Norfolk and Suffolk
NHS Foundation Trust
Norfolk and Suffolk
NHS Foundation Trust
Hellesdon Hospital
Drayton High Road
Norwich NR6 5BE
Tel: 01603 421421
Web: www.nsft.uk
Norfolk and Suffolk NHS Foundation
Trust values and celebrates the
diversity of all the communities we
serve. We are fully committed to
ensuring that all people have equality
of opportunity to access our service,
irrespective of their age, gender,
ethnicity, race, disability, religion or
belief, sexual orientation, marital or
civil partnership or social & economic status.
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different language, please contact PALS
and we will do our best to help.
Email: PALS@nsft.nhs.uk
or call: PALS Freephone 0800 279 7257
© 2015 NSFT. All rights reserved. NSFT Comms/15/016. GFX 3770
Quality Account
2014-15
Contents
Page
2014-15 Statement of Directors’ Responsibilities in respect of the Quality Report
Independent Auditor’s Report
Statement from the Chief Executive
Information about the quality account
Looking forward
Feedback on Quality Priorities 2014-15
Statements of Assurance from the Board
Review of Services
Research
Commissioning and Quality Innovation Goals (CQUIN) agreed with Commissioners
Statements from the Care Quality Commission (CQC)
Data Quality
Quality Initiatives
Implementing Recovery through Organisational Change (ImROC)
Crisis Care
Child Family and Young People Pathway
Drug and Alcohol Services
Secure Services
Learning Disability Services
National Recognition
Quality indicators
Key Quality Indicators
Evaluation of Patient Safety
Infection Prevention and Control (IPAC) Activities
Physical Health
Sign Up to Safety Plan
Positive and Proactive Care
Evaluation of Clinical Effectiveness
Evaluation of Patient Experience
Serious Incidents (SIs)
Patient Led Assessments of the Care Environment (PLACE)
Service User Survey
Staff Survey
Commissioners and Stakeholder Comments
NSFT Governors
NHS South Norfolk CCG, on behalf of the Norfolk CCGs
Great Yarmouth & Waveney Clinical Commissioning Group
Healthwatch Suffolk
Healthwatch Norfolk
Health Overview and Scrutiny Committee
Key and glossary
How you can get involved
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Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
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Quality Account 2014 -15
Norfolk and Suffolk NHS Foundation Trust
2014-15 Statement of Directors’
Responsibilities in respect of the
Quality Report
– CQC Intelligent Monitoring Report dated
November 2014
The Directors are required under the Health
Act 2009 and the National Health Service
(Quality Accounts) Regulations to prepare
Quality Accounts for each financial year.
Monitor has issued guidance to NHS
Foundation Trust Boards on the form and
content of annual quality reports (which
incorporate the above legal requirements) and
on the arrangements that NHS Foundation
Trust Boards should put in place to support
the data quality for the preparation of the
Quality Report.
In preparing the Quality Report, Directors
are required to take steps to satisfy
themselves that:
• The Quality Report presents a balanced
picture of the NHS Foundation Trust’s
performance over the period covered
• The performance information reported in the
Quality Report is reliable and accurate
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Report,
and these controls are subject to review to
confirm that they are working effectively
in practice
• The data underpinning the measures of
performance reported in the Quality Report
is robust and reliable, conforms to specified
data quality standards and prescribed
definitions, is subject to appropriate scrutiny
and review
• The content of the Quality Report meets the
requirements set out in the NHS Foundation
Trust Annual Reporting Manual 2014-15
and supporting guidance
• The content of the Quality Report is not
inconsistent with internal and external
sources of information including:
– Board minutes and papers for the period
April 2014 to March 2015
– Papers relating to Quality reported to the
Board over the period April 2014 to
March 2015
– Feedback from commissioners dated
April 2015
– Feedback from governors dated May 2015
– Feedback from local Healthwatch
organisations dated May 2015
– Feedback from Overview and Scrutiny
Committee dated May 2015
– The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009, dated May 2015
– The national patient survey published 2014
– The 2014 national staff survey published
February 2015
– The Head of Internal Audit’s annual opinion
over the Trust’s control environment dated
May 2015
The Quality Report has been prepared in
accordance with Monitor’s annual reporting
guidance (which incorporates the Quality
Accounts regulations) as well as the standards
to support data quality for the preparation of
the Quality Report (available at
www.monitor.gov.uk/annualreportingmanual)
The Directors confirm to the best of their
knowledge and belief they have complied
with the above requirements in preparing the
Quality Report.
By order of the Board
Date
Chairman
Date
Chief Executive
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
3
Independent Auditor’s Report to the
Board of Governors of Norfolk and
Suffolk NHS Foundation Trust on the
Quality Report
We have been engaged by the Board of
Governors of Norfolk and Suffolk NHS
Foundation Trust to perform an independent
assurance engagement in respect of Norfolk
and Suffolk NHS Foundation Trust’s Quality
Report for the year ended 31 March 2015 (the
“Quality Report”) and certain performance
indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March
2015 subject to limited assurance consist of
the national priority indicators as mandated by
Monitor:
• 100% of Care Programme Approach (CPA)
patients receive follow-up contact within
seven days of discharge; and
• Minimising delayed transfer of care.
We refer to these national priority indicators
collectively as the “indicators”.
Respective responsibilities of the
Directors and auditors
The Directors are responsible for the content
and the preparation of the Quality Report in
accordance with the criteria set out in the NHS
Foundation Trust Annual Reporting Manual
issued by Monitor.
Our responsibility is to form a conclusion,
based on limited assurance procedures, on
whether anything has come to our attention
that causes us to believe that:
• the Quality Report is not prepared in all
material respects in line with the criteria set
out in the NHS Foundation Trust Annual
Reporting Manual;
• the Quality Report is not consistent in all
material respects with the sources - specified
in the Detailed Guidance for External
Assurance on Quality Reports; and.
• the indicators in the Quality Report identified
as having been the subject of limited
assurance in the Quality Report are not
4
Norfolk and Suffolk NHS Foundation Trust Quality Account
reasonably stated in all material respects in
accordance with the NHS Foundation Trust
Annual Reporting Manual and the six
dimensions of data quality set out in the
Detailed Guidance for External Assurance on
Quality Reports.
We read the Quality Report and consider
whether it addresses the content requirements
of the NHS Foundation Trust Annual Reporting
Manual, and consider the implications for our
report if we become aware of any material
omissions.
We read the other information contained in
the Quality Report and consider whether it is
materially inconsistent with:
• Board minutes for the period April 2014 to
May 2015;
• Papers relating to Quality reported to the
Board over the period April 2014 to
May 2015;
• Feedback from Commissioners dated
May 2015;
• Feedback from Governors dated May 2015;
• Feedback from local Healthwatch
organisations dated May 2015;
• Feedback from Overview and Scrutiny
Committee dated May 2015;
• The Trust’s complaints report published
under regulation 18 of the Local Authority
Social Services and NHS Complaints
Regulations 2009, 2014-15;
• The 2014-15 national patient survey;
• The 2014-15 national staff survey;
• Care Quality Commission intelligent
monitoring report; and
• The 2014-15 Head of Internal Audit’s annual
opinion over the Trust’s control environment.
We consider the implications for our report if
we become aware of any apparent
misstatements or material inconsistencies with
those documents (collectively, the
“documents”). Our responsibilities do not
extend to any other information.
We are in compliance with the applicable
independence and competency requirements
of the Institute of Chartered Accountants in
England and Wales (ICAEW) Code of Ethics.
Our team comprised assurance practitioners
and relevant subject matter experts.
This report, including the conclusion, has
been prepared solely for the Board of
Governors of Norfolk and Suffolk NHS
April 2014 to March 2015
QA 2015 040615 numbered for insertion to ARA :Layout 1 09/06/2015 08:26 Page 31
Governors of Norfolk and Suffolk NHS
Foundation Trust as a body, to assist the Board
of Governors in reporting Norfolk and Suffolk
NHS Foundation Trust’s quality agenda,
performance and activities. We permit the
disclosure of this report within the Annual
Report for the year ended 31 March 2015, to
enable the Board of Governors to demonstrate
they have discharged their governance
responsibilities by commissioning an
independent assurance report in connection
with the indicators. To the fullest extent
permitted by law, we do not accept or assume
responsibility to anyone other than the Board
of Governors as a body and Norfolk and
Suffolk NHS Foundation Trust for our work or
this report save where terms are expressly
agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance
engagement in accordance with International
Standard on Assurance Engagements 3000
(Revised) – ‘Assurance Engagements other
than Audits or Reviews of Historical Financial
Information’ issued by the International
Auditing and Assurance Standards Board
(‘ISAE 3000’). Our limited assurance
procedures included:
• Evaluating the design and implementation of
the key processes and controls for managing
and reporting the indicators.
• Making enquiries of management.
• Testing key management controls.
• Limited testing, on a selective basis, of the
data used to calculate the indicator back to
supporting documentation.
• Comparing the content requirements of the
NHS Foundation Trust Annual Reporting
Manual to the categories reported in the
Quality Report.
• Reading the documents.
A limited assurance engagement is smaller
in scope than a reasonable assurance
engagement. The nature, timing and extent
of procedures for gathering sufficient
appropriate evidence are deliberately limited
relative to a reasonable assurance
engagement.
Limitations
Non-financial performance information is
subject to more inherent limitations than
financial information, given the characteristics
of the subject matter and the methods used
for determining such information.
The absence of a significant body of
established practice on which to draw allows
for the selection of different but acceptable
measurement techniques which can result in
materially different measurements and can
impact comparability. The precision of
different measurement techniques may also
vary. Furthermore, the nature and methods
used to determine such information, as well as
the measurement criteria and the precision
thereof, may change over time. It is important
to read the Quality Report in the context of
the criteria set out in the NHS Foundation
Trust Annual Reporting Manual.
The scope of our assurance work has not
included governance over quality or nonmandated indicators which have been
determined locally by Norfolk and Suffolk NHS
Foundation Trust.
Conclusion
Based on the results of our procedures,
nothing has come to our attention that
causes us to believe that, for the year ended
31 March 2015:
• the Quality Report is not prepared in all
material respects in line with the criteria set
out in the NHS Foundation Trust Annual
Reporting Manual;
• the Quality Report is not consistent in all
material respects with the sources specified
above; and
• the indicators in the Quality Report subject
to limited assurance have not been
reasonably stated in all material respects in
accordance with the NHS Foundation Trust
Annual Reporting Manual.
KPMG LLP
Statutory Auditor
6 Lower Brook Street,
Ipswich, Suffolk. IP4 1AP
27 May 2015
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
31
Statement from the Chief Executive
This has been a challenging 12 months for our
Trust, and we recognise that the high quality
standards that we aspire to achieve have not
always been met. That is a personal
disappointment to me and I know it is to my
colleagues on the Trust Board.
The commitment of our Board is that
2015-16 and beyond is going to be a time of
improvement, with a clear focus on quality
and of improving the working lives of
our staff.
On inspecting us in October 2014, the Care
Quality Commission (CQC) stated in its report:
‘Overall, we saw that staff were kind, caring
and responsive to people and were skilled in
the delivery of care’.
To have skilled and competent staff, who
care and respond to the needs of our service
users is the starting point for our achieving
high quality standards. Our Board has
described the end of 2014-15 as our
‘turning point’.
This will be the point from where we
demonstrate that we learn from our mistakes
and ensure they are not repeated. We will
ensure that our day to day practices offer high
quality, safe services which are the norm not
the exception.
Most significantly, we will celebrate and
share our successes with our service users,
carers and commissioners. We will continue
to give full credit to our staff to motivate them
to continue to deliver ever increasing levels
of quality.
Some of the key quality improvements and
achievements we have already made include:
• A safe staffing review for in-patient areas
was completed and £2.6m investment
made into recruiting more staff.
• 16 new doctors have been recruited to
improve services and reduce locum use.
• A new 12-bed mental health assessment
ward opened in March to reduce out of
area placements.
• In partnership with MIND, we introduced a
mental health crisis telephone line, available
seven-days-a-week in Norfolk.
• Significantly reducing out of area
placements of our service users
• Our Trust has been awarded the five-year
contract for the new Norfolk and Waveney
Wellbeing service.
6
Norfolk and Suffolk NHS Foundation Trust Quality Account
• We have been awarded the new £1.3m
Liaison and Diversion contract, offering
early intervention, and diverting people,
who require mental health services, away
from the criminal justice system.
But we know there is still much work to be
done. The CQC inspection report also rated
our Trust overall as ‘inadequate’ and
recommended to our regulator, Monitor, that
we were put in to ‘special measures’, which
was enacted in February 2015.
The report highlighted the need to improve
staff morale, staffing levels, bed availability,
staff training and visible leadership across our
Trust. It held no surprises for us and, although
much work had already begun to address
many of these issues when the report was
published in January this year, further
improvements will be delivered over the
coming months.
I am more confident that as we enter a
period of stability and support that ‘special
measures’ offers us, we are in a better position
to meet the challenges we face than we have
ever been before.
Our Quality Improvement Plan and the
Quality Goals outlined within this Quality
Account will provide the framework for our
continued progress. We know what is
important, we understand where we got it
wrong and we are putting it right; these
priorities and plan will ensure we stay
on track.
Our Board recognises that being truly visible
leaders who are ready to listen and respond,
as well as lead, has to be our approach
moving forward and with that approach we
have been able to address, quickly and
effectively, a number of issues raised by
the CQC.
We must not ignore the other positive
elements of the inspectors’ report highlighting
areas of existing good practice, such as:
• The Dementia Intensive Support Team (DIST)
introduced an innovative helpline to provide
advice to carers and care homes. The team
was recognised for their achievements by
being shortlisted for a Positive Practice in
Mental Health Award 2014.
• Examples of innovative multi-disciplinary
working within our Child, Family and
Young People services. The young people’s
April 2014 to March 2015
in-patient unit was also commended last
year, following assessment by the Quality
Network for In-patient CAMHS, which
praised the collaboration between staff and
service users, and staff morale.
• By collaborating with Norfolk and Suffolk
Constabularies, we are helping to reduce
the number of people unnecessarily
detained under Section 136. In Norfolk, a
team of qualified mental health nurses are
working in the police control room and in
Suffolk, nurses work with police officers in
a triage car which can attend incidents
around the county.
• Our Dementia and Complexity in Later Life
teams (DCLL) have integrated with GPs and
social workers to improve outcomes for
patients, and as part of the Health
Foundation’s two-year project ‘Closing the
Gap in Patient Safety’, will be looking at
preventing falls and medication errors
among people using dementia care services.
All of this is a real testament to the
commitment and professionalism of our
staff and on behalf of the Board I’d like to
acknowledge their ongoing support
and dedication.
It will be critical to work with staff, service
users, our Governors, commissioners and
other stakeholders, to continue to build on
quality improvements to our services.
We will continue to listen, to learn, to
improve and to raise the bar on quality
through 2015-16 and beyond.
Statement of accuracy
I confirm that to the best of my knowledge,
the information contained in this document
is accurate.
Michael Scott
Chief Executive
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
7
Information about the quality account
The purpose of the quality account is to ensure
that NHS organisations are accountable for the
quality of services they provide. The quality
account is a way in which the Board of
Directors demonstrates that it takes seriously
its responsibilities for promoting, monitoring
and leading on quality. It includes several
quality priorities explicitly agreed by the Board
of Directors for 2014-15. These were identified
in a process which began with stakeholder
consultation followed by widespread
dissemination of options and collation
of feedback.
Seclusion and restrictive interventions:
Use of restrictive interventions will
reduce to below the national
benchmarking average by
1 April 2016.
This priority will be led by the Director of
Nursing, Quality and Patient Safety.
Physical health
95% of service users admitted to a
ward for more than 24 hours will
receive a physical health check. This
will be recorded on the service user
(patient) record (Lorenzo) along with
any action plan if a physical health
need is identified.
Looking forward
Priorities for Improvement in 2015-16
*This plan
can be found
on NHS Choices
website at
http://www.
nhs.uk/NHS
England/
special
measures/
Documents/
May%20
2015/
norfolk-and
-suffolk-action
-plan-may
-2015.pdf
8
This is the section of the Trust’s Quality
Account that looks forward to 2015-16 and
identifies our goals for improvement. The
rationale for why these goals have been chosen
and how progress will be monitored is
described below.
Our Trust has agreed a number of priorities
which support our Quality Improvement Plan
and which include goals to improve practice,
where deficits have been identified from the
service user survey, local and national clinical
audits and local feedback, including complaints
and serious incident investigations.
The priorities our Trust has agreed will help
us to improve the quality of care we offer. They
are based on feedback from service users and
carers who have told us how services could be
improved. We have also looked at what we can
learn from complaints and incidents, and from
national research into good practice.
Each of these priorities will support our
Quality Improvement Plan and each will be
led by an Executive Director to ensure
progress is made.
This progress will be reported to our full
Board of Directors four times a year.
This priority will be led by the Norfolk and
Suffolk Operations Directors, supported by the
Physical Health Team.
Patient Experience
(Reference: Quality Improvement Plan RE6)*
Trust service users (with Care
Programme Approach entitlements)
will report that they were involved in
their care plans at a level at or above
the national benchmarking average
when the 2016 results are published.
This will be measured via the Service User
Survey, ‘Have you agreed with someone from
NHS mental health services what care you
will receive?’
Clinical Effectiveness
(Reference: Quality improvement Plan SA9)*
All locality governance groups will
be able to demonstrate that learning
from incidents has led to changes in
practice by 1 October 2015.
Patient safety
(Reference: Quality Improvement Plan SA4)*
Norfolk and Suffolk NHS Foundation Trust Quality Account
This priority will be led by the Norfolk and
Suffolk Operations Directors and all managers
will take action and respond to information
coming from the Patient Safety Team.
April 2014 to March 2015
Feedback on Quality Priorities 2014-15
The Quality Account published in 2014
identified five new quality targets, with a
further three quality targets carried forward
from 2013-14. This section demonstrates the
progress that has been made in the past
12 months.
Patient Safety
Priority 1 – To implement a system
that ensures that all patients/service
users in contact with mental health
services access relevant physical
healthcare screening and services.
Where we were:
This priority arose from the National Audit of
Schizophrenia published in 2012. Following
discussion with commissioners a number of
systems were put in place for community
patients which acknowledged that our Trust
carried responsibility for the physical health of
its service users, usually in partnership with
primary care services.
Where we are now:
In 2014-15, this priority was clarified as the
implementation of the Lester Tool and
adopted as a National CQUIN target. Results
of round two of the National Audit identified
that the Trust performance in monitoring the
five cardio-metabolic health risk factors had
improved and the Trust had moved from
53rd position to 39th position out of the
64 organisations taking part. Although this
identifies an improved position nationally,
completion of all five elements of the tool
remained low and an action plan was put in
place and led by the Physical Health Strategy
Group. Our Trust has subsequently submitted
data to a follow up audit and the results
are awaited.
Priority 2 – Being able to access
services quickly.
Where we were:
This priority was identified by service users
responding to a consultation and reflected the
view that there were delays in accessing NSFT
services following referral.
Where we are now:
The following table identifies the waiting
times for services in the three commissioned
areas of the Trust, as of 31 March 2015. The
target in all cases is for 100% of patients to
be seen within the number of days stated in
the contract.
(QA1)
IAPT Services - seen within 28 days of referral
Month
Jan
Feb
Mar
Qtr
Gt Yarmouth & Waveney
80.58%
94.30%
97.85%
88.87%
Norfolk
95.76%
100.00%
99.85%
98.49%
Suffolk
99.80%
99.84%
99.35%
99.63%
Trust
93.05%
99.00%
99.34%
97.10%
Suffolk
97.25%
97.83%
98.23%
97.76%
Trust
98.63%
98.76%
98.57%
98.65%
(QA2)
Secondary Care Services - seen within 18 weeks of referral
Month
Jan
Feb
Mar
Qtr
Gt Yarmouth & Waveney
100.00%
99.73%
100.00%
99.92%
Norfolk
99.03%
98.99%
98.19%
98.73%
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
9
Priority 3 – Being confident that the
Trust learns from mistakes and puts in
place plans to reduce similar risks.
Where we were:
The Francis Inquiry in 2013 identified the need
for organisations to have a greater openness
and ‘candour’ with service users and patients
when safety incidents occur.
While our Trust did have a process for
investigating safety incidents, it had not fully
demonstrated that actions from investigations
were being completed or that lessons learned
were being shared.
Where we are now:
The recent Care Quality Commission (CQC)
report identified that this issue was still a
cause for concern, and this priority has been
included in the Trust’s Quality Improvement
Plan to ensure action is taken.
Our Trust has also implemented a policy to
ensure that ‘Duty of Candour’ is applied and
that evidence that action is being taken is
regularly presented to our Board.
Patient Experience
Priority 4 – Being able to contact a
mental health worker out of hours,
and the inclusion of emergency
contact details in Crisis or
Contingency Plans for service users.
although when plans were in place they were
found to be of high quality and to contain the
relevant contact numbers.
Although our Trust produced general
information about its services, there was, at
times, a lack of direct contact numbers for
clinical teams for our service users in a crisis or
out of hours.
“Crisis team are not a helpful service
for a person in a real crisis”
“My care plan was discussed fully
and I was involved”
Where we are now:
The guidance remains consistent that all
service users should have a Crisis, Contingency
or Recovery Plan and this should contain
contact details for emergencies and out
of hours.
Monitoring this will become easier with the
roll out of a single online patient/service user
record (Lorenzo) in Spring 2015, where plans
will be recorded.
In the meantime, a small audit of
community teams was undertaken in February
2015. Although a relatively small sample
of 51 cases is not fully representative, the
cases were drawn from teams right across
our localities.
This audit has shown that the number of
service users having a crisis plan has increased,
but only 55% of the plans contain the
contact numbers.
Where we were:
Audit demonstrated that less than 50% of our
service users had a Crisis Plan in place,
(QA3)
Combined Total
(n = 51)
Central Norfolk
West Norfolk
East Suffolk
West Suffolk
(n = 9)
Gt Yarmouth
& Waveney
(n = 6)
(n = 51)
(n = 51)
(n = 51)
7/9 (78%)
3/6 (50%)
9/12 (75%)
10/12 (83%)
There is a Crisis / Contingency Plan in place
40/51 (78%)
11/12 (92%)
The Crisis / Contingency Plan includes specific telephone contact details out of working hours in
case of emergency
22/40 (55%)
10
7/11 (64%)
Norfolk and Suffolk NHS Foundation Trust Quality Account
3/7 (43%)
April 2014 to March 2015
1/3 (33%)
5/9 (56%)
6/10 (60%)
In addition, in January 2015 a 6pm to 8am
crisis support line was launched in Norfolk in
partnership with MIND. All service users are
given the contact number.
If the support line proves successful,
ongoing funding will be sought and plans to
roll out a similar support line in Suffolk will
be discussed.
Priority 5 – All in-patient areas will
have a programme of activities which
will be available seven days a week
including evenings.
Where we were:
Feedback from our 2013 National Service User
Survey showed our Trust to be in the top 20%
of mental health trusts for providing activities
both at weekends and during the week.
However, staffing shortages in some areas
were leading to the programme not being
delivered consistently.
Where we are now:
The original TOC guide was launched in July
2010 to build on good practice and to include
and recognise carers as partners in care. NSFT
signed up as official members of the TOC
scheme in May 2014.
By signing up to the TOC membership
scheme, our Trust has committed to ensuring
that carers are valued for the vital role they
play and are identified as equal partners
in care.
Since signing up to the scheme, our service
lines have taken an active role in ensuring that
self-assessments are in place and the carer’s
role is acknowledged and supported. Our
teams have also set up monitoring groups
where self-assessments can be discussed
locally, good practice shared and any issues
addressed. Oversight is provided at a strategic
level by the Carers Leads Advisory group.
Clinical Effectiveness
Where we are now:
This priority was set without a clear and
measurable goal and a new method of
measurement has been implemented through
the use of an individual monitoring form. This
form has been introduced for all in-patients
and is used in conjunction with daily ward
meetings, which enable service users to
discuss activities for the day and for the staff
to tailor the programme accordingly.
The form will demonstrate the activity that
is available and taken up by the service user
and may also be used in reviews to identify
changes in mental state.
Priority 6 – The Trust will use the
Triangle of Care (TOC) self-assessment
tool as a starting point before
consulting with carers on an
appropriate action plan. Its
implementation and effectiveness
will be monitored and reported to
carers, service users and
commissioners.
Where we were:
Local feedback identified that carers were not
always involved or considered in the care of
the service user. While a number of initiatives
were in place to improve the situation, the
implementation was variable across the Trust.
Priority 7 – When a new medication is
prescribed, the prescriber should
always discuss this with the service
user first. Information leaflets should
be given and this should be recorded
in the service user’s record.
Where we were:
The National Service User Survey and the
National Audit of Schizophrenia both
indicated that some service users did not feel
that they were consulted in changes to their
medication or given enough information.
Where we are now:
The National In-patient Survey in 2014
revealed that:
• Patients reporting that the purpose of their
medication had been explained in a way
that they could understand decreased from
45% to 34%.
• Patients reporting being fully informed
about the side effects of the medication
dropped from 34% to 19%.
For both responses the Trust’s score fell within
the lowest 20% of trust scores.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
11
QA 2015 040615 numbered for insertion to ARA :Layout 1 09/06/2015 10:31 Page 38
(QA4)
Q24 Purposes of medications
explained completely
Q25 Told completely about the
side effects of the medication
0%
10%
Denotes Trust’s position within the above ratings
20%
Best performing Trusts
The Trust is disappointed in these results but
notes that many of the respondents would
have accessed services in 2013, and
improvements have been made since then.
An audit carried out in March 2015 has
identified that 82% of service users were
engaged in a discussion about their
medication and 56% reported having the
side effects explained.
Following the results of the service user
survey, a Trust-wide action plan has been
put in place and progress will be reported
to Senior Management Forum.
Priority 8 – Having a care coordinator
who gets to know you and can
ensure continuity of care.
30%
40%
About the same
50%
60%
70%
Worst performing Trust
Where we were:
This priority was identified by service users
during a period of time when there was a
major service restructuring programme in
place, with movement of care coordinators
between teams having a real impact on
service users.
“I feel that I have been left high and dry
after my change of care coordinator”
Where we are now:
Whilst recognising the importance of this
priority, there is no straightforward way of
measuring achievement. The Trust do regularly
collect data on the number of cases awaiting
care coordinator allocation, and this
information is provided as an indication of
our performance against this priority.
(QA5)
Unallocated cases in the last three months of 2014-15
Locality
Number of cases
(Jan 15)
Number of cases
(Feb 2015)
Number of cases
(March 15)
270
196
109
53
174
20
51
267
162
98
61
189
6
51
286
188
141
0
221
6
0
Central adult
Central CFYP
Coast adult
Coast DCLL
West adult
West CFYP
West DCLL
This issue is predominantly related to care in
Norfolk where a number of initiatives have
been put in place to mitigate the risks to
service users:
• Allocation of £2.6 million to provide
additional staff.
12
Norfolk and Suffolk NHS Foundation Trust Quality Account
• All relevant staff in service teams can access
all cases, ensuring any member of the team
can provide assistance to a service user
when required.
• Service users can access groups within the
Norfolk Wellbeing service if appropriate.
April 2014 to March 2015
Statements of Assurance from the
Board
The wording in the following statements is
required in the DH regulations for producing
Quality Accounts. The statements are required
nationally to enable the public to compare the
performance of individual trusts and are
therefore common across all Quality Accounts.
We have provided some explanation of the
terms used in the glossary, but if you would
like any further explanation please contact the
Patient Advice and Liaison Service (PALS) on
Freephone 0800 279 7257.
Review of Services
During 2014-15 NSFT provided and/or
subcontracted eight NHS services: adult
services, children’s services, drug and alcohol
services, improving access to psychological
therapies (IAPT), learning disability services and
(QA6)
older people’s services. The Trust also provides
forensic and Tier 4 Child and Adolescent
Mental Health Services (CAMHS)
commissioned by NHS England rather than
local CCGs. The Trust has reviewed all the
data available on the quality of care in all of
these services.
The income generated by the NHS services
reviewed in 2014-15 represents 92.06% of
the total income generated from the provision
of NHS services by the Trust for 2014-15.
The quality of care the Trust has provided
has been reviewed in a number of ways. This
is via the collection of systematic performance
data against Monitor, CQC and CCG quality
targets as well as clinical audits, surveys,
analysis of complaints and serious incident
data, and informal feedback from service users
and carers. However data is gathered, the
Trust system of meetings ensures that it is
reported, and that action plans for
improvement are put in place where needed.
Quality of care review methods
Data type
Lead
Reported to
Action
Clinical
Audit
Audit lead
Quality Governance
Committe
• Action plan developed and implemented
by relevant lead clinician.
• This is then monitored by the audit
department and a re-audit undertaken as
indicated to demonstrate that the plan has
improved the service.
• Locality Governance dashboards incorporating
audit compliance and audit results databases
are updated monthly and shared with Localities
to enable them to compare their performance
with other areas and to see, at a glance, where
further action is required.
Complaint
Complaints
manager
Quality Governance
Committee
• Action plan developed and implemented
by relevant manager.
• Where there is learning for other areas, the
action plan is shared through a variety of
mechanisms including access to the plan and
the production of themes that are shared
with all areas, policy amendments and
adjustments to training packages.
Feedback
from visits
Non-executive Modern matrons
Directors
and ward managers
• Action plan developed to resolve any issues
that arise.
Feedback
Head of
Governance
• Quality Improvement visits carried out by
clinicians, governors, commissioners and
partner agency representatives.
Quality Governance
Committee
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
13
During 2014-15, one national clinical audit
and one national confidential enquiry*
covered NHS services that the Trust delivered
(in terms of collecting patient level data).
During that period, NSFT did not take part
in the national clinical audit: Prescribing
Observatory for Mental Health (POMH)**.
* A national confidential enquiry is a
nationwide review of clinical practice
which when completed leads to
recommendations for improvement.
** The Trust has not to date participated in
the POMH audits as these are audits
prescribed by the Observatory and were
not considered to be relevant to the
priorities of the Trust. The Trust will
participate in the audits commencing in
February 2015 and the results will be
reported in the 2015-16 Quality Account.
The national clinical audits and national
confidential enquiries that the Trust was
eligible to participate in during 2014-15 were:
• Prescribing Observatory for Mental Health:
prescribing topics in mental health services.
• Mental health clinical outcome review
programme: National Confidential Inquiry
into Suicide and Homicide by People with
Mental Illness (NCISH).
The national clinical audits and national
confidential enquiries that NSFT actually
participated in during 2014-15 are as follows:
• Mental health clinical outcome review
programme: National Confidential Inquiry
into Suicide and Homicide by People with
Mental Illness (NCISH).
The national clinical audits and national
confidential enquiries that the 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.
(QA7)
National Confidential Enquiries
14
Name
Completed and status
Number of cases and percentage
of registered cases required
National Confidential
Inquiry Into Suicide and
Homicide by People
with Mental Illness
Continuous audit
N/A
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
The reports of two national clinical audits
carried out by NSFT were reviewed in 2014-15
and the Trust intends to take the following
actions or has taken action to improve the
quality of healthcare provided:
(QA8)
Actions following audit
National audit of psychological therapies (published 2012-13)
Actions reported in 2014
Progress against actions
Improving access for older people by:
Implementing a training programme for
IAPT team members in working with
older adults (Great Yarmouth and
Waveney (GY&W)).
All staff have now attended training
Providing workshops within residential
and sheltered housing (Norwich).
These sessions have now been delivered.
Improving accessibility by:
Extending hours within the day in which
interventions can be provided by therapists
(West Norfolk & GY&W).
The service is now provided from 8am to 8pm.
Development and provision of resources
in a range of languages.
IAPT services across the Trust are working together
to collate therapy resources in other languages.
Interpreting services are accessed where the need
for this is identified.
Consulting with service user forums
regarding the report findings.
The report findings have been shared with the
forums.
Adapting Patient Experience Questionnaire
to capture feedback from those dropping
out of treatment with follow up.
Where service users do not automatically opt in to
the service within two weeks of receipt of the
referral, they are contacted by telephone.
Plans to evaluate the Ready to Change
programme; a new way to deliver guided
self-help for people with mild / moderate
depression and / or anxiety (Suffolk
Wellbeing service).
Six-month evaluation incorporating data as well as
staff and service user feedback. This model is now
being adopted across Suffolk.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
15
(QA8 continued)
National audit of schizophrenia: (Second round)
Actions reported in 2014
Progress against actions
Following the publication of the report,
a time limited steering group was set up
to review the findings and coordinate
actions. This steering group acknowledged
that most of the actions required were
already in progress through other pieces
of work in the Trust.
The steering group is due to end in April 2015 and a
report will be produced, summarising the actions
completed and the reporting mechanism for further
actions.
Action plans include Improving carers
satisfaction with the support and
information they receive through
application of the Triangle of Care and
support of Service User/Carer Forums.
Providing information and supporting
decision making about medication though
education and training of medical staff,
medicine information sessions in
in-patient areas.
Supporting best practice in the prescribing
of antipsychotic medication through
medical staff training plan, development
of prescribing guidelines and alerts on
prescription cards to prompt reviews.
The review into availability and use of
psychological therapies will be coordinated
by Lead Clinicians.
Monitoring and interventions for physical
health problems through shared care
protocols with primary care, named
physical health leads in each locality and
a physical health champion for each team,
physical health monitoring in clozapine
and depot clinics.
16
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
The reports of 70 local clinical audits were
reviewed by the provider in 2014-15 and
NSFT intends to take the following actions
to improve the quality of healthcare provided in
relation to the three audits selected:
(QA9)
Actions following audit
Actions Taken
Audit Title
Suicide Prevention:
The Trust has continued to undertake monthly
audits which have measured its progress
against nationally approved standards using
evidence-based audit tools (National Patient
Safety Agency (NPSA) Preventing Suicide
Toolkit) for in-patient wards and a purposive
sample* of community teams.
Charge Nurses and Community Team Leaders take
immediate action following any audited practice
that falls below 100% compliance.
Action plans in in-patient wards have related to
giving information about medications to service
users, discharge planning, contingency planning,
discharge CPA reviews, care planning and risk
assessment for changes in observation levels and
involving service users and carers in discharge
planning.
Actions in Community Teams have included:
timely reviews of assessments, recording service
users’ involvement in care planning, accessibility
of risk assessments, identification of lead
professionals, completion of data protection
act forms, involvement of carers in
assessment process.
Additional Observations:
The Trust undertakes bi annual audits of
Additional Observations. Data is collected by
the Modern Matrons for their service and
action plans are submitted at point of data
submission.
Actions have included: monitoring and scrutiny of
observation records by team leaders, monitoring
of adherence to requirement to review care plans
as observation levels change, local re auditing to
measure compliance.
Medical Staff Audits:
Medical staff have completed many audits
throughout the year, and participated in Trust
wide audits.
Topics have included: admission summaries,
blood test monitoring, clozapine monitoring,
clinical coding, health records, use of MHA,
ADHD, smoking rates in an in-patient area,
medication prescribing for dementia.
Actions resulting from an audit of Physical
examination and investigations for psychiatry
in-patients at Woodlands Unit, Ipswich Hospital
included: the development of a pro-forma to
guide and record physical health parameters
on admission following multi professional
team feedback.
* A purposive sample is a sample of people who have the characteristics that are required for the study
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
17
The Trust participates in the National
Confidential Inquiry into Suicide and Homicide
by People with Mental Illness as previously
documented, with excellent compliance scores.
Should the Trust have a serious incident
resulting in a child’s death or near miss, this
would be referred to the Norfolk and Suffolk
Safeguarding Children’s Boards for
consideration under the Serious Case Review
(SCR) guidance as outlined in Working Together
to Safeguarding Children 2013, and be
reported in the three-year national report. For
the period being looked at there has been one
SCR involving a child known to the Trust in
Suffolk, and to which the Trust contributed as
part of the management review. As a member
of the Norfolk and Suffolk Safeguarding Child
and Adult Boards: the Trust will take account of
all recommendations arising from SCRs,
regardless of whether or not Trust services were
involved. The Trust is currently participating in
an Adult SCR involving two adults known to
Suffolk services, and a further joint Suffolk and
Norfolk Adult SCR related to a service user
known to the Trust in both counties.
Research
The number of patients receiving NHS services
provided or sub-contracted by the Trust from
April 2014 to March 2015, who were recruited
during that period to participate in research
approved by a research ethics committee,
was 250.
To support research in the Trust, NSFT
Research has launched a new online referral
system and register which enables clinicians to
support all service users to take part in research.
This has also been a successful year for research
capacity with several Trust members obtaining
places on national research MSc, PhD and
Fellowship schemes. The launch of the service
user, carer and public involvement in research
initiative (inspire) has proven to be very popular,
with 40 current members across Norfolk and
Suffolk.
Commissioning and Quality Innovation
Goals (CQUIN) agreed
with Commissioners
A proportion of the Trust’s income in 2014-15
was conditional on achieving quality
18
Norfolk and Suffolk NHS Foundation Trust Quality Account
improvement and innovation goals agreed
between the Trust and any person or body with
which it entered into a contract, agreement or
arrangement for the provision of NHS services,
through the Commissioning for Quality and
Innovation (CQUIN) payment framework.
The Trust has a contract with Norfolk*
(CCG), Suffolk CCG and Cambridge and
Peterborough CCG for the provision of mental
health services to the population of Norfolk
and Suffolk, and with NHS England (specialist)
Commissioning Group for the provision of low
and medium secure services and Tier 4 Child
and Adolescent Mental Health Service.
The Trust has a contract with Norfolk*
and with Great Yarmouth and Waveney
CCGs for the provision of Increased Access
to Psychological Therapy (IAPT) services. In
addition, Norfolk Public Health commissions
the Norfolk Recovery Partnership (NRP)
for drug and alcohol services for prisons
and community.
For the contract with Norfolk* and with
Great Yarmouth and Waveney CCGs, a total of
seven goals to improve quality were agreed as
part of the main contract and a further four
goals attributed to the contract to provide IAPT
services. The eleven goals agreed accounted for
1.5% of the total contract value and an
additional 1% was allocated to system wide
indicators. The rationale for these goals
included suggestions from service user
feedback as well as pre-defined national
priorities. The goals covered all services
delivered by the Trust and the three domains
of quality: patient experience, patient safety
and clinical effectiveness.
The CQUIN contract with Suffolk CCGs
included eight goals covering the full value of
the scheme. The goals covered a range of
topics including, wellbeing, IAPT, data
collection for the national patient safety
thermometer**, increased efficiency of
psychiatric liaison services and raising
awareness in police services.
A total of seven goals to improve quality
were nationally agreed for secure services by
the 10 regional area teams. This covered a
diversity of goals including an education and
training package and assuring the
appropriateness of unplanned admissions.
Further details of the agreed goals for 201415 and for the following 12 month period are
available electronically on request from the
contracts department on 01603 421251.
April 2014 to March 2015
QA 2015 030615:Layout 1 09/06/2015 08:57 Page 19
The value of the scheme represents 2.5% of
the total contract value and approximately
84% compliance has been achieved in Norfolk
and Suffolk.
The income received which was conditional
upon achieving quality improvement and
innovation goals in the main contracts
2014-15 is forecast to be £4,182,137 this
compares with the income received in
2013-14 which was £4,165,914.
*Comprising South Norfolk, North Norfolk,
West Norfolk and Norwich City Clinical
Commissioning Groups
**Patient safety thermometer is a national
patient safety initiative which records a
number of safety concerns that measure
the provision of ‘harm free care’ including
pressure ulcers and falls
***Monitor is the regulator for
Foundation Trusts
(QA10) CQC Ratings
This rating led to the CQC recommending to
Monitor*** that the Trust be placed in ‘special
measures’. This means that an Improvement
Director has been appointed and the Trust will
work with a buddy trust to learn from them.
A Quality Improvement Plan is now in place
and is being monitored by the Trust Board and
reviewed at monthly meetings with Monitor
and the CQC.
Statements from the Care Quality
Commission (CQC)
The Trust is required to register with the Care
Quality Commission (CQC). Its current
registration status is ‘registered to provide
assessment or medical treatment for persons
detained under the Mental Health Act 1983
and treatment of disease, disorder or injury’.
The CQC has taken enforcement action
against NSFT during 2014-15 and in February
2015 the Trust was put into ‘special measures’.
The Trust has not been eligible for any
special reviews or investigations by the CQC
during 2014-15.
During 2014-15, the CQC undertook a
number of visits to the Trust to check
compliance with registration against the
essential standards and compliance with the
Mental Health Act for people detained. This
culminated in a ‘Comprehensive inspection’ in
October 2014 which inspected the Trust and
produced a report for each service line. The
Trust then received a rating for each service
line against the five domains of: Safe,
Effective, Responsive, Caring and Well-led.
The ratings received are shown below:
All of the CQC reports are available at
www.cqc.org.uk. The CQC visited all of the
registered sites and inspected all in patient
areas and a selection of community teams in
line with their policy. The new reporting
method reflects the service provided rather than
the location, but the reports do identify the
location where practice is commented on.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
19
Data Quality
Norfolk and Suffolk NHS Foundation Trust
will be taking the following actions to
improve data quality:
• Excellent data quality is essential to the
delivery of excellent quality care. NSFT will
continue to ensure data quality
improvements are made to support services
through provision of easily accessible
available performance reporting through
Abacus and MIS, the Trust’s business
intelligence reporting systems, overseen by
the Data Quality Group.
• These systems provide daily updates which
are accessed by business support staff. Any
data quality issues can be passed to the
appropriate staff member for correction.
• A monthly data quality meeting is held and
attended by a wide range of staff to discuss
data quality issues, new updates where
applicable and Information Standards Board
changes which may affect reporting and
therefore data quality.
• Data quality is also mentioned in staff job
descriptions, ensuring that staff are held
accountable for data quality.
• Norfolk and Suffolk NHS Foundation 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:
• Which included the patient’s valid NHS
number was 94.98% for admitted
patient care:
– Not applicable for out-patient care
– Not applicable for accident and
emergency care
• Which included the patient’s valid General
Medical Practice Code was 99.89% for
admitted patient care:
– Not applicable for out-patient care.
– Not applicable for accident and
emergency care.
NSFT information governance assessment
reports the overall score for 2014-15,
submitted in March 2015, was 80% and was
graded ‘not satisfactory / red’ under national
information governance rules.
20
Norfolk and Suffolk NHS Foundation Trust Quality Account
Action plans are being developed with regards
to those requirements that did not achieve
Level 2. This is monitored at the Information
Governance Committee with the expectation
that these improvements will be in place before
the next submission due in March 2016.
The Information Governance Risk Register,
and also information governance related
incidents that are reported through the Trust
Datix reporting system, are continuously
reviewed and reported quarterly to the
Information Governance Committee for action.
The information quality and records
management attainment levels assessed within
the information governance toolkit provide an
overall measure of the quality of data systems,
standards and processes within an organisation.
Further details on information governance
can be found at
www.commissioningforhealth.nhs.uk
The Trust was not subject to the payment by
results clinical coding audit during 2014-15 by
the Audit Commission.
Quality Initiatives
This section summarises quality information
specific to Norfolk and Suffolk NHS
Foundation Trust.
Key Performance and Developments
during 2014-15
This section allows the Trust to highlight quality
matters from 2014-15 that have not been
addressed elsewhere in the report. The Quality
Account has already highlighted specific areas
where quality is not as high as the Trust would
expect; however, there are many areas of
excellent and innovative practice.
Implementing Recovery through
Organisational Change (ImROC)
The Trust has taken part in the national ImROC
initiative which aims to put people with mental
health problems at the heart of service delivery
and to enable them to rediscover a sense of
wellbeing and purpose in their lives.
An important channel of this initiative has
been the continued success of our Recovery
College. The College was set up in September
2013 to deliver a range of courses and
April 2014 to March 2015
424 service users, carers or supporters having
taken part.
The Recovery College is overseen by a
steering group in which service users, carers,
staff and governors are all represented.
Evaluation of the courses has been very
positive (409 respondents):
workshops to empower people with mental
health challenges to become experts in their
own recovery.
The success of the College has seen the
number of tutors grow from seven staff and
five peer tutors to 19 staff and 19 peer tutors
by the end of the first year. In the four terms
the College has been operating, its
programme has expanded to deliver courses
across all five localities with 411 staff and
(QA11)
How would you describe the value of the course for your own recovery
or for the recovery of someone you support?
1%
Excellent
34%
Good
Poor
65%
What next for 2015-16
Targets for year two of the Recovery
College include:
• Collaborating with partners to produce
workshops which focus on dementia and
older peoples services, forensic services,
youth services, drugs and alcohol services.
• Working with Equal Lives and the Shaw
Trust to create courses on mental health,
employment and work.
• Working with Cambridgeshire and
Peterborough NHS Foundation Trust (CPFT)
to share some courses already co-produced
and to develop further courses on
relationships and intimacy, and music and
mental wellbeing.
• Seeking other opportunities to increase
partnership, co-production and delivery
of courses.
• We have extended the eligibility to access
courses to include service users who have
been discharged from services (and who
have a discharge care plan) for up to one
year post discharge and will continue to
identify ways of widening the eligibility
criteria further.
• Continue to evaluate student experience.
• Identification of a process to measure
recovery outcomes for students and
peer tutors.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
21
Crisis Care
Crisis care is a priority for the Trust and in
addition establishing the crisis telephone line
mentioned on page 6, the Trust has signed up
to the Crisis Care Concordat in both Norfolk
and Suffolk. This is a national programme
which brings together NHS trusts, local
authorities and the police to review crisis care
as a system-wide issue in order to develop
shared goals and a collaborative approach.
Norfolk
In addition to reflecting the crisis care priorities
outlined in this report, an important outcome
of the Norfolk Concordat is the provision of a
mental health team within the Norfolk
Constabulary Contact and Control room.
The team consists of four staff who are able
to speak to service users and provide
professional, specialised advice. The team
ensure callers receive the best and most
appropriate care and can reduce the need for
involvement by the police.
The team monitors performance and has
reported a 30% drop in the number of people
detained under section 136*. This is a positive
step towards meeting the objectives of the
Safer Place to Be report, published in October
2014 following a survey of all health-based
places of safety across the country.
http://www.cqc.org.uk/content/safer-place-be
*Section 136 is a section of the MHA which
enables a police officer to remove a person
to a place of safety to undergo a mental
health assessment.
Suffolk
In Suffolk the action plan for the Concordat
covers a range of issues that are being
addressed in collaboration with the local
authority and police. These include: service
user involvement, the use of section 136 and
improving the knowledge of professionals
involved in primary care to help them to
manage people who may be at risk of
committing suicide.
In addition, we are currently evaluating a
CQUIN initiative which sees staff from our
Trust linked with police to assess care needs in
22
Norfolk and Suffolk NHS Foundation Trust Quality Account
a crisis situation. As we have seen in the
Norfolk scheme, working with police has also
reduced the number of people detained under
section 136.
Improving access to psychological
therapies in Suffolk
As part of the IAPT agenda, we are taking
active steps to ensure access to our wellbeing
services is as easy as possible, including:
• 24/7 online self-referral system available in
multiple languages
• Parts of the service being accessible without
a need for an assessment
• Providing workshops to community groups,
workplaces and colleges
• An active presence on social media
We are involving service users in the
development and maintenance of the service
by seeking feedback via Patient Experience
Questionnaires and inviting previous service
users to attend our service user group.
A recent example of this work was a SPEAK
poster developed by the service user group to
encourage more people to seek help for stress,
anxiety and/or depression. This poster is also
being used as a template to advertise our new
developments aimed at increasing access to
psychological therapies for people with long
term physical health conditions.
Improving access for Black and Minority
Ethnic (BME) service users
Through innovative working with third sector
partners VoiceAbility, the Suffolk Wellbeing
Service (SWS) has achieved a 16% access rate
to its services by the BME community in
Suffolk. VoiceAbility is an advocacy group that
aims to bring together organisations to
support people facing disadvantage and
discrimination (www.voiceability.org).
SWS has engaged with community
networks to raise awareness of the services
they offer and routes to access them. Building
strong links with the BME community has also
enabled SWS to deliver culturally sensitive
Stress Management workshops in community
venues, providing services in an environment
where people feel safe and empowered.
April 2014 to March 2015
Child, Family and Young People
Pathway
Friends and Family Pathway
The Central Norfolk Early Intervention Team
has begun a pilot scheme which aims to
ensure that all carers have equal and
consistent access to support services. The
Family Involvement Team, with consent from
the service user, can offer the family:
• Initial telephone or face to face meeting to
answer questions and discuss any concerns.
• Information packs, including guidance on:
the Team, medication, unusual experiences,
support services available to carers, family
work offered by the Team and details of the
Friends and Family Group (a rolling group,
held monthly and facilitated by staff).
• Six follow up sessions to look in more detail
at the family’s role in supporting the
service user.
The Team has received positive informal
feedback and the success of the pilot will be
evaluated using future feedback collected
regarding the Friends and Family pathway.
users received a consistent and effective
approach to their care.
The POG tool enables staff to evaluate
service users by ‘risk’, ‘motivation’ and ‘need’,
and to group their clients accordingly. The tool
incorporates information from previous
assessments as well as subsequent
engagements to assign a client to either
Purple (Intensive), Orange (Enhanced) or
Green (Standard) groups. Staff can then
determine the appropriate level and intensity
of engagement each service user requires.
The benefits of the POG tool are:
• Enables staff to accurately and effectively
prioritise their time and caseload.
• Gives staff ownership of their caseload and
it’s management.
• Provides insight into service users
motivation and engagement with
treatment.
• Supports the progress of service users
through the service, particularly those
engaged with the service for long periods
of time.
• Assists managers in monitoring workload
and allocation of new client work.
Secure Services
School Twilight Sessions
This service offers free, direct access to
specialist mental health professionals,
consultation and training for teachers and
other school staff. The sessions include
information on topics such as self-harm and
eating disorders, as well as the opportunity to
ask questions.
Drug and Alcohol Services
Drug and alcohol services are provided by the
Trust in partnership with the Matthew Project
and RAPt, collectively known as the Norfolk
Recovery Partnership (NRP).
POG Rating System
Due to growing caseloads, it was recognised
that a tool was needed to assist staff to make
best use of their time and to ensure service
2014-15 has been a challenging year for
Secure Services, but also a productive one:
• The service has developed a strategy for
supporting carers and a Steering Group is
working through the ‘Triangle of Care’
actions with the support of carers
themselves, a champion from each area and
involvement from Suffolk Family Carers.
• The service has developed a strategy for
improving staff wellbeing and engagement,
introducing a quarterly staff forum and staff
recognition scheme.
• In June 2014, the Trust commissioned
a ‘Review of progress made following
the Exploratory Review relating to three
in-patient deaths within Secure Services
in 2013’. It revealed that, of the
14 recommendations made in the
Exploratory Review, 12 have been
implemented fully and two require further
work to complete. The reviewer noted that
a number of other positive changes have
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
23
occurred and commended the management
team and the service for the progress made.
• Each area of the Service has strengthened
its Service User involvement throughout
2014 with attendance at forums increasing.
• In 2014 we introduced Quarterly Learning
Events – half day service-wide events which
focus on governance and quality.
• In April 2014 we started a NHS England
funded partnership with HMP Wayland to
develop a PIPE (Psychologically Informed
Planned Environment) and the country’s first
Category C Personality Disorder Assessment
& Treatment Service which officially opened
in February 2015.
Learning Disability Services
Bowel Care Passport
Our Suffolk Adult Learning Disability Service
has developed an innovative tool to improve
patient care, in response to the findings of the
Confidential Inquiry and two local serious case
reviews relating to the premature and
preventable deaths of people with a
learning disability.
The ‘bowel care passport’ acts as a care
plan and a guidance document to ensure all
care providers know how to best support the
individual with bowel care. Service users own
the passport which is used to share
information with their GP and other health
providers when accessing services.
The passport was developed in consultation
with service users, staff and bowel care
specialists at Ipswich Hospital.
chaired by service users and supported by
the Modern Matron and IMPACT
advocacy service.
*The Trust is not commissioned to provide
learning disability services in Norfolk.
LISTEN
Staff from East Suffolk worked with service
users and carers to respond proactively to
complaints regarding service users’
experiences of crisis care. The LISTEN (Listen,
Involve, Shared, Time, Empathise, Next)
acronym was developed to remind staff of the
key issues to consider when communicating
with service users and carers. Posters and
prompt cards were printed and distributed to
staff throughout the Trust.
CRAM
In East Suffolk, it was recognised that there
was a need to improve the clinical quality of
patient records. A local audit was devised to
consider each of the teams and identify areas
of strength and weaknesses. Individual action
plans were developed in response to these
findings. The outcomes of the action plans
were re-examined and revealed that one inpatient team had shown significant
improvement. The model employed by this
team was then shared as best practice with
other teams. The successful approach
involves using the CRAM acronym within
patient notes to remind staff to consider
care plan, risk assessment, activity and
mental state.
LD Service User Forums
National Recognition
Some people using our learning disability
services reported that the mental health
forums were not representative and were too
difficult to understand. To ensure that people
with a learning disability were empowered to
contribute to the work of our Trust, we set up
dedicated service user forums in both
Waveney and Suffolk.*
Service users meet monthly to discuss the
care they receive from NSFT, and they are
invited to contribute to discussions about
changes to the service. Both forums are
24
Norfolk and Suffolk NHS Foundation Trust Quality Account
AIMS (Accreditation for In-patient
Mental Health Services) accreditation
In February 2015 Waveney ward at Hellesdon
Hospital attained AIMS accreditation, joining
several other wards across the Trust which
have already been awarded this standard. The
AIMS accreditation is a standards-based
accreditation programme designed to improve
the quality of care in in-patient mental health
April 2014 to March 2015
wards run by the Royal College of
Psychiatrists.
Further information can be found at:
http://www.rcpsych.ac.uk/workinpsychiatry/qu
alityimprovement/qualityandaccreditation/psyc
hiatricwards/aims.aspx
East Suffolk Excellent accreditation
for ECT team
In February 2015 the East Suffolk Electro
Convulsive Therapy (ECT) team based at
Woodlands received a renewed accreditation
of ‘excellent’ from the Royal College of
Psychiatrists Centre For Quality Improvement
(CCQI). This is a voluntary accreditation
scheme which ensures that the best standards
of care are provided to service users who
receive ECT therapy.
Further information about the scheme can
be found at:
http://www.rcpsych.ac.uk/workinpsychiatry/qu
alityimprovement/qualityandaccreditation/ectcl
inics/ectas/ectasstandards.aspx
Fermoy Unit, Queen Elizabeth Hospital;
Frank Curtis NSFT Library and NSFT
Research Team, Hellesdon Hospital;
Sandringham and Blickling Wards,
Julian Hospital
Two of our nominees – Sandringham and
Blickling Wards and also Steve Birt – were
specially selected for the Outstanding
Contribution to Learning award.
Sandringham and Blickling Wards were
praised for their contribution to an innovative
pilot project called ‘Collaborative Learning in
Practice’ (CLiP), which enables clinical areas to
host an increased number of student nurses
by utilising a coaching model to provide
comprehensive support and guidance.
The Trust is delighted that Steve Birt was
awarded both the Learning Support Award
and the award for Outstanding Contribution
to Learning in recognition of his approach to
mentoring and vital role in the support
of students.
Woodlands Safewards Model
The team’s Lead Nurse, who chairs the Trust
wide ECT special interest group, has also
become an honorary member of (NALNECT)
National Association of Lead Nurses for ECT.
Workforce Partnership Practice
Education and Learning Support
Awards
Four individuals and three teams from our
Trust were nominated for regional excellence
awards in recognition of their contribution to
supporting learning and education. The
awards, which were presented on 16 March
2015, saw nominations for:
• Mentor / Practice Teacher Award:
Melanie Grose, Criminal Justice Mental
Health Liaison Practitioner; Ronnie Simpson,
Staff Nurse, Blickling Ward
• Learning Support Award – Foundation
degree: Steve Birt, Care Pathway and
Discharge Nurse, Assessment and Treatment
Service, Bury St Edmunds
• Learning Support Award – Apprenticeships:
James Lunny, Education and Development
Team
• Team Award: Mental Health Liaison Team,
Woodlands, which provides the base for acute
mental health services in East Suffolk, has
become the first unit in the Trust to adopt the
Safewards model. The model encourages
service users and staff to work together to
reduce factors such as aggression and selfharm. A Department of Health paper stated
that the Safewards model had ‘demonstrated
significant effectiveness in achieving
reductions in incidents of conflict and the use
of physical restraint…’ and it is employed as
best practice across a number of mental
health trusts.
Staff at Woodlands received an initial
introduction to the 10 interventions outlined
in the model, with ongoing support for
implementation of the Safewards approach
being delivered by staff champions and
through monthly progress reviews.
The model is now being adopted across
the Trust.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
25
• Data is submitted to commissioners where
it is scrutinised and challenged where
necessary.
Quality Indicators
Seven Day Follow Up
This indicator is described as “The percentage
of patients on CPA who are followed up
within seven days after discharge from
psychiatric in-patient care”.
NSFT considers that this data is as described
for the following reasons:
• NSFT has robust systems in place to check
the quality of data.
NSFT has taken the following actions to
improve this percentage, and so the quality of
its services, by:
• Business Support Managers check the
systems and liaise with clinical staff to check
any data that appears to be outside normal
parameters.
• Data is discussed at local management
groups as well as Trust wide performance
groups.
(QA12)
Prescribed
information
Related NHS
Outcomes
framework domain
2012-13
2013-14
2014-15
The percentage of
patients on CPA who
were followed up within
seven days after discharge
from psychiatric
in-patient care.
Preventing people
from dying
prematurely.
95.9%
97.89%
98.57%
This is a national
definition reported
to Monitor.
Enhancing quality of
life for people with
long term conditions.
Target 95%
The latest available data produced by NHS
England shows that the national average score
for the period October to December 2014 was
97.3%. The highest performing area scored
99.6% and the lowest area scored 94.9%.
• NSFT has robust systems in place to check
the quality of data.
• Data is submitted to commissioners
where it is scrutinised and challenged
where necessary.
Access to CRHT
NSFT has taken the following actions to
improve this percentage, and so the quality
of its services, by:
This indicator is described as “The proportion
of in-patient admissions gate kept by the crisis
resolution home treatment teams”.
NSFT considers that this data is as described
for the following reasons:
26
Norfolk and Suffolk NHS Foundation Trust Quality Account
• Business Support Managers check the
systems and liaise with clinical staff to
check any data that appears to be outside
normal parameters.
• Data is discussed at local management
groups as well as Trust wide
performance groups.
April 2014 to March 2015
(QA13)
Prescribed
information
Related NHS
Outcomes
framework domain
2012-13
2013-14
2014-15
The percentage of
admissions to acute
wards for which CRHT
acted as gatekeeper.
Enhancing quality of
life for people with
long term conditions.
92.40%
99.69%
97.46%
This is a national
definition reported
to Monitor.
Target 95%
The latest available data produced by NHS
England shows that the national average for
the period October to December 2014 was
97.8%. The highest performing area scored
100% and the lowest performing area
scored 82.5%.
Readmission Rates
NSFT considers that this data is as described
for the following reasons:
• NSFT has robust systems in place to check
the quality of data.
NSFT has taken the following actions to
improve this percentage, and so the quality
of its services by:
• Ensuring that discharge planning is robust
and that the discharge policy is followed.
• Ensuring patients receive a follow up visit
within seven days of discharge and
telephone contact within 48 hours of
discharge.
(QA14)
Prescribed
information
Related NHS
Outcomes
framework domain
The percentage of
patients aged
Helping people to
recover from episodes
of ill health or
following injury.
0-15
16 or over
readmitted to a hospital
which forms part of the
Trust within 28 days of
being discharged from
a hospital which forms
part of the Trust.
2012-13
No
2013-14
2014-15
5.9%**
No
re-admissions.
5.3%
7.87%
admissions*
6.2%
* NSFT did not have beds for under 14s in 2012-13
** The number of readmissions refers to the specialist tier 4
CAMHS unit which was not opened in previous years
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
27
It should be noted that the Monitor guidance
has been changed and that in previous years
the ages reported were 0-14 and 15 and over.
This does not affect the reported numbers as
the Trust does not admit people under 16 to
adult beds.
Staff Survey
The national NHS Staff Survey is a mandatory
requirement for NHS organisations, with
results being used by NSFT to understand the
views of its staff and to inform improvements
in the workforce arena. The most recent
survey took place in September to
October 2014, with results published on
24 February 2015.
(QA15)
Prescribed
information
Related NHS
Outcomes
framework domain
2012
2013
2014
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.
Ensuring that people
have a positive
experience of care
3.32
3.08
2.99
National average: 3.57. Top scoring Trust: 4.15.
The scores achieved are from a maximum possible score of five.
NSFT considers that this data is as described
for the following reasons:
• In order to get feedback from as many staff
as possible, for the first time, NSFT
undertook the survey as a census of all
employed staff. In previous years it has
undertaken a sample survey. Whilst the
percentage response rate is therefore lower
than previous years, the number of staff
who responded is far more representative
than in previous years (1,336 staff
responded out of 3,676 staff surveyed in
2014 compared to 341 out of 840 staff
surveyed in 2013).
• Whilst recognising the significant level of
organisational change that had impacted
staff in the 12 months prior to the survey,
NSFT is disappointed by the results. The
results, however, highlight issues that the
Trust is already aware of and is addressing.
These issues reflect feedback also received
from the CQC inspection that was held at
the same time as the survey. Improving staff
engagement is an absolute priority of NSFT.
28
Norfolk and Suffolk NHS Foundation Trust Quality Account
NSFT is taking the following actions to
improve this percentage, and so the quality
of its services, by:
• Engaging independent consultants to
work with NSFT to review its values and
behaviours.
• Reviewing its operating model and
developing a responsibilities and
accountabilities framework to support this.
• Investing in leadership and management
development.
• Continuing to implement its Wellbeing
Strategy including the roll out of Wellbeing
Weeks across the Trust and the Healthy
Worker training programme.
• Implementing a fifteen point plan endorsed
by the Board of Directors to improve staff
engagement.
• Implementing its Recruitment and Retention
Strategy to fill vacancies, including
additional posts added to the establishment
to support safer staffing, and to improve
the retention of staff.
• Reviewing its mandatory training strategy
and moving to a more competencybased approach.
April 2014 to March 2015
NSFT has taken the following actions to
improve this percentage, and so the quality
of its services, by:
Community Service User Survey
NSFT considers that this data is as described
for the following reasons:
• The Trust commissions an outside agency,
Quality Health, which is an ‘approved
provider’ to undertake the survey.
• Action plan for improvement is monitored
at the Senior Managers Forum and Locality
governance meetings.
• It should be noted that the sample is drawn
from service users accessing services before
the results of the previous survey are
known. We would therefore not expect to
see any improvements as a result of the
action plan in the next survey.
(QA16)
Prescribed
information
Related NHS
Outcomes
framework domain
2012
2013
2014
The trust “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.
Enhancing quality of
life for people with
long term conditions.
NWMHFT
NSFT
NSFT
8.7
8.6
7.5
Ensuring that people
have a positive
experience of care.
SMHP
8.8
Range of scores: 7.3 – 8.4.
The scores achieved are from a maximum possible score of ten.
Incident Reporting
NSFT has taken the following actions to
improve this percentage, and so the quality of
its services, by:
NSFT considers that this data is as described
for the following reasons:
• Staff report all incidents using the electronic
Datix system.
• All incident reports are reviewed by the Risk
Management Team and clinical managers
required to investigate and sign off each
incident before closing the event.
• Health, safety and security audits are carried
out on all Trust premises which include a
review of incident reporting trends.
• These are subject to discussion at the
Incident and Patient Safety Group meetings.
• Staff are encouraged to report all incidents
and the Trust has recently introduced an
upgrade to the report form and Datix
dashboard, which provides clinical
managers with a live overview of the
reported incidents in their area.
• Incidents are reviewed by the patient safety
team to identify themes and patterns,
working with clinical areas and
stakeholders, such as the police, to
implement changes where required.
• Serious Incidents are managed in
accordance with national guidance.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
29
(QA17)
Related NHS
Outcomes
framework domain
1 October 2012
to
31 March 2013
1 April 2013
to
30 Sept 2013
1 October 2013 1 April 2014
to
to
31 March 2014 30 Sept 2014
1 October 2014
to
31 March 2015
Treating and
caring for
people in a safe
environment
and protecting
them from
avoidable harm
2,835 incidents*
reported.
3,395 incidents*
reported.
4,065 incidents* 4183 incidents*
reported.
reported.
4,018 incidents
reported
42.2 incidents
per 1000
occupied bed
days.**
31.63 incidents
per 1000
occupied bed
days.**
37.87 incidents
per 1000
occupied bed
days.**
55.48 incidents
per 1000 bed
days.**
3 incidents
(0.07%) led to
severe harm
7 incidents
(0.25%) led to
severe harm.
National average
0.5%.
7 incidents
(0.2%) led to
severe harm.
3 incidents
(0.07%) led to
severe harm.
3 incidents
(0.1%) led to
severe harm.
8 incidents (0.2%)
led to a death
10 incidents
(0.35%) led
to a death.
25 incidents
(0.7%) led
to a death.
7 incidents
(0.2%) led
to a death.
National
average 0.3%.
6 incidents
(0.1%) led
to a death.
National
average 0.8%.
NB. The
reporting rate
of 42.2 incidents
is rated 5th out
of 55 mental
health
organisations
and puts the
Trust in the
top 25%.
National
average 0.7%.
NB. The
reporting rate
of 31.63
incidents is
rated 20th out
of 55 mental
health
organisations
and puts the
Trust in the
middle 50%.
NB. The
reporting rate
of 37.87
incidents is
rated 12th
out of 56
mental health
organisations
and puts the
Trust in the
top 25%.
Differences between the National Reporting
and Learning System (NRLS) data for deaths
and the figure for Serious Incidents are due
to the different reporting requirements.
NRLS guidance requires that only deaths of
suspected suicide are reported to the system,
whereas Serious Incident reporting will include
all forms of unexpected death (e.g. incidents
where information suggests it may be due to
an accidental overdose).
* An incident is defined as “any unintended
or unexpected incident which could have, or
did, lead to harm for one or more patients
30
Norfolk and Suffolk NHS Foundation Trust Quality Account
NB. The
reporting rate
of 55.48
incidents is
rated 10th out
of 54 mental
health
organisations
and puts the
Trust in the
top 25%.
NB. This data is
subject to change
following final
ratification and
report from NRLS.
receiving NHS-funded healthcare”.
(www.nrls.npsa.nhs.uk) Organisations that
report more incidents usually have a better
and more effective safety culture because
they are aware of the problems and able to
act to improve.
** A bed day is used as a measure to
enable comparison between Trusts of
different sizes. The measurement accounts
for differences in the number of beds a
hospital may have and just considers the
days the beds were occupied.
April 2014 to March 2015
Key Quality Indicators
The Board receives regular reports on the
quality of services which are measured
through the domains of patient safety, clinical
effectiveness and patient experience. Key
performance indicators (KPIs) are identified by
the Board as internally generated or enforced
by contractual obligations with partner
organisations. These indicators are reported in
a monthly business performance report, and
other measures of quality are reported
through the reporting system to evaluate
services. The indicators reported here have not
been changed following the 2013-14 Quality
Account to provide consistency and enable
comparisons to be made.
(QA18)
Key performance indicator
Target
Trust
position
2012-13
Trust
position
2013-14
Trust
position
2014-15
95%
95.9%
97.89%
98.57%
4.1
7.61
7.31
5.72
3.8
2.74
2.74
4.19
95%
92.40%
99.69%
97.46%
<7.5%
4.55%
4.80%
4.55%
No admissions
6.2%
5.9%*
5.3%
No readmissions
97.55%
99
15
0
98.05%
72
17
0
96.71%
78
12
0
137.65%
131.76%
Patient safety
• Seven-day follow up of service users following their
discharge from in-patient services.
• Absconsions of detained patients from Adult wards
as a ratio of 100 detained patients.
• Ratio of in-patient serious untoward incidents
(e.g. suicide) per 10,000 occupied bed days.
Clinical effectiveness
• Access to crisis resolution and home treatment services.
• Delayed transfers of care, relating to other support
needs (like housing) following discharge from hospital.
The increased
numbers of delayed
transfers are attributable
to a reduction in
capacity and funding
in social care though
the number remains
within target.
• Readmission rates
Age 0-15
Age 16+
Patient experience
• CPA patients having formal review within 12 months.
95%
• Waiting times. Number of people waiting 18 weeks or greater.
• Number of under-18 year old admissions to adult acute ward.
• Number of under-16 year old patients admitted
0
to adult acute wards.
• Meeting commitment to serve new psychosis cases
95%
by early intervention teams.
* The number of readmissions refers to the specialist tier 4 CAMHS unit which was not opened in previous years
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
31
Evaluation of Patient Safety
The Trust continues to report all Serious
Incidents on receipt of an initial report. This is
reported as good practice by the National
Patient Safety Agency.
The latest report from the National Reporting
and Learning System for the period April 2014
to September 2014 shows that the Trust is the
10th highest reporter of all 56 mental health
trusts in that period.
(QA19)
Are you actively encouraging reporting of incidents?
The comparative reporting rate summary shown below provides an overview of incidents
reported by NHS organisations to the National Reporting and Learning System
(NRLS) occurring between 01 April 2014 to 30 September 2014. Your organisation reported
4,183 incidents (rate of 55.48) during this period.
Organisations
Figure 1: Comparative reporting rate per 1,000 bed days for 56 mental health organisations
0
20
40
60
80
100
Reporting rate (per 1,000 bed days)
Your organisation’s reporting rate
Highest 25% of reporters
Middle 25% of reporters
Lowest 25% of reporters
Source: NHS national Reporting and Learning System. www.nrls.npsa.nhs.uk/patient-safety-data
The median reporting rate for this cluster is 32.82 incidents per 1,000 bed days.
32
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
Infection Prevention and Control
(IPAC) Activities
The IPAC annual work plan is devised to
identify and implement activity which will
deliver the priorities described in key
documents and guidance, including: the
Health and Social Care Act 2008 (rev.2010),
CQC Regulation 12 objective 8, national
best practice standards. The completion of
the IPAC annual work plan is overseen by the
IPAC Committee, the Quality Governance
Committee and the Trust Board.
Key achievements resulting from
implementation of the IPAC plan for
2014-15 have been:
• An improved training programme for our
local infection prevention and control
supporters (LIPACS) to enable them to more
effectively monitor and manage their
environment and support local staff.
• Modification of the hand hygiene tool to
improve suitability for community teams.
• A programme of audits to raise awareness
of standards and address deficits.
There has been one confirmed outbreak of
Norovirus infection involving a significant
number of staff and patients. All standard
IPAC interventions were applied with
additional focus on cleaning objects handled,
such as keys, and on staff behaviour, such as
chewing pens.
There have been no cases of MRSA
bacteraemia or of Clostridium difficile
attributed to the Trust. Patients identified as
being colonised with MRSA have been treated
according to Trust guidance.
The priorities for the forthcoming year include:
• Improving compliance with mandatory
education in IPAC procedures through a
range of learning and assessment
opportunities.
• Improved focus to ensure actions identified
by audit are implemented and completed.
• Strengthening the role of the LIPACS within
clinical teams.
Physical Health
Our Physical Health Strategy Group (PHSG),
which includes representatives from all
localities and staff groups within our Trust,
aims to improve the focus on physical health
throughout the Trust by creating effective
initiatives which are implemented uniformly
across the services.
The PHSG has commissioned task and finish
groups to address a range of issues including
in-patient areas, community teams, Clozapine
clinics and smoking cessation. The group
reports to the Quality Governance Committee
and to the Trust Board.
Key achievements this year have been:
• Demonstrated improvements in the
completion of documentation relating to a
patient’s physical health and evidence of
actions taken where physical health
problems have been identified.
• Opportunities for all staff, either at the
University of East Anglia, University Campus
Suffolk or at local and ward level, to
undertake education and training
appropriate to the needs of their service.
• Scenario training delivered within wards to
assist staff to recognise when a patient is
deteriorating and to practice resuscitation
response.
• Improving the knowledge of local physical
health link staff through forum activities
and individual supervision.
• Engagement with community teams and
the decision to implement the national
Rethink tool ‘My Physical Health’ as a
document for raising and addressing
physical health issues.
• The launch of a Recovery College module
focusing on physical health.
Some of the priorities for the coming year
are to:
• Develop pathways for focusing on physical
health to aid collaboration between primary
care and mental health services.
• Establish a multidisciplinary health and
wellbeing working group as a sub-group of
the PHSG. This will focus on diet and
exercise and modifiable behaviours such as
smoking, alcohol and drug use.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
33
• Develop care plans specifically to ensure
standardised care for patients with longterm conditions.
• Work within the current networks to ensure
patients at the end of life are identified and
receive the best evidence-based care,
supported by other agencies and using
standard documentation recognised by all
care providers.
Sign Up to Safety Plan
In October 2014 the Trust signed up to the
National Patient Safety First Campaign to
demonstrate our commitment to continuously
drive forward improvements in patient safety.
This initiative will be led by the Director of
Nursing, Quality and Patient Safety, and the
Chief Executive will have continued oversight
of progress.
The six key areas identified to improve
safety are:
• Reduce the number of service user to
service user assaults within older people’s
in-patient services.
• Reduce harm resulting from falls.
• Provide in-patient services that are safe for
service users.
• Provide an environment that reduces the
risk of harm.
• To ensure the Trust embeds a safety culture
based on openness transparency and
learning from previous incidents.
• To improve the community mental health
teams performance in updating risk
assessments in line with policy and
best practice.
Positive and Proactive Care
In April 2014 the DH published the report
‘Positive and Proactive Care’ focusing on the
need to reduce the use of restrictive
interventions (restraint) by staff in mental
health trusts.
‘Restraint’ describes a range of
interventions, from touching a person’s arm to
full restraint in which staff use validated
methods to prevent assaults and self-harm.
As noted on page 30, our Trust has a high
rate of incident reporting and any episode of
34
Norfolk and Suffolk NHS Foundation Trust Quality Account
restraint is recorded. The Trust has been
identified as a high user of restraint and has
now put in place a plan to reduce the use of
restrictive interventions over the next
18 months.
Evaluation of Clinical Effectiveness
Our clinical effectiveness strategy sets out the
structures and processes for ensuring clinical
effectiveness across the Trust.
The implementation of NICE guidance and
adopting nationally agreed best practice is
central to ensuring good quality outcomes
for patients.
NICE guidance for 2014 included:
• Medications – discussed by our Drug
and Therapeutics Committee.
• Products designed to prevent pressure
ulcers – discussed in the Physical
Health Group.
• Psychosis and schizophrenia in adults,
bipolar disorder, delirium and autism in
adults – reviewed and implemented
where appropriate.
The Trust audit schedule includes audits that
measure compliance against the NICE
guidance and best practice. Where noncompliance is identified, an action plan to
improve is implemented and incorporated into
the audit cycle.
Monitor identifies a number of measures of
clinical effectiveness including access to crisis
resolution and home treatment teams before a
person is admitted to hospital, and ensuring
service users are followed up within seven
days of discharge from an in-patient ward.
These are reported to Monitor and the Trust
continues to report excellent compliance with
the targets. See page 26 to 27.
The reports by CQC indicated that clinical
effectiveness within the Trust was affected by
poor levels of appraisal and supervision, as
well as mandatory and specialist training.
These issues are being addressed as part of
our Quality Improvement Plan.
April 2014 to March 2015
Evaluation of Patient Experience
Service User and Carer Involvement
Our Trust values the role played by service
users and carers who engage in a number
of ways to provide feedback and contribute
to improvements.
Our Trust has groups for adult mental
health service users and carers across the
region, in West Norfolk, City and South
Norfolk, North Norfolk, Great Yarmouth and
Waveney, East Suffolk and West Suffolk. The
groups are open to people who are using or
who have used mental health services and
their carers.
Service users and carers from our locality
groups play an important role in influencing
developments within the Trust and are actively
involved in the interview process for
appointing new staff.
Other areas where our service users have been
involved include:
• Consultation on the development of a new
12-bed assessment ward based at our
Hellesdon Hospital site and supporting the
development of the assessment ward at the
Wedgwood Unit.
• Implementing a new Trust-wide patient
record system, Lorenzo.
• Contributing to the development of a
community action plan to improve services.
• Training for new ward staff in complaints
and communication.
• Working with staff to produce service
specific leaflets for both in-patient and
community services.
• Working with staff to develop the LISTEN
cards and posters, which describes the
approach to how service users wish to be
involved in their care.
Our wellbeing services have locality groups in
West Norfolk, Great Yarmouth and Waveney,
East and West Suffolk. The Norfolk Central
group will be re-launching in
April 2015.
Wellbeing groups have been actively
involved in:
• Developing a website and social media
platform.
• Wellbeing governance and team
management meetings.
• Attending and reviewing current
workshops and providing feedback and
recommendations.
Two new groups for people with a learning
disability have been developed in Lowestoft
and Stowmarket, the groups are open to
people who are using our learning disability
services, plans for future work include:
• Working with staff to produce learning
disability specific courses at our
Recovery College.
• Being involved in the recruitment of
new staff.
• Working on a poster to advertise the group.
The Norfolk Youth Council is fully established
and meets monthly in Norwich with separate
locality groups across the county. In Suffolk
the group meets fortnightly and is currently
developing locality-based groups.
Some of the Youth Councils’ achievements in
2014-15 include:
• Co-produced the job description for peer
support worker for youth pathway and
participated in recruitment panels.
• Delivered a workshop for Ipswich hospital
staff concerning young people’s experiences
in A&E.
• Worked with A&E Managers to identify a
suitable area of the A&E to be used by
young people.
• Collaborated with Mental Health Liaison
Nurse to produce written information for
young people.
• Contributed to a module regarding
psychosis delivered to fourth-year medical
students at University of East Anglia.
• Delivered a workshop for year 10 students
at Coplestone High School for the school
mental health day.
• Contributed to a Recovery College group
which is looking into developing courses for
young people.
• Two Norfolk youth council members
attended a European Parliament sponsored
project in Rome in March, 2015 to create
guidelines for improving care and access for
young people with mental health needs.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
35
• Plan for eight members of the Norfolk
Youth Council to attend the International
Association of Youth Mental Health in
Canada in October 2015.
Service User and Carer Involvement
Strategy
Our Trust values the role played by service
users and carers who engage in a number of
ways to provide feedback and contribute to
improvements.
A project group, incorporating
representatives from our Trust wide forums,
service user and carer governors, members of
the Board of Directors, NSFT staff and
stakeholders, has developed a new service
user and carer involvement strategy called
‘Improving Services Together’.
The strategy outlines our commitment to:
• Providing opportunities for service users and
carers to have their say in Trust business.
• Providing opportunities for service users and
carers to use their skills to develop services.
• Changing the way we provide services in
line with our commitment to organisational
change.
• Strengthening our links with our partner
agencies.
• Reaching out to diverse and underrepresented groups.
• Ensuring that service users and carers are
involved in monitoring of the Trust’s
strategy and in judging its effectiveness.
The Trust continues to work with a number of
agencies that represent service user and carer
views, these include: Suffolk Family Carers,
Suffolk User Forum, Carers Agency partnership
and Healthwatch.
Friends and Family Test (FFT)
Both the Francis report, regarding Mid
Staffordshire NHS Foundation Trust (2013),
and the Berwick Report, ‘Improving the safety
of patients in England’ (2013), highlighted the
need for patients to be more engaged and
their voices to be heard regarding the service
they receive within the NHS.
The Friends and Family Test (FFT) was
devised to address this, and to determine
patient satisfaction with NHS services. The
Department of Health stipulated that all
mental health and community services
offer the test by January 1, 2015. The FFT
was implemented across our Trust on
1 October, 2014.
The primary aims of the FFT are to:
• Gather feedback from patients immediately,
or soon after, care has been received.
• Provide a broad measure of patient
experience that can be used alongside other
data.
• Identify areas where improvements can be
made and practical action can be taken.
• Empower patients to make informed
choices about their care.
The FFT consists of one key question: ‘How
likely are you to recommend our service / team
to friends and family if they needed similar
care or treatment?’ with responses ranging
from ‘extremely likely’ to ‘extremely unlikely’.
Service users also have the option to answer
‘don’t know’.
Cards have been designed to capture
responses to the FFT; one for in-patients and
one for community-based services. The cards
are filled out at the point of discharge from
in-patient services, and intermittently for all
community-based services.
(QA20)
How likely are you to recommend our service / team
100
80
%
56%
60
40
26.8%
20
5.3%
3.6%
3%
5.3%
Extremely
unlikely
Don’t know
0
Extremely
likely
36
Likely
Norfolk and Suffolk NHS Foundation Trust Quality Account
Neither likely
nor unlikely
Unlikely
April 2014 to March 2015
The bar graph (QA20) shows responses to the
FFT received by the Trust from 1 October, 2014
to February 2, 2015. It demonstrates that
56% of service users and carers would be
‘extremely likely’ to recommend the service
they received and 26.8% would ‘likely’
recommend the service.
The following table identifies the number of
responses received from service users since the
FFT was launched in October 2014.
(QA21)
Month
October 2014
November 2014
December 2014
January 2015
February 2015
Response Numbers
300
46
30
38
24
It is disappointing that the response rates have
declined but the Trust is working hard to
increase the response rates and improve
engagement with service users and carers
through the following:
• Reviewing the format of the current
questionnaire to make it more user friendly
and engaging.
• Increasing communication to all staff and
patients to demonstrate the positive
changes that have been made following
feedback.
• Considering the use of other feedback
methods, such as the use of texting and
using volunteers to gather feedback.
Services will be expected to use the
information to make improvements in their
areas and a ‘You Said – We Did’ poster will be
developed to enable services to show what
changes have been made in response to
feedback. By demonstrating the positive
impact of communicating feedback, we hope
to encourage more service users to complete
the FFT.
“The team that came out were excellent
and covered everything.”
“I was treated with respect and empathy
and instantly felt I had made the correct
decision in seeking help.”
“Need better equipment and facilities.”
Complaints
Our Trust is committed to using complaints as
a means by which learning and development
can occur. Our Trust aims to consider
complaints in an open and transparent way.
At the time of reporting (April 2015), our
Trust had logged as received 608 complaints
during April 2014 – March 2015 (544 in
2013-14). The majority of complaints related
to “all aspects of clinical care” (43%),
followed by “attitude of staff” (22%).
At the time of reporting 523 complaints
have been responded to. Of these complaints
26% were upheld, 25% were partially upheld
and 33% were not upheld by our Trust. 16%
of complaints were stood down for reasons
including the service user not providing
consent to a complaint being made on their
behalf, the complainant not confirming the
details of their complaint and the complaint
was found to refer to another agency.
Our Trust has been informed that following
the response to a complaint, eight
complainants requested review of their
complaint by the Parliamentary and Health
Service Ombudsman (one to the Local
Government Ombudsman). The Ombudsman
requested information from our Trust to assist
their investigation.
During this year our Trust has implemented
changes to the Complaints Procedure in order
to develop the experience and response to
complainants. This has included all complaint
responses going through a quality check by
the Complaints team prior to the Chief
Executive viewing and signing all letters.
Feedback from the Trust’s Board of Governors
observed this has contributed to an
improvement in the tone, sensitivity and
completeness of response letters. Our Trust’s
Non-Executive Directors continued to view a
sample of complaints on a monthly basis.
Learning from Complaints
The CQC published its inspection report in
February 2015. The inspection findings
conclude there was limited evidence to
demonstrate the Trust implemented learning
from Serious Incidents (SIs), Complaints and
other patient safety indicators.
It is the Trust's contention that it does learn
from SIs, complaints and other patient safety
incidents. System changes often result in the
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
37
form of policy amendments, adjustment to
training and clinical care pathways. Learning is
also shared via a quarterly Patient Safety
Newsletter and sections at Trust forums
(Nursing Leadership and Modern Matrons).
However, the external inspection has
prompted reflection and review of the
current actions and how this critical area can
be developed.
Actions
The following outlines four actions which have
been implemented and will be evaluated as
part of the Quality Improvement Plan:
manner) that patient safety information has
reached their level / awareness. The aim is
to receive assurance that information is
reaching the targeted areas and to identify
any blockages in the flow of information.
The Trust’s Patient Advice and Liaison Service
(PALS) continues to be available to provide
support to service users, carers and members
of the general public who seek to find
information or to resolve their concerns
without the desire or need to use the
complaints procedure. PALS can be contacted
on 0800 279 7257.
Serious Incidents (SIs)
Communicating learning
• Increase frequency of Patient Safety
Newsletter from quarterly to bi-monthly.
• On the alternate month, send an e-bulletin
to managers and clinical leads.
• Refresh the Patient Safety intranet page,
ensuring high quality, accessible
information is available to all staff.
• Provide learning summaries to Trust forums
(e.g. Nursing, Modern Matrons) and put the
presentation onto the Trust intranet.
Supporting managers to enhance
their understanding and role within
Patient Safety
• Create a tips / guidance booklet for
managers with practical ways in which they
can drive patient safety and quality to be
high on the agenda of their respective
clinical teams.
• Creation and distribution of a ‘lessons
learnt’ poster which clinical teams will be
able to use to share learning with staff in a
succinct visual way.
Connection with localities
• The implementation of the Governance
business partner model will support direct
channel of information from patient
safety indicators.
Assurance learning has reached all levels
• To implement a system or process of
checking with staff (in a safe confidential
38
Norfolk and Suffolk NHS Foundation Trust Quality Account
Our Trust continues to report all Serious
Incidents (SIs) in accordance with national
guidance. Incidents may subsequently be
stood down if an explainable cause is
identified i.e. if a death is found to be as a
result of physical or natural causes.
From April 2014 to March 2015, 228
(172 in 2013-14) SIs were reported by NSFT,
of which 139 (130 community and nine
in-patient) were unexpected deaths. At the
time of reporting, 15 have been determined
to be due to a natural cause. The remaining
SIs involved service users who were accessing
a range of in-patient and community services
across our Trust. They were engaged with
services at the time of their death or had been
discharged within the previous six months.
Our Trust uses Root Cause Analysis
methodology to consider the timeline and
factors that influenced an incident. Through
group review the analysis identifies learning
actions. In the past year our Trust has
strengthened oversight for a number of
Serious Incidents through the engagement of
Executive and Non-Executive Directors in
setting the terms of the investigation and
agreeing the final report.
Learning from Serious Incidents plays a
critical role in developing services. Examples
of learning include adjusting the level of
observations for people experiencing acute
periods of distress requiring restrictive
intervention and affirming the actions required
of staff when a service user misses an
appointment. This is important because
evidence informs us that missing an
appointment can be an indicator of increasing
April 2014 to March 2015
Patient Led Assessments of the Care
Environment (PLACE)
risk. Learning from Serious Incidents has also
contributed to the design of clinical forms for
the single electronic health record system.
PLACE assessments are undertaken by the
Trust on an annual basis and include service
users as part of the inspection teams. For the
assessments carried out in 2014, when
benchmarked nationally against the other
49 mental health trusts, the Trust performed
as follows:
(QA22)
Criteria
National Benchmark
NSFT Score
National Score
Mental Health
99.63%
91.57%
89.22%
97.56%
97.75%
85.42%
88.90%
88.78%
10th
20th
28th
6th
Cleanliness
Food
Privacy and Dignity
Condition, Appearance and Maintenance
It should be noted that, due to changes in the
assessment methodology and scoring for the
Food and Privacy, Dignity and Wellbeing
sections, comparison between 2013 and 2014
is not possible.
The scores attained were as follows:
(QA23)
PLACE Evaluation results
Location
Cleanliness
2013
2014
National Overall
average Ward
95.75% Org
Food
2013
National
average
85.41%
Privacy, Dignity Condition, Appearance
and Wellbeing
and Maintenance
2014
Overall
ward
org
2013
2014
2013
2014
National
average
88.9%
Overall
ward
org
National
average
88.78%
Overall
ward
org
Wedgwood
99.48%
99.94%
97.88%
86.70%
93.68%
85.85%
96.25%
90.35%
Carlton Court
99.48%
99.48%
97.18%
96.20%
95.71%
92.06%
97.50%
99.62%
Fermoy Unit
97.46%
99.03%
96.83%
90.00%
89.14%
81.67%
83.33%
98.36%
Hellesdon Hospital
98.73%
99.11%
96.45%
95.15%
Meadowlands
99.40%
Chatterton House
99.07%
Woodlands
99.25%
99.95%
96.21%
St Clements Hospital
99.44%
99.33%
97.31%
86.37%
97.58%
73.61%
90.91%
92.16%
The Julian Hospital
99.14%
99.95%
96.34%
93.50%
92.66%
91.83%
95.38%
99.35%
The Norvic Clinic
98.94%
99.66%
96.38%
93.77%
97.57%
95.11%
97.83%
99.72%
Northgate Hospital
99.63%
99.06%
96.77%
95.06%
94.71%
87.38%
94.74%
99.18%
–
97.16%
–
95.31%
93.07%
91.12%
92.86%
99.03%
–
94.55%
–
85.34%
–
–
83.45%
–
88.39%
–
97.22%
86.86%
89.84%
97.76%
87.05%
The blanked out boxes indicate that Chatterton House and Meadowlands are no longer used for in-patients.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
39
The reduction of the scores noted for the
Wedgwood unit is due to major building
works being underway at the time which
impacted on the environment and quality of
dining experience, however, the food
satisfaction at ward level score remained
high (93.46%).
The scores for cleanliness were above the
2013 national average for all sites assessed
except Northgate and St Clements which
both showed a slight deterioration. Both
sites receive regular visits from the Quality
Assurance department within the facilities
team, and improvement has been seen with
no complaints from service users or staff.
The 2014 survey questionnaire was
substantially redeveloped and updated in
order to reflect changes in policy, best practice
and patterns of service. New questions have
been added to the questionnaire, and existing
questions modified. This means that for all
questions, the results from the 2014 survey
are not comparable with the results from
previous surveys.
Community Survey
A response rate of 32% was achieved; the
national average was 29%.
Further information about the survey can
be accessed via the CQC website on
http://www.cqc.org.uk/content/communitymental-health-survey-2014 or type ‘service
user survey’ into the CQC website search box.
This national survey enables the Trust to be
benchmarked against other mental health
trusts. The survey questions are grouped into
nine sections and the table below shows the
Trust scores compared to other mental
health trusts.
Service User Survey
The CQC requires Trusts to undertake national
service user surveys each year and this survey
involved 57 mental health NHS Trusts. This is
the second year in which our Trust has
undertaken a survey of service users in the
community, and a survey of in-patients.
(QA24)
S1. Your Health and Social Care Workers
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
S2. Organising your care
S3. Planning your care
S4. Reviewing your care
Worse
S5. Changes in who you see
Worse
0
1
2
3
4
5
6
7
8
9
About the same
10
S6. Crisis Care
Worse
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
0
1
2
3
4
5
6
7
8
9
10
S7. Treatments
S8. Other areas of life
Best performing Trusts
Worst performing Trust
Denotes Trust’s
position within the
above ratings
'Better/Worse'
Only displayed when
this trust is better /
worse than most
other trusts
S9. Overall
These results are subject to an action plan
which was developed by the Senior Managers
Forum, which will continue to monitor
40
Norfolk and Suffolk NHS Foundation Trust Quality Account
progress, and also locality-based action plans
which will be monitored within the Locality
Governance meeting.
April 2014 to March 2015
(QA26) – Q51 Patients’ long-standing
medical conditions
In-patient Survey
This survey is not a mandatory requirement
and was undertaken by 23 mental health
trusts. The data is presented differently to the
community survey and can only be compared
with the 23 Trusts who participated.
A response rate of 27% was achieved by
our Trust.
Key findings
There was a decrease in the number of people
rating their care as excellent from 27% in
2013 to 17% in 2014. The percentage of
people who rated their care as either
‘excellent, very good or good in 2013 was
74% with a decrease to 70% in 2014.
Deafness or severe hearing impairment
Blindness or partially sighted
A long-standing physical condition
A learning disability
A long-standing illness, such as cancer, HIV,
diabetes, chronic heart disease, or epilepsy
No, I don’t have a long standing condition
(QA25) – Q47 Level of care rating
This year the full results of the in-patient
survey have been broken down and attributed
to the individual wards. This enables our wards
to implement a targeted action plan for
improvement.
It should be noted however that the
numbers responding are small so may not be
fully representative.
Excellent
Very good
Good
Fair
Poor
The survey also asks respondents about any
long-standing conditions which are important
to consider in the effective delivery of
comprehensive care.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
41
Staff Survey
(QA27)
Summary of the response rate and the four best and worst key findings
for the Trust
2012-13
2013-14
Trust
(published Oct 13) (published Oct 14) Improvement (+)
Response Rate
Trust National
Average *
Trust National Deterioration (–)
Average*
41%
36%
50%
42%
-5%
Top two ranking scores
NB: While guidance requires the Trust to report the top four scores, unfortunately NSFT is only able to report
two scores in the top scoring section of the report
% of staff experiencing
physical violence from staff
in the last 12 months
% of staff having equality and
diversity training in last 12 months
Bottom four ranking scores
% of staff agreeing that their
role makes a difference to patients
Staff recommendation of the
Trust as a place to work or
receive treatment
% of staff having well-structured
appraisals in last 12 months
Staff motivation
2%
3%
6%
4%
+4%
73%
67%
71%
67%
-2%
88%
90%
83%
89%
-5%
3.08
3.55
2.99
3.41
-0.09
35%
42%
24%
37%
-11%
3.65
3.85
3.62
3.79
-0.03
* National average scores are for mental health / learning disability trusts.
Future Priorities and Targets
As set out under the commentary on page 28,
improving workforce engagement is one of
three core strategic workforce priorities. The
Trust recognises that the previous 12 months
has been a particularly difficult time for its
staff in the context of an unprecedented level
of organisational change to support the Trust’s
Service Strategy. The majority of the required
change has now been implemented, leading
to a greater level of stability for most staff over
the coming year.
Detailed plans are being developed to
support the 2014 to 2019 Workforce and
Organisational Development Strategy in
regard to each of the priority areas: staff
engagement, flexible workforce and
skilled workforce.
42
Norfolk and Suffolk NHS Foundation Trust Quality Account
The focus areas for the staff engagement
strategy are as set out above, which includes
promoting a safe and healthy working
environment.
In addition to the Trust-wide approach to
improving staff engagement, existing Locality
Workforce Plans will be reviewed to respond
to area specific priorities highlighted by the
Staff Survey results.
The Trust is committed to making
improvements across all Key Findings as
benchmarked against previous Staff Survey
results and other mental health trusts.
Progress will be monitored taking account
of the measures set out under the
commentary above.
Further information about the survey, and a
full breakdown of results, can be accessed via
a dedicated website on
http://www.nhsstaffsurveys.com.
April 2014 to March 2015
Commissioners and
Stakeholder Comments
The comments received from commissioners
and stakeholders are appreciated by the Trust
and are used to inform and improve
subsequent accounts. In some cases where
minor changes are suggested, these have been
incorporated for this year but in other cases,
where more substantial changes are
suggested, these have not been included but
will inform change next year. It should also be
noted that the Quality Account will be
published separately and the layout will
change accordingly.
NSFT Governors
‘The comments below are submitted by
representatives of the Norfolk and Suffolk
Foundation Trust’s governors:
Members of the NSFT’s governors have
scrutinised the Trust’s 2014-2015 Quality
Account. We acknowledge the care taken to
gather and compile this data and are assured
of its integrity.
The Account analyses the key challenges
facing the Trust and describes action plans and
monitoring processes to deal with them. Rising
demand for services have resulted in pressure
on the availability of beds, whilst staffing
shortages have likewise affected clinical care in
the community. The reorganisation of services
which took place in response to a reduction (in
real terms) of funding has proved a challenge
to both staff and service users. There is
currently the added pressure of scrutiny by the
Care Quality Commission and MONITOR. The
Trust Board has assured the governors that it is
striving to regain stability, whilst maintaining
and improving the quality of its services.
The governors acknowledge the Trust’s
focus on recruitment during the current
national shortage and availability of clinical
staff and the difficulties in attracting staff to
the area we serve. In accordance with CQC,
we acknowledge the excellence, dedication
and resilience of our present clinical staff.
The governors continue to support the
implementation of the Triangle of Care and the
growth of IMROC (implementing recovery
through organisational change).
The governors continue to represent and
communicate public opinion to the nonexecutive directors of the Trust and, when
appropriate, challenge the executive strategic
decisions they oversee.
We aim to uphold the Trust’s ethos in its
delivery of the Trust strategy. We are
particularly concerned in monitoring the
Board’s current Quality Improvement Plan
and quality goals as described in the
Quality Account.
The governors appreciate transparency of
the information shared with us by the Board
that facilitates us in our responsibilities of
representing service users, carers, staff and the
public we serve.
The governors continue to both challenge
and encourage the Trust in its endeavour to
deliver quality services in safe environments,
both inpatient and to the majority of its service
users living in the community. We support the
priorities stated in the Quality Account in
regards to provision of prompt services to
people in crisis and the provision of quality
care plans for all of its service users. We
support the Trust’s use of service user and staff
surveys and in developing a responsive and
reflective complaints process. Also we exhort
the Trust’s focus on physical health and its
participation in national research into good
practice, particularly around schizophrenia.
The governors share the Trust’s determination
in its continued attempt to improve the
quality of patient care, dignity and respect.
The governors acknowledge the Chief
Executive Officer’s recognition of the
challenges faced by the Trust and the
improvements that have been achieved at the
time of writing this response.
We also appreciate and find useful the
comments in the report on the Quality
Account provided by both Norfolk and
Suffolk Healthwatch.’
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
43
NHS South Norfolk CCG, on behalf of
the Norfolk CCGs
NHS South Norfolk CCG, on behalf of the
Norfolk CCGs, is pleased to support the
Trust in its publication of the 2014-15
Quality Account.
Having reviewed the mandatory detail of
the report, we are satisfied that the Quality
Account incorporates the mandated
elements required, based on available data.
The CCG recognises that the Trust has
experienced significant challenges over
2014-15, including a new style of CQC
inspection that occurred during October 2014
rating the Trust overall as inadequate. The Trust
was subsequently put into ‘special measures’
in February 2015 by Monitor, the Trust’s
regulator. The CCG believes that this will
trigger a very significant year of change for the
Trust, where turnaround is a necessity and a
follow up CQC visit in about a year’s time.
The CCG has been actively involved in
supporting the Trust with continuous
monitoring through Clinical Quality Review
Meetings (CQRM’s) and supporting the
Safewards work through a local Commissioning
for Quality and Innovation (CQUIN) scheme
for 2015-16.
The Trust has an excellent history of
appropriate reporting of Serious Incidents,
which is indicative of its open and transparent
approach around issues affecting patient safety.
There is however further work that needs to be
achieved in relation to ensuring that learning
from these serious incidents is embedded into
practice and service delivery. The Trust has
always demonstrated excellent engagement
and working relationships with the CCG in
matters relating to patient safety and has
welcomed challenges posed by the CCG in this
area to ensure services are safe
for patients.
Throughout 2014-15 we have continued to
see a number of patients who have had to
transfer out of county in order to access acute
in-patient care. The Trust committed to end this
during 2014-15. Whilst numbers were
significantly reduced, this has not yet been
achieved. The CCGs note the Trust has a
new 12-bed mental health assessment ward
in March 2015 to help reduce out of
area placements.
The CCG also notes the quality priorities
identified for 2015-16 and would prefer that
workforce should feature within these. The
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Norfolk and Suffolk NHS Foundation Trust Quality Account
CQC identified a number of areas of concern in
regards to workforce from staff morale, staffing
levels, training and leadership issues which all
have a direct impact on patient safety. The
quality of services can be assured to be safe
and responsive with a well-trained, valued and
motivated staff group.
The CCG looks forward to continuing to
working in a positive and collaborative manner
with the Trust to continue improvements in
patient care during the coming year.
Great Yarmouth & Waveney
Clinical Commissioning Group
Great Yarmouth & Waveney Clinical
Commissioning Group as a commissioning
organisation of NSFT supports the organisation
in its publication of a Quality Account for
2014-15. We are satisfied that the Quality
Account incorporates the mandated elements
required based on available data. The
information contained within the Quality
Account is reflective of the Trust over the
previous 12 month period.
In our review we have taken account of
the clinical quality and safety improvement
priorities identified for 2015-16 and support
the identified improvement objectives in the
quality and safety of care provided to Great
Yarmouth & Waveney residents. The Trust will
do this by:
Improving Patient Safety;
The Trust Board’s aim is to reduce the use of
restrictive interventions to below the national
benchmarking average by 1 April 2016.
The Trust Board’s aim is that 95% of service
users admitted to a ward for more than
24 hours will receive a physical health check.
Improving Patient Experience;
The Trust Board will measure service user’s
involvement with their care through the Service
User Survey to ensure that this is at a level at or
above the national benchmarking average
when the 2016 results are published. Service
users will be asked ‘Have you agreed with
someone from NHS mental health services
what care you will receive?’
April 2014 to March 2015
Improving Clinical Effectiveness;
The Trust Board will actively monitor the
implementation of actions arising from Serious
Incident investigations and the correct
application of the Duty of Candour. The CCG
expects that this will result in the sharing of
learning from incidents that informs changes
in practice and decision making.
We note that learning from incidents has
been included as a priority in the Trust’s
Quality Improvement Plan and that a Duty of
Candour Policy has been implemented during
2014-15.
Great Yarmouth and Waveney CCG also
notes the quality priorities identified for
2014-15 and in particular the deterioration in
feedback from patients about explanations of
prescribed medications. The CCG does
recognize that there may be a delayed
measurable improvement due to the timings
on the national surveys. We anticipate
improvements within the next published
survey as a result of the clinical improvements
being made.
The Trust has stated that, for the second
year running, it has not participated in the
Prescribing Observatory for Mental Health
clinical audit as these were not considered
to be relevant priorities of the Trust during
2014-15. The CCG looks forward to receiving
the results of these audits which the Trust
intended to commence in February 2015.
We recognise the challenge of being placed
in Special Measures by Monitor puts the Trust
under great scrutiny and challenge; the CCG
would like to acknowledge and commend the
Trust on its openness and transparency within
the Quality Account about the outcomes of
the Care Quality Commission inspection in
October 2014 and commitment to making the
required improvements. The CCG would also
like to acknowledge the areas of good
practice observed during the inspection. The
CCG asks that the section within the report
about the Care Quality Commission
inspections undertaken in 2014-15 be
developed further to include a list of all
services and locations inspected by the CQC
with a brief overview of the outcomes. Where
there has been areas of non-compliance, we
request that the Trust clearly states what these
consist of and what the Trust is doing / has
done to address these concerns.
The CCG believes that the Annual Quality
Account presents the Trust with an
opportunity to share with service users the
significant service changes that have occurred
within 2014-15 and provide an update on
how these service changes continue to be
monitored. Recognition of patient
engagement and the voice of the service user
are requested to be included.
The Great Yarmouth & Waveney Clinical
Commissioning Group looks forward to
working with the NSFT during 2015-16.
Healthwatch Suffolk
The CQC inspection of the Norfolk and Suffolk
Foundation Trust in October 2014 raised some
significant concerns about performance. This
quality account reflects some of these
challenges and sets out plans to address the
issues raised. It is imperative that services are
well-led and this requires staff at all levels to
communicate openly and effectively without
fear of reprisal. It is evident that some staff
have not felt valued or listened to by
senior staff.
Feedback on 2014-15 Quality Priorities
For a number of these priorities, progress is
limited or there is insufficient data yet
available to judge how much progress has
been made. This seems to be recognized in
particular for priorities 1 and 3 which
essentially continue in 2015-16. Evidence of
adequate progress on priority 4 (small audit,
limited improvement on care plans), priority 5
(introduction of a form but has the staffing
issue been resolved?) and priority 6 (how
widely is the TOC tool used?) is also lacking.
On priority 7 the scale/reliability of the audit in
March 2015, reporting improvements in
service user involvement in their medication
planning, is not described.
On priority 8, Healthwatch Suffolk, while
recognizing that there were particular
problems during the period of major service
restructuring, is by no means convinced that
the ongoing problem of continuity in care
coordination is one confined to Norfolk. We
would like to see more evidence that this
problem is being overcome by ensuring
adequate training, organisation and resourcing
of teams within the Trust. This priority is
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
45
related to the 2015-16 Patient Experience
priority on service user involvement in care
planning which it is suggested could be
widened to address the care continuity aspect.
On priority 2, the waiting times as of 31st
March show that mandatory requirements are
almost being achieved and it is to be hoped
that at least this level of performance will be
consolidated.
The results of a Healthwatch Suffolk survey
of the Access and Assessment Service in 2014
show that service users were generally
satisfied with the amount of time they had to
wait to book an appointment within the Trust.
However, service users were still concerned at
waiting times for subsequently receiving
treatment with almost 9 out of 10 service
users still waiting at the time they were polled,
often also lacking adequate communications
on what was happening.
Quality priorities 2015-16
The proposed quality priorities make reference
to meeting national benchmarking averages.
Many readers however will not know what
these are and they need to be spelled out and
enumerated in the text. The priority
descriptions are very short and technical.
Reference to the Trust Quality Improvement
Plan (a separate document) is actually
necessary to be able to understand what is
intended. Précised text from the latter should
be added to provide a fuller description for
each priority.
Patient experience - Quality
improvement plan reference RE6
It is notable that response rates to the Family
and Friends Test (FFT) have declined and
therefore it is questionable how representative
these views are of the organisation as a
whole. Healthwatch Suffolk would therefore
encourage the Trust to seek more innovative
ways of gathering this data. It is also evident
that improving staff engagement must be a
priority for the Norfolk and Suffolk Foundation
Trust. The staff survey FFT falls below that
national average, indicting a lack of
confidence by staff in the trusts ability to
deliver acceptable services, again the response
rates remain low.
46
Norfolk and Suffolk NHS Foundation Trust Quality Account
Healthwatch Suffolk’s project exploring
patient experiences of accessing the Norfolk
and Suffolk Foundation Trust services via the
Access and Assessment Team (AAT) indicate
that there remains confusion about processes
within the trust, this may be in part due to the
reorganisation of services, but reflects the
need for better communication with patients
to avoid stress and anxiety at the point of
entry into or between the Norfolk and
Suffolk Foundation Trust services which
was highlighted during Healthwatch
telephone interviews.
Experiences reported to Healthwatch
Suffolk also highlight a lack of consistency in
staff seeing patients, a sense of uncertainty
about the purpose of interventions, limited
co-production of care plans with patients, a
lack of information and support for carers and
in some cases such a lack of compassion and
understanding that patients and their carers
came away feeling worse after appointments.
Many of these concerns are indicative of
resourcing problems and / or poor
management. However, while benchmarking
against the 2016 service user survey is a good
idea, we are concerned at the delay involved
before this feedback is obtained. We suggest
that additional means of monitoring progress
are identified to provide nearer term, and
ongoing, feedback on service user experience.
The CQC did not dispute in its inspection
that the Norfolk and Suffolk Foundation Trust’s
staff are, on the whole, caring. This is backed
up by the Healthwatch Suffolk Survey which
shows 92% of patients agreeing that they had
been treated with respect and dignity at all
times and 76% feelings that their views were
listened to, although there is room for
improvement. It appears that around half
those surveyed had not actually commenced
the treatment they require.
The Quality Improvement Plan more widely
addresses the quality of services delivered by
Community teams including the
implementation of the Waves model and a
crisis support line for service users with
personality disorder. Lack of provision for
personality disorder has been a key concern
flagged to Healthwatch by services users and
we would like to see an additional priority
defined to cover this area under the `Patient
Experience` heading.
More generally, the issue of Crisis Care has
been an area where service users have raised
April 2014 to March 2015
serious concerns in the past with both
Healthwatch Suffolk and Suffolk User Forum
and dialogues with senior Trust staff have led
to various initiatives and pilots, carried forward
under the Crisis Concordat, and we would like
to see final implementation and embedding
of these developments as a key priority for
2015-16. Key aspects are:
• an appropriate place of safety for service
users in crisis to go to which is not a police
cell, even when under the influence of
alcohol or drugs
• psychiatric liaison available in all A&E
departments in timely fashion – say within
one hour
• a 24/7 Suffolk wide crisis telephone line
manned by suitably trained and
empathetic staff
• proactive planning of community care to
avoid relapse after crisis and, where
necessary, to enable rapid return to
secondary Norfolk and Suffolk Foundation
Trust care to avoid serious deterioration
of health
Patient safety - Quality improvement
plan reference SA4
We fully support the CQC view that ““Use of
restrictive interventions will reduce to below
the national benchmarking average by
01.04.16” is an essential priority.
The target that 95% of service users
admitted to the ward where they stay for
more than 24 hours will have a physical health
check is welcomed, given the risks of comorbid long term conditions, however a
timescale should be associated with this
objective and any steps taken and planned
should be recorded in the Care Plan.
Clinical effectiveness - Quality
improvement plan reference SA9
The priority that “all locality governance
groups are able to demonstrate that learning
from incidents has led to changes in practice
by 01.10.15” appears focused on reducing
Serious Incidents and complaints and is
certainly an area of improvement that we
would support. The question is however what
will be the measure as to whether a sufficient
change in practice has been achieved by the
date indicated? Would this be that all relevant
staff will report a debriefing has taken place
following a serious incident and identify what
they have learnt?
The CQC identified concerns about the
ability of staff to learn from complaints and
incidents and whilst a plan to improve this is
now in place, this will require a whole system
approach that ensures transparency and
changes to the way in which staff view,
manage and learn from complaints.
Additional comments
The draft text lacks both a contents page,
laying out the general structure of the
document, and a numbering scheme making
it difficult to identify the context of individual
sections. The document is also full of jargon
and is essentially structured to meet internal
NHS reporting requirements. It is not, in its
present form appropriate for service users,
carers or the general public.
While it is appreciated that the Trust is
required to report to a certain format it is
suggested that a more readable document
could be achieved by making greater use of
charts and diagrams to present information
and highlighted text boxes on each page to
summarise main points in simple language. It
is also strongly recommended that the Trust
produce a shorter `easy read` version of the
final Quality Account, specifically designed for
service users and carers, in order to reach a
wider stakeholder audience.
It was pleasing to read about the success of
the Recovery College and the improvements to
the Improving Access to Psychological
Therapies (IAPT) services, which also includes
service user involvement and improved
methods of access. There is evidence of service
user involvement in the planning of services,
such as the learning disability forums and
some positive examples of innovative and
collaborative approaches to delivering services
was evident.
The CQC has highlighted some areas of
excellent practice and other areas where
significant improvements must be made.
Ensuring that staff voices are heard and that
their views are acted upon to improve services
is essential, as is the on-going involvement of
patients and their carers in the planning and
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
47
delivering of services to ensure that services
are responsive to the needs of the local
population in Suffolk. Where innovative staff
have developed new initiatives and tools these
could be shared more proactively across
the trust.
Healthwatch Suffolk looks forward to
seeing the Norfolk and Suffolk Foundation
Trust achieve its goals for the coming year and
is eager to work with the Trust in helping it to
achieve those goals.
Healthwatch Norfolk
Healthwatch Norfolk appreciates the
opportunity to make early comments on the
Quality Account in order to influence the
substance of the report. We also appreciate
the increased pressures on NSFT from reduced
funding, rising demand and external
inspection; and are particularly concerned that
increased pressure to meet particular targets
detracts from the wider objective of providing
the best service for users.
Patient safety
We agree that reducing seclusion and
restrictive intervention is a key priority but ask
that the potential knock-on effect on incidents
is carefully analysed.
Monitoring physical health is also a key
priority but as part of a general concern about
treating the whole patient with potentially a
combination of mental, physical and social
care needs. We are particularly concerned
that with the pressure on beds and the need
to move patients between services, that this
bigger picture may be lost by over-emphasis
on a particular target. Meeting the 95%
target for physical health but missing some in
the 5% category with significant physical
health problems would not constitute success.
Patient experience
Clinical effectiveness
We agree the importance of demonstrating
learning from incidents by changing practice
where relevant.
Feedback on Quality Priorities 2014-15
Ensuring that 100% of patients are seen
within the number of days stated in the
contract and that patients are correctly
allocated to the various priority queues
remains a key priority. Will an Executive
Director be responsible for this target?
The follow-on in 2015-16 from the
priority 4 (being able to contact a mental
health worker out of hours) is not
entirely clear.
• Is the service only available to users with
a crisis plan?
• Will the service be available in Norfolk
throughout 2015-16?
• Will the service be available at weekends?
• What are the contingency
arrangements for users, carers and
members of the public not covered by
the service?
We will continue to work with the Trust to
ensure that the views of patients, carers
and their families are taken into account
and to make recommendation for change
where appropriate.
Health Overview and Scrutiny
Committee
The Norfolk Health Overview and Scrutiny
Committee has decided not to comment on
any of the Norfolk provider Trusts' Quality
Accounts for 2014-15 and would like to stress
that this should in no way be taken as a
negative comment. The Committee has taken
the view that it is appropriate for Healthwatch
Norfolk to consider the Quality Accounts and
comment accordingly.
We agree the importance of involving users,
and where relevant their carers, in their care
plans while also seeking that 100% of users
actually have a care plan.
48
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
Key and glossary
AAT
BMI
CAMHS
CPA
CQC
CQUIN
CRHT
DH
IAPT
IPAC
KPI
LIPACS
NCE
NCISH
NHSLA
NICE
NPSA
NSFT
NWMHFT
PALS
PbR
PC-MIS
PEAT
PET
PLACE
POMH
QRP
RAPt
RCA
SCR
SI
VTE
Access and Assessment team
Body mass index
Child and Adolescent Mental Health Service
Care programme approach
Care Quality Commission
Commissioning for Quality and Innovation
Crisis resolution and home treatment
Department of Health
Improving access to psychological therapies
Infection prevention and control
Key performance indicator
Local infection control prevention and control supporter
National confidential enquiry
National confidential enquiry into suicide and homicide
for people with mental illness
NHS Litigation Authority.
National Institute of Health and Care Excellence
National Patient Safety Agency
Norfolk and Suffolk NHS Foundation Trust
Norfolk and Waveney Mental Health Foundation Trust
Patients’ Advice and Liaison Service
Payment by results
Patient case management information system
Patient Environment Action Team
Patient experience tracker
Patient led assessment of the care environment
Prescribing Observatory for Mental Health
Quality and risk profile
Rehabilitation of Addicted Prisoners Trust
Root cause analysis.
Serious case review
Serious incident
Venous thrombo embolism
How you can get involved
As a member of Norfolk and Suffolk NHS Foundation Trust, individuals can help shape
the way the Trust plans and provides mental health services in Norfolk and Suffolk.
Membership is free, and members will receive regular information about the Trust’s plans and
developments. They will be invited to public meetings and receive a copy of our newsletter,
Insight. Members are also able to stand for election as a governor, or vote in our annual
governor elections. Join now by calling 0870 707 1647. Alternatively, visit www.nsft.nhs.uk
to sign up on line.
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
49
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Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
Norfolk and Suffolk NHS Foundation Trust Quality Account
April 2014 to March 2015
51
Norfolk and Suffolk
NHS Foundation Trust
Norfolk and Suffolk
NHS Foundation Trust
Hellesdon Hospital
Drayton High Road
Norwich NR6 5BE
Tel: 01603 421421
Web: www.nsft.uk
Norfolk and Suffolk NHS Foundation
Trust values and celebrates the
diversity of all the communities we
serve. We are fully committed to
ensuring that all people have equality
of opportunity to access our service,
irrespective of their age, gender,
ethnicity, race, disability, religion or
belief, sexual orientation, marital or
civil partnership or social & economic status.
If you would like this leaflet in large print,
audio, Braille, alternative format or a
different language, please contact PALS
and we will do our best to help.
Email: PALS@nsft.nhs.uk
or call: PALS Freephone 0800 279 7257
© 2015 NSFT. All rights reserved. NSFT Comms/15/016. GFX 3770
Quality Account
2014-15