
Percentage Average 2013/14
Minor Injuries Unit and Walk in
Centres*
Percentage Average 2014/15
* 2013/14 figures are for Minor Injuries Centre only 2014/15 figures include Slough Walk in Health Clinic. There has also been
some change in the methodology to ensure visitors report in higher numbers and anonymously. Response rates for Community
Hospital Inpatients 1013/ 1099 and MIU 4496/476.
Percentage
Figure 3 Percentage of patients who rated the service they received as very good or good.
100
90
80
70
60
50
40
30
20
10
0
*Community Mental
Health
Community Physical
health
Mental health
Inpatients
Patients in
Community
Hospitals
2012/13 Average
97
85
74
94
2013/14 Average
94
86
75
97
2014/15 Average
93
89
83
96
(*2012/13 Community mental health results only include learning disability and older people’s services as data for
adult and children services are unavailable. Community Mental Health Teams and Electroconvulsive therapy
included for 2013/14). Source: Figures 1-3 Trust Patient Experience Reports.
Figure 4 Total numbers of responses over the year.
Total Number of Responses
Community Physical health
11190
Community Mental health
1301
Community Inpatients
1418
Mental Health Inpatients
669
Total Number of Good or Better Responses
9978
1215
1357
556
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3,630 service users and carers have provided feedback
(in quarter 4) through the internal patient survey
programme, with 90% saying their experience was
good or better. In addition 99% of patients with a
Learning Disability who gave feedback said that they
found their meeting with the service helpful. The vast
majority of services have maintained high levels of
satisfaction.
In terms of volume the level of positive feedback
received by services far outweighs the negative
feedback found in complaints and on NHS Choices.
Patient ‘big conversations’ including an event for
people with learning disabilities have been very
successful.
Increased
patient
and
public
representation on key groups and projects has
occurred. Examples include the medical revalidation
group and a collaborative project group developing
Physician Associate courses at Reading University.
The Trust is prominently involved with the Thames
Valley Patient and Public Involvement, Experience and
Engagement (PPIEE) Strategy Group.
Learning from Complaints
During quarter four the Trust received 60 formal
complaints. This compares to 56 in quarter three, 67
in quarter two and 61 in quarter one (248 in the full
year). In addition, 7 complaints were received which
were being led by another organisation (in
comparison with eight in quarter three, nine in
quarter two and five in quarter one).
The main themes from the formal complaints received
were: care and treatment (29), communication (11)
and, waiting times for treatment and attitude of staff
both with 6.
Services receiving the highest number of complaints in
quarter four were: Community Mental Health Teams
(13), and Talking Therapies (5). All other services
which received a complaint experienced 4 or fewer
complaints in the quarter.
The formal response times for quarter four, including
those with agreed re-negotiated timescales, was 96%.
This compares to 88% in quarter three. The average
time taken to investigate and respond to a formal
complaint was 31 days.
Waiting times for (CAMHS) remain high; it is pleasing
that a recent business case for increased funding has
been approved. This will allow the service to recruit
more staff which will lead to an improvement in the
timeliness of appointments. In addition, in an effort to
offer support to families who are waiting for their
child to receive an assessment, staff have been
working closely with voluntary agencies who are now
offering pre-diagnosis workshops to parents and
carers. Information leaflets for parents advising them
about other support and information sources they
may wish to access have been introduced, together
with an information leaflet designed for schools. It is
envisaged that the number of complaints concerning
access to CAMHS will reduce as a result of these
initiatives.
Complaints received in relation to the provision of
community mental health services remain in the
majority. A review of Community mental health
services is due to be published in May 2015 which will
enable the Trust to implement actions to improve
this.
It is recognised that staff attitude can significantly
influence the overall experience of patients and other
users of our services. Complaints concerning staff
attitude have been a consistent theme in this and
previous quarters. However, it is worth noting that
compared to quarter three, the numbers of
complaints received about staff attitude have
dropped by almost half, from 11 to 6. The ‘Smile’ and
‘SHINE’ campaigns launched in February 2015 may be
contributing to this downward trend.
Annual Parliamentary Health Service Ombudsman
(PHSO) activity.
The Trust has been informed of eight complaints
under investigation by the PHSO during 2014/15. In
addition, there has been one complaint which was
received via the PHSO and we were requested to
reconsider our decision not to investigate locally. This
was a complaint relating to care and treatment
received over ten years ago and the complaint was
investigated and responded to based on the
information available in the clinical records.
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One of the eight complaints was about the delay and
omission of paperwork relating to Continuing
Healthcare Funding was responded to locally with the
agreement of the complainant without a formal PHSO
investigation taking place.
In addition there was a complaint received during
2013/14 about communication and access to
children’s therapies as not being taken forward for
investigation as the PHSO reported that there was no
case to answer.
The remaining seven complaints received during
2014/15 were:
1. A complaint about the diagnostic process for a
Deep Vein Thrombosis by the WestCall Out Of
Hours GP Service. This was found to be
partially upheld and there has been an
adaption to the diagnostic criteria used as a
result of this complaint.
The Patient Experience and Engagement Group are
actively monitoring the action plans that arise from
PHSO investigations on a quarterly basis, which acts as
a forum to share practice and learning across the
different specialities and geographical localities.
2. A complaint where a patient felt there was
inaccurate historical information held on their
medical records was found to be not upheld.
The following complaints remain under investigation
by the PHSO at the time of reporting:
3. A complaint about delays in assessment and
treatment for a patient accessing the Complex
Needs Service.
4. A complaint about the admission criteria to a
community inpatient ward.
5. A complaint about the exercises given by the
community physiotherapy service which the
patient feels had a detrimental effect on their
recovery.
6. A complaint about the accessibility and
communication with one of our Community
Mental Health Teams.
7. A complaint was raised which spans multiple
services which include the Common Point of
Entry, Complex Needs Service and Corporate
services (regarding changing his medical
records).
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National Community Mental Health Survey
The Trust uses national surveys to find out about the
experiences of people who receive care and
treatment. The annual Community Mental Health
Patient survey was published in September 2014. This
year’s survey asks different questions to previous
years and therefore the results are not directly
comparable overall.
The survey this year had 33 questions (compared with
38 last year), categorized within nine Sections. A score
for each question is calculated out of 10.
A questionnaire was sent to 850 people who received
community mental health services. Responses were
received from 238 people (28%).
This year the Trust has not received any ratings where
performance has been judged to be lower than the
majority of other Trusts, last year there were 12
questions rated in this category.
There is one question which is identical to previous
years where patients were asked whether services
involved a member of your family or someone else
close to you, as much as you would like. Previously
the Trust was rated as performing lower than the
majority of other Trusts in this area and this year is
rated as performing at the same level as the majority
of other Trusts. It is not unusual for families to report
that they do not feel sufficiently involved or listened
to, so this is an area where further improvement is
sought.
The Trust would like to see improvement next year in
how patients rate performance in supporting them to
manage in a crisis in their illness. An initiative, in
conjunction with the Centre for Mental Health, to get
service users back into employment is a key patient
outcome which should be reflected in the national
survey results for future years.
Figure 5 National Community Mental health survey 2014
(Source: DoN CMHS overview report)
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2014 National Staff Survey
Figure 6 details the key results of the 2014 National
staff survey, which was conducted between October
and December 2014. As a result of the Trust’s decision
to complete the survey electronically the response
rate increased with over 1,800 staff participating. All
staff had the opportunity to participate in the survey.
The results are very positive and the Trust is again in
the top 20% of similar Trusts for staff engagement.
The Staff engagement measure is an overall rating
that includes staff motivation at work, staff
recommending the Trust as a place to work and
receive treatment and the ability to contribute
towards improvements at work. This result is
particularly important as research conclusively
demonstrates that the most powerful indicator from
the survey in predicting the quality of care and
performance of Trusts is the level of staff
engagement.
The most significant improvement was in how
appraisals are carried out. This year the Trust scored
highest in comparison with similar Trusts – 96% of
staff responding said they had had an appraisal in the
last 12 months and a higher percentage than last year
(48% compared with 40%) said it was a wellstructured appraisal. This is because of the
improvements the Trust made to the appraisal
process, guidance and paperwork. Also, the Excellent
Manager Programme which was run for Trust
managers has contributed to better quality appraisals.
These scores are reinforced by the responses to
questions which asked staff if they noticed a positive
difference in their managers. The aim for the year
ahead is to further increase the scores for ‘well
structured’ appraisals.
similar Trusts for staff agreeing that they would feel
secure raising concerns about unsafe clinical practice.
This was 9 percentage points better than last year.
There has been significant work in this area over the
year with increased awareness of the policy and
practice on raising concerns, together with the
improved response rate this demonstrates that
progress has been made.
However, the Trust recognises that there is still more
to do in creating a culture where everyone feels safe
to speak up and this will continue to be an area of
focus over the next few years.
One concerning result was staff perceptions about
equal opportunities in respect of career progression
and promotion. Although the score was in line with
the national average it was less positive than last year.
It is vital that staff have confidence in the integrity of
the recruitment and selection processes. The Trust
has clear policies and processes in this area. In line
with the Trust values, poor practices that
inadvertently or otherwise damage some colleagues’
confidence in their manager’s judgments will be
identified and addressed.
The results overall for 2014 were the most positive to
date for the Trust. Next year’s staff survey will
provide evidence as to whether planned further
improvements make a difference for staff.
Of the 1700 who replied to the question:
1. 49% agreed or strongly agreed “Over the last
12 months I have noticed a positive difference
in how my line manager listens to me and
involves me in decisions that affect work.”
2. 50% agreed or strongly agreed “Over the last
12 months I have noticed a positive difference
in the way my line manager role models the
behaviours required by the Trust.”
Also at a time when the media is reporting that only
two thirds of staff feel secure in whistleblowing on
poor care; the Trust had the best score (78%) amongst
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Figure 6 2014 National Staff Survey
Question Question
reference
Trust
2012
%
Trust
2013
%
Trust
2014 %
62
71
73
69
75
78
71
58
62
62
54
64
69
71
60
Q5a
Care of patients / service users is my organisations top
priority (agree or strongly agree)
My organisation acts on concerns raised by patients
and service users (agree or strongly agree)
I would recommend my organisation as a place to
work (agree or strongly agree)
If a friend or relative needed treatment, I would be
happy with the standard of care provided by this
organisation (agree or strongly agree)
I look forward to going to work (often or always)
National
average for all
mental health
trusts 2014 %
65
62
58
59
54
Q5b
I am enthusiastic about my job (often or always)
74
71
74
68
Q12a
Q12b
Q12c
Q12d
Q8g
How satisfied am I that the organisation values my
47
44
47
42
work (Satisfied or very satisfied)
Q11c
Senior managers try to involve staff in important
35
41
41
32
decisions (agree or strongly agree)
Q11d
Senior managers act on staff feedback (agree or
26
38
41
29
strongly agree)
Q18a
My organisation treats staff who are involved in an
54
54
51
44
error, near miss or incident fairly (agree or strongly
agree)
Q18b
My organisation encourages us to report errors, near
88
90
88
86
misses or incidents(agree or strongly agree)
Q18d
My organisation blames or punishes people who are
10
9
10
15
involved in errors, near misses or incidents (agree or
strongly agree
Q18e
When errors, near misses or incidents are reported my
63
67
67
62
organisation takes action to ensure that they do not
happen again (agree or strongly agree)
Q18f
We are informed about errors, near misses or incidents
51
48
51
46
that happen in the organisation (agree or strongly
agree)
Q18g
We are given feedback about changes made in
49
48
51
48
response to reported errors, near misses and incidents
(agree or strongly agree)
Q19b
I would feel secure raising concerns about unsafe
74
71
78
69
clinical practice (agree or strongly agree)
Q19c
I am confident that my organisation would address my
58
55
65
57
concern (agree or strongly agree)
(Source: 2014 National Staff Survey Table A3.2: Survey questions benchmarked against other mental health/learning
disability Trusts).
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2.1.2 Patient Safety
Trust has maintained a positive culture with respect to
incident reporting in comparison with similar Trusts.
In particular, staff feel increasingly secure in raising
concerns (Q19b) and confident that the organisation
will address these (Q19c).
Patient safety is fundamental to care and the Trust
wants to continue to protect patients from avoidable
harms. This can be achieved by encouraging a
positive patient safety culture within the Trust and
ensuring a safe and reliable delivery of health care.
This has been measured through an increased positive
staff survey response to questions regarding incidents
and learning. The staff survey (Fig.6) indicates that the
Figure 7 Overview of Developed Pressure Ulcers on inpatient wards during the last 12 months.
2014 - 2015
Apr
Q1
May
Jun
Category 2 PU
Cat 3 & 4 PU Avoidable
2
1
1
1
Cat 3 & 4 PU Unavoidable
Grand Total
0
3
0
2
Developed
Pressure Ulcers
Jul
Q2
Aug
Oct
Q3
Nov
Sep
4
0
5
0
3
0
0
4
0
4
1
4
Q4
Feb March Total
Dec
Jan
3
0
4
0
4
1
2
2
4
0
4
0
3
0
39
5
2
5
2
6
0
5
0
4
1
5
0
4
0
3
6
50
This is not all the PU events on the wards as we separate developed within our services and those inherited from
other services. These are just the developed. We currently do not investigate developed category 2s so these cannot
be identified as avoidable or unavoidable
harms at the frontline, and to provide immediate
The Trust has focussed on pressure ulcer prevention
information and analyses for frontline teams to
with the aim of reducing the number of avoidable
monitor their performance in delivering harm free
pressure ulcers to zero. Category 2 pressure ulcers are
care.
not investigated so are not distinguished as avoidable.
The wards monitor days without a developed category
The NHS Safety Thermometer records the presence or
2, 3 or 4 pressure ulcers and celebrate when they
absence of four harms:
achieve 90 days. 3 of 7 wards are yet to achieve this, 2
•
Pressure ulcers
wards have achieved over a year and one of these is
•
Falls
currently over 500 days.
•
Urinary tract infections (UTIs) in patients with
a catheter
Figure 7 gives an overview of those Pressure Ulcer
•
New venous thromboembolisms (VTEs)
Events classed as serious (Category 3 and 4) during
the past 9 months which have developed whilst the
These four harms were selected as the focus by the
patient is cared for on one of our inpatient units. It
Department of Health’s QIPP Safe Care programme
was disappointing that in November and December
because they are common, and because there is a
three pressures ulcers were identified which could
clinical consensus that they are largely preventable
have been prevented. Full investigations were
through appropriate patient care. The concept of
undertaken to ensure we learn why they were not
Harm Free Care was designed to bring focus to the
prevented and to ensure that these lessons are shared
patient’s overall experience. Patients are assessed in
with staff.
their care settings. Measurement at the frontline is
intended to focus attention on patient harms and
Patient Safety Thermometer
their elimination.
The NHS Safety Thermometer is the measurement
tool for a programme of work to support patient
All eligible patients are surveyed on one day of the
safety improvement. It is used to record patient
month. This is typically around 1350 patients for the
Trust.
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The national average for harm free care is 93.8% for
the past 12 months to March 2015. The average
monthly percentage for the Trust over the 12 months
to March 2015 is 92.1%. The Trust has a lower number
of harm free patients due to the significant number of
‘old’ pressure ulcers. This means that patients have
acquired the pressure ulcers in another setting before
coming in to our care. When compared nationally the
data shows that compared to all organisations the
Trust has a higher percentage of pressure ulcers
reported. Nationally ‘new’ pressure ulcers accounted
for 21.8% of all pressure ulcers reported whereas
these account for just 18.7% of all pressure ulcers
reported in the Trust for the 12 months to March
2015.
The number of community pressure ulcers has
continued to reduce in quarter 4, however (Fig 7). The
percentage of falls with harm has usually been lower
than the national percentage (Fig 9). The Trust has a
lower percentage of harms due to catheters and UTI
but a higher percentage due to Venous Thrombo
Embolism (VTE). Although there were just 2 VTEs on
inpatient wards for 14/15 and the data for providing
risk assessment and prophylaxis for VTE is significantly
higher than the national line (Appendix D).
Figure 8 Community Pressure Ulcers
250
Number
200
150
100
50
0
Q4 2013/14
Q1 2014/15
Q2 2014/15
Q3 2014/15
Q4 2014/15
Figure 9 Falls resulting in harm all services, inpatients and community.
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2.1.3 Quality Concerns
The Quality Committee of the Trust Board identify and
review the top quality concerns of the organisation at
each meeting to ensure that appropriate actions are
in place to mitigate them. They are identified through
some of the information sources provided within this
account together with intelligence received from
performance reports, our staff and stakeholders.
The current Trust quality concerns relate to four
broad theme areas and the Board monitor the actions
being taken to mitigate these.
 Staffing shortages in key areas
 Increasing demand against block contract
funding
 Internal cultures
 Sharing of learning.
Additional information on the progress in tackling key
quality concern priorities is also contained within Part
two of this report both within the section on priorities
for 2014/15 and the section on priorities for 2015/16.
Some specific examples are included below.
Nursing Vacancies
Nursing and increasingly therapy staff vacancies mean
that more agency staff are covering shifts. Research
shows that often agency staff do not offer the same
level of care as a permanent member of staff and
therefore the quality of care has potential to be
impacted. Equally, if there is insufficient nursing staff
to offer a service the quality of care may be impacted.
The level of vacancies across the trust means that
there is increased risk of poor staff morale, serious
incidents, complaints and poor patient satisfaction
scores. The services particularly affected are Mental
Health, Learning Disabilities and Community Inpatient
Units, Crisis resolution and home treatment teams
(CRHTT), Community Nursing Services particularly
Bracknell and Slough, Musculoskeletal physiotherapy
and Community Mental Health Teams. Inpatient safe
staffing levels are monitored on a monthly basis and
correlated across to incidents. Managers are
monitoring staff morale and caseload levels.
There is an increasing national shortage of registered
nursing staff and additional student placements have
been commissioned, however these will not qualify
for 3 years. Human Resources (HR) is working with
services to develop recruitment campaigns to attract
nursing staff. The trust is developing a workforce plan
as there is a need to redesign the workforce to meet
the increasing demand and staffing shortages. Where
appropriate, changes in skill mix are being considered.
Child and Adolescent Mental Health (CAMHS)
The Trust Board is aware of the concerns associated
with increased demand on CAMHS services within tier
3 and 4 having received regular reports. Waiting lists
are of concern in several areas within the service.
Minors continue to be admitted to the Prospect Park
Place of Safety (POS) and acute adult wards because
insufficient specialist tier 4 CAMHS beds are available.
Children and young people are safe in the POS or
ward but the environment is not optimal for them and
therefore quality of care is compromised.
Additional investment has been provided to reduce
waiting lists and, prior to Christmas, the lists were
reducing. Following the New Year, however, they
slowly rose again. A triage process is in place to
monitor children on the waiting list and high risk
patients are seen immediately.
The CAMHS service is using the funding received from
winter pressures to manage risk by seeing those
clients identified as high risk and seeing children more
quickly when they present at A&E. This short term
funding is also being used to extend the common
point of entry opening hours until 8pm with sessions
are being offered at weekends. In addition, an
extended hours’ pilot is taking place in the Windsor
and Maidenhead specialist CAMHS service.
A tier 3 business case has been presented to
commissioners for additional resourcing. A tier 4
business case has been presented to NHS England for
the creation of a 24/7 unit at Berkshire Adolescent
Unit - this is agreed in principle.
A significant proportion of additional ‘parity of
esteem’ funding will be allocated to CAMHS in
2015/16 to increase the number of staff available to
work with children across Berkshire. This should help
reduce waiting lists and improve the quality of care.
The University of Reading has been approached to
assess those waiting on the Autistic Spectrum
Disorder pathway to reduce waits in that service.
Meetings have also been set up with colleagues in the
Unitary Authorities to understand their current
provision regarding the emotional health and wellbeing of children (including tier 1 and 2 services).
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Ward environments
Some mental health wards, inherently, present a
greater risk for the organisation in terms of the nature
or vulnerability of the patients accommodated. The
Board has particularly focussed on the learning
disability, Psychiatric intensive care unit and older
peoples wards to seek reassurance that the
environments and culture on these are conducive
with optimal patient care.
Intervention has been put in place where necessary to
improve leadership, staff supervision, performance
management and culture on these wards.
Safe staffing levels are monitored on a monthly basis
and have been maintained. Steps have been taken to
avoid agency use or, where this is absolutely
necessary, to use regular agency staff who know the
ward well. Staff have worked hard with
commissioners and local authorities to return patients
to appropriate community placements in a timely
fashion when inpatient care is no longer required.
Common Point of Entry, Crisis Resolution Home
Treatment Team (CRHTT) and Community Mental
Health (CMHT)
The interface between these three teams has been of
some concern. It is important that it is clear which
team is taking ownership of vulnerable and at risk
patients at any time and that there is effective
communication between services and with referrers,
partners, patients and families at all stages of the care
pathway.
Patients often present with complex
problems which could fall between agencies and
services so excellent collaboration is required. One
common example would be the combination of
mental health, substance misuse and social problems.
CRHTT caseloads are often much higher than the
service was originally designed to cover.
A review of CPE has been commissioned and a
business case for additional investment into CRHTT
has been presented to commissioners under mental
health ‘parity of esteem’ proposals because their
caseloads continue to be over and above the level
originally commissioned.
Waiting Times for Services
Where a patient is waiting for over 18 weeks or above
the target commissioned their experience will be
affected. Services under performing in December
2014 included:
1. Musculoskeletal physiotherapy (MSK) - waiting 7
weeks against a target of 4-6 weeks
2. Hearing and balance paediatrics (East Berkshire) waiting 7 weeks against a target of 4 weeks
3. Speech and Language Therapy Ear Nose and Throat
(West) - waiting times up to 26 weeks
4. Children’s Occupational therapy (West) - waiting 26
weeks against a target of 18 weeks. There is high
demand for this service in this area. ,
5. Children’s physiotherapy (East) - waiting 26 weeks
against an 18 week target.
6. Children's Integrated Assessment (East) - waiting 26
weeks against a target of 18 weeks
Actions have been taken in each service to resolve
these waiting times. In MSK physiotherapy additional
locum staff have been brought in to help address
demand. A demand and capacity action plan has been
created to address children’s waiting list pressures on
service delivery in the immediate future. This action
plan is intended to mitigate the risk of increased
waiting times and to ensure time is protected to
complete a scoping exercise into practise across the
service. Where relevant services are trying to recruit
additional staff; in the mean time staff are being
moved to provide cover. Agencies are being contacted
should recruitment be unsuccessful. Caseloads are
being reviewed to improve throughput. Waiting times
are monitored on a monthly basis. The Trust Board
receives reports on waiting lists and seeks assurance
that actions to address these are being implemented.
Falls
Some wards have been noted to have a higher
number of falls than expected in comparison with
others. This is partly related to the nature of the
patients on the wards. However, staffing levels, ward
leadership, learning culture and other factors play a
part. Falls action plans have been developed and low
rise beds procured which are particularly good for
managing older adults at a high risk of falls. Falls are
monitored on a monthly basis by the Executive.
Additional investment into staffing for wards where
required has been agreed.
Record Keeping
The quality of record keeping across the trust remains
inconsistent and can be improved further. A record
keeping strategy is in place for implementation across
the Trust. For mental health inpatients there is a peer
review process in place to improve the quality of risk
assessment recording and patient and carers’ views.
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Demand Pressure on Services and Staff Morale
For some staff groups there is a perception that
management do not recognise the pressure additional
demand is placing on their service in particular
community nursing services. This means that when
questioned some staff might say their morale is low
and that the Trust does not listen to their concerns.
-
Number of patients who abscond or fail to
return from leave at the agreed time
Number of patients found on the floor on
each ward every 24 hours
Number of patient on patient assaults on each
ward every 24 hours
Community Health Inpatient Rehabilitation Wards
Managers are monitoring staff morale. The results of
the national staff survey and staff pulse checks
indicate that BHFT is in the top 25% of trusts. The CEO
is building a culture of patient safety based on Trust
vision and values and members of the Board regularly
visit services. Listening into Action is a key staff
engagement process.
A workforce review is
underway for community nursing led by the Deputy
Director of Nursing.
Safe Staffing
During 2014/15 the trust has publicly declared that
ward staffing levels have been safe.
-
Actual versus planned staffing levels
Pressure ulcers developed whilst in the care
of trust staff declared
Number of patients found on floor on each
ward every 24 hours
Numbers and types of incidents on each ward
every 24 hours
All wards have other professionals working with
patients during the day including doctors and allied
health professionals such as occupational therapists
and physiotherapists. All of these staff, along with the
nurses, provide care to patients on Trust wards.
The Trust monitors on a daily basis the levels of
registered nurse and healthcare assistant staff on a
shift. The staffing numbers for each shift on each
ward have been agreed with the Trust Board. The
number of staff required on each ward have been
agreed using nationally recognised workforce tools
that take in to account the number of beds on a ward
and the amount of care that the patients on the ward
need. The workforce analysis showed that three
wards required additional investment for more staff.
This additional investment was provided to the wards
from April 2014.
The Trust agreed that staffing is safe on a ward when
it has at least 90% of shifts filled because wards can
cope with one fewer member on a shift providing this
does not happen too often.
In assessing whether the wards were staffed safely
the Director of Nursing considered the following
information and whether there was any correlation to
reduced staffing levels:
Mental Health and Learning Disability Inpatient
Wards
- Actual versus planned staffing levels
- Numbers and types of incidents on each ward
every 24 hours
- Number of times prone restraint used on each
ward every 24 hours
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2.1.4 Clinical Effectiveness
The Trust aims to provide services based on best
practice through the implementation of the National
Institute for Health and Care Excellence (NICE) Quality
Standards and increasing access to psychological
therapies in secondary care this will include mapping
of skills within the workforce, training and supervision
of staff.
Implementation of the National Institute for Health
and Care Excellence (NICE)
In November 2013 NICE published guidance PH48 Smoking cessation in secondary care; acute, maternity
and mental health was issued. This builds on previous
NICE guidance issued around smoking cessation and is
based on the duty of health care providers to protect
the health of, and promote healthy behaviour among,
people who use, or work in, their services; including
providing them with effective support to stop smoking
or to abstain from smoking while using or working in
secondary care services.
Within the Trust the aim is to support tobacco
reduction amongst staff and patients. This will be
achieved by becoming a smoke free organisation
during 2015/16 through encouraging temporary
abstinence of tobacco during contact with the
organisation or by quitting.
Recommendations within NICE guidance relevant to
the Trust:
•
Provision of information to patients for
planned or anticipated use of secondary care
•
Identification of people who smoke and offer
help to stop
•
Provision of intensive support for people
using mental health services
•
Provision of information and advice for carers,
family, other household members and
hospital visitors
•
Advise on and provide stop smoking
pharmacotherapies
•
Adjustment of drug dosages for people who
have stopped smoking
•
Making stop smoking pharmacotherapies
available in hospital
•
Putting referral systems in place for people
who smoke
•
Provision of leadership on stop smoking
support
•
Development and communication of smoke
free policies
•
•
Supporting staff to stop smoking
Provision of stop smoking training for
frontline staff
The approach is to implement becoming a smoke-free
organisation using a staged approach to maximise the
chance of long term success with implementation of
the full range of recommendations within the
guidance. The implementation of key milestones is
staggered with the goal of being totally smoke free by
October 2015.
The proposed Key Milestones around the staged
implementation are:
•
Implementation of recommendations to
support staff reduction of tobacco by March
2015 to include not smelling of smoke,
professional image, not being seen smoking in
or out of uniform during working hours
•
Implementation
of
recommendations/
abstinence of patients in own homes during
treatment and care delivery, OPD, hospital
grounds during July 2015
•
Implementation of full recommendations /
abstinence for patients within inpatient wards
commencing October 2015
Child & Adolescent Mental Health (CAMHS)
There has been a continued increase in the demand
for specialist CAMHS and the Trust has been working
closely with both the local commissioners, NHS
England and local authorities to agree plans to ensure
that effective care is provided for children and young
people with mental health problems. Additional
resource this year has enabled plans to be put in place
to keep children safe, but waiting times still remain
unacceptably high for those requiring the service.
Over the winter months the hours for specialist
CAMHS support through the common point of entry
(CPE) service has been extended from 8am-8pm
(previously 9am-5pm). The trial has been successful
and has given the ability to respond to young people
in crisis later in the afternoon when they are home
from school. A report showed that CPE had an
additional 150 contacts in January calling during the
extended period and prevented 20 young people
presenting in A&E.
Staff in the service are working hard to ensure good
communication with people who are waiting, and
providing information on what to do if something
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changes. This was as a specific action following a
complaint.
Working with health commissioners for support in
delivering more timely services, an exciting
development is the agreement to create a 24 hour 7
day a week inpatient unit for children in Berkshire
which will allow care to be provided close to family
and home. Additional ‘parity of esteem’ funding has
been agreed for 2015/16.
The service has been working to increase service user
participation and as part of this a series of summer
building inspections was carried out by service users
who walked round buildings and identified the
changes they thought would benefit the environment
for others. As a result of their feedback, art workshops
for service users have been held, the outputs of which
will be put on display. The literature and information
in the public waiting areas has been reviewed. In
particular more positive information has been
provided where possible and locations have been
adjusted so that service users feel more comfortable
to pick it up. Work is being carried out with the
estates teams to develop separate areas in waiting
rooms for younger children and teenagers and ensure
that all waiting rooms have a staff photo board in
them.
Increasing access to psychological therapies in
secondary care.
We aimed to achieve the following:
1.
Minimum of 70% of Trust Care Pathways staff
with clinical contact and not employed as a qualified
psychologist or psychotherapist to have completed
training in three psychological techniques.
2.
Minimum of 40% of Care Pathways clients,
who have been open to the teams for more than 4
months at the end of the year, to have been offered a
psychological package.
3.
Minimum of 75% of those clients who accept
and complete a psychological intervention, to have
completed outcome and satisfaction measures
This priority has been delivered through a number of
steps. At the beginning the Trust produced a training
package which established the required training and
supervision for staff. Workshops were held and
locality leads and champions were identified.
Three techniques were chosen based on their
suitability as brief stand-alone, intervention to
address specific difficulties commonly presenting as
part of the complex problems experienced by clients
in the Pathways teams (Problem Solving; Behavioural
Activation; and Graded Desensitisation). Psychologists
from within each Pathway team volunteered to
develop and teach the training packages.
The content of the three training programmes
(including e-learning, podcasts and manuals) were
developed to enable staff to understand and utilise
the psychological techniques with suitable clients.
These will provide the essential learning but the
teaching methods in each locality will be according to
local requirements.
The trainers are working with Learning & Education
and Informatics to create three e-learning/podcast
teaching packages and accompanying manuals.
Supervisors have been identified to facilitate group
supervision in teams to support and consolidate
learning and ensure/monitor quality standards for
delivery of the interventions.
The Trust committed funding to engaging a
production company to create three training modules
when it was identified that no training packages
currently on the market were suitable for the
audience. In addition, psychologists from all localities
and L&D have been released to develop the content
of the training packages and facilitate their
production.
The training packages consist of the following
modules for each of the three interventions:
- Internet based teaching, including slides and video
that provide the rationale and aims for each
intervention, as well as clear guidance on how to work
through the techniques with clients and examples via
role play.
- Manuals for clinicians to guide them through the
intervention; how to engage clients, working safely,
the required steps, how to overcome obstacles, and
endings.
- Manuals for clients that outline the purpose and
steps of the interventions, as well as providing work
sheets and self-help hints.
These modules have been developed for all three
interventions and are available to staff.
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The three training modules (including e-learning and
manuals) provide the essential information to enable
staff to understand and utilise the psychological
techniques with suitable clients. In order to ensure
that staff understand the materials and to support
skilled application, the teaching will be supported by
additional psychology input in each locality.
The delivery of this is will be according to local
requirements. Three teams have had between 1 and 3
teaching or workshop days based around internet
training packages and facilitated by locality
psychologists, one locality have an external
psychologist contracted to provide teaching and
supervision, 2 localities have dates for teaching days
scheduled. For the 4 localities where training has been
completed, approximately 79% of staff have been
trained.
Psychologists in the localities are providing group
supervision for community mental health staff to
facilitate appropriate selection of clients to work
through the interventions, discuss application of the
materials and any obstacles so as to support safe and
effective care.
Achievements
As evidenced below the Trust has achieved well above
the minimum of 40% of care pathways clients, who
have been open to the teams for more than 4 months
at the end of the year, to have been offered a
psychological package.
Figure 10
Community Mental Health Team
Reading
Bracknell
Windsor and Maidenhead
Wokingham
West Berkshire
Slough
March 2015
64.16%
50.16%
53.39%
59.37%
41.23%
50.28%
Of those who were offered a psychological package of
care the trust aimed to achieve a minimum of 75% of
those clients who accepting, and completing a
psychological intervention. An average of 68% (n=941)
of those offered a psychological intervention
(N=1384) accepted it, evidence of outcome measures
was limited and this is going to be continued to be
reviewed and measured in 2015/16.
Informatics arrangements (RiO care plans) for the
recording, collation and reporting of psychological
interventions offered have been established
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2.1.4 Health Inequalities
Health Visiting
The Trust aimed to ensure that services responded
better to population need. In 2013 the Trust
recognised that it needed to increase the number of
employed health visitors.
The Trust had a growth target of 52 new health visitor
posts to achieve between April 2013 and April 2015.
This was in addition to filling all vacant existing health
visitor posts which totalled approximately 9 staff in
April 2013. Therefore, a total of at least 62 more
health visitors was required to be recruited by 2015,
to meet our target of having 185 health visitors across
Berkshire. Supporting the training of health visitors
was part of the implementation plan.
There were 165 health visitors across BHFT at the end
of December 2014. Another 23 completing their
training in January 2015 were appointed which brings
the total to 189. This exceeds the Trust’s target and
represents an important success at a time when other
Trusts are also trying to increase health visitor
numbers.
Health visitors have been allocated across Berkshire as
they have been recruited based on a model agreed
with public health and the 6 local authority directors
across Berkshire. This ensures that the areas of
greatest need have the greatest part of the resource.
To improve accessibility of the age 2 reviews
especially for working parents and hence improve
uptake, the evening clinic trialled at Bracknell has
proved very successful and will become a permanent
feature. In, Slough the team has used the new
community room in the large Tesco store in the centre
of town which has also had excellent attendance and
will be now be used on a regular basis as well as the
Saturday review slots in a Slough children’s centre .
The next steps for the 2 year reviews are to link up
with those children in childcare settings to ensure the
results of their health reviews contribute to the early
year’s development assessment undertaken. This
work is being carried out with local authority
colleagues.
Within Windsor, Ascot and Maidenhead the health
visiting teams are in the process of reviewing how
they run the drop in clinics and they have undertaken
additional surveys of families to contribute to this
work. They will be sharing what works best with all
teams at the end of the project and this will be used
together with the client survey results to help improve
the clinic experience for all. In the meantime they
have produced a health visitor newsletter for parents
in response to feedback which is already proving
popular. In response to feedback from parents, the
visit will be a combination of family focused
conversations which include an holistic assessment to
identify those families needing additional support.
The antenatal, new birth and post natal assessments
have now been combined into one document to help
ensure that clients are not asked the same questions
repeatedly as the information from the first
assessment follows through into the others.
Diabetes Education Project
An agreement was reached in July 2014 that the
Equality & Inclusion Strategic objective to “reduce
inequalities in service usage by people with protected
characteristics which correspond with inequity in life
expectancy and health outcomes” would be met by
developing and delivering a Diabetes Education
programme across the Trust for staff. The Trust will
progress work on improving access to people with
long term conditions such as diabetes, who live in
socio-economically deprived areas’.
Key objectives
1. To raise awareness amongst staff of Type 2
diabetes
2. To develop education materials relating to
Diabetes Type 2
3. To increase recognition and identifying people
who may have undiagnosed diabetes (as set
out below)
4. To ensure that staff with protected
characteristics access education materials
5. To ensure the diabetes education is rolled out
to target staff working in in areas of greater
prevalence. To develop this to enable a focus
on (population) wards where there is
deprivation and/or people with protected
characteristics who make them more
vulnerable to the disease, namely Reading
and Slough
6. To run the proposed education programme
across all Trust services in Berkshire
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7. To develop a tool to measure results
A group was established in August 2014 with the aim
to take early action with the large numbers of people
expected to be diagnosed with Diabetes over the next
5 years and for the large number who remain
undiagnosed. The Trust is developing an education
programme to raise diabetes awareness both
internally with staff and externally with patients.
5. To request staff demographics from HR and
work closely with Healthy Hearts and other
Trust programmes to create a Trust health
and well-being page for our staff
6. To work with Diabetes UK from April 2015
onwards to create a risk assessment tool that
can be anonymised for Trust staff so that data
on success of the project can be collected
specifically for the Trust and outcomes
measured
Key outcomes to date
1. The information for staff was updated with
respect to diabetes and the associated risk
factors
2. The Trust devised and launched a Diabetes
Type 2 quiz as a survey monkey to be
completed by staff to establish a baseline on
knowledge and numbers of staff motivated to
complete this. It was sent out in November
and 129 staff completed the survey.
3. The Trust launched the Diabetes Education
project with three roadshows –one at Upton
Hospital, Bracknell and at Prospect Park
Hospital for staff to make them aware of the
risk factors for diabetes and how this may
affect them or their families personally. This
was to launch the project ‘Together we can
defeat Diabetes’ which started on World
Diabetes Day-November 14th 2014.
4. Trust communications were used to publicise
information, quizzes on Team Brief and on
Newsline in December 2014. This encouraged
staff in all disciplines to be alert to the risk
factors and to signpost themselves and their
patients who may exhibit these risk factors to
undertake
recognised
diabetes
risk
assessment.
Future activity in progress
1. To continue the project until World Diabetes
day November 2015
2. To re-advertise the Diabetes survey monkey
and measure changes in uptake and
knowledge
3. To develop a factsheet to be attached to all
payslips in April/May 2015
4. To design information posters with Diabetes
recognition information for display in Slough
and Reading to all waiting areas and staff
areas
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2.2 Priorities for Improvement 2015/16
2.2.1 Patient Safety
The Trust’s aim is to foster an environment where
staff are confident to raise concerns about patient
safety. Learning occurs with respect to errors,
incidents, near misses and complaints across the
organisation.
Further initiatives to achieve this will be implemented
during 2015/16 and described in the Quality Account.
The Trust will continue to engage with and contribute
to cross organisational initiatives such as the patient
safety collaborative. We will report specifically on the
following:
Staff survey results will demonstrate continued
improvement (Questions 18 and 19) with the aim of
being amongst the best 20% of similar Trusts for these
measures. An internal audit by Baker Tilly into staff
raising concerns/whistleblowing has been carried out.
The recommendations from this report will be fully
implemented.
Safe Staffing - having the right capacity of registered
nurse and care staff on each ward allows staff to have
the best chance of achieving safe care. To ensure that
patients receive a safe and quality service capability of
the workforce is also important. To monitor safety of
care delivered on the wards, the Director of Nursing
and Governance reviews a range of quality indicators
on a monthly basis alongside the daily staffing levels.
These indicators will be reported on:
1. Community wards
-Falls where the patient is found on the floor
(An unobserved fall)
-Developed pressure sores
-Medication related incidents
2. Mental health wards
-AWOL (Absent without leave) and absconsion
-Patient on patient physical assaults
-Seclusion of patients
-Use of prone restraint on patients
Quality Concerns - the following quality concerns
were reported in 2014/15:
1. Nursing vacancies
2. CAMHS
3. Ward environments
4. Interfaces between mental health services
5. Waiting times
6. Falls
7. Record Keeping
8. Demand and associated pressures.
The outcomes of the identified actions for each
quality concern will be reported on along with the
expectation that the risk associated with the concern
is minimised. Any new quality concerns which are
identified in 2015/16 will be reported on together
with the required action and outcomes.
2.2.2
Clinical Effectiveness
NICE guidelines, technology appraisals and quality
standards
provide
valuable
evidenced-based
information on clinically effective and cost-effective
services. The Trust has continued to demonstrate
100% compliance with technology appraisals but
levels of assurance around other NICE guidelines
compliance assurance has reduced to below 75%.
NICE guidance will be prioritised and assurance will be
sought through expert opinion and clinical audit that
all high priority guidance is adhered to. Assurance on
all NICE guidance above 80% will be achieved.
2.2.3 Patient Experience
We will continue to report on the friends and family
recommendations with an aim of further increasing
this. A Friends and Family Test for Carers has been
created which will be distributed to services from
February 2015. This will give our carers the
opportunity to share their experience with us in a
dedicated way. Whilst this is not mandated within the
Friends and Family national guidance, the Trust
recognises the crucial role that carers have and the
value that their feedback has. The Trust aims to
demonstrate continuing improvement during the year
and recommendation levels which are among the best
of similar Trusts where this comparison is possible.
Learning from complaints will remain a priority as will
improving national surveys results.
2.2.4 Health Promotion
The Trust will deliver its priority to become smoke
free across all sites in 2015/16. Delivery of the
implementation plan will be reported on quarterly
throughout the year and fully documented in the
2016 Quality Account. This will have a major positive
impact on the physical and mental health of patients
across all services and will also promote healthy lives
among staff. The plans include a programme of
activities for staff and patients to support them in
stopping smoking.
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Work to tackle diabetes and increase awareness
among staff and patients will continue. This will focus
on targeting high risk groups. Initiatives to support
weight loss and exercise will be promoted.
Several clinical audits have indicated less than optimal
monitoring of physical health risk factors, including
weight monitoring, blood pressure and smoking
among young people and adults with mental health
problems. Associated action plans will be
implemented to improve the physical health of these
patients and further clinical audits carried out in this
area.
Monitoring of Priorities for Improvement.
These will be monitored on a quarterly basis by the
Quality Assurance Committee as part of the Quality
report and the Board of Directors will be informed of
performance against agreed targets. We will report on
our progress against these priorities in our Quality
Account for 2016.
2.3 Statements of Assurance from the
Board
During 2014/15 the Trust provided 72 NHS services.
The Trust Board has reviewed all the data available to
it on the quality of care in all 72 of these NHS services.
The income generated by the NHS services reviewed
in 2014/15 represents 100% of clinical services and
94% of the total income generated from the provision
of NHS services by the Trust.
The data reviewed aims to cover the three dimensions
of quality – patient safety, clinical effectiveness and
patient experience. Further improvements in the
metrics used and processes in place to gather good
quality data in these areas were implemented early in
2014/15. The key quality performance indicators
presented to the Board have been further reviewed.
Details of a selection of the measures monitored
monthly by the Board which are considered to be
most important for quality accounting purposes are
included in Part 3. These incorporate more than three
indicators in each to the key areas of quality.
23
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2.4 Clinical Audit
During 2014/15, 9 national clinical audits and 1 national confidential enquiry covered relevant healthcare services which
Berkshire Healthcare Trust provided.
During 2014/15 Berkshire Healthcare NHS Foundation Trust participated in 100% (n=9) national clinical audits and 100%
(n=1) national confidential enquiries of the national clinical audits and national confidential enquiries which it was
eligible to participate in.
1.
2.
3.
4.
5.
6.
7.
8.
9.
NCAPOP - Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)
NCAPOP - National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
NCAPOP - Sentinel Stroke National Audit Programme (SSNAP)
NCAPOP - Chronic kidney disease in primary care
a. Pilot only – Not applicable
NCAPOP - Epilepsy 12 audit (Childhood Epilepsy)
a. No relevant patients
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH) National Audit - Prescribing Observatory for
Mental Health (POMH): Topic 14: Prescribing for substance misuse: alcohol detoxification
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 12: Prescribing for people with
personality disorder
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 9: Antipsychotic prescribing in people
with learning disabilities
Non-NCAPOP - National Audit of Intermediate Care
1. Mental health clinical outcome review programme: National Confidential Inquiry into Suicide and Homicide for
people with Mental Illness (NCISH)
Four National audits were removed from the quality account list in-year.
1. Non-NCAPOP - National Audit of Seizures in Hospitals (NASH)
o Removed 9/7/14
2. Non-NCAPOP - Parkinson's disease (National Parkinson's Audit)
o Removed 2/6/14
3. Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 6: Assessment of side effects of depot
antipsychotic medication
o Postponed in light of national CQUIN – September 2014
4. Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 15: Use of Sodium Valproate
(provisional)
o Postponed to September 2015
The reports of 6 (100%) national clinical audits were reviewed in 2014/15. This included 3 national audits that collected
data in 2013/14 that the report was issued for in 2014/15.
•
•




POMH - Topic 4: Prescribing antidementia drugs
POMH - Topic 10: use of antipsychotic medication in CAMHS
National audit of Schizophrenia 2013
POMH - Topic 14: Prescribing for substance misuse: alcohol detoxification
National Parkinson Audit 2012 (890)
National Audit of Intermediate Care 2014
The national clinical audits and national confidential enquiries that Berkshire Healthcare Foundation Trust participated
in, and for which data collection was completed during 2014/15, are listed in Figure 10 alongside the number of cases
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submitted to each audit or enquiry as a percentage of the number registered cases required by the terms of the audit or
enquiry.
Figure 11
Diabetes (Adult) ND(A), includes National Diabetes
Inpatient Audit (NADIA)
National Chronic Obstructive Pulmonary Disease
(COPD) Audit Programme
Sentinel Stroke National Audit Programme (SSNAP)
Ophthalmology
Epilepsy 12 audit (Childhood Epilepsy)
Non-NCAPOP audits
Prescribing Observatory for Mental Health (POMH):
Topic 14: Prescribing for substance misuse: alcohol
detoxification
Prescribing Observatory for Mental Health (POMH):
Topic 12: Prescribing for people with personality
disorder
Prescribing Observatory for Mental Health (POMH):
Topic 9c: Antipsychotic prescribing in people with
learning disabilities
National Audit of Intermediate Care
Other audits reported on in-year (data collected in
previous year(s)
POMH - Topic 4: Prescribing antidementia drugs
POMH - Topic 10: use of antipsychotic medication in
CAMHS
National audit of Schizophrenia 2013
National Parkinson Audit 2012
Registered to participate.
Registered to participate.
Registered to participate.
(TBC – still not confirmed details on national QA list)
No relevant patients
Data collected March – April 2014
54 patients submitted, across 6 teams.
Report received September 2014
Data collected June-July 2014
31 patients submitted, across 4 teams
Report received January 2015
Data collected February-March 2015
56 patients submitted, across 6 teams
Report due July 2015
Data collected June-July 2014
14 service elements included. Report received January 2015.
Data collected October 2013
88 patients submitted, across adult and CAMHS services
Data collected March 2014.
48 patients submitted, across CAMHS services.
Report received October 2014
111 patients submitted, across adult and CAMHS services.
The data collection period - 1st August 2012 to 11 January 2013.
20 consecutive patients to the Elderly Care audit
10 patients to the Physiotherapy Audit.
Occupational Therapy, and Speech & Language services did not
participate in the audit
The reports of all the national clinical audits were reviewed in 2014/15 and Berkshire Healthcare Foundation Trust
intends to take actions to improve the quality of healthcare which are detailed in Appendix B.
Local Audits
 Registered – (157 last year) 106
 Completed- (56 last year) 87 (may have started in previous year)
 Active – (159 last year) 170(may have started in previous year)
 Awaiting action plan – (19 last year) 21
The reports of 44 local clinical audits were reviewed by the Trust in 2014/15 and Berkshire Healthcare Foundation Trust
intends to take actions to improve the quality of healthcare which are detailed in Appendix C. (NB: Projects are only
noted as ‘completed’ after completion of the action plan implementation, which is why there may be more local
projects ‘reviewed’ than total ‘completed’).
25
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2.5 Research
The number of patients receiving NHS services provided
or sub-contracted by the Trust that were recruited to
end of March 2015 to participate in research approved
by a research ethics committee was as follows:
891 patients were recruited from 94 active studies, of
which 421 were recruited from studies included in the
National Institute of Health Research (NIHR) Portfolio
and 470 were from non-Portfolio studies. This is a
significant increase on the previous year.
2.6 CQUIN
A proportion of the Trust’s income in 2014/15 was
conditional upon achieving quality improvement and
innovation goals agreed between the Trust and the
Clinical Commissioning Groups (CCGs) through the
Commissioning for Quality and Innovation payment
framework. Further details of the agreed goals for
2014/15 and for the following 12 month period can be
found in Appendix E & F.
The income in 2014/15 conditional upon achieving
quality improvement and innovation goals is
£3,640,914. The associated payment received for
2013/14 was £4,547,516.
2.7 Care Quality Commission
The 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
Berkshire Healthcare Foundation Trust during 2014/15.
The Trust has not participated in any special reviews or
investigations by the Care Quality Commission during
the reporting period.
In 2013/14 the CQC inspected Sorrel ward where they
raised two concerns and an improvement notice was
given in respect of Outcome 1 (Respecting and involving
people who use services), and Outcome 2 (Consent to
care and treatment). For Outcome 1, the CQC said, “It
was not clear if people’s views and experiences were
taken into account in the way the service was provided
and delivered in relation to their care”. For Outcome 2,
the CQC said, “It was not clear that care and treatment
was planned and delivered in a way that ensured
Figure 12 R&D recruitment figures 2014/15
Type of Study
No of
Participants
Recruited
NIHR Portfolio
421
Student
377
Other Funded (not
93
eligible for NIHR
Portfolio & Own
Account (Unfunded)
Source: R&D department.as of 12.05.2015
No of
Studies
55
28
11
people's safety and welfare”. On this latter point, the
CQC wanted to see improvement in the quality and
triangulation of risk assessments, care planning and
progress notes recorded on the Trust’s clinical record
keeping system.
In August 2014 the CQC re visited Sorrel ward and lifted
the two concerns which had previously been raised.
The Trust received a CQC Mental Health Act (1983)
thematic review during the reporting period. The Trust
was asked by the CQC to coordinate the inspection on
behalf of the local authority, Thames Valley Police,
South Central Ambulance Service and other
stakeholders. The inspection focused on patients within
the Windsor and Maidenhead area and included people
who had experienced a mental health crisis and who
are detained under Section 136 of the Mental Health
Act (MHA). The CQC will publish the findings in June
2015.
The current quality intelligence draft report which has
replaced the CQC Quality & Risk Profile can be found at:
http://www.cqc.org.uk/Provider/RWX
Figure 13 details the priority bandings on a scale of 1 to
4, with 4 being the lowest concern. The Trust is
currently banded as a priority level 3 and this is due to a
higher than expetced number of parlimentary health
service ombudsman (PSHO) inquiries into our
complaints. It has been established that this number is
in fact increased due to a backlog of complaints being
cleared by the PHSO in the time frame reported on
rarther than an increase in the number reported to the
PHSO.
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Figure 13
2.8 Data Quality and Information
Governance
The Trust submitted records during 2014/15 to the
Secondary Uses Service (SUS) for inclusion in the
Hospital Episode Statistics which are included in the
latest published data.
Data quality audits were carried out on all lines that
were rated as low (‘red’) quality in the IAF. The findings
of these data quality audits were shared with the Data
Quality Group and the Trust Senior Management Team
The key measures for data quality scrutiny mandated by
the Foundation Trust regulator Monitor and agreed by
the Trust Governors are:
•
100% enhanced Care Programme Approach
(CPA) patients receiving follow-up contact
within 7 days of discharge from hospital
•
Admission to inpatients services having access
to crisis resolution home treatment teams
•
Delayed transfers of care
BHFT was not subject to the Payment by Results clinical
coding audit during the reporting period by the Audit
Commission
The percentage of records in the published data which
included the patient's valid NHS Number was:
100% for admitted patient care
100% for outpatient care
The percentage of records which included the patient's
valid General Practitioner Registration Code was:
100% for admitted patient care
100% for outpatient care
100% for emergency care (Minor Injuries Unit)
Information Governance
The Trust Information Governance Assessment Report
overall score for 2014/15 was (66%) and was graded
satisfactory (Green).
The Information Governance Group is responsible for
maintaining and improving the information governance
Toolkit scores, with the aim of being satisfactory across
all aspects of the IG toolkit for Version 12.
Data Quality
The Trust has taken the following actions to improve
data quality.
The Trust has invested considerable effort in improving
data quality. An overarching Information Assurance
Framework (IAF) provides a consolidated summary of
every performance information line and action plans.
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3.1 Review of Quality Performance 2014/15
In addition to the key priorities detailed, the Trust
Board receives monthly Performance Assurance
Framework reports related to key areas of quality.
These metrics are closely monitored through the Trust
Quality Governance systems including the Quality
Executive Group and the Board Audit Committee.
They provide assurance against the key national
priorities from the Department of Health’s Operating
Framework and include performance against relevant
indicators and performance thresholds set out in the
Compliance Framework. The data source for all
information within this section is the Trust assurance
performance framework unless otherwise stated.
Patient Safety
The Trust aims to maximise reporting of incidents
whilst reducing the severity levels of incidents
through early intervention and organisational
learning. Organisations that report more incidents
usually have a better and more effective safety
culture.
Never Events
Never events are a sub-set of Serious Incidents and
are defined as ‘serious, largely preventable patient
safety incidents that should not occur if the available
preventative measures have been implemented by
healthcare providers’. The Trust has not reported any
never events in 2014/15.
Incidents
and
Serious
incidents
requiring
investigation (SIRI)
Reporting levels remain consistent over recent
quarters, with over 2,287 incidents reported in Q4
compared to 2,400 in Q3.
Figure 14 below shows the numbers of SIRIs reported
monthly in comparison with the previous two financial
years. The chart shows that the overall annual
numbers of SIRIs have remained fairly consistent.
Figure 14
SIRI Year on Year
Comparison…
100
99
89
91
2012-13
2013-14
0
2012-13 2013-14 2014-15
2014-15
The severity model is as expected, with near miss / no
harm incidents accounting for the largest proportion
of reports, followed by minor, then moderate
incidents. The top 5 incident categories for Q4 Trustwide were:
1. Pressure ulcers
2. Assaults
3. Behavioural
4. Falls
5. Non physical assaults
Key Learning points from SIRIs in 2014/15:
1. Standards of clinical record-keeping including
triangulation of information from all sources into
effective clinical assessments and care planning.
2. Historical information including summaries in
current records.
3. Multi-Disciplinary / Multi-Agency Planning and Coordination for patients presenting with complex
mental, physical and social needs.
4. Interface with substance misuse agencies and
access to dual diagnosis specialists in each locality.
5. Changes in Risk Post-Discharge from Mental
Health Inpatient Units. Careful consideration needs to
be given to changes in levels of assessed risk when
mental health inpatients are discharged. Patients
whose risk is contained on inpatient units may
suddenly be re-exposed to outside stressors and risks
in the community.
6. Carer / Family Involvement in care planning and
treatment.
Trust-Wide Initiatives Informed by SIRI Learning
1.
One of the key recurrent findings in mental
health SIRIs is around the quality of risk assessments
and clinical record-keeping. The Trust launched a new
record-keeping strategy in 2014/15, and has revised
the Risk Assessment Policy and training. Auditing and
one-to-one peer supervision have been extended
from mental health inpatient units out into the
community teams to support improvement.
2.
Work is in progress to provide further support
for mental health professionals in assessing and
treating suicide risk; lead professionals are involved in
promoting best practice with reference to the
Interpersonal Theory of Suicidality (Joiner, 2005); this
is also being piloted as an evaluation framework in
SIRI investigations.
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3.
The Trust is reviewing its operational model in
relation to Crisis Resolution and Home Treatment. SIRI
cases have exemplified the systemic challenges faced
in delivering this service, and have informed the
decision to undertake an operational review.
Figure 15 Suicides
25
Number
20
15
10
5
Suicides in 12 Months (rolling year total)
Mar-2015
Jan-2015
Feb-2015
Dec-2014
Nov-2014
Oct-2014
Sep-2014
Aug-2014
Jul-2014
Jun-2014
May-2014
Apr-2014
Mar-2014
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Aug-2013
Jul-2013
Jun-2013
May-2013
Apr-2013
Mar-2013
Feb-2013
Jan-2013
0
Mental Health: Suicides in Month
In 2013/14 there were 15 suicides in total compared to 17 in 2014/15, all recorded suicides have occurred in the
community there have been no suicides in any of our inpatient facilities. 2014/15 began with a reduction; however,
quarter 2 figures rose and were more in line with the higher level seen in 2012/13. This was due to a spike in
September 2014, rather than a spread across all months of the quarter, and did not turn out to be an upward trend.
The figure for 2014/15 turned out to be lower than the peak number seen in 2012/13, and is lower than the annual
projection based on regional data. Clinicians have worked hard to improve processes for assessing and managing
risks for patients in relation to suicide and self-harm.
Figure 16 Absent Without Leave (AWOL) on a Mental Health Section
Total Number
25
20
15
10
5
AWOLS on MHA section (RQ)
Mar-2015
Feb-2015
Jan-2015
Dec-2014
Nov-2014
Oct-2014
Sep-2014
Aug-2014
Jul-2014
Jun-2014
May-2014
Apr-2014
Mar-2014
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Aug-2013
Jul-2013
Jun-2013
May-2013
Apr-2013
Mar-2013
Feb-2013
Jan-2013
0
Target AWOLS (less than)
There have been fluctuations in patients AWOL from the ward and in episodes of absconding. There has not,
however been any clear trend in these areas. (The figures shown for each month are rolling quarters)
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Figure 17 Absconsions on a Mental Health Act (MHA) Section
30
Total Number
25
20
15
10
5
Absconsions on MHA section (RQ)
Mar-2015
Feb-2015
Jan-2015
Dec-2014
Nov-2014
Oct-2014
Sep-2014
Aug-2014
Jul-2014
Jun-2014
May-2014
Apr-2014
Mar-2014
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Aug-2013
Jul-2013
Jun-2013
May-2013
Apr-2013
Mar-2013
Feb-2013
Jan-2013
0
Target Absconsions less than
The definition of absconding used is different than AWOL, in that this refers to the patients who are usually within a
ward environment and are able to leave the ward without permission. There appears to be a correlation with the
occupancy levels on the wards. The highest number being reported in June and December 2014 when the wards
were at virtually full capacity and with high levels of patient dependency. A number of initiatives have been
considered to help reduce the number of absconsions;
1. To make sure all the fences were in good repair, bolt down garden benches away from fences [so that they
could not be moved to the fence to assist with absconding and instigate a regular checking programme of
the fences / garden areas.
2. Tighten the function and process for having a dedicated member of staff out on the ward at all times. This
person must be additional to the member of staff doing intermittent and general observations.
3. Extra vigilance within outside areas [garden/courtyard].
4. Implement regular slot in staff meetings where staff discuss and reflect on physical and relational security
issues. This includes as a minimum: discussion of boundaries, therapy, patient mix, patient dynamic,
patient’s personal world, physical environment, visitors and other external communication and may be
facilitated by the See, Think, Act Relational Security Explorer
5. Robust risk assessment and management plan on admission to focus on AWOL and Absconsions.
6. Implement anti-absconding interventions - all staff to complete the workbook training sessions on: rule
clarity; signing in and out book; identification of those at high risk of absconding (targeted nursing time for
those at high risk); promoting contact with family and friends; promotion of controlled access to home;
careful breaking of bad news; contact cards; post incident debriefing; MDT review following two absconding
episodes.
The monthly figures are rolling quarters so the graph demonstrates that in the last 3 months of the year the target
for the Trust was achieved.
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Figure 18 Falls
Total Number
Slips, trips and falls (monthly number per 1,000 Occupied Bed Days)
15
10
5
0
Slips, trips and falls (monthly per 1,000 Occupied Bed Days) : Number
Linear (Slips, trips and falls (monthly per 1,000 Occupied Bed Days) : Number)
Slips Trips and Falls
The number of slips, trips and falls is now being recorded per 1000 bed days (since April 2014), and therefore
comparative data is not presented. Falls continue to be above the target per 1,000 bed days on a number of our
mental health and physical health wards. The ‘Falls safe plan’ is in place on all wards. Actions have included
examining whether further assistive technologies may reduce the number of falls and changes to staff working hours
as falls on the ward tend to occur between the hours of 6pm to 10pm. Since February 2015, the wards have been
monitoring cognitive impairment of clients who have experienced a fall and whether the fall was witnessed. Future
monitoring will include when the patient was last checked prior to the fall.
Figure 19 Medications Errors
680
660
640
620
600
580
560
540
Medication rolling 12 months
Linear (Medication rolling 12 months)
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Medication errors
There were over 600 reported medications errors during the year. There has been 1 error rated as severe and 2
rated as moderate during the year with respect to patient harm. All others were of low severity. The incident rated
as severe involved a patient receiving palliative care being administered a higher dose of morphine than prescribed
through a syringe driver. Following a full investigation it was concluded that the patient’s death was not caused by
the overdose. The nurse involved has been working under supervision and competencies reassessed. One moderate
incident involved a patient on shared care receiving a prescription for dementia medication from both the Trust
memory clinic and the GP. Both were administered by a care worker. Following this incident the shared care
processes have been reviewed. Another moderate incident involved a patient continuing to pick up a repeat
prescription for psychiatric medication from the GP when she became pregnant and taking medication which could
be harmful in pregnancy for the first 5 months. She missed planned psychiatric outpatient appointments during this
period. When the incident was reported an urgent appointment took place to review the medication.
Audits have been carried out and action plans implemented with respect to ‘blank boxes’ on medication charts
where it is not clear whether prescribed medication has been given or not. The Trust is looking at the options for
electronic prescribing which will reduce medication errors and recording errors.
Figure 20 Patient to Staff Physical Assaults
80
70
Total Number
60
50
40
30
20
10
Physical assults on staff (RQ)
Mar-2015
Feb-2015
Jan-2015
Dec-2014
Nov-2014
Oct-2014
Sep-2014
Aug-2014
Jul-2014
Jun-2014
May-2014
Apr-2014
Mar-2014
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Aug-2013
Jul-2013
Jun-2013
May-2013
Apr-2013
Mar-2013
Feb-2013
Jan-2013
0
Target less than
(Assaults on staff)
There have been fluctuations in the level of physical assaults on staff by patients with an increase in trend over time.
Often these changes reflect the presentation of a small number of individual inpatients. The number of assaults on
staff remains at 53 in the rolling quarter to March 2015. In March 2015, one assault on a staff member from the
Crisis Home Treatment Team East was rated as moderate, all other incidents in March 2015 were rated as low or
minor. The assaults were carried out by 23 separate patients during the rolling quarter, four clients responsible for 4
incidents each.
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Apr-2012
May-2012
Jun-2012
Jul-2012
Aug-2012
Sep-2012
Oct-2012
Nov-2012
Dec-2012
Jan-2013
Feb-2013
Mar-2013
Apr-2013
May-2013
Jun-2013
Jul-2013
Aug-2013
Sep-2013
Oct-2013
Nov-2013
Dec-2013
Jan-2014
Feb-2014
Mar-2014
Apr-2014
May-2014
Jun-2014
Jul-2014
Aug-2014
Sep-2014
Oct-2014
Nov-2014
Dec-2014
Jan-2015
Feb-2015
Mar-2015
Total Number
Physical Patient to patients assaults (RQ)
Mar-2015
Feb-2015
Jan-2015
Dec-2014
Nov-2014
Oct-2014
Sep-2014
Aug-2014
Jul-2014
Jun-2014
May-2014
Apr-2014
Mar-2014
Feb-2014
Jan-2014
Dec-2013
Nov-2013
Oct-2013
Sep-2013
Aug-2013
Jul-2013
Jun-2013
May-2013
Apr-2013
Mar-2013
Feb-2013
Jan-2013
Total Number
Figure 21 Patients to Physical Assaults
60
50
40
30
20
10
0
Target less than
(patient assults)
The level of patient on patient assaults appear to fluctuate, 146 patient on patient assaults were reported in 2013/14
compared to 112 in 2014/15. All incidents in March were rated as low or minor risk
Figure 22 Compliments
600
500
400
300
200
100
0
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19
21 21
Mar-2015
23
Feb-2015
25
Jan-2015
15 15
Dec-2014
Nov-2014
21
Oct-2014
23
Sep-2014
Aug-2014
26
Jul-2014
20 20
Jun-2014
May-2014
19
Apr-2014
Mar-2014
14
Feb-2014
25
Jan-2014
11
Dec-2013
14
15
Nov-2013
19
Oct-2013
16
Sep-2013
16
Aug-2013
20
Jul-2013
Jun-2013
10
May-2013
16
Apr-2013
23
Mar-2013
15
Feb-2013
Jan-2013
Total Number
Figure
Figure23
23Compliments
Complaints
30
24
20
16
12
14
5
0
Source complaints reports 2014/15
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3.2 Monitor Authorisation
Performance in relation to metrics required by Monitor, the Foundation Trust regulator, has achieved the required targets. This relates to mental health 7 day follow up
(98.2%), delayed transfer of care (1.9%), community referral to treatment compliance (98.1%), Care Programme Approach review within 12 months (96%) and new early
intervention in psychosis cases 124 (136 13/14).
Figure 24
2011/12 2012/13
2013/14
2014/15
National Average Highest and
2014/15 Q4
Lowest
The percentage of patients on Care Programme Approach who were
98%
96%
95.8%
98.2%
97.2%
followed up within 7 days after discharge from psychiatric in-patient
care during the reporting period
Berkshire Healthcare trust considers that this percentage is as described for the following reasons:
In line with national policy to reduce risk and social exclusion and improve care pathways (CQC 2008) we aim to ensure that all patients discharged from mental health
in patient care are followed up (either face to face contact or by telephone) within 7 days of discharge, this is agreed and arranged with patients prior to discharge to
facilitate our high level of compliance.
Berkshire Healthcare trust has taken the following actions to improve this percentage, and so the quality of services:
Berkshire Healthcare trust meets the minimum requirement set by Monitor of 95% follow up through the implementation of its Transfer and Discharge from Mental
Health and learning Disability In-patient Care Policy. In addition the data is audited as part of the independent assurance process for the Quality Account and any actions
identified through this are fully implemented to ensure that we maintain our percentage of compliance.
Figure 25
2011/12
2012/13
2013/14
2014/15
National
Average
2014/15 Q4
98.1%
Highest and
Lowest
The percentage of admissions to acute wards for which the Crisis
100%
94%
97.6%
97.7%
Resolution Home Treatment Team acted as a gatekeeper during the
reporting period
Berkshire Healthcare trust considers that this percentage is as described for the following reasons:
Crisis resolution and home treatment (CRHT) teams were introduced in England from 2000/01 with a view to providing intensive home-based care for individuals in
crisis as an alternative to hospital treatment, acting as gatekeepers within the mental healthcare pathway, and allowing for a reduction in bed use and inappropriate inpatient admissions. An admission has been gate kept by the crisis resolution team if they have assessed the patient before admission and if the crisis resolution team
was involved in the decision making-process, which resulted in an admission.
Berkshire Healthcare trust has taken the following actions to improve this percentage, and so the quality of services, by:
The Trust Admissions policy and procedures provides a clear framework to ensure that no admissions are accepted unless via the urgent care service and has increased
our percentage compliance
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Figure 26
2011/12
2012/13
2013/14
2014/15
National
Average
(2013/14
23014/15 not
available)
8.8%
Highest and
Lowest
National
Average
3.57
Highest and
Lowest
4.15
The percentage of MH patients aged— (i) 0 to 15; and (ii) 15 or over,
9%
12%
13.3%
11.09%
readmitted to a hospital which forms part of the trust within 28 days
of being discharged from a hospital which forms part of the trust
during the reporting period
Berkshire Healthcare trust considers that this percentage is as described for the following reasons:
The Trust focusses on managing patients at home wherever possible and has fewer mental health beds for the population than in most areas. Sometimes the judgement to
send a patient home may be made prematurely or there may be a deterioration in the patient’s presentation at home due to unexpected events.
Berkshire Healthcare trust intends to take the following actions to improve this percentage, and so the quality of services:
Further work will be done by the relevant Service Improvement Group to work on the high level of readmissions, to identify why the trust has seen an increase and to
identify actions to reduce it.
Figure 27
2011/12
2012/13
2013/14
2014/15
The indicator score of staff employed by, or under contract to, the trust
3.55
3.61
3.76
3.79
during the reporting period who would recommend the trust as a
65%
64%
69%
provider of care to their family or friends
Berkshire Healthcare trust considers that this data is as described for the following reasons:
The Trust’s score is better than average and improving year on year. Possible scores range from 1 to 5, with 1 indicating that staff are poorly engaged (with their work, their
team and their trust) and 5 indicating that staff are highly engaged. Advocacy of recommendation along with staff involvement, and staff motivation are strong indicators of
the level of staff engagement with in the trust.
Berkshire Healthcare trust has taken the following actions to improve this data, and so the quality of services, by:
Implementing a five year Organisational Development strategy which has at its heart the achievement of high levels of staff engagement and through that high quality care
and service delivery. The specific objectives of the strategy, to be implemented in stages over five years are: To enable every member of staff to see how their job counts, to
listen and involve staff in decisions that impact their areas of work, to provide support for their development, and to develop our clinical and managerial leaders. In this,
Berkshire Healthcare Trust has signed up to the national Pioneer initiative – Listening into Action – aimed at engaging and empowering staff in achieving better outcomes
for patient safety and care.
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Figure 28(New section score for 2012/13)
2011/12
2012/13
2013/14
2014/15
National Average
Highest and
Lowest
7.3-8.4
Patient experience of community mental health services indicator
8.5
8.7
7.8
About the same as
score with regard to a patient’s experience of contact with a health
similar Trusts
or social care worker during the reporting period
Berkshire Healthcare trust considers that this data is as described for the following reasons:
The Trusts score is in line with other similar Trusts
Berkshire Healthcare trust has taken the following actions to improve this data, and so the quality of services, by:
Being committed to improving the experience of all users of their services. Data is collected from a number of sources to show how our users feel about the service they
have received. Actions are put in place through a number of initiatives to improve both an individual’s experience and if required to change the service provision.
Figure 29
The number of patient safety incidents reported
Rate of patient safety incidents reported within the trust during the
reporting period per 1000 bed days
The number and percentage of such patient safety incidents that
resulted in severe harm or death
*NRLS report published April 2015, covering 1st April 2014 – 30th
2011/12
2012/13
2013/14
2014/15
National Average
3995
19.7
3661
30.2
3754
32.7**
3642
N/A
31.4**
32.82*
29 (0.7%)
42 (1%)
33
(0.9%)**
49 (1.3%)**
1.0%*
Highest and
Lowest
September 2014 **Trust figure
Berkshire Healthcare Trust considers that this data is as described for the following reasons:
The above data shows the reported incidents per 1,000 bed days with the targets set based on average reporting for the year. In the NRLS most recent report published in
April 2015, the median reporting rate for the cluster nationally was 32.82 incidents per 1,000 bed days (but please note this covers the 6-month period April-September 2014,
for which period the NRLS gives the BHFT rate as 53.97 incidents per 1,000 bed days). High levels of incident reporting are encouraged as learning from low level incidents
is thought to reduce the likelihood of more serious incidents.
Overall Incident reporting volume is in line with previous years.
The percentage of such incidents resulting in severe harm or death is slightly higher than in previous years, but is proximal to the national rate for the cluster of 1.0% shown
in the most recent NRLS report, published in April 2015.
Berkshire Healthcare Trust has taken the following actions to improve this percentage, and so the quality of services, by the following:
Hosting Serious Incident learning events and online resources for clinical staff.
Bolstering the internal governance and scrutiny of serious incident reports, their recommendations and action plans.
Implementation of strategies to address common findings in serious incident reports, including clinical record keeping and triangulation of patient risk information.
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Figure 30 Annual Comparators
Patient Safety
Target
CPA review within 12 months
95%
Never Events
Infection Control (MRSA bacteraemia)
Infection Control (C.difficile)
0
0
<6 per annum (reduced
from <10)
Increased reporting
Medication errors
Clinical Effectiveness
Mental Health minimising delayed transfers
of care
Mental Health: New Early Intervention cases
A&E: maximum waiting time of four hours
from arrival to admission/transfer/discharge
Completeness of Mental Health Minimum
Data Set
Completeness of Community service data
Referral to treatment information
Referral information
Treatment activity information
Patient Experience
Referral to treatment waiting times – non
admitted -community***May 2013 Updated figure to include Slough WIC
RTT (Referral to treatment) waiting times Community: Incomplete pathways
2011/12
2012/13
97.6%
97.9%
96.4%
96%
1
1
15
0
0
5
0
0
5
0
0
0
574*
562
614
606
Cumulative total year end
3%
1.1%
2.6%
1.5%
Average percentage in year
155
99.6%
154
99.9%
136
99.9%
124
99.5%
Year to date
Year average
1) 97%
1) 99.6%
1)99.8
1)99.8
1) 99.56%
2) 50%
50%
50%
50%
2) 97.9%
-
2)98.62
-
2)97.8
70%
67%
99%
2) 99.2%
72.3%
62.4%
98.0%
95% <18 weeks
99.9%
99.9%
98.1%
99.8%
92% <18 weeks
-
-
99%
100%
<7.5%**
99
95%
2013/14
2014/15
Commentary
For patients discharged on CPA in year last 12
month average
Full year
Full year
Year to date C. Diff due to lapses in care
New Monitor target for Identifiers 97% for
2012/13, target for 2011/12 was 99%.
Year end average (new 2013/14)
Waits here are for consultant led services in
East CHS, Diabetes, and Paediatric services
from referral to treatment (stop clock).
Notification has been received from NHS
England to exclude Sexual Health services
from RTT returns last 12 month average
Year end average (new 2013/14)
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Patient Experience
Target
Access to healthcare for people with a Score out of 24
learning disability
Complaints received
<25 per month
Complaints
100%
Acknowledged
within 3 working days
90% Complaints resolved
within agreed timescale
of complainant
2011/12
2012/13
2013/14
2014/15
22
22
Green 22
Green 21
232
100%
250
91.3%
193
93.3%
244
100%
20.3 last 12 month average
Year end (20/20)
92%
2014/15 note change to indicator previously 80%
Responded within 25 working days (% within an
agreed time)
64%
(82%)
Commentary
*Community Health services joined the Trust**Delayed transfers of care (Monitor target) is Mental Health delays only (Health & Social Care), calculation = number of days delayed in month divided by OBDs (Inc. HL) in month. New
calculation used from Apr-12
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3.3 Statement of directors’ responsibilities in respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service Quality Accounts Regulations
to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports
(which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put
in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting
Manual 2014/15; The content of the Quality Report is not inconsistent with internal and external sources of
information including:
1.
Board minutes and papers for the period April 2014 to May 2015
2.
Papers relating to Quality reported to the Board over the period April 2014 to May 2015
3.
Feedback from the commissioners dated May 2015 (to be received by 19th May)
4.
Feedback from governors dated April 2015
5.
Feedback from Local Health watch organisations dated April 2015
6.
The trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, dated May 2015
7.
The national patient survey 18th September 2014
8.
The national staff survey 24th February 2015
9.
The Head of Internal Audit’s annual opinion over the trust’s control environment dated April 2015
10.
CQC Intelligent Monitoring Report April 2015
The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;
the performance information reported in the Quality Report is reliable and accurate; there are proper internal
controls over the collection and reporting of the measures of performance included in the Quality Report, and these
controls are subject to review to confirm that they are working effectively in practice; the data underpinning the
measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality
standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been
prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts
regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support
data quality for the preparation of the Quality Report.
(available at www.monitor-nhsft.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in
preparing the Quality Report.
By order of the Board
12/05/2015 Date
12/05/2015 Date
John Hedger Chairman
Julian Emms Chief Executive
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Appendix A: Quality Strategy
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Appendix B National Clinical Audits Reported in 2014/15 and results received that were applicable to Berkshire Healthcare NHS Foundation Trust
National Clinical Audits Reported in 2014/15 and results received that were applicable to Berkshire Healthcare NHS Foundation Trust
National Audits
Reported in 2014/15
Non-NCAPOP audits
POMH - Topic 4:
Prescribing antidementia
drugs
Recommendation (taken from national report)
Actions to be Taken
Data was submitted on over 9,000 patients with dementia, nearly 70% of whom were
prescribed an anti-dementia drug. Donepezil was by far the most commonly
prescribed AChE inhibitor. There was marked variation in the prevalence of antidementia drug prescribing across the 54 participating mental health Trusts, from 35%
to 98% in the samples submitted. The proportion of patients prescribed an
antipsychotic drug also varied markedly across Trusts, from 0% to almost 70%.
Multivariable analysis revealed that the variables significantly associated with being
prescribed an anti-dementia drug included living at home (with or without a carer),
being in the 66-75 age group, female gender and White ethnicity. Both severity and
sub-type of dementia were also significantly associated with prescription of antidementia medication: these drugs were most commonly prescribed for patients with
Alzheimer's, followed by mixed dementia and Parkinson's disease/Lewy body
dementia, and for patients with dementia of moderate severity rather than mild or
severe illness.
Produce Trust Guidelines for prescribing of anti-dementia drugs (to
include the standards set by the POMHUK audit.)
Improve monitoring as part of memory clinic processes.
The older people mental health localities have been encouraged to
re-audit using the POMH UK standards and share the results in the
cross county meetings.
POMH - Topic 10: use of
antipsychotic medication
in CAMHS
The audit shows an improvement in the number of young people having undertaken
appropriate investigations prior to initiating antipsychotic medication and an
improvement in the monitoring of side effects since the baseline audit. However in
comparison to other trusts BHFT performed worse than average with clear room for
improvement. BHFT fared well in regards to recording the reasons for medication to
be started and in following up young people in appropriate time scales however fared
very poorly in recording of baseline measures and follow up measures.
The National level results highlight that 16% of admissions were planned for those
patients admitted under the care of a general adult psychiatrist for alcohol
detoxification. The respective figure for those under the care of a specialist in alcohol
detoxification was 93%.
The Trust’s performance for the NICE guideline on the proportion of patients
prescribed medication for alcohol withdrawal is in line with the national standard of
95%.
BHFT was successful in completing 85% cases as planned of alcohol detoxification.
Creation and adoption of antipsychotic initiation monitoring pack.
Training for staff on above.
Exploration of adoption of RiO based e-system to record above
information.
POMH - Topic 14:
Prescribing for substance
misuse:
alcohol
detoxification
The largest effect size could be achieved through addition of the
AUDIT-C questionnaire to the ‘admission pack’ (a group of
documents and checklists circulated at admission). This would allow
swift and immediate assessment of newly admitted patients’ alcohol
histories, while not adding substantively to workload of clerking
doctors and admitting nurses.
A full action plan is being circulated for review and comment to
clinical staff
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Other audits reported on in-year (data collected in previous year(s)
National audit of
Availability and uptake of Psychological Therapies was average for our Trust though
Schizophrenia (2013)
was still below what should ideally be provided
Performance in monitoring of Physical Health risk factors was average for our Trust.
Even then, it is below the ideal target and was poor for provision of intervention for
service users with elevated blood pressure
Many aspects of Prescribing Practice were approx. average for our Trust. However, a
higher than average proportion of service users whose illness was not in remission
did not appear to have an acceptable reason for not having had a trial of clozapine
Priority 1:
1.1 Physical health– an action plan will be developed following the
outcomes of the annual inpatient MH physical health CQUIN. Senior
MH nurses are taking the lead on ensuring that actions from both this
inpatient focussed CQUIN and the community based National Audit of
Schizophrenia are amalgamated and robust. With the implementation
of the Lester resource and measurement of compliance via a quality
improvement project, with subsequent action planning if required.
1.2 Psychological therapies
This has been and will continue to be developed via a process of
teaching for staff, plus manuals for clinicians and patients. These will
enable staff to meet the CQUIN requirements including staff having
completed training in 3 psychological techniques and psychological
packages offered to patients open to teams for more than 4 months.
1.3 Prescribing antipsychotics
To be developed via continued implementation of actions in order to
improve compliance with NICE guidance
Priority 2:
2.1 Patient involved in prescribing/capacity & consent
2.2 Pathway to clozapine / initiation
Nurse Leads to work with nurses and social workers to support them
in the provision of psycho education for service users.
Liaison with CRHTT in the support of patients taking Clozapine whilst
in the community. Clozapine specialist nurse to provide training
sessions at MDT for CMHT nurses. Quality improvement project to be
undertaken by clinicians into clozapine initiation
2.3 High dose antipsychotic prescribing / compliance with BNF.
Staff to be consulted on reasons/barriers for not complying, and for
potential solutions. Discuss opportunities for liaising with junior
doctors. Quality improvement project into BNF maximum doses for
high dose antipsychotics to be undertaken by clinicians.
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National Parkinson Audit
2012 (890)
National Audit of
Intermediate Care 2014
(1847)
This national audit is unique in that it has an entirely integrated multi-professional
approach, involving elderly care and neurology consultants who care for people
with movement disorders, Parkinson‘s nurse specialists, and occupational
therapists, physiotherapists and speech and language therapists who also care for
people with Parkinson‘s. The audit involves all these professions in measuring the
quality of their practice, within their model of care provision.
The results from the National Parkinson’s Audit has shown that BHFT have come out
extremely well in our care for Patients with Parkinson’s, far exceeding the national
average in most areas audited that we participated in.
The services involved in the care of Parkinson’s patients, but did not participate in
the National audit (Occupational Therapies and Speech & Language Therapies) need
to review the outcomes and shortcomings highlighted at a national level from the
Parkinson’s National report.
This national audit is a re-audit.
The audit is a unique collaboration between the British Geriatrics Society, the NHS
Benchmarking Network, ADASS, the Patients Association, other professional bodies,
NHS organisations and Local Authorities. In 2013, 92 Clinical Commissioning Groups
(CCGs) registered to join the audit (compared to 62 PCTs in 2012). Some
organisations registered jointly or in clusters and so the total number of CCGs
covered was 107 and Local Authorities, 19. In population terms, the audit covered
half the English NHS. 202 providers got involved and provided data for 410
intermediate care services and over 8,000 service users. Additional elements were
introduced to NAIC 2013.
These were to include both crisis response services and re-ablement services (to
ensure all functions of intermediate care were captured).
A 6 page service user questionnaire, focusing on clinical outcome measures replaced
the patient level audit for bed based intermediate care services. Patient Reported
Experience Measures (PREMs) were developed for both bed and community based
intermediate care services.
The report has been received by local teams. There was a high level
of compliance with all standards.
The report has been circulated to leads in the service for comment
and input. At this stage, a full action plan has not be developed,
however the Trust has already registered to participate in the 2015
National audit.
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Appendix C Local Clinical Audits Reported in 2014/15:
Audit Title
1
Audit of anti-infective prescribing on BHFT impatient wards (Antibiotics)
(2014)
2
Re-Audit: Consent to Treatment (2013)
3
Re-Audit: Clinical Supervision
(2014)
4
Child protection clinical supervision - quantitative study
5
Dental Decontamination
(2014)
Conclusion/Actions
There have been routine audits in this area as part of the infection control team’s programme of
work. The aim of the audit was to ensure that local policy (ICC014) on antibiotic prescribing was
followed. There is an increased risk of patients developing Clostridium difficile infections (which are
linked to poor antibiotic prescribing). The audit identified several areas for improvement.
Action: An agreed Action Plan has been implemented to ensure this is monitored as part of the IC
programme of work.
This is a CQC related re-audit. The first cycle of the audit was carried out by a CQC inspection. It was
identified that documentation of consent fell below the standard. As a result much work has been
done following the last audit. The purpose of the re-audit was to further review documentation of
patients consent to treatment. A plan of re-audit was implemented.
The aim of the re-audit was to establish the level of compliance with Clinical and Management
Supervision for all BHFT staff, including clinical and non-clinical staff. Some criteria have shown an
improvement since the previous audit last year, however, some have also declined. Action plans are
currently in development to ascertain how improvements (where relevant) can be made. The
following areas of actions have been noted and will be followed up as part of the normal process.
Inform staff re: content, frequency, and training availability
Records of supervision and work/reflective diaries to be maintained accurately
Staff to attend supervision and training.
The aim of the audit was to ascertain if practitioners are receiving Child Protection Supervision in
line with recommended time frames following new policy in 2012. The findings identified that 76%
of practitioners working with the 0-19 children’s community health teams across Berkshire were
compliant with receiving individual child protection supervision between September 2012 and April
2013. Action: On-going monitoring of compliance. .
The aim of the audit was to assess the dental services’ ability to comply with the essential quality
requirements as set out in National guidance, and also their environment and their use of personal
protective equipment.
There were 17 standards that were non-compliant within all clinics, seven of these related to the
issues requiring support from the Estates Department. The audit report will be disseminated to the
Joint Heads of Service for Dental in accordance with the requirements of the Trust IPC annual audit
programme. Managers will be responsible for ensuring identified deficiencies are addressed.
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6
Audit Title
Quality and timing of GP letters (2014)
7
Management of Depression in Older Adults (2013)
8
Audit of Pathway of Inpatient Services (2013)
9
Audit Of Urinary Catheter Care Bundle
10
Client, Patient or Service User? The views of healthcare workers and the
people they care for (2014)
Conclusion/Actions
The audit was carried out in March 2013 covering all new patient referrals to Reading South
Community Mental Health Team for Older People from June 2012 to November 2012. The audit was
chosen due to anecdotal concerns about the length of time taken to complete documentation
following the change in 2010 from paper patient records to an electronic recording system (RIO) of
patient records. The audit identified that a high percentage of risk assessments were not completed
in a timely basis. An action plan is in place to improve this.
The audit looked at how staff from the Reading Older People’s Mental Health Services assessed
people with depression and whether information was provided to patients on their condition and
treatment Action: Present findings at the Reading OPMHS team meeting and the West Berkshire
Clinical Effectiveness Meeting for the OPMHS.
The aim of the audit is to confirm whether appropriate processes are in place around admission,
treatment and discharge to and from Trusts inpatient services for people with learning disabilities.
The audit concluded that appropriate processes are in place for admission, treatment and discharge
to and from inpatient services. The action plan relates to completion of fields on RiO.
The aim of the audit was to assess compliance with the requirements set out in the urinary catheter
care bundle through review of completion/documentation on the care bundle. The audit found that
community nursing demonstrated a high level of compliance with the requirements set out in the
urinary catheter care bundle in comparison to inpatient wards.
Action: An ongoing plan for management and monitoring has been developed.
The aim of the audit was to review consistency across documentation in the Trust, in light of
awareness that different terms maybe preferred by different professionals. The term ‘patient’ was
also termed as a ‘client or ‘service user’
Action: The report is to be shared with Patient Experience, for information.
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11
Audit Title
Re-Audit to ensure quality of accompanying documentation for patients
admitted to community inpatient wards
12
Reaudit: Consent to ECT
13
Audit of assessment letters sent to GP’s by Clinical, Counselling
Psychologists and Psychological Therapists
14
Audit of antipsychotic medication monitoring for older adults with
dementia
Conclusion/Actions
The community hospitals have criteria and principles that support appropriate use of the
community beds, providing clear guidance for the referrer around documentation and processes
required to support a safe transfer. These criteria were shared with PCT, GP's, secondary care and
unitary authorities' partners prior to approval within BHFT. Anecdotal evidence from ward staff
across all wards is that referrers are not adhering to the criteria and principles for admission and
this has potential to impact on patient safety. The aim of the audit was to gain objective evidence
around the adherence to the admission criteria and principles that can support communication for
improvement with relevant referrers.
Action: The action plan is to be shared with the Hospital development group as sub-group of Adult
SIG.`
The audit objective was to monitor current standard of obtaining consent to ECT and whether BHFT
ECT department were compliant with national guidelines, if patients had a capacity assessment and
relevant documentation was in place prior to ECT.
Action: The audit findings resulted in the flowing action points:
Monitor Capacity Assessments completion at each ECT
Maintain updates of current & training of new ECT ward based leads
ECT treating staff to check pathway at each treatment and
ECT Pathway documentation sent to ECT on Completion
The aim of the audit was to establish if good practice is being followed in communicating through
letters written by clinical and counselling psychologists to GPs. 100% compliance was met in all four
service standards.
The decision to start anti-psychotics drugs for older adults is made in the context of a careful riskbenefit assessment. Although anti-psychotic medication has an important role in treatment of
serious mental illness, it needs to be used with careful monitoring of physical health. Early detection
is important to allow medication to be altered and adverse effects on physical health to be treated.
The aim of the audit was to ensure that older adult services in Berkshire comply with Trust
guidelines on anti-psychotic monitoring, to raise awareness of current guidelines and provide
further education and reaudit following interventions to assess whether improvements have taken
place, or whether further intervention is necessary. The audit identified low levels of compliance
with monitoring.
Action: The presentation was shared with local staff, and a revised monitoring form trialled.
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15
Audit Title
Prolactin monitoring in general adult inpatients receiving antipsychotics
16
GP Referrals to Memory Clinic
17
Clinical audit of the copying of Windsor, Ascot & Maidenhead Memory
Clinic letters to patients, their families and carers
18
Survey of provision of Psychological services to Bluebell Ward
19
School Nursing Assessment Audit
Conclusion/Actions
The aim of the audit was to improve current clinical practice by establishing clear guidance on the
use of antipsychotic drug treatment. A raised level of prolactin is a common consequence of the
treatment, with clinically short and long term effects. Compliance was tested against three audit
standards.
Action: The project was shared with local staff.
The aim of the audit was to ensure that the GP referral forms had vital information about the
patients which helps in their assessment of memory issues including documented information on
the required tests
Action: The agreed action is to educate GPs to emphasise the importance of a standard referral.
In Berkshire Healthcare NHS Foundation Trust, a policy (Copying Letter to Patients; CCR107) was
drawn up advising that letters should be copied to patients. Given the wealth of guidance, it
seemed appropriate to seek to audit this element of practice within the Windsor, Ascot & Memory
Clinic service.
The audit identified that 58.8% patients had received a copy of their initial assessment letter but
only 12% of cases where the letter was sent to the patient’s carers.
Action: The project has been fed back to the locality clinic business meeting.
The project was to review the psychological therapies available to the ward and stakeholder
opinions of these, plus what stakeholders would like to see offered. 33 responses were received in
total.
Action: The report was shared locally.
This audit has been undertaken as part of the Berkshire Healthcare Foundation Trusts (BHFT)
Universal Children’s Services Improvement School Nursing Sub Group requirements, to assist with
the quality assurance and development of the School Nursing assessment process and recording.
The audit did identify areas of high compliance, but there were 33% of cases where all sections with
demographic information had not been completed.
Action: Record keeping task group to update assessment paperwork
Written guidance for practitioners
Training on the use/content of progress notes
Audit tool to be amended to reflect change from Notable events to Event Timeline.
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20
21
Audit Title
Early Detection of Deterioration in Health Score on In Patients Units
CMHT Risk Assessment Triangulation Audit Initial Results from Audit
Pilot
Conclusion/Actions
Older adult psychiatric inpatients often have multiple physical health co-morbidities and their
physical health is as much a priority as their mental health. This quality improvement project was
conceived after noticing multiple incidents of patients having abnormal physical observations
recorded which should have warranted urgent review by a doctor, but were not raised as a concern.
The audit identified that physical observations are poorly understood and under-utilised by mental
health nursing staff.
The project received raised some significant concerns over (lack of) use of NEWS, and also the lack
of knowledge of observations and the interpretation/escalation procedure. As such it was taken to
CEG as a special paper, and directly reported to the medical and nursing directors
Action:
Redoing the training in NEWS for all staff to ensure staff understand importance of scoring and
escalating concerns.
Relaunch of NEWS
The aim of the audit is to help review how effective the work by the Risk Management and Crisis
Contingency Sub Group implemented across the Trust is, and to ensure on going high quality of
record keeping.
Action: To set up a workshop for the auditors to ensure consistency in undertaking of the audit
across the trust
To undertake Peer review audit across the localities
To undertake the next round of audits once the workshop has been undertaken. Provisionally
October’s Audit
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22
Audit Title
Annual Audit of PGD's for Diphtheria Tetanus Polio PGD
23
Child Sexual Exploitation: An Audit of Staff Knowledge and Training
Needs
24
Clostridium Difficile Infection (CDI)
Commissioning
(East Berkshire CCG’s) -
Conclusion/Actions
The aim of the audit was to ensure documentation required during administration of the DTP
immunisation under Patient Group Direction (PGD) is of the highest standard. The audit set out to
demonstrate that the PGD system of staff training, signing of the PGD and the correct
documentation on each child’s PGD consent form was correct.
Action: The consent forms for DTP and Meningitis C need to have “Site of immunisation” and
“Route of immunisations – intramuscular (IM) or sub-cutaneous (SC) added to them to improve the
recording of these areas.
The parent information sheet given to the child after the session stating what vaccine they received
that day should be changed to include which arm each vaccine was given in.
Staff training record sheet needs to be fully completed for each PGD that is being used. These are
currently under review by the Patient Group Direction (PGD) working group.
The audit commissioned by Health Education Thames Valley was conducted to explore the child
sexual exploitation (CSE) knowledge and training needs for staff required to undertake Level 2 and
above safeguarding training across Thames Valley. This included staff from across the nine health
care Trusts (including South Central Ambulance Service), and health care staff working in the
community, including GPs, dentists and pharmacists.
Action: The audit report will be shared with lead for safeguarding children, and deputy director of
nursing.
The Clinical Audit Department at Berkshire Healthcare NHS Foundation Trust was commissioned by
the three Clinical Commissioning Groups in the East of Berkshire (Slough, Bracknell & Ascot and
Windsor & Maidenhead) to undertake an audit on Clostridium Difficile Infection and how it is
managed and reported within the respective surgeries.
The audit was designed to identify appropriate monitoring and reporting of patients who have been
selected in the specific surgeries as having a Clostridium Difficile Infection episode recorded within
their patient notes."
Action: The completed audit report has been sent to the Commissioning CCG Lead.
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25
Audit Title
Clostridium Difficile Infection (CDI)
(West Berkshire CCG’s) Commissioning
26
Blank boxes on all Inpatient units, on drug administration chart during
the previous 7 days.
27
Review of Medicines Management Audit on all CHS inpatient wards in
Berkshire Health.
Conclusion/Actions
The Clinical Audit Department at Berkshire Healthcare NHS Foundation Trust was commissioned by
the four Clinical Commissioning Groups in the West of Berkshire (Newbury & District, North & West
Reading, South Reading and Wokingham) to undertake an audit on Clostridium Difficile Infection
and how it is managed and reported within the respective surgeries.
The audit was designed to identify appropriate monitoring and reporting of patients who have been
selected in the specific surgeries as having a Clostridium Difficile Infection episode recorded within
their patient notes.
Action: The completed audit report has been sent to the Commissioning CCG Lead.
The main aim of the audit was to identify a percentage of patients with a blank box on a specific
ward over the course of one week.
Blank boxes are an issue on all inpatient wards. Overall the Community Health service wards had a
higher mean rate of blank boxes (40.6%) compared to mental health wards (32.6%)
Action: A number of agreed actions for change have been developed and in process of
implementation. All inpatient units to include shift co-ordinator to double check of all inpatient
charts at end of shift. All inpatient units to regularly audit and record blank boxes to ensure that
improvements are measured. Ward managers to regularly discuss blank boxes with identified
nurses and if necessary start completing incident forms to emphasize the importance.
This audit was undertaken on all community inpatient wards across BHFT. It was a structured
interview to benchmark existing medicines management services on all community health services
inpatient wards against compliance with Care Quality Commission (CQC) standards for management
of medicines. The aim of the audit was to establish what systems are in place on the wards to
enable the services to manage their medicines safely, securely and effectively, to identify gaps in
staff knowledge on medicines and on Trust medicines related policy and procedures, identify
training needs of staff, to establish the extent of patients’ access to information about their
medicines and to identify areas requiring improvement. Findings identified training issues and some
staff being unaware of Trust policy.
Action: An agreed action plan is in place and is in the process of implementation. This covers a plan
for administration of PODs, increased staff knowledge, and better guidance to staff.
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28
Audit Title
Audit of registered Female genital mutilation (FGM) cases in Garden
Clinic, Upton Hospital.
29
Patient Group Directions (PGD)s use in Family Planning Services - Quality
assurance & documentation
30
Evaluation of Bracknell Home treatment Team
32
ECT Clinical Global Impression Scale Survey
Conclusion/Actions
This is a retrospective audit looking at registered cases of FGM in clinic. This is an important issue as
FGM interferes with the normal functioning of the external female genitalia and can result in a
range of physical health complications. It is illegal in the UK and patients need to be made aware of
this.
Action: A plan to revise proformas relating to this has been put in.
The aim of this audit was to examine if Family Planning PGDs are being used appropriately within
the service and documentations are adhered to in accordance with national recommendations. It
was identified that overall, PGDs were used appropriately and safely within the family planning
service. The audit found low risk to the organisation as compliance is good, and the policy is
generally being adhered to.
Bracknell home treatment team was set up in November 2011. This is the first service evaluation.
The aim of the audit was to evaluate the operation of Bracknell HTT between November 2011 and
November 2012 and measure it against the HTT operational policy and guidelines.
The audit discovered that data on admission and discharge were not always available on RIO.
It was recommended that all services that make referrals to Bracknell HTT should be familiar with
the referral criteria to the HTT, thus preventing inappropriate referrals and delay in patients
receiving appropriate care. It was identified that documentation of care provided to patients
required improvement.
Action: The audit is to be repeated in one year.
The aim of the audit was to assist the ECT department to produce quality account treatment
outcomes records. Survey of the CGIs (Clinical Global Impression) would then produce results of use
and success or failure of treatments that would be available in the public domain.
Results of successful ECT outcomes will support continued use of this treatment and will be an
indicator of treatment success for patients.
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33
Audit Title
Wrong Route of Administration or oral/enteral feeding (1178)
34
Audit of medication prescribing procedures and patterns in Berkshire
Community Dental Service (2014)
35
Audit of Dental Service Compliance with HTM 01-05 (Decontamination)
Conclusion/Actions
Nasogastric tube (NGT) feeding is common practice particularly in community children’s nursing.
Thousands of tubes are inserted daily across the UK without incident (NPSA 2011). However, there
is a risk that the tube can become misplaced into the lungs during insertion, or move out of the
stomach at a later stage.
The audit indicated that there was 100% compliance in all criterion for Specialist Children’s Service
in the East (6 of the 7 children). Specialist Children’s Services West were not compliant in criterion
2, 12,13. The evidence from the audit (criterion 5,6,7) showed evidence that there was 100%
compliance in the safe placement of NGT. Since the audit Specialist Children’s Services are now
being managed across East and West (one service). All staff are now aware of the Enteral feeding
policy and that a misplaced NGT is a ‘Never Event’.
Action: Recommendations have been developed and are in place, to ensure that all staff are aware
of the policy on Enteral feeding.
Prescription forms are an important financial asset for the NHS and any theft and misuse can
represent a significant financial loss.
The aim of the audit was to assess the procedures followed by clinics and to compare to local
policies and national guidelines.
The audit identified that only one clinic was recording numbers of prescriptions on a separate sheet
which is completed with the patient's name and medications prescribed when that script is used.
The aim is to re-audit in 12 months.
Action: An agreed action plan is in place to ensure that prescription records are accurately kept.
The aim of the audit was to demonstrate to patients and those observing quality standards in
dentistry that the local provider of a dental service is capable of operating in a safe and responsible
manner with respect to decontamination of instruments and dental equipment.
BHFT compliance with the standards was high with three clinics scoring 100% compliance and three
further clinics 98% and one clinic 91%.
Action: An agreed action plan is in place that ensured that Joint Heads of Service for Dental
reviewed the information within the report.
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36
Audit Title
Recording and use of NEWS scores on rehabilitation patients.
37
JD/QIP Risk assessment: A quantitative and qualitative review of current
practice within the CRHTT.
38
Quality of Referrals to Social care for Child Protection concerns.
Conclusion/Actions
BHFT is using the National Early Warning Score (NEWS) on inpatient wards as part of the effective
management of those in their care. The scoring system provides a tool to help detect a
deterioration in patients conditions and to provide a framework in which clinical support can be
sought and appropriate action taken. The audit identified several areas for improvement in
utilisation of the NEWS score.
Action: The report was shared with local staff. A plan of work to ensure that NEWs is effectively
embedded within the organisation is underway.
Risk assessment is one of the most important aspects of mental health practise. Especially in the
Crisis Resolution Home Treatment Team (CRHTT), where, cases are managed in the community. It is
necessary that a concise risk assessment is completed, to assist the service providers to provide the
best available support for each service user under crisis. This aim of the audit was to give an
overview of the current practise and suggest areas for improvement of assessing risk in acute
settings such as the CRHTT service covering the Reading area. The findings of this audit suggest that
there are aspects of the current practice of risk assessment within the CRHTT which are to be
commended upon.
Action: The audit report will be shared with the CRHTT managers and Reading CRHTTT mental
health professionals.
Safeguarding children often involves several agencies working together with a family to protect the
child. Feedback was received from Children’s Social Services at Reading Borough Council which
inferred that some referrals received from health practitioners were “inappropriate”.
A decision was made by the Safeguarding Children Team to review the referrals that Health
Practitioners sent into Children’s Social Services to ensure that the referrals met the threshold for
intervention from children’s social care when appropriate. The audit identified the need for a
standardised form to be implemented across Berkshire.
Action: Recommendations have been agreed and an action plan is in place to ensure that a
standardised form across Berkshire is implemented.
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39
Audit Title
Audit of Consultation Psychiatry to the General Hospital.
40
Effectively embedding psychosocial interventions into Slough CMHT.
41
Improving patient experience of Minor Nail Surgery care package - 2013
(1678)
Conclusion/Actions
There is increasing evidence that understanding patients' psychiatric conditions can help acute care
to improve physical care.
The purpose of the study was to give clear evidence of the amount of work undertaken at Wexham
Park Hospital in terms of providing psychosocial assessment to individuals attending A&E following
deliberate self-harm, or patients who present with psychiatric comorbidity associated with chronic
physical illnesses. The audit also covered staff commitment to completing the risk assessment and
the assessment of clustering to these patients after the assessment. The main finding related to
resource issues.
Action: A plan to discuss liaison requirements has been put in to place, combined with more training
for staff to further improve risk assessment.
This was a small scale audit which involved carrying out a survey using Rio to check if any
psychosocial interventions were being used by staff who have already graduated from the course. It
also involved sending out questionnaires to gain qualitative information. The aim of the audit was
to better embed PSI into the clinical area.
Action: A plan to improve integration of PSI techniques into practice as part of the project, was
implemented.
The purpose of this survey was to establish baseline data of patient experiences of the Minor Nail
Surgery package of care, and their treatment outcomes, provided by the podiatry service. The
questionnaire asked for the patient’s comments and views of their experiences from the first to
their final appointment. A total of 27 questionnaires were returned from patients who were seen
during November and December 2013. A significant proportion rated their feedback as good or
above, presenting a low risk to organisational reputation, or of complaints.
Action: The survey findings were shared with local team members.
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42
43
Audit Title
IPC Urinary catheter care bundle audit (annual) - Sept 2013.
JD/QIP Capacity to consent to have acetylcholinesterase inhibitors
(2062)
Conclusion/Actions
Patients development of, and on-going suffering with UTIs are a cause of increased costs to the
Trust, both in terms of required levels of care, and medications. In order to reduce the risk of
infection to a minimum BHFT had chosen to focus on ensuring that catheters are managed as per
evidence based best practice. The project also determined whether staff are completing the care
bundle documentation and adhering to policy. The audit showed that community nursing continues
to demonstrate a higher level of compliance with the requirements set out in the urinary catheter
care bundle than the inpatient wards.
Action: Local staff are more aware of the requirements of when the catheter care bundle should be
implemented. Documentation points have also been highlighted to staff.
Documentation of the diagnosis and capacity to consent to medication prescribed in memory clinics
is necessary in order to demonstrate that memory clinics are acting ethically and that they meet
standards set by the Department of and the Care Quality Commission.
The NICE guidelines on dementia (NICE-SCIE guideline, 2007) advise that health and social care
professionals should always seek valid consent from people with dementia. This needs to be
evidenced to demonstrate compliance.
The audit found that there was an improvement in the documentation of capacity and consent
relating to medication decisions in the memory clinic from the initial audit in 2013 to the re-audit in
2014.
Action: An action plan is to be developed.
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44
Audit Title
Mental Health CQUIN (prt2) Audit (2092)
Conclusion/Actions
This audit is part of the 2014/15 Commissioning for quality and innovation (CQUIN) guidance.
This first sample audit was to establish a baseline of where the Trust stands against the Mental
Health CQUIN so any gaps could be identified and appropriate actions implemented to fully meet
this guidance. Guidance stated the following requirements:
The number of patients in the audit sample for whom the provider has provided to the GP an up-todate copy of the patient’s care plan, which sets out appropriate details of all of the following:
• all primary and secondary mental and physical health diagnosis, including ICD codes;
• medications prescribed and monitoring requirements; and
• physical health condition and ongoing monitoring and treatment needs.
88% met the criteria for sending an up-to-date care plan to the GP. This means 12% of Trust wide
Care plans had not been uploaded onto RIO.
The CQUIN will be on the programme for
2015/16 – and will be included on the Trust audit plan to facilitate support.
Action: Care Plan documentation will be developed to provide the required fields to record ICD10
codes on CPA Care Plans and further guidance will be issued for clinicians on recording. The audit
results and action plan will be reviewed by the Acute Care Forum who will monitor the action plan
delivery. Locality teams will review own results and produce appropriate actions to improve any
areas not fully meeting each criteria. Ongoing review to ensure actions have been implemented will
occur, and there will be a repeat audit in quarter 4.
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Appendix D Safety Thermometer Charts
Below are the figures for the year on the number of patients surveyed
Data capture period
Harm free care in BHFT
Q4 2014/15
Q3 2014/15
Q2 2014/15
Q1 2014/15
93.2%
92.2%
91.3%
91.7%
Number
surveyed
4089
4064
3908
4144
of
patients Harm free
nationally
93.9%
94%
93.7%
93.8%
care
When compared nationally the data shows that BHFT has a higher % of all pressure ulcers, but the gap is closing as
can be seen below.
All Pressure Ulcers BHFT
2
1.8
1.6
Percentage
1.4
1.2
ALL ENGLAND
1
0.8
BHFT
0.6
0.4
0.2
0
Q3 13/14
Q4 13/14
Q1 14/15
Q2 14/15
Q3 14/15
Q4 14/15
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Types of harm
The chart below splits the types of harms across the whole organisation. Pressure ulcers remain the highest harm
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Appendix E CQUIN 2014/15
Expected Financial Value of Goal
(subject to agreement of weighting)
£43,204.45
East Goal Number
1a
Description of Goal
Friends and Family Test – Implementation of staff FFT
1b
£14,401.48
1c
Friends and Family Test - Early Implementation – Outpatient and Day Case
Departments
Friends and Family Test - Phased Expansion
2
Safety Thermometer - Reduction in pressure ulcers
£100,810.37
4a
Cardio Metabolic Assessment for Patients with Schizophrenia
£57,605.93
4b
Patients on CPA: Communication with GPs
£28,802.96
Local 5a
Frail Elderly – HWPFT
£180,018.52
Local 5b
Frail Elderly – FPFT
£144,014.82
Local 5c
Local 6
Participation in integrated working with the Frimley System
Care Planning – EAST
£108,011.11
£144,014.82
Local 7
7 day working
£100,810.37
Local 8
Psychological Interventions in Secondary Care
£86,408.89
Local 9
Employment Support
£86,408.89
Local 10
Smoking
£100,810.37
Local 11
CRHTT/Urgent Care
£100,810.37
Local 12
CAMHS
£100,810.37
£43,204.45
£1,440,148.18
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Goal Weighting
(% of CQUIN scheme available)
3.0%
Expected Financial Value of Goal
£65,282.56
3.0%
£65,282.56
1c
Friends and Family Test - Early Implementation – Outpatient and
Day Case Departments
Friends and Family Test - Phased Expansion
3.0%
£65,282.56
2
Safety Thermometer - Reduction in pressure ulcers
7.0%
£152,325.97
4a
4b
Cardio Metabolic Assessment for Patients with Schizophrenia
Patients on CPA: Communication with GPs
4.0%
2.0%
£87,043.41
£43,521.71
Local 1
Care Planning - WEST
9.5%
£206,728.10
Local 2
IV treatment (H@H) - WEST
9.5%
£206,728.10
Local 3
Re-admissions (H@H) - WEST
9.5%
£206,728.10
Local 4
NEL- West
9.5%
£206,728.10
Local 7
7 day working
8.4%
£182,791.17
Local 8
Psychological Interventions in Secondary Care
7.4%
£161,030.31
Local 9
Employment Support
7.4%
£161,030.31
Local 10
Smoking
8.4%
£182,791.17
Local 11
CRHTT/Urgent Care
8.4%
£182,791.17
100.00%
£2,176,085
West Goal Number
1a
Description of Goal
Friends and Family Test – Implementation of staff FFT
1b
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Appendix F BHFT draft CQUINs 2015/16
Please note that these are only the agreed Local CQUINs, mandated CQUINS and the associated value of all CQUINs are still to be finalised.
Indicator
Indicator Name
Description of indicator
Number
Local 1
Children’s transition (physical and mental health) BHFT children’s services will, where relevant to the needs and wishes of young people, work jointly
with internal and external services in supporting global transition to Adult services in accordance
with national guidance described in 'Moving on Well', through multi agency participation in Person
Centred Health Care Plans.
This would include all BHFT professionals involved in the care of young people taking responsibility
for referral of identified physical and mental health conditions to appropriate services linked to their
specialities.
Local 2
Local 3
Hydrate
Engagement in meaningful and purposeful
activity
The role of Health Plan Coordinator will be agreed according to the criteria within 'Moving on Well'
and
based
on
the
identified
'most
significant
area
of
need’.
The end outcome of this programme, and that which will be measured, will be an increase in the
percentage of young people who report the transition process as having been a positive experience.
To ensure that patients hydration is given a high priority and its importance is understood by staff as
well as patients and carers. Information regarding importance of hydration will be readily available
on the ward and discussions will be had with patients/carers on admission, throughout their stay
and prior to discharge. All patients will have a risk/ needs assessment and care plan if risk identified.
Where this identifies a need for supervision and support to achieve sufficient hydration, a user
friendly chart to monitor intake will be implemented. It is important that patients and their carers
understand the reasons for adequate hydration. Therefore the purpose of the hydration chart is to
provide some patient ownership where possible with the aim that they will understand the
importance of hydration and maintain their fluid intake following discharge. A staff education
programme will be undertaken by the Trust in order to support the launch of Hydrate. This CQUIN
will include patients on all community health and older adult wards.
In quarter 4 the Trust will communicate any learning from the project with staff working in the
community.
BHFT staff in the Community Mental Health Teams will work collaboratively with all secondary care
patients under CMHT, aged 18-65, and other third party agencies to develop education, training,
employment or volunteering opportunities. This will be dependent on service user choice and ability
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using an Individual placement and support model if appropriate.
Local 4
Smoking Cessation
To improve the physical health of Mental Health inpatients (Prospect Park) by offering Nicotine
Replacement Therapy (NRT) to those patients who have been identified as being smokers, and to
provide NRT to those who agree to commence this treatment within 2 hours of admission to an
inpatient area. This is an option to assist in abstinence of tobacco whilst on the ward. This will
exclude Learning Disabilities and those who lack mental capacity to make the decision.
Local 5
7 Day working
1.The treatment plan of all new admissions under a section will be reviewed, on the phone, by the
on-call Consultant between 5pm and 12 midnight, 7 days a week (this includes adult and Older Adult
patients and also those admitted under section MHA)
2. Weekend medical cover will be enhanced with Consultant/ Specialty Doctor presence on site at
PPH between 9 am and 5pm to
1. review all new admissions under a section (patients admitted after midnight)
2. ·provide medical input to CRHTT for decisions about appropriateness of admissions to PPH
3. ·prescribing for CRHTT patients where clinically required
4. ·medical input, as required, for APOS and seclusions
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Appendix G Statements from Stakeholders
Quality Account: Views of the Council of Governors
At a meeting of their Strategy Group on the 9th April Governors received the most recent version of the Quality
Account and broadly endorsed it as an accurate assessment of performance, noting in particular a new section
(Quality Concerns) detailing the action in train to address key issues which carried a risk to safety, the effectiveness
of treatment and patient experience of care.
Two members of Council in particular expressed thanks for the scope of the document and for the key achievements
which it described - including the metrics relating to staff engagement - and asked that these comments should be
recorded in the Quality Account.
It was agreed that significant improvements over the previous year should be summarised at the beginning of the
document and that the final version should reflect as far as practicable some of the issues identified before and after
the meeting as requiring further clarification.
Governors noted with approval that they would have a fuller opportunity to discuss key metrics from staff surveys
following a presentation at their May meeting.
Further detailed written comments would be taken into account in preparing the next Quality Account.
Response
The Trust welcomes the feedback from the Governors Strategy Group and the suggestions for improvement received
from the Council throughout the year. Where possible these have been included in particular clarity has been
provided on the numbers of patients and staff surveyed.
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Wokingham Healthwatch
“Healthwatch Wokingham Borough congratulate Berkshire Healthcare Foundation Trust on an open and transparent
Quality Account for 2014/15. We are pleased to see greater mention of issues around CAMHS with it featuring in
the complaints, Quality concerns and clinical effectiveness sections. Because you do not include your priorities for
the year ahead it’s impossible to tell from this document if your Board see CAMHS as a priority for improvement in
the coming year?
Healthwatch Wokingham Borough recognise the complexity of commissioning and the impact this has on CAMHS –
we would like to get a better sense of how you as the main community provider are experiencing co-commissioning
across health and social care and teams working together in an integrated way – and what impact this has on the
user of the service and quality of service being delivered in particular. “
Trust Response
The Trust welcomes the feedback from Wokingham Healthwatch and will include identified quality concern areas,
including CAMHS as priorities for the year ahead to be reported on in the 2016 Quality Account.
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Comment for BHFT 2015 Quality Account
Thank you for the opportunity to comment on your 2015 Quality Account.
We note that there is an increasing focus on Child and Adolescent Mental Health Services (CAMHS) and that an
independent review has been carried out to improve care pathways and reduce waiting times. We see that new
referrals for CAMHS are increasing and we suspect this will continue as we were recently informed that there are
issues where professionals are not sure who should be carrying out the referral. We would like to see the
strengthening of relationships between professionals, a clear referral process that everyone understands simple
pathways and shorter waiting times to ensure no one is missed or unnecessarily delayed.
We have received positive feedback about Community Nursing from people with learning disabilities. Quote; “Nurse
visits and explains things well”. From the responses received from self-care week which Healthwatch analysed
community midwife teams and health visitors were valued and praised.
We note that you have said 75% of complaints received relate to mental health services and that you are further
reviewing how patient experience can be improved in this area.
We hear feedback regarding the Community Mental Health Team (CMHT) and more specifically Crisis Home
Resolution (CHR). People tell us that the complaints would reduce if it was clearer to them when they should be
calling CHR. This ranges from people waiting too long to call as they know the service is under pressure, thinking that
they are helping others, to calling when they do not necessarily need to. We are told that it would help if the time to
call could be further tailored to their individual needs.
The Crisis Response Team has had more negative than positive responses around access, understanding of situations
and appropriate responses rather than “text book” responses. Also the unwillingness to deal with people with dual
diagnosis.
There is concern that services for individuals will be affected should a complaint be raised. We feel this is an area the
NHS as a whole needs to address.
We are told that patients would like improved communication. For example where there is a wait for a service they
would like to know rather than being told nothing.
We have received feedback that meetings with deaf people are carried out even though the signer has not arrived
yet. This is a larger issue across the NHS which needs to improve.
Positive feedback is also received relating to CMHT, quote “Fantastic service from Bracknell Mental Health Team at
Churchill House”. Again at Churchill House “Very good receptionist friendly and helpful makes all the difference”.
We have also received positive feedback about the Rapid Assessment Clinic at St Marks. Quote; “All staff extremely
courteous and never feel rushed.”
We look forward to continuing to work with Berkshire Healthcare with the aim to improve patient engagement and
experience.
Trust Response
The Trust Welcomes the feedback on the Quality Account from Healthwatch Bracknell and the additional
information provided to assist in improving services for patients.
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Healthwatch Reading
Healthwatch Reading welcomes the opportunity to comment on BHFT Quality Accounts for 2015. We congratulate
you on the improvements you have made in your friends and family scores and your dedication to implementing this
and your commitment to making quality improvements across the services you offer. The main points we would like
to raise are:




We welcome the references to patient involvement work that in previous accounts has been
lacking. However we feel that there is not enough evidence of patient engagement and putting patients at
the heart of services. We would encourage further partnership working with local Healthwatchs to gather
qualitative evidence to improve services and shape them to meet patient needs as a move to improving this.
We have been impressed with the way the Trust deals with complaints and with the timeliness in which they
are dealt with, although we have concerns that most complaints are about care and treatment, and would
be keen to see evidence of how this learning is being translated into service improvements.
We have continuing concerns about the CAMH service. We continue to hear feedback from local families
about wait times and the impact this is having on their child and their family life. We recognise the reviews
that have taken place and would be keen for the Trust to take a focus on key service improvements as well
as increasing capacity of this much valued service.
We welcome the appointment of BHFT as a provider of primary care for Circuit Lane Surgery in Reading and
will be following and monitoring the impact this has on patient experience of members of Circuit lane.
Trust Response
The Trust is grateful for the feedback from Healthwatch Reading and welcomes the emphasis on improving Child and
Adolescent Mental Health Services and the support for the Trust’s involvement in Primary Care at Circuit Lane
Surgery.
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Healthwatch West Berkshire comments on BHFT Quality Account 2015
Thank you for the opportunity to comment on this year’s Quality Account. We were pleased to see that on a wide
range of indicators the BHFT is performing above the average of trusts and often in the top 20%. Many indicators
also show an improvement over previous years. Where there are problems, there is generally some process to help
address them (such as the Smile and SHINE campaigns). We were also pleased to see a number of examples of
involving service users and other stakeholders (and we have welcomed the continuing regular engagement with
Healthwatch’s from across Berkshire through the year). Even if we comment on some more negative aspects, our
overall view is therefore a positive one.
It is good to hear (p.4) that you are starting to think about appropriate structural models in line with the Five Year
Forward View thinking.
On a point of presentation, in last year’s Quality Account each priority had the desired ‘Aim’, ‘Primary Measure’ and
‘Outcome’ and it might have been helpful for this year’s Account to have reported against each of these.
It is good to see that BHFT’s results are above the average for other trusts in the National Community Mental Health
Survey (p.8).
The National Staff Survey results (p.9) are impressive, producing results in the top 20% for similar trusts on staff
engagement. It is good that 96% of staff had had an appraisal but, although there has been an increase in those
saying they were well structured, it is still worrying that less than half, 48%, said it was well structured.
It is unfortunate that the aims on pressure ulcers were not met (p.11). Because of the different way in which the
information is reported, it is difficult to make comparisons with the previous year.
We are pleased that the issue of CAMHS is addressed (pp. 7, 13, 16-17) as in our experience this continues to be an
area of concern. As you say, young people have to wait too long for treatment. It is good that you are taking action
including extending the common point of entry, seeking more resources, making the case for a Berkshire Adolescent
Unit and working with the local authorities and the involvement of service users in improvement. We look forward
to hearing of progress on this.
We congratulate you on having met the target for increasing the number of health visitors (p.18).
The work on the Diabetes Education Project (p.19) sounds worthwhile but there is a lack of clarity on intended
outcomes (as opposed to means) and how they are to be achieved (there is discussion of education and awareness
raising but how was it intended that this would be translated into making an impact?). It is also not clear what
difference this work has been able to make. There also appears to be some confusion in point 5 of the objectives
which talks about focussing on ‘wards’ where there’s more likely to be a prevalence of diabetes, “namely Reading
and Slough”. There will undoubtedly be more of a problem in those local authority areas, but there are also areas of
deprivation across the county, including wards in West Berkshire, and it is important that these are not excluded. It
is also not clear how much of this work has been undertaken in partnership with other stakeholders (such as
voluntary organisations, CCGs, local authorities and Healthwatch). This would seem to be an issue where more could
be achieved working together than the sum of individual contributions.
In the section on ‘absence without leave’ and ‘absconding’ (p.28) it is noted that there has been an increase in the
number of absconsions of those on a MHA Section but the report says there has not been a clear trend. However,
the number has been over the target (of 15) for 10 of the 11 months of the year and was consistently higher than
any month since November 2012 (a period of one year and five months). Those elevated numbers over such a
considerable period would suggest a need to look for an explanation and consider actions to address the issue.
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As we said at the beginning, though inevitably we have highlighted queries and areas of potential concern, overall
we are pleased to see the high quality presented in this report and we commend the Trust for its work.
Trust Response
The Trust welcomes the feedback from Healthwatch West Berkshire.
With respect to diabetes, we acknowledge that there are areas of significant need and deprivation in West Berkshire.
There has been very good work in West Berkshire over recent years in improving diabetes care through health and
social care providers including Berkshire Healthcare and the Royal Berkshire Hospital working together. CCGs and
local GPs have led on much of this work and patient and carers groups have been very much involved.
The absconding figures included in the Quality Account are ‘rolling quarter’ figures so the number for March relates
to the combined episodes for January, February and March. It is true that absconding rates, in particular, during the
year were higher than the previous year. Several factors effect absconding levels including the presentation of
individual patients, occupancy levels as well as relational, procedural and physical security measures. The target of
less than 15 incidents per quarter (or 5 incidents per month) across the Trust was achieved by the end of the
reporting year. It is likely that some of the actions taken by the Trust have had an impact on this measure. Details
have been included in the final, published Quality Account following this feedback.
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Wokingham Health Overview and Scrutiny Committee reviewed the draft Quality Account 2015 for Berkshire
Healthcare NHS Foundation Trust and have made the following comments:





That with regards to the 2014 National Staff Survey it was noted that whilst performance against the
following questions was better than comparator Trusts, performance had decreased from the previous year;
‘My organisation treats staff who are involved in an error, near miss or incident fairly (agree or strongly
agree)’ and ‘My organisation encourages us to report errors, near misses or incidents.’ It is appreciated that
reporting errors is a key focus for the Trust.
It was noted that the national average for harm free care was 93.7% for the past 12 months to December
2014. The average monthly percentage for the Trust over the 12 months to December 2014 was 91.5%. The
Trust had a lower number of harm free patients due to the significant number of ‘acquired’ pressure
ulcers. When compared nationally the data showed that compared to all organisations BHFT had a higher
percentage of pressure ulcers reported. It was positive to note that the number of community pressure
ulcers had reduced in quarter 3, however.
Members questioned how many complaints had been taken to the Ombudsman.
Members noted the Trust’s priority to become smoke free across all sites in 2015/16 and questioned
whether this would also apply to visitors.
Concerns were expressed regarding the ongoing issues relating to the length of CAMHS waiting lists.
Trust Response
The Trust welcomes the feedback from the Wokingham Health Overview and Scrutiny Committee and for the
Committee’s involvement in making suggestions to help improve the final report.
The number of complaints taken forwards by the Ombudsman in 2014.15 was eight a section on this has now been
included in the Quality Account.
The smoke free requirement does apply to visitors on Trust sites.
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Slough Health Overview and Scrutiny Committee 12th June 2015
Earlier this year, Berkshire Healthcare NHS Foundation Trust Chief Operating Officer David Townsend attended our
Health Scrutiny Panel. He presented the Quality Account, and our views were requested. The areas discussed by the
Panel were as follows:
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Patient satisfaction – the percentage of patients who rated the service they received as ‘very good’ or ‘good’
was 96% and the majority of services had increased their satisfaction ratings on previous years. Members
welcomed this improvement and asked how this compared to other areas. It was responded that the Trust
was ranked in the middle quartile.
Pressure ulcers – the prevalence of pressure ulcers was very closely monitored and the Panel welcomed the
Trust’s ‘zero tolerance’ approach to avoidable pressure ulcers (figure 6, page 18). It was noted that
reporting was encouraged and full investigations were carried out in instances of available pressure ulcers of
which there had been three identified in the most recent quarter. A Member asked whether the figures
measured whether patients suffered repeated instances of pressure ulcers. Mr Townsend said he would
further investigate whether these figures were available.
Falls – a similar proactive approach was being taken in relation to falls with further work to check patients
had drink, access to the toilet etc. to reduce the likelihood of a fall.
Record keeping – the Quality Concerns (from page 20 of the agenda) highlighted that record keeping
‘remained inconsistent’ and Mr Townsend explained some of the reasons behind this, including the fact that
parts of the RiO patient record system were nationally procured which limited the ability of the Trust to
bring about improvements. However, it was recognised as a key challenge that the Trust was seeking to
deliver further improvement.
Staffing – Members asked a range of questions about the level of staffing vacancies and the arrangements
for ‘safe staffing’ of wards. It was noted that there was a national shortage of nurses and a workforce plan
was being developed. Minimum staffing levels on wards were published daily and were reviewed monthly
by the Director of Nursing. Safe staffing levels had been declared on all wards.
Staff morale – noting the increased demand for services, a Member asked about the level of staff morale
and how it was being improved. It was responded that the most recent Staff Survey had generally been very
positive and although the growing pressure on staff were recognised by managers. The Listening to Action
process had proved successful in engaging staff.
CAHMS – pressure on children’s mental health services were acknowledged due to an increased number of
referrals. The Trust was working closely with local authority and other partners on securing early
intervention in Tier 2 services and NHS England was increasing investment in Tier 4 services. Extra money
winter resilience funds had supported more weekend and evening clinics which had been successful and it
was hoped they could be continued.
Medication errors – concern was expressed about the number of medication errors. Mr Townsend
indicated that reporting such errors was encouraged and there were various types of error ranging from
failure to properly complete paperwork through to administering the wrong medicine. Members
encouraged the Trust to provide a breakdown of the medication error figures to show them by category to
give a better indication of the relative severity of the various errors.
Smoking ban – the introduction of the smoking ban were discussed including whether it had had an impact
on staff morale. Staff had not been allowed to smoke on duty since 1st March 2015 and the impact was
being monitored. Early signs were that it was working well and there were no indications that it was
negatively affecting staff morale.
Clinical Audits – in response to a question, Mr Townsend summarised the audits undertaken during the
year. Members noted that the report contained detailed and often quite technical information about the
various audits and it was suggested that a high level summary of key audits and findings would help lay
readers.
Staff assaults – it was asked what action was being taken to minimise staff assaults. It was noted that
reporting was encouraged for assaults of every level of severity. The Panel were informed that serious
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
assaults were rare and many were carried out by a very small minority of patients, often suffering from
mental health conditions. The Trust benchmarked well compared to their peers and appropriate training
was provided.
Patients AWOL – the Panel pointed out that there appeared to be a high number of patients absent without
leave. The difference between patients not returning after leave and those absconding wards was
noted. Wards were not locked environments and there was balance to be struck in the appropriate level of
security. Members suggested further information be provided on the length of time patients had
absconded.
This is to be noted as the Council’s official response to the account.
Trust Response
The Trust welcomes the feedback from the Slough Health Overview and Scrutiny Committee and for the
Committee’s involvement in making suggestions to help improve the final report.
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BERKSHIRE HEALTHCARE TRUST QUALITY ACCOUNT 2015 – BRACKNELL FOREST COUNCIL HEALTH OVERVIEW AND
SCRUTINY PANEL COMMENTS 16th June 2015.
The Panel welcomes the transparency in this informative Quality Account.
The Panel gave particular attention to mental health services during 2014-15, not least because this is an underrecognised and very important service area for the NHS. Our work included: a briefing session with BHFT and Council
staff; a visit to Prospect Park hospital to meet patients and staff (where the care and dedication shown by staff
towards patients was clearly evident to us); and a very constructive meeting of the Panel with the BHFT’s Chief
Executive and senior staff, in public. Our overall impression is that the Trust has performed well for Berkshire
residents in 2014/15, in challenging circumstances.
Pages 7-8: We welcome the candour shown in the section about learning from complaints.
Page 14: We are concerned about the increased use of agency staff, given the adverse impacts on patient care and
the Trust’s finances. We welcome the Trust’s efforts to increase the proportion of permanent staff.
Pages 14-17: The Panel has been concerned for some time about the adequacy of Child and Adolescent Mental
Health Services across Berkshire. We are encouraged to see the Trust’s efforts to increase capacity and reduce
waiting lists, particularly as the demand for CAMHS services is increasing.
Page 22: The Panel supports the Trust’s priorities for improvement in 2015/16. However, we think there should be
more recognition of the challenging financial and staffing circumstances which mental health Trusts are facing.
Page 33: We congratulate the Trust on the continual increase in the number of compliments received.
Page 36: We are concerned to see the above-average percentage of re-admissions to hospital, and welcome the
Trust’s commitment to address its causes.
Finally, we would observe that for a lot of the datasets the sample size is too small to be statistically significant.
Trust Response
The Trust welcomes the feedback from the Bracknell Forest Council Health Overview and Scrutiny Committee and
these will be reviewed and taken into consideration in developing the Quality Account for 2016.
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Commissioner Response Berkshire Healthcare NHS Trust QUALITY ACCOUNT 2014/15
Prepared on behalf of Bracknell and Ascot CCG; Newbury & District CCG; North and West Reading CCG; Slough CCG;
South Reading CCG; Windsor, Ascot and Maidenhead CCG and Wokingham CCG.
Statement
The Clinical Commissioning Groups (CCGs) are providing a response to the Quality Account for 2014/15 submitted by
Berkshire Healthcare Foundation Trust (BHFT.)
The Quality Account provides information and a review of the performance of the Trust against quality improvement
priorities set for the year 2014-15 and gives an overview of the quality of care provided by the Trust during this
period. The priorities for quality improvement are also set out for the next 12 months.
The CCG’s support the Trust’s openness and transparency. They are committed to working with the Trust to achieve
further improvements and successes in the areas identified within the Quality Account. This will be carried out
through a number of both proactive and reactive mechanisms and collaborative and integral working.
The Trust’s Quality Priorities highlighted in the 2013/14 Quality Account were Patient Safety; Clinical Effectiveness;
Health Inequalities and Patient Experience. We are pleased to note that the Trust has also included two other
priorities which are Efficient and Organisation Culture.
There is a good narrative around the actions undertaken for these priorities; however, there does not appear to be
evidence in the Quality Account of the improvement outcomes as stipulated in last year’s accounts.
The CCGs welcomed the improved 2014 National Staff Survey, particularly around the significant improvement in
appraisals for staff and the improvement in staff who felt that they could whistleblow if there was a concern.
The Trust should be commended on the work already undertaken to reduce the number of developed pressure
ulcers on the inpatient wards. It was pleasing to note that two wards have not had a developed pressure ulcer for
over a year. The CCGs acknowledge that there remains further work on three other wards which have not achieved
the 90 day pressure ulcer free target. The Commissioners understand that all pressure ulcers are investigated for
lessons learnt, however it is only the grade 3 and 4 that are reported as Serious Incidents to the Commissioners.
The Trust has been working closely with staff and has held a number of Listening into Action events to work out ways
to improve patient and carer experience from a frontline perspective. The CCGs are interested in the impact that
these have made. It is positive to see that from the National Community Mental Health Survey that the Trust is
performing at the same level as other Trusts, which is an improvement from previous years.
It has been a difficult year for the CAMHS service, and the Commissioners are pleased to provide further support for
the service through the Parity of Esteem process. The Commissioners will continue to work with BHFT to reduce
waiting lists and improve quality of care. The Trust has been honest in its evaluation of the interface between
Common Point of Entry (CPE), Community Mental Health Teams (CMHT) and Crisis Response and Home Treatment
Teams (CRHTT) and the Commissioners look forward to working with the Trust on improving the service for 2015/16
through the parity of esteem process.
The Commissioners would be interested in the forthcoming year to see whether there is a correlation between
reduced staffing levels and the level of risk to patients during each 24 hour period as identified by the Director of
Nursing in the section on Safe Staffing.
The Commissioners are supportive of the Trust’s ambition for a smoke free organisation, and acknowledge the
challenges BHFT will face to implement the NICE guidance in relation to this. The Commissioners have incentivised
the Trust for this ambition through a 2015/16 CQUIN and will be monitoring the progress of this initiative through
the year.
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The Trust was innovative in looking at their training packages for staff when no suitable training was available for the
increasing access to psychological therapies in secondary care CQUIN. Following the training, staff should be able to
deliver psychological techniques with suitable clients.
Priorities for 2015/16
The Commissioners would like an understanding of how the Trust decided upon their quality priorities for 2015/16;
however the Commissioners would support the priorities that the Trust has selected to continue to build upon these
from last year.
The Trust has selected broad topics for their quality priorities and the Commissioners would appreciate details of any
measures chosen to evaluate/confirm the Trust’s success on these priorities in 2015/16. The priorities identified for
2015/16 are Patient Safety; Clinical Effectiveness; Patient Experience and Health Promotion.
The Commissioners would like to continue to be informed of any new Quality Concerns being identified during
2015/16 for the opportunity to support the Trust with these.
The Commissioners are pleased to note that the Trust was able to resolve the concerns raised by CQC in relation to
Sorrell Ward, and that these Improvement Notices are now lifted. We welcome BHFT’s coordination of the multiagency thematic review of people who have had a mental health crisis and were detained under Section 136 of the
Mental Health Act, and we look forward to the report being published in June 2015.
The CCG acknowledge the Trust’s achievement of the Monitor standards, and the Commissioners support the
further work by the Service Improvement Group to reduce the number of mental health readmissions within 28 days
of discharge.
Trust Response
The Trust welcomes the feedback on the Quality Account from the Clinical Commissioning Groups and the support
that commissioners have provided throughout the year. The Parity of Esteem investment for 2015/16 is focussed on
addressing key areas of risk highlighted in the Quality Account ‘quality concerns’ section particularly with respect to
Child & Adolescent Mental Health and Crisis Response and Home Treatment services.
The specific improvement outcomes identified in the previous 2014 Quality Account are generally included in the
narrative and accompanying tables within the 2015 Quality Account. This includes outcomes related to patient
experience (friends & family test; learning from complaints and compliments); clinical effectiveness (smoking
cessation; NICE quality standards; access to psychological therapies) and health inequalities (health visitor numbers;
local inequalities initiatives). Specified patient safety metrics related to the staff survey are achieved and reported.
Those related to patient harm are reported using different metrics associated with the NHS safety thermometer but
details of suicide rates, serious incident reporting, falls and medication errors are fully included within part 3 of the
account.
The priorities for 2015/16 were developed during the year in conjunction with Trust Governors, Board members,
Clinicians and other key stakeholders whilst building on previous quality priorities. The priorities are consistent with
the Trust’s Quality Strategy and are aligned, where possible, with CQUINs and quality standards included in the
contract for 2015/16 negotiated with commissioners.
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Appendix H
INDEPENDENT AUDITOR’S REPORT TO THE COUNCIL OF GOVERNORS OF BERKSHIRE HEALTHCARE NHS
FOUNDATION TRUST ON THE QUALITY REPORT
We have been engaged by the Council of Governors of Berkshire Healthcare NHS Foundation Trust to perform an
independent assurance engagement in respect of Berkshire Healthcare NHS Foundation Trust’s Quality Report for
the year ended 31 March 2015 (the ‘Quality Report’) and certain performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following two national
priority indicators:


The percentage of patients on Care Programme Approach who were followed up within seven days after
discharge from psychiatric in-patient care during the reporting period;
The percentage of admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as
a gatekeeper during the reporting period.
We refer to these two 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 2014/15 (‘the Guidance’); and
•
the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality
Report are not reasonably stated in all material respects in accordance with the NHS Foundation Trust
Annual Reporting Manual and the six dimensions of data quality set out in the Guidance.
We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation
Trust Annual Reporting Manual and consider the implications for our report if we become aware of any material
omissions.
We read the other information contained in the Quality Report and consider whether it is materially inconsistent
with:
•
Board minutes for the period April 2014 to April 2015;
•
Papers relating to quality reported to the board over the period April 2014 to May 2015;
•
Feedback from Commissioners, dated May 2015;
•
Feedback from governors, dated May 2015;
•
Feedback from local Healthwatch organisations, dated May 2015;
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•
Feedback from Overview and Scrutiny Committee dated May 2015;
•
The trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS
Complaints Regulations 2009, 2014/15;
•
The 2014/15 national patient survey;
•
The 2014/15 national staff survey;
•
Care Quality Commission Intelligent Monitoring Reports, 2014/15;
•
the Head of Internal Audit’s annual opinion over the trust’s control environment, dated May 2015 and
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 Berkshire Healthcare
NHS Foundation Trust as a body, to assist the Council of Governors in reporting the NHS Foundation Trust’s quality
agenda, performance and activities. We permit the disclosure of this report within the Annual Report for the year
ended 31 March 2015, to enable the Council of Governors to demonstrate 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 Berkshire Healthcare NHS Foundation Trust for our work or this report, except where terms are
expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on Assurance
Engagements 3000 (Revised) – ‘Assurance Engagements other than Audits or Reviews of Historical Financial
Information’, issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited
assurance procedures included:
•
Evaluating the design and implementation of the key processes and controls for managing and reporting the
indicators
•
Making enquiries of management
•
Testing key management controls
•
Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation
•
Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the
categories reported in the Quality Report.
•
Reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing
and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a
reasonable assurance engagement.
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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 affect
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 of these
criteria, may change over time. It is important to read the quality report in the context of the criteria set out in the
NHS Foundation Trust Annual Reporting Manual.
The scope of our assurance work has not included governance over quality or non-mandated indicators, which have
been determined locally by Berkshire Healthcare NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year
ended 31 March 2015:
•
the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS
Foundation Trust Annual Reporting Manual;
•
the Quality Report is not consistent in all material respects with the sources specified in the Guidance; and
•
the indicators in the Quality Report subject to limited assurance have not been reasonably stated in all
material respects in accordance with the NHS Foundation Trust Annual Reporting Manual and the six
dimensions of data quality set out in the Guidance.
KPMG LLP
KPMG LLP, Statutory Auditor
KPMG LLP
15 Canada Square
London
E14 5GL
28 May 2015
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