A University Teaching Trust
Quality Account
2014/15
Where People Matter Most
Contents
Introduction to the Quality Account...............................................................................................................6
What is a Quality Account...............................................................................................................................6
What is Quality................................................................................................................................................6
Quality Improvement Strategy........................................................................................................................6
Trust Assurance Framework............................................................................................................................7
Trust Values.....................................................................................................................................................9
Quality Improvement Framework with our Commissioners...........................................................................9
Commissioners Assurance Programme – Quality Improvement (CAP-QI)......................................................9
Quality Requirements...................................................................................................................................10
Part 1
Statement on Quality from the Chief Executive............................................................................................11
Patient Stories...............................................................................................................................................16
Anne’s Story – ‘Recovering’...........................................................................................................................16
Terry’s Story – ‘Stains’...................................................................................................................................17
A Brief Look-Back and Forward.....................................................................................................................20
Part 2
Priorities for Improving Quality.....................................................................................................................21
Performance against our 2014/2015 Priorities – Summary..........................................................................21
Priorities for 2015/2016................................................................................................................................23
2015/16 – Priority 1 – Improving patient experience through improved staff satisfaction, staff
morale and engagement...............................................................................................................................24
2015/16 – Priority 2 – Organisational improvements in patient safety through learning lessons
from Root Cause Analysis..............................................................................................................................27
2015/16 – Priority 3 – Ensuring we have the right skills in the right place at the right time........................29
NHS Litigation Authority................................................................................................................................31
Part 2(B)
Statement of Assurance from the Trust Board.............................................................................................32
2014/15 Audit / Research / Data Quality Information..................................................................................32
National Clinical Audits and National Confidential Enquiries........................................................................32
Clinical Research............................................................................................................................................37
Commissioning for Quality and Innovation (CQUIN) payment framework...................................................38
Care Quality Commission – Registration Status............................................................................................38
Manchester Academic Health Science Centre (MAHSC)...............................................................................38
FOCUS ON: Care Quality Commission Compliance Visits..............................................................................39
Data Quality and Information Governance...................................................................................................39
Information Governance Toolkit...................................................................................................................40
Mandated Quality Indicators.........................................................................................................................40
Mental Health Trusts National Performance Data........................................................................................41
Mandated Quality Indicators.........................................................................................................................41
Quality Indicator 1 – CPA 7 Day Follow Up....................................................................................................42
Quality Indicator 2 – Gatekeeping.................................................................................................................43
Quality Indicator 3 – Readmission within 28 days.........................................................................................45
Quality Indicator 4 – Staff Satisfaction..........................................................................................................45
Quality Indicator 5 – Patient Experience of Contact with Workers...............................................................47
Quality Indicator 6 – Patient Safety Incidents – Reporting...........................................................................49
Quality Indicator 7 – Patient Safety Incidents – Severity..............................................................................49
Part 3
Review of Quality Performance over the Year..............................................................................................52
Quality Monitoring Process...........................................................................................................................52
Embedding recommendations from the Francis Report...............................................................................52
Risk Summits.................................................................................................................................................53
Intelligent Monitoring Report.......................................................................................................................53
Listening into Action.....................................................................................................................................54
Learning Lessons...........................................................................................................................................56
Performance against our 2014/2015 Priorities.............................................................................................57
2014/2015 Priority 1 – Staff Morale and Engagement..................................................................................57
2014/15 Priority 2 – Learning Lessons from Root Cause Analysis.................................................................60
2014/15 Priority 3 – Safe Staffing.................................................................................................................61
NHS Equality Delivery System (EDS)..............................................................................................................64
Patient Safety ...............................................................................................................................................70
Serious Incident Requiring Investigation (SIRI)..............................................................................................70
Incident Reporting.........................................................................................................................................73
3
Safeguarding Adults......................................................................................................................................74
Patient Experience........................................................................................................................................75
Survey Outcomes – Care Quality Commission Survey of Community Mental Health Services ...................75
Complaints and PALS Activity.......................................................................................................................78
Improvements in Patient Engagement.........................................................................................................80
Service User and Carer Engagement............................................................................................................80
Patient Stories..............................................................................................................................................81
Entry and Exit Questionnaires......................................................................................................................84
Eliminating mixed sex accommodation/patient safety audit.......................................................................85
Effectiveness.................................................................................................................................................86
Transformation Programme.........................................................................................................................86
Divisions Review of Quality Performance over the Year..............................................................................87
Psychological Services Division (PSD) – Introduction to our PSD Services and Approach to Care...............87
Adult Mental Health Division: Inpatient and Urgent Care............................................................................90
Health and Well-Being Service......................................................................................................................91
Later Life Division..........................................................................................................................................92
Prison Division...............................................................................................................................................93
Adult Community and Social Care Inclusion Division...................................................................................93
Monitoring and Reporting............................................................................................................................96
Performance Report – Monthly....................................................................................................................96
FOCUS ON: Quality Dashboard.....................................................................................................................97
Patient Led Assessment of the Care Environment (PLACE) Results..............................................................99
Dignity Walks ..............................................................................................................................................101
HealthWatch...............................................................................................................................................102
Appendix A: Statements from External Bodies...........................................................................................103
Stakeholders................................................................................................................................................103
Keeping Stakeholders Informed..................................................................................................................103
Manchester Clinical Commissioning Groups – Joint Commissioning Team................................................104
HealthWatch...............................................................................................................................................106
Statement from Manchester City Council Health Scrutiny Committee......................................................107
Changes made following the submission of the Quality Account to stakeholders.....................................109
4
Appendix B – Statement of Directors Responsibilities in Respect of the Quality Account.........................110
Appendix C – Commissioning for Quality and Innovation Framework (CQUIN).........................................111
2014/2015 CQUIN’s....................................................................................................................................111
2015/16 CQUIN’s........................................................................................................................................112
Appendix D – Local Clinical Audits..............................................................................................................113
Summary Report of Audit Projects (including reasons for non-completion).............................................114
Summary of Completed CAP Audits...........................................................................................................115
Withdrawn from Clinical Audit Programme 2014/2015.............................................................................116
Summary of Competed and Approved CAP Reports 2014/15 including Actions and Assurance Levels ...118
Summary of Local Audit Projects 2014/2015 including Actions and Assurance Levels..............................126
Jargon Buster .............................................................................................................................................140
How to Contact Us......................................................................................................................................144
Helping us to help you................................................................................................................................145
5
Introduction to the Quality Account
What is a Quality Account?
The Quality Account demonstrates our strong commitment to monitoring and improving the quality
of our services across Manchester. It offers an opportunity to reflect on our work in the previous
year and describes our plans and priorities for the coming twelve months. The Quality Account
enables stakeholders to hold us to account whilst working with us in delivering the best quality of
care that we can across the Manchester system. The information we present within this document
allows you to see how we use the data about the organisation to inform our learning and develop
our quality and approaches to risk in the future.
What is Quality
The Department of Health defines quality as providing safe services, being effective in how we
provide those services and ensuring the experience of our service users is to the standard they
expect. We agree with this definition and our aim is make sure quality is at the heart of everything
we do as an organisation. We believe all our services should need to be quality focussed and that
staff should be open and honest in communicating any difficulties and challenges they encounter in
delivering the best possible service. We are working closely with all our stakeholders to further
develop a culture that seeks to exceed expectations of quality. Like all NHS organisations, there are
occasions when things go wrong and we are committed to our duty of candour, to openness and
transparency and to learning from incidents to improve how we care for people in the future.
Quality Improvement Strategy
We have been working with four pillars of Quality since 2010: Regulation, Safety, Experience and
Effectiveness. We have worked to align our governance and assurance processes with these pillars
and it has allowed us to maximise improvements, reporting, partnerships and opportunities for
developing our approaches to quality. In line with the national quality agenda, we continue to drive
improvement through the pillars. We will work closely with NHS England, the Department of Health,
the Trust Development Authority, the Care Quality Commission and our local commissioners to build
upon our approaches and refine our quality systems further.
During 2014/2015, the Trust has continued to work in close partnership with the three Manchester
Clinical Commissioning Groups (CCGs) and Manchester City Council to improve and further develop
the quality of care provided to our service users and their families. We have also worked with
Specialist Commissioners to deliver mother and baby and prison healthcare services. In December
2014 we were successful in our bid to become the lead provider for healthcare services into both
Her Majesty’s Prison Manchester and Her Majesty’s Prison Buckley Hall. The Trust has been the lead
provider of healthcare for HMP Manchester since April 2011 and recently received a positive report
from the Care Quality Commission for its prison healthcare services. The Trust’s bid to provide
similar services at HMP Buckley Hall is new business and an extension to the range of specialist skills
and experience offered by the Trust.
Our Quality Improvement Strategy for 2013 – 2016 is available on our website. This document has
been updated and now runs from 2015 to 2018. The revised Quality Improvement Strategy was
approved by the Trust’s Quality Board during its February 2015 meeting. It identifies three priorities
for the Trust with specific projects listed against each of the priorities. These long-term quality
priorities will be monitored and embedded within our annual quality account. They are:
http://nww.mhsc.nhs.uk/downloads/policies/corporate%20services/Draft%20Quality%20Improvem
ent%20Strategy%202015-2018.pdf
More people will recover from mental health problems and feel supported in
achieving a good quality of life
People will feel safe when accessing our services with fewer people suffering
avoidable harm
People will have a positive experience of their care and support
Trust Assurance Framework
The Trust Board Assurance and Escalation Framework underpin our approach to quality governance
and improvement. We will continue to review our Framework to ensure we have got things right and
keep improving our awareness of risk, improvements and supporting the operational teams to
deliver the highest quality of care to our service users.
Throughout this Quality Account, we have tried to state which Committee is responsible for each of
our Quality Improvement initiatives to allow you to gain an understanding of our governance
processes relating to quality and safety. The Quality Board oversees our approach to quality
monitoring through direct reports from these Committees, as well as reporting to the Trust Board.
The Quality Board is chaired by a Non-Executive Director who takes a lead on quality. Our
operational teams also dedicate time to address quality and governance issues within local
reporting, and representation at the Integrated Risk Management and Clinical Governance
Committee and the Operational Management Team meeting as well as other committees.
7
Trust Assurance Framework1
1
Please refer to the jargon buster on Page136 of this quality account for explanations of acronyms used
8
Trust Values
Information contained within this Quality Account aims to comply with our Trust values.
Truthfulness
•Maintaining an honest and open dialogue with staff and service users to ensure that we provide
best advice and integrated care solutions that respond to specific need
Respect
•Valuing people – service users, staff and partners – respecting their dignity and seeking to deliver
appropriate care and services tailored to the individual
Understanding
•An ongoing commitment to research and development; to continuously extend our knowledge and
skills, so that the latest teaching and practice are at the heart of our service development
Standards
•Setting the highest standards of professionalism, safety, security and confidentiality in all that we
do
Togetherness
•A commitment to partnership so that services can be fully integrated to reflect the needs of service
users, carers and communities.
We have been working with services to look at how we can use the Trust values in different practical
ways. Examples include the use of values-based questions in recruitment and selection; the
introduction of our staff charter; action plan guidance which is tested against values; and the
delivery of values-based training to teams.
Quality Improvement Framework with our Commissioners
Throughout the year, we worked closely with our Commissioners to agree, monitor and evaluate
quality improvements across our services. This allows Commissioners to identify their key focus
areas for quality and offers us an opportunity to review our internal approaches. In terms of quality
monitoring, our Commissioners completed site visits, attended high level investigation panels and
have dedicated quality meetings with the Executive Team, clinicians and service leads. The Trust
currently has three quality improvement schemes underway with Commissioners that are reported
on quarterly, with additional reports throughout the year as required. These include:
Commissioners Assurance Programme – Quality Improvement (CAP-QI)
The CAP-QI was originally developed in 2011 and was further refined throughout 2013/2014. Due to
progress made during the year, it was agreed that in 2014/15, the CAP-QI was to be monitored
through the monthly Quality and Performance meetings.
The main themes covered by the CAP-QI were:
• Patient safety
• Safeguarding
• Mental Health breaches
• Lengths of stay
• Mental Health admissions
• Agency staff.
9
Significant progress was made with the CAP-QI during 2014/15 and as a result, the residual issues
have been incorporated into the 2015/16 Quality Requirements programme. The CAP-QI therefore
ceased to exist from 1st April 2015.
Quality Requirements
The Quality Requirements are monitored as part of our ongoing contract monitoring meetings with
the CCGs. They cover a number of areas, including:
•
•
•
•
•
Mental Health
Mother & Baby
Prison
Social Care
Public Health
The 2014-15 contracts included over 40 targets and thresholds which must be met. Failure to meet
the required thresholds could result the need to produce remedial action plans to address any gaps,
or in some cases, in some form of financial penalty. The following table sets out the national and
locally agreed quality requirements that were included within the 2014/2015 contract.
For the 2014/15 contracts
National Operational Standards
National Quality Requirements
Locally determined Quality
Requirements
Total
Mental Health
Mother & Baby
2
5
22
10
0
0
29
10
10
Part 1
Statement on Quality from the Chief Executive
Welcome to Manchester Mental Health and Social Care Trust’s Quality Account. The Quality Account
provides us with an opportunity to report on our delivery of high quality, safe and effective services
throughout the last twelve months. It also allows us to set out our quality improvement plans for the
coming year.
We are fully committed to the continuous improvement of our service user experience and the
quality of care we deliver. We believe there is nothing more vital for any care provider than to meet
the needs of service users and to do that well. This year has seen many changes in the Trust,
including a number of significant transformational projects and changes in the leadership and
management of the organisation. We have been working with all our partners to monitor the
potential impacts of those changes and will continue to build upon that work in the coming year.
Manchester’s three CCGs initiated a strategic review of mental health services for the city when they
came into being in April 2013. This work was supported by Manchester City Council. The Trust
therefore halted its programme of work to become a Foundation Trust to ensure that services were
aligned to these new commissioning intentions and the long-term plans for a best-in-class mental
health system for Manchester capable of meeting existing and future need. This work has developed
during 2014/2015 with the Trust discussing the future organisational form with the CCGs and the
NHS Trust Development Authority (TDA).
This has resulted in a Trust Board decision to move to the point of appraising options for future
organisational form with the TDA, Manchester City Council and the three CCGs. A Sustainability
Steering Group has been established to oversee this process. Our common purpose is to explore
how best to develop mental health services across Greater Manchester and deliver the vision
outlined in the commissioning intentions developed to date. This is an exciting opportunity as the
‘Devolution Manchester’ gathers pace and becomes a reality.
We have worked in an open and transparent way with our commissioners throughout the year
across a number of forums, including monthly Quality and Performance meetings and a Quality
Surveillance Group (QSG) and risk summit process with NHS England that undertook a 360° review of
the quality of care we provide. The risk summit is a forum which consists of representatives from
NHS England, the Care Quality Commission (CQC), the TDA, Commissioners and Health Education
England, as well as the Deanery, the CCGs and Manchester City Council.
The issues that we have addressed as areas for immediate improvement as part of the risk summit
process focussed upon a small number of areas that included:
•
•
•
•
Safeguarding
Urgent care systems management
A shared data dashboard
Improving organisational learning
11
The urgent care system overview identified that a multi-organisational approach is needed and the
shared data dashboard is now being used routinely.
Additionally, we have established a regular quality assurance programme that considers both the
safeguarding investigation processes and the quality of these through a clinical case review audit.
We were pleased to receive a significant assurance opinion for the joint Safeguarding Audit in
November 2014. We have also implemented a more robust root cause analysis process to further
improve and embed organisational learning.
In the last twelve months, the Trust has focussed upon the people that contribute to and use our
services to inform our pursuit of quality. The Trust Board recognises that people are our most
precious resource and will continue to look at new ways of involving service users, staff and carers in
helping us to shape services. Our patient feedback and patient digital stories are of great importance
to the Trust Board and decision makers. The stories impact directly upon our approaches to care and
have been included in this quality account to demonstrate this commitment.
A number of our quality achievements through the year are highlighted within this report and we
hope all our stakeholders take as much pride as we do in our successes. This year has seen us
continue to achieve high performance with the NHS Safety Thermometer, and we continued to
receive high scores in a number of areas within the national patient survey of Community Mental
Health Services.
We have also seen areas of quality improvements highlighted, including through the visits
completed by the CQC in 2014. The Mental Health Act administration by the Trust was found to be
good, especially as the Trust cares for patients with a high acuity level and with a high number of
people detained under the Mental Health Act. The Trust has been visited by the Chief Inspector of
Hospitals CQC team in March 2015. A full review of Trust services was undertaken and the outcome
of the visit is expected in May 2015.
Our 2014 NHS staff survey identifies challenges and highlights the need for continuous
improvement. The Trust acknowledges that improvement is required. We are in the lowest 20% of
Trusts nationally and this is under close scrutiny by the Board. The results have been presented to
each division to identify their key areas to address.
In January 2014, Professor Stephen Singleton OBE provided the Trust Board with a diagnostic
overview of our areas of strength and weakness, with particular reference to the ways in which we
approach our improvement work, our culture and issues around staff morale. Professor Singleton
helped us to develop a staff-led, 90-day plan which demonstrated that the Board is not only listening
and hearing, but also responding to issues and concerns raised by staff in a spirit of greater openness
and cooperation.
The 90 day plan was incorporated into the national Listening into Action framework (LiA). LiA is an
evidence-based approach which has already supported culture change across 30 NHS organisations
nationally, and is expected to support improvements in staff morale. LiA commenced prior to the
12
staff survey being undertaken and it is considered that this was too early to have an effect on the
outcome of the staff survey for 2014/2015. It is expected that these improvements will become
evident in 2015/2016.
During 2014/2015, we continued to align our clinical work with the recommendations in the Francis
Report. Throughout the year, we have continued our work to embed Compassion in Practice and
ensure that the ‘Six C’s’ are role modelled at all levels. Heads of Professions have worked with teams
across the Trust to develop a multi-professional vision about how we, as a Trust, embed compassion
in every element of practice. Our engagement work to date has led to the identification of key
statements and intentions as well as individual professional pledges aligned to the Six C’s.
There have been other challenges for the Trust this year, too. Serious incidents requiring
investigation are a priority for the Trust. Pages 70 to 73 of this Quality Account set out our reporting
and governance arrangements for processing and learning from serious incidents. This is also a
specified quality improvement priority for 2015/2016, as set out on page 25 of this quality account.
You will be aware that delivering NHS urgent care services is becoming increasingly difficult. This
year we are very disappointed to report that there have been 4 patients who have waited for more
than 12 hours for admission to a mental health bed after it was identified that they needed specialist
care and treatment. These delays were not the best experience that someone in our care should
have. As a result we are working with the other providers from across the city, the CCGs, the
ambulance service and NHS England to unpick the systematic issues that affect the local and regional
mental health care system.
In response to patient safety concerns and staffing pressures in later Life In patient areas, a decision
was made by the Executive Team of the Trust to close Cedar Ward and to reconfigure the remaining
two Later Life Wards, (Cavendish and Maple). The Later Life wards had previously adopted an
Advanced Care model which had allowed admission of up to 15 younger people with physical health
needs to the wards. Over time this had resulted in some serious incidents involving service users
and the model was not meeting the needs of either younger or older people on the wards.
Cedar Ward had the highest rate of staff turnover in the Trust during 2014-15 with many staff
reporting that they found the mix of service user needs on the ward difficult to manage. In view of
the safety concerns the closure of Cedar Ward had to progress quickly without the usual full
consultation processes, but close engagement of service users and carers and briefings with Later
Life staff, including Later Life Consultants took place, along with engagement with and support from
the Joint Unions.
The closure of Cedar Ward was risk assessed and an individual plan for all service users and carers
was implemented ensuring that service users who transferred to Cavendish Ward did so safely and
effectively. The two remaining wards are each operating with 20 beds and the qualified staff from
Cedar Ward have all been retained on these two wards to ensure that safer staffing levels are in
place and that the previous overreliance on agency staffing ceases. Cedar Ward will be reconfigured
following environmental works as an Adults of Working Age Ward which will substantially assist with
current bed pressures in Manchester.
13
The Executive Team also supported a number of plans to improve length of stay on the wards and
during March 2015 the Later Life wards achieved a shorter length of stay than at any time over the
year 2014-15. Further changes to assist with reducing the length of time which service users need to
stay in hospital will be assisted by the appointment of two new social worker posts for the Later Life
wards and additional community developments will help to support service users in the community,
preventing avoidable hospital admissions. The Later Life Community and Day Services will be
modernised and redesigned over 2015-16 to enable improvements in services for older people and
their carers to be implemented. This work has already commenced with the training of Day Services
nurses in Psychological Therapies, improving the access of older people to evidence based therapy.
As many of you will be aware, I joined the Trust in December 2012 and have been very impressed
with the dedication and commitment of staff to patient care and making our services better for
everyone in Manchester. I have visited services across the Trust which has helped me to gain an
understanding of what is important to our stakeholders and also helped me to consider our priorities
during 2014/15. I have worked with other members of the Trust Board to develop our plans for the
future and ensure we focus upon what is important for our patients.
My personal objective is to make sure that everyone employed by the organisation feels confident
and capable in making change and improving services. During 2015/16, our focus will be on how we
work as a team across the organisation. Leadership at all levels will be required to meet the
challenges and changes we face together.
Feedback and patient experience data will be vital in shaping our services in the coming years and
we will be looking at improving our communications with patients, families and staff to make sure
everyone has a voice in the Trust. Your comments, suggestions and complaints will be our key tool
for learning and measuring our success. There are also several projects planned to increase the ways
we will report to you throughout the year on our Quality Account and the priorities within it.
We were delighted that our patient experience and feedback systems were again shortlisted for a
number of national awards in 2014/2015. Our service users and carers continue to work with us so
that the Trust can learn from their experiences and continually improve the quality of care and
treatment that we provide. The majority of our service users continue to provide positive feedback
on the experience of their care. This is set out in detail on pages 79 - 80 of this Quality Account.
We are pleased to report that the improved patient flow within the Trust has enabled the reduction
of our ‘out of area placements’. This has resulted in an improved patient experience by providing
local care to more people.
Our 2014/15 quality priorities were selected to demonstrate our confidence in continuing
improvement and our ability to be ambitious in delivering the highest quality of services. We sought
out areas that were falling short of the standards we set ourselves, and worked together to take
action to improve. We also looked at additional ways to benchmark ourselves against other
providers and challenge assumptions. This year’s Quality Account includes several examples of this,
including the section on our mandated indicators. We believe this offers additional opportunities for
our stakeholders to review our performance against a national platform and hold us to account.
14
As a Board, we applaud the staff for caring for patients in the way that they do. We are committed
to working with staff to improve their experience at work. We are neither complacent nor
unrealistic about the challenges staff face every day in delivering safe, sustainable and high quality
services in all areas of the Trust’s work. We know there are areas that we need to work on and we
believe any successful organisation has to constantly evolve and adapt as part of a process of
continuous improvement. This is something that we need to do together. I will also be looking to
our key partners to enable a truly systemic partnership approach in supporting staff to do – and to
be – the very best they can.
I am pleased to offer assurance that, to the best of my knowledge, the information in this document
is accurate and up to date. On behalf of the Trust Board, I hope that this document provides clear
evidence of our continued pursuit of improving quality, accountability and safety for all our
stakeholders, but most importantly, those who need and use our services.
Michele Moran
Chief Executive
15
Patient Stories
Patient stories were first introduced at the beginning of 2012. They are shown at the beginning of
each Trust Board meeting, and used in a range of different ways to raise awareness around the
impact of Trust services as experienced by our service users and their families. The programme was
developed to improve compassion, dignity and respect across all of our services. The stories ensure
that Board members are directly informed of specific patient and carer experiences, including what
has worked well and what has not gone so well and, importantly, ensures that Board members are
able to appreciate the impact that these experiences have had at the time on the individual story
teller. The stories are delivered as three to four minute digital vignettes, with a voice-over from the
service user written in their own words. These stories provide a reminder that all Trust Board
discussions link directly to patient care and treatment.
Anne’s Story – ‘Recovering’
Anne’s story was shown at our August 2014 Trust Board meeting. This story highlights the well
known difficulties that are often experienced by carers in Manchester, but also acknowledges the
improvements that have been made to community mental health services over the years and the
importance of stability and consistent care to support recovery goals.
Anne’s story is about her son Paul, who was first referred into mental health services by his GP in
1995, following a series of concerns about his mental health and well being. Back then, Paul’s care
was provided within the community, but it pre-dated the establishment of community mental health
teams. Anne and Paul were not happy with how staff initially responded; Paul was given a lot of
medications which appeared to have adverse effects.
Anne begins her story by talking about how her son Paul was first diagnosed with schizophrenia. The
seriousness of his condition became clear to Anne following an inpatient admission at Park House
when the nurse explained some of the potential risks that Paul was facing, which included suicide.
Anne describes this in her story as being one of the worst days in her life.
Anne continues her story by reflecting on how much mental health care, and support for carers has
improved over the past 20 years. She felt that her sons care at the time was patchy and inconsistent,
and that she as a carer wasn’t respected or consulted as much as she could have been. She
describes a lack of support and a lack of respite, highlighting that this left her feeling very alone.
Things started to improve for Anne and her son Paul when the CMHT’s were formed. Anne explains
how Paul’s care has been consistently provided by the same team (the North West Area CMHT), who
now know both Paul and Anne very well. Anne finds them to be very respectful, and that they know
when a more prompt intervention is required. Anne also speaks about the invaluable role of local
carer groups in offering emotional and practical support to people in caring roles.
Anne talks about Paul’s medications and the support that he receives around this to maintain a good
quality of life, and enjoy the things that he likes to do. Again, a successful factor in this success has
been the staff at the Clozapine clinic, who know both Paul and Anne very well, and are able to
regularly review Paul’s medications and health through close monitoring.
16
The Trust has developed a process and protocol to redefine the role of community mental health
teams. Community Mental Health Teams (CMHTs) have been pivotal in the delivery of community
services to psychiatric patients for several decades. The protocol sets out some guiding principles of
access, inclusion and exclusion criteria, the role of CMHTS, how discharge of patients should be
determined, the interdependence of CMHTs and key partners such as social services and general
practitioners, as well as establishing how CMHTs should relate to other Trust services, mainly Home
Treatment Teams, Assertive Outreach Teams (AOT), the Early Intervention Service (EIS) and
inpatients. It is hoped that the protocol will further support teams to provide continual high quality
care and treatment, providing effective and consistent care which benefits people like Anne and her
son Paul.
The Trust has agreed a Greater Manchester (GM) CQUIN around clozapine, which was currently
included in the 2014/2015 CQUIN programme. As part of this CQUIN the Trust was required to
agree common GM wide work such as standards, processes, training, working with CCGs and GPs to
ensure information is robustly recorded on patient record systems. The Trust was also required to
share 12 months of Serious and Untoward Incident (SUI) review data for clozapine, and to regularly
update on specific actions being undertaken as a result of identified learning.
Paul still struggles with aspects of his day to day life, but continues to receive a very good level of
support from the different mental health professional involved in his care. Despite these challenges,
Paul was able to graduate from University and is currently pursuing a career in horticulture.
Anne believes that the Cognitive Behavioural Therapy that Paul receives is making a significant
difference to his life, and that the entire care team continue to be very respectful to Anne in her role
as a carer.
In preparing her story for Trust Board, Anne wished to communicate two clear messages to all trust
Board members. These were:
•
•
Always listen and take note to what carers tell us
Continuity of care is very important too service users and their families.
Anne’s story can be seen by accessing the following link:
http://library.mhsc.nhs.uk/SiteDirectory/evidence/201415/%27Recovering%27%20%20digital%20patient%20(carer)%20story.wmv
Terry’s Story – ‘Stains’
Terry’s story was shown at our Trust Board in February 2015. His powerful story highlights issues
relating to sexual abuse in childhood and the subsequent impact that this can have upon mental
health and wellbeing when not adequately addressed by health professionals.
In his story, Terry reflects back on his childhood, which he recalls in the main as being happy and
care free. He then goes on however to describe how this was bought to an abrupt end when aged
17
around seven years old both he and his brother were subject to a sustained period of rape and
sexual abuse by a family member.
Terry talks about the shame and the anger that he felt at the time, and how this extended into in
adulthood. He also talks about how he developed a lack of trust, and that he pushed those closest to
him away including the people who were trying to help him through his difficulties. Terry then
reflects on how these difficulties ultimately led to drug and alcohol abuse.
Terry’s story goes on to describe a period where he became settled in his life. He talks about his
wife and two children and his family home. He continues to reflect though on how he felt like a
fraud during this time and that he wasn’t good enough for the life he was leading. He eventually
pushed his family away and shortly afterwards found himself homeless in London and addicted to
crack cocaine.
Terry eventually made his way back home with some help from his friends but soon became
homeless again eventually living in a drug den with crack dealers in Manchester. He became
addicted to heroin and was eventually offered detox support. Terry describes how he came to suffer
some serious physical injuries following a fall, which resulted in him being hospitalised for over a
year. He reflects on the therapy he received from his psychiatrist, who helped him to get to the root
of his problems. Terry describes how he eventually went to the Police to report the abuse. He
highlights how he had decided to live again, and reflects on how the shame was never his to carry in
the first place.
Terry concludes his story by reflecting on how lucky he has been with the support he has received.
He describes how he has had a good community psychiatric nurse, a good psychiatrist and good
support from the Trust’s Recovery and Connect services. He describes how these individuals and
services have cared about him and how they have helped him to regain his Trust. Terry brings his
story to an end by talking about how he is much happier now, and has a positive and healthy outlook
on life.
As well as services and support provided by the Trust around substance misuse, there is a range of
more specialist services where our staff can signpost or refer service users who are experiencing
difficulties with drug use. These include RISE Manchester which is a confidential adult drug
treatment service, delivered by three charities working together to provide comprehensive,
recovery-focused treatment for any Manchester resident with substance misuse problems. This is an
anonymous service for people who are using drugs and want to reduce the risks and potential harms
of their drug use. The service provides needle exchange but will also support people in other aspects
of harm reduction around drugs.
An Intake Service, provided by Addiction Dependency Solutions (ADS), offers an easily accessible
engagement and assessment service for adults enabling them to access appropriate recoveryfocused treatment and support. ADS also welcome individuals who are concerned about a relative or
friend's drug use. There is also a Clinical Service, managed by CRI, which provides an integrated
treatment service for adults enabling them to stabilize and reduce their drug use.
18
A Recovery Service, managed by Lifeline, offers interventions to enable adults to become drug free
or recover from their addiction to drugs. This includes promoting and supporting reintegration
including housing and employment advice and support.
The Brian Hore Unit offers abstinence-based treatment for people with alcohol problems, including
those with dual diagnosis (people with both substance abuse and mental health issues), who live in
Manchester. Emphasis is placed on individual and group therapy and the unit aims to provide
patients with the knowledge and skills they need to live a good quality of life without alcohol or illicit
substances. Patients are expected to attend sober and not be under the influence of illicit drugs, so
that the environment is supportive and conducive to change. Patients are encouraged to take
responsibility for their own recovery and use their experience to help other patients in groups.
All clinical staff at the Trust are required to undertake mandatory training around dual diagnosis
every two years, and for specific staff there is a mandatory one day workshop where issues are
explored in much fuller detail. The Trust also provides a Dual Diagnosis service, which manages the
treatment of service users who have a history of substance misuse and concurrent mental health
problems. This is a citywide service with a clinic at each in-patient site in the Trust. The Dual
Diagnosis Team provides services, offers advice and intervention and provides guidance to
practitioners, service users and carers involved with a range of health and social care agencies.
The Trust provides a Homeless service which is a small specialist community based team who work
with people who are homeless where there are concerns over their mental health. The service,
which has clinics and liaison workers at hostels provides initial mental health assessments and follow
up care if required.
Terry still receives support from Trust services who are helping him to pursue a wide range of
creative goals and interests around areas such as digital media and the performing arts. He is also
attending a mindfulness course and engages in peer support opportunities with other like minded
service users.
Terry’s story can be seen by accessing the following link:
http://library.mhsc.nhs.uk/SiteDirectory/evidence/201415/%27Stains%27%20%20digital%20patient%20story.wmv
19
A Brief Look-Back and Forward
During 2014-15, the Trust has continued to deliver an extensive range of mental health, Health and
Wellbeing and prison healthcare services to approximately 13,000 people, plus the wider
constituency of public health functions for the residents of the City of Manchester.
The Trust’s service users have once again demonstrated their recognition of the quality and
responsiveness of Trust services and the professionalism, dedication and determination of staff
which is evident in our service improvements, research, the provision of high quality services and
nominations for national awards.
The Trust has maintained high performance in the majority of the required performance targets and
standards, and where it has fallen below expectations, has implemented remedial actions to deliver
improvements.
As part of the wider system of health and social care, the Trust has continued to contribute to the
development of the citywide initiatives and in particular the strategic “Living Longer, Living Better”
integration programme for Manchester.
The Trust has demonstrated its effectiveness in a number of areas during the past year and is
ensuring that for the next two years, it has effective and measurable plans that will address its key
challenges.
We are committed to maintaining effective relationships with all our partners, including our
commissioners, and to working alongside our Local Authority to provide high quality health and
social care services which meet the needs of our local communities. In November 2014, the
Chancellor of the Exchequer and leaders of the Greater Manchester Combined Authority signed a
devolution agreement. The agreement will result in devolving new powers and responsibilities to
Greater Manchester, and Greater Manchester adopting a directly elected Mayor for the city-region.
As ‘Devolution Manchester’ gathers pace this commitment will become increasingly important.
The CCGs’ and City Council’s future commissioning intentions, as well as those of our specialist
commissioners dominated Trust corporate activity during 2014-15 and will continue into 2015-16 in
terms of new service models. Significant clinical time will also be required in order to respond fully
to these commissioning intentions for a new system of mental health services across the city.
20
Part 2
Priorities for Improving Quality [1]
Performance against our 2014/2015 Priorities – Summary
Progress Symbols:
Priority and Quality
Pillar
Priority 1: Staff
Morale and
Engagement
Clinical Effectiveness
Priority 2: Learning
Lessons from Root
Cause Analysis
Patient Safety
[1]
√ - Achieved
♦ - Partially Achieved
+ - Not Achieved
Progress
Project
Status
Committee
Introduction and implementation of
programme of communications and
engagement in response to Professor
Singleton’s report.
Achieved
Workforce and Organisational
Development Committee
√
Introduction and implementation of Friends
and Family Test for staff.
Achieved
Workforce and Organisational
Development Committee
√
Implement a range of specific measures to
improve staff engagement & support.
Achieved
Workforce and Organisational
Development Committee
√
Review of root cause analysis processes to
ensure thorough understanding of the causes
of Serious Incidents Requiring Investigation.
Achieved
Quality Board
√
Implementation of a new RCA Process.
Achieved
Quality Board
√
Identification by teams and heads of service to
provide a focus for quality improvement.
Partially Achieved
Quality Board
♦
Further information providing specific details on progress against the priorities we set out in our 2014-2015 Quality Account is available on pages 57-63
21
Priority 3: Safe
Staffing
Patient Safety
To ensure the right skills are in the right place
at the right time is a key component of the
Trust’s clinical strategy and is a direct response
to the implementation of the national nursing
strategy and the 6 C’s.
Achieved
Trust Board
√
To review workforce requirements and to
appropriately staff in-patient areas in line with
this review.
Partially Achieved
Trust Board
♦
Staff to present their experiences of care so
that the Trust Board understands the care
provided to patients.
Achieved
Quality Board
√
The Quality Improvement Priorities for this year are new initiatives; therefore performance data for previous years is not available. Quality
improvement is a continuous process within the Trust and each of the above listed initiatives will continue to be delivered during 2015/16.
22
Priorities for 2015-2016
In developing the Trust priorities for 2015-2016, we have looked at the local feedback, engagement,
reports and learning from 2014-2015 as well as the national quality agenda. As you will be aware,
the final report into the care at Mid-Staffordshire NHS Foundation Trust was published in 2013. This
report, lead by Sir Robert Francis QC, described the events at Mid-Staffordshire Hospital and called
for a fundamental change to the way we approach quality and care. We believe our priorities for the
coming year continue to demonstrate our commitment and pledge to learn from local incidents, but
also reflect the national findings included in the Francis report.
In determining local priorities and projects, we have undertaken a review of the governance data
and also performed consultation exercises which have included the views of the patient and the
public, stakeholders in the community and voluntary sector and staff. Throughout the year we have
spoken directly with service users and carers who have provided us with suggestions in terms of
quality areas of focus for 2015/2016. These discussions have taken place during meetings of the
Trust’s Service User and Carer Forum.
You will notice that some of our ongoing quality projects were also referred to in our 2014-15
Quality Account. We believe these projects remain relevant but will also benefit from ongoing
monitoring and improvements as a result of learning in the previous year. This should encourage
staff to continuously improve and also to use learning to sustain improvements.
Our priorities are set out against the top three priorities within our Quality Improvement Strategy,
We have selected priorities that cover all of our mental health, community health and prison
services, although some will only affect specific areas of the Trust. The projects are then linked to
the quality pillars to improve understanding of our aims and identify who will be responsible for
delivering improvement and reporting progress.
We have also agreed that in 2015-16 progress against at least one of our priorities and associated
indicators will be reported to our Service User and Carer Forum, which meets monthly. We believe
that this is an important demonstration of our commitment to being open and accountable,
providing a key external stakeholder group with the opportunity to monitor and challenge our
quality approaches. Details of the work relating to this will be included in our next Quality Account.
When selecting our projects and priorities we look at national, regional and local factors to inform
our choices. The detail of this will be more evident in documents such as our Clinical Audit
Programme for the coming year or in the work of specifically established work groups looking at
performance following any change in service.
In 2015-16, we will develop the Quality Improvement page on our internet site to provide additional
information on some of the projects we are currently undertaking.
23
2015/16 - Priority 1 – Improving patient experience through improved staff satisfaction, staff morale and engagement.
Quality Pillar: Clinical Effectiveness and patient experience
This priority will be led be lead by our Director of Workforce and Organisational Development.
Our 2014 NHS staff survey demonstrates that improvement is required. The Trust is in the lowest 20% of Trusts nationally for Staff Engagement and this is
high on the agenda of the Trust Board. The results have been presented to the Trust Board, the Senior Management Board and the Leadership Forum in
order to identify key actions that are required to improve the levels of staff morale and engagement across the Trust.
The Listening into Action framework which the Trust is utilising has already helped more than 40 NHS organisations nationwide. This is an evidence-based
approach which supports culture change. Described as ‘inverting the pyramid’, its objective is to empower staff at all levels, particularly those working in
frontline services. This quality priority will support the Trust in its ongoing work to foster a culture of quality, high performance, continuous service
improvement and excellence by supporting staff to meet both their own personal standards of care and the aims and objectives of the organisation.
The quality priority provides a framework to facilitate ongoing change through improvements in staff engagement and in supporting staff to deliver high
quality patient care which maximises opportunities for recovery and enhances the patient experience. The NHS Staff Friends and Family Test (SFFT) was
introduced in April 2014. It is based on evidence from research and uses data from the Staff Survey which demonstrates clear links between staff morale
and patient experience, the positive impact of staff engagement on patient satisfaction and other measures. It shows close association between high levels
of staff advocacy (willingness to recommend) and positive patient experience. It also builds on recommendations from the Francis Report that staff views
could provide an important test of quality of care and from experience with the Patient Friends and Family Test. The SFFT has great potential to assist the
NHS to promote better staff experience, greater patient confidence and better staff engagement.
The quality priority will aim to empower staff and increase staff satisfaction using the work undertaken via Listening into Action, the Staff Survey and the
staff Friends and Family Test all of which will be managed under the umbrella of the Organisational Development strategy and plan to improve the
experience of staff leading to a more positive patient experience.
24
Quality
Improvement
Project
Seek ways to
improve staff
morale and
engagement, to
improve the staff
survey scores
achieved in 2015.
Rationale for selection and expected
outcome
The quality of care that patients receive
depends first and foremost on the skill and
dedication of NHS staff. Engaged staff are
more likely to have the emotional resources
to show empathy and compassion, despite
the pressures they work under. Individuals
who are committed to their organisations
and involved in their roles are more likely to
bring their heart and soul to work, take the
initiative, ‘go the extra mile’ and collaborate
effectively with others. (Kings Fund, Staff
Engagement 2015)
There is a recognised correlation between
high levels of staff engagement and patient
related indicators such as mortality levels,
positive CQC inspections and good financial
governance.
LiA is a nationally recognised systematic,
compelling and practical response to working
with frontline staff to work on sustainable
improvements on the quality and safety of
care and the patient experience. LiA is a way
of working with staff in a very different way,
bringing them to the forefront and
supporting them to deliver change. The
process is based on a structured, outcomedriven, evidence-based ‘route map’ which
links the engagement effort to ‘hotspots’,
opportunities and priorities for the Trust in
terms of patient care and being a ‘great place
to work’.
Target
•
•
•
•
•
•
•
•
•
How we will measure our success
Monitoring
Establish a further cohort of
pioneering teams to drive
forward LiA initiatives during
2015/2016
Grow the role of LiA
influencers in order to get
breadth to the impact of LiA
beyond those directly involved
in schemes
Engage with staff and identify
a minimum of 4 ‘people
schemes’ during 2015/2016
Engage with other
organisations to learn from the
best in achieving grass roots
led change
Undertake a base line
assessment against the Kings
Fund’s Building Blocks for Staff
Engagement
Refresh the OD strategy
Undertake the LiA pulse check
across the organisation and
achieve an improved response
rate
Continued delivery of the Staff
FFT programme
Ensure an increase in the
overall staff satisfaction scores
within the 2015/2016 national
NHS staff survey
•
•
•
•
•
•
•
•
Monitoring will take place in
a range of ways and via a
number of different
mechanisms including:
LiA influencer meetings
Pass it on events
The Trust Leadership Forum
and Senior Management
Board
The Operational
Management Team
The 2015/2016 NHS staff
survey report
Staff FFT feedback
Internal ‘temperature
checks’ undertaken during
the year
Reporting
Workforce
Organisational
Development
Committee and
Board
and
Trust
25
Implement a
range of specific
measures to
improve staff
engagement &
support
•
Further refine the Personal Review
Process, to ensure high quality reviews
are completed and accuracy of
reporting figures.
•
Increased completion rate
for Personal Reviews and
higher levels of reported
satisfaction with the quality
of Personal Reviews in the
2015 Staff Survey
•
Maximise use of the Centralised
Training Budget and ensure equity of
access to increase access to continued
professional development
•
•
Focus on health, wellbeing and safety
of staff through a more proactive
occupational health / staff support
provision based on prevention and
early intervention
•
Develop appropriate SLAs
for occupational health
and staff support service
provision including
measures to address
stress related absence
•
Ensure fairness and equity for all the
workforce
•
Embed the role of equality
and diversity champions
within teams and divisions
•
Monthly Combined Performance
Report/Quarterly Workforce
Report to Board
•
Fortnightly Reports to line
managers
•
2015 staff survey
Workforce and
Organisational
Development
Committee
Equitable distribution of
funding to different staff
groups and divisions
26
2015/16 - Priority 2 – Organisational improvements in patient safety through learning lessons from Root Cause Analysis.
Quality Pillar: Patient Safety
This priority will be led by our Chief Nurse and Director of Quality Assurance.
Organisations with a culture of high reporting are more likely to have developed a strong reporting and learning culture. It is important that we report
incidents and near misses. This information is used in a number of ways to improve patient safety. Reporting in this way not only helps us to learn - it can
help us to understand if we need to change our processes to improve patient safety and supports the work that we do to identify where we need to focus
resources, such as training and finances.
The quality priority will support the Trust to improve how we embed any learning which is identified from when things go wrong. We will aim to achieve
this be developing and introducing a dynamic process of staff engagement post incident, which will be led by our Head of Patient Safety in partnership with
the Heads of Profession
Quality
Improvement
Project
Making services
safer
Rationale for selection and expected outcome
Target
The Trust will ensure that when key learning is identified as part
of the Serious Incidents Requiring Investigation (SIRI) process
there are suitable mechanisms in place for staff to engage in
practice change as part of a future preventative strategy.
How we will measure our success
Monitoring
Reporting
•
All clinical leads and
managerial leads to attend
High Level Incident Panel
(HLIP) meetings.
•
Attendance
monitoring
through minutes
of HLIP
Integrated
Risk
Management and
Clinical Governance
Committee
and
Trust Board
•
Clinical and managerial leads
to take local leadership to a
new level in order to
contribute to the embedding
of learning and culture
change
•
Clinical leaders
and managers to
demonstrate local
improvements in
embedding
learning through
the reduction of
themes that are
currently
repetitive
Integrated
Risk
Management and
Clinical Governance
Committee
and
Trust Board
27
Identifying
thematic learning
to make services
safer
Embedding
learning to drive
forward
improvements
The development of a clinically led NHS creates the need for
professional leadership of the changes required to address the
themes and trends identified in SIRIs.
•
The Heads of Profession will support the Head of Patient Safety
who will lead on the implementation actions required in order to
achieve this.
Any learning or themes as a result of incidents will be distributed
to a wider audience across the Trust in order to ensure that
learning is embedded within the divisions and that it is used to
drive forward improvements in safety and quality.
Audit projects identified as
part of HLIP process to
identify ways of
demonstrating practice
change as appropriate.
• Audits available
•
Production of a clear and
robust implementation plan
with detailed actions to
address repeating themes
and trends
• Progress reports
delivered within
the assurance
framework
•
Post HLIP Lessons learned
summaries for all staff to be
produced detailing themes,
lessons and necessary
changes to practice.
•
Lessons learned
summaries
available
•
Personal change
stories from
individual staff and
teams
•
All staff to contribute to
practice change, both
personally and within their
teams.
• The Heads of
Profession report
Integrated Risk
Management and
Clinical Governance
Committee and
Trust Board
Integrated
Risk
Management and
Clinical Governance
Committee
and
Trust Board
28
2015/16 - Priority 3 – Ensuring that we have the right skills, in the right place at the right time.
Quality Pillar: Clinical Effectiveness
This priority will be led be led by our Chief Nurse and Director of Quality Assurance.
Every one of our service users should feel assured that robust checks are in place to ensure their safety, protection and overall care experience at all times.
The development and piloting of a sophisticated process of revalidation at the Trust will ensure that every nurse remains fit to practice to the highest
standards, so that our service users continue receiving the highest levels of care in the safest possible environment.
This quality priority will support the trust to work towards ensuring improvements around achievement of mandatory training and personal development
reviews by all staff in order to enable the introduction of a sophisticated nurse revalidation system
Quality
Improvement
Project
Right staff, in the
right place at the
right time
Rationale for selection and expected outcome
This project has been identified in order to ensure that the Trust
continues to make certain that services are staffed to a sufficient
level in order to guarantee safe high quality patient care
•
To achieve safe staffing
requirements against the
staffing establishment
•
This will be monitored
via the E-rostering
system and the UNIFY
submission which
takes place on a
monthly basis
Professional Nurse
Forum,
Quality
Board and Trust
Board
Competent care
provision
For Trust staff to be sufficiently competent to deliver the care
that is needed by patients
•
To achieve all training,
personal development
review and clinical
supervision requirements
•
To monitor the
numbers of staff each
month who are
completing
mandatory training,
personal development
reviews, clinical
supervision and any
other training as
required.
Professional Nurse
Forum, Quality
Board and Trust
Board
Target
How we will measure our success
Monitoring
Reporting
29
Introducing a
robust nurse
revalidation
system
This project recognises the Trust’s commitment to the new code
of conduct for nurses, and will ensure that our staff will be
supported to achieve revalidation in line with the Nursing and
Midwifery Council (NMC) requirements.
•
All nurses achieve
revalidation in a timely
fashion
The Trust will ensure that the provider recommendations from
the ‘Shape of Caring’ report are robustly embedded within the
organisation.
•
The introduction of a
revised and robust
approach to
preceptorship
•
To identify a month
on month revalidation
target and to report
on any progress or
achievement against
the target
•
A Shape of Caring task
and finish group
Professional Nurse
Forum, Quality
Board and Trust
Board
30
NHS Litigation Authority
In March 2013, the Trust was assessed against Level 1 of the Risk Management Standards set by the
NHS Litigation Authority. The Trust achieved 50/50 score.
The Assessment at Level 1 looks at our procedural documents across 5 areas of risk:
•
•
•
•
•
Governance
Learning from experience
Competent and capable workforce
Safe environment
Specific areas for Mental Health and Learning Disability Trusts including clinical supervision,
clinical risk assessment, medicines management.
The assessor noted significant evidence of areas of good practice in the procedural document
relating to:
•
•
•
Care of the deteriorating patient
Policy on procedural document
Training and HR policy documents.
The Trust was allowed to share these documents with other Trusts as examples of good practice.
This assessment has been reported to the Trust’s Risk Committee.
From April 2014, the NHS Litigation Authority has stopped assessing Trusts and will not be producing
further updated Risk Management standards. However, the Trust is continuing to use the Risk
Management standards 2013/14 as a benchmark for developing future procedural documents.
31
Part 2 (B)
Statement of Assurance from the Trust Board
2014-15 Audit / Research / Data Quality Information
During 2014-15, Manchester Mental Health and Social Care Trust provided and/or sub-contracted six
relevant health services. Manchester Mental Health and Social Care Trust has reviewed all available
data on the quality of care in all six of these relevant health services.
The income generated by the relevant health services reviewed in 2014-15 represents 100% of the
total income generated from the provision of relevant health services by Manchester Mental Health
and Social Care Trust for 2014-15. The relevant health services provided by the Trust are in the
following six areas:
•
•
•
•
•
•
Adult Mental Health
Later Life Mental Health
In-Reach Prison Mental Health
Prison Health
Health and Wellbeing services
Perinatal Mental Health
The Trust sub-contracted one service to Manchester MIND for staff to our Assertive Outreach
Service during 2014-15. The Trust has reviewed all the data available to it on the quality of care in all
relevant health services. This includes the three dimensions of quality: patient safety; clinical
effectiveness; and patient experience. Reports relating to these areas are considered monthly by
our Quality Board.
National Clinical Audits and National Confidential Enquiries
National Clinical Audits
During 2014/15, there were 3 national clinical audits and zero national confidential enquiries that
covered the relevant health services that Manchester Mental Health and Social Care Trust provides.
The national clinical audits and national confidential enquiries that Manchester Mental Health and
Social Care Trust was eligible to participate in are as follows;
•
•
•
National Audit of Schizophrenia 2 - 2013/14 (which extended into 2014/2015)
POHM – UKQIP 6d: Assessment of the side effects of depot antipsychotics
POHM – UKQIP 9C: Antipsychotic Prescribing in People with Learning Difficulties
The Trust did not take part in the following national clinical audits for the reasons set out on page
33:
•
•
POHM – UKQIP 6d: Assessment of the side effects of depot antipsychotics
POHM – UKQIP 9C: Antipsychotic Prescribing in People with Learning Difficulties
32
During 2014/15 Manchester Mental Health and Social Care Trust participated in 100% of national
clinical audits and 0% of national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in.
The Manchester Mental Health and Social Care Trust would have undertaken the POHM – UKQIP 6d:
Assessment of the side effects of depot antipsychotics, but this project has been removed from the
national schedule because of the national CQUIN audit looking at physical health. Manchester
Mental Health & Social Care Trust also did not be take part in the POHM – UKQIP 9C: Antipsychotic
Prescribing in People with Learning Difficulties in February 2015 as there are not any Learning and
Disability services provided within the Trust. This means the next POMH audit that the Trust will be
taking part in is May 2015 (ADHD) and September 2015 (Valproate).
The national clinical audits and national confidential enquiries that Manchester Mental Health and
Social Care Trust participated in, and for which data collection was completed during 2014/15, are
listed below alongside the number of cases submitted to each audit or enquiry as a percentage of
the number of registered cases required by the terms of that audit or enquiry.
Name of Audit / Inquiry
Number of
Cases
% of
National
Cases
Submitted
Reported to
National Audit of Schizophrenia
Case note audit –
68 returned (from
consultant
psychiatrists)
Case note
audit – 1.21%
Service User
Survey –
1.53%
Carer Survey –
1.34%
Royal College of Psychiatry
Service User
Survey – 52
returned (out of a
sample of 200)
Carer Survey – 15
returned (out of a
sample of 200)
The report of one national clinical audit was reviewed by the provider in 2014/15 and Manchester
Mental Health and Social Care Trust intends to take the following actions to improve the quality of
healthcare provided:
Name of Audit/enquiry
National Audit on
Schizophrenia
Published
Date
14 October
2014
Improvement Actions
Monitored by
The national audit of schizophrenia 2 results was
th
published on the 10 December and trusts
received their individual reports in the following
week. The chief pharmacist and 3 consultants
attended the NAS2 teams’ feedback event on the
th
10 where the North West results were
presented to an audience consisting of
representatives from each North West mental
Royal College
of Psychiatry
33
health trust. Early actions were agreed and one
of the consultants agreed to feed these back to
her colleagues in in-patient services. An initial
th
meeting on the 8 January chaired by the
medical director reviewed the report and agreed
th
a paper for Quality board on the 14 January.
The Trusts NAS2 results were then presented to
the January Quality board to acknowledge the
findings and agree the work to be undertaken.
th
The report was shared on the 19 March at the
integrated risk and governance committee where
local results were reviewed and action planning
discussed. Medicines management committee
reviewed the results in January 2015 and
discussed how these linked to planned audit,
training for Drs and individual prescribing
performance.
Preliminary actions following the publication of
the NAS 2 report focussed on the main areas of
• Service provision and experience
• Physical health
• Prescribing
• Psychological therapies
Integrated
Risk
Management
and Clinical
Governance
Committee
Service provision and experience
An area to note was the finding that service users
did not know who to contact in a crisis. This had
improved when teams had been previously
issued with contact cards provide details on key
contacts and to signpost to the choice and
medication website via the use of QR codes. It
was agreed to print 10,000 of these cards, and to
distribute them to care coordinators for cascade
to service users.
Integrated
Risk
Management
and Clinical
Governance
Committee
A further action was to explore if the Trust had
any further supply of the advance directive
booklets, and explore the costs of re-printing
these so that they can be made available to
service users and carers
It was noted that the Trust is responsive at
dealing with physical health issues/problems
once identified but that the full range of required
tests are not undertaken often enough. The
need for improved physical health monitoring
had been identified as part of an ongoing NICE
review. A range of actions have been agreed to
include
Integrated
Risk
Management
and Clinical
Governance
Committee
• Undertaking checks to ensure that every
team has access to an NMP
• Assessing the current skill mix within
Integrated
Risk
Management
and Clinical
34
•
•
•
•
•
•
nursing teams
Ensuring that the CLAHRC project is
established across the Trust
Reviewing the role of health and well being
staff
Improving the use of CPA via identified
learning from the current CPA CQUIN
programmes
Reviewing how the Trust uses use
outpatient/treatment suites
Exploring the role of research and
innovation in determining projects that can
include physical health
Making better use of mobile working
Governance
Committee
A full copy of the Trust report following the National Audit of Schizophrenia second round of audit is
available on the Royal College of Psychiatrists website. A direct link to the report is included below.
http://www.rcpsych.ac.uk/workinpsychiatry/qualityimprovement/nationalclinicalaudits/schizophren
ia/nationalschizophreniaaudit/reports.aspx#round2reports
This report provides full details on the national findings from the National Audit of Schizophrenia,
and also compares the Trust results and outcomes to the other 64 Mental Health Trusts/Health
Boards in England and Wales who submitted data.
The Clinical Audit Programme for 2014/15
Clinical Audit Programme (CAP)
2014/15
13%
Completed
Withdrawn
87%
35
During 2014/15, 11 primary audits were selected to be completed for the Clinical Audit Programme
(CAP). This required the completion of 23 individual clinical audit reports in total as some projects
were audited on a quarterly basis.
During 2014/15, 3 audit reports were withdrawn for various reasons. Where a report was
withdrawn, a clear rationale was provided by the audit lead with mitigating circumstances fully
explained. A total of 62 2 audit reports are detailed with assurance and actions in the Summary
Report of Audit Projects (The National Audit on Schizophrenia round 2 2013/14 is reported in a
separately published report distributed by the Royal College of Psychiatry).
The Trust completed its involvement in the National Audit of Schizophrenia round 2 2013/14 in
November 2014, when the National Report and Trust Report were received respectively. The Chief
Pharmacist and several Consultant Psychiatrists attended a North West Regional event organised by
the National Audit of Schizophrenia project team. At this event the recommendations and results
were discussed at length to provide a clear understanding of improvements that are required for a
positive impact on patient care in the management of schizophrenia and schizoaffective disorder.
The reports of the 42 local clinical audits were reviewed by the provider in 2014/15 and Manchester
Mental Health and Social Care Trust intends to take the following actions to improve the quality of
healthcare provided:
•
•
2
To ensure that the Clinical Audit and Quality Coordinator within the quality and governance
team provides support and assistance to all staff involved in the clinical audit programme.
To ensure appropriate and robust administrative support is in place to facilitate the delivery
of the Clinical Audit Programme for 2015/2016.
Excludes the 3 withdrawn audits
36
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
To continue to review and improve clinical audit training, with a specific focus on Healthcare
Quality Improvement Partnership (HQIP) training sessions to ensure best practice .
To ensure that all actions and recommendations from the internal audit report on the
Trust’s clinical audit activities are fully delivered.
To continue to attend and support HQIP events and Regional Audit meetings to encourage
best practice and where possible collaborative working.
To continue to redesign the audit training programme specifically in place for our clinicians
so that it reflects best practice and meets personal development criteria.
To deliver bespoke training audits for individual teams and services where this has been
identified as a learning and development need.
To establish a presence at corporate induction so that new members of staff are fully aware
of the important role of clinical audit in improving quality and patient experience.
To continue to provide an introduction on Trust audit processes and contacts to trainee
doctors starting a new training rotation at the Trust.
To continue to liaise with junior doctor audit leads to organise project presentations at the
end of training rotations to initiate feedback from their peers and share good audit practice.
To encourage greater involvement from divisional leads in the contribution to the Clinical
Audit Programme to establish audit projects that will be completed cost effectively and by
the deadlines set.
To continue with the ongoing development of a training resource area on the staff intranet
site and external links (HQIP etc) regularly updated to improve access to information.
To ensure that the ‘limited assurance’ list of the previous year’s audits is provided to Junior
Doctors as suggestions for re-audit to encourage and influence topic choice.
To introduce systems to lead to improvements in the monitoring process, such as diary
reminders for each clinical lead at each step of the audit cycle. This will help to ensure a
higher completion rate for the clinical audit programme.
To work more closely with the divisions to ensure robust communication of audit results and
an increased involvement and ownership of the management of action plans.
To work to increase the levels of service user and carer involvement in the development and
delivery of our annual Clinical Audit Programme.
To offer library resource support by including the ‘Athens’ link within the registration form.
A detailed list of audits including the level of assurance and any improvement actions identified for
individual audits can be found in Annex D of this document.
Clinical Research
The number of patients receiving relevant health services provided or sub-contracted by Manchester
Mental Health and Social Care Trust that were recruited during that period to participate in research
approved by a research ethics committee was 800.
The Research and Innovation Department currently hosts 10 major grants from the National
Institute for Health Research (NIHR), totalling £9.7 million: 4 programme grants, 5 research for
patient benefit grants and 1 health services delivery grant. The Trust has also had 112 active studies
in 2014-15, of which 65 were NIHR portfolio studies. We have continued our role of sponsor in two
37
clinical trials, and successfully completed the project to build our own in-house Research Pharmacy
Unit in July 2014. This has not only added to our own capacity to do clinical trials, but we are also
providing support for other trusts in the Greater Manchester area. Clinicians and academics
associated with the Trust have published 186 academic journal articles, with 82% of these occurring
in the top 50% of journals ranked by the Institute for Scientific Information in its database of highly
cited researchers.
Achievements in clinical impact this year have included;
• Further development of a tele-health system to monitor symptoms in schizophrenia – this system
is now being trialled in our CMHT’s.
• Development of our own in house R&I Pharmacy has not only allowed us to expand our research
portfolio (in particular in commercial studies) but has also allowed us to provide support to (and
gain income from) other Trusts within Greater Manchester.
• Dementia researchers were shortlisted in both the HSJ and Greater Manchester Clinical Research
Awards and the Worship II Team won the ‘Outstanding Contribution’ Award at the latter event.
Commissioning for Quality and Innovation (CQUIN) payment framework
A proportion of Manchester Mental Health and Social Care Trust’s income in 2014/2015 was
conditional upon achieving quality improvement and innovation goals agreed between Manchester
Mental Health and Social Care Trust and any person or body they entered into a contract, agreement
or arrangement with for the provision of relevant health services, through the Commissioning for
Quality and Innovation payment framework. Further details of the agreed goals for 2014/2015 and
for the following 12 month period are available in appendix C of this Quality Account, or online at:
http://www.mhsc.nhs.uk/media/106292/cquin%202014-15.pdf
Working with the Manchester CCGs and the Specialised Commissioning Team, the Trust agrees a
target for improvement that is broken down into four quarterly milestones. Progress is then
reported back to Commissioners at our Quality Monitoring meetings. In 2014-15, 2.5% of the
Trust’s income was dependent on achieving our CQUIN targets. The remaining 97.5% of the Trusts
income is subject to our contracts with Commissioners. Further details of the agreed goals for 201415 and for the following 12-month period are available in Appendix C of this document and
electronically on our website.
Care Quality Commission - Registration Status
Manchester Mental Health and Social Care Trust is required to register with the Care Quality
Commission (CQC) and its current registration status is registered without conditions. The Care
Quality Commission has not taken enforcement action against Manchester Mental Health and Social
Care Trust during 2014/15. Manchester Mental Health and Social Care Trust have not participated in
any special reviews or investigations by the Care Quality Commission during 2014/15. The Trust has
been subject to a full inspection by the CQC which took place in March 2015.
Manchester Academic Health Science Centre (MAHSC)
Greater Manchester is the only area north of Cambridge to be designated as an Academic Health
Science Centre (AHSC) by the Department of Health. AHSC status is a quality stamp that marks
38
Manchester Academic Health Science Centre (MAHSC) out as an internationally recognised hub of
excellence in research, innovation, education and healthcare delivery.
Designation as an Academic Health Science Centre is a mark of recognition that Manchester is a
leading international centre of excellence in education, research, healthcare, industry collaboration
and – crucially – the translation of cutting edge developments in science into the care that our
patients receive. MAHSC is a partnership between The University of Manchester and six Greater
Manchester NHS healthcare providers – including this Trust - with world-class academics and
researchers from the University of Manchester.
We share a common goal of giving patients and clinicians rapid access to the latest research
discoveries, and improving the quality and effectiveness of patient care. MAHSC exists to help
researchers, clinicians and the healthcare industry bring the latest scientific discoveries to bear on
the treatment that we offer to our service users. This is important because Greater Manchester has
some of the poorest health outcomes in the UK.
MMHSCT is proud to be involved in the MAHSC partnership. We are one of the most research active
trusts in the country and have one of the highest levels of recruitment to clinical trials for mental
health in the country.
FOCUS ON: Care Quality Commission Compliance Visits
You can visit the CQC website area for the Trust at http://www.cqc.org.uk/directory/TAE
A full CQC inspection of all Trust services took place in March 2015. The outcome report following
this inspection process is due to be received by the Trust in May 2015.
Data Quality and Information Governance
The Trust recognises the importance of accurate and timely information to support the delivery of
safe and efficient patient care and the management and monitoring of its services. Demographic and
clinical data must be accurately recorded to defined standards to provide a sound basis for clinical
decision-making, to reduce risk and to be used for statistical analysis at local and national level. We
are working with our services to review our data systems and are continuously seeking to improve
data quality. As part of our work, Informatics staff regularly undertakes data-cleansing exercises and
meet with staff across the Trust to present the data we hold about our patients and services.
Manchester Mental Health and Social Care Trust submitted records during 2014/15 to the Secondary
Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published
data. The percentage of records in the published data (April 2014 to January 2015):


Which included the patient’s valid NHS Number was:
97.9% for Inpatient Care
100% for Outpatient Care


Which included the patient’s valid General Medical Practice Code was:
100% for Inpatient Care
100% for Outpatient Care
39
The Data Quality Dashboard also includes a Data Validity Summary figure which is an average validity
score for all of the data items included in the Dashboard. For the same period the Trust’s Data
Validity Summary score was 98.8% which is higher than the national average of 96.2%.
Information Governance Toolkit
Manchester Mental Health & Social Care Trust’s Information Governance Assessment Report overall
score for 2014-2015 was 74 % and was graded green, meaning ‘satisfactory’.
Initiative
2013/14 Assessment
2014/15
Assessment
Clinical Information Assurance
Confidentiality and Data Protection Assurance
Corporate Information Assurance
Information Governance Management
Information Security Assurance
Secondary Use Assurance
Trust Overall Score
Satisfactory
Satisfactory
Satisfactory
Satisfactory
Satisfactory
Satisfactory
72%
Satisfactory
Satisfactory
Satisfactory
Satisfactory
Satisfactory
Satisfactory
74%
Manchester Mental Health and Social Care were not subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission.
Manchester Mental Health and Social Care Trust monitors and improves data quality through two
groups:
•
The monthly Information and Data Quality Group ensures that appropriate mechanisms are
in place to meet all local and national information requirements, develops and supports the
implementation of all strategies, policies and protocols relating to data quality and ensures
that appropriate reporting processes are in place to monitor and improve data quality where
problems are identified.
•
The monthly Operational Management & Performance Committee discusses specific data
quality issues with clinical and operational staff, provides feedback where required and
ensures that significant data quality issues which affect Trust performance are addressed
and resolved quickly.
Mandated Quality Indicators
From 2012-13, NHS providers have been required to include performance information against a
range of quality indicators. These indicators have been selected against the NHS Outcomes
Framework and the 5 domains within that Framework. We welcome this requirement, as it
increases the opportunity for benchmarking, but also provides our stakeholders with a clearer
understanding of our quality performance in a national context. There is some cross-over with
information we routinely provide in the Quality Account, including the performance data above, but
this area offers additional information on our performance against other Trusts and improvement
actions. The mandated quality indicators for inclusion in the 2014-15 quality account include:
40
•
•
•
•
•
•
•
CPA 7 Day Follow Up
Gatekeeping
Readmission within 28 days
Staff Satisfaction
Patient Experience of Contact with Workers
Patient Safety Incidents - Reporting
Patient Safety Incidents – Severity
Mental Health Trusts National Performance Data
All NHS mental health and learning disability Trusts are required to meet national performance
indicators. The table below illustrates the performance against those indicators for the year so far.
The table below sets out performance during 2014/15 calculated from the Trust’s own data systems.
Item
2011/12
2012/13
2013/14
2014/15
Threshold
CPA 7 Day Follow-Up
CPA Review Within 12 Months
Delayed Transfers Of Care
96.7%
95.7%
2.6%
98.7%
95.6%
2.5%
96.9%
95.0%
3.6%
98.2%
95.9%
4.1%
>= 95%
>= 95%
<= 7.5%
CRHT Gate keeping
Meeting commitment to serve new
psychosis cases by early intervention
teams
Data Completeness: Identifiers*
Data Completeness: Outcomes**
Access To Healthcare: Learning
Disabilities
Readmission within 28 days (aged 16
or over)
Readmission within 28 day (aged 015)***
96.7%
98.2%
97.2%
96.1%
>= 95%
N/A
N/A
N/A
95%
N/A
99.3%
82.4%
99.6%
88.1%
99.7%
73.0%
99.7%
80.4%
>= 97%
>= 50%
96.7%
98.7%
96.2%
97.3%
>= 95%
N/A
N/A
10.2%
12.7%
N/A
N/A
N/A
N/A
N/A
N/A
*The 2014/15 figure is the position up to and including Month 11 data - Month 12 data is not due to
be submitted until 22/04/2015
**The 2014/15 figure is the position up to and including Month 11 data - Month 12 data is not due
to be submitted until 22/04/2015
***The Trust does not provide services to people aged 0-15
this specifies the indicators that were subject to an additional assurance check as part of the
external assurance opinion.
Mandated Quality Indicators
For the 2014-15 Quality Account, all NHS providers are required to include performance information
against the above range of core quality account indicators derived from the NHS Outcomes
Framework. We have provided up to date performance figures for all of the relevant indicators, plus
some additional supporting narrative where appropriate. The information that follows has been
prepared in line with national guidance. Where any additional local criteria is applied this is referred
to in the individual quality indicator sections as appropriate.
41
Quality Indicator 1 – CPA 7 Day Follow Up
Percentage of patients on Care Programme Approach who were followed up within 7 days after
discharge from psychiatric in-patient care
Manchester Mental Health and Social Care Trust considers that this data is as described for the
following reasons: this data is regularly monitored and reported to the Trust Board within the
monthly Integrated Performance Report.
The Trust applies the following additional, local criteria:
•
•
The indicator excludes patients transferred to a Non-NHS psychiatric inpatient ward when
discharged from inpatient care.
The indicator excludes patients who leave the country on discharge, regardless of whether
they have been removed as a result of legal proceedings.
The position for the year end 2014/15 is 97.3% which is an increase of 1.1% compared to last year’s
figure of 96.2% and continues to be above the national target of 95%.
Manchester Mental Health and Social Care Trust has taken the following actions to improve this
percentage, and so the quality of its services, by, establishing an alert system which flags up when a
7-day follow-up is required to the community team at an early stage; identified a dedicated Service
Manager responsible for 7-day follow up who will monitor progress and performance on a daily
basis. In addition, all Ward and Community Team managers, and their assistant managers and
deputies, have been instructed to ensure a named person is agreed at discharge CPA/Ward rounds
who will undertake 7-day follow-up.
This quality indicator is performance managed at the monthly Operational Management and
Performance Committee meeting. This is chaired by our Director of Operations and attended by
Directors and senior managers to monitor the Trust’s achievement against national performance
measures.
In order to benchmark the Trust’s performance against other providers, the following chart
highlights the Trust score and compares it to the minimum and maximum Trust scores across
England and to the all England score. Please note that the data presented in the chart is for Quarter
3 (October to December 2014) only.
42
CPA 7 day follow up
2014/15 - Quarter 3.
100%
100.00%
98.00%
97.70%
97.30%
96.00%
94.00%
92.00%
90%
90.00%
88.00%
86.00%
84.00%
Trust score
Trust score
Minimum score
Minimum score
Maximum score
Maximum score
All England score
All England score
Quality Indicator 2 – Gatekeeping
Percentage of admissions to acute wards for which the Crisis Resolution Home Treatment Team
acted as a gatekeeper during the reporting period
Manchester Mental Health and Social Care Trust considers that this data is as described for the
following reasons: this data is regularly monitored and reported to the Trust Board within the
monthly Integrated Performance Report.
The Trust applies the following additional, local criteria:
•
Patients transferred from Non-NHS hospitals for psychiatric treatment are excluded from
the indicator.
The position for the year end 2014/15 is 96.1% which is a decrease of 1.1% from last year’s figure of
97.2% but continues to be above the national target of 95%.
The main reason for any cases where gatekeeping is not being carried out prior to admission to the
Trust’s acute admission wards or Psychiatric Intensive Care Units (PICUs) is Approved Mental Health
Professional’s (AMHP) not making contact with the Gate keeping team prior to or following a Mental
Health Act Assessment. The Urgent Care Team is working closely with the AMHP Manager to ensure
that performance improves in this area.
Manchester Mental Health and Social Care Trust has taken the following actions to improve this
percentage, and so the quality of its services, by, establishing a citywide 24/7 gatekeeping team to
ensure effective gatekeeping is undertaken. This team began their specialist function in June 2014
43
and have been fully operational since November 2014. The main function of this team is to ensure
that all patients who may be considered as requiring inpatient admission are reviewed by the gate
keeping team and offered the least restrictive environment in which to receive care. This may
include home treatment. The Standard Operating Procedure for Gatekeeping has been agreed and is
fully operational. The Gate keeping team are operationally managed by the Specialist Practitioner for
Urgent Care and Supervised by the Lead Consultant for Urgent Care.
The Gatekeeping team aim to complete all gate keeping assessments face to face. In March 2015
there were 121 requests for gatekeeping assessments and 81 were completed face to face. The main
reason for not completing gate keeping face to face is during Mental Health Act Assessments where
the Approved Mental Health Professional has made the decision that face to face gate keeping is not
required or appropriate.
This quality indicator is performance managed at the monthly Operational Management and
Performance Committee meeting. This is chaired by our Director of Operations and attended by
Directors and senior managers to monitor the Trust’s achievement against national performance
measures.
In order to benchmark the Trust’s performance against other providers, the following chart
highlights the Trust score and compares it to the minimum and maximum Trust scores across
England and to the all England score. Please note that the data presented in the chart is for Quarter
3 (October to December 2014) only.
CRHT Gatekeeping
2014/15 - Quarter 3.
100.00%
100%
97.80%
Maximum score
All England score
95.80%
90.00%
80.00%
73%
70.00%
60.00%
50.00%
40.00%
30.00%
20.00%
10.00%
0.00%
Trust score
Minimum score
44
Quality Indicator 3 – Readmission within 28 Days
Percentage of patients aged— (i) 0 to 15; and (ii) 16 or over, readmitted to a hospital which forms
part of the trust within 28 days of being discharged from a hospital
Manchester Mental Health and Social Care Trust considers that this data is as described for the
following reasons: the data is reported within the urgent care and inpatient services quality
dashboards and in the monthly acute care performance report. The data is monitored on a monthly
basis at the adult inpatient and urgent care group and the acute services improvement board
meetings.
Manchester Mental Health and Social care Trust has taken actions to improve on this figure and so
improving the quality of its services. The Trust Established a 24/7 face-to-face gatekeeping team to
ensure a robust assessment of appropriate alternatives to admission. The gatekeeping team is led by
a Consultant Psychiatrist and Urgent Care Practitioner who oversee and review all admissions to the
Trust. A process for reviewing all re-admissions to identify contributing factors and further
opportunities has been established and will be monitored throughout the year by the team and at
divisional meetings. Service improvement work (which began in 2013) will continue with Community
Services to develop integrated pathways and whole systems management of patient care.
Investment has been made Mental Health Home Treatment Team to strengthen the provision of
home based treatment as an alternative to hospital admission. These teams will continue to embed
the work around readmissions during 2015-16.
Trust
for Readmission
within
28 days for 2014/2015 is 12.7% ***
Please note
thatScore
this figure
is for all Trust
wards.
Quality Indicator 4 – Staff Satisfaction
Percentage of staff employed by, or under contract to, the Trust during the reporting period who
would recommend the Trust as a provider of care to their family or friends
Manchester Mental Health and Social Care Trust considers that this data is as described for the
following reasons: This information is obtained directly from the Staff Survey as reported by the
Care Quality Commission.
The NHS staff survey is undertaken on an annual basis and the questions contained within are set by
NHS England. The question asked is ‘I would be happy with the standard of care provided by this
organisation’. The Staff Friends and Family Test, launched in April 2014 asks the question ‘how likely
are you to recommend this organisation to friends and family if they need care or treatment’.
The 2014 Staff Survey results show that 43% of staff were happy with the standard of care provided
by the Trust. This is a decrease of 1.8% in comparison with 2013 and 5% reduction in comparison
with 2012. The historical results for 2012, 2013 and 2014 are highlighted in the graph below:
45
Percentage of staff are happy with the standard of care
provided by the Trust
49%
48%
48%
47%
46%
44.80%
45%
44%
43%
43%
42%
41%
40%
2012/13
2013/14
2014/15
The following table shows the percentage of staff who would recommend the Trust to friends and
family if they needed care or treatment in response to the Staff Friends and Family test
questionnaire. (The Staff Survey was undertaken in Q3).
Q1
2014/15
53%
Q2 2014/15
Q3 2014/15
Q4 2014/15
2014/15 Total
47%
43%
55%
51%
Therefore whilst the Staff Survey response demonstrate a decrease in staff satisfaction in terms of
recommendation of the Trust as a provider of care to their families or friends, the staff friends and
family response shows a slightly improved position.
The following questions taken from the Staff Survey, feed into the Key Finding ‘Staff
recommendation of the Trust as a place to work or receive treatment’. The percentages for Q12a –
Q12d are created by combining the responses for those who “Agree” and “Strongly Agree”
compared to the total number of staff that responded to the question. This demonstrates a slight
reduction in comparison with last year across all four questions.
Trust
in
2014
Q12a
Q12b
Q12c
Q12d
KF24.
"Care of patients / service users is my organisation's top
priority"
"My organisation acts on concerns raised by patients / service
users"
"I would recommend my organisation as a place to work"
"If a friend or relative needed treatment, I would be happy
with the standard of care provided by this organisation"
Staff recommendation of the trust as a place to work or
receive treatment (Q12a, 12c-d)
Trust
In
2013
52
Average
(median) for
mental Health
trusts
65
59
71
62
40
43
54
60
42
47
3.18
3.57
3.27
53
46
Manchester Mental Health and Social Care Trust intends to take the following actions to improve
this score:
•
•
•
•
•
•
•
•
•
The 2015/16 Staff Friends and Family Test will be launched on Friday 1st May 2015. All Trust
staff will be invited to complete the survey. Delivery of this project will result in the Trust
being able to test levels of staff morale and satisfaction throughout the Trust on a quarterly
basis.
The implementation of this quality project will help the Trust to better understand and
contextualise the results from the annual staff survey.
We will continue to value and develop our staff so that the Trust is an employer of choice for
caring, compassionate and committed professionals.
We will ensure that regulatory and professional compliance to deliver quality service
provision which focuses on safety, reducing harm and enabling a positive experience whilst
in the Trust’s care or employment is maintained and exceeded where possible.
We will continue to analyse and action plan against the 2014 staff survey outcomes, with
identified delivery outcomes to ensure improvements are delivered as identified by the
results. This will include appropriate development and implementation of a system to
support ongoing staff FFT requirements.
We will review development and implementation of revised appraisal systems and
processes.
We will develop systems and processes to engage and communicate with people both to
share information and seek involvement in decision making.
We will incorporate outputs from the Staff Survey, Staff FFT and Listening in Action (LiA)
Programme into an overarching action plan.
We will continue with the roll out of the e-rostering system to support appropriate use and
deployment of staffing resources and compliance with safe staffing requirements.
Quality Indicator 5 – Patient Experience of Contact with Workers
Patient experience of community mental health services indicator score with regard to a patient’s
experience of contact with a health or social care worker
Manchester Mental Health and Social Care Trust considers that this data is as described for the
following reasons: This information is obtained directly from the Patient Survey as reported by the
Care Quality Commission.
Manchester Mental Health and Social Care Trust intends to take the following actions to improve
this score and so the quality of its services by:
•
•
•
Further developing our range of mechanisms for gathering and sharing patient feedback
across all service areas by seeking feedback from service users, carers and stakeholders.
Continuing to link quantitative data with personal accounts from service users to
contextualise experiences of care, including the embedding of our digital stories programme.
Ensuring that our work around dignity and respect continues to extend into communitybased settings (through our dignity walks and informal PLACE programme).
47
•
Refining our customer care sessions within mandatory staff training to emphasise the need
for kindness and compassion.
Developing service user and carer involvement and input into the recruitment and selection
of staff at a range of levels to test out values around compassion, dignity and respect.
Triangulating data from different sources to ensure a deep dive into specific service areas to
provide assurance around the quality and experience of care.
•
•
The following graph shows data on the patient experience of community mental health services
indicator score with regard to a patient’s experience of contact with a health or social care worker. It
highlights the Trust score in relation to the minimum and maximum Trust scores across England and
against the national average score.
Patient experience of community mental health services
2014 Trust scores in comparison to other mental health trusts
8.6
8.4
8.4
8.3
8.2
7.9
8
7.8
7.6
7.3
7.4
7.2
7
6.8
6.6
Trust
Minimum
Trust
Minimum
Maximum
Maximum
National average
National average
Manchester Mental Health and Social Care Trust continues to receive positive patient feedback in
response to contact with health and social care workers. For two consecutive years (2012 and 2013),
the Trust received the highest score of all mental health trusts in England in this thematic area.
For 2014, the Trust score fell only marginally short (by 0.1 out of 10) from being the highest score in
England. The Trust score of 8.3 for this mandatory quality indicator is well above the national
average and only marginally short of the overall maximum score for all NHS Trusts.
In 2014, Trust scores were better than all other mental health trusts in relation to ‘Your Health and
Social Care Workers’. They were about the same as all other mental health trusts in the remaining 8
thematic areas. Out of the 33 questions, The Trust received better scores in comparison to other
mental health trusts in England in 5 areas. The Trust received the highest overall score for all mental
health trusts in England in one question area. Trust scores were about the same as all other mental
health trusts in the remaining 27 questions. As with 2012 and 2013, the Trust did not receive any
scores in the worst 20% of all mental health trusts.
48
Quality Indicator 6 – Patient Safety Incidents - Reporting
Number and, where available, rate of patient safety incidents reported within the trust during the
reporting period, and the number and percentage of such patient safety incidents that resulted in
severe harm or death.
Patient Safety Reporting 2014/15
Manchester Mental Health and Social Care Trust has increased its level of reporting through to the
NRLS over the previous 6 monthly period.
Manchester Mental Health and Social Care Trust has taken the following actions to continue to
improve these percentages and so the quality of its services by;
•
•
•
•
•
•
•
•
•
Ensuring regular reports to the Trust’s Integrated Risk Management and Clinical
Governance Committee to identify learning to improve systems and the quality and
safety of patient care.
The DATIX incident reporting form has been updated in line with NRLS which has recoded incidents to align with the NRLS system.
Staff only have to use a series of drop down boxes to ease navigation within the system.
A drop down box prompts staff to consider aspects of the “Being Open policy” and Duty
of Candour issues, by asking 5 key questions.
If ‘Control and Restraint’ is picked as a category, other drop down boxes appear also for
the reporter to enter data relating to level of restraint use, the position and the length of
time restraint is used.
If Serious Incident Requiring Investigation (SIRI) is selected as a category of incident, the
reporter is prompted to update the Chronological History of Risk Events (CHORES) and
this is being audited to ensure compliance.
A training programme is in place to train staff on the job and part of existing meetings
and also as surgeries in the local site.
Regular feedback reports are provided to all staff through the Divisions to ensure timely
sign off of incidents.
Divisions are asked to ensure learning form incidents and SIRIs are discussed at their
respective Governance and Quality monthly meetings and recorded in the minutes as
appropriate.
Quality Indicator 7 – Patient Safety Incidents - Severity
The graph below shows the severity of Patient Safety Incidents during the period 1st April 2014 to
September 2014
Manchester Mental Health and Social Care Trust considers that this data is described for the
following reasons: this data is monitored and reported through the Integrated Risk Management
and Clinical Governance Committee. For serious incidents, Quality Board received summarised
reports by exception. These are detailed within a High Level Investigation Panel (HLIP) Report.
49
Incidents reported by degree of harm for mental health organisations
1st April to 30th September 2014
70.00%
60.70% 60.20%
60.00%
50.00%
40.00%
31%
30.00%
29.40%
20.00%
7.30%
10.00%
9%
0.30%
0.50%
0.70%
0.60%
0.00%
None
Low
Moderate
All mental health organisations
Trust figures
None
854
Low
417
Severe
Death
Your organisation
Moderate
133
Severe
7
Death
8
Nationally, 70 percent of incidents are reported as no harm, and just under 1 per cent as severe
harm or death. However, not all organisations apply the national coding of degree of harm in a
consistent way, which can make comparison of harm profiles of organisations difficult. Organisations
should record actual harm to patients rather than potential degree of harm. Benchmarking the Trust
figures nationally it appears that we are in line with the national figures for reporting rates of harm.
Patient Safety Incidents (PSI) Definition
The Trust interprets PSIs as any unintended or unexpected incident which could have or did lead to
harm for one or more patients receiving NHS funded care. We report all PSIs, whether we consider
they were preventable or not, to allow us to improve safety, knowledge and practice across our
services.
Manchester Mental Health and Social care Trust has improved its reporting rate in comparison to
last year and continues to take actions to improve. All PSIs classified as severe harm and death are
reviewed by clinicians and submitted to the National Reporting and Learning System (NRLS) on a
monthly basis. We define harm as injury, suffering, disability or death. Harm includes mental or
psychological as well as physical harm and, where PSIs are reported as mental or psychological harm,
our clinicians will take a range of factors into account when determining the extent of harm
suffered. The levels of severity are:
50
None - A situation where no harm occurred: either a Prevented Patient Safety Incident or a No Harm
Patient Safety Incident.
Low - Any unexpected or unintended incident which required extra observation or minor treatment and
caused minimal harm, to one or more persons.
Moderate - Any unexpected or unintended incident which resulted in further treatment, possible surgical
intervention, cancelling of treatment, or transfer to another area and which caused short term harm, to one
or more persons.
Severe - Any unexpected or unintended incident which caused permanent or long term harm, to one or
more persons.
Death - Any unexpected or unintended incident which caused the death of one or more persons.
We believe this interpretation has been applied consistently through centralised quality checking of
all reported PSIs.
Details of the national risk matrix that we replicate locally can be found at:
http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=60149&...
Our policies relating to risk management, incident reporting and learning and embedding can be
found at: http://www.mhsc.nhs.uk/about-the-trust/freedom-of-information/our-proceduraldocuments.aspx
Table 1
NRLS Provided data tables
Reporting Period:
April 2013 – September 2013
Comparative reporting rate, per 1,000 bed days,
for 56 mental health organisations
Number and percentage of Patient Safety
Incidents (PSIs)that resulted in severe harm
Number and percentage of Patient Safety
Incidents (PSIs)that resulted in death
MMHSCT
Highest MH Trust
Nationally
Lowest MH
Trust Nationally
800
6609
401
17.41
34.04
18.77
2; 0.3%
34; 1.5%
1; 0.0%
7; 0.9%
76; 3.2%
0; 0.0%
MMHSCT
Highest MH Trust
Nationally
Lowest MH
Trust Nationally
Table 2
NRLS Provided data tables
Reporting Period:
April 2014 – September 2014
Comparative reporting rate, per 1,000 bed days,
for 56 mental health organisations
Number and percentage of Patient Safety
Incidents (PSIs)that resulted in severe harm
1419
6609
401
32.71
34.04
18.77
0.5%
34; 1.5%
1; 0.0%
Number and percentage of Patient Safety
Incidents (PSIs)that resulted in death
0.6 %
76; 3.2%
0; 0.0%
51
Part 3
Review of Quality Performance over the Year
Quality Monitoring Process
The Quality Board has delegated responsibility on behalf of the Trust Board to provide oversight and
scrutiny to the quality and risk processes in the Trust. The Quality Board receives information from
across the Trust on a monthly basis and provides reports to the Trust Board. To ensure a rigorous
approach to quality monitoring, the Quality Board has standing agenda items but can also add
special items to the agenda and invite service leads and representatives from across the Trust to
present papers and attend. The process for monitoring quality and risk in the Trust is summarised in
the diagram below, but further information can be found in our Trust Assurance Framework and
Annual Governance Statement.
Trust Board
•The Trust Board receives a monthly Clinical Governance report prepared by the Medical Director and Chief Nurse and Director of
Quality Assurance. They also receive regular performance reports and the minutes of the Quality Board which are presented by the
Chair of the Quality Board.
Quality Board
•Provides assurance to Trust Board in relation to quality, safety, and risk issues in line with the Quality Improvement Strategy
capturing four key pillars of Regulation, Patient Safety, Patient Experience and Clinical Effectiveness, . They receive reports from
Committees but also have the ability to request additional reports from across the service or other groups and committees. The
Quality Board links with the Operational Management Team and QIPP (Quality, Innovation, Productivity and Prevention) Programme
Board and members of those groups are represented at the meetings .
Risk Committee* (this commitee merged with the Clinical Governance Committee during (April) 2014 and is
now referred to as the Integrated Risk Management and Clinical Governance Committee
•The Risk Committee provides an assurance to Quality Board that risk registers and risks of all types are identified, monitored and
effectiveness issues are considered on behalf of the Trust. Also considers serious and untoward incidents and ensures they are
properly investigated and lessons learned .
Clinical Governance Committee* (See above)
•Provides assurance to Quality Board in relation to clinical effectiveness including research and development, clinical audit, NICE
guidance and lessons learned.
Patient Experience Committee
•Provides assurance to Quality Board in relation to Service User and Carer Engagement and Service User Experience.
All our Committees complete an effectiveness review of their membership, terms of reference,
reporting and monitoring each year. This offers assurance to the Trust Board that we have the
correct monitoring processes in place.
Embedding recommendations from the Francis Report
During 2014/15 we continued to align our clinical work with the recommendations in the Francis
Report published in February 2013. Throughout the year, we have continued our work to embed
Compassion in Practice and ensure that the Six C’s are role modelled at all levels using the Trust's
Multi Professional Vision as the strategy for change. In the last year, our Heads of Professions have
worked with teams across the Trust to further develop the multi-professional vision about how we,
as a Trust, embed compassion in every element of practice. Our engagement work to date has led to
52
the identification of key statements and intentions as well as individual professional pledges aligned
to the Six C’s.
Risk Summits
During 2014/15 the Trust has been subject to the NHS England Risk Summit process based on issues
raised by the CCG’s as part of the Quality Surveillance Group process. The oversight from the risk
summit process has:
•
Acknowledged that the safeguarding processes have improved and returned a substantial
audit opinion;
Identified a common dashboard of information between the Trust and the CCG’s;
established an urgent care review group that is seeking to improve the urgent care system
across Manchester that is beyond the control of the Trust;
Identified improvements that the Trust can complete to contribute to the wider urgent care
system.
•
•
•
NHS England are due to convene a summary risk summit, a date of the meeting is awaited at the
time of writing. The Trust has committed to continuous improvement throughout the risk summit
process and will continue to do so in the future.
Intelligent Monitoring Report
In November 2014, the CQC published their intelligent monitoring information report. The report
considers 59 different indicators, from sources such as Mental Health Minimum Data Set (MHMDS),
Electronic Staff Records (ESR), the NHS staff survey, bed occupancy rates, the national health
outpatient survey and concerns raised by Trust staff. From these indicators, each Trust is placed into
a priority band from 1 (highest perceived concern) to 4 (lowest perceived concern). The CQC
highlight that although the banding will help to identify which mental health trusts to inspect first,
they do not represent a judgement or a ranking of care quality.
As highlighted earlier, the CQC categorises Trusts into four bands – band 1 is the highest perceived
risk and band 4 the lowest. Trusts are assigned proportional score based on the number of
indicators identified as a ‘risk’ or ‘elevated risk’ using the following formula below to produce a %
score. Thresholds for the bands are:
-
Band 1 ≥ 6.5%
Band 2 < 6.5%
Band 3 < 4.0%
Band 4 <2.0 %
The formula used to calculate the risks is as follows:
(number of risks) + (number of elevated risks x2) = overall risk score
Overall risk score/ maximum possible risk score = proportional score
53
Following their calculation, the CQC concluded that the Trust be assigned to Band 1 with a
proportional risk score of 7.27. This was based on the following indicators which were identified as
risks or elevated risks by the CQC.
1. Percentage re-admissions of less than 7 days out of total admissions (MHMDS)
2. Proportion of new service requests received yet to have a first assessment (IAPT)
3. Proportion of service requests that have waited more than 28 days from referral request
received date to date of first treatment (IAPT)
4. Length of stay <7 days - informal patients as proportion of all informal patients (MHMDS)
5. Escalation score (TDA)
6. Proportion of days sick in the last 12 months for Medical and Dental staff (ESR)
7. Proportion of days sick in the last 12 months for Nursing and Midwifery staff (ESR) elevated risk
As such, the report identifies 6 risks and 1 elevated risk out of 55 applicable indicators (4 do not
apply to the Trust). Using the formula detailed above, this give the proportional risk score of 7.27%
as detailed below:
(6)+(1x2) = 8
8/110 (maximum possible risk score*) = 7.27%
This puts the Trust above the 6.5% threshold and in band 1
Listening into Action
In Early 2014, Professor Stephen Singleton was asked by the Chair of the Trust Board to undertake
an independent evaluation of the Trust. This was an evaluation which was based primarily on
interviews, meetings with staff and stakeholders as well as a review of Trust documentation.
As a result of this evaluation, Professor Singleton identified a key priority, which was Staff morale,
common purpose, the culture and ways of working inside the organisation. In May 2014, the Trust
Board made the decision to commit to a new way of working, ‘Listening into Action’ (LiA). This is an
approach which has been adopted by over 40 NHS Trusts nationally and once embedded and
sustained, is demonstrating improved staff morale.
The key principle of LiA is to fundamentally shift how we work and lead, putting staff - who know
the most - at the centre of change. This change is led directly by the CEO, who supports the changes,
through a willingness to break through existing assumptions, myths, bureaucracy, blockages,
blockers and engrained ways of working to make room for something new.
The Chief Executive Officer (CEO) works closely with a team of frontline staff, the LiA Sponsors, who
have oversight of the changes and feedback directly to the CEO on the issues associated with leading
changes at the frontline. The Trust then embarked on a number of changes, following ’Big
Conversations’ with staff, which identified key themes across the organisation, often relating to
service issues which had been in the organisation for some time. As a result of these conversations,
54
16 Pioneering teams, led by Clinical and managerial leads were established to make the changes
staff wanted to see.
These teams have now made a number of changes to improve care and remove some of the
frustrations created by bureaucracy at the frontline. Here are some of the outcomes delivered to
date:
Standardising the Clinical model for Memory Services
This team is working to create one model across the patch, as staff at the Big Conversations
articulated frustration at the different models used in North, Central and South Manchester.
Although the essence of the service was the same, they were operating slightly differently as well as
dealing with the challenge of long waiting times.
The main focus of the work was to roll out the same Memory Assessment across the Trust. This has
already now been rolled out across North and Central. In addition this team has delivered a number
of quick wins:
•
•
•
•
•
•
Development of Memory Assessment Service pathway for all three services.
Access to neuro-imaging for Doctors in North which has reduced the time Doctors have to
wait prior to making a diagnosis.
Waiting times for diagnosis and treatment have been reduced by :
-Nurses in North Manchester requesting CT scans after memory assessments have been
completed. (This previously required them to write a report and then ask the Consultant to
refer the patient for a scan).
- A Nurse Prescriber Out Patient Clinic has been developed to undertake follow-ups , thus
utilising the nurses specialist skills, releasing Consultant time for new patients.
Memory services have increased their participation in research.
All teams in North, Central and South are now providing the same information packs to
patients, ensuring consistency.
Leaflets are being harmonised across the patch so that wherever patients access memory
services, they will receive standardised information.
Out Patient Services improvement
Out-Patient services have been under review for some time and there was a key priority to reduce
the number of cancelled clinics. This team has introduced new guidance to all staff involved in Out
Patient Services to reduce the number of cancelled clinics as well as reducing the time for booking
an appointment to four weeks, from six weeks. They have also identified a ‘flexible’ appointment in
out -patient clinics, to enable ward staff to refer discharged patients at short notice. This should
provide greater support to newly-discharged patients and resolve any immediate issues identified on
returning to the Community.
The demand for access to out- patient clinics continues to rise in line with the increased demand for
services. In order to create capacity for new patients, North West Community Mental Health Team is
now supporting patients who are stable in the community to transfer to the care of their GP in
collaboration with local Practices.
55
Appropriate use of Patient Transport
This team is focusing on promoting the recovery of clients through the use of appropriate transport.
This will encourage clients to develop confidence in the use of public transport as part of their
recovery plan, rather than defaulting to the use of taxis. Staff are supporting clients to access the
most appropriate form of transport according to their need. It is anticipated that this will also
promote recovery and independence.
One Patient Record
One of the key areas that staff talk about is the duplication of records – paper and electronic. This
Pioneering Team has piloted the scanning of paper records onto the electronic record, so that all
documents are in one place and can be accessed through a single route. This has released precious
clinical time as well as ensuring that paper documentation is secured alongside the electronic
record, providing clinicians with a comprehensive picture of the patient’s progress. Following
evaluation, this will be rolled out across the Trust over the next 6-9 months.
Listening into action is therefore delivering small scale changes through the effective engagement
and leadership of frontline teams. It is anticipated that this spread of innovation, as it continues, will
become the way of working at the Trust, with staff making the changes they want to see - improving
services for patients, whilst improving their own job satisfaction as well as further developing their
own skills in delivering change.
Learning Lessons
In the following sections we provide an overview of different areas of our quality governance
approach. This includes the data collected by each of our governance leads working across areas of
the service. The challenge for health and social care providers is to use this information in the most
effective way to continuously review and improve their services. This is often a task for Board level
groups and Committees who use the collated reports and monitoring to identify key and recurrent
themes, and work with services to deliver a Trustwide response.
The information we collected throughout 2014-2015 has been considered both internally and with
our external stakeholders to help us identify and agree our priorities for 2015-16. We will try to build
upon the successes of this year and take action to avoid repeating issues highlighted to us through
service user and carer feedback, complaints, audits, recommendations and lessons learned from
Serious Incidents Requiring Investigation (SIRIs).
These include the importance of good communication within the multi disciplinary team, rigour in
maintaining and recording levels of observations and ensuring that risk formulations are robust. To
improve how we deliver services we have introduced Situation, Background, Assessment and
Recommendation (SBAR). This is a proven method of improving the reliability of communication
between teams. Matrons now audit levels and recording of observations as part of their weekly
quality checks and work has progressed through Listening into Action to review and improve risk
assessment and formulation.
56
Some of the emerging themes are things that we would expect to see as areas for ongoing or
continuous improvement, such as risk assessments, staff-related issues and physical health. While
the overarching topic may not change, we do see differences in the detail of the issues being raised
by people accessing our services.
We will continue to look at the national changes currently taking place and seek to use the
significant restructuring in health and social care to help us to review, challenge and ultimately
improve the outcomes for those accessing our services.
Performance against our 2014/2015 Priorities
This area provides information on our progress against the priorities we set out in our 2014-2015
Quality Account. We selected three priorities following consultation with stakeholders and have
monitored their progress through our Committees during the year.
Priority 1 – Staff Morale and Engagement
Introduction and implementation of programme of communications and engagement in response
to Professor Stephen Singleton’s report
A 90 day plan was developed and introduced early in 2014 which has now been fully implemented.
In order to drive the necessary culture change the Trust signed up to Listening into Action in June
2014, which focuses on developing a culture of staff led organisational change. The Trust identified
12 sponsors and over 100 influencers to actively participate in addressing the concerns that staff
raised through the Big Conversations. The Big Conversations gave the Trust the opportunity to listen
to the some of the main frustrations experienced by our staff, and importantly some time to focus
on practical solutions to these. Over time, it is hoped that this will have appositive impact on staff
morale.
For the 2014 national staff survey, whilst the feedback improved with 51% of all staff responding to
the survey, it was disappointing that the overall scores for staff satisfaction and engagement
remained in the bottom 20% of Mental Health Trusts nationally. However, it should be noted that
the Trust was only in the early stages of implementing Listening into Action when the 2014 staff
survey was completed so whilst disappointing the results were not entirely unexpected.
The Trust’s Organisational Development (OD) Strategy has been revised to bring together the key
themes from the Listening into Action big conversations and Professor Singleton’s report into a
comprehensive action plan. A full update of the OD action plan occurred at the end of 2014/15 and
it was pleasing to see how much work has been completed. This will be further refreshed now that
the 2014 staff survey results have been published and will continue to be a priority focus throughout
2015/16.
A staff charter to address the expected behaviours of staff at every level of the Trust and leaders
establishing the right environment has been developed by staff and trade unions. This was launched
through midday mail and a copy was sent out to every employee with their payslips. This was
57
followed by a discussion at the Trust’s leadership forum regarding embedding the charter in day to
day practice.
Introduction and implementation of the Friends and Family Test for staff
The Trust commissioned Picker Institute to undertake the Staff Friends and Family Test (FFT), which
was first implemented in April 2014. The primary purpose of the Staff FFT is to support local service
improvement work. Data is collected and submitted quarterly for quarter 1, quarter 2 and quarter 4
at the end of each quarter. For quarter 3 (October to December 2014) there was no requirement to
run a separate FFT as the annual NHS Staff Survey is administered at this time which includes the FFT
questions. At the end of each quarter the results are shared both internally and with our
commissioners.
In total during 2014/15 1847 staff were invited to complete the FFT and 1016 responses were
received, a total of 55%. This is against a target of 40%. The Staff FFT asks two questions;
• How likely are you to recommend this organisation to friends and family if they needed care
or treatment?
• How likely are you to recommend this organisation to friends and family as a place to work?
51% of staff responded that they were either highly likely or likely to recommend the Trust to friends
and family if they needed care or treatment. 25% responded passively and 24% negatively.
43% of staff responded that they were either highly likely or likely to recommend the Trust to friends
and family as a place to work. 20% responded passively and 35% negatively.
Implement a range of specific measures to improve staff engagement and support
Value and develop staff
The Trust has revised its appraisal process during 2014 which now provides greater focus on
personal reviews and reflection, incorporates quarterly reviews to ensure regular opportunities for
reflection and feedback and has a defined personal development plan. The Trust is fortunate in
having retained a centralised training budget to support the Continuing Professional Development of
staff. The year-end position 2014/15 for appraisal completion was 61%, a much improved position
from earlier in the year. The 2014 staff survey demonstrated an improvement from the previous
year in the percentage of staff who left their appraisal feeling that their work was valued.
‘Employee of the Month’ awards are given in recognition of staff who live the values of the
organisation, put patients first and demonstrate a commitment to continuous service improvement.
The Trust also recognises the loyalty, quality and dedication of our staff and in recognition of this, is
committed to celebrate with those staff who have reached certain service ‘milestones’ by providing
a system of awards for both long service while in service, and, when people retire with long service.
The staff charter also outlines the commitment from the Trust to ‘value staff regardless of
profession, grade, speciality or area of work’ and to ‘Understand the resources and training needed
to enable staff to do their job’.
58
Analyse and action plan against the 2013 survey
Rather than produce a separate action plan to address the staff survey, many of the themes
correlated with those identified through the Singleton Report and therefore one OD action plan was
developed to support the delivery of the OD strategy, the Staff Survey and the Singleton Report. The
monitoring of this took place through the Workforce & OD Committee and direct reports to Trust
Board.
Improve Engagement and Communication with staff and their involvement in decision making
Signing up to Listening into Action (LiA) was a key action to delivering strong direct staff engagement
and breaking down barriers that often exist in large hierarchical organisations. This process began
with the ’listening’ stage through the Big Conversations and then led to the development of schemes
to act on unlocking the blockages that employees perceive prevents innovation and service
improvement.
The ‘action’ stage identified schemes which were led by a triumvirate of doctor, nurse and manager
and were supported by LiA sponsors and Lean Six Sigma experts. A motivating and energising ‘Pass it
On’ event was held at the end of 2014-15 to share the successes that had been achieved, pass on the
learning to others and identify the next phase of schemes.
In relation to communication, key messages from Trust Board are shared electronically through
Board News and daily bite-size updates provided through Midday Mail. Face to face communication
is done through delivery of Team Brief to staff at all levels, Leadership Forum for managers in the
Trust and team meetings for all staff. Management supervision also provides a vehicle for ensuring
the delivery of Trust priorities and ensuring all staff are supported in meeting those priorities.
Delivery of service improvement in adult inpatients and urgent care has been staff-led through
engagement events, the development of Standard Operating Procedures across the Trust developed
by those on the front line and regular information sharing had formal consultations held to manage
change. Whilst the re-procurement/decommissioning of some services from Manchester City
Council has been difficult, front line staff have been engaged in developing new models of care
within a reduced cost envelope.
LiA continues to deliver staff led change and improvement right across the Trust. This has involved a
number of quick wins including:
•
•
•
•
the introduction of a scanned document facility on our Amigos Patient Administration
System (PAS)
Reduced waiting times for diagnosis and treatment within the Trust’s memory services
Introduced changes in the organisation of team meetings held in community settings in
order to avoid duplication and free up additional time for clients
Introduced additional IT learning suites across the Trust to improve access to e-learning for
our staff
59
•
•
Introduced a ‘Procurement Made Easy’ guide for staff which clarifies the procurement
process and reduce delays in receiving goods
Introduced a search engine onto our Amigos PAS in order to enable easy access to patient
data.
A key principle of LiA is that it fundamentally shifts how we work and lead, putting staff - who know
the most - at the centre of change. Its approach has created energy amongst staff and has provided
a focus for review. It has enabled us to reflect on developments, achievements and gaps, supported
us to get together across the service and provided space to discuss and think about what we might
do more collaboratively. Since we started, we have involved just over 200 people in frank and open
debate about the way they want to work, what gets in the way and how we could do things better.
This has been refreshing, invigorating and hugely rewarding to see people growing in confidence,
seizing the initiative and making a real difference to our traditional custom and practice. Our mantra
has been ‘better to ask forgiveness than permission’ as staff put forward all kinds of inventive
solutions to everyday glitches and problems. We are now in the implementation phase. We’ve got
11 pioneering projects and 5 enabling schemes underway. All developed collaboratively and all led
by our staff.
Implementation of e-rostering system to support appropriate deployment of staffing resources
The Project has been implemented in all inpatient areas and has commenced in community teams
and other clinical teams. The next stage will be achieving the benefits realisation phase of the
project against the Trust’s requirements for staffer staffing and ensuring we have the most
appropriate utilisation of staff across the Trust – the right numbers, with the right skills at the right
time.
Priority 2 – Learning lessons from root cause analysis
Review of root cause analysis (RCA) processes to ensure thorough understanding of the causes of
Serious Incidents Requiring Investigation (SIRI)
The Trust has reviewed its RCA processes, and with the support of an external company with mental
health expertise has delivered a reflective practice based workshop to 25 staff who are part of the
approved Trust register of SIRI investigators. The reflective practice workshop focused on three
completed cases where participants were able to critically evaluate the approach that was taken and
consider best practices approaches to the use of RCA techniques. This approach allowed the
opportunity for approved SIRI investigators to update their skills and refine techniques that enhance
and improve RCA reviews.
Implementation of a new Root Cause Analysis (RCA) process
The new process was agreed with commissioners and commenced in January 2015 based on the
learning form the reflective practice workshop. The process provides a ` health check ` for all SIRIs
declared and key components of the service delivered are examined including the CPA process, risk
assessments and prescribed treatment. Where any significant failings are found a more
comprehensive RCA is conducted. As part of the process the revised HLIPs will focus on the key
60
clinical leads and senior managers from the area where the SIRI occurred in terms of presenting the
case for review and outlining the changes in practice needed. It is intended that this approach will be
effective in ensuring that learning becomes more embedded through greater staff engagement.
Identification by teams and heads of service to provide a focus for quality improvement.
The Trust introduced and implemented a programme of ‘Peer Review Inspections’ based on the
CQC’s quality and risk profile in November 2014. The purpose of this activity was to support front
line staff in preparing for the CQC Inspection in March 2015. Each of the Peer review Inspections
involved groups of service users and carers, who were able to focus on specific patient focussed
aspects of the activity. Feedback from staff has been broadly positive regarding the Peer Reviews,
which will now continue as a standard going forward.
Following a rigorous recruitment activity which involved staff, service users and carers, the Deputy
Chief Nurse and Deputy Director of Quality Assurance was appointed and in post from January 2015
to support the Chief Nurse in providing a focus for quality improvement.
The role of the matron has been reviewed during 2014/15, with some operational requirements
having been removed to enable them to be visible clinical and quality leaders. This was agreed in
March 2015 and a workshop on 10th April will finalise this.
A Physical Health Care Lead was appointed in March 2015 to provide additional and focussed
support with the quality and safety requirements associated with the parity of esteem agenda for
physical health and mental health. The Professional Nurse Forum was also re-established in March
2015.
Priority 3 – Safe staffing
To ensure the right skills are in the right place at the right time is a key component of the Trust’s
clinical strategy and is a direct response to the implementation of the national nursing strategy
and the 6 C’s.
To ensure the right skills are in the right place at the right time is a key component of the Trust’s
clinical strategy and is a direct response to the implementation of the national nursing strategy and
the 6 C’s. During 2014/15, a set of standards for inpatient nurses was produced by the Deputy Chief
Nurse in collaboration with Ward Managers and Matrons at the Trust. The standards are aligned
with the 6 C’s.
This work, which was led by the Heads of Profession through the Multi-Professional vision and
strategy, focuses on the key skills of our clinicians that are required within our services. They also
embrace the culture and values set out with the Chief Nursing Officers strategy and vision of the 6
C’s in Nursing Practice. This has provided the cornerstone to approaches taken including those
around recruitment ensuring a more values based form of interviewing new recruits to the
organisation.
61
The Heads of Professions have adapted the inpatient nursing standards to produce a further set of
standards for all health care professionals employed by the Trust, which are also aligned to the 6 C’s.
The Chief Nurse and the Deputy Chief Nurse are members of the Greater Manchester and Lancashire
Nursing Revalidation Board, to support registered nurses to demonstrate the required skills and
experience in order to revalidate.
To review workforce requirements and to appropriately staff in-patient areas in line with this
review.
During 2014/15, the Trust has implemented a series of monthly reviews which look at workforce
requirements in relation to staff within inpatient services. These monthly reviews of staffing
transparently collate the numbers of bank and agency staff that have worked shifts and also
highlight the reasons why. In order to safely and consistently staff the inpatient wards, an
innovative agreement with the Directors of Nursing across Greater Manchester and Lancashire has
been agreed whereby staff can be requested from the nurse banks of neighbouring Trusts.
A review was also undertaken and presented to Quality Board and Trust Board focussing on
Registered Nurse to patient ratios and Registered Nurse to support worker ratios. Work is underway
to recruit to improve these ratios particularly at night with agreement reached to ensure that where
there were lower RMN to patient ratios, particularly at night, that this is addressed.
Monthly fill rates based upon established nursing levels are reported both at ward level on a daily
basis and monthly results are provided to the Trust Board. The Trust has also engaged in a scoping
exercise for staffing levels that is being led nationally by NICE to review the evidence around staffing
levels within inpatient mental health services.
Staff to present their experiences of care so that the Trust Board understands the care provided to
patients.
During 2014/15, the Trust has fully implemented the 90 day plan which was introduced following the
review undertaken by Sir Stephen Singleton. This was delivered via the Listening into Action
process- which has given staff a voice at all levels.
There have been a number of different opportunities for staff to present their experiences of
providing care which have included; Quarterly pulse checks the Staff Survey Staff Friends and Family
test and Schwartz Rounds. The Executive Team have also participated in a programme of ‘back to
the floor’ experiences. These have taken place throughout 2014/15 and have provided Executive
Team members with an opportunity to meet up with front line staff at service level, and to witness
any good practice, challenges or issues within those services. The executive back to the floor
activities have replaced the ‘leadership walk’ programme which has featured in previous Quality
Accounts. This was bought about as a result of feedback from our staff on how we could improve the
ways in which staff are able to present their experiences of providing care to our patients.
62
During 2014/15, the Trust continued to implement our innovative digital story programme. There
were occasions during the year where staff stories were produced as part of this story, and some of
these have been shown at the beginning of Trust Board meetings during the year. The main purpose
of the staff stories was to provide a reminder that all Trust Board discussions link directly to patient
care and treatment, highlighting the crucial role that staff take on in delivering high quality, safe and
effective mental health and social care services in Manchester.
‘Mike’s story’ was shown at the beginning of a Trust Board meeting held in June 2014. It offered a
frank and candid account of his journey into mental health nursing, as well as an insight into the
values and principles that still apply to his profession some 30 years later.
Mike’s story highlights a series of unsuccessful attempts at a variety of different careers, until by
accident he found himself in a mental health day hospital near Hull. This was Mike’s first
introduction into mental health services. He highlights his first day on an adult male long stay unit,
describing a positive experience with a patient that ultimately enticed him into the profession and
left a long lasting impression.
In producing his digital story, Mike reflected on the values and principles that are required within
mental health nursing, he described these as honesty, integrity and treating people with respect,
compassion and kindness.
On the day when Mike visited the mental health ward for the first time, he remembers that there
was very little interaction between the staff and the patients, and recalls how upsetting and
saddening this was to witness this at the time. He recalls how well he was received when he showed
some basic compassion and kindness to the patients, and the personal impact that this had. In his
story, Mike explained that the perceived culture of targets and performance sometimes gets in the
way of the ability of staff to live and breathe their values and principles on an everyday basis, using
their passion, expertise and experiences to bring about changes in ways which benefit front line care
and treatment.
The Trust is currently exploring the possibility of producing a further series of patient stories in
partnership with Patient Voices during 2015/16.
63
NHS Equality Delivery System (EDS2)
Assessment against the Equality Delivery System for Manchester Mental Health and Social Care
Trust.
The Equality Delivery System (EDS) has been created to help NHS organisations understand how
equality can drive forward improvements and strengthen the accountability of services to patients
and the public. By using the EDS, NHS organisations can also be helped to deliver on the Public
Sector Equality Duty (PSED). Manchester Mental Health and Social Care Trust has adopted the
system as the framework to achieve compliance with the Public Sector Equality Duty, and as a way
of demonstrating a robust commitment to this important equality, diversity and inclusion. It also
ensure that everyone - patients, public and staff - have a voice in how organisations are performing
and where they should improve.
At the heart of EDS2 are 18 outcomes, against which NHS organisations assess and grade
themselves. They are grouped under four goals;
1.
2.
3.
4.
Better health outcomes
Improved patient access and experience
A representative and supported workforce
Inclusive leadership
These outcomes relate to issues that matter to people who use and work in the NHS. EDS2 is not a
self-assessment tool. Performance is assessed and graded by NHS organisations in discussion with
local people and the workforce. To help with the grading, national and local sources of evidence are
given for each outcome. As NHS organisations use EDS2, NHS England will collate the particular
pieces of evidence that are being used for specific outcomes, with a view to sharing good practice
nationally. The Trust can be rated ‘undeveloped’, ‘developing’, ‘achieving’ or ‘excelling’ for each of
the 18 EDS2 outcomes. The Trust’s assessment against these outcomes is highlighted in the table on
the following page.
The Equality Delivery System works by ensuring that all of the work of the Trust is benefiting
protected groups in different ways. It is also about creating a future system where our stakeholders
are the ones that are assessing our performance rather than the Trust doing a simple self
assessment. The Trust has already identified that one of our main priority areas in better delivering
our equality objectives will be around strengthening our links with local communities and in
delivering more robust community engagement. Embedding this approach in the future will enable
the Trust to provide detailed information and evidence to local groups and organisations who can
then provide us with appropriate feedback on how well we are performing.
64
The Trust’s assessment against the Equality Delivery System for 2014/15.
Goal
Outcome
Evidence
1. Better health outcomes
1. Services are commissioned, procured
and designed to meet the health
needs of local communities.
2. Individual people’s health needs are
assessed and met in appropriate and
effective ways
3. Transitions from one service to
another, for people on care
pathways, are made smoothly with
everyone well-informed.
4. When people use NHS services their
safety is prioritised and they are free
from mistakes, mistreatment and
abuse
5. Screening, vaccination and other
health promotion services reach and
benefit all local communities
The Trust provides the Manchester Health & Wellbeing Service, which is a citywide service which
has a lead responsibility for improving the health of people across the city. This service works to
promote the health and wellbeing of all people who live or work in the city. Their teams include
Sexual Health and harm reduction, Public Mental Health, Preventing the Major Killers, Stop
Smoking, Resource and Information and Health Trainers, physical activity, oral health
improvement and the South Manchester healthy living network.
The NHS should improve
accessibility and
information, and deliver the
right services that are targeted,
useful, useable
and used in order to
improve patient
experience
The Trust works with individual service users and their families to assess needs and provide
services that are goal orientated and recovery focused. Any changes that need to be made to care
and services are discussed as appropriate with service users and their carers. The Trust regularly
seeks feedback from service users and carers on ways in which this can be improved, in order to
minimize the impact of change on individuals. The needs of service users are also assessed in line
with the Trust’s CPA policy.
The Trust has a range of safety policies in place which safeguard patients from abuse, harassment,
bulling and violence. Regular patient safety audits are undertaken with a minimum of 90 service
users on a monthly basis on inpatient wards. The results are these are shared with the Trust’s
commissioners and discussed during quality review meetings.
Goal
Outcome
Evidence
2.Improved patient access and
experience
1. People, carers and communities can
readily access hospital, community
health or primary care services and
should not be denied access on
unreasonable grounds
2. People are informed and supported
to be as involved as they wish to be
in decisions about their care.
3. People report positive experiences of
the NHS
The Trust is able to demonstrate that patients, carers and communities can access services and
are not denied access on unreasonable grounds. All service delivery related policies are equality
impact assessed against the protected characteristics as are any substantial service changes or
reconfigurations.
The NHS should improve
accessibility and
information, and deliver the
right services that are targeted,
useful, useable
and used in order to
improve patient
experience
The Trust is fully commitment to engaging with users and carers at a range of different levels and
in promoting equality of opportunity. This involvement helps to ensure that we are able to make
improvements to the care and treatment that is provided to individuals, and also contributes to
ongoing efforts to continually learn from the patient experience and drive forward improvements
across our services.
65
4. People’s complaints about services
are handled respectfully and
efficiently
A huge amount of activity has taken place during the current year. This activity supports the Trust
in providing high quality care and treatment and supports the organisation in becoming a more
responsive and better Trust.
The Trust uses a wide range of different mechanisms to capture the views of services users, and to
test out their experiences and levels of satisfaction with our services In total, during 2013/2014
4228 entry and exit questionnaires have been completed by service users across the Trust. These
questionnaires have been received from more than 70 different service areas from across each of
the care groups. The Trust provides a Patient Advice and Liaison service and operates a
complaints system in line with the NHS complaints regulations. These services are promoted via
posters and leaflets and are available in a range of different languages and formats if this is
required. The Trust also delivers customer care training to all staff through induction, face to face
training and e-learning.
Service users and carers have been working with the Trust’s complaints team to better
understand their experiences of using the NHS complaints system, with a view to changing our
procedures around how complaints can be better handled in the future. Service users have told
the Trust that the complaints system should be simple, quicker and more responsive, particularly
when complaints are raised at a local service level.
Goal
3. A representative
supported workforce
and
The NHS should Increase
the diversity and quality of the
working lives of the paid and
non-paid workforce, supporting
all staff to better respond to
patients’ and
communities’ needs
Outcome
Evidence
1. Fair NHS recruitment and selection
processes lead to a more
representative workforce at all
levels.
2. The NHS is committed to equal pay
for work of equal value and expects
employers to use equal pay audits to
help fulfil their legal obligations.
3. Training
and
development
opportunities are taken up and
positively evaluated by all staff.
4. When at work, staff are free from
abuse, harassment, bullying and
violence from any source.
The Trust has published a public sector equality duty paper outlining how it demonstrates due
regard in the exercise of its functions to the nine protected characteristics (age, disability, gender
reassignment, marriage and civil partnerships, pregnancy and maternity, race, religion and belief,
sex and sexual orientation). This document also published equalities information to demonstrate
our compliance with the duty, and in particular, provided information on all staff in post across a
range of areas including:
•
•
•
•
•
•
•
Trust profile and equality reporting (against the Manchester population)
Staff in post
Trust agenda for Change band profile benchmarking
Profile of current staff
Disability monitoring
Employee relations cases and disability monitoring
Recruitment activity
66
5. Flexible working options are
available to all staff consistent with
the needs of the service and the way
people lead their lives.
6. Staff report positive experiences of
their membership of the workforce.
•
•
•
•
New starters
Leavers
Employee relations
Training applicants and attendees
This information provided assurances across the current reported characteristics that recruitment
and selection processes are fair, and that levels of pay and related terms and conditions are
determined against a nationally agreed framework, which is fair and inclusive. Information is also
readily available and published within quarterly Trust Board reports to provide assurances that
appropriate staff development mechanisms are in place, and that staff are confident and
competent in delivering their roles.
The Trust also currently operates a range of staff specific policies to ensure that employees are
free from abuse, bullying, violence and harassment. Staff are made aware of flexible working
policies and procedures and are supported with major health and lifestyle issues through current
health and safety policies as well as access to occupational health services.
The Services also offer a number of volunteering opportunities to support individuals’ health and
wellbeing and move them through a process to paid employment as an outcome, if appropriately
identified (e.g. SMHLN with over 200 regular volunteers). Equality and Diversity training is
delivered via e-learning but also face to face which uses internal metrics as detailed above.
Training and development opportunities are widely advertised and taken up from mandatory
training through to apprenticeships, university modules and CPD. All training and development is
evaluated and evaluation results are reported to a Learning and Development Strategy Group that
meets monthly and is representative of the Trust Divisional structure. The Trust also uses value
based recruitment in order to ensure that we have the best possible staff to respond to our
patients and communities needs.
Goal
Outcome
Evidence
3. Inclusive leadership
1. Boards and senior leaders routinely
demonstrate their commitment to
promoting equality within and
beyond their organisations
2. Papers that come before the Board
All Trust Board members undertake induction training. A mandatory element of this is around
Equality and Diversity training. An annual equality and diversity report is provided for the Trust’s
Quality Board which sets out progress and achievements around equality and diversity, sets out
how the Trust develops relationships within local communities and with key partners across
Manchester.
NHS
organisations
should
ensure that equality is
everyone’s
business,
and
67
everyone is expected to take an
active part, supported by the
work of specialist equality
leaders and champions
and other major Committees identify
equality-related impacts including
risks, and say how these risks are to
be managed
3. Middle managers and other line
managers support their staff to work
in culturally competent ways within
a work environment free from
discrimination
The Trust Board receives regular updates on equality, diversity and inclusion within a combined
nursing and clinical governance report, and is aware of key developments, particularly in relation
the 2010 Equality Act.
There is awareness at Trust Board executive level of the Competency Framework for Equality and
Diversity Leadership. However this is not robustly applied at this stage.
All line and middle managers are required to undertake mandatory E&D training 3 yearly. This
training is integrated into the Trust’s e-learning platform and is also offered face to face and via
workbooks all of which complies with the Core Skills Framework content.
Learning & Development send mandatory training compliance reports on a monthly basis to all
managers. The reports include the overall Trust compliance figure (as all staff are deemed to
require E&D as core training), though the reports can be drilled down to the level of divisions,
services, departments and individuals.
Each of the Divisions receive updates around equality and diversity as appropriate during
governance and quality meetings.
68
Annual evaluation
The Trust has undertaken the above assessment against each of the outcome areas in the Equality
Delivery System. These assessments were shared externally as required and have also been
presented to the Patient Experience Committee. The Trust’s main objective under the EDS for
2014/2015 year were to identify equality and diversity ‘champions’ within service areas to ensure
that equality and diversity considerations are factored into service delivery and design.
The Trust has recently refreshed the E:Learning training and implemented the ‘core-lite’ national
programme. The key difference being that all staff (whether clinical or not) can take the assessment
first and if they pass with 100%, they are deemed competent and do not need to complete the
programme. We have also re-started a face to face delivery option in recognition that some staff
have difficulty accessing a PC or prefer face to face delivery. It is hoped that this will increase overall
compliance. Both the Equality & Diversity ‘core-lite’ E:Learning and Equality & Diversity face to face
training are at level 1 and cover Human Rights and Reasonable Adjustments.
The Trust reviewed and updated its Equality and Diversity Policy in June 2014. The purpose of this
Policy is to fully explain the commitment that Manchester Mental Health and Social Care Trust has
towards dealing fairly with issues of equality of opportunity and anti-discriminatory practice both in
the provision of services and in our role as a major employer. Trust staff have worked closely with
service users and carers in the development of a spiritual space on the old ‘chapel corridor’ at Park
House. This facility was opened in May 2014.
The Trust is developing Culturally-adapted Family Intervention (CaFI) to meet the specific needs of
African Caribbean people diagnosed with schizophrenia and their families. The treatment manual is
in development and the study will begin recruitment of 30 service users and families from inpatient
and community settings across the Trust footprint to test and evaluate CaFI early 2015. The Trust
will also implement cultural competency training for staff directly involved and seminars for the
wider organisation.
The Trust has been awarded a further £250,000 grant from National Institute for Health Research
(NIHR). This will involve a cultural adaptation of a brief psycho-education programme to increase lay
knowledge about schizophrenia with the aim of improving engagement and access to care for ‘hardto-reach’ ethnic minorities.”
During 2014/15 259 specific meetings and activities involving service users, carers, the community
and voluntary sectors and other local stakeholders were organised. These meetings involved Service
user and carer involvement within the Trust Research and Development committee, meetings with
Manchester Carers Forum, the delivery of service user and carer induction training and Trustwide
ward activities steering group meeting to name a few.
In total, during 2014/2015, 5094 entry and exit questionnaires have been completed by service users
across the Trust. This is an increase on the 4228 completed during 2013/2014. These questionnaires
have been received from over 75 different service areas from across each of the Trust’s divisions.
69
Of these, 2224 have been completed when service users first entered Trust services and a further
22870 were completed by service users when they were discharged either from one service into
another, or discharged from our services altogether. The Trust will continue to ensure that we
remain compliant with the demanding requirements of the 2010 Equality Act, and that staff are fully
aware of their own personal responsibilities around each of the protected characteristics so that we
can continue to offer safe, high quality and effective are to all of Manchester’s residents, regardless
of age, disability, gender reassignment, marriage or civil partnership, maternity or pregnancy, race,
religion or belief, sex and sexual orientation.
Patient Safety
Serious Incident Requiring Investigation (SIRI)
Our Integrated Risk Management and Clinical Governance Committee receives reports on all SIRIs in
the Trust. A SIRI is an incident which occurs, resulting in:
•
•
•
•
The unexpected or avoidable death of one or more patients, staff, visitors or members of
the public.
Permanent harm to patient, staff, visitor or the public where the outcome required lifesaving treatment.
An event that prevents or threatens to prevent the Trust’s ability to deliver healthcare
services.
Adverse media coverage or public concern about the organisation.
There were 53 SIRIs and 5 deaths in custody reported over the last twelve months, which represents
an increase compared to figures reported for the same period last year (April 2013 – March 2014).
The Trust records a low level of complaints where a SIRI has taken place. This has been an ongoing
pattern and a possible reason is because of the immediate involvement of relatives in the process
and the feedback mechanism of outcomes and learning in line with the Trust’s “Being Open and
Duty of Candour Policy”.
We are disappointed that these include three 12 hour breaches that occurred in Accident and
Emergency settings and a 12 hour wait in a prison cell. We have made changes to our escalation
protocols and are continuing to review with commissioners how best to prevent these from
happening. The details of the breaches are as follows:• On 14th February 2015 Patient C attended the Accident and Emergency Department at
University Hospitals of South Manchester NHS Foundation Trust (South A&E Dept) at
18.56hrs. After a number of assessments an informal admission was agreed at 1.40am. A
bed was confirmed in West Sussex at 8.00am (on 15th February 2015). During the period of
identifying an inpatient bed and arranging transport, Patient C deteriorated and due to
change in presentation, was assessed under the Mental Health Act and placed on a section
2. Private secure ambulance transport from Birmingham was arranged to enable
appropriate transfer to the bed in West Sussex. The Expected Time of Arrival (ETA) of the
transport was 15.00hrs; however the ambulance did not arrive until 16.41hrs. Patient C
left the A&E Dept at 16.55hrs. This meant that Patient C was in the A&E Dept for a total of
70
22 hours and for 15.17hrs after the original decision to admit (DTA) to an inpatient bed,
thus resulting in a breach of one of the Department of Health’s targets for A&E waiting
times [1].
• On 19/12/14 at 4.00pm Patient B attended the A&E Department at Manchester Royal
Infirmary (Central A&E Department). After assessment, a decision to admit was made at
6.35pm. It was found that he was resident in London and after contacts with services in
London a bed was identified. However transport could not be arranged to take him until
the following day. In the interim a bed was identified in Safire at 3.00am and arrangements
were made to transfer him by ambulance. By 4.00am the ambulance had not arrived due
to diversions to other emergencies. At 6.35am there was a 12 hour breach. The patient
was transferred to SAFIRE at 8.00am by a private ambulance company.
• On 12th July 2014, Patient A attended A&E Department at Manchester Royal Infirmary
(Central A&E Department) at 21.30 hrs. Patient A had a diagnosis of autism and severe
learning disability. Patient A was assessed under the Mental Health Act and placed on a
section 2 with a decision to admit made at 01.50hrs on 13th July 2014. A bed was formally
identified at 11.30am. Patient A did not leave the A&E Dept until 3.30pm. This meant that
Patient A was in the A&E Department for a total of 18 hours and for 13.7 hours after the
decision to admit to an inpatient bed. thus resulting in a breach of one of the Department
of Health’s targets for A&E waiting times.
• On 26th July Patient D was arrested and detained on following an assault on a member of
staff. Patient D was being transferred to A and E for assessment of their mental health
where a further assault of the ambulance crew occurred. As a result Patient D was
transferred to a police station and was not admitted to an inpatient bed until 31st July
resulting in being in a police cell for over 99 hours.
[1]
The Department of Health has set out targets for A & E department waiting times.
It is expected that the majority of patients (95%) who attend A & E will spend less than 4 hours in the
department. When a patient has spent more than 4 hours in A & E from the time they presented to the time
they left the department, this is recorded and reported as a 4 hour breach.
No patient should spend more than 12 hours in A & E following a decision being made that they need to be
admitted to an inpatient bed. If a patient remains in A & E for more than 12 hours following a decision to
admit them to an inpatient bed being made, this is recorded as a 12 hour breach (trolley breach). This classed
as a local “never event” and is reportable to NHS England, Monitor, and the Trust Development Authority, and
is investigated as a Serious Incident.
A decision to admit a patient to an inpatient bed is made when the assessing clinician (with admission rights)
sees the patient in A & E and decides they need further assessment or treatment in an inpatient facility. For
patients who are assessed under the Mental Health Act the DTA can be taken as when one or both medical
recommendations are completed.
71
Over the year we have continued to review and improve our SIRI process both in terms of timeliness
and quality of reports. We have made changes in the following areas and agreed revisions to our SIRI
process with commissioners as from January 2015.
•
The 24/72 hour report has been changed to a 24/48 hour report to ensure timeliness’ in
identification of SIRIs and establishing a SIRI investigation team to review the incident.
•
There are now revised timescales for internal submission of SIRI reports to the Chief Nurse
to allow sufficient time for amendments and any additional information requests.
•
All SIRI investigators are tasked with ensuring that feedback is provided to the staff and
teams that have been involved in the incident.
•
We have delivered additional training for all our SIRI investigators from an external company
with mental health expertise for all SIRI investigators. The workshop which was attended by
25 staff comprised of a review of three recent SIRIs, with presentations from the panel chairs
followed by a critical friend challenge exercise.
•
The workshop, which was well received by the participants, allowed the opportunity to
consider a standardised best practice approach to investigations and report writing to
further improve the overall quality of the final reports.
• Changes have been made to the High Level Investigation Panel (HLIP) process specifically in
relation to who presents the SIRI reports to the High Level Investigation Panel Meetings, so
that the lead clinician for the division takes responsibility for the dissemination and
implementation of the learning.
A HLIP meets once our SIRI review panel has concluded their investigations. These meetings are
chaired by a Non-Executive Director and attended by Executive Directors, members of the Risk Team
and senior Managers and clinical leads from the service area where the SIRI has occurred. The HLIP
panel considers the information gathered and seeks to challenge, promote improvement and ensure
strategic involvement and awareness in the SIRI. This supports the local services in affecting change
but also ensures Trust Wide learning and promotes our Trust values of Truthfulness, Respect,
Understanding and Togetherness by involving a wider team.
Mechanisms for embedding learning
There are regular reports on themes and learning which are provided a part of the SIRI process,
complaints and PALS function as well as patient experience , this supports the organisation to be
attuned to the areas of practice that need improvement. There are a range of mechanisms to
integrate this learning into Trust business examples include;
•
The use of Effectiveness Days to focus on themes that have been identified in SIRISs.
Examples of this include topics on, dual diagnosis, physical health.
72
•
Safeguarding Children Annual Improving Practice day focuses on key learning both from
any SCRs where there were mental health factors but also from other SCRs across
Manchester.
•
Identification of specific SIRI factors as a source on risk registers.
•
Identification and use of CQUIN measures to improve practice in areas that have been
identified through SIRIs. Current examples on this include the work on CHORES,
monitoring of observations and learning lessons once.
•
Assigning specific work steams as part of the Matrons work plan, e.g. auditing care
plans, designing ward round proforma, undertaking resuscitation equipment audits.
•
Production of learning from SIRIs by the suicide prevention group and publication of
learning points on the Trust intranet page.
•
Patient Safety campaigns e.g. Falls week, Medication Matters Safety Week.
•
Changes to content of training packages or introduction of new training in response to
learning from SIRIs .e .g Physical health training to in patient staff, revised clinical risk
assessment training after the learning from the Mr Z homicide review.
•
Identification of priorities for improvement in the annual Quality Account.
Incident Reporting
The total number of incidents reported over the past 12 months (April to March 2015) has been
5390 this is compared to 4801 for the previous year. A substantial amount of work has been
undertaken in 2014-2015 to improve incident reporting rates and their quality. Training has been
delivered to a wide range of staffing groups who both report and review incidents.
As well as internal incident reporting, the Trust also contributes to the National Reporting and
Learning System (NRLS). This system looks at incidents where there has been an identified patient
safety incident.
The most recent nationally reported figures for 1st April 2014 to 30th September 2014 were published
on 8th April 2015. This is highlighted in the following graph, which compares a cluster of 56 Mental
Health Trusts across the country; the comparative reporting rate is per 1,000 bed days.
During the period the Trust reported 1419 patient safety incidents through to the National Reporting
and Learning System (NRLS). This compares with a reporting rate of 942 patient safety related
incidents for the same period the previous year.
73
The Trust is pleased with the increase in reporting rates and it is reflective of improvements that
have been made throughout the year within the organisation and in partnership with NRLS. The
Trust continues to be in the mid range of reporting however that position has improved
considerably over the past year and continues to move higher in the mid range field.
Safeguarding Adults
Ongoing work includes:
• A Safeguarding Adults Governance Group that meets monthly and provides the Trust with a
safeguarding oversight meeting to review case audits / monitor action plan and feedback to
teams on any practice issues.
• Regular monthly Quality Assurance audits of 20 cases, focussing on specific teams across the
Trust each by experienced social workers – with learning fed back to care coordinators and
managers. This is reported to the internal safeguarding governance meeting each month.
• Improved reconciliation of Manchester integrated Care and Recording Environment (MiCare)
referrals onto Amigos, with monthly reports produced and fed back to Manchester City
Council (Section 75 Group).
74
•
•
•
•
•
•
Agency social worker in post plus one day per week practice support from an experienced
social worker / Approved Mental Health Practitioner (AMHP) to support teams.
Additional training sessions provided to teams as requested.
Two-day training course taking place later this year.
Job description prepared and sent to Establishment Control Panel (ECP) for safeguarding
practice lead.
Established a regular quality assurance programme that considers safeguarding investigation
processes and the quality of these through a clinical case review audit. We received a
significant assurance opinion for the joint Safeguarding Audit in November 2014.
We have implemented a more robust root cause analysis process to further improve and
embed organisational learning.
Over the next year, the adult safeguarding process will continue to be improved and monitored.
Patient Experience
Survey Outcomes-Care Quality Commission Survey of Community Mental Health Services
In September 2014, the Care Quality Commission (CQC) published its benchmark report and national
survey of community mental health services in England. The report provided an overview of key
results against each of the questions asked in the survey, and compared Trust scores against those
achieved by other mental health Trusts across England.
The 2014 survey of people who use community mental health services involved 57 NHS trusts in
England (including combined mental health and social care trusts, Foundation Trusts and community
healthcare social enterprises that provide mental health services). The CQC received responses from
more than 13,500 people, a response rate of 29%. The response rate for the Trust was 27%, which is
2% below the national average. This is consistent with previous returns. Service users aged 18 and
over were eligible for the survey if they were receiving specialist care or treatment for a mental
health condition and had been seen by the trust between 1st September 2013 and 30th November
2013. The survey included people in contact with local NHS mental health services, including those
who receive care under the Care Programme Approach (CPA). Fieldwork took place between
February and June 2014.
The table below provides a snapshot of Trust scores for each section of the survey report, in
comparison with the 57 other mental health trusts in England.
75
Thematic scores from the 2014 national patient survey
In 2014, Trust scores were better than all other mental health trusts in relation to ‘Your Health and
Social Care Workers’. They were about the same as all other mental health trusts in the remaining 8
thematic areas. Out of the 33 questions, The Trust received better scores in comparison to other
mental health trusts in England in 5 areas.
Areas where Trust scores were considered as ‘better’ by the CQC
Question
Trust Score
Highest score
received
Does the care plan you receive take your personal circumstances into account?
8.3 out of 10
8.3 out of 10
Were you given enough time to discuss your needs and treatment?
8.3 out of 10
8.4 out of 10
Were you involved as much as you wanted to be in discussing your care?
8.5 out of 10
8.6 out of 10
In the last 12 months did you get help around your physical health needs?
6.0 out of 10
6.1 out of 10
Did staff understand how your mental health needs affect other areas of your life?
7.8 out of 10
8.1 out of 10
In the 2014 survey report, the highest thematic Trust scores received were around ‘planning your
care’ (8.9 out of 10), and the lowest were received around ‘other areas of life’ (5.4 out of 10).
However, Trust scores for ‘other areas of life’ are still comparable to those received by the 57 other
mental health trusts in England.
76
Trust scores are generally comparable to scores received by neighbouring mental health trusts in the
North of England. MMHSCT was ranked either second or third in five out of nine thematic areas.
Trust
H&SC
workers
Org
Care
Planning
care
Reviewing
care
Other
areas
Overall
5 Borough's
7.5
8.3
6.9
7.5
6.1
6.3
6.8
4.6
7.1
CWP
8.2
9
7.8
8
6.6
7.3
7.6
5.8
7.8
MMHSCT
8.3
8.9
7.5
7.9
6.7
6.3
7.4
5.4
7.6
Merseycare
8.1
8.9
7.5
8.2
6.1
6.9
7.7
5.6
7.5
Lancs Care
8
8.8
7.4
7.8
7.1
6.8
7.8
5.5
7.4
Pennine
Care
8
8.7
7.2
7.7
6.9
7
7.3
5.5
7.4
GMW
8
8.6
7.1
7.8
6
6.7
7.3
5.4
7.5
Cumbria
8.4
9
7.5
7.8
6.9
6.9
7.6
5.6
7.5
Leeds/York
8.1
8.6
7.4
7.8
7.4
6.4
7.4
4.9
7.5
8
8.6
7.1
7.6
5.6
6.6
7.1
5.6
7.2
7.9
8.7
7.3
7.5
6.4
6.6
7.2
5.7
7.5
Bradford
Derbyshire
Changes
Crisis
care
Treatments
Comparison of thematic scores for 2014
MMHSCT scores compared to the highest Trust scores from the North of England
MMHSCT
Highest North of England score
9
8.4
8.9
7.8
8.2
7.4
8.3
7.5
7.9
7.4
6.6
7.8
7.8
7.3
7.6
5.8
6.3
5.4
H&SCW
Org care
Planning
care
Reviewing
care
Changes
Crisis care
Treatments Other areas
Overall
The Trust also received the fifth highest overall aggregate score of neighbouring mental health trusts
in the North of England. This is based on the combined scores from each of the thematic areas and is
highlighted in the graph below. The total aggregate scores were just short of those reported from
Merseycare NHS Trust and Lancashire Care NHS Foundation Trust, with the highest scores in 2014
coming from Cumbria Partnership and Cheshire and Wirral Partnership NHS Foundation Trust.
77
2014 Patient Survey aggregate scores
Trust aggregate score in comparison to neighbouring mental health trusts
70
68.1
68
67.2
66.6
66
64
62
66.5
66
65.7
65.5
64.8
64.4
63.4
61.1
60
58
56
Complaints and PALS Activity
During 1st April and 31 March 2015 the Trust received 189 formal complaints (including joint
complaints where the Trust took the lead in the investigation) from service users, relatives and
advocates representing an overall decrease of 4% compared with 2013/14.
The Trust welcomes feedback from service users, carers and their families and both the Complaints
and Patient Advice and Liaison Service (PALS) team will work together to continue to promote
services and signpost people to the complaints procedure where issues cannot be resolved locally.
During this period, 189 complaints were made by 168 complainants, with multiple complaints being
received by 17 of 168. Where complainants make multiple complaints in quick succession an
investigating manager from another part of the service, or a more senior manager, will review the
complaints to ensure fair investigations are taking place.
The most significant changes were seen by a reduction in the number of complaints received by the
Adult Inpatient Service, a decrease of 44% and Adult Community and Social Inclusion, a decrease of
15%.
By comparison, the Corporate Services showed an increase of complaints in which there were 9 in
2014/15 compared to 1 in 2013/14. Complaints concerning Later Life Inpatient services increased
from 5 in 2013/14 to 15 in 2014/15 and Prison Health Services showed an increase of complaints
from 4 in 2013/14 compared to 9 in 2014/15.
In total, 14 complaints were reopened during 2014/15 compared with 19 complaints reopened in
2013/14, which is a decrease of 26%.
78
The PALS service received 1,253 enquiries to their service during 2014/15, a decrease of 26%
compared to the previous year. Of the 1,253 enquiries, 156 concerns were logged, which represents
a decrease of 20% compared with the previous year.
The PALS team provided support to the complaints service during 2014/15 therefore reducing their
activity on the wards. In addition, 29 local complaints/concerns were resolved and reported by 17
teams/wards to the complaints department by frontline staff, which represents a decrease in the
reporting rate of 24% compared with the previous year.
During the period 1 April – 31 March 2014 the Trust received 66 compliments from service users and
their relatives during quarter four, making a total of 415 for 2014/15.
The following chart provides an overview of data for 2014/15 in comparison to 2013/14:
Comparison of Complaints, PALS activity and Compliments
2013/14 to 2014/15
1800
1692
1600
1400
1253
1200
1000
800
450
600
415
400
196
189
200
38
29
0
Complaints
PALS Contacts
2013/14
Informal
Concerns/Complaints
Compliments
2014/15
There were 6 Ombudsman referrals during 2014/15, which is the same in comparison to 2013/14.
Of the 6 referrals, two investigations are completed and have been returned both not upheld and
with no further actions. The remaining four are still with the Ombudsman.
There were 46 Inquests held in 2014-15 and at the end of the reporting period there were 46
outstanding inquests. The Trust received five Regulation 28 Reports from the coroner in 2014/15.
The Reports were discussed at Integrated Risk Management and Clinical Governance Committee.
The attendant action plans will be monitored by Integrated Risk Management and Clinical
Governance Committee and progress reported to Quality Board.
* The Coroner now has a legal power and duty to write a Preventing Future Death reports (PFD) or
Regulation 28 Report following an inquest if it appears there is a risk of other deaths occurring in
similar circumstances. This is known as a 'report under regulation 28' because the power comes
79
from regulation 28 of the Coroners (Inquests) Regulations 2013. The report is sent to the people or
organisations who are in a position to take action to reduce this risk. They then must reply within 56
days to say what action they plan to take.
Improvements in Patient Engagement
Service User and Carer Engagement
Providing high quality care and improving the experiences of our service users and carers is an
important aspect of what we do. Capturing and responding to the views of our service users plays a
central part in the wider quality improvement agenda at the Trust. The Trust has a range of
mechanisms in place which it can utilise in order to gauge the views and experiences of service users
and carers on a wide range of care and treatment issues.
During 2014/2015, the Trust has continued to offer service users opportunities for involvement in a
range of different activities at different levels, in accordance with our service user and carer
strategies. These activities are helping to build and strengthen the relationships between staff,
those using our services and their families. This engagement is helping the Trust to learn from these
experiences, to continually improve the quality of care and treatment provided and to ensure that
service user and carer involvement continues to be a core value at the organisation. During 1st April
2014 to 31st March 2015, 259 activities, including meetings, focus groups, listening exercises and
local forums were organised specifically for service users, carers, and the wider public. This is
comparable to the 260 events that took place during 2013/2014.
Considerable effort has gone into increasing the mechanisms that the Trust has created to ensure
that it can listen to the views of service users and carers and increase its intelligence-gathering
around a wide range of patient experience issues. Some of these developments have included:
• Continuing our work to involve patients and their families in activities to improve and enhance
care planning processes as part of a 5-year Care Programme Approach National Institute for
Health Research (NIHR) programme grant. Further workshops are planned for service users,
carers and staff.
• Provided a robust response to the Francis report, and formally accepted all recommendations
relating specifically to patient involvement and patient feedback.
• Delivered an annual programme of innovative digital patient and carer stories.
• Worked in partnership with service users and carers to examine candidate values within the
Trust’s recruitment and selection processes.
• Trust representatives spoke at the NHS East of England regional conference on patient
engagement and use of digital storytelling.
• Reviewing the arrangements around the Trust’s service user and carer forum, to ensure more
ownership over agenda setting and exploring different ways of working.
• Receiving the 2014 PLACE assessment results for the Trust, and participating in further interim
PLACE assessments in partnership with service users and carers.
• Involving service users and carers at the Trust’s annual general meeting, and showcasing our
work around Dementia and later life services.
80
• Involving service users and carers in the launch of a mental health charter, in partnership with
Manchester’s community and voluntary sector.
• Involving service users and carers in the early development of CQUIN priorities for inclusion in
the 2015/2015 contract.
• Working with service users and carers to develop quality priorities for 2015/2016.
• Involving service and users directly in the delivery of the Trust’s Clinical Audit Programme.
• Completing an early implementation project to embed the patient Friends and Family Test in
accordance with national guidance.
• Supporting the service user and carer voice to participate in ongoing consultations around
Manchester City Council’s funding reductions.
• Working with service users and carers to develop quality priorities for 2015/2016, for inclusion
within the 2014/2015 Quality Accounts.
• Involving service and users directly in the development of the Trust’s Clinical Audit
Programme for 2015/2016.
• Commencing the fieldwork element of the 2015 national patient survey of community mental
health services.
• Securing national recognition at the 2015 PENNA national awards as a result of the service
user and carer engagement around the inpatient service improvement programme.
• Continued support for the establishment of a city wide patient council to further increase the
impact of the user/carer voice within Manchester, including discussion at the Trust’s Service
User and Carer Forum, and at the Executive Team.
• Continuing to monitor whether or not our service users have had their rights explained to
them if they were detained under the Mental Health Act.
• Ensuring service users and carers have a voice in the redevelopment of outcome based
recovery services in Manchester.
• Designing and distributing ‘contact cards’ for service users so that they can use their
smartphones to access information on meds and side effects, and to ensure they have up to
date information about how to contact their care coordinator in a crisis.
• Developing and publishing an easy read guide for patients and carers on the Trust’s ongoing
work to eliminate mixed sex accommodation and maintain privacy and dignity within inpatient
settings.
These activities will strengthen the current systems for service user and carer engagement and will
also ensure that the Trust continues to broaden the range of mechanisms available to service users
and carers who want to become involved, as well as the ability to capture the patient experience in
more inclusive ways.
Patient Stories
Patient stories were first introduced at the beginning of 2012, and are shown at the beginning of
each Trust Board meeting. The Trust has continued to implement its patient story programme
through 2014-15. The programme aims to develop awareness around the impact of Trust services as
experienced by our service users. The programme has been developed as part of ongoing
arrangements to improve dignity and respect across all health and wellbeing services. The stories are
delivered as two- to three-minute digital vignettes, with a voice-over from the service user.
81
In 2014-15, the majority of Trust Board meetings have started with a patient story. A number of
themes and trends have emerged within the stories themselves. These issues include the
importance of kindness, compassion and dignity when providing care and treatment, and meeting
the physical health needs of our service users. Some stories highlight challenges around mental
health stigma, the need for a more integrated and joined up healthcare system, issues around dual
diagnosis and the stigma that can be associated with mental illness.
Service users reflected on how they had sometimes faced challenges when discussing their mental
health needs with GPs, and highlighted experiences when care coordination and integrated working
across different agencies and services had not been as robust as it could have been. The stories also
highlighted themes around sexual abuse, depression, drug addiction, homelessness and alcohol
misuse and the impact that these issues can have on ongoing mental health difficulties.
The stories have also identified a range of important lessons learned, particularly around recognising
that mental illness can lead to loneliness and social isolation for many people if left unsupported.
They also serve as a reminder to staff in terms of recognising and addressing any physical needs that
our service users may have. Other important issues highlighted include the significance of providing
carers and families with good information, advice and support to help them undertake their caring
role, and the importance of ensuring that there is appropriate and robust communications between
the different agencies and organisations that provide help and support to our service users and their
families in Manchester.
The Trust has taken steps to address many of the issues identified from the patient story
programme. We have developed a welcome pack for all new admissions onto inpatient wards. This
provides important information relating to the rights and responsibilities of patients who have been
detained under the Mental Health Act. A separate information pack for carers has also been
drafted. This also provides helpful information aimed at families and signposts carers to local
organisations where additional help and support can be available. We also continue to work in close
partnership with Manchester Carers Forum, to ensure that the voice of carers can be heard at
different levels within the Trust.
The Trust offers a range of services that can support Manchester residents who suffer from anxiety
and severe depression. The Complex Primary Care Psychology Service provides specialist, evidencebased psychological therapies to clients with chronic, complex emotional adjustment disorders.
Clients are referred either direct from GPs and other healthcare providers, such as Consultant
Psychiatrists, or who are 'stepped-up' from briefer, less intensive interventions provided by local
primary care mental health teams.
The Recovery Pathways service is the Trust’s social care, recovery and inclusion service. They help
people to lead valued lives by providing or enabling access to high quality support, goal-focused
activity, self-developmental study, training and employment services. The service aims to enable
personal recovery and wellbeing strategies, build confidence and skills, and support access to
socially inclusive moving on opportunities. The services are able to help people to have aspirations,
achieve their goals and be part of their communities. The service is broken down into a range of
82
areas which include Recovery and Connect Teams (running the Enablement Programme), Creative
Wellbeing - incorporating Start and Studio One and occupational therapy.
The Trust’s Creative Wellbeing service is an evidence-based service comprising Start and Studio One
and offers structured and goal focused creative wellbeing activities including ceramics, mosaics,
painting & drawing, photography, textiles, and mixed media. Through specially constructed
interventions that embed wellbeing awareness into creative activities, the team help people to
notice, improve and maintain mental wellbeing, develop coping strategies and self-management
skills, and feel greater empowerment in their lives. Creative Wellbeing teams work alongside the
Recovery Pathways Occupational Therapists, who support people using services, and offer specific
interventions to help people overcome challenges and barriers to engagement.
Creative Wellbeing helps people to regain confidence and rebuild skills to move on to wider
opportunities in education, training, employment or the community. Goals are discussed from the
outset, and people who receive a service meet regularly with their individual art tutors to review
needs, aspirations and goals.
Through our Brian Hore Unit, the Trust is able to offer abstinence-based treatment for people with
alcohol problems, including those with dual diagnosis (people with both substance abuse and mental
health issues), who live in Manchester. Emphasis is placed on individual and group therapy and the
unit aims to provide patients with the knowledge and skills they need to live a good quality of life
without alcohol or illicit substances. Patients are expected to attend sober and not be under the
influence of illicit drugs, so that the environment is supportive and conductive to change. Patients
are encouraged to take responsibility for their own recovery and use their experience to help other
patients in groups.
All clinical staff at the Trust are now required to undertake mandatory training around dual diagnosis
every two years, and for specific staff there is a mandatory one day workshop where issues are
explored in much fuller detail. The Trust also provides a Dual Diagnosis service, which manages the
treatment of service users who have a history of substance misuse and concurrent mental health
problems. This is a citywide service with a clinic at each in-patient site in the Trust. The Dual
Diagnosis Team provides services, offers advice and intervention and provides guidance to
practitioners, service users and carers involved with a range of health and social care agencies.
The Trust provides a Homeless service which is a small specialist community based team who work
with people who are homeless where there are concerns over their mental health. The service,
which has clinics and liaison workers at hostels provides initial mental health assessments and follow
up care if required.
The Trust provides information to staff on different agencies that can offer help and support to
service users who have experienced abuse or other similar traumatic experiences. This includes
organisations such as Victim Support and the Men’s Advice Line. The Trust also has in place a robust
safeguarding adults at risk procedure which both supports and informs practitioners in their work to
safeguard adults currently at risk of abuse or mistreatment.
83
The Trust's psychotherapy services provide specialist, evidence-based psychological therapies to
clients with personality and complex chronic emotional adjustment disorders. Clients are referred
either direct from GPs and other mental health providers or are stepped up from briefer, less
intensive interventions provided by local primary care mental health teams. Clients will usually have
had a previous mental health intervention, and have a degree of complexity such as personality
disorder, poor response to previous psychological interventions or difficulty with engagement.
Entry and Exit Questionnaires
The Trust employs entry and exit questionnaires as a means of testing patient satisfaction, and has
continued with this approach during 2014/2015.
The aim of the questionnaires is to capture the views of service users when first coming into contact
with Trust services, or when moving along the care pathway. The questionnaires are then offered
again to service users when they have been discharged either from one service into another, or
discharged from Trust services altogether.
In total, during 2014/2015, 5094 entry and exit questionnaires have been completed by service users
across the Trust. This is an increase on the 4228 completed during 2013/2014. These questionnaires
have been received from over 75 different service areas from across each of the Trust’s divisions.
Of these, 2224 have been completed when service users first entered Trust services and a further
22870 were completed by service users when they were discharged either from one service into
another, or discharged from our services altogether. Over the course of the year, this has provided
the Trust with the following information.
Upon entry into Trust services (out of 2224 completed questionnaires)
2013 to
2014
score
2014 to
2015
score
81%
86%
Service users who stated that mental health staff took enough time to listen to them and
explain what would happen and how they would help upon entry to services
95%
94%
 -1%
Service users felt that staff spoke to them about personal goals and outcomes upon entry
into the service
90%
92%
 +2%
Question Area
Service users at the Trust who found that access into services was either easy or very easy
Shift in
score
 +5%
84
Upon exit from Trust services (out of 2870 completed questionnaires)
2013 to
2014
score
2014 to
2015
score
Service users who felt that the treatment they had received had met most or all of their
needs
86%
89%

+3%
Service users who felt that they were involved in making decisions about their care and
treatment
88%
90%

+2%
Service users at discharge who indicated that the staff who were involved in providing
their care were helpful
95%
95%

Service users who rated the overall quality of the care they had received as either good or
excellent
94%
93%

-1%
Service users who stated that they had been given information about how to get help in a
crisis upon discharge
91%
90%

-1%
Service users who would recommend the Trust to friends and family if they needed
similar help and support with their mental health needs
92%
91%
Question Area
Shift in
score
No
change
 -1%
Despite a slight deterioration in scores in some areas from those reported in 2013/2014, The Trust is
pleased to report that the majority of service users provide positive feedback at both entry into and
exit from Trust Services.
Eliminating mixed sex accommodation/patient safety audit
As part of the Trust’s quality reporting schedule, there is a requirement to ask a minimum of 90
inpatients each month specific questions in relation to eliminating mixed sex accommodation
(EMSA), and whether or not they feel safe whilst staying on Trust inpatient wards.
For the 12-month period from April 2014 to March 2015, 1897 out of 2541 service users asked, 2384
(94%) indicated that they always felt safe whilst on a ward.
Month survey
undertaken
April 2014
May 2014
June 2014
July 2014
August 2014
September 2014
October 2014
November 2014
December 2014
January 2015
February 2015
March 2015
TOTAL
Number of
Patients asked
232
262
231
248
267
186
263
188
237
159
91
177
Patients who always
felt safe
221
246
215
232
255
177
247
168
222
149
89
163
Patients who did
not feel safe
11
16
16
16
12
9
16
20
15
10
2
14
Average
Percentage
95%
94%
93%
94%
96%
95%
94%
89%
94%
94%
98%
92%
2541
2384
157
94%
85
Patient report safety on Trust inpatient wards - annual summary
April 2014 to March 2015
100%
2
98%
11
12
16
16
9
16
16
15
10
98%
96%
14
20
94%
96%
95%
94%
93%
92%
95%
94%
94%
94%
94%
92%
90%
89%
88%
86%
232
262
231
248
267
186
263
237
188
84%
159
91
177
82%
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
Always felt safe
Did not
average %
With the exception of November 2014 (89%), for all other reports over 90% of all service users
staying on a trust inpatient ward always felt safe.
This is comparable to the report provided in the 2013-2014 Quality Account which reported that out
of 2014 service users, 1897 (93%) fed back that they felt safe whilst staying on one of the Trust’s
inpatient wards. There were no mixed sex accommodation breaches in 2014-2015 on any of the
Trust’s inpatient wards.
Effectiveness
Transformation Programme
Transformation Programme is the name we have given to our review of the multi-professional
services strategy. It reminds us that everything we do should be designed with our core objectives in
mind, developed in partnership with staff, service users and carers to ensure it is fit for purpose and
delivered at the point of need.
Our ambition is to create a fully integrated model of care so we can deliver end-to-end care
pathways tailored to the needs of individual service users. Our Stepped Care Model of service
delivery will support these pathways with the focus on supporting the service user at the right time
(step), in the right place and with appropriate stepping up or down to reflect their needs (right care).
Since April 2014, the Trust has been building upon its approach with stronger emphasis on clinical
leadership via it’s Transformation Programme Board, as well as service transformation and
integration, thus ensuring services can meet the needs of the future in the most cost-effective and
efficient way within the identified financial resources.
86
The Trust Board approved the planned service improvement projects as outlined in the Trust’s two
year operating plan for 2014-15 and 2015-16 and regular updates are provided regarding progress.
As part of the Trust’s wider Transformation programme during 2014/-15, the specific areas of
development and improvement undertaken:
•
Strong focus on uniformity and consistency of practice across all inpatient and urgent care
teams in an integrated way including the reductions in length of stay and the
implementation of standard operating procedures;
•
Complete redesign of current urgent care services to establish a 24/7 service across the city
with the creation of new teams to improve the timely access to crisis support, home
treatment and/or inpatient services where appropriate and maximise the inpatient capacity
with variation in practice minimised;
•
Commencement of redesigning Adult Outpatient Services with the initial focus on reducing
variation in practice across the different consultant teams and standardisation of
administrative processes;
•
Piloting of mobile working to support community staff.
The next phases of transformation are:
•
Development and implementation of a model for Outpatient Services which is a fully integral
part of the Trust’s Community Services;
•
Full implementation of mobile working for all Community Services;
•
Redesign of ‘ageless’ Community Services with appropriate embedding of standard
operating procedures to minimise variation of practice across the city of Manchester;
•
Alignment of Trust services to support the Manchester’s Living Longer, Living Better
Programme of reform for delivering integrated care with other partners including NHS, local
authority and voluntary sector.
Divisions Review of Quality Performance over the Year
Our Divisions are the operational working groups split by service. The Divisions in the Trust lead on
the operational application of the business, governance, quality and performance elements. They
meet monthly, with meetings often being split into business and governance sessions with various
other working groups to lead on individual projects. They are multi-disciplinary meetings and feed
into the Operational Management and Performance Committee. Additional information being
available on request to quality.admin@mhsc.nhs.uk
Some examples of the work completed by the Divisions in year are:
Psychological Services Division (PSD) - Introduction to our PSD Services and Approach to Care
Working across our Community Mental Health Teams, Primary Care Mental Health teams,
Psychotherapy Services, Later Life Services and Physical Health Services, our Psychological Services
87
Division offers a broad spectrum of psychological assessment and specialist, evidence-based
psychological therapies to clients experiencing a range of complex emotional adjustment disorders,
psychosis and personality difficulties. The Division also comprises a specialist citywide eating
disorders service and citywide psychosexual service. During 2014-15 we have been providing
temporary management oversight of additional Trust services such as Health and Wellbeing
Services, ADHD Services, Dual Diagnosis and Alcohol Services and the Specialist Affective Disorders
Service.
In addition to direct clinical activity, PSD also supports other areas of service delivery via indirect
work, including training, consultation, supervision, sharing of case formulation, audit and research
activity.
Psychological Services has a reputation within the Trust for quality and innovation and contributes
significantly to wider operational and strategic agendas. Members of PSD also make a substantial
contribution to Trust business - for example, as chairs and panel members of Trust reviews into
Serious Incidents. Team members also support the Trust’s staff wellbeing agenda via provision of
specialist psychological therapies for staff, including mindfulness groups and drop-ins.
The Division has close links with the University with respect to clinical research projects and has a
number of academic joint appointments within the staff group. The Division is the host for the
Manchester University Clinical Psychology Doctorate Training Programme and is strongly committed
to the maintenance and further development of these contributions, as well as to increasing the
scope and range of services it provides.
Some examples of the key quality achievements of the past year within the Psychological Services
Division are as follows:
Achievements:
•
Transforming our Step 3 and 4 Services to deliver more equitable and efficient services
whilst still retaining service quality. This has included standardisation of our letters across
services, and a number of waiting list initiatives, such as the establishment of a single
Cognitive Analytic Therapy waiting list, to ensure equity of access across the city.
•
Held a successful PSCG Away day in March 2014, with presentations by our service user
group (Manchester Psychological Service User Movement), our staff group, clinicians,
researchers and senior managers, with clinical workshops held on quality clinical practice.
•
Successfully established new Mental Health Practitioner posts in South Manchester
Integrated Care (Neighbourhood) Team to assist with the integrated care agenda and
worked towards delivering this model for the North of the city, with the support of North
CCG.
•
Secured funding for new Physical Health Psychology posts from the acute Trusts of
Manchester to improve the clinical services available to people with physical health
problems.
88
•
Initiated a service transformation project within our IAPT services, following guidance from
the National IAPT team, which is helping to reduce our waiting times at this step of care,
along with other service efficiencies.
•
Provided training to IAPT Psychological Wellbeing practitioners in the Northwest to enhance
their effectiveness using basic level Psychodynamic Interpersonal Therapy skills. This
training is delivered in partnership between the Trust and Manchester University and
commissioned by Health Education Northwest.
•
Established new weekly Drop-in/One –Stop resource at Harpurhey Wellbeing Centre, which
includes mini assessments for people who have been referred to the PCMHT and where risk
may be present.
•
Strengthened links with our Service User Group MPSUM, who attend Psychological Services
Management Group on a quarterly basis and contribute to recruitment of our clinical staff.
•
Reduced waiting times in our Mental Health Neuropsychology service and centralised this
service to deliver service efficiencies.
•
Established Living and Learning (DBT) Groups for older people with Personality Difficulties
and delivered training in PD to a wide range of other staff groups.
•
Took an active part in research projects and bids e.g. the CaFI research project for African
Caribbean families where a family member has a psychosis diagnosis, and a Baby Triple P
research bid for the Mother and Baby ward.
•
Delivered training to improve the clinical work of staff within the Trust and at other
organisations, e.g. the Department of Health and Ministry of Justice Knowledge and
Understanding Framework (KUF), Lancashire Care and Pennine Care, and workshops in
Transference Focussed Psychotherapy.
•
Completed a PCMHT/Eating Disorder Service Pilot. This was then established within the
service and embedded in the clinical pathway.
•
Continued to deliver and develop a number of supervision contracts to support high quality
clinical work e.g. ‘For Dementia’ charity, Universities of Manchester, Manchester
Metropolitan and Salford Universities, CMFT Acute Trust.
•
Commenced delivery of the D58 course, which will enhance Psychodynamic Psychotherapy
training for North West clinicians. This project is in partnership with the Tavistock and
Portman NHS Foundation Trust.
•
Developed a training programme for nursing staff within later life services enabling delivery
of new depression and anxiety therapy groups for older people in day care services.
•
Developed a new partnership with Pennine Acute Trust Occupational Health Service to
deliver psychological interventions to staff of the Acute Trust and to Doctors in training.
•
Developed a new partnership with 42nd Street to deliver interventions to young people with
personality difficulties, building on the ‘15’ therapeutic community model.
•
•
Significantly developed mindfulness-based work for service users and staff within the Trust.
Developed Schwarz Centre Rounds with the support of the Chief Executive. The Trust held
its first Schwarz Round on Thursday 20th March 2014 – the first mental health trust in the
North West to do so. A regular programme has followed during 2014-15 whereby there is a
panel-led discussion focusing on a particular case study or clinical area, which helps staff to
openly and honestly discuss social and emotional issues that arise in caring for patients.
89
•
Initiated improvements in administrative and clinical procedures within the ADHD service to
deliver clinical efficiencies and a higher quality service for service users.
•
•
Provided primary care staff to work with the Gateway referral team.
Maintained a high level of achievement against required Performance Targets.
Adult Mental Health Division
Inpatient and Urgent Care
Some examples of the key quality achievements of the past year within inpatient and urgent care
services are as follows:
•
•
•
•
•
•
•
•
•
•
An overarching service description of Urgent Care Services has been developed and agreed
and will be in operation from 27th March 2015. The service description covers the standard
operating procedures for the 3 locality based Emergency Department Liaison Teams, The
citywide Patient Flow and Capacity Team, The citywide Gate Keeping Team, The citywide
Urgent Care Access Team, The locality based Home Treatment Teams and Safire, the
citywide Assessment Unit.
The 3 Emergency Department Liaison Teams are all commissioned to provide 24/7 senior
nursing cover to the Acute Trust Emergency Departments.
The Urgent Care Access Team and Home Treatment teams provide a 24/7 service including
the provision of the Trust’s Crisis line for existing service users.
Opened Mental Health Assessment Suite at the MRI in the first quarter of the year, to
support the reduction in 4 hour breaches by mental health service users at A&E.
Improved incident reporting trend with an increased number of lower graded incidents and
a reduction in the higher graded incidents. The inpatient and urgent care services form
58.1% of the trusts overall reporting figures. The Acute services manager, Governance lead
and Matrons review the Datix incidents on a weekly basis in order to respond promptly to
trends issues and concerns.
Created and sustained a “safe wards” implementation champion group with representation
from all acute wards and PICUs – this is now being rolled out other divisions.
Significant reduction in the number of patients who go AWOL and improved report and
respond relationship with Greater Manchester Police with the establishment of telephone
triage system.
The use of the CHORES recording system, maintains the focus on ensuring that self harm risk
events are recorded accurately on the Clinical History of Risk events – this has shown
improvement above the improvement trajectory agreed with commissioners.
The number of SIRI investigations within the Division has increased from 8 in 2012/13, and
presently stands at 11 in 2014/15.This increase may be partly explained by an increased
emphasis on safety, standards of care and near misses as inclusive criteria for consideration
of whether a SIRI should occur. The Action plans from SIRI are now generally completed by
managers from the Division in which the incident occurred. This has improved the
effectiveness of the action plans and also improved the embedding of the learning from
these incidents within the Division.
The Patient experience committee has reported that the percentage of patients on the
wards reporting improvements in feeling safe has risen from 85% to 94 %. Patients report
90
•
•
•
•
increased satisfaction in relation to access, staff listening and explaining, and goals and
outcomes being discussed. They have also reported improved levels of satisfaction on
discharge from the wards in relation to their needs being met, involvement in decision
making, staff being helpful, quality of care, crisis support and information, and the FFT.
Overall, the trends in complaints show that since 2012/2013, there has continued to be a
reduction in the number of complaints about care and staff issues, with complaints about
discharge and beds also reducing. The top three areas of complaint were around medication,
communication/support and appointments. The reduction in complaints about care and
discharge demonstrates the efforts of the work of the PALS service and front line staff in
resolving issues locally and the work undertaken in the Inpatient Service Improvement plan.
All trends in complaints are discussed at the Divisional Group meetings and the quarterly
reports are available on a dedicated complaints area on SharePoint accessible to staff. In
respect of PALS the teams/wards who received the highest number of PALS concerns were
Bronte, Elm and Redwood wards; all issues were resolved locally. The community meetings
on the wards and the presence of PALS at Drop Ins encourage feedback from service users
and their families. The Care Group Quality and Governance meetings consider any patterns
and trends including remedial action that requires taking in respect of the above
teams/wards.
Safeguarding: There has been considerable work to ensure that staff are adequately and
appropriately trained in safeguarding, and the recent Trust audit on compliance showed
significant assurance. Training compliance is at 84% for children’s safeguarding and 82% for
adult safeguarding in this division. Additional training sessions have been widely advertised
recently for ward managers and CPLs to improve standards.
Implementation of Acute Care Capacity plan resulting in reduced length of stay, increased
number of discharges and reduced numbers of Service users placed in out of area beds. This
project was recognised by being shortlisted for a health Service Journal Award.
Health and Well-Being Service
Some examples of the key quality achievements of the past year within Health and wellbeing
services are as follows:
•
•
•
•
•
•
Customer satisfaction Survey carried out with Stop Smoking service clients.
Development of a new template for capture of GP practice data for smoking services.
Online application system for training and improved monitoring and evaluation system
introduced as part of the programme.
Governance Action Plan updated on a quarterly basis, reported to Service Quality &
Governance meetings and used to develop team service plans.
Audits to improve learning and quality improvements in the service carried out across the
care group.
Work undertaken with staff across Trust services to ensure NICE and other relevant guidance
is implemented (i.e. dental milk programme is reviewed against the National Dental Milk
Guidelines, NICE Public Health quality standards (QS43) (1) regarding supporting people to
stop smoking and about how PH45 on tobacco harm reduction has/will change practice).
PH45 guidance acknowledges that the most effective way to quit smoking is abrupt quitting
91
•
•
whilst outlining that there are other ways to reduce the harm from smoking while still using
nicotine. The guidance recommends harm-reduction approaches which may or may not
include temporary or long-term use of nicotine containing products. The guidance contains
12 recommendations and we have recommended 7 actions for the Trust in terms of quality.
Risk Registers for teams updated and reviewed at team meetings and by senior managers on
a monthly basis.
Service represented on Integrated Risk Management and Clinical Governance Committee.
Later Life Division
Some examples of the key quality achievements of the past year within later life services are as
follows:
•
•
•
•
•
•
•
•
Continued to listen to, respond and use the views collated from our Patient Experience,
Compliments and Complaints and face-to-face contact to make sure people who use the
service are heard and involved in its formal structures. We hold meetings on inpatient wards
and involve Service users and carers in recruitment as standard.
Individuals from the Governance team are invited to attend and provide quarterly reports
and papers to the Later Life Quality and Governance meetings. To date, there is not a service
user/carer representative at the Later Life Quality & Governance meeting, though we would
like to address this in 2015-16.
Although the Trust Recovery Project has concluded, the Later Life Division maintains its
‘recovery lead’ and he provides an overview of recovery activity within the Trust and how
the Division is linked into that activity. The lead also provides a quarterly update to the Later
Life Quality and Governance Group.
We have introduced a Dementia garden project on two sites, Inpatients at North for Maple
and Cedar Ward and Victoria Park Day services. The garden has been based on evidence
from the Kings Fund. The quality benefits of the space and the therapeutic benefits have
been realised by the both carers and patients in the area.
Safety, effectiveness and patient experience are all monitored on an ongoing basis through
the Trust’s quality and governance systems, for example, Datix reporting, complaints and
PALS, entry and exit questionnaires. This information is regularly discussed and learning
considered within the Divisions Quality and Governance meeting.
Links to the other Divisions are being continuously developed to facilitate learning and
implement improvements. This has included representation at the Trust wide meetings, such
as Trust Risk and Integrated Governance Committee. We have also completed an exercise to
review the divisions Governance Structure and documents comply with the Trust’s Quality
and Assurance frameworks.
A log of NICE guidance and its responses is maintained at the Later Life Quality and
Governance meetings. The Later Life NICE lead provides a quarterly update to the Quality
and Governance meetings, as well as to the Trust’s Clinical Governance Committee.
The division introduced a pilot to increase staff in an area that used high agency and Bank
staff numbers. The aim was to have more regular staff that is trained and familiar with the
patients on the ward for continuity. The project was based on over establishment. The
outcome is that this has saved money from high agency costs and improved quality by
92
•
•
•
having regular staff. Further evaluation is required. There is also Trust wide work being
undertaken to review safer staffing.
The later life Division continues to undertake audits as per the forward audit plan and the
lead auditor attends the Quality and Governance meeting and presents the results of the
audit. There is also an action plan presented and services action the required
recommendations.
The Division continues to show good progress on the CQUINs and Advancing Quality
measures. This is reported quarterly to the division meeting and also to the Trust monthly
performance monitoring meeting.
The Division has presence of a senior pharmacist who provides reports from the Medicines
Management Committee and the Resuscitation Committee quarterly.
Prison Division
The Trust has been successful in its bid to continue to provide healthcare services into
HMP Manchester, and has also acquired HMP Buckley Hall.
Some examples of the key quality achievements of the past year within the Prison division are as
follows:
• Service delivery is reviewed monthly against national and local standards including PHQI and
NICE at Care Group meetings and is on track for achievements of relevant targets.
• The Care Group risk register is reviewed and amended monthly to ensure effective risk
management and increase safety.
• Incidents reported via Datix have been monitored monthly and learning implemented.
• The CQC has inspected the prison healthcare services and reported that it was good with no
areas of non compliance.
• Patients are moving to having their medications held in possession which will enable them to
self care and be independent.
• Service users continue to have a key role in the design and evaluation of services delivered.
Adult Community and Social Care and Inclusion Division
Some examples of the key quality achievements of the past year within the Adult Community and
Social Care and Inclusion division are as follows:
Improving access times into our services
• The Community Mental Health Service Area Teams are multi-disciplinary in nature, and
provide a service to Adults of Working Age (AOWA) whose complex mental health needs
require input beyond the level of expertise that can be provided by Primary Care services.
• The Area Teams provide an interface with Primary Care services, enabling service-users to
‘step-up’ to the Area Team for more specialist care, and to ‘step-down’ to Primary Care as
the service user’s condition and circumstances improve.
• Practitioners will provide initial assessments, and subsequently plan, implement and oversee
comprehensive packages of Health and Social Care provision with the CPA framework.
Practitioners within Area Teams will work in partnership with people with mental health
93
problems, their carers / families, our Primary Care colleagues, and Third Sector
organisations.
•
•
•
Gateway Review
Gateway Service has undergone a LEAN/Six Sigma review leading to the development of a
new pathway for referral management, streamlining the process and reducing the time
taken for referrals to pass on to the receiving teams significantly, and enabling the reduction
in use of agency staff by 33%. A substantive manager has been appointed to lead the team,
and a LiA project is underway to improve the quality of the triaging process for new
referrals.
Empowering our staff to increase staff satisfaction
As part of The Adult Community and Social Inclusion Division, some staff have been involved
within all phases to date in Listening into Action which is moving into the ‘Action’ Phase,
staff across the division are involved as part of the 11 Pioneering Teams and 6 ‘Enabling our
People Schemes’. The division also has influencers of this initiative who are keen to lead and
be involved in change within the Trust
Several members of staff have been involved in devising Standard Operating Procedures
SOPs for various parts of the division. SOPs are based on LEAN/Six Sigma principles currently
in development are SOPs for:
•
•
•
Out Patient Service
Community Area Teams
Gateway
Involvement in this work enables staff to feel empowered and able to influence practice and
it ensures that the SOPs built in standards are achievable and ultimately result in the care we
deliver to our service users is at the highest level.
•
•
•
•
•
Research activities within the Division
During the year users of our services and staff have been involved in a number of research
projects including
Enhancing the Quality of User Involved care Planning in mental health services (EQUIP) –
aimed at improving user and carer involvement in care planning.
Reducing relapse and suicide in bipolar disorder (PARADES) Study Group – Various research
projects involving staff and service-users.
CLARCH – Physical health and Severe Mental Illness project (In association with the
University of Manchester).
The Assistant Manager for Central East Area Team has recently been to Dubai in
connection with EQUIP (EQUIP is a collaborative project between the University of
Manchester University of Nottingham, Nottinghamshire Healthcare NHS Trust
Manchester Mental Health and Social Care Trust) The EQUIP project examines ways to
improve use and carer involvement in care planning in mental health services.
94
Helping the organisation to learn from incidents
• The Division are taking the issues/findings from Serious Incidents Requiring Investigation
(SIRI) and Complaints and are drilling down to a service/team level analysing clusters and
patterns and ensuring lessons learned are put in place at service level. This process is
reviewed on a monthly basis review at the monthly Quality & Governance meetings. This
process is then replicated in individual service meetings to embed learning. The division is
looking at how best we ensure lessons learnt are sent back through the organisation to close
the feedback loop.
•
•
•
•
•
•
•
•
•
•
Service Developments
The in-house interpretation and translation service has continued to extend its service
supporting the Trust’s professionals working with people who speak languages other than
English. New capacity is in place and the service now offers 41 languages.
Throughout 2014/15 the Enablement programme has supported all long-stay service users
(previously engaging with day centres) out into community activities. Teams have in addition
worked with Recovery Pathways Occupational Therapists to develop a case review system
that focuses Enablement packages successfully. The courses wherever possible have been
co-designed and co-delivered. Courses aim to be socially inclusive, and to build resilience,
insight, confidence, independence, knowledge and skills, community connections and
support networks.
The Individual Placement & Support service (IPS) assists and supports service user on a Care
Programme Approach who are looking towards gaining and retaining employment. The IPS
Employment Specialists are integrated into the Area Teams across the city and use an
international evidence based approach that is endorsed by The Centre for Mental Health.
Bramley Street was commissioned by the Clinical Commissioning Group as part of the inpatient capacity work. It is a 12 bedded low level Rehabilitation unit in Salford.
Practice around safeguarding adults and children continues to be a key priority. External
audit of compliance with policy gave substantial assurance in respect of the Trust’s
application of the policy.
Acacia and Anson have had one peer visit each in preparation for forthcoming CQC
inspections. It has been confirmed that CQC will be attending Anson Rd on 24th -27th March.
Outpatients – we have reviewed the current process for Adult Outpatients and are
implementing a Standard Operating Procedure.
A Recovery and Connect team service user won the ‘Changing Lifestyle Recognition Award’
at the Manchester Sports Awards and was invited to represent Manchester in the Greater
Manchester Sports Awards on 7th November 2014.
Start2, the Trust’s remote mental health support package, won the UK Digital Entrepreneur
Award 2014, in the category Innovation in the Public Sector. The Digital Entrepreneur
Awards are the UK's only national awards dedicated to internet entrepreneurialism. Start2
also achieved Highly Commended in this year’s National Nominet Internet Awards, and was
shortlisted for the HSJ awards.
On Monday 29th September 2014, MP Mike Kane visited St Andrew’s Church in
Wythenshawe to mark the official opening of a mural created by the Arts and Wellbeing
95
•
•
•
•
project, Studio One. Members created the mural, in partnership with Manchester Adult
Education Service and Artist Andy Fear at St Andrews Church in Wythenshawe.
In September 2014 HRH the Princess Royal visited a Trust-backed football project meeting
participants at Manchester City Football Club’s Academy. Ibrar Ahmed, a Crisis Team worker
at Park House.
Acacia and Anson Road are participating in the Safe Wards Project which aims to reduce
conflict on in patient wards. The project involves making positive changes to the
environment and also ensuring staff show increased mindfulness around how they
communicate with service users.
There is an increased Occupational Therapy Service at Anson Road to reduce barriers to
efficiency current staffing levels did not reflect recommendations and is in line with core
values of the trust – Putting patients’ first, ensuring quality and safety.
The service users of Acacia together with a music therapist on secondment from Manchester
Metropolitan University have created a music CD which features a variety of styles and
moods. Service Users took a great deal of pride from this initiative
Plans for 2015/16
Over the next year the Adult Community and Social Inclusion Care Division has set priorities for
improvements in the following areas:
1) Implementation of Standard Operating Procedures (SOPs) for Outpatients; Area Community
Teams; and Individual Budgets (IBs). SOPs for Outpatients and IBs have been completed and
implemented. The SOP for the Area Teams has been drafted and is awaiting sign-off prior to
implementation
2) Roll out mobile working. Tablets have been rolled out to the Review Team and all six
Community Area Teams, the final team receiving theirs last week.
3) Establish an Assertive Outreach pathway. Work continues to establish an agreed service
model for a proposed Manchester Engagement Team, integrating the staffing resources of
Assertive Outreach and the Homeless Mental Health Team. The proposed service model,
care delivery pathways and ‘critical to quality’ measures are planned to be presented to the
Transformation Programme Board next month.
4) Improve working relationships with our stakeholders including GPs and Inpatient Services.
Regular liaison takes place between service managers in the Adult Community and Social
Inclusion Care Division and Adult Acute, and pathways developed to improve allocation of
care coordinators for inpatients. Gateway continues to liaise with GPs on an individual basis
in response to referral advice queries.
Monitoring and Reporting
Performance Report – Monthly
The Integrated Performance Report provides the Trust Board with an overview of the Trust’s
performance against the targets we need to meet for 2014-15. It is an exception report so focuses
on areas where we are over or under the expected performance levels, giving the reasons for that
difference in performance. The content of the report is reviewed regularly and changes are made as
determined by the needs of the Trust Board or external reporting requirements. Recent additions
include the Safer Staffing return and additional detail around A&E 4 Hour Waits. You can access our
monthly integrated performance reports through the Trust Board papers we publish online.
96
FOCUS ON: Quality Dashboard
There are now a number of Quality Dashboards available that triangulate data from Finance, DATIX,
ESR and AMIGOS. Below is a screenshot of the Quality Dashboard for the Mental Health Home
Treatment teams.
Triangulating data from different systems allows rankings to be calculated that provide a more
holistic picture of what is occurring on a ward. The example below calculates the resource ranking by
using data from Amigos (Bed numbers), Finance (Bank and Agency, Overtime) and Sickness (ESR).
97
A Trust-wide Quality Dashboard was available during 2014-15. This is currently under review whilst
the Quality Measures for 2015-16 are being been determined:
98
Work will continue throughout 2015-16 to provide more functionality and additional metrics.
Patient Led Assessment of the Care Environment (PLACE) Results
Good environments matter. Every patient should be cared for with compassion and dignity in a
clean, safe environment. Where standards fall short, they should be able to draw it to the attention
of managers and hold the service to account. PLACE assessments provide motivation for
improvement by providing a clear message, directly from patients, about how the environment or
services might be enhanced.
April 2013 saw the introduction of PLACE, which is a system for assessing the quality of the patient
environment, replacing the old Patient Environment Action Team (PEAT) inspections. The
assessments apply to hospitals, hospices and day treatment centres providing NHS funded care. The
assessments see local people go into hospitals as part of teams to assess how the environment
supports patient’s privacy and dignity, food, cleanliness and general building maintenance. It focuses
entirely on the care environment and does not cover clinical care provision or how well staff are
doing their job.
The assessments take place every year, and results are reported publicly to help drive improvements
in the care environment. The results show how hospitals are performing nationally and locally.
The assessments give patients and the public a voice that can be heard in any discussion about local
standards of care, in the drive to give people more influence over the way their local health and care
services are run.
99
Assessment teams are collaboration between staff and patient assessors, therefore patients must
make up at least 50 per cent of the assessment team. Anyone who uses the service can be a patient
assessor, including current patients, their family and visitors, carers, patient advocates or patient
council members.
MMHSCT Results
MMHSCT completed their PLACE assessments for 2014 in May at Park House and in June at Laureate
House. We received the official results on 27th August 2014. This was after they had been reviewed
for accuracy and then submitted to the national system.
Table 1 below shows the scores from 2014 and indicates that there has been an improvement in all
bar one area when the scores are combined for the Trust. There are two areas where the score has
reduced, in comparison to last year. This slight reduction still means that the overall score was more
than 92%, which is excellent. One area relates to Anson Road but this reduction is less than 1% and it
remains at 97.69% which is an excellent result. The food scores at Laureate House have reduced by
3.54% and this will be reviewed and followed up with the Matron team.
Comparison results 2013 – 2014 MMHSCT
Venue
Cleanliness
Food
2013
98.66%
2014
99.09%
2013
96.47%
2014
92.93%
Privacy,
Dignity Facilities/Condition
and Wellbeing
appearance
and
maintenance
2013
2014
2013
2014
81.41% 86.93% 89.93%
94.18%
Park
House
95.86%
99.87%
89.50%
92.73%
86.89%
92.24%
93.23%
95.68%
Anson
Road
98.61%
97.69%
N/A
N/A
70.43%
90.48%
77.88%
98.21%
TOTALS
97.71%
98.88%
92.98%
92.83%
79.57%
89.88%
87.01%
96.02%
Laureate
House
Analysis of the data shows that the privacy and dignity score was lower than 90% due to the fact
that the single bedrooms at Laureate House did not have “viewing panels or spy holes”. In addition
to this the data suggested that the reception areas in both Park House and Laureate House did not
allow enough space for confidential issues to be discussed.
There were comments about the taste and choice of food on one of the wards and this appears to
be the reason for the lower score. The Matron team will be meeting with the UHSM dietician to
discuss this. The slight reduction in cleanliness in Anson Road appears to have been as a result of a
100
change in domestic operatives. This has been addressed by the Unit Manager and will continue to be
monitored by the covering Matron.
The chart below shows how MMHSCT scored in relation to neighbouring Mental Health Trusts. The
figures shown are total percentages of all areas.
100
90
80
70
60
50
40
30
20
10
0
Cleanliness
Food
Privacy, Dignity and Wellbeing
Facilities
Post PLACE inspection an action plan was developed to address the areas of deficit. The Matron
team have since carried out Matron checks to ensure that the improvements have been made. In
addition to this the action plan will be made available at the next Informal PLACE inspection for all
members of the assessing team to review.
Dignity Walks
Patient-led dignity inspections were introduced into the Trust in 2010 by the then Dignity Matron
and the Carer Champion for Dignity. The inspections cover environment, staff attitude, patient
feedback, social and activity spaces and areas of improvements suggested by the team. Wards are
only informed an hour at the most in advance of the visit. A report on the day is then filled out and
shared with to the ward manager.
A series of dignity walks have taken place throughout 2014-15 and have looked at the environment,
feedback from patients, staff attitude as observed by the team, social and activity areas and any
areas for improvement. The dignity walks have taken place on all inpatient wards at Park House,
North Manchester General Hospital, and at Laureate House at Wythenshawe Hospital. They have
also been undertaken on the Trust’s Swift Assessment For the Immediate Resolution of Emergencies
(SAFIRE) Unit, and at the Trust’s Rehabilitation services, Anson Road and Acacia. Dignity walks have
also taken place within all of the Trust’s day services.
Feedback, good practice and issues of concerns following each of the dignity walks is reported to our
Patient Experience Committee and the feedback this year has been mainly positive. Changes have
been made to the approach of the dignity walks, including arranging for Trust leads to be involved to
allow issues to be addressed, wherever possible, on the day of the visit. There has been a marked
101
improvement from the visit issues raised in the previous year - particularly regarding staff attitude
and increased ward activities.
The dignity walks will continue in 2015-16. A schedule has already been drafted, and this will be
shared at an upcoming meeting of the Trust’s Patient Experience Committee. We will continue to
report back on the progress with this to the Patient Experience Committee and Quality Board
throughout the year.
HealthWatch
Healthwatch Manchester replaced Local Involvement Networks (LINKS) which ceased to exist on 31st
March 2013. Healthwatch is a consumer champion for both health and social care. The Health and
Social Care Act 2012 established Healthwatch in April 2013.
Healthwatch Manchester is an independent organisation; it employs its own staff and involves
volunteers, so it can become the influential and effective voice of the public. One of the main aims
of Healthwatch Manchester is to give local residents and communities a stronger voice to influence
and challenge how health and social care services are provided across the city. Healthwatch
Manchester has a seat on the statutory Health and Wellbeing Board at Manchester City Council. This
helps to ensure that the views and experiences of patients, carers and other service users are taken
into account when local needs assessments and strategies are prepared.
Healthwatch Manchester enables local people to share their views and concerns about local health
and social care services to help build a picture of where services are doing well and where they can
be improved.
Manchester Mental Health and Social Care Trust welcome the important contribution being made by
Healthwatch Manchester in helping to improve the quality of health and social care services. We
welcome the opportunity to work closely with Healthwatch, and have already established a positive
working relationship, which we will develop further during 2015-2016. The Trust will continue to
support Healthwatch Manchester in any specific activities that relate directly to mental health
experiences, and will ensure that there are continual opportunities for regular dialogue and
information sharing during 2015-2016.
102
Appendix A
Statements from External Bodies
As part of the external assurance process and to promote strong partnership working with our key
stakeholders, we have asked our local Healthwatch, Manchester Clinical Commissioning Groups and
the Manchester City Council Health Scrutiny Committee to make statements on our Quality Account.
All stakeholders received a copy of the Quality Account on 23rd April 2015 and were asked for
statements to be returned by 22nd May 2015, allowing 30 for consultation.
Stakeholders
There are many definitions of stakeholders in business and public sector or from a health and social
care perspective. These can include:
-
A person or persons with an interest or concern in something
Those who are involved with an organisation and are vital to its survival and success
Any group or organisation who can affect or is affected by the achievement of an
organisations objectives.
Initially, stakeholders were classified into 4 categories: employees, shareholders, customers and the
general public. In a health and social care setting, customers include patients and carers. The general
public is all of the diverse communities we serve. There are also the regulators and different health
and social care interest groups, private sector and the voluntary or community sector organisations.
Each stakeholder has different priorities. For customers, it is often the availability and quality of the
service. Other groups may have their own professional vested interest to pursue, and with regard to
staff, there are different professional perspectives in each employee category. Each viewpoint may
or may not relate to the quality and availability of the service we deliver. We accept that
stakeholders have differing priorities and when referring to the quality of a service it is vital we
recognise the different takes on how quality is defined. If we refer to our customer perspective then
they must have a say in how the quality of their service is shaped.
Stakeholder definition provided by a member of the Service User and Carer Forum 2012
Keeping Stakeholders Informed
Throughout the year we keep our stakeholders informed through a range of communication tools
including our newsletters, meeting and attendance at events held by the Trust.
In 2015-16, we will be looking at ways to improve communication relating directly to our Quality
Improvement Strategy and Quality Account).
If you have any suggestions as to how we might add to our communications activity to help keep
stakeholders informed, then we would love to hear from you. You can use the ‘contact us’ section at
the end of this document to give us your suggestions and feedback.
103
Manchester Clinical Commissioning Groups – Joint Commissioning Team
Commissioner Statement in Relation to Manchester Mental Health and Social Care Trust Quality
Accounts 2014/15
104
105
Health Watch
HealthWatch Statement in Relation to Manchester Mental Health and Social Care Trust Quality
Accounts 2014/15
106
Manchester City Council Health Scrutiny Committee
Manchester City Council Health Scrutiny Committee Statement in Relation to Manchester Mental
Health and Social Care Trust Quality Accounts 2014/15
107
108
Changes made following the submission of the Quality Account to stakeholders
The Quality Account was submitted to our stakeholders on 23rd April 2015. During the time since
submission the Trust has continued to review the content of the Quality Account with the support of
Service Users and Carers, External Auditors (PwC) and internal committees including the Quality
Board. No substantial changes have been made to the 2014/15 Quality Account as a result of the
feedback received from external stakeholders*.
*Other generic typing and grammatical changes have been made which have not impacted on the content of
the Quality Account
109
Appendix B
Statement of Directors Responsibilities in Respect of the Quality Account
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial
year. The Department of Health has issued guidance on the form and content of annual Quality
Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health
Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality
Accounts) Amendment Regulations 2011 and the National Health Service (Quality Accounts)
Amendment Regulations 2012)).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
•
the Quality Account presents a balanced picture of the Trust’s performance over the period
covered;
•
the performance information reported in the Quality Account is reliable and accurate;
•
there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, 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 Account is robust
and reliable, conforms to specified data quality standards and prescribed definitions, and is
subject to appropriate scrutiny and review; and
•
the Quality Account has been prepared in accordance with Department of Health guidance.
The directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
110
Appendix C
Commissioning for Quality and Innovation (CQUIN) framework
2014/15 CQUINs
National
Regional
Greater Manchester
Local
Indicator
Ref
Description of Indicator
Goal
Weighting (%
of CQUIN
scheme
available)
N1a
Friends and Family Test - Implementation of
Staff FFT
2.00%
£30,313
N1b
Friends and Family Test - Early
Implementation
1.34%
£20,234
N1c
Friends and Family Test - Phased Expansion
3.34%
£50,547
N2.1
NHS Safety Thermometer
6.67%
£101,095
N3a
Cardio Metabolic assessment for Patients
with psychoses
4.33%
£65,628
N3b
Patients on the CPA: Communication with
General Practitioners
2.33%
£35,315
Dementia
8.00%
£121,253
GM1
Clozapine Governance
5.42%
£82,149
GM2
Improved partnership working between NHS
organisations and GMP at a local and GM
level
9.16%
£138,835
GM3
Learning Lessons Once
6.67%
£101,095
GM4
Mental Health Payment by Results
3.75%
£56,837
L1
Service User Management Plans
9.40%
£142,472
L2
Service User Observations
9.40%
£142,472
L3
Recurring Patient Safety Theme
9.40%
£142,472
L4
Recovery orientated programme for CMHT
service users on CPA
9.40%
£142,472
L5
Data Collection to inform Psychological
Therapies Transformation
9.40%
£142,472
100%
£1,515,662
R1
Expected Financial
Value of Goal
111
Commissioning for Quality and Innovation Framework (CQUIN)
2015/16 CQUINs
Indicator
Ref
Description of Indicator
Goal
Weighting (%
of CQUIN
scheme
available)
Expected Financial
Value of Goal
National
Greater Manchester
Improving recording of diagnosis in A&E
8.00%
£119,313
N1 8b
Reduction in A&E MH re-attendances
12.00%
£178,969
N2 4a
Cardio metabolic Assessment and treatment
for patients with psychoses
8.00%
£119,313
N2 4b
Communication with general practitioners
2.00%
£29,828
GM1
GM employment and mental health
10.00%
£149,141
GM2
GM partnership working
10.00%
£149,141
L1
Peer support
12.50%
£186,426
L2
Reducing % of service users on CMHT
waiting list progressing to crisis pathway
(crisis teams/A&E)
12.50%
£186,426
L3
Peer review
12.50%
£186,426
12.50%
£186,426
100%
£1,515,662
Local
N1 8a
L4
Service user involvement in clinical services
delivery
112
Mother & Baby Contract
2014/15
Improving physical healthcare to reduce premature
mortality in people with severe mental illness (SMI)
Friends and Family Test - Only one element further
implementation of patient FFT and staff FFT.
Dashboard
Mother/infant relationship
Training and supervision of clinical staff to deliver
interventions to improve mother/Infant interaction
and care
4,542
4,542
1,817
18,167
16,350
Prison Contract
2014/15
Suicide Prevention
Care Programme Approach Audit
Chronic Disease Care
40,869
40,869
40,869
113
Appendix D
Clinical Audit Programme
Please note the Trust also produces a full annual audit report to the Trust Board that offers additional detail of the audits completed in the Trust and
improvement measures.
Summary Report of Audit Projects (including reasons for non-completion)
Summary of Completed Clinical Audit Programme Audits
CAP Number
Audit Name
3002/3008
Medicines Reconciliation/Allergy recording
3002a/3008a
Medicines Reconciliation/Allergy recording
3002c/3008c
Medicines Reconciliation/Allergy recording
3003
Medicines Kardex audit
3004
DUTHIE safe handling of medicines
3006
Rapid Tranquilisation
3007
Omitted Doses
3007b
Omitted Doses
3007c
Omitted Doses
3009
Mental Health Act - Consent to Treatment Forms
3009b
Mental Health Act - Consent to Treatment Forms
114
3009c
Mental Health Act - Consent to Treatment Forms
3010
Community Medicines
3020
Record Keeping
3021
National Early Warning System (NEWS)
3022
Risk Assessment
3022a
Risk Assessment
3022b
Risk Assessment
3022c
Risk Assessment
3023
Supervision
Withdrawn from the Clinical Audit Programme 2014/15
CAP Number
Audit Name
3002b/3008b Medicines Reconciliation/Allergy recording
3007a
Omitted Doses
Reason
This project will contribute to a CQUIN and the Trust’s commissioners
have set an alternative deadline of January 2015 for this project in
partnership with the Trust CQUIN/Audit lead. This was confirmed by
the Chief Pharmacist in November 2014. The Quarter 3 report was
therefore withdrawn.
Audit 3007a Omitted Doses was withdrawn from the quarter 2 clinical
audit programme. The reasons provided by the interim audit lead (Chief
Pharmacist) were that the lead nurse undertaking the audits had left
and her replacement was unable to start until September 2014. The
medicines management team did manage to deliver the quarter 1
audits in the post holders absence but realised that because of capacity
that it would not be feasible to deliver it again during quarter 2.
115
The Trust undertake these audits quarterly which is more frequent than
required and it was felt by the interim audit lead that the community
medicines audit needed to be prioritised ahead of these two audits.
3009a
Mental Health Act - Consent to Treatment Forms
Audit 3009a MHA consent to treatment was withdrawn from the
quarter 2 clinical audit programme for the same reasons as project
3007a. The reasons provided by the interim audit lead (Chief
Pharmacist) were that the lead nurse undertaking the audits had left
and her replacement was unable to start until September 2014. The
medicines management team did manage to deliver the quarter 1
audits in the post holders absence but realised that because of capacity
that it would not be feasible to deliver it again during quarter 2. The
Trust undertake these audits quarterly which is more frequent than
required and it was felt by the interim audit lead that the community
medicines audit needed to be prioritised ahead of these two audits.
116
Assurance Ratings
The table below provides a description of the different levels of assurance that are applied to completed audits as part of the Trust Clinical Audit
Programme
Level of
assurance
Description
High
The review did not identify any weaknesses that would impact on the achievement of the key system, function or
process objectives. Therefore we can conclude that key controls have been adequately designed and are operating
effectively to deliver the key objectives of the system, function or process.
As a result, a high level of assurance can be given that the system of control is designed to meet the Trust’s objectives
and controls are consistently applied over [name of review] at the time of our audit.
There are some weaknesses in the design and/or operation of controls, however the likely impact of these weaknesses
on the achievement of the key system, function or process objectives is not expected to be significant. Furthermore,
these weaknesses are unlikely to impact upon the achievement of organisational objectives.
As a result significant assurance can be given that there is a generally sound system of internal control, designed to meet
the organisation's objectives, and that controls are generally being applied consistently at the time of our audit.
There are weaknesses in the design and / or operation of controls which could have a significant impact on the
achievement of the key system, function or process objectives but should not have a significant impact on the
achievement of organisational objectives.
As a result there is limited assurance as weaknesses in the design and/or inconsistent application of controls over [name
of review] at the time of our audit put the achievement of the system’s objectives at risk in a number of the areas
reviewed.
There are weaknesses in the design and/or operation of controls which not only have a significant impact on the
achievement of key system, function or process objectives but may put at risk the achievement of organisation
objectives.
As a result there is no assurance as weaknesses in control, and/or consistent non-compliance with key controls over
[name of review] at the time of our audit, could result (have resulted) in failure to achieve the organisation’s objectives
in the areas reviewed.
Significant
Limited
No
117
Summary of completed & approved Clinical Audit Programme reports 2014/15 including assurance levels and improvement actions
Limited Assurance Audits
8
CAP Number
3002/3008
Significant Assurance
Audits
8
Audit Name
Medicines
Reconciliation/Allergy
recording
Medicines
Reconciliation/Allergy
recording
Assurance TBC
Reports withdrawn
Total Number
4
0
3
23
Improvement Actions to be Taken
•
•
•
•
•
3002a/3008a
High Assurance Audits
•
•
•
•
Assurance Level
Continue to undertake monitoring and focus on SAFIRE as the admission unit for
services.
Additional pharmacist and technician now being recruited to for urgent care.
Continue to audit allergy status as a separate ward target.
Work with the urgent care board to incorporate medicines reconciliation as a
measure into the in-patient dashboard.
Work with South Manchester to change the role of the technician at Laureate
House to include daily medicines reconciliation as at Park House.
High
Continue to undertake monitoring and focus on SAFIRE as the admission unit for
services.
Work with the urgent care board to incorporate medicines reconciliation as a
measure into the in-patient dashboard.
Work with the new urgent care pharmacy staff due to commence 6th October to
explore medicines reconciliation in home treatment services.
Work with South Manchester to change the role of the technician at Laureate
House to include daily medicines reconciliation as at Park House.
Significant
Medicines reconciliation is only a part of the work of the clinical pharmacist and it is
important to ensure that the pharmacists are still available to attend ward rounds, counsel
patients and support the full range of medicines management functions in addition to
medicines reconciliation.
118
CAP Number
3002c/3008c
Audit Name
Improvement Actions to be Taken
Medicines
Reconciliation/Allergy
recording
•
3003
Medicines Kardex audit
3004
3006
Continue to undertake monitoring and focus on SAFIRE as the admission unit for
services.
Work with the urgent care board to incorporate medicines reconciliation as a
measure into the in-patient dashboard.
High
•
•
•
•
Reminder memo summarising annual audit.
Medicines link nurse audit.
Reminder to all wards and prescribers.
Ensure that all pharmacists are working consistently across the Trust.
High
DUTHIE safe handling
of medicines
•
•
Circulate to Matron meeting and Ward Manager meetings.
Individual Ward Managers to receive memo from Chief Pharmacist and Lead Nurse
regarding medicines management standards compliance.
Significant
Rapid Tranquilisation
•
•
Audit to be shared with Ward Managers, Matrons and Medicines Link Nurses.
Ward Managers to share audit finding with their teams and reiterate importance
of Trust Policy implementation.
Continue with monthly audit completion.
Circulate to Ward Governance and Clinical Governance meetings and Matrons
meeting.
Limited
Audit feedback to all care groups via appropriate care group meetings.
Audit feedback to ward teams.
Link nurses will continue to collect audit data re: omitted doses and provide
quarterly reports to medicines management committee in addition to immediate
ward feedback where issues are identified.
Significant
•
•
•
3007
Assurance Level
Omitted Doses
•
•
•
119
CAP Number
Audit Name
Improvement Actions to be Taken
Assurance Level
3007b
Omitted Doses
•
•
•
Audit feedback to all care groups via appropriate care group meetings.
Audit feedback to ward teams.
Link nurses will continue to collect audit data re: omitted doses and provide
quarterly reports to medicines management committee in addition to immediate
ward feedback where issues are identified.
Significant
3007c
Omitted Doses
•
•
•
Audit feedback to all care groups via appropriate division meetings.
Audit feedback to ward teams by service managers.
Link nurses will continue to collect audit data re: omitted doses and Lead Nurse
will provide quarterly reports to medicines management committee in addition to
immediate ward feedback where issues are identified.
Significant
E-mail reminder sent to all Ward Managers and Matrons requesting that they
remind teams of the requirements for keeping Consent to Treatment
documentation with prescription charts.
Consent to Treatment training arranged for Medicines Management team to
ensure all team have required knowledge to support ward teams to practice safely
and within the legislation.
Interim report prepared for discussion and actions within care group and Matrons
meetings.
Audit to be presented to Ward Managers and Matrons highlighting that they must
comply with legal requirements for keeping Consent to Treatment documentation
with prescription charts.
Consent to Treatment information to be shared within teams to ensure all teams
have required knowledge to support ward teams to practice safely and within the
legislation.
Interim report prepared for discussion and actions within Division and Matron
meeting.
Limited
3009
Mental Health Act Consent to Treatment
Forms
•
•
•
•
•
•
•
120
CAP Number
3009b
Audit Name
Mental Health Act Consent to Treatment
Forms
Improvement Actions to be Taken
•
•
•
3009c
Mental Health Act Consent to Treatment
Forms
•
•
•
•
3010
Community Medicines
•
•
•
•
Assurance Level
Audit to be presented to Ward Managers and Matrons highlighting that they must Limited
comply with legal requirements for keeping Consent to Treatment documentation
with prescription charts.
Consent to Treatment lists to be shared within teams to ensure all teams have
required knowledge to support ward teams to practice safely and within the
legislation.
Q4 report to be completed with support of Medicines Management team, when
this project is passed on to the Mental Health Act Team
Audit to be presented to Ward Managers and Matrons highlighting that they must
comply with legal requirements for keeping Consent to Treatment documentation
with medication cards.
Consent to Treatment lists to be shared within teams to ensure all teams have
required knowledge to support ward teams to practice safely and within the
legislation.
Rc’s to be sent CQC guidelines and standards concerning completing
authorisations.
This will be placed on the agenda for consultants meetings in May 2015Audit to be
presented to Ward Managers and Matrons highlighting that they must comply
with legal requirements for keeping Consent to Treatment documentation with
medication cards.
Significant
Email sent to all CMHTs reminding them of the importance of legal requirements
for the prescribing of depot medication.
Care Group Managers to share audit and findings with all team managers, for
cascading to individual teams.
Teams to identify Medicines Link Nurses for each team, who will support team to
develop and address audit outcomes.
Lead Nurse to arrange forum for link nurses to present audit and to develop a
collaborative action plan going forward.
Limited
121
CAP Number
Audit Name
Improvement Actions to be Taken
•
•
•
•
•
•
•
•
•
•
•
•
Assurance Level
Feed back of audit to Care Group with individual results.
Training of CPNs on depot SOP 23 and use of Amigos meds administration form.
Review SOPs relating to medicines management within CMHTs.
Development of a standardised form for booking depots in and out and for patient
own drugs.
SOPs to be sent out to all CMHTs as a reminder to all Care Coordinators.
Action taken immediately-chief pharmacist emailed team managers reminding
them of the legal prescription requirements.
Expired prescriptions were re-written.
Feed back of audit to teams with individual team results.
Discussion of audit results with medical director and lead for medical education
Feedback to MMC.
Discussion of audit results with medical director and lead for medical education.
Feedback to MMC.
Transfer of stable patients to GP for prescribing and administration of depot
antipsychotics.
Review reasons for home depots. Transfer to GP if appropriate. Identify depot
clinic/ set up depot clinic to accommodate patients who do not require home
depot and are not suitable for transfer to GP.
3020
Record Keeping
•
•
•
Re audit of start time of entries written
Re audit un-countersigned notes
Guidelines to be cascaded, entries to be discussed in supervision and
matrons/managers to discuss outcome of audit.
Limited
3021
National Early Warning
System (NEWS)
•
Staff will ensure that observations are taken as prescribed by the observation Significant
prescription chart. This chart must be reviewed on a regular basis, in line with the
most recently prescribed observations and the changes must be made to the
observation prescription chart. Where it is known that baseline parameters are
122
CAP Number
Audit Name
Improvement Actions to be Taken
•
•
•
•
•
3022
Risk Assessment
•
•
Assurance Level
known to fall outside the normal range this should be clearly documented on the
observation prescription form. All patients must have a physical observation
prescription form in place.
In cases when a patient refuses to have their physical observations taken the
practitioner must undertake an observation of their consciousness level and
respiration rate. This must be recorded and signed on the relevant NEWS chart.
In cases when a patient has a combined or single score of 3 following completion
of physical observations follow up actions need to be undertaken as either
directed by the physical observation prescription form, physical health care plan,
medical or MDT review or a combination of the above. Any scores of 3 or more
should be highlighted in the clinical records and any follow up clinical action or
discussions must be documented.
Any registered clinical staff who have not completed their on line training and or
been assessed as competent must do so as soon as possible.
wards who have achieved 100% compliance with completion of the NEWS forms
and appropriate follow up (when needed) should be reviewed by their relevant
Matron in relation to training a sample of appropriately skilled support staff to
undertake physical observations in line with NEWS.
Whilst it was not part of the audit the author suggests that all wards purchase and
have available manual monitoring equipment for blood pressure, pulse and oxygen
saturations, as a back up in the event that electronic equipment either fails or
supplies an abnormal reading.
All wards to continue complete a formal monthly audit submitted 1 week prior to
all ward managers’ meetings for collation as minimum.
These to be reviewed in the ward manager meetings and care group action plan
devised to address short falls.
Limited
123
CAP Number
Audit Name
Improvement Actions to be Taken
•
•
•
3022a
Risk Assessment
•
•
•
•
•
•
•
•
3022b
Risk Assessment
•
•
•
•
•
•
Matrons to complete quality check Audit.
Create an electronic audit of key standards in conjunction with Performance
department.
Audit to be repeated during 2015/2016 with more robust focus on specific areas
where improvement has been identified
Ward managers to increase supervision time to check adherence to process.
Ward managers to offer protected time to ensure staff have enough time to
complete paper work.
Ward managers to ensure staff are competent on CPA and understand the
importance of recording collaborative working or refusal.
Ward managers to ensure weekly monitoring and report to Matrons and discuss
outcomes in Ward managers meeting. Prompt in management supervision.
Ward Managers to monitor compliance to process Standard 5 MHA Rights &
Advocacy within appropriate timescales for new admissions on day of admission.
Ward managers to review schedules of the named nurse and re-design to balance
shifts to ensure named nurse attends ward round once per month as a minimum.
Wards to ensure nurse attend ward round for their patients.
Acting Acute Services Manager Adult Inpatients to Meet with the Associate
Director - Informatics and Development to review the request made in 2012/13 for
an electronic report to enable an at a glance view of the data for ward managers.
Ward managers to increase supervision time to check adherence to process.
Ward managers to offer protected time to ensure staff have enough time to
complete paper work.
Ward managers to ensure staff are competent on CPA and understand the
importance of recording collaborative working or refusal.
Ward managers to ensure weekly monitoring and report to Matrons and discuss
outcomes in Ward managers meeting. Prompt in management supervision.
Ward Managers to monitor compliance to process Standard 5 MHA Rights &
Advocacy within appropriate timescales for new admissions on day of admission.
Ward managers to review schedules of the named nurse and re-design to balance
Assurance Level
Limited
Limited
124
CAP Number
Audit Name
Improvement Actions to be Taken
Assurance Level
shifts to ensure named nurse attends ward round once per month as a minimum.
• Wards to ensure nurse attend ward round for their patients.
• Acting Acute Services Manager Adult Inpatients to Meet with the Associate
Director - Informatics and Development to review the request made in 2012/13 for
an electronic report to enable an at a glance view of the data for ward managers.
3022c
Risk Assessment
•
•
•
•
3023
Supervision
•
•
•
•
•
Organise a matron away day in order to review auditing systems and agree a single
matron workplan
Ensure that matrons have a higher visibility on the wards by focussing more clearly
on quality issues
Take on board any feedback from the CQC following their inspection visit
regarding patient centred care plans and other quality standards relevant to the
matrons
To ensure that any re-audit focuses on specific priorities, rather than reading all
standards
Ensure that the one person not receiving supervision has an immediate plan with a
named supervisor and date for supervision.
Ensure that all remaining supervisors attend training and are on the register.
Feedback audit results to staff via share point and at the Occupational therapy
committee and forum March 2015.
Discuss and agree recommended changes to SOP at the OT committee and finalize
and agree changes at the OT forum.
Re-audit in 1years time and include audit of a sample of supervision notes to
provide evidence that notes are recorded and stored securely.
Significant
High
125
Summary of completed & approved local audit reports 2014/15 including assurance levels and improvement actions
Limited Assurance Audits
15
Project
Number
2027
Significant Assurance Audits
19
High Assurance Audits
2
Service Evaluations
6
Audit Name
Improvement Actions to be Taken
An audit of the
assessment and
management of cardio
metabolic risk factors in
Schizophrenia in an
inpatient rehabilitation
unit
Stream Line assessments to every 2 weeks of:
• Blood Pressure
• BMI
• Weight
• Waist Circumference
• Smoking Status
• Each patient every month to have a Rethink Physical Health Questionnaire
• Every three months they have their glucose, cholesterol and other routine bloods and
ECG and get a Framingham risk score calculated and documented on AMIGOS
2031
Collection of data of
bleeps and on call
activity of SHO at nights
at NMGH
•
Report shared with Liaison Nurse Committee, to consider the finding of the service
evaluation to inform suggestions for service improvement on night activity.
2034
Service user experience
of clinical consultations
with psychiatrists
•
•
•
2048
High Dose Antipsychotic
Prescribing on a
Psychiatric Intensive
Care Unit and Bronte
Ward
•
•
Distribution of results to MDT at the BHU.
No indication for re-audit from these findings.
Further research work into involvement of service-users in shared decision making
process - AS to complete on-going research.
Re-audit of High Dose Antipsychotic Treatment
All patients on HDAT should have this clearly recorded in front of their medication
charts preferable in RED ink.
Total Number
42
Assurance Level
Significant
N/A - Project is a
service evaluation
therefore the
assurance framework
cannot be applied as
with an audit
Significant
Significant
126
Project
Number
2058
Audit Name
Attendance at
therapeutic activities in
an Inpatient Rehab Unit
Improvement Actions to be Taken







2072
2073
Service evaluation of
referrals to South
Mersey CMHT
•
Audit of safeguarding
documentation and
communication
following assessment at
Gaskell house
•
•
•
Assurance Level
The team will continue to explore the issue of poor attendances to activities on the
unit by constantly re-assessing whether the existing groups fit in well with patient’s
recovery. The team will also have to consider what measures can be put in place to
ensure improved attendances.
The team will examine the financial implications in more detail in future with groups
facilitated by external staff members, such as Art Group.
The team are also considering having a generic time-table of activities which can be
given to patients at the time of admission, so that they are aware of the different
activities that take place.
To aim to achieve a balance between giving patients the autonomy to choose their
groups and how best to maximise their attendances.
To reflect to patients in team meetings/ CPA reviews about their attendances and
reasons for non-attendance.
How can we get patients more involved in planning/reviewing groups? Having a
service user representative attending a group focus meeting with Ward Manager and
staff.
To tie in the group attendances with CPA, ward progress and potentially contributing
towards quicker discharges.
Significant
Results of this service evaluation to be fed into Community Services/Outpatients
review via Community Consultants' forum.
Re-evaluate waiting times now that Gateway service has been in place for some time.
N/A - Project is a
service evaluation
therefore the
assurance framework
cannot be applied as
with an audit
Limited
Dr Adam Dierckx to take proposals for ‘special notes’ on amigos to be used for
electronic documentation of safeguarding information to PTQG to get care group wide
consensus.
PSMG protocol meeting group to include recommendation for section headed
safeguarding on all final assessment letters in their review / standardization of letters
across the care group.
127
Project
Number
2074
Audit Name
Risk Assessment and
Capacity in Relation to
Patients’ Admitted to a
Later Life Ward
Improvement Actions to be Taken
•
•
•
Trust to prioritize creating safeguarding for children tab on amigos.
Re-audit in 6-12 months following implementation of safeguarding headings.
All assessment letters to have a section headed safeguarding, to prompt comment re
assessment of impact of mental health on parenting capacity.
•
•
•
Dissemination at doctor induction.
Presentation to the Later Life Quality and Governance group.
Feedback from Trust risk management group regarding the most appropriate method
for recording capacity.
Re-audit after these areas have been addressed.
•
2076
Audit of risk assessment
and Crisis Team triage
for admissions to a later
life assessment ward
•
•
2077
Evaluation of predictors
of Quality of Life and
change in Quality of Life
with Treatment in the
Specialist Service for
Affective Disorders a
Tertiary Mood Disorders
Clinic
•
•
Assurance Level
Limited
Significant
The data should be shared with the later life care group both in terms of its strategy
and whether the project to close 10 beds within later life the inpatient service is to be
actioned, as it will be important that risk assessments and gate keeping are robust and
alternatives to admission thoroughly explored.
Given that Mental Health Liaison Nurses are now available across all three sites 24
hours per day, it would be worth re-auditing in about 6 months, once they are firmly
embedded into services.
The data should be shared with the later life care group both in terms of its strategy
and whether the project to close 10 beds within later life the inpatient service is to be
actioned, as it will be important that risk assessments and gate keeping are robust and
alternatives to admission thoroughly explored.
Given that Mental Health Liaison Nurses are now available across all three sites 24
hours per day, it would be worth re-auditing in about 6 months, once they are firmly
embedded into services.
N/A - Project is a
service evaluation
therefore the
assurance framework
cannot be applied as
with an audit
128
Project
Number
2078
Audit Name
Care of the deteriorating
patient; analysis of the
use of Early Warning
Systems and the SBAR
Communication tool
Improvement Actions to be Taken
•
•
•
•
•
•
•
2087
2088
Audit of patient
identification on adult
inpatient units in
MMHSC
•
Audit of one to one time
spent with nurses and
doctors on Bronte ward
•
•
•
•
•
•
•
Assurance Level
Develop communication to iterate importance of observation prescription.
Develop communication and training to iterate and explain importance of observation
interval documentation.
Develop communication and training to iterate and explain importance of dated, time
recorded and initialed observations.
Develop communication and training to iterate and explain importance of recording
clearly when observations are not recorded
Develop further training to improve frequency and accuracy of scoring of Early
Warning Scores.
Develop further training to improve triaging skills and to iterate importance of
documentation where aggregate NEWS scores were 5 or more or where a single
parameter scored 3, to reduce incomplete, incorrect or absent documented action
plans.
Develop training tool to improve understanding, uptake and use of documenting SBAR
communication tool in notes.
Limited
Ward staff and managers to discuss the possibility of managing their stationery
actively.
Ward staff to assimilate photographs as a part of admission process for a patient.
Ward staff to adopt a folder for a medication card.
Ward staff to document consent on AMIGOS.
Re-audit in 6 months.
Limited
Re-audit over a longer time period could provide a more accurate reflection of the
frequency of one-to-one interactions.
A wider audit, across inpatients units throughout the trust, could be used to
understand more about trust-wide achievement and variation.
Increase the potential for staff nurses to have a protected time for 1:1 interaction.
Limited
129
Project
Number
2092
Audit Name
Audit of the use of
Clozapine Assays across
MMHSC
Improvement Actions to be Taken
•
•
•
•
•
•
•
2094
2096
2102
Audit to assess
adherence to NICE
quality standards for
depression in adults, in
the West Central Older
Adult Out-patient service
2013
•
•
Medicines Adherence:
involving patients in
decisions about
prescribed medicines
and supporting
adherence
•
Standardised assessment
and Outcome Measure
Records – Adult
inpatient OTs
•
•
•
•
•
Assurance Level
Education and training - city wide teaching and dissemination of audit report. Report
to be emailed to all clinicians.
Recommended changes to guidelines when reviewed in October 2014.
Education and training - city wide teaching and dissemination of audit report. Report
to be emailed to all clinicians.
Memo to all clinicians to add smoking status on the special notes section.
IT department to add Clozapine section.
Review of guidelines in October 2014.
Development of local guidance.
Limited
A depression checklist in each West Central Older Adult (patients with ICD-10 code
F32-33) patient notes is available so that the relevant information is easily accessible
to clinicians.
AUDIT/Management Project to review:
- clustering values associated with diagnoses of depression
- current and past diagnoses of depression
- Assessment of contributing factors: Why do patients remain under secondary
care services with diagnoses of depression in remission?
Significant
An audit presentation to clinicians of all grades including seniors to be held at the
MMHSC educational meeting at Wythenshawe.
Trust wide email outlining some important points found from the audit.
A re-audit at some point in the next few years, can be undertaken by any doctor, audit
department could co-ordinate this and suggest to future trainees in induction
meetings.
Significant
Findings of the audit presented and discussed at the Occupational Therapy forum.
Findings of the audit to be incorporated into the Trust work on outcome measures led
by the Medical Director – Head of OT to feedback.
Workshops / working group regarding outcome measures to be undertaken to
Limited
130
Project
Number
Audit Name
Improvement Actions to be Taken
•
•
2104
DVLA guidelines given to
patients
•
•
•
•
2105
2106
Antipsychotic
polypharmacy amongst
general adult and
rehabilitation inpatients
prevalence and rationale
•
Audit of
Recommendations from
the HASCAS Inquiry into
the Care and Treatment
of Mr Z
•
•
•
•
Assurance Level
determine which outcome measures may be useful in this setting and how they could
be implemented.
Guidelines to be developed regarding the use of outcome measures within adult
inpatient occupational therapy.
The use of outcome measures to be re-audited at a specified date once guidelines
have been implemented.
Present findings at the consultant community care group meeting.
Present findings at audit meeting.
Patient information leaflet on driving for clinicians to refer to and give to patients
when they come for assessment.
A re-audit will be completed within 12 months.
Limited
Present audit results locally alongside brief teaching on the guidelines regarding
antipsychotic polypharmacy.
Recommend that any inpatients discharged on antipsychotic polypharmacy have the
reason explicitly recorded in Discharge Summary under “Medications on Discharge”.
To be requested by Educational Supervisors of core trainees with inpatient
responsibilities.
Significant
Re-circulate communication standards and clinical supervisors to be reminded to
routinely monitor compliance.
Re-circulate the Managerial Supervision Template to managers to highlight best
practice.
Circulate the audit report to local area leads/managers who will be asked to distribute
and discuss in service/locality meetings. The actions highlighted are to:
a) Remind staff of the importance of including and documenting consideration of
safeguarding issues in supervision.
b) Remind staff to include crisis information and number of contracted sessions on
therapy plans.
Significant
131
Project
Number
Audit Name
Improvement Actions to be Taken
•
2107
Monitoring of physical
health and related risk
factors at Anson Road
rehab unit
•
•
•
•
•
•
2108
Risk of associating ECG
records with wrong
patients
•
•
•
•
2110
New patient referral
waiting time for general
adult psychiatry
outpatient clinic
1.
2.
3.
4.
5.
Assurance Level
c) Remind staff to routinely offer a copy of the clinical letter to patients and to
record in clinical notes where this is refused.
Repeat audit in 12 months time.
The doctors should make sure that they have filled in the physical health Proforma
and requested routine bloods and ECG while clerking in the new admissions.
Health Performa is too long and time consuming and perhaps can be made more
intuitive in its next update.
Staff should be doing LUNSERS on regular basis.
Blood results and ECG should be kept in the physical notes at all times for quick
references.
There should be separate areas in Amigos for recording investigations and scanning
ECG.
This audit should be repeated in a years’ time.
Limited
Establish if there is a risk of associating ECG records with wrong patients in your
services and if similar incidents have occurred.
Consider if immediate action needs to be taken locally and develop an action plan, if
required, to reduce the risk of a similar incident occurring.
Disseminate this Alert to all nursing, medical and engineering staff who are using or
maintaining ECG machines.
Share any learning from local investigations.
Significant
Consider text/ email reminder system.
Consider allocating a middle grade Doctor to each CMHT.
Consider alternatives to gateway system .
Increase the number of weekly new patient assessment slots.
Increase in the number of team assessments so that an appropriate need for
psychiatric review can be identified.
6. Regular liaison meetings with GPs to discuss referrals and offer verbal or written
Limited
132
Project
Number
Audit Name
Improvement Actions to be Taken
Assurance Level
advice that could potentially minimise the need for new patient assessments.
7. Re-audit new patient waiting times in 18 to 24 months – to provider time for system
change.
Additional recommendations from audit presentation at South MMHSCT Weekly Psychiatry
Teaching Meeting on 23rd July 2014:
•
•
•
•
2111
2114
2115
Consider alternative to Gateway system as it may be contributing to the delay.
Consider utility of offering patients more regular follow up appointments as opposed
to discharging them from clinic and having them re-present soon after as new
patients.
Consider utilising an opt-in system for CMHT services.
Training for new trainees on how respond to DNA situations.
Audit on use of
neuroimaging in
diagnosis of Dementia
Prescribing of regular
medications on Safire
Ward following
medicines reconciliation
•
There are different models used in different areas for timely diagnosis. It would be
beneficial to introduce a model which allows the patient to be seen earlier.
Significant
•
Consider re-audit with a larger sample of patients should there be further concern or
clinical incidents in this area.
The results of this audit should be considered in future if weekend provision of
pharmacy services is discussed. This would clearly have significant financial
implications, and the predictable effects of the lack of weekend pharmacist cover
were not the reason for this audit being completed
Significant
Documentation in ECT
Clinics
•
•
•
Correspondence sent to ECT prescribers (Consultants), highlighting this issue.
Correspondence sent to ECT prescribers (Consultants), highlighting this issue.
Written notice in ECT suite reminding juniors of information required for each
treatment.
Continued development of 'ECT clinic' service to check MMSE of patients. Progress
update from Dr. Sharma.
Significant
•
•
133
Project
Number
Audit Name
Improvement Actions to be Taken
•
•
•
2116
2120
Recovery orientated
practise for CMHT
service users on CPA
CQUIN L4
High Dose Antipsychotic
Therapy HDAT
prescribing in a
community setting
•
•
•
•
•
•
•
•
2121
Monitoring of physical
health assessments for
admissions to Bronte
Ward
•
•
•
Assurance Level
Change format of current ECT prescription to include prompt for VTE risk assessment,
ASA grade and use of ventilation.
Consider separate audit examining documentation in adverse events.
Dr Sharma to feedback to anaesthetic colleagues highlighting the issue.
Development of a programme to improve recovery oriented practice as part of the
2014/15 CQUIN which includes:
Improving staff knowledge of recovery oriented practice.
Supporting staff to create records which reflect recovery oriented practice.
Replicate this audit quarterly as part of the 2014/15 CQUIN.
Negotiate improvement trajectory with commissioners as part of 2014/15 CQUIN.
Limited
Results of the Audit will be presented and discussed at the Medicines Management
Committee.
Doctor to give short talk on the importance of regular monitoring of patients on HDAT
in relation to blood test and ECG.
Community team including the care coordinator to be made aware of patients being
on HDAT needing regular monitoring of investigations and review of their HDAT
prescription.
Re-audit in 6 months.
Looking at extending this project to involve other Community Mental Health Teams
across Manchester whilst re-auditing.
Significant
Consider AMIGOS physical health pro-forma instead of paper ones in consultation
with junior doctors.
Increase awareness of need for physical and need for documentation of attempts if
refusing. This could be done at induction and during Audit meetings.
Re – audit.
Significant
134
Project
Number
2122
2126
Audit Name
Improvement Actions to be Taken
•
Await results of other ongoing audits in Laureate House.
Evaluation of the
management of
pregnant women with
schizophrenia or schizoaffective disorder
•
•
Develop pro – forma’s for outpatient clinic appointments.
Discuss with the Information Department whether a separate heading can be
introduced for Amigos entries that is labelled ‘safeguarding children’.
This has been discussed with the Perinatal Faculty of the Royal College of Psychiatrist
and it was agreed that Dr Wieck should establish a working group.
N/A - Project is a
service evaluation
therefore the
assurance framework
cannot be applied as
with an audit
Audit of clinical
supervision for
Occupational therapists
•
Take action to ensure data is collected from staff who didn’t respond to the request
for data.
Ensure that the people not receiving supervision have an immediate plan with a
named supervisor and date for supervision.
Ensure that all supervisors have a date to attend supervision training to become trust
approved supervisors .
Feed back audit results to staff via share point and at the Occupational therapy forum
August 2014.
Re-audit in 6 months time and include audit of a sample of supervision notes to
provide evidence that notes are recorded and stored securely.
Significant
Increase awareness of using the 12-page tool as a means of making a complete
psychosocial needs and risk assessment that is robust and compliant with NICE
guidance. Providing assurances as to the quality of the doctor’s assessment as well as
meeting the trust’s requirements. To be done at Junior Doctor Induction February
2015.
Significant
•
•
•
•
•
2128
Assurance Level
Audit of self harm in
later life assessment
referral and
communication
•
1. Amend relevant trust-wide six-monthly junior doctor presentation to
emphasize this point
2. Disseminate results to Later Life Care Group Leads (strategic and operational)
Dr Lennon, John McGrath & Phil Hardman
3. Present audit and plan at citywide teaching 21 January 2015.
135
Project
Number
2130
2132
3024
Audit Name
Standardized assessment
and Outcome Measure
Records – Occupational
Therapists working on
the area teams for adults
of working age within
MMHSCT
Professional Social Work
Supervision
Service Evaluation Study
of Acacia Unit
Improvement Actions to be Taken
Assurance Level
•
Increase awareness of the importance of post-A&E assessment communication with
GPs. To be done at Junior Doctor Induction February 2015 (as per point 1 above).
•
Limited
•
•
•
•
•
Findings of the audit to be presented and discussed at the occupational therapy
forum.
Findings of the audit to be presented to the Head of Service
Findings of the audit to be presented to the Operational Management team
A plan regarding the provision of Occupational therapy to be developed by the Head
of Service and the Professional Lead in liaison with the operational and divisional
management team.
To be re audited in September 2015.
Develop options appraisal.
Attend relevant work streams.
Implement model through operational management.
Develop performance indicators.
•
EDS AMHPs to be offered AMHP / social work supervision within next 6-8 weeks.
High
•
•
•
Medical student attached to Dr Richard Jones in summer term 2016 will complete the
following plan
1) Will analyse the patient sample included in this study with the longer mirror period
calculated until 31/01/2016.
2) Will analyse the new sample of patients discharged after 01/02/2014.
3) The existing tool and methodology will be used.
4) The same primary and secondary outcome measures will be presented by the use of
descriptive statistic with the use of the same statistic tests.
N/A - Project is a
service evaluation
therefore the
assurance framework
cannot be applied as
with an audit.
136
Project
Number
3030
Audit Name
Improvement Actions to be Taken
5) The results will be included in the report attached to the present report to enable the
comparison of the results.
Reasons for DNA
appointments in an
outpatient setting
•
•
Contact details of patients should be updated before every clinic appointment.
Reminders by text messages could be introduced at 10 and 3 days prior to the
appointment.
•
A detailed trust protocol for managing DNAs should be drafted and finalized at the
community consultants meeting and meeting with managers for relevant care groups.
Consultants’ secretaries should be responsible for arranging and sending outpatient
appointments. Currently, this practice varies from locality to locality. The current
practice is likely to cause inconsistency in approach and can potentially cause errors.
A re-audit to be planned after 18 months.
•
•
3032
Assurance Level
Disulfiram treatment for
patients with alcohol
dependence in Brian
Hore Unit
•
•
•
•
•
•
To disseminate the results and recommendations to the clinical staff members who
works in Brian Hore Unit.
To give awareness about the importance of monitoring mental health on a monthly
basis which includes mental state examination, risk assessment and documentation of
a clear management plan.
To provide awareness about the importance of documenting and providing
psychosocial interventions with disulfiram treatment.
To discuss about dose titration in the Alcohol Directorate meetings and come to a
consensus about that and decide whether to include this in the re audit.
To include guidelines for the management of disulfiram in the local Doctors / clinicians
Induction Pack for Brian Hore Unit.
The criteria and the proforma for the re audit needs to be reviewed in the next 3 to 4
months. To re audit this topic in 4 to 6 months’ time.
An assurance level is
not required for this
project as it does not
measure performance
against an agreed
standard for patients
attending
appointments at
MMHSCT. This report
does however provide
data and insight into
how service user
attendance to
outpatient clinics can
be improved.
Significant
137
Project
Number
3039
Audit Name
SOP 09b –Storage of
Medicines –
Temperature Monitoring
of Clinic Rooms and
Medicines Refrigerators
Improvement Actions to be Taken
•
•
•
3046
Monitoring and
Intervention to improve
cardiovascular/metabolic
risk at Station Rd
•
•
•
•
3051
Audit of NICE Guidelines
for Treatment of Post
Traumatic Stress
Disorder
•
Assurance Level
Repeat the instructions of how to complete the temperature check daily, including the
details of how it should be completed consistently at the same time each day (ideally
at the hottest time) and by the same grade of staff.
Ask the ward staff to reread this SOP insuring each ward manager/ senior nurse signs
a sheet after claiming they have read and understood this information. Ask them to
apply this knowledge to the relevant situations on their wards.
Clinical areas are to raise concerns of excessive temperatures with the Medicines
Management Team for immediate actions and to the Estates Team for longer term
actions.
Limited
The audit will be presented and firstly discussed with the consultant at CRS Station
Rd.
A proforma will be devised to assist in following up physical health interventions as
well as initiating them in the correct service users. This will be supplied to the
consultant for 3 monthly reviews. It can be filed in the paper notes, where ECGs are
also filed. Recording on the computer system could be achieved by giving the
proforma to the nurse or doctor who writes up the computer entry for each clinic
review and it could be recorded under the title ‘physical health’. The consultant is the
only permanent member of staff so completing the proforma would be their
responsibility but where possible it could be delegated to a junior doctor.
The results of monitoring and interventions can be discussed with the GP at regular
intervals (6 monthly meetings have been arranged).
A re-audit in 6 months – 1 yr could also include effectiveness of the interventions (ie.
How many have successfully stopped smoking, got cholesterol <5).
Limited
Re - circulate summary of NICE guidance for treatment of PTSD to all PSCG staff
highlighting importance of i) recording clinical rationale for any exceptions ii) routinely
providing a copy of therapy plans to patients and their GPs and ensuring this is
uploaded to Amigos.
High
138
Project
Number
3052
3054
Audit Name
Improvement Actions to be Taken
Evaluation of the
Effectiveness of Later
Life Day Hospital Crisis
Intervention in
Preventing In-patient
Hospital Admissions
•
Re - audit of quality of
discharge letters from
the South Team of the
Early Intervention
Service
•
•
•
•
Assurance Level
There are no specific action plan recommendations from this evaluation. The report
clearly highlights the benefits of the PAU as a supportive service to those with
enduring mental health illness, and prevents hospital admissions and supports the
RCPsych’s report findings, whilst also providing assurance of the PAU’s operational
policy.
A future recommendation would be a re - evaluation to see whether attendance and
review at the PAU continues to prevent hospital admissions. A further area that could
be considered would be to assess the nature of the interventions patients received
when attending the PAU
Significant
Presentation of the audit findings at an EIP Service Away Day
Discharge presentation in which the discharge procedure is discussed with all staff at
a Service Away Day should be carried out.
Closure template should include step to check for presence of template adherent
discharge letter
Limited
139
Jargon Buster
You can access the Trust Jargon Buster at:
http://www.mhsc.nhs.uk/service-users/jargon-buster.aspx
Within the Quality Account we also use;
6 (Six) C’s
ADHD
ADS
Advocate
AMIGOS
Antipsychotic Medications
AOWA
Assertive Outreach Team
AWOL
Back to the Floor
CaFI
CAP-QI
Care Co-ordinator
Care Plan
CEO
COO
CPA
Care, Compassion, Courage, Confidence, Competence and
Communication.
Attention Deficit Hyperactivity Disorder
Addiction Dependency Solutions.
A person who speaks or writes in support or defence of a person or
cause. Across the Trust there is professional advocacy which is usually
provided by ReThink, but there are lots of different types of advocate
including legal or peer advocacy.
Trust's electronic patient record system.
Used in the treatment of psychosis, especially schizophrenia, and acute
or severe states of mania, depression, or paranoia.
Adults of Working Age.
A team who work specifically with Service Users who have been
involved with Mental Health Services but for various reasons the
Service User finds it difficult to engage
Absent without Leave - This is used when the person is detained under
the Mental Health Act and goes missing without having authorised
leave. They are also classed as AWOL if they have leave but don’t
return. In the case of an informal patient we would call them ‘missing
person’ and not AWOL.
Senior staff visit wards to look at quality and risk areas and get to see
for themselves rather than be reliant on reports. They will meet with
patients, carers and staff and can get increased understanding of
things that are working well and areas that need improvement.
Culturally-adapted Family Intervention.
Commissioner Assurance Plan for Quality Improvement – a plan put in
place between the Trust and the Commissioners with actions needed
to improve the quality of our services for the benefit of patients.
A Care Coordinator is a health care professional, usually a nurse, who
‘coordinates’ the care of a patient. Community based they will work
with the patient and help develop their care plan.
A plan to make sure that service users have care and support. Sets out
treatment and goals for recovery and agreed plans between services
and the patient.
Chief Executive Officer
Chief Operating Officer
Care Plan Approach -This is the approach that sets out how we
complete care plans and what we do.
140
CQC
Carer
CHORES
Clinician
Commissioners
Community Mental Health
Team (CMHT)
CCG
CQUIN
CRHT
DATIX
Dignity Walks
Dual Diagnosis
Duty of Candour
ECP
E-learning
ESMA
ESR
FFT
Francis Report
Care Quality Commission - The independent regulator of all health and
social care services in England. They visit services and monitor the
quality and risk of health and social care providers.
A person who looks after a family member, partner or friend who
needs assistance because of their illness, frailty or disability.
Chronological History of Risk Events Shared - The Trusts electronic
record of the risk events related to a patient so the historical picture is
available for everyone working with the patient and their carers.
A physician or other qualified person who is involved in the treatment
and observation of patients.
In Manchester this refers to the Clinical Commissioning Group and is
the body that purchases services from the Trust. It may also refer to
the visiting inspector from the Care Quality Commission
A team that provides support or emergency intervention in the
community.
Clinical Commissioning Group - See Commissioners above - Replaced
the Primary Care Trust.
Commissioning for Quality and Innovation - A scheme between the
Trust and the Clinical Commissioning Groups to set quality
improvement aims with financial reward for delivery.
Crisis Resolution Home Treatment Team - A team that provides
support or emergency intervention in the community.
This is the software name of the Trust's Risk Management Incident
Reporting System. We use this system to record all the patient safety
incidents and any other incidents that occur in the Trust.
Service users and other agencies inspect wards to ensure that service
users are treated with respect and dignity. These are patient led and
managed by the Matrons.
Service users who have both mental and substance misuse problems.
This is the requirement for the Trust to exercise candour in its
information sharing following a serious incident.
Establishment Control Panel.
Refers to the use of electronic media and information and
communication technologies.
Eliminating Mixed Sex Accommodation - This was the national
approach to ensuring hospital wards have single sex accommodation –
so males and females aren’t sharing the same sleeping areas etc.
Electronic Staff Record.
Friends and Family Test.
Robert Francis QC's report outlines how Mid Staffordshire NHS Trust
was preoccupied with cost cutting, targets and processes and which
lost sight of its fundamental responsibility to provide safe care. This
was a national public inquiry and has recommendations that all
providers can learn from.
141
Gateway Function Service
Healthwatch
HLIP
IAPT
Information Governance
Toolkit (IG)
I &IT
Inpatient
LiA
LiLY
Manchester MIND
Mental Health Act 1983
(MHA)
Mental Health Tribunal
MHMDS
Monitor
National Clinical Audits
National Confidential
Enquiries
NCISH
NICE
NED
NIHR
NRLS
OD
PARS
Project giving people easier access to be referred to the Trust's
services.
A local consumer champion for health and social care.
High Level Investigation Panel.
Improving Access to Psychological services - This is a national approach
and all commissioners and providers are looking at improving the
availability of psychological services for patients.
Information Governance ensures necessary safeguards for, and
appropriate use of, patient and personal information.
Informatics and Information Technology.
A patient who stays in a hospital while receiving medical care or
treatment.
Listening into Action
Liaison in Later Years
A charity which helps people with a mental health problem to have
somewhere to turn for advice and support.
The legal framework governing the compulsory treatment of people
with Mental Illness in England and Wales.
Independent bodies who make decisions when a service user or carer
has applied for discharge from hospital when the patient is detained
under the Mental Health Act.
Mental Health Minimum Dataset.
Monitor has an ongoing role in assessing NHS trusts for foundation
trust status, and for ensuring that foundation trusts are well-led, in
terms of both quality and finances.
National clinical audit is designed to improve patient outcomes across
a wide range of medical, surgical and mental health conditions.
Project which promotes improvements in health care by reviewing
particular areas on a wide scale and collating data from lots of services.
National Confidential Enquiries into Suicide and Homicide by People
with a Mental Illness. (See National Confidential Enquiries above)
National Institute for Health and Care Excellence - The body that sets
the best practice in clinical approaches and releases guidelines and
information to all healthcare.
Non-Executive Director.
National Institute for Health Research.
National Reporting and Learning System - Trusts across England and
Wales report all their patient safety incidents to the NRLS and they
release combined and individual reports so we get a national picture of
the types of incidents being reported.
Organisational Development.
Physical Activity Referral Service - Helps people living with long term
health conditions to increase their levels of physical activity in a safe
and structured way.
142
PALS
Patient Safety
Thermometer
PD
PFD
PICU
PLACE Programme
POMH
PSED
PSI
Psychiatrist
QIPP
Quality Dashboards
Quality Improvement
Strategy
ReThink
RCA
SAFIRE
SBAR
S.O.P.s
Stakeholders
Statement of Assurance
Stonewall
SIRI
SUS
TDA
Ward Manager
Patient Advice and Liaison Service - A service which can give help,
advice or information on the services provided.
This is a national tool for measuring Patient Safety – we submit data
and every other Trust does to.
Personality Difficulties.
Preventing Future Death.
Psychiatric Intensive Care Unit – A unit that offers increased support
for patients who are having more difficulty when admitted.
Patient Led Assessments for the Care Environment.
Prescribing Observatory for Mental Health - Aims to help specialist
mental health Trusts/healthcare organisations improve their
prescribing practice.
Public Sector Equality Duty.
Patient Safety Incidents.
Qualified medical doctors who have done further training in treating
mental health conditions.
Quality, Innovation, Productivity and Prevention - National programme
intended to be a resource for everyone in the NHS, public health and
social care for making decisions about patient care or the use of
resources.
A dashboard is an information tool that provides data around
performance, quality or clinical areas. Usually a single page so it’s a
quick glance guide.
The Trusts strategy which identifies three priorities for the Trust with
specific projects listed against the priorities.
A charity which helps people living with mental disorders
Root Cause Analysis.
Swift Assessment For the Immediate Resolution of Emergencies.
Situation, Background, Assessment and Recommendation.
Standard Operating Procedures.
A person, group, organisation, member or system that affects or can
be affected by an organisation's actions.
An organisation publishes a statement of assurance to tell the public
that management cares about running an efficient and law abiding
organisation.
A charity working for equality and justice for lesbians, gay men and
bisexuals
Serious Untoward Incident or Serious Incident Requiring Investigation.
Secondary Uses Service.
Trust Development Authority
The Senior Nurse in charge of running a hospital ward
143
How to Contact Us
Quality Account
Your views are important to us and any questions or comments you have regarding this report can
be sent to our Head of Patient Experience in the first instance:
Head of Patient Experience
Manchester Mental Health and Social Care Trust,
2nd Floor, Chorlton House
70 Manchester Road, Chorlton-cum-Hardy
Manchester, M21 9UN
Email: janet.sinclair@mhsc.nhs.uk
Telephone: 0161 882 1378
Fax: 0161 882 1090
Other Comments, Concerns, Complaints or Compliments
The Trust positively welcomes all types of feedback on the services we provide. If you would like to
make a comment, suggestion, compliment or complaint, we recommend in the first instance that
you contact our Patient Advice and Liaison Service (PALS).
•
By telephone on 0161 882 2084 / 2085 or on the mobile 078152 84660 during normal office
hours 9am - 5pm, Monday to Friday (excluding public bank holidays).
•
By writing to the following address:
Patient Advice and Liaison Service
Manchester Mental Health and Social Care Trust
11th Floor
Hexagon Tower
Crumpsall Vale
Manchester M9 8GQ
•
By email to PALS@mhsc.nhs.uk
If you would like to make a formal complaint, you can contact the Complaints Manager on
0161 882 1355. Please be assured that your complaint will be treated in the strictest
confidence and raising your concerns will not harm or prejudice the care you or the person
you care for receives.
144
Helping us to help you
If you need help to access this document in your language, please contact the link-worker service on 0161
276 5259.
Arabic
‫كدعاسن يك اندعاس‬
‫ىلع لصحت يك ةدعاسملا يف بغرت تنك اذا‬
‫ةيلصالا كتغل ىلا ةمجرتم ةقيثولا هذه نم ةخسن‬
، ‫ىلع طابترالا يفظوم ةمدخب لاصتالا ءاجرلا‬
‫ فتاهلا‬0161 - 2765259
Cantonese
幫助我們協助你。
如你需要協助以取得這文件的中文版本, 請致電聯絡員服務部,
電話號碼 0161 276 5259。
Farsi
‫مینک کمک امش ھب ام ات دینک کمک ام ھب‬
‫سرتسد ھب زاین رگا‬
‫دیراد دوخ نابز ھب کرادم نیا ھب ی‬
‫ ھرامش ھب ھمجرت دحاو اب افطل‬5259 276 0161
‫دیریگب سامت‬
French
Aidez nous à vous aider. Si vous nécessitez accéder a ce document en français, veuillez contacter le service
Linkworker au numéro suivant 0161 276 5259.
Somali
Ina caawi si aanu kuu caawinno
Hadii aad u baahantahay malafkan oo afkaaga ku qoran,fadlan la xiriir
adeega Af celiyayaasha telefoonka 0161 276 5259.
Urdu
‫۔ہاچ نواعت اک پا ںیمہ ۔لیک ےنرک ددم یکپا‬
‫واتسد نا‬
‫رگ ا ۔لیک ےنھجمس ںیم نابز ینپا وک تازی‬
‫ینابرہم ۓ‬
‫ارب وت ےہ ترورض یک ددم وکپا‬
0161 276 5259 ‫ےس سورس رکروکنیل‬
‫ەںیرک ہطبار رپ‬
If you require the document in larger print, Braille, audio or other formats
please contact the Communications Team on 0161 882 1093 or e-mail:
communications.admin@mhsc.nhs.uk
145
Manchester Mental Health and Social Care Trust has
arrangements in place to upload our Quality Account
to the NHS Choices website and send a copy of our
Quality Account to the Secretary of State by
30th June 2015. This will be completed on behalf of the
Trust by the Director of Communications, Engagement
& Partnerships and the Communication Department
146
147