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Avon and Wiltshire Mental Health Partnership NHS Trust
Quality Account
2014/15
Contents
Part 1: Chief Executive’s statement on behalf of the Board
Introducing Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)
Part 2a: Our priorities for improvement in 2015/16
Priority 1: To improve service user and carer experience
Priority 2: To improve the clinical effectiveness of our services
Priority 3: To reduce avoidable harm
Priority 4: To improve the physical health of our patients
Priority 5: To provide services that are compliant with the Care Quality
Commission’s (CQC) Fundamental Standards of care
Part 2b: Statements relating to quality
2.1
Review of services
2.2
Participation in clinical audits
2.3
Participation in clinical research
2.4
Commissioning for quality and innovation (CQUIN payment framework
2.5
Care Quality Commission (CQC) registration
2.6
Quality of data
2.7
Safeguarding
Part 3: Our care quality achievements in 2014/15
3.1
National indicators
3.2
Patient Experience - How we did
3.3
Effectiveness – How we did
3.4
Safety – How we did
3.5
Service user, carer and patient experience
3.6
Learning from incidents
3.7
Patient environment
3.8
Staff survey
Part 4: How we developed our Quality Account
APPENDICES
Appendix A: External assurances and comments
Appendix B: Glossary of terms
Appendix C: Statement of Directors’ Responsibilities
Appendix D: Information by Clinical Commissioning Group Area
Appendix E: More information on quality indicators
This document is available on our website
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Part 1: Chief Executive’s statement on behalf of the Board
Our absolute focus is on improving the quality of our care and the services we provide. I
am therefore pleased to introduce on behalf of our Trust Board, our sixth Quality
Account. This document summarises the quality improvements we have made to the
safety and effectiveness of our services and highlights our focus on improving the
experiences of those who use them.
The central purpose of our Trust is to provide the highest quality mental healthcare that
promotes recovery and hope. This Quality Account describes the progress we have
made over the last twelve months and outlines our quality priorities for the coming year.
These have been shared with our staff, service users, carers and commissioners; so that
everyone is aware of the steps we are taking and the impact we want them to have.
The past year has been one of consolidation but also one with significant challenges for
us. We have continued to embed the changes we in 2013 with our clinically and locally
led service delivery units that are providing services which respond more quickly to the
needs of their local communities. Our real time quality improvement system has
continually evolved to meet the end user’s needs and the support provided to our
operational services by our central quality improvement function has been commended.
The Trust has dealt with the increased demands made on mental health as well as a
national shortage in qualified nursing staff. The impact of these issues has meant our
wards not always having beds available to admit people as close to home as they should
be. Also some of our wards have had to temporarily close beds where we do not have
enough qualified people to staff them safely.
Additional pressures on the overall health and social care system have contributed to
patients who are ready for discharge being delayed in mental health beds because
suitable alternative beds have not been available. We are working with our
commissioners and local authorities to resolve these issues.
In June 2014 the Trust received an inspection from the Care Quality Commission’s Chief
Inspector of Hospitals. The inspection was comprehensive and, as well as identifying
areas of good practice and praising our staff for their compassion and caring attitudes,
we were notified of areas of significant concern where we were required to make
improvements. These priority areas were: the safety of the environment of our inpatient
wards, particularly in relation to ligature risk; ensuring safe staffing numbers and
improving our systems and processes to ensure organisational action and learning from
incidents, reviews or other sources of information.
To make these improvements the Trust implemented a comprehensive plan of action and
internally tested our compliance by way of independent visits and developmental support
from specialist staff.
In December 2014 the Trust was re-inspected by the CQC to test our improvements and
we are pleased that these met the CQCs expectations. In addition to these areas the
Trust continues to work on the findings of the CQC report as we recognise that we still
have more to do to ensure that we have fully embedded the necessary improvements in
to our clinical practice and service provision.
We are not prepared to stand still. We strive to maintain a culture of continuous quality
improvement through ward and team self-assessment, a programme of mock inspections
and quality visits and a comprehensive programme of clinical audit.
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In last year’s Quality Account we set out our Quality Priorities for the year and we are
pleased that our work in these areas has progressed well. Our inpatient services were
successfully accredited with the Carers Trust Triangle of Care in May 2014 and our
community services are ready to apply in May 2015. We have increased the number of
service users taking part in the Friends and Family Test service user survey and ensured
that our services have listened and responded to this valuable feedback. The physical
health of our most seriously ill patients has been a key area of focus ensuring all
inpatients receive a thorough physical health check and that we work with GPs and other
health professionals to ensure safe and coordinated treatment for both physical and
mental health conditions.
In the past year we have continued to achieve against the majority of our contractual and
national quality performance indicators as well as delivering successfully the quality
improvement incentive schemes agreed with our commissioners, however we know
through the experience of the CQC inspection that we cannot be complacent. We must
continuously strive to improve what we do. We will check and check again how we are
doing, to ensure that we routinely provide safe, clinically effective and caring services.
In the coming year, we have identified a series of quality in response to the feedback of
our regulators, commissioners, our service users and carers’ and our staff. Our objective
is to deliver high quality services Trust wide, which are clinically led, locally driven and
quality focused and to support this we have set following Quality Priorities for 2015/16:






We will deliver high quality services Trust wide and aim to achieve a CQC rating of
at least ‘good’ across all inpatient, community and specialist services
We will continue to implement the ‘Safewards Model’ and reduce the need for
restrictive interventions and improve the use of positive and proactive approaches
to care and above all to improve the safety of our wards
To provide services that our service users would recommend to their friends and
family and continue our work to improve our partnership working with carers
To improve the clinical effectiveness of our approach to assessment and care
planning
Implement a new electronic patient record and improve how we record our clinical
practice
We will continue our work to make sure that that we give equal attention to the
physical health of our service users as we do to their mental health.
Our service delivery units will also be continuing to focus on key local areas for
improvement in partnership with their patients, service users, carers and commissioners.
We have maintained open and honest relationships with our local communities, the
people who use our services, NHS commissioners, GP Commissioners and local
authorities over the last year. We will build on these relationships to ensure that we
improve and develop our services in response the needs of our local communities.
I verify to the best of my knowledge that the information in this document is an accurate
and true account of the Trust’s quality of services.
Iain Tulley
Chief Executive
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Guidance to help you when reading this document:
1. We have used a “traffic light” system to rate how well we have done against the
standards we have set for ourselves. These are:
Red
Standard not met / poor result
Amber
Standard nearly met / adequate result
Green
Standard met / good result
2. We have also used arrows to show the direction of change against target level over
the past year as follows:
▲ = Improving
► = No change
▼ = Deteriorating
3. There is an explanation of some terms in the glossary in Appendix B.
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Introducing Avon and Wiltshire Mental Health Partnership NHS Trust
(AWP)
AWP is a major provider of recovery focused mental health services. Our objective is to
be the organisation of choice for service users, staff and commissioners alike, providing a
comprehensive range of specialist Mental Health services in primary, secondary and
tertiary care settings, across our existing geographical area.
AWP provides services for people with mental health needs, for people with learning
disabilities combined with mental health needs and for people with needs relating to drug
or alcohol dependency. We also provide secure mental health services and work with
the criminal justice system.
We operate from more than 100 sites across Bath and North East Somerset (B&NES),
Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire, as well as
providing specialist services for a wider catchment extending across the South West.
We are committed to the delivery of safe, accessible, effective, leading edge, innovative
and person-centred services which intervene early and effectively and concentrate on
recovery and reablement. We work together with our health and social care partners to
provide service users with increased choice in the way they receive support and care
which is closer to their homes and to avoid, where possible, disruptive inpatient stays.
In 2014/15 the Trust’s community services saw 31,685 individuals from just over 36,000
referrals, and had more than 301,405 contacts with service users (either via the
telephone or face to face). In addition, 2,212 people were admitted into our inpatient
units for more intensive treatment.
Our turnover in 2014/15 was £198m and we employed an average of 3298 (whole time
equivalent) staff from a variety of professional backgrounds including psychiatrists,
psychologists, mental health nurses and allied health professionals.
Fundamental to delivering quality services is continuing to embed the principles of the
NHS Constitution within the organisation. This constitution sets out rights of patients,
public and staff, pledges which the NHS is committed to achieve, together with
responsibilities which the public, patients and staff owe to one another to ensure that the
NHS operates fairly and effectively.
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Part 2a: Our priorities for improvement in 2015/16
Our Trust aim is to deliver high quality services Trust wide, which are clinically led, locally
driven and quality focused.
Set out below are the priorities we are planning to deliver in the year ahead which will be
monitored and reported through the Trusts internal quality governance and assurance
systems and as required to our Clinical Commissioning Groups’ contract quality
governance meetings.
To provide
services that are
compliant with
the CQCs
Fundamental
Standards of Care
Improve service
user and carer
experience
To consistently
deliver high quality
services which are
clinically led, locally
driven and quality
focused
Improve patient
safety by
reducing
avoidable harm
To improve
clinical practice:
assessment
formulation and
care planning
Improving how
we record our
clinical practice
in the electronic
patient record
Improved physical
health care
through
comprehensive
health checks
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Priority 1: To improve service user and carer experience
Description of issues and rationale for prioritising
Understanding the experience of our service users and carers is key to informing how we
make adjustments and improvements to our services to meet the needs and expectations
of those using them.
The Carers Trust ‘Triangle of Care’ Membership Scheme is a recognised as a way to
demonstrate our commitment to working in partnership with carers.
The actions we will take in 2015/16 are set out in the table below:
Improvement
Priority
To provide
services that our
service users will
be confident to
recommend to
their friends and
family if they
required similar
treatment.
Actions
Development of a new Service User and
Carer Involvement Strategy developed in
partnership with our service users and
carers
Complete an in depth thematic analysis of
patient feedback and findings from
incident reporting
The use of the Friends and Family Test
(FFT) as a mechanism for gathering realtime service user feedback
Improved use of technology to gather
service user feedback
Development of survey tools to improve
the accessibility of the FFT
To enhance
carers experience
through improved
partnership
working and carer
support.
We will continue to use the Carers Trust
‘Triangle of Care’ self-assessment
improvement tool across the Trust and
take forward identified improvement
actions
Implementation of our Family Friends’ and
Carers Charter
Rolling out carer awareness training
across all teams
Simplifying carer recording processes on
RiO
Success measures
Delivery of new strategy endorsed by
our Trust-wide Involvement Group
Evidence of actions completed to
address themes from thematic
analysis
Evidence of local improvement
actions in response to the patient and
carer experience
90% of our service users will
recommend our services via the
‘Friends and Family Test’
Consistent response rates of 15% for
community services across all of our
service delivery units
Submission for phase two Triangle of
Care accreditation
Triangle of care improvement plans in
place for 100% of teams and wards
95% of carers asked if they have a
carer or person who supports them
85% teams completed carers
awareness training
Updating and improving carer information
on Carers pages of internal and external
website
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Priority 2: To improve the clinical effectiveness of our services
Description of issues and rationale for prioritising
Clinically effective care is about providing the right care, at the right time and achieving
the right outcome.
We know from our clinical audit programme, patient feedback, incident investigations and
our regulators that we can do more to improve our clinical practice to achieve the best
possible outcomes for our service users.
The actions we will take in 2015/16 are set out in the table below:
Improvement Priority
Actions
To ensure that all service
users receive a
comprehensive
assessment including
formulation, assessment
of risk, and have a
clinically effective care
plan that is agreed by the
service user
Training and development of
staff on formulation,
assessment and care planning.
Audits of the clinical record demonstrate
that 85% of records have formulation
summary recorded.
The clinical toolkit will be
reviewed as per yearly review
cycle.
95% of service users records include a
risk assessment
Guidance on recording
assessments and formulations
for clinicians will be refreshed
following the introduction of
open RiO.
Checklists for managers will be
developed which will enable the
review of assessments,
formulation and care plans.
These will be used monthly.
Development of clinical
networks to advise on clinical
effectiveness and standards
To improve the quality of
the electronic patient
record (EPR) to aid and
reflect clinical practice
and decision making
Development and agreement of
Trust standards for the
completion of a good quality
patient record
Tailoring of the new EPR to the
needs of service users and staff
Success measures
90% of service users have crisis and
contingency plan
85% of service users care plans contain
the following elements:





statement of need which has
been identified during
assessment
goals
interventions with timescales
evidence of service user and
carer involvement in the
development of the care plan
are agreed and signed by the
service user
New records management standards
agreed by end of September 2015
85% compliance with monthly audits of
the clinical record
Improved scores in staff feedback survey
on use of the EPR
Implementation of a new EPR
Delivery of training
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Priority 3: To reduce avoidable harm
Description of issues and rationale for prioritising
Providing services that are safe and free from harm is our highest priority. We know from
themes reappearing in our findings from incident investigations that we need to do better
to truly listen, learn and act when things go wrong.
‘Sign up to Safety’ is a campaign that aims to make the NHS in England the safest
healthcare system in the world, building on the recommendations of the Berwick Advisory
Group. The ambition for the NHS in England is to halve avoidable harm in the NHS and
save 6,000 lives as a result.
Investigations into abuses at Winterbourne View Hospital and Mind’s Mental Health
Crisis in Care: physical restraint in crisis (2013) showed that restrictive interventions have
not always been used only as a last resort in health and care. During the coming year we
will continue our work to implement the new Department of Health best practice guidance
to ensure service user and staff, safety dignity and respect.
The actions we will take in 2015/16 are set out in the table below:
Improvement Priority
Listening to patients,
carers and staff, learning
from what they say when
things go wrong and
taking action to improve
patients’ safety.
Our aim is to reduce
avoidable harm by 50% in
line with NHS England’s
‘Sign up to Safety’
campaign to save lives
and reduce harm for
patients over the next 3
years.
To reduce the use and
need for restrictive
interventions and improve
the use of positive and
proactive approaches to
care
Actions
Success measures
We will develop and deliver a
patient safety improvement
plan and set out our actions
to meet the Sign up to Safety
pledges:
Achieve CQC rating of ‘good’ in the
safe domain
1.
2.
3.
4.
5.
Put safety first
Continually learn
Honesty
Collaborate
Support
8% reduction in falls leading to a
fracture
Maintain and improve our position
in the top 25% of organisations by
the rate of incidents reported.
Evidence of discharging our duty of
candour for 100% of serious
incidents
90% of actions completed on the
Patient Safety Development Plan
Implementation of
Department of Health
Guidance ‘Positive and
Proactive Care: reducing the
need for restrictive
interventions’.
Adoption of the 2015 update
of the Mental Health Act
1983: Code of Practice
*
‘Safewards Model’ implemented on
all wards
15% reduction in all restrictive
practices
10% reduction in the use of
seclusion above 8 hours duration
Improved score for national
inpatient survey question ‘Do you
feel safe?’
*
A model of care designed to reduce the use of restrictive practices such as restraint or rapid
tranquilisation.
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Priority 4: To improve the physical health of our patients
Description of issues and rationale for prioritising
The severely mentally ill (SMI) patient population makes up five per cent of the total
population but accounts for 18 per cent of total deaths. There is an excess of over 40,000
deaths among SMI patients which could be reduced if SMI patients received the same
healthcare interventions as the general population.
We will continue to prioritise work this year to ensure that our highest risk patients
receive comprehensive physical health checks whilst in our care and that appropriate
action is taken when issues are identified alongside the communication of all identified
physical and mental conditions to the GP. The primary aim is to reduce premature
mortality, improve patient safety, patient experience and quality of life, through shared
communications and coordination of treatments.
The actions we will take in 2015/16 are set out in the table below:
Improvement Priority
*To reduce premature
death and improve the
physical health condition
of severely mentally ill
patients and ensure
physical health needs are
identified and treated.
Actions
All inpatients will receive a
comprehensive physical health
assessment within 72 hours of
admission to a ward
The full implementation of
appropriate processes for
assessing, documenting and acting
on cardio metabolic risk factors for
patients with schizophrenia in our
wards and early intervention (EI)
services.
All inpatients will receive a daily
assessment of their physical health
condition.
Success measures
Meeting 90% (inpatient) and
80% (EI) compliance with the
completion cardio metabolic risk
factors assessed via the
National Audit of Schizophrenia
Improved score for national
inpatient survey question ‘Do
you feel enough care was taken
of your physical health needs?’
95% of inpatients with physical
health assessment within 72
hours of admission
85% of inpatients receive daily
physical health assessment
Care plans to fully reflect actions to
address lifestyle and physical health
needs
*Ensuring that discharge
summaries and care
plans are shared with
GPs and include
comprehensive
information including
diagnosis, medications,
physical health
conditions and recovery
interventions.
Development of comprehensive
guidance and training for clinical
practitioners on the inclusion of
diagnosis, medications, physical
health conditions and recovery
interventions in care plans for
inpatients
Meeting 90% compliance
assessed by a local audit of care
plans
Improved score for national
inpatient survey question ‘Do you
feel enough care was taken of
your physical health needs?’
*Part of the 2015/16 CQUIN (Commissioning for Quality and Innovation) scheme which is where Trusts can
earn additional income dependent on the delivery of a set of measured quality improvement objectives.
Details are set out at the following link: http://www.awp.nhs.uk/media/725392/cquin-scheme-2015-16.pdf
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Priority 5: To provide services that are compliant with the Care Quality
Commission’s (CQC) Fundamental Standards of care.
Description of issues and rationale for prioritising
The Government’s response to the Francis inquiry included new measures aimed at
improving openness and transparency, and setting minimum standards of care. From
April 2015 the Department of Health and CQC have developed a new approach to
regulating, inspecting and rating health and social care services based on new
Fundamental Standards regulations that set clear standards below which care must
never fall.
We have work to do to make sure that we understand the new regulations and to make
sure that our services are fully compliant with them. We want to build on our progress
last year when we introduced a new approach to continuous quality improvement
developing local clinical leadership and accountability. Above all we believe that we are
beginning to change the culture of our teams and wards to own the quality of the care
they provide and to strive to continually improve it.
The actions we will take in 2015/16 are set out in the table below:
Improvement Priority
To ensure that all services
are compliant with the CQC
Fundamental Standards of
care
Actions
Self-assessments of compliance at
ward and team level
Development of a dashboard to
provide information at ward and team
level to inform improvement activity
Locally led and independent/peer
review quality walk around programme
Mock inspections and independent
compliance checks
‘15 steps challenge’ visiting
programme
Quality improvement training and
specialist support for projects
Quality improvements plans in place
for all service delivery units
Success measures
To receive no CQC
compliance actions at
inspection across all five key
questions:
Is the service:





Safe?
Caring?
Effective?
Responsive to
people’s needs?
Well-led?
95% of wards and teams are
taking part in the selfassessment
20% increase in the number
of registered quality
improvement projects
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Part 2b: Statements relating to quality
The Trust’s approach to quality improvement is set out in our Quality Improvement
Strategy 2013 to 2017. (Available on our website http://www.awp.nhs.uk/newspublications/publications/trust-strategies/)
The strategy builds on our commitment to be a Trust which is driven by quality, clinically
led and which is heavily influenced by the views of patients and carers. Our approach to
quality improvement is supported by:
•
an organisational environment focused on quality improvement
•
a defined ‘Quality Assurance Framework’
•
delivery through quality priorities owned and developed by delivery units and
Corporate Directorates.
The plans also seek to improve quality systems and processes, including those
underpinning functions essential for delivering high quality care, such as finance and
human resources.
The following statements provide information to show that the Trust is performing to
essential standards, that we measure our clinical processes and performance and are
involved in national projects to improve quality.
The Board and it’s Quality and Standards Committee receive and review assurance and
progress reports on a regular basis.
2.1
Review of services
During 2014/15 AWP has provided NHS inpatient and community mental health services
organised across eight service delivery units, including:

Specialised and specialist drug and alcohol services

Secure services

Locality led service delivery units across the six local authority areas we
serve which provide inpatient and community mental health services to
adults.
The Trust has reviewed all the data available to it on the quality of care in the above NHS
services.
The income generated by the NHS services reviewed in 2014/15 represents 100% of the
total income generated from the provision of NHS services by the Trust during 2014/15.
2.2
Participation in clinical audit
National Clinical Audit is designed to improve patient outcomes across a wide range of
mental health conditions. Its purpose is to engage all healthcare professionals across
England and Wales in systematic evaluation of their clinical practice against standards
and to support and encourage improvement and deliver better outcomes in the quality of
treatment and care. In mental health there are a number of audits run by the Royal
College of Psychiatrists Prescribing Observatory for Mental Health (POMH) and the
National Clinical Audit and Patient Outcomes Programme (NCAPOP).
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During 2014/15, one national clinical audit and one national confidential enquiry covered
NHS services that AWP provides. During that period AWP participated in 100% of the
national clinical audits and 100% of national confidential enquiries in which it was eligible
to participate.
The national clinical audits and national confidential enquiries that AWP was eligible to
participate in during 2014/15 are set out in table 1 below.
The national clinical audits and national confidential enquiries that AWP participated in
during 2014/15 are set out in table 1 below.
The national clinical audits and national confidential enquiries that AWP participated in,
and for which data collection was completed during 2014/15, are listed below in Table 1
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.
Table 1 – Participation in National Clinical Audits
*National Audit Topics that AWP was eligible to
participate in
AWP
involvement
** Cases
submitted /
cases required
POMH 9c Antipsychotic Prescribing for People With
a Learning Disability
YES
55
National Confidential Inquiry into Suicide and
Homicide by People with Mental Illness
YES
43/53
*Table 1: Showing the National Audits the Trust was eligible to participate in, those it did participate in, and
the level of completion of data requirements.
POMH- Prescribing Observatory for Mental Health (Royal College of Psychiatrists)
** No set number of cases are required
2.2.1 Quality improvement actions from national clinical audit
The reports of four national clinical audits were reviewed by the Trust in 2014/15 and
AWP intends to take the following actions to improve the quality of healthcare provided:
National Audit of Schizophrenia
This audit of 84 cases, 14 service user surveys and 12 carer surveys, from 24 teams
showed improvements on the previous audit and results were generally better than the
national average. Areas for improvement were: use and recording of advance decisions;
recording of physical health indicators; recording of smoking cessation advice;
antipsychotic polypharmacy rates. Actions on physical health were address through the
implementation of the National Mental Health CQUIN. Polypharmacy was addressed by
medical directors. Improvement actions relating to recording and use of advance
decisions remain to be implemented fully.
POMH 4b: Prescribing of Anti-dementia Drugs
This audit of 342 cases from 16 teams showed high levels of compliance with the
standards. No improvement actions were required.
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POMH 12 b: Prescribing for People with a Personality Disorder
Data for 155 service users was returned by 10 teams. Results were acceptable, similar to
the national picture but had improved since the previous audit. The main concern was
weak documentation of decisions to prescribe antipsychotic medication. No actions were
needed beyond sharing results for discussion with governance groups.
POMH 14a: Prescribing for Substance Misuse: Alcohol Detoxification
POMH 14a audited the quality of alcohol detoxification for mental health inpatients
needing an unplanned detox. There are 20 to 30 such cases per year in AWP, 15 were
audited. Whilst numbers are low alcohol detoxification is dangerous and needs careful
management. Areas for improvement are being addressed by the Dual Diagnosis
Consultant Nurse and Specialist Consultant by revisions to detox protocols.
2.2.2 Quality improvement actions from local audits
The reports of some 60 local clinical audits were reviewed by the Trust in 2014/15 and
AWP intends to take a number of actions to improve the quality of healthcare provided.
AWP-079-15 Positive Cardio metabolic Indicators in Schizophrenia (National
Mental Health CQUIN)
Considerable work was carried out to implement assessment of cardio metabolic risk
factors. This audit looked at the assessment and interventions for smoking, drug use,
alcohol use, body mass index, blood glucose and blood lipid levels (8 indicators in total).
We reviewed our results locally and compliance was very high with 1306 of 1400
interventions or tests being done. Compliance was 93.3%. Data was returned for 100
required service users. Of these 88% of service users had all 8 indicators met. Actions
were not required, and this work will continue in 2015/16 to our early intervention teams.
74 providers participated in the CQUIN with a range of scores: 0-100; the national
average score: 39.52%; 2/3 of providers scored less than 50%. Scoring 52% AWP are
placed at the 72nd percentile and in to the top 3rd of Trusts.
AWP-077 Transitions Between Oxford Health Child and Adolescent Mental Health
Services (CAMHS) and AWP Adult Mental Health Services & Re-audit of Transition
Protocol in Swindon, Wiltshire and BANES CAMHS
This audit looked the interface between AWP and Oxford Health Trust in three localities.
Oxford Health reviewed 28 patients and AWP 26. Compliance with the protocol was
generally high and areas of suboptimal compliance were low risk. Actions were to
establish joint clinics, create shared lists of patients over 17 years of age or in early
intervention services. These actions have been completed. This audit was highly
collaborative and resolved some persistent misconceptions. For example there was a
perception that referrals were slow to be picked up and exceeded the four week waiting
time limit. However these delays were because of the way referrals were written in
advance, asking for care to transfer on the service user’s 18th birthday.
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2.3
Participation in clinical research
The Trust is committed to research being part of everything we do. We support high
quality research into the prevention, treatment and management of mental health
problems, addictions and dementia and aim to put research findings into clinical practice
wherever possible. AWP ensures we give everyone who uses AWP services, their
carer’s and families (as well as our staff) the chance to find out about research they could
take part in.
This forms our pledge to make Research for All. In March 2014 AWP became an
Everyone Included Trust, which is our way of making sure everyone has the choice to
receive information about research.
AWP works with the National Institute for Health Research (NIHR) and the West of
England Clinical Research Network (WE CRN). The Trust also collaborates locally with
universities and acute Trusts through Bristol Health Partners (BHP), the West of England
Academic Health Science Network (AHSN) and the NIHR Collaborations for Leadership
in Applied Health Research and Care West (CLAHRC West).
The Research and Development (R&D) department supports the Department of Health
contract for the National Suicide Prevention Programme grant led by Professor Gunnell
at the University of Bristol. It also runs the BEST Evidence in Mental Health clinical
question answering service in collaboration with the Cochrane Group at the University of
Bristol.
This financial year AWP has participated in 92 research studies (April 2014 to March
2015) of which 51 were National Institute for Health Research (NIHR) adopted studies.
12 of these studies were sponsored by commercial companies. 41 of these were student
and non-NIHR portfolio research. AWP continues to act as a Participant Identification
Centre for work with RICE (Research Institute for the Care of the Elderly) and now also
works with North Bristol NHS Trust on other NIHR studies.
For our last full year of data (April 2013 to March 2014), comparable figures were: 96
active studies in AWP, 45 NIHR studies, 10 sponsored by commercial companies. AWP
recruited a total of 978 patients into NIHR studies during this period.
The number of patients receiving NHS services provided or sub-contracted by AWP in
2014/15 that were recruited during that period to participate in research approved by a
research ethics committee was 701 (correct at 16 March 2015). This represents a 28%
reduction in research participation into NIHR studies, the complexity of the studies has
dramatically increased by 18% on last financial year.
2.4 Commissioning for Quality and Innovation (CQUIN) payment
framework
Two and a half per cent of the Trust’s income in 2014/15 was conditional on achieving
quality improvement and innovation goals agreed between AWP and any person or body
they entered into a contract, agreement or arrangement with for the provision of NHS
services, through the Commissioning for Quality and Innovation Payment Framework.
During 2014/15 the Trust CQUIN schemes included a series of initiatives agreed locally
for each CCG area along with three nationally set schemes. The Trust achieved
measurable improvements and received payment for all of the CQUIN schemes.
Further details of the agreed goals for 2014/15 and for the following 12 month period are
available electronically in an additional document which is available from our website:
http://www.awp.nhs.uk/news-publications/publications/quality-account/
15
2.5
Care Quality Commission (CQC) registration
AWP is required to register with the CQC and its current registration status is fully
registered without conditions.
The CQC has taken enforcement action against AWP during 2014/15.
AWP has not participated in special reviews or investigations by the Care Quality
Commission during 2014/15.
Chief Inspector of Hospitals Inspection June 2014
In June 2014 the Trust received a comprehensive inspection, as part of the pilot for the
new inspection approach for mental health trusts, led by the CQC Chief Inspector of
Hospitals. The Trust was inspected over more than a week by a team of over 70
individuals.
The report highlighted areas for improvement as well as recognising the kind, caring and
responsive approach of our staff and noted their high skills in the delivery of care. The
report also highlights examples of good practice including evidence based practice,
centres of excellence in specialist services and motivated clinical leadership.
As a result of the inspection the Trust received a report summarising the findings stating
that “the trust needs to take significant steps to improve the quality of their services and
we find that they are currently in breach of regulations.” Enforcement Actions were
issued to the Trust which gave strict timescales for the Trust to make the required
improvements.
Set out below are the four key areas covered by the enforcement action:




Regulation 10 Assessing and mentoring the quality of service provision - in
relation to several examples where the Trust could not demonstrate that it had
taken appropriate action or learned from previous CQC inspections or when things
had gone wrong
Regulation 15 Safety and suitability of premises - for Fromeside medium
secure unit in Bristol, in relating to dirty carpets and ligature points
Regulation 15 Safety and suitability of premises - for Hillview Lodge acute
adult inpatient ward in Bath, about standards of maintenance, décor, cleanliness
and lack of privacy and dignity
Regulation 22 Staffing - for Fromeside, relating to sufficient numbers of suitably
experienced staff
As a result many actions have been completed and improvements made such as
increased recruitment, staffing being more closely matched to capacity and needs, an
accelerated anti ligature and replacement and refurbishment programme to deal with
estate issues, more training and changes to some of our systems.
In December 2014 the Trust received a follow up inspection to test whether the
improvements had been made in these areas. The Trust is pleased to have been
informed that the CQC were satisfied that improvements were made to allow the
enforcement notices to be lifted.
The report can be found at the following link with full details of the findings.
http://www.cqc.org.uk/directory/rvn
At the post inspection quality summit hosted by the CQC and the NHS Trust
Development Authority (TDA), the CQC expressed its confidence in the leadership of the
Trust to resolve the inspection issues and to take the Trust forward. The solution to some
16
of these historic issues will require a co-ordinated push from the Trust, commissioners
and social care colleagues as well as support from the CQC and the TDA.
Our Trust accepts the inspectors’ conclusions and reaffirms its absolute commitment to
delivering consistently the required standards.
We are confident that by continuing to work with our commissioners we will strengthen
our services and meet the CQC requirements.
17
2.6
Quality of data
The Trust has a comprehensive and systematic approach to the management of the
quality of data held on its patient information system RiO, which is used for reporting.
The quality of the electronic patient record is audited monthly via the Trust’s Records
Management audit, which requires senior clinicians to review five randomly selected
records and to rate them against 10 criteria. This is supported by a suite of
‘completeness’ metrics that check that key information is available for all patients
accessing services and that staff are entering data into the system in a timely manner.
Results for these indicators are reported internally to Board Committee and Board and
externally to Commissioners each month and team / ward level information is available in
‘real time’ to allow managers to track their performance.
Results are presented in table 2 below. Performance across the quality audit and the
completeness metrics remains strong, however 2014-15 has seen a dip in performance
for the timeliness of data entry. We understand this fall to be due to pilot work we are
undertaking to improve the recording of telephone contacts.
Table 2: Data quality measures
Target
level
2013/14
2014/15
Records Management: monthly audit (local indicator)
75%
84%
87.1%

Data completeness - core fields for patient identification
(national indicator)
97%
99.9%
99.9%
►
Data completeness - outcome fields (national indicator)
50%
81.2%
79.6%
▼
Data quality: completion of NHS number (national indicator,
new for 2014-15)
99%
NA
99.9%
Data quality: completion of ethnic category (national
indicator, new for 2014-15)
90%
NA
100%
Data quality: completion of risk assessment (local indicator,
new for 2014-15)
85%
NA
99.9%
Data quality: completion of crisis, relapse and contingency
plans (local indicator, new for 2014-15)
85%
NA
89.5%
Data timeliness - system updated in three days of actual
event (local indicator)
95%
95.1%
93.2%
▼

The Trust will be taking the following actions to improve data quality:


We will continue to complete the Records Management audit on a regular basis,
but will review the focus of the audit and the targets to ensure both remain
relevant and are supporting continual improvement in record keeping.
Completeness metrics for all nine protected characteristics will be provided
routinely in 2015/16, allowing for further analysis (meeting the requirements of the
Equality Act).
18
Our performance against other key areas of data quality is as follows:
The 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 100% for admitted patient care.
General Medical Practice Code was 100% for admitted patient care.
The Trust’s Information Governance Assessment report score overall for 2014/15 was
77% and was graded satisfactory (green).
AWP was not subject to the Payment by Results clinical coding audit during 2014/15 by
the Audit Commission.
2.7
Safeguarding
The Trust continues to regard safeguarding as a priority to protect the people, their
families and the communities we work with.
AWP remains an active member of the safeguarding multi agency partnerships in our
area, including Safeguarding Children and Safeguarding Adults Boards, Domestic
Violence partnerships, †MAPPA Strategic Management Boards and Contest and Prevent
partnerships.
This year there have been significant developments in safeguarding that have led to
further development work in the Trust including the on-going actions following the Savile
reports, changes to the law including the placing of adult safeguarding on a statutory
footing and the Supreme Court judgements in relation to Deprivation of Liberty
Safeguards for adults under our care, emerging new issues, including female genital
mutilation, child sexual exploitation and modern day slavery, as well as lessons from our
own internal investigations in to serious incidents.
The Trust has also been involved in working with local authorities, commissioners and
local multi agency safeguarding partnerships to develop a range of improvements in
safeguarding practice and policy.
The Trust has implemented procedures, systems and training, with over 900 staff
receiving counter terrorism Prevent ‡HealthWRAP training by the end of 2014/15. The
Trust has seen a continuing rise in casework in this area.
2014/15 has seen a rise in safeguarding activity levels with nearly 2000 contacts to the
safeguarding team from practitioners during the year. This rise in activity is due to
increases in safeguarding statutory duties, the number and complexity of safeguarding
partnerships, safeguarding governance requirements and serious case review
processes.
In 2015/16 we prioritised improvements in the following areas:
†
Multi-Agency Public Protection Arrangements (MAPPA) is the name given to arrangements in England
and Wales for the "responsible authorities"
‡
HealthWRAP is the prescribed Home Office/Department of Health training package for Prevent (as a key
part of the government’s CONTEST counter terrorism strategy)
19

Planning for the implementation of the Care Act 2014, including the new statutory
duties and roles , and the change to person centred adult safeguarding

Planning for the implementation of the new CQC revised regulations on
Safeguarding (draft Regulation 13)

Commencing use of the new safeguarding function within the RiO and ensuring
effective recording of safeguarding information in other electronic patient record
systems

Delivering the detailed actions set out in the Safeguarding Children, Safeguarding
Adults at Risk, Domestic Abuse, MAAPA, Prevent and Historical Abuse action
plans in the Trust.

Managing the increased demand for safeguarding activity, including safeguarding
cases management and enhanced safeguarding governance activity with
safeguarding partnerships and commissioners
20
Part 3: Our care quality achievements in 2014/15
The Trust has a robust performance and quality improvement strategy. From Board level
to frontline services, quantitative and qualitative information is scrutinised covering the
areas of patient experience, effectiveness and safety. Reports are reviewed monthly by
the Board, and across the Trust, including external scrutiny by our commissioners and a
range of care forums. This approach has helped to systematically improve the quality of
services.
Trust’s quality surveillance system, called ‘Information for Quality’ (IQ), reports data at
ward and team level up to local area service delivery unit and Trust level. The system
reports across seven key domains as an early warning system to identify areas for
improvement.
In this section, we describe:

what we achieved during the year across the areas of patient experience,
effectiveness and safety and,

how we have progressed with our quality improvement priorities alongside a series
of quality indicators that we routinely use for measuring the quality of services.
For each domain of quality, we have included some measures, as key quality indicators,
which show data for the Trust overall. Area level breakdowns to enable local comparison
are available in Appendix D and further information on the definitions of the measures
used is included in Appendix E.
3.1
National Indicators
Set out in the section below are the national quality indicators that trusts are required to
report in their Quality Account.
Where the data is made available to the trust by the Health and Social Care Information
Centre (HSCIC), a comparison of the numbers, percentages, values, scores or rates of
the trust are included.
3.1.1 Care programme approach (CPA) seven day follow up
National data - CPA seven day follow up
Data Source: Health and Social Care Information Centre (HSCIC)
*Trust Performance Reporting
period
(for 3 months in quarter)
Quarter 3 2014/15
Quarter 4 2014/15
Number
%
Number
%
484/497
97.4%
454/474
95.8%
Quarter 3 2014/15
Quarter 4 2014/15
National Average
97.3%
97.2%
Highest Score Nationally
100%
100%
Lowest score nationally
90.0%
93.1%
*The national requirement is to report against the previous two reporting periods. The Trust interprets
this to be the previous two quarters as reported by the HSCIC.
21
The Trust considers that this data is as described for the following reasons: The
Trust submits data to the HSCIC for the periods reported and confirm that the
reported performance is in line with the Trusts locally reported data.
The Trust intends to take/has taken the following actions to improve this percentage,
and so the quality of its services, by maintaining robust monitoring arrangements to
ensure that key elements of care, such as contacting service users following discharge,
are provided routinely to all service users. This approach has led to consistently high
performance for this indicator year on year.
3.1.2 Admissions to inpatient services have had access to crisis resolution
home treatment teams
National data - admissions to inpatient services have had access to
crisis resolution home treatment teams
Data Source: Health and Social Care Information Centre (HSCIC)
*Trust Performance Reporting
period
(for 3 months in quarter)
Quarter 3 2014/15
Quarter 4 2014/15
Number
%
Number
%
177/185
95.7%
162/177
91.5%
Quarter 3 2014/15
Quarter 4 2014/15
National Average
97.8%
98.1%
Highest Score Nationally
100%
100%
Lowest score nationally
73.0%
59.5%
*The national requirement is to report against the previous two reporting periods. The Trust interprets
this to be the previous two quarters as reported by the HSCIC.
The Trust considers that this data is as described for the following reasons: The
Trust submits data to the HSCIC for the periods reported and confirm that the
reported performance is in line with the Trusts locally reported data. The fall in Q4 is
related to a change in clinical practice in Wiltshire that has inadvertently caused
deterioration in the reported performance.
The Trust intends to take the following actions to improve this percentage, and so
the quality of its services, by maintaining a robust monitoring process to ensure that
key elements of care, such as ensuring that community treatment is considered as
an alternative to inpatient care for service users in crisis, are provided routinely to all
service users.
22
3.1.3 Ensuring that people have a positive experience of care
Data is provided for this indicator from the annual Care Quality Commission Community
Mental Health Survey. The indicator is a composite, calculated as the average of four
survey questions that relate patients’ experience of contact with a health and social care
worker.
Currently the HSCIC have not published this indicator for 2014. We understand this to
be because the survey questions in 2014 were changed and therefore the preceding two
surveys from 2012 and 2013 are not able to be compared reliably with the 2014 results.
National Data – Patient experience indicator
Reporting
Period
AWP
Score
England
average
Highest
score
nationally
Lowest score
nationally
2013
83.5
85.8
90.9
80.9
2012
85.8
86.5
91.8
82.6
The Trust considers that this data is as described for the following reasons: The data
reflects the Trusts current position as benchmarked against other similar organisations.
The score is judged by the CQC as ‘about the same’ compared to other Trusts. Further
detail on our results for the national Community Mental Health Survey are detailed in
section 3.5.3.
The Trust intends to take the following actions to improve this score, and so the quality of
its services, by:

using the national Friends and Family Test survey which provides team and ward
information on service users’ experience on a monthly basis. This allows quick
and focused local responses to specific issues raised and informs Trust wide
improvement actions.

ensuring that all Local Delivery Units review the quantitative and qualitative
community survey data and plan local actions focused on the areas needing
improvement.
23
3.1.4 Treating and caring for people in a safe environment and protecting them
from avoidable harm
Patient safety incident data is collected centrally by the National Reporting and Learning
Service (NRLS). Two measures are reported below for the rate of incidents reported per
1000 bed days and the rate of incidents which are categorised as causing severe harm
or death.
National Data – Patient safety incident data
Reporting
Period
(6 months)
AWP Score
Number
England
Average
Highest score
nationally
Lowest
score
nationally
Rate
i) Rate of patient safety incidents reported per 1000 bed days
01/10/11 to
31/03/12
01/04/12 to
30/09/12
01/10/12 to
31/03/13
01/04/13 to
30/09/13
01/10/13 to
31/03/14
01/04/14 to
30/09/14
2816
24.16
23.5
86.99
0.00
3026
30.19
23.8
70.29
5.44
2742
27.4
32.3
99.8
0.00
3367
34.47
28.03
67.06
0.00
3538
36.22
28.5
58.69
0.00
3772
41.21
32.8
90.4
7.25
ii) Rate of incidents reported that caused severe harm or death
01/10/11 to
31/03/12
01/04/12 to
30/09/12
01/10/12 to
31/03/13
01/04/13 to
30/09/13
01/10/13 to
31/03/14
01/04/14 to
30/09/14
37
1.3%
1.3%
5.3%
0.0%
59
1.9%
1.6%
9.1%
0.1%
32
1.2%
1.3%
9.4%
0.0%
41
1.2%
1.3%
5.3%
0.0%
18
0.5%
1.1%
5.4%
0.0%
34
0.9%
1.0%
5.9%
0.0%
*Incident data is reported via the National Reporting and Learning Service. Not all organisations apply the
national coding of degree of harm in a consistent way, which can make comparison of harm profiles of organisations
difficult.
Notes
24
The Trust considers that this data is as described for the following reasons:
The data concurs with our own data and we are pleased to note the increase in reporting
(both in terms of numbers and rate per thousand bed days) between 2011 and 2014. We
believe that this is as a result of actions taken to ensure continuous improvement, such
as thematic reviews and executive led quality improvement visits both of which have
encouraged reporting and promoted a patient safety culture.
We note that our percentage of incidents causing severe harm or death is below the
national average. We are confident that our criteria, for serious untoward incidents, is
appropriately inclusive and we are assured through our topic specific benchmark work
that all efforts are made to make sure our services are as safe as possible.
The Trust is taking the following actions to improve this percentage rate, and so the
quality of its services, by:
The Trust credits the ease of use of its web incident reporting system together with its
promotion of a fair blame culture for the improved percentage rate and it plans to further
improve through targeted work across services to challenge incident reporting cultures.
3.1.5 Staff Friends and Family Test
Data is provided for this indicator from the annual NHS Staff Survey. The indicator is the
percentage of staff who answer either ‘agree’ or ‘strongly agree’ to the question “If a
friend or relative needed treatment I would be happy with the standard of care provided
by this organisation”.
National Data – National NHS Staff Survey - Friends and Family Test
Reporting
Period
AWP
Score
England
average
Highest
score
nationally
Lowest score
nationally
2014
47%
66%
93%
36%
2013
48%
65%
94%
38%
The Trust considers that this data is as described for the following reasons:
The question gives us an indication of staff confidence in the quality of care provided.
Staff survey results for 2014 are disappointing but not unexpected. Against a
backdrop of NHS pressures, CQC scrutiny and criticism, our staff have experienced
significant internal change during the year and some have experienced job
uncertainty. We have analysed the data from the National Survey as well as
conducting a quarterly staff friends and family test surveys.
The Trust is taking the following actions to improve this percentage rate, and so the
quality of its services, by:
Clear themes emerge from the survey feedback and we have set out our approach to
addressing these in section 3.8.
25
3.2
Patient experience - How we did
Understanding the experience of our service users and their carers is fundamental to the
Trust making sure that we provide good quality services. We continuously strive to
improve quality in response to service users and carers experiences.
The Friends and Family Test (FFT) survey was introduced to the NHS in 2012 as a single
measure to look at the quality of care across the country, promoting the principle that all
people should have the opportunity to feed back about their care and treatment.
The FFT is a single question that asks people who use the services whether they would
recommend the service to friends and family who need similar care or treatment. In
addition it asks them to give the reason for their response; it is these comments that can
be used locally to highlight good practice and address concerns much faster than more
traditional survey methods.
AWP introduced the FFT ahead of the national schedule as a national early adopter pilot
site in 2013 and 2014. In 2014/15 our focus was to improve the use of the FFT in our
community teams and to ensure that this valuable feedback was being promptly
responded to by our teams and wards.
Progress with our 2014/15 priorities to improve patient and carer experience
Last year, our priority quality improvements for service user and carer experience were:


To use of the Friends and Family Test service user survey to improve service user
experience by taking prompt action at ward and team level in response to regular
feedback from service users and their carers
Using the Carers Trust ‘Triangle of Care’ framework to improve carers’ experience
through improved partnership working and carer support.
3.2.1 The NHS Friends and Family Test (FFT)
Aims
Actions
Success measures 2014/15
Outcome
To improve service
user experience by
taking prompt action
at ward and team
level in response to
regular feedback
from service users
and their carers
To share our real-time service
user and carer feedback from the
‘Friends and Family Test’ with
staff, service users and carers in
wards, reception areas and via
our service user and carer groups.
Evidence of local
improvement actions
and sharing
feedback.
We will develop improvement
actions in partnership with our
service users and their carers.
Achieved
Improved scores for
the ‘Friends and
Family Test’.
Progress 2014/15
All Service Delivery units have evidenced how they are sharing feedback and developing
improvement actions in partnership with staff, service users and carers locally.
We have improved our overall survey response rates from 10.2% in March 2014 to 12.5% in
March 2015, achieving 14% in December 2014.
The score is based on the percentage of service users who would recommend our services and
this has fluctuated over the year around 88 to 90%, moving from 88.8% in March 2014 to 89.7%
in March 2015.
National data available for February 2015 shows AWP scoring above average at 90.5% ‘would
recommend’, compared to the national benchmark for mental health services of 85%.
26
Engagement with the Friends and Family Test
The key to success of the FFT as a service improvement tool is ensuring the
engagement of staff and service users in the process of receiving and responding to the
comments received. To do this we have improved our guidance and promotional
materials and supported staff in collating and presenting their feedback. Using the ‘you
said we did’ format we have used posters in wards and waiting areas but also involved
service users and carers in meetings to review feedback and to help plan actions.
We measure this in two ways as shown in Graph 1 and 2 below:
i.
Percentage of responses that provide a comment – we have seen an increase
over the year from 70% to 79%. This indicates that the majority of services users
who respond provide a comment. It gives some indication of the level of
confidence that the Trust will listen and act on their concerns. In addition, the
majority of feedback received is praise which is motivating for staff. See 3.5.4. for
examples of feedback and improvements.
ii.
Response rate – this measures the percentage of service users who have
responded to the survey out of those who have had a care review or been
transferred or discharged from care.
We have improved overall from 10.3% in March 2014 to 12.5% in March 2015
although we have noted a recent fall. Notably our community services have
increased from 8.7% March 2014 to 11.3% in March 2015. This is set out in
Graph 1 below. In 2015/16 we will continue to improve the consistency of the use
of the FFT across all service areas.
Graph 1 – Friends and Family Response Rate 2014/15
27
Our Friends and Family Scores
We score the FFT based on the percentage of responses that would or would not
recommend our services to their friends or family.
Graph 2 below sets out the range of scores across the year for the percentage who
would recommend, this shows a fluctuation through the year with a small overall
increase.
From January 2015 national data has been published for all mental health Trusts. In
February, AWP performed above the national average; 90.5% of service users would
recommend our services, compared to 85% nationally. Fewer AWP service users said
they would not recommend AWP services than nationally (AWP 2.9%, national 5%).
When compared to Mental Health Trusts providing similar services, we are one of the top
performers for the number of surveys received.
Graph 2 - Friends and Family Scores 2014/15
Note: ‘would recommend’ includes ‘extremely likely’ and ‘likely’. ‘Would not recommend’ includes ‘unlikely’
and ‘extremely unlikely’ Responses not shown were either neutral or ‘don’t know’.
28
3.2.2 Our work with carers and the Carers Trust Triangle of Care
In the last year, we have continued our work to improve our partnership working with
carers using the Carers Trust ‘Triangle of Care’ toolkit and this will continue into 2015/16.
Accreditation for inpatients in phase 1 of the Triangle of Care was achieved in May 2014
and for community teams in phase 2 in May 2015.This relates to improved partnership
working on acute inpatient units, rehabilitation units and intensive teams.
This scheme is recognised nationally as a way of demonstrating a commitment to
working in partnership with carers. All teams and wards have a Carer Champion who has
received specialist training and lead the use of the Triangle of Care self-assessment
toolkit locally. The toolkit provides a framework based around the six key standards, as
below, and supports teams to plan and take actions locally to meet them.
The six key standards of the Triangle of Care
1. Carers and the essential role they play are identified at first contact or as soon as
possible thereafter.
2. Staff are ‘carer aware’ and trained in carer engagement strategies.
3. Policy and practice protocols re: confidentiality and sharing information, are in
place.
4. Defined post(s) responsible for carers are in place.
5. A carer introduction to the service and staff is available, with a relevant range of
information across the care pathway.
6. A range of carer support services is available.
Aims
To improve carers’
experience
through improved
partnership
working and carer
support.
Actions
We will continue to use the Carers
Trust ‘Triangle of Care’ selfassessment improvement tool in all
services and take identified
improvement actions.
Implementation of our Family
Friends’ and Carers Charter.
Success measures
Membership of
Triangle of Care.
2014/15
Outcome
Achieved
Evidence of 80% of
teams and wards
using the toolkit and
making
improvements.
Progress 2014/15
The Trust submitted evidence for the second phase of the process and was awarded
accreditation for community teams in May 2015.
Actions identified by the Triangle of Care have been implemented with positive results, including
carer training, streamlined processes for recording carer work on the patient record (RiO) and
Advance Care Planning for which carers and staff have co-produced an information pack and
training.
29
Alongside the efforts at local level, the Trust has maintained a Trust wide Carers’ Forum
that has led the Trust’s work with carers and partner organisations. In particular the group
has advocated for dedicated time for carers work which has been agreed in four
localities. It has also overseen the delivery of specialist carer and family training and
ensured that all staff receive local training on carer awareness. Four carers from the
Carers Forum represent carer views at the Trust Wide Involvement Group.
In the National Community Mental Health Survey 2014 there is a specific question on
‘family and carers’:
Have NHS mental health services involved a member of your family or
someone else close to you, as much as you would like?
59% said yes, definitely; 25% said yes, to some extent; 14% said no, not as much as
they would like. Compared nationally AWP score about the same' as most other trusts
for this question.
Family, Friends’ and Carers’ Charter
This charter was developed in 2014 through co-production with carers and staff. The
Charter contains a series of statements that can be measured, to demonstrate AWP’s
continuing commitment to working in partnership with carers. Posters with the standards
have been developed for display in reception and waiting areas and leaflets containing
the Charter will be given to carers alongside any information that is normally given to
them. Details are published on the Trust’s website. Carers are offered the opportunity to
give feedback on how well these standards are being delivered.
30
3.2.3 Patient experience indicators
The metrics below in Table 3 reflect key measures of quality for measuring patient
experience.
These indicators are measures of access to services for assessment and how we are
making reasonable adjustments to meet the needs of those service users with a learning
disability; as well as various other elements of patient experience such as:
 ensuring inpatient accommodation meets the dignity and privacy needs of all
sexes
 a score for patient experience from the national Care Quality Commission survey
 a staff survey indicator of how our staff feel about the services they provide
Table 3: Patient experience – how we did
Indicator
Standard
2013/14
2014/15
(numerator /
denominator
Service users seen for their first appointment
within four weeks of their referral
95%
Compliance to Department of Health
standards for eliminating mixed sex
accommodation
100%
99%
96.4%
►
(12,764 /
13,246))
100%
100%
►
All criteria met
Fully met
Fully met
►
NHS community mental health survey patient
experience question
‘Overall, how would you rate the care you
have received from NHS
Mental Health Services in the last 12 months?’
National
Average
Achieved
Achieved
►
Staff Friends and Family
National
Average
3.55
Below
average
3.37
Below
average
3.33
▼
Meeting six criteria for access to healthcare
for people with a learning disability
Score for staff survey question on staff
recommendation of the trust as a place to
work or receive treatment
Compliance
The poor performance of the staff survey indicator is a key concern of the Trust Board as
this is a key indicator of the quality of our services. Further information on staff
experience measures and plans for improvement is included in section 3.8. In 2014/15
the Trust implemented the Department of Health Staff Friends and Family quarterly
survey to help us monitor this more regularly.
31
3.3
Effectiveness - How we did
Effective services are defined as providing the right care to the right person at the right
time.
Progress with our 2014/15 priorities to improve effectiveness
Last year, our two priority areas for quality improvements were to improve:

our approach to formulation in our assessment of service users to help our clinical
practitioners develop more clinically effective care plans

the effectiveness of our care pathways and interventions with service users
3.3.1 Improving our approach to formulation
Aims
To improve our
approach to
formulation in our
assessment of
service users to
help our clinical
practitioners
develop more
clinically effective
care plans
Actions
Training and development of
staff on formulation.
Availability of on-line resources
through our clinical toolkit.
Success
measures
Audits of the
clinical record
demonstrate that
85% of records
have a formulation
summary recorded.
2014/15
Outcome
Partly
achieved
March 2015
83.9% of
records have a
formulation
summary
recorded
Progress 2014/15
The Trust has completed the planned actions however the success measure does not reflect
the desired improvement.
The measure above is based on a monthly Records Management Audit for each team which
includes a review of records to test if a formulation is present and meets the best practice
guidance outlined in the Clinical Toolkit.
Scores for this audit at the beginning of the year in April 2014 were at 80.1%. Through the
year there have been fluctuations around this level with our end of year results showing a
some overall improvement with 83.9% of records reviewed had a formulation recorded.
The Trust has developed guidance in the Clinical Toolkit to support staff to develop clinical
formulations to inform care planning and intervention. This is available via Ourspace.
Team based training in formulation has started to be delivered by Trust psychologists to
support this alongside additional training for individuals delivered during 2014.
This work will be continuing as part of the improvement work planned for clinical practice of
assessment and care planning.
32
3.3.2 To improve the effectiveness of our care pathways and interventions with
service users
Aims
Actions
Success measures
2014/15
Outcome
To improve the
effectiveness of
our care pathways
and interventions
with service users.
Delivery of local area quality and
service improvement plans to
improve the care pathways and
interventions provided to service
users.
Successful delivery of
local area quality
improvement plans.
Partly
Achieved
Progress 2014/15
During the year our Service Delivery Units have progressed with their local quality plans which
were developed to meet the specific needs and priorities of the local health community. We have
rated this as partly met because not all of our plans were completed as we had to refocus efforts
after the CQC inspection in June 2014.
Several of the improvement initiatives were part of the Trusts §CQUIN programme agreed in
partnership with commissioners. Some examples of the schemes delivered by area are as
follows:







Implementation of ‘Alcohol Use Disorders Identification Test Consumption tool’. This aids
the identification of people who would benefit from reducing or ceasing drinking alcohol.
(B&NES)
Improved effectiveness of inpatient stay and discharge planning in partnership with other
services (Bristol)
Transition arrangements with Child and Adolescent Mental Health Care services (North
Somerset)
Autism early intervention (South Gloucestershire)
Acute hospital dementia assessments (Swindon)
Review of community mental health services model (Wiltshire)
Collaborative multidisciplinary risk assessments involving the service user (Medium and
Low Secure Services)
§
CQUIN is Commissioning for Quality and Innovation. It is a scheme whereby Trusts can earn additional
income dependent on the delivery of a set of measured quality improvement objectives.
33
3.3.3 Effectiveness indicators
This section demonstrates how we are doing on key measures of effectiveness as set out
in table 5.
These measures are indicators for:

ensuring service users have a timely review of their care

ensuring assessments are made so that service users are only admitted to
inpatient care if no other care in the community is appropriate

monitoring that we are identifying the expected number of cases of psychosis
through early intervention for the population of the health community served.
Table 5: Effectiveness – how we did
Indicator
Standard
2013/14
2014/15
(numerator /
denominator
Annual CPA review (care plan review)
95%
96%
95.6%
▼
(2,668 /
2,791)
Admissions to inpatient services have had access
to crisis resolution home treatment teams
95%
97%
95.4%
▼
(752 / 788)
Minimising delayed transfers of care
<7.5%
6.5%
9.2%
▼
(12,568 /
137,059)
Number of people receiving early intervention
182
246
261
▲
The Trust has seen an increase in delayed transfers of care. This is attributed to
increasing difficulty in finding appropriate care home placements for service users with
highly complex health and social care needs. We are working closely with partner
organisations to ensure timely discharge and is hoping to see an improvement in
2015/16.
34
3.4 Safety – How we did
It is not only crucial that services are as safe as they can be, but that we can
demonstrate this to ourselves, our partners, our services users and carers and to the
public.
Progress with our 2014/15 priorities to improve safety
Last year our priority areas for safety quality improvements were:

To focus on the physical health of our severely mentally ill (SMI) patients to reduce
premature death, improve patient safety, patient experience and quality of life
through shared communications and reconciliation of treatments. This was a
national CQUIN scheme.

To reduce the use and need for restrictive interventions and improve the use of
positive and proactive approaches to care.
3.4.1 Improved physical health checks including assessment of cardio metabolic
risk factors.
People with Serious Mental Illness have much higher morbidity and mortality rates,
compared to the general population. It is acknowledged that service users within mental
health services do not always receive the physical health care intervention they require.
The following improvements were designed to directly tackle this issue (see also 3.4.2).
Aims
Actions
Success measures
Reduce premature
death in severely
mentally ill patients
and ensure
physical health
needs are
identified and
treated
The full implementation of
appropriate processes for assessing,
documenting and acting on cardio
metabolic risk factors in inpatients
with schizophrenia
Meeting 90%
compliance assessed
via the National Audit
of Schizophrenia.
2014/15
Outcome
Partly
achieved
52%
National
score
88-98%
Local score
Progress 2014/15
The Trust has completed and submitted data to the national audit team. Locally results have
been analysed and show compliance to be high between 88-98%. National data however is
contradictory and the national scoring methodology is recognised by NHS England as
unconventional and over punitive.
The Trust acted to make sure that for patients with schizophrenia, an assessment was completed
for each of the following key cardio metabolic parameters (as per the 'Lester tool'), with the results
recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a
record of associated interventions:
The parameters are:
•
•
•
•
•
•
Smoking status
Lifestyle (including exercise, diet alcohol and drugs)
Body Mass Index
Blood pressure
Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate)
Blood lipids
35
3.4.2 Communication with GPs to improve physical health care and reconciliation
of treatments
Aims
Ensuring that
discharge
summaries are
shared with GPs
and include
comprehensive
information
including
diagnosis,
medications,
physical health
conditions and
recovery
interventions.
Actions
Development of comprehensive
guidance and training for clinical
practitioners on the inclusion of
diagnosis, medications, physical
health conditions and recovery
interventions in discharge
summaries for inpatients
Success measures
Meeting 90%
compliance assessed
by a local audit of
care plans.
2014/15
Outcome
Partly
achieved
84% audit
score
Progress 2014/15
The second and complimentary part of the national physical health care scheme was to focus on
ensuring the sharing of appropriate physical and mental health information with GPs.
Guidance was issued to staff on the key improvement areas as below, as well as a
comprehensive review and rewrite of the Physical Health Policy.
The Trust focused efforts on a standardised system across all wards using the ‘Interim Discharge
Summary’ letter. This is the document that is issued to GPs within 24 hours of a patients
discharge from a ward. The Trust is completing an audit of discharge letters in April to provide the
evidence of improvements.
Areas of improvement are in the use of ICD 10 coding of physical health diagnosis included in
letters to GPs.
36
3.4.3 Reducing the use and need for restrictive interventions
Aims
To reduce the use
and need for
restrictive
interventions and
improve the use of
positive and
proactive
approaches to
care
Actions
Implementation of Department of
Health Guidance ‘Positive and
Proactive Care: reducing the need
for restrictive interventions’.
Success measures
‘Safewards Model’
implemented on all
wards.
2014/15
Outcome
Partly
achieved
A reduction in all
restrictive practices of
20% over two years.
Progress 2014/15
The Safewards model is being implemented across the Trust and 31% of wards have
implemented one or more of the 10 Safewards Interventions. With the support of
commissioners the Trust has recently appointed a Service User Involvement Worker to
support the implementation of Safewards and ensure service user involvement.
Staff guidance and checklists have been developed with full clinical engagement.
The Trust has participated in two national benchmarking exercises in the use of restrictive
practices. Overall AWP has an average number of incidents of restraint compared to
other Mental Health Trusts and lower than average incidents of face down restraint than
other Mental Health Trusts. We have scored our progress this year as amber as we do
not have reliable data to evidence any progress towards our reduction target.
37
3.4.4 Safety indicators
This section demonstrates how we are doing on key measures of safety as set out in
table 8.

Care Programme Approach (CPA) 7 day follow up – for ensuring all patients are
contacted post discharge when most vulnerable

How service users felt about the safety of services

Staff sickness absence: we believe a stable, healthy and consistent staff team makes
for a safer and more reassuring service for our service users, carers and visitors

Maintaining services that are free of the risk of hospital communicated and acquired
infections
Table 6: Safety – how we did
Indicator
Target
2013/14
2014/15
(numerator /
denominator
CPA seven day follow up
95%
98%
96.5%
▼
(2,024 / 2,097)
Percentage answering ‘yes always’ to
the survey question ‘During your most
recent stay did you feel safe?’
Staff sickness absence data
cumulative average over past 12
months
Meeting objectives for the reduction of
infections of Clostridium difficile and
Methicillin-resistant Staphylococcus
aureus (MRSA)
41%
34%
▼
4.6%
4.51%
4.51%
►
Reduction
Achieved
Achieved
►
National
Average
41%
The Trust has maintained standards to the national expectations for CPA seven day
follow up and infection control.
Our indicator score for patients feeling safe as an inpatient our score remains about the
same as other Trusts but has dipped to below the national average. We are therefore
prioritising more work this year to improve the safety of our wards.
38
3.5
Service user, carer and patient experience
In 2014, we gathered feedback from service users and carers about their experience of
care through the national community mental health survey, the annual inpatient survey
and regularly via the Friends and Family Test across all our services. Complaints, praise
and feedback is received via the Patient Advice and Liaison Service (PALS) and there is
further feedback from incident data and CQC inspections and visits.
This information is used to inform our on-going actions to improve quality and the annual
priorities for quality improvement.
3.5.1 Patient Advice and Liaison Service (PALS), praise and complaints
2011/12
2012/13
2013/14
2014/15
No of formal complaints
278
302
272
314
No of informal complaints
27
103
88
72
Total
305
405
360
386
Referred to Parliamentary and
Health Service Ombudsman
19
21
7
12
PALS cases
1688
1485
1631
1887
Praise received
709
782
849
724
The table below shows the classification of themes arising from complaints and PALS.
The classification list has been revised this year to match the themes used by the Care
Quality Commission. Examples of the topics these themes contain have been given in
the table, but these lists are not exhaustive.
Five themes from our feedback
Complaints
PALS
Responsive (includes access to services,
responsiveness to referrals and inpatient bed
management)
75
360
Effective (includes clinical care, CPA, discharge
from services, MHA, physical healthcare)
138
437
Caring (includes attitude of staff, privacy and
dignity, communication)
119
387
Safety (includes medication, nutrition, personal
safety, safeguarding, personal property)
47
191
Well led (incudes policy and procedure, health
records, complaints handling, requests for
information, user and carer involvement)
7
512
386
1887
TOTAL
39
3.5.2 National survey findings
Community Mental Health Survey 2014
The Trust is within the expected range for mental health trusts and scored ‘about the
same’ as other mental health trusts for all eight sections of the published results of the
annual national Community Mental Health Survey. See the table below.
The report is available on the Care Quality Commission website at the following link:
http://www.cqc.org.uk/provider/RVN/survey/6 (scroll to second half of webpage).
Section heading
Score out of
10 for your
How this score
compares with
other trusts
trust (2014)
Health and Social Care Workers
7.7
Average
Organising care
8.6
Average
Planning care
7.0
Average
Reviewing care
7.6
Average
Changes in who people see
6.6
Average
Crisis Care
6.0
Average
Treatments
7.2
Average
Other areas of life
4.9
Average
Overall views and experiences
7.2
Average
In response to our community survey results and the many service user comments
received, our local service delivery units have developed their own action plans, each
focussing on a small number of areas where there is scope for improvement. Issues
being addressed include:






Service user access to information about contacting others with lived experience
Helping service users to understand how different organisations work with each
other
Making sure that people know who is in charge of their care when there is a
change.
Good crisis support, including a review of local resourcing
Fully involving service users in care planning, so that issues that are important to
people in their lives are addressed
Making sure that service users fully understand the purposes and side effects of
medication
40
Inpatient survey 2014
This year, most scores improved for interactions with psychiatrists in comparison to last
year. Trust wide actions following the 2013 survey have resulted in service users
reporting a more positive experience.
Scores also improved compared to last year for people having been contacted by the
mental health team since they left hospital. The AWP score (94%) was the highest of all
mental health trusts taking part in the survey.
Feedback was less positive than last year for service users’ interactions with nurses.
Some comments suggested that lower scores for nurses listening carefully might be
related to staff workloads.
Scores were lower than last year for questions about talking therapies. National scores
for questions about medication were generally low and AWP scores were average within
that range. Service users continue to ask for more ward activities and some were
concerned about their safety on the ward.
Locality action plans have picked up a number of issues from the inpatient survey results
including:
 Increased local staffing to improve ward activities offered at weekends
 Implementation of the Safe Wards initiative
 Nursing staff having the time to talk to patients
41
3.5.3 Friends and Family Test survey results
Since April 2013, we have received over 12,800 completed surveys from service users
across AWP to tell us whether they would recommend our services to friends and family.
We received 4524 surveys in 2013/14 and 8320 in 2014/15.
The survey provides immediate feedback to staff about service users’ satisfaction with
their current care.
More people chose to comment on their experience of care than last year. The majority
of the comments are positive.
The ward is quiet and
restful, offering
comfortable
accommodation ...
The staff are always
available and very
helpful. It is a useful
place to recover.
I have received support and
understanding and kindness in
difficult times just when needed.
‘I didn't get enough
one on one time.’
Didn't listen to
me properly.’
I really enjoy going to
the Active Life Groups,
as I really like the sports
and it has boosted my
confidence and helped
my social anxiety in
meeting other people
with similar problems
Very happy, as a
family we don’t
know what we
would have done
without you.
You learn a lot ... you
get back your life and
it’s the best feeling in
the world
42
Across the Trust, improvements have been made in response to Friends and Family Test
feedback. See below for some examples:

Service users in the Early Intervention service in Swindon said that they would like
more group activities. In July, a group of service users were taken to
Bournemouth beach for a day out and a rock climbing trip was organised in
October.

Community staff were asked to be more discreet about wearing their identity
badges when carrying out home visits.

A series of complaints and comments about the environment on Juniper Ward in
North Somerset were received. Staff decided to act and worked with service users
to re paint the ward in their own time.
43
3.6
Learning from incidents
During 2014/15 our staff reported 9,260 incidents, of which 108 were considered serious.
A serious incident is defined as any event or circumstance arising that led to serious
unintended or unexpected harm, loss or damage.
Every serious incident is investigated by a senior member of staff to identify the root
causes and to share lessons learned to prevent reoccurrence. These investigation
reports are quality assured through the Trust’s internal governance processes and also
through scrutiny by the Commissioner of the relevant service.
There is close monitoring to ensure the implementation of recommendations arising from
SUIs. The themes identified from serious untoward incidents are shown in the chart
below:
Themes from Serious Untoward Incidents 2014/15
35
29
30
23
25
19
20
24
23
19
24
20
19
18
16
15
12
11
7
5
7
8
6
3
1
12
10
2
3
4
23: Security
10
11
22: Safeguarding
15
9
8
7
1
Examples of actions taken as a result of serious untoward incidents include:





An extensive programme of anti-ligatures works in in-patient units.
Improving the safety of garden environments for service users.
Reiterating to staff that service users and carers should be seen independently of
each other and should both be asked about current as well as past abuse.
Raising the profile amongst clinical staff of neuroleptic malignant syndrome.
Implementation of a number of training solutions to further help and support staff
in discharging their duties.
44
(blank)
32: Physical Healthcare
31: Care Pathway
30: Crisis and Contingency
29: Cross Organisation Links
27: Admin system change
26: Training
25: Supervision
24: Staffing
20: Resources
21: Risk Assessment
19: Records Management
18: Policy Compliance
17: Patient Clinical Condition
16: Multi agency arrangements
15: Medicines
13: Information sharing
12: Environment
10: Discharge
11: Dual Diagnosis
09: Diagnosis/Formulation
08: CPA
07: Communication
06: Clinical practice
05: Carers/Family
04: Capacity
03: Capability
01: Access
02: Best Practice Adherence
0
The Trust also produces regular Safety Matters Bulletins for staff to share learning from
thematic analysis of incidents. There has been a particular focus this year on learning
from medication incidents.
3.7
Patient environment
The national framework for the monitoring and assessment of the patient environment is
the Patient-Led Assessments of the Care Environment (PLACE).
These assessments were introduced in April 2013 to replace the former Patient
Environment Action Team (PEAT) assessments which had been undertaken from 2000 –
2012 inclusive. AWP volunteered to be one of the pilot sites for mental health services
and as a result significant changes were made to the assessment tool.
The table below shows the four areas of assessment outlining the national average score
and the score achieved by AWP in the last two years.
Please note that as a result of changes made to the assessment methodology and
scoring algorithm used to produce the results two of the four domains, comparative
analysis of results between 2013 and 2014 is not reliable.
National Average
2014
AWP Score
2013
AWP Score
2014
Change
Cleanliness
97.25%
91.86%
99.41%

Condition, Appearance and
Maintenance
91.97%
87.11%
94.65%

Privacy, Dignity and
Wellbeing
87.73%
89.27%
89.03%

Food & Hydration
88.79%
92.68%
89.12%

45
3.8
Staff survey
AWP values the hard work of our staff and their dedication to providing high quality
mental health care and we have committed to supporting and developing our staff as a
strategic priority.
We maintain regular ‘temperature checks’ on staff experience and wellbeing through the
use of a quarterly internal survey that incorporates the Staff Friends and Family test. This
complements the annual NHS Staff Survey that seeks response to questions that relate
to staff pledges in the NHS Constitution. We invite our entire workforce to respond to
both surveys to gain the best insight into staff experience.
Survey results are analysed by Locality as well as providing a Trust wide picture. Results
are used to develop and refine plans to improve staff experience of working at AWP. The
Trust wide results of the 2014 Annual Staff Survey are reported below.
We were pleased with receive feedback from such a significant proportion of our staff
exceeding the national average as shown in the table below:
Response rates for 2013 and 2014
2013
2014
Trust
National average
Trust
National average
48.4%
50.8%
51%
42%
(1704 staff)
(1790 staff)
Positive results evidence improvement in areas where significant focus has been applied.
We have increased training and appraisal rates as a means of improving staff skills and
confidence to deliver safe, high quality care. The Trust is pleased to see evidence that
our emphasis on the reporting of incidents and concerns about clinical practice is
reflected in the results. Taken alongside increased reporting of incidents, this survey
result evidences a positive reporting culture.
46
The most recent results are set out in the table below.
National Staff Survey Comparative Results 2013 and 2014
Top 5 Ranking Scores
Trust
2013
*National
average 2013
Trust
2014
*National average
2014
%
change
% of staff appraised in last 12
months
83%
88%
91%
88%
+8%
% of staff receiving health and
safety training in the last 12
months
69%
74%
79%
73%
+10%
% of staff agreeing that they
would feel secure raising
concerns about unsafe clinical
practice
-
-
70%
69%
No
comparab
le
question
in 2013
% of staff having equality and
diversity training in the last 12
months
58%
64%
68%
67%
+10%
Fairness and effectiveness of
incident reporting procedures
3.52
3.52
3.53
3.52
+.01%
*National average
2014
% change
Lowest 5 ranking scores
Trust *National average Trust
2013
2014
2013
% of staff feeling pressure in
last 3 months to attend work
when feeling unwell
24%
22%
25%
20%
+1%
% of staff receiving job-relevant
training, learning or
development in the last 12
months
82%
81%
77%
82%
-5%
% of staff experiencing
harassment, bullying or abuse
from staff in last 12 months
22%
21%
27%
21%
+5%
% of staff reporting good
communication between senior
management and staff
31%
31%
26%
30%
-5%
3.93
3.83
3.76
3.84
-0.17%
Effective team working
*National averages for mental health and learning disability Trusts
47
Our ambition is to be the best Mental Health Employer in England and as such we take
this feedback from staff seriously. Action is being taken at two levels. At a Trust wide
level the following approaches will target key areas of concern:

Pressure to attend work when unwell:
Recruitment and Retention Strategy to increase our substantive staff and retain
our existing workforce
An active Health and Wellbeing Programme of work led by our Health and
Wellbeing Manager. This programme provides staff with financial benefits (e.g.
salary sacrifice schemes and retail discount and support to stay well physically
and mentally.

Availability of job relevant training:
Launch of the Development HIVE, an interactive tool, that allows staff to see the
full range of learning, development and support opportunities available. Major
areas of development in the year ahead include recruiting at least 100 apprentices
and appraisal training to ensure appraisers have the skills, confidence and tools to
deliver an excellent appraisal.

Bullying and Harassment:
We recently launched a new Bullying and Harassment Policy which clearly defines
bullying and harassment, how to get help and how to report it. A campaign
approach is raising awareness of this throughout the Trust and close partnership
working with Staff Side representatives to ensure that the policy is visible and
actively used.
48
To deeply understand the issues behind staff reported bullying and harassment in
the staff survey we have commissioned an independent partner to run
engagement events with staff. The output of this work will help to inform what
further actions we can take to address this concerning issue.

Senior Leader Communication:
We have launched an accredited leadership development programme in
partnership with the University of the West of England. This will see 160 middlesenior managers supported to develop leadership competence and confidence.
This programme is complemented by local and national development programmes
offered by the South West Leadership Academy and NHS Leadership Academy.

Effective Team Working:
Research shows that high performing teams provide safer, higher quality care.
We have launched a major programme of Team based Working that will see every
team in the Trust, clinical and non-clinical, supported to undertake team
development by 31 March 2016. We have partnered with recognised experts in
team development, Aston OD, to deliver this programme.
To bespoke the implementation of the programmes described above a Workforce
Development Plan has been developed for each Locality based on specific need. The
implementation of Workforce Development Plans will be closely monitored.
The Board maintains active oversight in all issues relating to our staff through the
Employee Strategy and Engagement Committee. This Committee maintains oversight of
staff survey responses and receives assurance that appropriate action is being taken in
response. The Board is committed to seeing positive change in survey results in the
coming year as evidence of improved staff experience and engagement.
49
Part 4: How we developed our Quality Account
This is the fifth year that NHS Trusts have reported formally on the quality of their
services.
Much of this report is set out to meet legal requirements. However we also report on our
priorities for improvement which have been agreed in partnership with clinicians, service
users and carers.
Our aim has been to produce a true and fair representation of our services, including
information that is meaningful, relevant and understandable to our service users, their
carers and the public.
Throughout the year, we have had ongoing engagement with service users and carers
across the Trust via our existing forums and the Trust Engagement Group. Each service
informs their quality improvement activities by gathering service user and carer feedback
from a variety of mechanisms: PALS, praise and complaints, annual surveys, real-time
surveys, service user and carer representation on Trust groups, focus groups and at
special events.
We have continued to develop the use of the Experience Based Design (EBD) approach
with resources and trained peer mentors offering support and we have also engaged
across the organisation with our staff and clinicians.
The Trust is also grateful to our service users, carers and staff who also commented and
contributed to this document.
External assurances and comments
We provided a draft of this Quality Account to the local area team of the NHS
Commissioning Board, North Somerset Clinical Commissioning Group as our coordinating commissioner, Wiltshire Health and Wellbeing Board, all six local authority
health overview and scrutiny committees and local Healthwatch groups and invited them
to review the document and provide us with comments.
In the time available, we have responded to these comments wherever possible by
adding information or making appropriate amendments while producing our final
document. The Trust is grateful to all of the above organisations for helping to verify the
content and for their suggestions for improving this document.
The verbatim comments received from the above organisations are available in full in
Appendix A of the downloadable version of our Quality Account, including appendices, is
available on our website
Concluding comments
We very much hope that the information contained in this document is useful and
meaningful, reinforcing the fact that providing high quality and safe services is AWP’s
highest priority and at the heart of all that we do.
We would value your feedback on this document so we can improve next year’s Quality
Account. You can contact us via the details below. Alternatively, if you would like further
information, a hard copy of this document, or have any questions, please contact us.
50
Contact us with your feedback or for further information at:
Email:
Communications@awp.nhs.uk
Telephone: 01249 468000
Or write to:
Quality Account
Communications Team
Avon and Wiltshire Mental Health Partnership NHS Trust
Jenner House
Langley Park Estate
Chippenham
SN15 1GG
Our full Quality Account, including the following appendices, This document is available
on the Trust’s website
or by request:
Appendices:
A
External assurances and comments
B
Glossary of terms
C
Statement of Directors’ Responsibilities
D
Information by PCT and local authority area
E
More information on the targets presented in tables
An additional document, Commissioning for Quality and Innovation (CQUIN), is also
available via the Trust website
51
APPENDIX A
External assurances and comments
The AWP draft Quality Account was circulated to the local area team of NHS England,
North Somerset Clinical Commissioning Group as our co-ordinating commissioner, all six
local authority health overview and scrutiny committees, Wiltshire Health and Wellbeing
Board and local Healthwatch groups with an invitation to review the document and
provide us with comments.
In the time available, we have responded to these comments wherever possible by
adding information or making appropriate amendments while producing our final
document. The Trust is grateful to all of the above organisations for helping to verify the
content and for their suggestions for improving this document.
In addition the Trust appointed Grant Thornton to carry out audit work in order to provide
external assurance on the Trust’s 2014/15 Quality Account.
Published below are the statements received from the associated organisation:
1.
Commissioners of our services
North Somerset Clinical Commissioning Group, lead Commissioner
North Somerset Clinical Commissioning Group (CCG) is the Coordinating Commissioner
for the Avon and Wiltshire Partnership (AWP) mental health service provision for six
locality CCGs - Bristol, South Gloucestershire, Banes, Swindon and Wiltshire and NHS
England (specialised services). South West Commissioning Support (SWCS), who
manage the contract on behalf of Commissioners, have provided a combined
commentary on the performance of the organisation. SWCS have put routine processes
in place with AWP to agree, monitor and review the quality of services throughout the
year covering the key quality domains of safety, effectiveness and experience of care.
Commissioners appreciate your sharing of the draft Quality Account for 2014/15 and are
pleased to accept the opportunity to comment. Commissioners have monitored the
safety, effectiveness and patient experience of the service provided by AWP during
2014-15. The Trust’s engagement in the quality contract monitoring process provides the
basis for commissioners to comment on the quality account including performance
against quality improvement priorities and the quality of the data included.
Commissioners recognise that this has been not only a year of transition for the Trust as
well as the commissioners but also a challenging year, including the comprehensive
CQC inspections, and welcome the efforts made by the Trust to implement the locality
based approach that enhances patient and staff experience.
Quality Accounts are intended to help the general public understand how their local
health services are performing and with that in mind they should be written in plain
English. The Trust has produced a comprehensive, well written Quality Account. It is
largely easy to read and clearly set out. All the relevant sections required are present and
it is clearly presented in the format required by the Department of Health Toolkit. AWP
has been open and transparent regarding the challenges and concerns and the CCGs
acknowledge this transparency.
Commissioners have reviewed and can confirm that the information presented in the
Quality Account appears to be accurate and fairly interpreted, from the data collected
with a balance of positive and negative results. The Quality Account demonstrates a high
52
level of commitment to quality in the broadest sense and is commended. The report
reflects some of the good work undertaken by the organisation and sets out the quality
ambitions and achievements of 2014/15 and sets the direction for 2015/16.
Commissioners support objectives which have clear outcomes for patients describing
how this intervention has made a difference to them. The Quality Account provides
information across a wide range of quality measures in relation to patient experience,
clinical effectiveness and patient safety.
All participating CCGs have structured monthly local quality review meetings with Avon
and Wiltshire Mental Health Partnership Trust, using a range of quality measures to help
to support and monitor improvements. Commissioners support and welcome the specific
priorities for 2015/16 to improve on patient safety, patient experience and effectiveness
which the Trust has highlighted in the Quality Account. All are appropriate areas to target
for continued improvement, building on achievements in 2014/2015.
The Quality Account sets out how patient safety data is collected centrally via the
National Reporting and Learning Service (NRLS), which includes any incidents that have
resulted in serious harm. The CCG supports the approach to thematic review of incidents
within the Trust, together with involvement of Trust Executives within dedicated quality
improvement visits.
The Quality account has a good focus on provision of harm free care however
Commissioners would like to see an overview of the Trust plan for the ‘sign up to safety’
campaign.
There has been good improvement in the management of Serious Incidents but there
remains significant work to do in terms of embedding learning across the organisation.
Capacity remains challenging but Commissioners note and commend the work done by
the Trust e.g. to place patients in services local to home.
There has also been an improvement in appraisal and supervision rates.
Further detail on outcomes from Safeguarding interventions would be helpful.
Commissioners would also like further information from the review with Oxford Health
and what the Trust aspiration is around partnership working across pathways, taking a
recovery approach and linking to the Care Act.
The staff survey results are disappointing and it would be helpful to see some of the
themes in more detail although the Trust is clearly actively addressing these issues as
illustrated by the development of their health and wellbeing strategy.
Overall Commissioners are happy to commend this Quality Account and AWP for its
continuous focus on quality of care. They look forward to continuing to work in
partnership with the Trust during 2015/16 and developing further relationships to help
deliver their vision of healthy people, living healthy lives, in healthy communities.
Jacqui Chidgey-Clark
Director of Nursing and Quality
North Somerset CCG
53
2.
Local Authority Overview and Scrutiny Committees (OSCs)
Collective response from Wiltshire Council, Bristol City Council and Swindon
Borough Council to the AWP Quality Account 2014/15
Wiltshire Council, Bristol City Council and Swindon Borough Council are currently
engaged in a scrutiny Joint Working Group on AWP, along with Bath and North East
Somerset and North Somerset. The Joint working Group are working closely with AWP to
support them in improving their services and outcomes based on the areas highlighted by
the CQC in recent inspections and are encouraged by the work that has been undertaken
to improve the quality of services. The priorities for improvement and shift of focus to a
quality focussed, locally integrated model which prioritises patient outcomes and quality
of experience above performance targets was supported by the Working Group.
Two informal joint working group meetings have taken place with Bristol City Council,
Wilshire Council, Bath and North East Somerset Council and North Somerset Council to
consider the recent Care Quality Commission quality report published in September
2014. Members hoped that the working group report recommendations will feed into the
AWP improvement plan.
In considering the Quality Account there was general consensus amongst members that
the priorities chosen were appropriate.
We would continue to emphasise the importance of improving the feeling of safety for
patients and have been pleased with the progress on the work to address the issue of
potential ligature points in the facilities. We would also like to highlight the continued
concerns regarding staff levels but have been encouraged by the fact that recruitment is
on track to resolve this and that staff training and induction programmes have been
improved to ensure good levels of competency. It should be praised that AWP staff are
overall deemed to be very caring.
Additional comments from North Somerset Council:
Overview
The Health Overview and Scrutiny Panel (HOSP) notes that this Quality Account (QA)
has been published in the shadow of recent CQC inspections of the Trust which
highlighted a number of key service areas requiring improvement. The Panel
acknowledges, however, that many of the issues identified by the CQC lie outside the
North Somerset service delivery area. Members are nevertheless encouraged by the
Trust’s progress in implementing an action plan addressing the CQC recommendations
and recognise that this is likely to deliver trust-wide improvements going forward.
With respect to the QA, the Panel particularly welcomes the commitment to the continued
embedding of the clinically and locally led service delivery model with increased focus on
early intervention/high accessibility; partnership working; and the delivery of integrated
care “in the best place at the best time”.
In general, Members felt that the Trust has demonstrated a good understanding of the
mental healthcare needs of communities in North Somerset.
Patient Experience
The Panel endorses the Trust’s 2015/16 priority: to improve service user and carer
experience and the greater emphasis on the systematic use of patient feedback to deliver
and evidence improvements in patient care. Members also welcome the priority of
further enhancing carers experience through improved partnership working and carer
support.
54
The Trust’s Friends and Families (FFT) results for 2014/15 show consistently high scores
and the Panel notes that it achieved its 2014/15 priority success measure of
demonstrating local improvement actions as a result of FFT feedback. Furthermore
Members welcomed the Trust’s progress in the delivery of improved partnership with
carers, using the Carer’s Trust “Triangle of Care” toolkit and the new care home liaison
arrangements with North Somerset Community Partnership.
Clinical Effectiveness
The Panel supports the objectives of the Trust’s 2015/16 clinical effectiveness priorities
focussing on ensuring the application of comprehensive patient assessments and
improving the quality of the electronic patient record.
Members are, however, concerned about the clinical implications of ongoing staff
shortages/retention issues and the impacts on capacity. The Panel recognises that
capacity is a vast challenge across the health sector nationally and acknowledges both
the practical steps being taken by the Trust to mitigate staffing issues and progress on
the implementation of its wider strategy of delivering a quality driven, locally integrated
model focussing on higher accessibility and early intervention.
With respect to the delivery of that model on the ground, Members are particularly
encouraged by the following improvements in North Somerset:






the joint staff training programmes with North Somerset Community Partnership;
training for GPs on dementia;
the successful establishment of Memory Clinics;
improved care pathway between CAMHS and Adult Mental Health Services;
the provision of Mental Health training to Weston General Hospital staff; and
The appointment of a Mental Health/Dementia liaison nurse at Weston General.
Patient Safety
The Panel supports the Trust’s safety priorities for 2015/16 (reducing avoidable harm and
improving the physical health of patients). These were priorities in 2014/15 and
Members note that the Trust made progress against the relevant performance measures
(ensuring that at least 90% of patients with Schizophrenia were assessed for cardio
metabolic risk and that the Safewards model is being implemented across all the Trust’s
wards). The Panel especially welcomes the greater emphasis on the physical wellbeing
of patients and the continuing focus in 2015/16.
With respect to its third 2014/15 safety priority (ensuring that discharge summaries are
shared with GPs), Members have had significant concerns about this issue and are
encouraged that the Trust is completing an audit of discharge letters to evidence the
anticipated improvements.
Members also welcome the following specific safety improvements implemented in North
Somerset:



the Juniper ward refurbishment (ligature prevention);
suicide prevention - the “Zero Tolerance project” developed in collaboration with
North Somerset Public health; and
the deployment of the 24hr crisis team (which Members especially welcome as
having made a significant difference).
NB: Bath and North East Somerset Council informed me that they would not be providing
a statement this year due to the election period.
55
3.
Joint Healthwatch Response prepared by Wiltshire Healthwatch
This statement is provided on behalf of the local Healthwatch organisations which exist in
the areas in which the Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)
operates. These areas are Bath and North East Somerset, Bristol, North Somerset,
South Gloucestershire, Swindon, and Wiltshire. The role of the Healthwatch service is to
promote the voice of patients and the wider public in health and social care services.
The AWP Chief Executive’s statement sets out key messages clearly and sets the scene
for the rest of the account. We welcome the Trust’s recent suggestion to produce an
executive summary of the account as we believe that this would make it more accessible
to the general public. A paragraph describing how feedback from service users and other
key stakeholders has informed improvement priorities would be a useful addition.
The readability of the document could be improved if the review of 2013-14 priorities
were to precede the overview of priorities for 2015-16. This would allow the reader to see
how progress has informed improvements and the setting of priorities for the year ahead.
The diagrammatic presentation summarising 2015-16 priorities is clear and effective and
the tabulated format which gives the details is easy to navigate.
Healthwatch appreciate that the Trust has made available materials including the quality
account, in different formats (e.g. as an audio version).
Healthwatch were concerned that enforcement actions were issued by the Care Quality
Commission (CQC) during their inspection in June 2014. However, we noted that the
CQC acknowledged the ‘kind, caring and responsive approach’ of the Staff. The rapid
and robust response that the Trust put in place to deal with these actions, resulted in
them achieving compliance following the CQC’s subsequent inspection in December
2014. We welcome the approach taken by the Trust and note their acknowledgement
that there is more to do in terms of fully embedding these improvements in clinical
practice and service provision. However we would like to see more reassurance for the
public that the priority areas are being resolved and that learning has occurred.
We note that the Trust has achieved below the national average on the National NHS
Staff survey friends and family test (FFT).This is concerning given that this is essentially
an indication of staff confidence in the quality of care provided by the Trust. However, we
note that a higher proportion of staff has completed the survey this year. We
acknowledge that this has been a challenging year for the Trust and that these local
challenges combined with national constraints would have impacted negatively on morale
and hence the confidence of staff. We would like to see these results improve
significantly over the next year and are therefore pleased to see that an action plan has
been put in place to improve staff wellbeing.
Healthwatch acknowledges that FFT feedback could be affected by feedback from
inpatients who have not elected to receive treatment. Healthwatch is reassured that AWP
has chosen to repeat the national inpatient survey, and suggests that further monitoring
of patient concerns continues.
We were reassured to see that in general, patients had reported more positive results
this year than last. However, we are concerned that only 34% of in-patients answered
‘yes, always’ to the question: ‘During your most recent stay, did you feel safe?’ We are
aware that over the last three years inpatients have become more acute in nature and
that there is a national shortage of registered mental health nurses and that these factors
may in part have impacted negatively on results. We are reassured to see that improving
patient safety on the wards is a priority for this year. However, we would like more detail
of how this is to be delivered. We would like to offer our help in engaging with in-patients
so that we can better understand the patient experience.
56
We welcome the work that the trust has undertaken to receive accreditation for the
Carers Trust Triangle. We hope that this results in further actions to provide a service
that promotes a whole-person approach and considers the impact of those who support
service users. We would like to see further work with local voluntary and community
sector groups to ensure service-users and those that care for them have a clear network
of support and advice within communities.
We recognise and acknowledge that the clinically and locally led service delivery units
has led to a more focussed response to the community it serves and we hope to see
further evidence of this to meet the service-users/carers needs, particularly with the
increase in demand.
We welcome the Trust’s priority to improve clinical effectiveness in relation to patient
assessment and formulation, with a measure of success for 85% of clinically effective
care plans to show carer and service user involvement. Although we would like to see a
higher figure as a measure of success, we acknowledge that this a combination of
several factors that will make up a comprehensive care plan.
Healthwatch appreciated the opportunity to meet with the Trust prior to their response to
the account as this acted as a valuable opportunity to ask questions and seek
clarification on a number of issues.
Local Healthwatch organisations will continue to work closely with service users, carers,
and the wider community to support the Trust in meeting its targets in their priority
areas. Furthermore, Healthwatch recognises that the wider health and social care
community has a role to play in the Trust’s performance and as such will take a particular
interest in monitoring the partnership effort to provide patients with a ‘seamless’ and good
quality experience of acute and primary health services and social care services.
57
4.
External Auditors – limited assurance report
Independent Auditor's Limited Assurance Report to the Directors of Avon and
Wiltshire Mental Health Partnership NHS Trust on the Annual Quality Account
We are required to perform an independent assurance engagement in respect of Avon and Wiltshire Mental
Health Partnership NHS Trust’s Quality Account for the year ended 31 March 2015 (“the Quality Account”)
and certain performance indicators contained therein as part of our work. NHS trusts are required by section 8
of the Health Act 2009 to publish a quality account which must include prescribed information set out in The
National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account)
Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations
2012 (“the Regulations”).
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
indicators:
 Percentage of patients on Care Programme Approach (CPA) followed up within seven days of
discharge
 Percentage of admissions to acute wards gate kept by the Crisis Resolution Home Treatment Team
(CRHT).
We refer to these two indicators collectively as “the indicators”.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The
Department of Health has issued guidance on the form and content of annual Quality Accounts (which
incorporates the legal requirements in the Health Act 2009 and the Regulations).
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:
 the Quality Account presents a balanced picture of the Trust’s performance over the period covered;
 the performance information reported in the Quality Account is reliable and accurate;
 there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are
working effectively in practice;
 the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and
 the Quality Account has been prepared in accordance with Department of Health guidance.
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
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 Account is not prepared in all material respects in line with the criteria set out in the
Regulations;
 the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014-15 issued by DH in March 2015 (“the Guidance”); and
 the indicators in the Quality Account identified as having been the subject of limited assurance in the
Quality Account are not reasonably stated in all material respects in accordance with the Regulations
and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations
and to consider the implications for our report if we become aware of any material omissions.
58
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:
 Board minutes for the period April 2014 to June 2015;
 papers relating to quality reported to the Board over the period April 2014 to June 2015;
 feedback from the Commissioners dated 21 May 2015;
 feedback from Local Healthwatch dated 11 June 2015;
 the Trust’s draft complaints report to be published under regulation 18 of the Local Authority, Social
Services and NHS Complaints (England) Regulations 2009, dated May 2015;
 feedback from other named stakeholder(s) involved in the sign off of the Quality Account dated 1
June 2015;
 the latest national patient survey dated 18 September 2014 (community mental health services);
 the latest national staff survey dated 24 November 2015;
 the Head of Internal Audit’s annual opinion over the trust’s control environment dated 22 May 2015;
 the annual governance statement dated 27 May 2015; and
 the Care Quality Commission’s Intelligent Monitoring Report dated November 2014.
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with these documents (collectively the “documents”). Our responsibilities do not extend to any
other information.
This report, including the conclusion, is made solely to the Board of Directors of Avon and Wiltshire Mental
Health Partnership NHS Trust.
We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have
discharged their governance responsibilities by commissioning an independent assurance report in connection
with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to
anyone other than the Board of Directors as a body and Avon and Wiltshire Mental Health Partnership NHS
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 under the terms of the guidance. 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;
 analytical procedures;
 limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation;
 comparing the content of the Quality Account to the requirements of the Regulations; and
 reading the documents.
A limited assurance engagement is narrower 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,
59
may change over time. It is important to read the Quality Account in the context of the criteria set out in the
Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health. This
may result in the omission of information relevant to other users, for example for the purpose of comparing
the results of different NHS organisations.
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by Avon and Wiltshire Mental Health Partnership NHS 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 Account is not prepared in all material respects in line with the criteria set out in the
Regulations;


the Quality Account is not consistent in all material respects with the sources specified in the
Guidance; and
the indicators in the Quality Account subject to limited assurance have not been reasonably stated in
all material respects in accordance with the Regulations and the six dimensions of data quality set out
in the Guidance.
Grant Thornton UK LLP
Hartwell Hose
55 – 61 Victoria Street
Bristol
BS1 6FT
18 June 2015
60
APPENDIX B - Glossary of terms
Care Programme
Approach (CPA)
The process that providers of mental health care use to coordinate the care, treatment and support for people who have
mental health needs.
Care Quality
The CQC is the independent regulator of health and adult
Commission (CQC) social care services in England. It also protects the interests
of people whose rights are restricted under the Mental Health
Act.
Clinical audits
Care Cluster
Clostridium
difficile
A systematic process for setting and monitoring standards of
clinical care. 'Guidelines' define what the best clinical
practice should be, 'audit' investigates whether best practice
is being carried out and makes recommendations for
improvement.
A Mental Health Care Cluster is part of a currency developed
to support Payment by Results for Mental Health Services.
Mental Health Care Clusters are 21 groupings of Mental
Health Patients based on their characteristics, and are a way
of classifying individuals utilising Mental Health Services that
is planned to form the basis for payment.
Clostridium difficile is a bacterial infection that most
commonly occurs in people who have recently had a course
of antibiotics and are in hospital. Symptoms can range from
mild diarrhoea to a serious inflammation of the bowel.
Commissioning for A payment framework that has been a compulsory part of the
Quality and
NHS contract from 2009/10. It allows all local health
Innovation (CQUIN) communities to develop their own schemes to encourage
quality improvement and recognise innovation by making a
proportion of NHS service provider’s income conditional on
locally agreed goals.
Crisis care
This is a short-term, community, intensive service, commonly
for adults (16 years and over) with severe mental illness such
as schizophrenia, manic depressive disorders and severe
depressive disorder. It is delivered by the Trust’s Intensive
Teams. Crisis care is provided to those in acute psychiatric
crisis of such severity that, without the involvement of a
CRHT, admission to hospital would be necessary.
South West
Dementias and
Neurodegenerative
Diseases Research
Network
(DeNDRON)
The regional branch of DeNDRoN is one of six topic-specific
clinical research networks funded by the Department of
Health in England. It supports the development and delivery
of clinical research in the NHS in the dementias, Parkinson’s
disease, motor neurone disease, Huntington’s disease and
other neurodegenerative diseases.
Early intervention
These teams work with service users and their families to
provide expert assessment, treatment and support at an early
stage in their psychosis, with a view to being able to minimise
61
its impact on their lives and avoid longer term need for mental
health services. Typically service users are aged 14 to 35
and this will be their first episode of psychosis and they will
receive up to three years support.
Equality Delivery
System
The EDS is a tool for NHS organisations – in partnership with
patients, the public, staff and staff-side organisations – to use
to review their equality performance and to identify equality
objectives and actions. It offers local and national reporting
and accountability mechanisms. Further information
available at the following link:
http://www.eastmidlands.nhs.uk/about-us/inclusion/eds/
Formulation
Formulation is the development of a tentative explanation of
why a person or family might be experiencing the difficulties
that they do. Formulation takes account of different contexts:
biological, psychological, social, and cultural and helps to
identify intervention strategies (treatments and care) best
suited to the individual which can then inform a personalised
care plan.
Foundation Trust
Foundation Trusts are a type of NHS organisation with
greater local accountability and freedom to manage
themselves. They remain within the NHS overall, and provide
the same services as traditional trusts, but have more
freedom to set local goals. Staff and members of the public
can join their Boards or become members.
Healthwatch England is the independent consumer champion
for health and social care in England. Working with a network
of 152 local Healthwatch, their role is to ensure that the
voices of consumers and those who use services reach the
ears of the decision makers. These organisations replace
Local Involvement Networks from April 2013.
Healthwatch
HoNOS
The ‘Health of the Nation Outcome Scale’ is a tool used by
mental health clinicians to rate the mental health of service
users. It is used before and after treatment so that changes
attributable to the treatment or intervention can be measured .
Hospital Episode
Statistics (HES)
HES is a national data source that contains details of all
admissions to NHS hospitals in England. It includes private
patients treated in NHS hospitals, patients who were resident
outside of England and care delivered by treatment centres
(including those in the independent sector) funded by the
NHS. HES also contains details of all NHS outpatient
appointments in England.
Information
Governance
Toolkit
An online tool that enables organisations to measure their
performance against information governance standards.
There are several elements of law and policy from which
information governance standards are derived. It
encompasses legal requirements, central guidance and best
practice in information handling, including:
 The common law duty of confidentiality
62





Data Protection Act 1998
Information security
Information quality
Records management
Freedom of Information Act 2000.
Mental Health
Minimum Data Set
(MHMDS)
The MHMDS is a mandatory data return for all NHS providers
of specialist adult mental health services. Data from the
Trust’s electronic patient records, relating to admissions,
appointments, CPA, and some basic demographic
information is submitted to the Department of Health on an
anonymised basis throughout the year.
Mental Health
Research Network
(MHRN)
The MHRN supports vital large-scale research which will help
to raise the standard of mental health and social care
research throughout England. In addition, it acts as a central
point of information and reference, connecting service users
and carers to researchers and mental health professionals.
NCAPOP
The National Clinical Audit and Patient Outcomes
Programme (NCAPOP) is a closely linked set of centrallyfunded national clinical audit projects that collect data on
compliance with evidence based standards, and provide
local trusts with benchmarked reports on the compliance and
performance. They also measure and report patient
outcomes.
The projects analyse data supplied by local clinicians
centrally and feedback comparative findings to help
participants identify necessary improvements for patients.
National Institute
of Health and
Clinical Excellence
(NICE)
NICE provides guidance, sets quality standards and manages
a national database to improve people’s health and prevent
and treat ill health.
NICE makes recommendations to the NHS on:
 New and existing medicines, treatments and procedures
 Treating and caring for people with specific diseases and
conditions
 How to improve people’s health and prevent illness and
disease.
National Patient
Safety Agency
(NPSA)
The NPSA leads and contributes to improved, safe patient
care by informing, supporting and influencing the health
sector.
They manage a national safety reporting system receiving
confidential reports of patient safety incidents from healthcare
staff across England and Wales. Clinicians and safety
experts analyse these reports to identify common risks to
patients and opportunities to improve patient safety.
National Reporting
and Learning
Service
NRLS – uses a National framework for reporting and learning
from serious incidents requiring investigation in the NHS.
NIHR Flexibility
NIHR FSF is a research funding stream designed to help
63
and Sustainability
Funding (NIHR
FSF)
research-active NHS organisations attract, develop and retain
high-quality research, clinical and support staff by supporting
the salaries of their Faculty members and associated
workforce in a flexible manner.
Overview and
Scrutiny
Committee (OSC)
Each local authority is required to have an OSC to scrutinise
public services outside its own organisation, including health.
It has statutory powers to call in witnesses from local NHS
bodies and make recommendations that NHS organisations
must consider as part of their decision-making processes.
Similarly, there is a requirement on NHS organisations to
consult with health overview and scrutiny committees when
considering substantial developments or variations to
services.
Patient Advice and
Liaison Service
(PALS)
PALS is an impartial service designed to ensure that the NHS
listens to patients, their relatives, carers and friends, answers
their questions and resolves their concerns as quickly as
possible.
PALS also helps the NHS to improve services and make
changes by listening to what matters to patients and their
families and friends.
POMH
Prescribing Observatory for Mental Health (Royal College of
Psychiatrists)
The Equality Act 2010 makes it unlawful to discriminate
against people with a ‘protected characteristic’
(previously known as equality strands / grounds).
Specified ‘protected’ characteristics are as follows:
• Age
• Disability
• Gender re-assignment
• Marriage and civil partnership
• Pregnancy and maternity
• Race including national identity and ethnicity
• Religion or belief
• Sex (that is, is someone female or male)
• Sexual orientation
Protected
Characteristics
Quality and
Healthcare
Governance
system
In AWP this is a combination of structures and processes
from Board to frontline that ensures quality standards are
being maintained, including:
 Ensuring required standards are achieved
 Investigating and taking action on sub-standard
performance
 Planning and driving continuous improvement
 Identifying, sharing and ensuring delivery of best practice
 Identifying and managing risks to quality of care.
64
RiO
RiO is the name of a new electronic patient record system
that largely replaces paper records.
RiO ensures that clinical staff have accurate, up to date and
secure information available around the clock. It provides
real-time information for assessment, care management,
progress notes and bed management.
RiO has been fully implemented across all AWP services.
Regulatory
framework
A framework or system of rules and requirements that are set
out by law in statutory legislation.
Safeguarding
A term used in conjunction with measures which are taken to
protect, safeguard and promote the health and welfare of
children and vulnerable people; ensuring they live free from
harm, abuse and neglect.
Safewards
The new 'Safewards' model is based on years of research by
nursing guru Len Bowers.
The research looked at potentially harmful events such as
aggression, rule breaking, substance use, absconding,
medication refusal, and self-harm and identified the most
effective ways of containing these negative events.
The model identifies a range of feasible interventions which
are proved to make a difference for example: using soft
words, mitigating bad news, using calm down methods and
providing reassurance.
Alongside increasing the use of such techniques, the model
drops some of the most disliked interventions such as
restraint, rapid tranquilisation and the outcome is that conflict
on wards decreased by 14.6 per cent and containment
activity decreased by 23.6 per cent.
http://www.safewards.net/model/model-diagram
Scorecards
Fully named The Balanced Scorecard, this is a performance
management tool that sets out in tabular form, in a single
place, all of the targets and standards the Trust must meet
and how we are doing against them. It is reported monthly to
the Board, Primary Care Trusts (PCTs) and local authorities,
and internally to our operational services. It enables
everyone to see what our performance is and to target
improvements where they are needed. It is supported by
weekly internal reports that break performance down to team
and ward level.
Serious untoward
Any event or circumstance arising that could have or did lead
or adverse Incident to serious unintended or unexpected harm, loss or damage.
(SUI)
Essentially serious adverse incidents are those which cause
(or have the potential to cause) the most harm either to
individuals (staff, service users, visitors, contractors, others)
or to the organisation. These include: unexpected deaths;
injuries causing major and permanent physical or
psychological harm; large-scale theft or fraud; outbreak of
65
Legionnaires disease; major fire or flood.
Social Care
Institute of
Excellence (SCIE)
SCIE is an independent charity, funded by the Department of
Health that identifies and disseminates the knowledge base
for good practice in all aspects of social care throughout the
United Kingdom.
Service Delivery
Units (SDU)
This is a term adopted by AWP to describe the way the
organisation has structured the management of its main
operational services and areas of business. Each SDU is led
by a Clinical Director, Managing Director and Head of
Profession and Practice
Strategic Executive A system for collecting weekly management information from
Information
the NHS. We use this system to report all Serious Untoward
System (STEIS)
Incidents (SUIs).
Thematic review
A systematic review of evidence around a particular theme of
patient safety such as medication or violence and aggression.
The process looks at what can be learnt from reported
incidents, issues raised with the PALS service, complaints,
claims and our investigations of suspected suicides.
We then compare our Trust to others and look at national
guidance and Trust policy on good practice and develop a
plan to turn our learning into action.
Think family model
This is a model of care that asks all professionals such as
health, social care, education, criminal justice to ‘think family’
so that there is no ‘wrong door’: Contact with any one service
gives access to a wider system of support. Individual needs
are looked at in the context of the whole family, so clients are
seen not just as individuals but as parents or other family
members. Services build on the strengths of families,
increasing their resilience and aspirations. Support is tailored
to meet need so that families with the most complex needs
receive the most intensive support.
Published by the Carers Trust (formerly The Princess Royal
Trust for Carers) and the National Mental Health
Development Unit it is a guide and toolkit which emphasizes
the need for better local strategic involvement of carers and
families in the care planning and treatment of people with
mental ill-health.
Triangle of Care
Western
Comprehensive
Local Research
Network (CLRN)
CLRNs work with their local NHS organisations to support
clinical research through funding staff and resources such as
information technology and office space.
Whole time
equivalent (WTE)
This is a measure used to present staffing numbers. Part
time hours are added together to calculate the figure.
66
APPENDIX C
67
APPENDIX D
Information by Clinical Commissioning Group
and Local Authority Area
This section provides an overview for the services that we provide to each of our six
Local Authority and Clinical Commissioning Group (CCG) areas. These areas are shown
in the map below alongside the location of in-patient sites.
68
1.
North Somerset
1.1
Overview of services in North Somerset
During 2014/15 AWP received 4,934 referrals for people registered to GPs in the North
Somerset area. Of these, the majority of service users were supported in the community,
however where necessary, some people were admitted into hospital for a period of
inpatient care. The total number of community based contacts and the total number of
inpatient admissions were as follows:


40,348 community contacts
322 inpatient admissions
Services are provided at two inpatient sites at the Long Fox Unit and Elmham Way, as
shown on the map above, and at community sites across the area.
1.2
How we have measured our service quality in North Somerset:
The table below presents local information, where it is available, for those indicators that
are presented in Part 3 of the main Quality Account.
Please note for several of the indicators presented in the main Quality Account we
do not have localised data available. We have therefore excluded these from the
tables below.
69
Measures of our service quality in North Somerset
Measure
Trust
Target
Level
Trust
2013/14
Trust
2014/15
N Somerset 2014/15
%
Numerator/
Denominator
Patient Experience
Service users seen for their first
appointment within four weeks
of their referral
95%
99%
96.4%
99.1%
1,778 / 1,795
Compliance to Department of
Health standards for eliminating
mixed sex accommodation
100%
100%
100%
100%
Meeting six criteria for access to
healthcare for people with a
learning disability
All Criteria
met
Fully met
Fully met
Fully met
Care Programme Approach
(CPA) annual review
95%
96%
95.6%
99.2%
515 / 519
Admissions to inpatient services
have had access to crisis
resolution home treatment
teams
95%
97%
95.4%
94.6%
88 / 93
Minimising delayed transfers of
care
<7.5%
6.5%
9.2%
4.7%
758 / 16,225
182
246
261
22
95%
98%
96.5%
99.2%
Reduction
Achieved
Achieved
Achieved
Effectiveness
Number receiving early
intervention
Safety
Care Programme Approach
(CPA) seven day follow up
Meeting objectives for the
reduction of infections of
Clostridium difficile and MRSA
256 / 258
70
2.
Bristol
2.1
Overview of services in Bristol
During 2014/15 AWP received 8,437 referrals for people registered to GPs in the Bristol
area. Of those accepted into the service, the majority were supported in the community,
however where necessary, some people were admitted into hospital for a period of
inpatient care. The total number of community based contacts and the total number of
inpatient admissions were as follows

66,291 community contacts

713 inpatient admissions
Services are provided at four inpatient sites, as shown on the map above, including
Southmead Hospital and Callington Road Hospital and at community sites across the
city.
2.2
How we have measured our service quality in Bristol:
The table below presents local information, where it is available, for those indicators that
are presented in Part 3 of the main Quality Account.
Please note for several of the indicators presented in the main Quality Accounts
we do not have localised data available. We have therefore excluded these from
the tables below.
71
Measures of our service quality in Bristol
Measure
Trust
Target
Level
Bristol 2014/15
Trust
2013/14
Trust
2014/15
%
Numerator/
Denominator
Patient Experience
Service users seen for their first
appointment within four weeks
of their referral
95%
99%
96.4%
93.1%
Compliance to Department of
Health standards for eliminating
mixed sex accommodation
100%
Meeting six criteria for access to
healthcare for people with a
learning disability
3,676 / 3,950
100%
100%
100%
All Criteria
met
Fully met
Fully met
Fully met
95%
96%
95.6%
78.9%
206 / 261
95%
97%
95.4%
96.7%
231 / 239
<7.5%
6.5%
9.2%
6.1%
3,256 / 53,113
182
246
261
81
95%
98%
96.5%
93.9%
Reduction
Achieved
Achieved
Achieved
Effectiveness
+Care Programme Approach
(CPA) annual review
Admissions to inpatient services
have had access to crisis
resolution home treatment
teams
Minimising delayed transfers of
care
Number receiving early
intervention
Safety
Care Programme Approach
(CPA) seven day follow up
Meeting objectives for the
reduction of infections of
Clostridium difficile and MRSA
755 / 804
72
3.
South Gloucestershire
3.1
Overview of services in South Gloucestershire
During 2014/15 AWP received referrals for 3,792 people registered to GPs in the South
Gloucestershire area. Of those accepted into service, the majority were supported in the
community, however where necessary, some people were admitted into hospital for a
period of inpatient care. The total number of community based contacts and the total
number of inpatient admissions were as follows:


34,672 community contacts
8 inpatient admissions
Services are provided at one inpatient site in Hanham as shown on the map above, as
well as from community sites across the area. South Gloucestershire patients are also
provided with services from locations in the neighbouring area of Bristol with inpatient
services at Callington Road Hospital and Southmead Hospital.
3.2
How we have measured our service quality in South Gloucestershire:
The table below presents local information, where it is available, for those indicators that
are presented in Part 3 of the main Quality Account.
Please note for several of the indicators presented in the main Quality Accounts
we do not have localised data available. We have therefore excluded these from
the tables below.
73
Measures of our service quality in South Gloucestershire
Measure
Trust
Target
Level
South Glos 2014/15
Trust
2013/14
Trust
2014/15
%
Numerator/
Denominator
Patient Experience
Service users seen for their first
appointment within four weeks
of their referral
95%
99%
96.4%
96.7%
Compliance to Department of
Health standards for eliminating
mixed sex accommodation
100%
Meeting six criteria for access to
healthcare for people with a
learning disability
1,806 / 1,868
100%
100%
100%
All Criteria
met
Fully met
Fully met
Fully met
Care Programme Approach
(CPA) annual review
95%
96%
95.6%
97.8%
408 / 417
Admissions to inpatient services
have had access to crisis
resolution home treatment
teams
Minimising delayed transfers of
care
95%
97%
95.4%
96.9%
63 / 65
<7.5%
6.5%
9.2%
0.0%
0 / 4041
182
246
261
25
95%
98%
96.5%
100%
Reduction
Achieved
Achieved
Achieved
Effectiveness
Number receiving early
intervention
Safety
Care Programme Approach
(CPA) seven day follow up
Meeting objectives for the
reduction of infections of
Clostridium difficile and MRSA
16 / 16
74
4.
Bath and North East Somerset (B&NES)
4.1
Overview of services in B&NES
During 2013/14 AWP received referrals for 3,735 people registered to GPs in the B&NES
area. Of these, the majority of service users were supported in the community, however
where necessary, some people were admitted into hospital for a period of inpatient care.
The total number of community based contacts and the total number of inpatient
admissions were as follows:


26,985 community contacts
140 inpatient admissions
Services are provided at two main inpatient sites at St Martins Hospital and Hill View
Lodge, as shown on the map above, as well as at community sites across the area.
4.2
How we have measured our service quality in B&NES:
The table below presents local information, where it is available, for those indicators that
are presented in Part 3 of the main Quality Account.
Please note for several of the indicators presented in the main Quality Accounts
we do not have localised data available. We have therefore excluded these from
the tables below.
75
Measures of our service quality in Bath and North East Somerset
B&NES 2014/15
Trust
Target
Level
Trust
2013/14
Service users seen for their first
appointment within four weeks
of their referral
95%
99%
96.4%
96.5%
Compliance to Department of
Health standards for eliminating
mixed sex accommodation
100%
100%
100%
100%
Meeting six criteria for access to
healthcare for people with a
learning disability
All Criteria
met
Fully met
Fully met
Fully met
Care Programme Approach
(CPA) annual review
95%
96%
95.6%
93.3%
279 / 299
Admissions to inpatient services
have had access to crisis
resolution home treatment
teams
Minimising delayed transfers of
care
95%
97%
95.4%
96.7%
59 / 61
9.2%
10.3%
1,039 /
10,096
Measure
Trust
2014/15
%
Numerator/
Denominator
Patient Experience
1,256 / 1,301
Effectiveness
Number receiving early
intervention
<7.5%
6.5%
182
246
261
38
95%
98%
96.5%
97%
Reduction
Achieved
Achieved
Achieved
Safety
Care Programme Approach
(CPA) seven day follow up
Meeting objectives for the
reduction of infections of
Clostridium difficile and MRSA
163 / 168
76
5.
Swindon
5.1
Overview of services in Swindon
During 2014/15 AWP received referrals for 4,937 people registered to GPs in the
Swindon area. Of these, the majority of service users were supported in the community,
however where necessary, some people were admitted into hospital for a period of
inpatient care. The total number of community based contacts and the total number of
inpatient admissions were as follows:


42,353 community contacts
247 inpatient admissions
Services are provided at three main sites, including Victoria Hospital and Sandlewood
Court as shown on the map above, as well as at community sites across the area.
5.2
How we have measured our service quality in Swindon:
The table below presents local information, where it is available, for those indicators that
are presented in Part 3 of the main Quality Account.
Please note for several of the indicators presented in the main Quality Accounts
we do not have localised data available. We have therefore excluded these from
the tables below.
77
Measures of our service quality in Swindon
Measure
Trust
Target
Level
Swindon 2014/15
Trust
2013/14
Trust
2014/15
%
Numerator/
Denominator
Patient Experience
Service users seen for their first
appointment within four weeks
of their referral
95%
99%
96.4%
99.1%
Compliance to Department of
Health standards for eliminating
mixed sex accommodation
100%
Meeting six criteria for access to
healthcare for people with a
learning disability
1,685 / 1,701
100%
100%
100%
All Criteria
met
Fully met
Fully met
Fully met
Care Programme Approach
(CPA) annual review
95%
96%
95.6%
97.7%
432 / 442
Admissions to inpatient services
have had access to crisis
resolution home treatment
teams
Minimising delayed transfers of
care
95%
97%
95.4%
98.4%
127 / 129
<7.5%
6.5%
9.2%
12.3%
2367 / 19,258
182
246
261
30
95%
98%
96.5%
99.2%
Reduction
Achieved
Achieved
Achieved
Effectiveness
Number receiving early
intervention
Safety
Care Programme Approach
(CPA) seven day follow up
Meeting objectives for the
reduction of infections of
Clostridium difficile and MRSA
259 / 261
78
6.
Wiltshire
6.1
Overview of services in Wiltshire
During 2014/15 AWP received 7,465 referrals for people registered to GPs in the
Wiltshire area. Of those accepted into service, the majority were supported in the
community, however where necessary, some people were admitted into hospital for a
period of inpatient care. The total number of community based contacts and the total
number of inpatient admissions were as follows:


71,891 community contacts
512 inpatient admissions
Services are provided at three main sites at Fountain Way, Charter House and Green
Lane Hospital, as shown on the map above, as well as at community sites across the
area.
6.2
How we have measured our service quality in Wiltshire:
The table below presents local information, where it is available, for those indicators that
are presented in Part 3 of the main Quality Account.
Please note for several of the indicators presented in the main Quality Accounts
we do not have localised data available. We have therefore excluded these from
the tables below.
79
Measures of our service quality in Wiltshire
Measure
Trust
Target
Level
Wiltshire 2014/15
Trust
2013/14
Trust
2014/15
%
Numerator/
Denominator
Patient Experience
Service users seen for their first
appointment within four weeks
of their referral
95%
99%
96.4%
97.4%
Compliance to Department of
Health standards for eliminating
mixed sex accommodation
100%
Meeting six criteria for access to
healthcare for people with a
learning disability
2,563 / 2,631
100%
100%
100%
All Criteria
met
Fully met
Fully met
Fully met
Care Programme Approach
(CPA) annual review
95%
96%
95.6%
98.4%
682 / 693
Admissions to inpatient services
have had access to crisis
resolution home treatment
teams
Minimising delayed transfers of
care
95%
97%
95.4%
91.5%
184 / 201
<7.5%
6.5%
9.2%
17%
5,148 /
30,262
182
246
261
65
95%
98%
96.5%
98%
Reduction
Achieved
Achieved
Achieved
Effectiveness
Number receiving early
intervention
Safety
Care Programme Approach
(CPA) seven day follow up
Meeting objectives for the
reduction of infections of
Clostridium difficile and MRSA
482 / 492
80
APPENDIX E
Further Information on Quality Indicators
This appendix explains the terms and sets out the calculation methods used to achieve
the figures and results listed in the tables included in the Quality Account:
Table 2: Data quality measures
Measure /
Indicator
Data
source
Records
management
standards
Data completeness
- core fields for
patient
identification: NHS
number, GP,
commissioner
code, date of birth,
gender and
postcodes
Data completeness
– core outcome
fields: employment,
settled
accommodation
and HoNOS
assessment
Data quality:
completion of NHS
number (national
indicator, new for
2014/15)
Denominator
Data
period
Electronic
Patient
Record
Shows the % of the specified criteria met for
records of service users on the caseload in the
previous month. Audit completed using a
random sample of five service users per team
or ward
March
2015
Electronic
Patient
Record
The
numerator
divided by
the
denominat
or
expressed
as a %
Number of
service users who
have received
services with all
the relevant fields
completed
Number of
service users
who have
received
services
1 Jan 2015
to 31
March
2015
Electronic
Patient
Record
The
numerator
divided by
the
denominat
or
expressed
as a %
The number of
service users who
have received
services and are
on Care
Programme
Approach (CPA)
with a valid entry
across the three
core outcomes in
the past 12
months
Number of
service users
who have
received
services and
are on CPA
1 Jan 2015
to 31
March
2015
Electronic
Patient
Record
The
numerator
divided by
the
denominat
or
expressed
as a %
Total number of
service users
during period with
valid NHS
Number recorded
in record
Total number
of service
users
receiving a
service during
the period
1 Jan 2015
to 31
March
2015
Definition
Numerator
81
Data quality:
completion of
ethnic category
(national indicator,
new for 2014/15)
Data quality:
completion of risk
assessment (local
indicator, new for
2014/15)
Data quality:
completion of crisis,
relapse and
contingency plans
(local indicator, new
for 2014/15)
Data timeliness system updated in
three days of actual
event
(inpatients and
intensive teams, 24
hours)
Electronic
Patient
Record
Electronic
Patient
Record
Electronic
Patient
Record
Electronic
Patient
Record
The
numerator
divided by
the
denominat
or
expressed
as a %
Total number of
service users
during period with
valid ethnicity
recorded in
record
Total number
of service
users
receiving
service during
the period
1 Jan 2015
to 31
March
2015
Total number of
service users in
the denominator
who have a risk
assessment
completed
Number of
service users
who are: on
CPA, have
been in our
care for at
least 3
months and
had at least
three
attended face
to face
contacts
1 Jan 2015
to 31
March
2015
The
numerator
divided by
the
denominat
or
expressed
as a %
Total number of
service users in
the denominator
who have a
documented crisis
relapse and
contingency plan
Number of
service users
who are: on
CPA, have
been in our
care for at
least 3
months and
had at least
three
attended face
to face
contacts
1 Jan 2015
to 31
March
2015
The
numerator
divided by
the
denominat
or
expressed
as a %
The number of
activities in the
denominator
recorded on the
electronic patient
record within 3
working days of
the event
(inpatients 24
hours)
The total
number of
admissions,
discharges,
referrals,
community
contacts and
outpatient
contacts
recorded
during the
period
1 Jan 2015
to 31
March
2015
The
numerator
divided by
the
denominat
or
expressed
as a %
82
3.1
National Indicators
All details at the Health & Social Care Information Centre website at the following link
https://indicators.ic.nhs.uk
3.1.1 Care programme approach (CPA) seven day follow up
Please see below under table 6 for local reported data. National data is provided for
last two reporting periods: 30 September to 31st December 2014 and 1st January to 31
March 2015.
3.1.2 Admissions to inpatient services have had access to crisis resolution home
treatment teams
Please see below under for table 5 for local reported data. National data provided for
last two reporting periods: 30 September to 31st December 2014 and 1st January to 31
March 2015.
3.1.3 Patient experience of community mental health services
The indicator is a composite, calculated as the average of 4 survey questions from the
annual national community mental health survey. The questions relate patients’
experience of contact with a health and social care walker. The questions are:
Thinking about the last time you saw this NHS health worker or social care worker for
your mental health condition…
 Did this person listen carefully to you?
 Did this person take your views into account?
 Did you have trust and confidence in this person?
 Did this person treat you respect and dignity?
For each Provider an average weighted score (by age and sex) is calculated for each of
the questions. Overall Trust scores are calculated as a simple average of the 4 question
scores. National scores are calculated by a simple average of the overall trust scores.
Data for 2014 is not presented due to the survey questions having been revised and
therefore 2014 results are not able to provide a reliable comparison on previous years
scores.
3.1.4 Nationally reported patient safety incident data
Data is produced by the National Patient Safety Agency, National Reporting and
Learning Service available at the following link:
http://www.nrls.npsa.nhs.uk/patient-safety-data/
3.1.5 Staff Friends and Family Test
Data is provided for this indicator from the annual NHS Staff Survey. The indicator is the
percentage of staff who answers were either ‘agree’ or ‘strongly agree’ with the question
“If a friend or relative needed treatment I would be happy with the standard of care
provided by this organisation”.
83
Table 3: Patient experience – how we did
Measure /
Indicator
Service users
seen for their
first
appointment
within four
weeks of their
referral
Data
source
Electronic
Patient
Record
Indicator
Compliance to Department
of Health standards for
eliminating mixed sex
accommodation
Definition
Numerator
Denominator
Data
period
The
numerator
divided by
the
denominator
expressed
as a %
Number of
service users
seen for their first
appointment
within four weeks
of the Trust
receiving the
referral
Number of
service users
referred to the
Trust to have
been seen for a
first
appointment
1 April
2014 to 31
March
2015
Further information
Seventeen principles to support the Department of Health
‘Delivering Same Sex Accommodation’ initiative have been
developed to ensure each organisation delivers the highest
standards of privacy and dignity within all areas of a hospital,
other trusts and providers.
Further information at the following link:
http://www.cqc.org.uk/sites/default/files/documents/supporting_no
te_mixed_sex_accommodation_for_external_publication.pdf
NHS Trusts make self-assessment against six criteria for meeting
the needs of people with a learning disability which are based on
recommendations included in Healthcare for All (2008). These
are set out in summary below:
1. Identification and flagging of patients with learning
disabilities
2. Providing readily available and comprehensible
information for patients with learning disabilities
Meeting six criteria for
access to healthcare for
people with a learning
disability
3. Protocols in place to provide suitable support for family
and carers who support patients with learning disabilities
4. Having arrangements to routinely include training on
providing healthcare to patients with learning disabilities
for all staff
5. Protocols in place to encourage representation of people
with learning disabilities and their family carers
6. Arrangements in place to regularly audit its practices for
patients with learning disabilities and to demonstrate the
findings in routine public reports
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NHS patient satisfaction
question
‘Overall, how would you rate
the care you have received
from NHS
Mental Health Services in
the last 12 months?’
Score for staff survey
question on staff
recommendation of the trust
as a place to work or
receive treatment
This represents the score for one question taken from the
national Care Quality Commission, Community Mental Health
Survey. The results of the last survey are available at the
following link:
http://www.cqc.org.uk/provider/RVN/survey/6
This represents the score for one question taken from the
national NHS staff survey available at the following link:
http://www.nhsstaffsurveys.com/Page/1006/Latest-Results/2014Results/
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Table 5: Effectiveness – how we did
Measure /
Indicator
Annual CPA review
Admissions to
inpatient services
have had access to
crisis resolution
home treatment
teams
Minimising delayed
transfers of care
Data
source
Denominato
r
Data
period
Electronic
Patient
Record
The number of
service users in
the
The numerator
denominator
divided by the
who have
denominator
received a
expressed as
review of their
a%
care and
treatment in the
last 12 months
The number
of service
users on
CPA who
have been
open to the
Trust for 12
months or
more
Snapshot
at 31
March
2015
Electronic
Patient
Record
The total
The numerator
number of
divided by the admissions that
denominator
were assessed
expressed as
by the crisis
a%
service prior to
admission
The total
number of
admissions
1 April
2014 to
31 March
2015
Electronic
Patient
Record
The numerator
divided by the
denominator
expressed as
a%
Total
number of
Occupied
Bed Days
(OBDs) in
the period.
1 April
20143 to
31 March
2015
Indicator
Number receiving early
intervention
The total number of 'new'
confirmed cases of psychosis
taken on by the Early
Intervention Teams.
(Target number of cases per
annum)
Definition
Numerator
Total number
of days
delayed during
the period
Further information
This target was set for mental health trusts as part of the
implementation of the National Service Framework for
Mental Health in 1999.
A specialist service for early intervention for patients with
psychosis must be provided in each local area:
Each CCG area has targets for new assessments.
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Table 6: Safety – how we did
Measure /
Indicator
Data source
Definition
Numerator
Denominator
Data
period
Electronic
Patient
Record
The number
inpatients
The numerator discharged
divided by the
to be
The number of
denominator
followed up
in-patients
expressed as within 7 days
discharged
a%
of discharge,
phone or
face to face
1 April
2014 to 31
March
2015
Percentage
answering
‘yes always’ to
the survey
question
‘During your
most recent
stay did you
feel safe?’
Inpatient
Survey
Report 2014
The
numbers of
people
answering
‘yes
definitely’ to
the question
“During your
most recent
stay did you
feel safe?”
Survey
conducted
May to
August
2014
Sickness
absence data
cumulative
average over
past 12
months
Internal
Electronic
Staff Record
(ESR)
sickness
absence
monitoring
CPA seven
day follow up
The numerator
divided by the
denominator
expressed as
a%
The number of
people
responding to
the question
“During your
most recent
stay did you
feel safe?”
Calculation is automatically made via input to
the national ESR database on the number of
sick days lost, head count of sick staff and
head count of all staff. Formulae not available.
1 April
2014 to 31
March
2015
Indicator
Further information
Meeting objectives for the
reduction of infections of
Clostridium difficile and
MRSA
NHS trusts are required to demonstrate year on year
reductions in the incidence of the hospital communicated
and acquired infection Clostridium Difficile and Methicillinresistant Staphylococcus aureus (MRSA)
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