Quality Report 2014/15
Quality Report
2014 - 2015
Quality Report 2014/15
CONTENTS PAGE
Page Number
PART ONE:
Statement on quality from the Chief Executive of the NHS foundation Trust
3
PART TWO:
Performance Against Priorities for Quality Improvement 2014/15
5
Priorities for Quality Improvement 2015/16
18
Statements of Assurance from the Board
24
National Quality Indicators
36
Further Quality Indicators
44
PART THREE:
Review of Quality Performance 2013/14
45
ANNEXES:
Annex A - Statements from Other Bodies
52
Annex B – Statement from the Directors
56
Glossary
58
Summary of changes following stakeholder commentary
60
Independent Auditors’ Limited Assurance Report to the Directors
60
2
Quality Report 2014/15
PART ONE: Statement on Quality from the Chief Executive of the Foundation Trust
On behalf of the Board of Nottinghamshire Healthcare, I am pleased to be able to present
our seventh Quality Account and our first as a Foundation Trust. This Account covers the
year April 2014 to March 2015. This report focuses on the quality of services we deliver and
is a statement of our openness and our wish to be publically accountable for the quality of
the services we deliver.
During the early part of the financial year we were inspected by the Chief Inspector of
Hospitals from the Care Quality Commission (CQC). The Care Quality Commission is the
independent regulator of health and adult social care in England who ensures that health
and social care services provide people with safe, effective, compassionate, high-quality
care.
Over 100 inspectors looked at the quality of the services we provide and we were delighted
to be rated as Good overall, with an outstanding rating for our caring staff. There was room
for improvement though, which you would expect in a Trust with such a diverse and
geographically spread range of services. There were some issues around safety and
compliance with the Mental Health Act. The issues that were raised have been taken very
seriously, indeed the Inspection Team commented on our immediate response, before the
inspection had even been concluded. The learning from this experience has not been lost
across the Trust and we await re-inspection at some time in the near future.
As I have already mentioned, during the year we were authorised by Monitor as a
Foundation Trust. This was a successful outcome after a year of assessment and external
scrutiny. Our standards and governance procedures were robustly examined and were
found to be strong enough to allow for authorisation. The scrutiny during this period and the
development of a robust Quality Governance Assurance Framework enhanced the way we,
as an organisation, think about quality and how it can be most effectively monitored by the
Board.
Cost Improvements are important for every NHS organisation, making sure that public
money is being invested in cost efficient and quality services. The impact of those
improvements on the quality of services we deliver is closely monitored by both our Medical
Director and our Director of Nursing, Quality and Patient Experience. We are determined to
ensure financial challenges do not impact on patient safety.
We are committed to operationalising our existing pledge to the ‘Sign Up to Safety’
campaign. Based upon the current quality priorities and strategic drivers six key areas have
been identified for the campaign to focus on. These are:
•
•
•
•
•
•
Restrictive practices
Suicide and self-harm
Assaults and violence
Medication errors
Pressure Ulcers
Falls
There is already significant work going on within the Trust under each of these categories
but the three year campaign will provide an opportunity to bring together all of this work
within a coherent framework with clearly identified goals and a work stream focused on
enabling mechanisms such as measurement techniques, analysis and service improvement
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Quality Report 2014/15
methodologies such as human factors. This will go some way to making further quality
improvements a reality.
As we move into 15/16 we are undertaking a series of engagement events to include our
staff in the development of our strategy refresh and how we want to shape the future of the
Trust. An exciting time but with a clear focus on delivering quality services day in and day
out to the patients, service users, carers and partners with whom we work.
To the best of my knowledge the information contained in the Quality Account is accurate.
Ruth Hawkins
Chief Executive
Date: 28th May 2015
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Quality Report 2014/15
PART TWO: Priorities for Improvement and Statements of Assurance from the
Board
Performance against Priorities for Quality Improvement 2014 / 15
This section of the Quality Report looks back at the Quality Priorities we set for 2014/15 and
the progress we have made to achieving them. Where the measures were the same in
2013/14 we have provided that information to demonstrate progress over time. These
priorities were identified and developed in consultation with commissioners, clinical divisions,
staff, service users, carers, the Joint Health Scrutiny Committee and Healthwatch. They also
reflected priorities identified through the national staff and patient surveys and our own
service user survey.
SAFETY
Quality Priority 1:
Reduce the impact of physical assaults on service users and staff
We chose this priority because of the number of assaults our service users and staff
experience which causes harm and affects service user experience and staff sickness levels.
This priority continued from 2013/14 however we changed the focus from reducing the
number of assaults to reducing the impact.
We said we wanted to:
We achieved:
Have no physical assaults within
categories of Severe Harm or Death
the There have been no physical assaults within
the categories of Severe Harm or Death
Reduction assaults by 10% within the The tables below demonstrate that the 10%
category of Moderate Harm for staff and target in the reduction of assaults within the
category of moderate harm for staff and
patients
patients has been achieved by the Trust.
Have no increase in staff sickness related to
physical assaults at work
Be in the top 20% of performing Trusts in the
category ‘staff experiencing physical violence
from patients, relatives or the public’ in the
National Staff Survey
The proportion of moderate harm incidents
as a percentage of all physical assault
incidents has reduced slightly from 2013/14.
Incidents on staff in 2013/14 was 22% and in
2014/15 21%. Incidents on patients in
2013/14 was 19% and in 2014/15 16%.
There has been no increase in staff sickness
related to physical assaults at work. The
figures have remained consistent throughout
the year at 0.07% with a slight reduction in
Q4 at 0.06%. In 2013/14 this was 0.8%.
2014 Survey - The Trust did not rank within
the top 20% of performing Trusts in relation
to this Staff Survey question (KF16).
However, staff reporting experiencing
physical violence has improved from 19%
(2013) to 17%; this is in line with the national
average for mental health/leaning disability
Trusts.
The best score for mental
health/learning disability Trusts in 2014 was
8% and the average score was 18%.
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Quality Report 2014/15
Number of Physical Assaults with Moderate Harm
Staff
231
226
222
106
217
213
168
209
188
Nov / Dec / Jan
Feb/Mar
132
67
13/14
Q1
July / Aug
Sept / Oct
14/15 Actu al (Cu mu lative)
14/15 10% Redu ction Target
Patients
91
89
17
13/14
Q1
87
24
July / Aug
14/15 Actual (Cumulative)
86
38
Sept / Oct
84
82
53
57
Nov / Dec / Jan
Feb/Mar
14/15 10% Reduction Target
The graphs illustrate the number of physical assaults reported as moderate harm against
service users and staff. To achieve the 10% reduction with a trajectory of reducing incidents
by 10% within the year no more than 209 staff assaults of 82 patient assaults should occur.
Evidence shows that Trust has achieved meeting its target. It should be noted that the Trust
received a limited assurance internal audit which identified that the degree of harm may not
have been applied consistently. This will be an area of focus during 2015/16.
A notable achievement was Topaz Ward at Rampton Hospital being awarded the Nursing
Times award for Patient Safety in Wells Road. The model of nursing care on Topaz and its
approach to risk management has developed significantly over the past two years. By
working collaboratively with their patients they ensure positive risk management and not only
has this seen a marked reduction in the levels of violence and self-harm on the ward, it has
also allowed the patients to have more responsibility, autonomy and opportunities on the
ward.
Looking forward to 2015/16
The Violence Reduction Strategy Group has developed of an action plan to implement the
Trust Violence Reduction strategy across the organisation. The implementation plans
provides a clear set of domains from creating a safe working environment to post incident
support and management with a set of actions to be implemented. Its primary focus is
establishing quality markers with regards to the prevention, minimising and management of
workplace violence across Nottinghamshire Healthcare NHS Foundation Trust. Reducing the
impact of violence continues to be a priority for improvement in 2014/15.
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Quality Report 2014/15
Quality Priority 2:
Improve the Quality of Record Keeping to Support Delivery of
Safe and Effective Person Centred Care
We chose this priority because clinical audits, CQC inspections and internal compliance
reviews had identified some deficiencies in record keeping. For services to be safe and
effective clinicians need accurate and timely information that clearly defines care
requirements. This was a priority in 2013/14 but what we measured in 2014/15 is different to
2013/14 and therefore it is not possible to provide accurate information to compare.
We said we wanted to:
We achieved:
Audits to demonstrate continued adherence The Trust continues to monitor the quality of
and improvement in compliance with Trust record keeping through its clinical audit
record keeping standards
process. Each clinical division has a clear
annual audit programme which includes the
quality of the Trust record keeping standards.
CQC
and
QUEST
inspections
to The Trust continues to measure standards of
demonstrate compliance with Outcomes 4 record keeping via both internal and external
and 21 (no target)
compliance reviews. The Trust is currently
reviewing its internal compliance review
process in line with the Care Quality
Commission (CQC) fundamental standards.
Forensic Services Division
Although there is some variability across the services some areas of improvement have been
noted such as evidence within the records of nursing care plans that had been signed by the
patient or gave the reason for them not doing so, patient involvement in formulation of care
plans and reading of patient’s rights. There are some areas where there is still some room
for improvement (e.g. more detailed recording of consent to treatment), and, where
improvement is required, services are looking at related actions within their own services.
Across services Ward Manager/Team Leader checks are performed at ward level to ensure
that standards are being adhered to and maintained. Additionally migration of identified
documents into the electronic records system (CESA) is continuing to be rolled out at
Rampton to improve consistency in record keeping across wards. Low Secure and
Community Forensic Services are now using the electronic running record within RiO (our
clinical information system).
Health Partnerships Division
Have moved to Survey Monkey for documentation audits which allow greater access to
information. There are many good examples of record keeping however some key areas for
improvement across the localities have been identified such as use of the consent to record
sharing form, recording information about allergies, falls risk assessments, initial and holistic
assessments and discharge planning.
Local Services Division
All teams across Local Services submitted a monthly records audit between Oct – Dec 2014
which identified some good practice and improvements from previous audits. Two teams
within Mental Health Services for Older People and one team in Intellectual Disability were
noted to be compliant across all core standards. Child and Adolescent Mental Health
Services (CAMHS) have demonstrated gradual but sustained improvement.
Looking forward to 2015/16
This is not going to be a specific, separate quality priority for 2015/16 as record keeping is
fundamental to all quality priorities and will be monitored as part of the ongoing monitoring of
each priority. Record keeping audits are included in each divisions clinical audit plan which
will be monitored by the Patient Safety and Effectiveness Committee.
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Quality Report 2014/15
Quality Priority 3:
Eliminate Acquired Avoidable* Stage 4 & Stage 3 Pressure
Ulcers; and Reduce the Number of Acquired Avoidable Stage 1
and 2
We chose this priority because many pressure ulcers are avoidable and cause unnecessary
harm and result in a poor patient experience. This was also a priority in 2013/14 and the
graphs below also show how we performed that year.
We said we wanted to:
We achieved:
50% reduction in acquired avoidable stage 1
pressure ulcers
50% reduction in acquired avoidable stage 2
pressure ulcers
0 acquired avoidable stage 3 pressure ulcers
The Trust did not meet its 50% reduction of
stage 1 pressure ulcer target.
The Trust did not meet its 50% reduction of
stage 2 pressure ulcer target.
The Trust reported 102 stage 3 acquired
avoidable pressure ulcers in 2014/15.
0 acquired avoidable stage 4 pressure ulcers The Trust reported 3 stage 4 acquired
avoidable pressure ulcers in 2014/15. None
have been reported since October 2014.
100% compliance against relevant CQUIN The Trust only partially achieved the CQUIN
targets
targets relating to pressure ulcers.
*The term ‘acquired’ means the pressure ulcer occurred whilst the patient was receiving care
from the Trust either as an in-patient or in the community. ‘Avoidable’ means we did not do
one of the following: evaluate the person’s clinical condition and pressure ulcer risk factors;
plan and implement interventions that were consistent with the persons needs and goals,
and recognised standards of practice; monitor and evaluate the impact of the interventions;
or revise the interventions as appropriate.
During 2014/15 the attention to this agenda has continued and is becoming more challenging
to maintain the continued improvement in performance and the work on this ambition has
seen a cultural change in clinicians. Although the targets have not been met, there has been
a considerable amount of improvement work through the year and some examples of this are
given below
•
The Bassetlaw Health Partnership (BHP) Tissue Viability team developed and
launched a bespoke React to Red training package for care homes around pressure
ulcer prevention in August 2014. This has been backed by the East Midlands
Academic Health Science Network – Patient Safety Collaborative and is now being
rolled out across some Clinical Commissioning Groups (CCGs) in the East Midlands.
BHP have the lowest incidence of care home pressure ulcers compared to those
localities within the Nottinghamshire CCG’s who have not yet commenced the
programme.
•
The Patient Safety Collaborative (PSC) is working with Maastricht University to learn
from the best and implementing a prevalence tool in the East Midlands to be able to
benchmark pressure ulcers locally, nationally and internationally, which will support
the training programme and Nottinghamshire Healthcare will be involved in this
project, and a member of the team has been seconded to the PSC to support roll out.
•
The Forensic Division have appointed a full time Tissue Viability Nurse. This has
included the implementation of pressure ulcer risk assessments in Offender Health,
and support with the management of complex wounds, and the education of all staff
within the division.
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Quality Report 2014/15
•
A recent market place event hosted by the
East Midlands Patient Safety
Collaborative had two presentations and both were from Nottinghamshire Healthcare
Tissue Viability Team showcasing the care home initiative and presenting a patient
and carer perspective of living with a pressure ulcer which were extremely well
received.
•
Clinical teams and the Tissue Viability Team have worked together to streamline
SystmOne so that all documentation relating to pressure ulcer prevention and
management is contained. This has been extremely well received and documentation
audits are showing a significant improvement in nursing documentation.
•
In November 2014 to coincide with World Stop the Pressure Day the team hosted a
conference for over 80 clinical staff from across the organisation to showcase and
celebrate the pressure ulcer journey within Nottinghamshire Healthcare over the past
two years. The event evaluated extremely positively and led to sharing of ideas and
service developments locally.
•
Root Cause Analysis action plan tracker showcased across organisations and
external interest from other provider organisations wanting to emulate the initiative.
Looking forward to 2015/16
This will continue to be a quality priority in 2015/16 as part of our participation in the Sign up
to Safety Campaign.
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Quality Report 2014/15
Quality Priority 4:
Improve Medicines Management to Reduce the Impact of
Medication Errors
We chose this priority because of the number of medication errors that are reported each
year. There were 684 reported in 2013/14 and these can potentially cause serious harm.
This was also a priority in 2013/14 however what we have measured has changed and it is
not possible to provide comparative information.
We said we wanted to:
We achieved:
0 never events
No never events reported in 2014/15 within
the Trust.
0 medication errors categorised as Severe No medication error incident reported in
Harm or Death
2014/15 within the Trust as severe harm or
death.
Audits to demonstrate compliance with The Trust continues to monitor the quality of
medicines management standards
medicines management standards through its
clinical audit process. Each clinical division
have a clear annual audit programme which
includes the quality of the Trust medicines
management standards.
The Trust has established a Trust wide Medication Safety Committee to monitor, promote
and advance a culture of medication safety as a priority across the Trust, through
encouraging increased reporting of medication errors, improving the quality of error reports,
and disseminating learning from medicines errors across the Trust to improve and inform
future practice
The group monitors any moderate and severe incidents related to medication errors
(administration and/or prescribing incidents). Following analytical scrutiny of these incidents
it was apparent that work is needed to train staff on how to grade incidents appropriately in
line with the Trust incident reporting policy as a significant proportion of incident did not meet
the definitions. 14% of the data submitted for medication incidents were reported as ‘Other’.
This is higher than the best practice standard of <=5%. Furthermore this makes it difficult to
establish learning. Work continues to be carried out to potentially remove the ‘Other’
category and establish a more appropriate outcome. Medication Alerts are received by both
Ulysses and from pharmacist's own alert processes. Work is being carried out to see if this
can be monitored and action via one process, via Ulysses. Medication audits are currently
being reviewed.
Indicators: - 0 Never Events
- 0 Medication Errors Categorised as Severe Harm
- 0 Medication Errors Categorised as Death
Trust Target
2014/15
Total Number of Medication
Errors (prescribing)
No target set
197
Total Number of Medication
Errors (administration)
No target set
279
Total Number of Medication
Errors Categorised Severe
Harm or Death
0
0
Number of Never Events
0
0
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Quality Report 2014/15
Looking forward to 2015/16
Medication safety will continue to be a quality priority in 2015/16 as part of our participation in
the Sign up to Safety Campaign.
PATIENT EXPERIENCE
Quality Priority 5:
Ensure Overall Experience of Patients, Carers, Service Users and
Staff is Positive and Consistent across all Trust Services
We chose this priority because patients need to be valued and respected, listened to and
communicated with effectively. Caring for people with a mental illness or physical healthcare
problem can be challenging and carers themselves need to be supported and well informed.
Staff engagement is a measure of employees’ emotional attachment to their job and
influences their performance and willingness to perform.
This was a priority in 2013/14. This is an area of ongoing development and improvement.
How we used to measure success was different in 2014/15 and therefore it is difficult to
provide information on the same measures as 2013/14.
We said we wanted to:
We achieved:
90% Service Quality Rating (Trust)
100% Compliance against relevant CQUIN
targets
0 severely / strongly critical postings via the
The Trust has consistently achieved the
target of 90% during the year for the Service
Quality Rating with a Month 12 performance
of 94%. Friends and Family Test Score was
97% for Month 12 (this is the percentage of
people who would be extremely likely or
likely to recommend our services if their
friends or family need similar care or
treatment).
In 2013/14 Local Services and Health
Partnerships achieved the ambition of 80%
positive response from Patient Satisfaction
Surveys.
The Trust met 100% compliance against
CQUIN targets relating to patient experience.
See detail in graphs below.
The Trust received 1 strongly critical posting
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Quality Report 2014/15
Patient Opinion website
via the Patient Opinion website. The posting
was in regards to the level of care provided
to a patient involving various service
providers. This was responded to and
improvements made to the care pathways.
Staff Voice and Staff Opinion implemented.
During the year the Trust has undertaken the
annual national NHS staff opinion survey, the
staff friends and family test and Investors in
People assessment. All of these provide the
Staff Voice and Staff Opinion implemented
Trust a good indication of the views and
opinions of our staff. From these the Trust
will develop an integrated action plan and
deliver on any actions raised. Dates and
timelines to be agreed.
Patient feedback processes can be provided
in a variety of ways including the Trust
By the end of 2014/15 all clinical teams to be Feedback Challenge, Patient Opinion
providing feedback
website and patient surveys questionnaires
and forum. Please refer to the narrative
below.
The Trust utilises Service User and Carer (SUCE) forms which when analysed enable the
Service Quality Rating to be calculated, the Patient Opinion website and the Trust Feedback
Matters website and respond to feedback using the ‘what we have done’ section together
with ‘you said we did’ posters across wards and clinics and community treatment services.
In addition, the Local Services Division have successfully launched "Highbury Live!" and
"Millbrook Live!" the third site at Bassetlaw will be launching "Bassetlaw Live!" in spring 2015.
Hosted by Mental Health Services for Older People (MHSOP), the "Live" initiatives are
central to the Local Services Division aspiration to involve the whole local community and
include, at their core, a Patient's Council. Capturing feedback from service users, carers and
the community is an essential component of each initiative and is key to improving services.
Many Trust services have a variety of coordinated initiatives including community meetings,
carer’s events and open evenings where people can meet as a group to discuss their
experiences and some have introduced involvement champions. The Specialist Services
Directorate has developed a number of initiatives to ensure that those patients with
Intellectual and Developmental Disabilities can provide feedback on the services received.
Rampton, as a bigger site, has a patient’s council with representatives from all services.
This is attended by all hospital managers and is seen as an important part of the hospitals
governance practices.
Most areas use the service liaison database to report informal concerns/complaints – this is
particularly well used in offender health with actions taken recordable on this system.
Offender Health also offers patients’ forums in differing forms in each area as well as
initiatives such as peer workers. All of the practices detailed above are well embedded and
consistently implemented but we continue to work with patients to explore alternative
approaches including encouraging greater use of the service user survey, patient opinion
and the role out of friends and family test.
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Quality Report 2014/15
Indicator: 90% Service Quality Rating
Trust Actual
March
(Month 12)
Year to Date
94%
94%
(based on
1954
responses)
(based on
26036
responses)
Local Services Division
Forensic Services
Division
Health Partnerships
Division
March
(Month 12)
Year to Date
March
(Month 12)
Year to Date
March
(Month 12)
Year to Date
92%
92%
68%
76%
96%
94%
(based on 401
responses)
(based on
4441
responses)
(based on 17
responses)
(based on
1210
responses)
(based on
1546
responses)
(based on
20395
responses)
Looking forward to 2015/16
This will continue to be a quality priority in 2015/16.
CLINICAL EFFECTIVENESS
Quality Priority 6:
Ensure Physical and Mental Health Care Needs of all users of
Trust Services are Met and Given Equal Priority
We chose this priority because there is evidence that people who use mental health services
are at an increased risk from physical healthcare illnesses and their life expectancy is
reduced. There is also evidence that people who suffer from long term physical health
problems are more likely to suffer from mental health issues. This was also a priority in
2013/14.
We said we wanted to:
We achieved:
100% compliance of completed physical
healthcare checks in records audit in line
with annual plan
The Trust has not met the 100% compliance
of completed physical healthcare checks in
records audit in line with annual plan.
In 2013/14 Local Services were reviewing
how to collect this information and Forensic
Services
achieved
95%.
This
has
deteriorated to 85% in 2014/15.
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Quality Report 2014/15
The Trust has not met 100% compliance
against set CQUIN targets.
100% compliance against set CQUIN targets
In 2013/14 the Trust met all the relevant
CQUIN targets. There are set by our
commissioners and the 2014/15 targets are
not a direct comparison.
This is a significant improvement within Local Services Division as the results now exclude
community adult mental health. They have been excluded following review of the Physical
Examination and Assessment Policy which clarified the requirements for these teams.
The Cardio Metabolic Assessment for Patients with Schizophrenia (Total Value = £67,637)
was a one-off CQUIN target, based on an audit conducted in Quarter 3. The outcome of this
is not yet available.
Looking forward to 2015/16
This will not be a separate quality priority for 2015/16. However, physical healthcare will be
included in the quality priority relating to clinical outcome measures including use of the
Physform. This will also include ensuring physical healthcare problems identified for mental
health services users are appropriately managed.
Additionally, a paper setting out proposals for the full implementation of NICE public health
guidance on smoking including no staff or patient smoking on Trust premises, including
grounds was presented to the Trust Board in February 2015. The proposals were supported
from the findings of a local pilot undertaken on two wards and the substantial experience of
Cheshire & Wirral Partnership NHS Foundation Trust who completed full implementation in
2013. The NICE guidance was formed of 16 recommendations of which 14 were relevant to
the Trust. A number of the recommendations had already been successfully implemented.
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Quality Report 2014/15
OTHER QUALITY PRIORITIES
Quality Priority 7:
Understand the Impact that Cost Improvement Programmes
(CIPs) Have on the Quality of Service Provision and Ensure
Identified Risks are Managed
We chose this priority because of the impact the economic climate has on NHS resources
and the need for the Trust to transform the way it works to increase productivity at a reduced
cost. We therefore need to ensure we understand the impact this might be having on our
services. This was also a priority in 2013/14 however because of the improvements we have
made to this process; most of our measures were different in 2014/15.
We said we wanted to:
We achieved:
At least one Clinical Confirm and Challenge Achieved prior to confirmation of 2014/15
carried out annually by ELT
CIPs. We also achieved this in 2013/14.
The process for the identification of specific,
Monthly CIP monitoring report with clearly
relevant and measurable quality metrics for
defined, specific, relevant, measurable
CIP schemes is part of the Quality Strategy
quality metrics
for 2014/15 - 2019/20.
In line with Monitor best practice, the Trust
has a structured approach to monthly Cost
Quality and Risk Committee to undertake a Improvement Plan (CIP) assurance reporting
deep dive into each CIP scheme with a to ensure the Board of Directors has strong
Quality Impact score of 8+
oversight and ownership of both financial and
qualitative aspects of the annual efficiency
programmes.
The overall CIP programme oversight remains through the Executive Leadership Team.
Divisional reports are received on a monthly basis with an escalation and assurance report
on to the Board. In addition to providing an overall RAG-rating status score for both
Deliverability and Quality Impact, the Trusts CIP Assurance Framework allows ELT and the
Board of Directors to gain specific assurances around those CIP schemes that have a quality
impact score of 8 or more. Any areas that require escalation or more intensive challenge
may be referred through to the Finance and Performance Committee or the Quality and Risk
Committee or ultimately the Board of Directors, as appropriate.
The Divisional overview for month 12 for the period ending 31st March 2015 is as follows:
Forensic Services - Overall status for quality impact was green. There was one current
scheme with a Quality Impact Assessment score of 8 or above.
Local Services - Overall status for quality impact was green. There were two schemes with a
Quality Impact Assessment score of 8 or above.
Health Partnerships - Overall status for quality impact was green. There are no current
schemes with a Quality Impact Assessment score of 8 or above.
Looking forward to 2015/16
This will continue to be a quality priority in 2015/16
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Quality Report 2014/15
Quality Priority 8:
Ensure the appropriate number and skill mix of staff for who the
outcome of appraisals, supervision and training support the
delivery of safe, high quality care
We chose this priority because the delivery of high quality services requires a highly trained
and skilled workforce. This was also a priority in 2013/14.
We said we wanted to:
We achieved:
In top 20% of performing Trust – NHS Staff
Survey Family and Friends Test
In top 20% of performing Trust – NHS Staff
Survey Structured Appraisals
Compliance with Trust Performance Targets
KF24 - Friends & Family Survey question.
The Trust ranked in the top 20% of
performing trusts. An improvement from
2013.
KF8 - Well Structured Appraisals. The Trust
score for 2014 was 49%, an improvement
from the 2013 score of 43%, The Trust
continues to be in the top 20% of performing
trusts
See graphs on next page
The Trust was rated in the top 20% of mental health/ learning disability trusts for 18 out of
the total 29 key findings in the 2014 NHS Staff Survey. A review of the Trust’s performance
in the NHS Staff Survey is provided below:
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Quality Report 2014/15
Looking forward to 2015/16
This will continue to be a quality priority for 2015/16 as part of the priority relating to having
the right number of staff with the right skills.
Priorities for Quality Improvement 2015/16
Our ambition is that every person who uses our services receives the best healthcare
possible every time they have contact with us. Listening to patients, their carer’s and families
will assist us to understand their experience and will help us to achieve this ambition. Our
staff are already recognised for delivering outstanding care and compassion for patients. We
are determined to build upon this achievement and strive to deliver integrated care that is
safe and effective every time. Our Quality Priorities for 2015/16 will help us to achieve this
ambition.
To agree our priorities for improvement for 2015/16 a number of consultation events were
held. Through the Joint Health and Scrutiny Committee, attended by HealthWatch, the
views of the wider public were considered. Views from our patients, carers, staff and other
stakeholders were sought through the Council of Governors Quality Interest (and Innovation)
Group and staff members were also consulted with via the Senior Nurse and Allied Health
Professionals Advisory Council. In addition, Nottingham City Clinical Commissioning Group
was consulted on behalf of all of our commissioners of services.
During 2014/15 the Trust started to report information on the quality of services around the
Care Quality Commissions (CQC) five domains: safe, caring, effective, responsive and wellled. This means the Trust can more easily identify whether the quality of services delivered
may not be fully compliant with CQC requirements. For 2015/15 we have chosen to develop
and report progress on quality priorities against these five domains. More information on
CQC and our compliance with their requirements can be found later in the report.
Sign up to Safety Campaign and the Patient Safety Collaborative
The Trust considers the safety of our patients and staff to be paramount and is therefore
committed to reducing avoidable harm. We are participating in the national ‘Sign up to
Safety’ campaign launched by NHS England to support their ambition of reducing avoidable
harm by 50% and saving 6,000 lives in three years. Their vision is for the whole NHS to
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Quality Report 2014/15
become the safest healthcare system in the world, aiming to deliver harm free care for every
patient every time.
Trust participation in the Campaign is also one of the strategic projects for the Trust in
2015/16 to support the delivery of our Integrated Business Plan. Our first three Safe Quality
Priorities are our pledges for improvement in the Campaign and are also aligned to the work
of the Patient Safety Collaborative established through the East Midlands Academic Health
Science Network. The Collaborative are developing a learning and improvement system to
support patient safety and quality improvement. The Trust is engaged in this Collaborative
who have provided a statement for this Quality Report in Section 3.
Monitoring Progress with Quality Priorities
The Board Committee with overall responsibility for monitoring the quality priorities is the
Quality and Risk Committee. This committee, which meets six times per year, received
during 2014/15 a regular Quality Priority Report to track progress with our ambition for each
priority. These monitoring arrangements will continue in 2015/16.
The reports identify actual and potential underperformance to act as a trigger to ensure
action is taken to improve performance against agreed trajectories. The Board of Directors
also regularly monitors key performance indicators through the monthly Quality and
Performance Report. This includes quality priority related information such as incidents,
CQC inspections and QUEST reviews (our internal inspection process), incidents, pressure
ulcers, patient experience, quality impact of cost improvement programmes (CIPs) and
workforce indicators such as safe staffing levels. The Board also receives regular service
user and carer experience (SUCE) reports.
Protected Characteristics
The Equality Act 2010 gives the Trust opportunities to work towards eliminating
discrimination and reducing inequalities in care. Our patients, service users and carers have
the right to be treated fairly and not to be discriminated against, regardless of their ‘protected
characteristics' (see a list of protected characteristics below). Laws under the Equality Act
set out that every patient should be treated as an individual and with respect and dignity.
The Trust already has clear values and principles about equality and fairness and achieved
1st place in the Stonewall Top 100 employers Index in 2015. This enables us to continue to
develop and deliver services which understand individual need and recognise and value
diversity. As part of our commitment to tackle health inequalities we have embedded
nationally required Equality Delivery System2 (EDS2) within our Strategic Equality and
Diversity Action Plan. This is monitored by the Workforce, Equality and Diversity subcommittee of the Board of Directors and the Equality, Diversity and Inclusion Community of
Interest. In monitoring the implementation of our quality priorities we will, where possible
report on the effectiveness of these by the protected characteristics. The Equality Act 2010
offers protection to nine characteristics. These are:
•
•
•
•
•
•
•
•
•
age
race
gender
gender reassignment status
disability
religion or belief
sexual orientation
marriage and civil partnership status
pregnancy and maternity
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Quality Report 2014/15
Quality Priorities 2015/16
The table below sets out our priorities, why we have chosen them and how, in addition to
monitoring progress at the Quality and Risk Committee as describe above, they will be
monitored and measured. Specific targets and trajectories for improvement, particularly
relating to safety will be developed where appropriate and included in the Trusts Quality
Strategy.
2015/16 Priority
Why we have chosen the
priority
How we will monitor and
measure the priority
SAFE
1
2
3
Reduce avoidable
harm focussing
on:
• Physical
assaults on
patients and
staff
• Pressure ulcers
• Medication
Errors
• Patient Falls
Suicide prevention
and reducing selfharm
Reduce restrictive
practice to ensure
the ‘least
restrictive’
principle is applied
for all patients
The Trust has chosen to focus
on these four areas of harm as
our monitoring of quality and
safety has identified these as
incidents that occur more
frequently and potentially could
cause significant harm.
The Trust continues to be
committed to reducing suicide
and self-harm as we
understand the harmful impact
this has on individuals, families
and the wider community. We
have a significant contribution
to make to the implementation
of the regional Suicide
Prevention Strategy working in
partnership with our local
health and social care
community.
The nature of services that the
Trust provides can mean that
on occasions physical
interventions need to be used
to ensure the safety of patients
or staff. We recognise that
using restrictive interventions
can delay recovery, and cause
both physical and psychological
trauma to people who use
services and staff. Therefore,
the Trust is committed to
Assaults - the Trust has a
Violence Reduction Strategy
which is monitored by the
Health, Safety and Security
Committee. The trajectories for
improvement will be consistent
with this Strategy.
Pressure Ulcers, Medication
Errors and Patient Falls – will
be monitored by the Patient
Safety and Effectiveness
Committee. Our ambitions for
improvement for these incidents
are in the process of being
consulted and agreed on as
part of the Sign up to Safety
Campaign.
This will be monitored by the
Patient Safety and
Effectiveness Committee. Our
ambitions for improvement for
these incidents are in the
process of being consulted and
agreed on as part of the Sign up
to Safety Campaign.
This will be monitored by the
Patient Safety and
Effectiveness Committee. Our
ambition for is in the process of
being consulted and agreed on
as part of the Sign up to Safety
Campaign.
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Quality Report 2014/15
4
Effective
implementation of
the Trusts Think
Family Strategy
developing therapeutic
environments where physical
interventions are only used as
a last resort.
The Trust aims to uphold all
adults' and children’s
fundamental right to be safe
from harm and exploitation. We
believe that safeguarding is
everybody’s business and have
put measures in place to
protect those least able to
protect themselves. For the
Trust, ‘Think Family’ means
securing better outcomes for
children, young people, adults
and families by co-ordinating
the support they receive from
all services delivered by the
Trust and our partners.
CARING (Patient Experience)
Caring for people with a mental
illness or physical healthcare
problem can be challenging
and carers need to be well
informed and be supported
themselves. Patients are at the
centre of healthcare. They
need to be valued and
Ensure the overall
respected, listened to and
experience of
communicated with effectively
patients, carers
with information in accessible
and service users
formats. They should be
5
and staff is
involved in developing their
positive and
own plan of care which meets
consistent across
their individual needs
all Trust services
6
Improve
experience
through better
management of
complaints
Staff engagement is a measure
of employees’ emotional
attachment to their job,
colleagues and organisation
which influences their
experience at work and their
willingness to learn and
perform.
Efficient and effective handling
of complaints ensures that NHS
organisations continuously
review and improve the quality
and safety of care they deliver.
The Trust is committed to
ensuring that our processes to
manage complaints meet
The Strategy has an
implementation plan and is
monitored through the
Trustwide Safeguarding
Strategy Group. A Performance
Framework to support this is
being developed.
This will be monitored through
the Service User and Carer
Experience (SUCE) Board
Reports and the indicators
included in the Board Quality
and Performance Report which
includes complaints response,
Friends and Family Test and
the Service Quality Rating
which is generated following
analysis of responses to patient
surveys.
Staff feedback is part of a
Strategic Project for 2015/16 to
support delivery of the Trusts
Integrated Business Plan and
will also be monitored through
that process.
This is part of a strategic project
for 2015/16 to support delivery
of the Trusts Integrated
Business Plan and will also be
monitored through that process.
The Trust has commissioned a
review of complaints
management. Any
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Quality Report 2014/15
national best practice. This will
ensure people who have a
cause for complaint are
supported and kept informed
throughout the process and
optimises the opportunities for
the Trust to learn and improve.
improvements identified when
the review is complete will be
actioned and progress
monitored through the Quality
and Risk Committee.
EFFECTIVE
7
Improve
monitoring of
clinical outcomes
consistently
across all services
to improve the
health and quality
of life of our
patients and
service users
Measuring change using
clinical outcome measures is
one way of the Trust monitoring
the clinical impact of the
services we provide for our
patients and service users.
We use a variety of clinical
outcome measures across our
services however we want to
develop a framework for this to
ensure there is a consistent
approach. Constant review of
our clinical outcomes
establishes standards against
which to continuously improve
all aspects of our practice.
This is part of a strategic project
for 2015/16 to support delivery
of the Trusts Integrated
Business Plan and will also be
monitored through that process.
The development and
implementation of a Clinical
Outcomes Framework will be
through the Patient Safety and
Effectiveness Committee.
RESPONSIVE
8
Ensure timely
access to services
which are
provided from a
choice of
appropriate
locations
The Trust is committed to
putting patients at the centre of
everything we do and this
includes ensuring people can
access services at times and
places which is convenient.
Waiting times are important as
they are a measure of how we
are responding to demands for
services.
The Trust will include the
recently mandated access
targets introduced by NHS
England and included in
Monitor’s Risk Assessment
Framework in the Board Quality
and Performance Report. These
relate to Psychological
Therapies and Early
Intervention in Psychosis.
Other waiting times are
monitored through contractual
monitoring with commissioners,
where there are breaches these
will be reported to the Board
through exception reporting.
The Finance and Performance
Committee will develop and
implement additional locally
agreed indicators.
Any concerns about access to
services will also be identified
through SUCE reports and
complaints
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Quality Report 2014/15
WELL-LED
9
10
11
The current economic climate
remains a challenge to the
Understand the
NHS and the Trust continues to
impact that cost
transform how it works to
improvement
increase productivity, but at a
programmes
reduced cost. The Trust needs
(CIPs) have on the to understand the potential
quality of service
risks to quality any cost
provision and
improvement programmes
ensure identified
(CIPs) could have and monitor
risks are
the implementation of these
managed.
programmes to identify any
actual quality issues emerging.
Ensure services
have the right
number of staff
with the right skills
to deliver high
quality care
Ensure the Trust
has a culture that
encourages staff
to have the
‘freedom to speak
up’
Each CIP scheme is risk
assessed for quality impact and
reviewed by the Director of
Nursing, Quality and Patient
Experience and Medical
Director prior to agreement and
key performance indicators to
monitor the quality impact are
agreed.
CIP schemes with a Quality
Impact Score of 8 or more are
included in the Quality and
Performance Board Report for
monitoring. In addition, the
Quality and Risk Committee
conduct ‘deep dives’ into any
high risk CIP schemes.
To support the delivery of high
quality services a highly trained
and skilled workforce is
required. We also need to
ensure that we know how many
staff and what there is enough
staff.
The Board Quality and
Performance Report includes;
safe staffing levels and key
performance indicators for
clinical supervision, appraisals,
mandatory training, sickness,
turnover and vacancy rate.
These are also monitored by
the Workforce, Equality and
Diversity Committee.
The Trust is committed to
ensuring services are safe and
that we are transparent in all
that we do. This means staff
must feel safe to speak up and
raise concerns and know they
will be listened to and action
taken. We already have
processes for this but we want
to reflect on the findings of the
‘Freedom to Speak Up’ review
and ensure we strengthen our
systems in response to
recommendations.
The Freedom to Speak Up
report will be reviewed in
conjunction with our established
systems and processes by the
Workforce, Equality and
Diversity Committee. Required
improvement actions will be
developed and monitored by
this Committee.
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Quality Report 2014/15
Statements of Assurance from the Board
This section has a pre-determined content to allow comparison between Quality Accounts
from different organisations. The content and wording within the light blue boxes are
requirements taken from Monitor’s Detailed Requirements for Quality Reports 2014/15. This
incorporates the requirements for all trusts to produce a Quality Account as set out in Quality
Account Regulations and additional requirements set by Monitor for foundation trusts.
Review of Services
During 2014/15 Nottinghamshire Healthcare NHS Foundation Trust provided and/or
subcontracted 151 relevant health services.
Nottinghamshire Healthcare NHS Foundation Trust has reviewed all the data available to
them on the quality of care in 151 of these relevant health services.
The income generated by the relevant services reviewed in 2014/15 represents 89% of the
total income generated from the provision of relevant health services by Nottinghamshire
Healthcare NHS Foundation Trust for 2014/15.
Participation in Clinical Audit
During 2014/15 6 national clinical audits and 1 national confidential enquiry covered the
relevant health services that Nottinghamshire Healthcare NHS Foundation Trust provides.
During that period Nottinghamshire Healthcare NHS Foundation Trust participated in 100%
national clinical audits and 100% national confidential enquiries of the national clinical audits
and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Nottinghamshire
Healthcare NHS Foundation Trust was eligible to participate in during 2014/15 are as
follows:
•
•
•
•
The National Prescribing Observatory for Mental Health (POMH) – 4 audits
National Audit for Schizophrenia
The National Audit of Intermediate Care during 2014/2015
National Confidential Inquiry into Suicide and Homicide for people with Mental
Illness (NCISH)
The national clinical audits and national confidential enquiries that Nottinghamshire
Healthcare NHS Foundation Trust participated in during 2014/15 are as follows:
•
•
•
•
The National Prescribing Observatory for Mental Health (POMH) – 4 audits
National Audit for Schizophrenia
The National Audit of Intermediate Care during 2014/2015
National Confidential Inquiry into Suicide and Homicide for people with Mental
Illness (NCISH)
The national clinical audits and national confidential enquiries that Nottinghamshire
Healthcare NHS Foundation Trust participated in, and for which data collection was
completed during 2014/15 are as follows:
23
Quality Report 2014/15
Audit Title
POMH (10c): Use of antipsychotic medicine
in CAMHS
POMH (14a): Prescribing for substance
misuse: alcohol detoxification
POMH (12b): Prescribing for people with
personality disorder*
Cases Submitted
% of the number of
registered cases
required
13
100%
8
100%
151
100%
Waiting outcome
100%
100
100%
28
97.5%
438
100%
*Only Forensic Services participated
POMH 9 Antipsychotic prescribing in people
with a learning disability
National Audit: Schizophrenia
National Confidential Inquiry into Suicide
and Homicide for people with Mental Illness
(NCISH)
National Audit
of Intermediate Care
All homicides, suicides, unexpected deaths and near misses involving patients of the Trust
are regarded as serious incidents and managed in accordance with the national guidance
and with agreed policies within the Trust and NHS England. The Trust therefore participates
in this research and reports its investigations to the National Confidential Inquiry.
The distinctive feature of each inquiry’s contribution is the critical examination by senior and
appropriately chosen specialists, of what has actually happened to patients. There are
established arrangements for communicating lessons learned (both within the Trust and
externally where appropriate), carrying out of gap analysis for any areas of concern,
developing any additional action plans where applicable to meet the recommendations of the
study and to ensure that there is a robust and expedient system for the dissemination of
implementation.
The reports of 4 national clinical audits were reviewed by the provider in 2014/15 and
Nottinghamshire Healthcare NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided:
As a result of participating in POMH Audit programmes (and other programmes of work) the
following actions have been taken:
Topic 10c: Use of antipsychotic medicine in CAMHS:
The main area which needs improvement is documentation of evidence in the clinical
records of assessment of extrapyramidal side effects (EPS), and measure of lipid profile for
those on established treatment. In order to facilitate this, the directorate may need to
consider local practice and systems with respect to:
1. The quality of pre-treatment screening.
2. Assessment of side-effects in children and adolescents with neurodevelopmental
disorders.
3. Continued physical health and side-effect monitoring.
Topic 12b: Prescribing for people with personality disorder:
This national audit using standards and treatment targets set by POMH-UK is designed to
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Quality Report 2014/15
compare current practice with NICE standards. Some scope for further improvement
particularly in the documentation of the indication for a prescribed antipsychotic and crisis
plans. The results of the audit were disseminated within the Forensic Division for further
discussion at a local level within individual services.
National Confidential Enquiry into Suicides & Homicides:
The NCISH publishes an annual report but this does not provide a local breakdown. Within
Local Services a quarterly report is produced which reviews all Unexpected Deaths and
includes analysis of trends identified within the National report. The Trust also participates in
the Nottinghamshire and Nottingham City Suicide Prevention Steering Group and have
participated in the development of the local Suicide Prevention strategy 2014-17.
National Audit: Schizophrenia:
Monitoring of physical health risk factors was average when compared to national results,
although below what is recommended. Improvement is required in the area of interventions
for patients with a BMI of more than 25, as an intervention only took place in 56% of cases
compared with the national figure of 71%. A regular review process will be instituted, at least
annually, to ensure that service users’ physical health status and medication are updated
and that interventions take place as per the ‘Don’t just screen, intervene’ initiative.
Although the availability and uptake of psychological therapies was average when compared
nationally, it was well below what should be provided. The Trust will Increase the uptake and
availability of CBT and family interventions in the management of people with a diagnosis of
schizophrenia.
Prescribing practice - two areas were identified as requiring improvement; the investigation
of medication adherence and substance misuse (other than those patients on clozapine
which scored 100%) in those people with poor symptom response.
National Audit of Intermediate Care:
Teams within Health Partnerships (HP) have accessed the audit results however due to the
differences in the various models in the provision of intermediate care across the division
and the very limited local feedback within the national report it is a challenge for HP services
to make comparative observations for local learning. Since the audit;
a) HP Adult Nursing Teams have had further structural changes which in some localities
has led to the previously separate Intermediate Care Teams becoming part of the
broader Integrated Teams and
b) Some of the CCGs have decommissioned Residential Intermediate Care beds
leading to different pathways and service provision for Intermediate Care in place
part year, (remainder of 2014/2015 and moving into 2015/2016).
The impact of this is that it is it is extremely difficult to apply any learning to the current
revised service models. In view of this during 2015/2016 the division will be monitoring the
effectiveness of the new service provision via the contracted KPI’s which set short term,
medium term and long term goals for the HP services.
The reports of 216 local clinical audits were reviewed by the provider in 2014/15 and
Nottinghamshire Healthcare NHS Foundation Trust intends to take the following actions to
improve the quality of healthcare provided:
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Quality Report 2014/15
Within our Forensic Services Division:
The reports of 72 local audits were reviewed.
The following actions have been taken to improve the quality of healthcare provided:
•
•
•
•
•
•
As a result of medical seclusion reviews audits undertaken following the CQC
inspection visit, local seclusion procedures have been reviewed and revised. A
template within RiO (electronic patient record) is now in use for the recording of
medical seclusion reviews at Arnold Lodge, Medium Secure Unit. Instances of late
occurring reviews are being escalated and themes identified.
At Wells Road (Low Secure Services) a flowchart has been designed and circulated
in relation to the suicide prevention strategy; for display in rooms where ward rounds
and CPAs take place.
A refresher of the CPA standards has been undertaken with the Occupational
Therapy Team at Wathwood, Medium Secure Unit.
In order to assist in identifying the reasons, and to assist in the reduction of these
occurrences, non-attendance of patients at Outpatient appointments is being flagged
within the incident reporting system at Rampton Hospital.
The Second Line Antidepressant Audit has informed a review of the protocol for
treatment of depression within the Offender Health Services and recommendations
relating to the revision of this are being considered.
Migration of identified documents into the electronic records system (CESA) is
continuing at Rampton Hospital which will provide more consistency in terms of the
how the patient records are kept and in the auditing of these.
Within our Health Partnerships Division:
There are 75 local audits registered on the 2014/2015 Audit Programme ranging from IPC,
Continence to Dental and Podiatry audits. There are 303 Actions identified on the HP Action
Plan Tracker from these local audits however please note that the data from Q3 2014/2015
is still in the process of being collated from the localities for these audits. Examples of
actions taken to improve the quality of services are as examples
•
B010-01 Dental - Delivering Better Oral Health Audit
Current guidelines for improving periodontal health were reviewed following this
audit; and
changes made to local practice included - Chlorhexidine mouthwash
only recommended for
acute gum problems and only for a short period of time
e.g. 2 weeks
•
B001-072 IPC Out of Hours Audit – Bassetlaw Hospital
Following the audit an OOH IPC Link Person was appointed as this had been noted
as a gap for the service; also new equipment was ordered e.g. examination trollies,
reflective jackets and single use stock e.g. tourniquets.
•
B016 Opioid prescribing in renal failure
Following the audit clerking proforma currently used for admissions to John
Eastwood Hospice to include a space to record blood results including renal function
which will prompt a review of opioid analgesia. It was found that 40% of patients had
renal function re-measured; It may not have been appropriate for patients to have
further blood tests, but for those where it is appropriate, a prompt to consider a
review date to consider repeat renal function to be introduced.
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Quality Report 2014/15
•
B001-040 IPC Phlebotomy (Inc. Sharps Bins) Nottingham North and East
Following the audit hand hygiene posters in each clinic were introduced.
•
B039 Trial of X-line Tibialis Posterior Dysfunction Orthoses (Bailey Insole
Audit)
Following this audit an exercise sheet to SystmOne templates was introduced.
Within our Local Services Division:
There were a total of 69 different audit topics completed in Local Services in 2014/15. The
following examples describe some of the actions taken within the Division to improve the
quality of services provided within the Division:
•
•
•
•
As a result of the Communication with GPs audit the electronic discharge summary
has been amended to ensure all recommended standards are recorded and shared
with the GP. This has now been rolled out to all inpatient areas and has helped
improve the accuracy and consistency of information being shared with both service
users and GPs.
A review of the Resuscitation: Emergency Bag Checklist audit resulted in a new
Checklist form being developed to better record all required standards. This has been
rolled out and embedded within all relevant areas and is completed on a weekly
basis.
An audit of Crisis Plans was undertaken across AMH and MHSOP; the results
provided good assurance that the vast majority of patients on CPA had a Crisis Plan.
However the report also recommended that standards for Crisis Plans should be
developed in order to increase the consistency of types of information being
recorded. These findings were used to help develop a local CQUIN on Crisis
Planning and this is being implemented in 2015/16.
A review of the key themes identified through both Serious Incident Investigations
and Coroner Court Inquests took place. As a result of the review it was
recommended that the Suicide Prevention Audit tool should be amended in order to
capture information on all the key themes identified; this led to a new Serious Incident
and Suicide Prevention Audit Tool being devised in Local Services. The audits have
already commenced and will be carried out in all clinical teams over a rolling
programme of audit.
Participation in Clinical Research
The number of patients receiving relevant health services provided or sub-contracted by
Nottinghamshire Healthcare NHS Foundation Trust in 2014/15 that were recruited during
that period to participate in research approved by a research ethics committee 1249.
Six natural groups have emerged within the Institute which have now been successfully
launched as six centres of excellence, with national and international reputations and these
are:
• Health and Justice.
• ADHD and Neuro-developmental Disorders.
• Old Age and Dementia.
• Translational Neuroscience.
• Social Futures.
• Education.
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Quality Report 2014/15
Participation in clinical research demonstrates Nottinghamshire Healthcare NHS Foundation
Trust’s commitment to improving the quality of care we offer and to making our contribution
to wider health improvement. There was an increase of 13.9% on the previous year. Our
clinical staff stay abreast of the latest possible treatments and active participation in research
leads to successful patient outcomes.
45 clinical staff participated in research approved by a research ethics committee at
Nottinghamshire Healthcare NHS Foundation Trust during 2014/15 covering Adult Mental
Health, Forensics, Children and Adult Mental Health Services and Community Healthcare
(Health Partnerships). The number of active National Institute for Health Research (NIHR)
portfolio studies and Non-Portfolio studies recruiting within Nottinghamshire Healthcare NHS
Foundation Trust gives an indication of the efficiency and success of its research activity.
During 2014/15 the Trust participated in 78 studies, of which 46 were NIHR adopted and 32
of which were non-portfolio studies. Comparison with 2013/14 research activity highlights
consistent performance in terms of participation in both National Institute for Health
Research Portfolio and Non-Portfolio Studies. Only 21 non-portfolio studies took place
during 2011 / 2012, 28 in 2012 / 13, this increased to 33 in 2013 / 14 and maintaining
consistency with 32 approved during 2014/15 highlighting an improvement in the
participation of non-portfolio studies within the Trust.
The table below shows a comparison of the total number studies which took place within the
Trust (both Portfolio and Non-Portfolio) between 2013/14 and 2014/15.
Research Activity 2013/14 & 2014/15:
Total Non-Portfolio Open Studies
Total Portfolio (active / recruiting) Studies opened
Total Portfolio Participant Identification Centre Studies
Total Portfolio Open Studies (including ongoing)
Total Open Studies
2013 / 2014
33
24
5
43
81
2014/2015
32
16
1
46
78
The number of National Institute for Health Research adopted studies which recruited within
the Trust during 2013/14 was 43, this increased to 46 during 2014/15 with a total of 16 new
studies being approved. This highlights a significant increase in Trust participation of
Portfolio adopted studies.
Nottinghamshire Healthcare NHS Foundation Trust records the number of studies for each
medical condition. This enables the Trust to monitor over-researched medical conditions and
to ensure that there is an equal distribution of research being conducted over a variety of
disease areas. Staff research, particularly exploring Alzheimer’s disease and Dementia
have seen an increase in research interest this financial year as well as a continuation in
research projects looking at ways to improve service delivery and Personality Disorder and
Psychosis focused research.
Commissioning for Quality and Innovation (CQUIN)
A proportion of Nottinghamshire Healthcare NHS Foundation Trust income in 2014/15 was
conditional upon achieving quality improvement and innovation goals agreed between
Nottinghamshire Healthcare NHS Foundation Trust and any person or body they entered
into a contract, agreement or arrangement with for the provision of relevant health services,
through the commissioning for Quality and Innovation payment framework.
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Quality Report 2014/15
Further details of the agreed goals for 2014/15 and for the following 12 month period are
available online at:
http://www.england.nhs.uk/wp-content/uploads/2014/02/sc-cquin-guid.pdf and
http://www.england.nhs.uk/wp-content/uploads/2015/03/9-cquin-guid-2015-16.pdf
CQUINs are intended to reward excellence and encourage providers to drive a range of
quality improvements on a continuous basis. Commissioners and providers agree each year
the detail of how national and local priorities will be measured and achieved. A series of
milestones and targets are agreed in advance and each provider is required to submit
evidence to commissioners at regular intervals.
The monetary total for income in 2014/15 conditional upon achieving quality improvement
and innovation goals was £7576k (actual £7077k). The monetary total for the associated
payment in 2013/14 was £7791K (actual £7318k).
Care Quality Commission (CQC)
The Care Quality Commission (CQC) is the independent regulator of health and adult social
care in England. All providers of regulated activities must be registered with the CQC under
the Health and Social Care Act 2008. From 1 October 2010, all health and adult social care
providers which were registered with the CQC were legally responsible for meeting essential
standards of quality and safety.
Nottinghamshire Healthcare NHS Foundation Trust is required to register with the Care
Quality Commission and its current registration status is registered to provide services with
no conditions attached.
The Care Quality Commission has not taken enforcement action against Nottinghamshire
Healthcare NHS Foundation Trust during 2014/15.
The Trust has agreed routine conditions to its registration with the CQC which describe the
locations from which they can legally operate their regulated activities. Other than these, the
Trust has unconditional registration with the CQC and no enforcement actions have been
taken by the CQC. On 1 October 2014 the CQC introduced their new approach to regulating,
inspecting and rating services including specialist mental health services. The CQC
inspectors now assess all health and social care services against the following five key
questions:
Are they SAFE?
Are they EFFECTIVE?
Are they CARING?
Are they RESPONSIVE?
Are they WELL-LED?
By safe, they mean that people are protected from abuse and
avoidable harm.
By effective, they mean that people’s care, treatment and
support achieves good outcomes, promotes a good quality of
life and is based on the best available evidence.
By caring, they mean that staff involve and treat people with
compassion, kindness, dignity and respect.
By responsive, they mean that services are organised so that
they meet people’s needs.
By well-led, they mean that the leadership, management and
governance of the organisation assures the delivery of highquality person-centred care, supports learning and innovation,
and promotes an open and fair culture.
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Quality Report 2014/15
The CQC’s Chief Inspector of Hospitals Inspection of the Trust took place from 28th April
2014. The feedback following the inspection recognised the outstanding caring and
committed staff the inspection team had met across services during the inspection. They
found there was a strong, visible person centred culture where staff and management
showed they were fully committed to working in partnership with people and to using
innovative ways to make this a reality for people who use the service. They also found good
examples of leadership across the Trust where senior staff communicated effectively and
were visible to staff and people who use services. Good management was recognised at
services such as Wathwood, the Personality Disorder Network, Learning Disability and Deaf
Services at Rampton, the Recovery College and Eating Disorder Services.
16
CHS – End of Life Care
0
-
Mental Health – Older People
0
-
3
4, 7, 21
0
-
Mental Health – CAMHS
1
16
Mental Health – Eating Disorders
0
-
0
-
0
-
Services for people with a Learning
Disability or Autism
Mental Health – Perinatal
Mental Health – Adult Community Based
Services
Mental Health – Rapid Response Liaison
Psychiatry
Mental Health – Crisis
0
-
Mental Health – Long Stay
2
10, 4
Mental Health – Adult Inpatient
1
4
Mental Health – PICU
1
1
Forensic Services
1
4
11**
-
Overall Rating
Outstanding
Good
Overall
Rating
CQC
Outcome*
1
Well-Led
-
CHS – Community Health Inpatient
Services
CHS – Children and Families
Responsive
0
CHS – Adult Community Services
Effective
17
Report
Caring
1
Safe
Legal
Requirement
The feedback also outlined some areas where practice could be improved. The CQC made
11 compliance actions (legal requirements) at locations operating in 8 of the 16 service types
inspected. The primary concerns were around records and the use of seclusion at local
learning disability services, seclusion reviews in medium secure provision and ligature points
in the rehabilitation units. In addition to the compliance actions, the CQC also made 49
practice recommendations which were intended to support service improvements. The
recommendations did not impact on the Trusts overall rating which was that it provided
‘Good’ services overall. The table below provides information on the outcome of the Chief
Inspector for Hospital Inspection (see key to outcomes below):
GOOD
Requires
Improvement
Inadequate
*See Key to Outcomes below.
**Other board assurance documents indicate that the CQC made16 compliance actions. These were calculated at the draft
inspection stage and some were counted twice if they spanned more than one individual service.
30
Quality Report 2014/15
The Trust implemented strong plans to address all of the identified areas of non-compliance
and these are monitored via divisional and Trust governance processes. The CQC has now
been informed that the Trust has completed the actions on their Chief Inspector for
Hospital action plan and now considers that they are meeting the required standards.
The CQC also completed a series of routine scheduled inspections of individual Trust
services during 2014/2015. Subsequent follow up inspections took place at HMP and YOI
Doncaster, HMP Wakefield and HMP Nottingham after the CQC found these services were
not complying with all of the standards they inspected. They judged the impact on people
who used the service to be minor. A minor impact is one which affects people’s safety but it
is not considered to be significant and it is thought that the matters could be resolved
quickly. The follow up inspections found HMP and YOI Doncaster and HMP Wakefield to be
compliant and HMP Nottingham to require further improvements. CQC have also inspected
Highbury Hospital however the final inspection report has not yet been published.
We have included in the table of inspections below the outcome of the CQC’s inspection of
Lincolnshire Partnership NHS Foundation Trust in respect of HMP North Sea Camp. This is
because the CQC found aspects of non-compliance which the Trust is committed to
addressing as the new provider of healthcare services there.
The table below provides details of these other CQC inspections for the period 2014/2015
which were in addition to those undertaken by the Chief Inspector of Hospitals:
Location
HMP & YOI Doncaster
HMP Wakefield
HMP North Sea Camp
(NOTE: The provider at the time of this
inspection was Lincolnshire Partnership
NHS Foundation Trust)
HMP Ranby
HMP Nottingham
Review Date
31/03/2014 - 01/04/2014
07/07/2014 - 08/07/2014
(Published March 2015)
21/07/2014 - 22/07/2014
25 July 2014
15/09/2014 - 16/09/2014
Outcomes Inspected
Judgement
1
Non-Compliant
4
Non-Compliant
9
Non-Compliant
16
Compliant
17
Non-Compliant
4
Compliant
6
Non-Compliant
10
Non-Compliant
14
Compliant
16
Compliant
1
Compliant
4
Compliant
6
Compliant
14
Non-Compliant
16
Non-Compliant
17
Compliant
1
Compliant
4
Non-Compliant
6
Compliant
14
Compliant
16
Non-Compliant
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Quality Report 2014/15
HMP & YOI Doncaster
HMP Nottingham
HMP Wakefield
March 2015
17 March 2015
1
Compliant
4
Compliant
9
Compliant
17
Compliant
4
Non-Compliant
16
Non-Compliant
6
Compliant
10
Compliant
19 March 2015
Key to Outcomes
1 - Respecting and involving people who use services
2 - Consent to care and treatment
4 - Care and welfare of people who use services
5 - Meeting nutritional needs
6 - Cooperating with other providers
7 - Safeguarding people who use services from abuse
8 - Cleanliness and infection control
9 - Management of medicines
10 - Safety and suitability of premises
11 - Safety, availability and suitability of equipment
12 - Requirements relating to workers
13 - Staffing
14 - Supporting workers
16 - Assessing and monitoring the quality of service
provision
17 - Complaints
21 - Records
Requirements, which are compliance actions, are made when a regulation has not been
met. The table below defines the outcomes against which compliance actions can be made.
These will change from 1 April 2015 with the introduction of new fundamental standards.
Section 1:
Involvement and
information
Section 2:
Personalised care,
treatment and
support
Section 3:
Safeguarding and
safety
Section 4:
Suitability and
staffing
Section 5:
Quality and
management
Outcome 1 (Regulation 17) Respecting and involving people who
use services
Outcome 2 (Regulation 18) Consent to care and treatment
Outcome 4 (Regulation 9) Care and welfare of people who use
services
Outcome 5 (Regulation 14) Meeting nutritional needs
Outcome 6 (Regulation 24) Cooperating with other providers
Outcome 7 (Regulation 11) Safeguarding people who use services
from abuse
Outcome 8 (Regulation 12) Cleanliness and infection control
Outcome 9 (Regulation 13) Management of medicines
Outcome 10 (Regulation 15) Safety and suitability of premises
Outcome 11 (Regulation 16) Safety, availability and suitability of
equipment
Outcome 12 (Regulation 21) Requirements relating to workers
Outcome 13 (Regulation 22) Staffing
Outcome 14 (Regulation 23) Supporting workers
Outcome 16 (Regulation 10) Assessing and monitoring the quality of
service provision
Outcome 17 (Regulation 19) Complaints
Outcome 21 (Regulation 20) Records
Nottinghamshire Healthcare NHS Foundation Trust has not participated in any special
reviews or investigations by the CQC during the reporting period.
32
Quality Report 2014/15
Data Quality
Nottinghamshire Healthcare NHS Foundation Trust submitted records during 2014/15 to the
Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included
in the latest published data. The percentage of records in the published data:
Which included the patient’s valid NHS number was:
• 99.6% for admitted patient care;
• 100% for out-patient care; and
• Not applicable for accident and emergency care
Which included the patient’s valid General Medical Practice Code was:
• 100% for admitted patient care;
• 100% for out-patient care; and
• Not applicable for accident and emergency care.
Information Governance Toolkit Attainment Levels
Nottinghamshire Healthcare NHS Foundation Trust Information Governance Assessment
Report overall score for 2014/15 was 82% and was graded Green
A validation exercise was conducted by Internal Audit 360 Assurance and final report
received in March 2015. 360 Assurance considered that at the time of the review the Trust
achieved level 2 and/or above across the board for all 12 criterion. Some of the actions will
be incorporated into next year’s action plans as is always the case but all actions were
completed. As a result the Trust attained Significant Assurance that there is a generally
sound system of control designed to meet the system’s objectives.
Clinical Coding Error Rate
Nottinghamshire Healthcare NHS Foundation Trust was not subject to the Payment by
Results clinical coding audit during the 2014/15 by the Audit Commission.
Nottinghamshire Healthcare NHS Foundation Trust will be taking the following actions to
improve data quality:
• Roles and responsibilities for data quality including Executive Director level have
been clarified.
• Strengthened governance accountability and the continued development of a new
Information Assurance Framework which outlines standards for maintaining data
quality on the Trusts key information in all formats. This covers the systems where
information is recorded and stored, and information ‘products’, that is the
performance measures and analysis of this information to make operational and
strategic decisions.
• The Performance Indicator Assurance Process provides details on our key
performance indicators (KPIs) used by the Board which includes: definitions,
technical specifications, reporting mechanisms, an assessment of the quality of the
data for each KPI and links to relevant policies and procedures.
• The role of Information Asset Owners and Administrators for our core information
systems is being enhanced and developed further, including training and support and
regular updates to the Strategic Information Governance Group.
33
Quality Report 2014/15
National Quality Indicators
The Department of Health identified 15 indicators which should be included in Trust Quality
Reports/Accounts, where they are applicable to services. Five of these indicators are
relevant to Nottinghamshire Healthcare NHS Foundation Trust; in addition we have chosen
to include the optional Friends and Family indicator. The indicators for the year ended 31
March 2015 subject to limited assurance audit are marked with the symbol
CPA 7 Day Follow-up
– The data made available to Nottinghamshire Healthcare NHS
Foundation Trust by the Information Centre with regard to the percentage of patients on
Care Programme Approach who were followed up within 7 days after discharge from
psychiatric inpatient care during the reporting period. An explanation of the indicator
construction is given on page 57.
The term ‘Care Programme Approach’ (CPA) describes the framework to support and
coordinate effective mental health care for people with mental health problems in secondary
mental health services. Although the policy has been revised over time, CPA remains the
central approach for coordinating the care for people in contact with these services who
have more complex mental health needs and who need the support of a multidisciplinary
team.
Following up someone on care programme approach (CPA) within seven days of discharge
from inpatient care reduces risk of harm and social exclusion and can maintain and improve
access to care. Trusts must ensure that a minimum of 95% of inpatients on CPA are
followed up within seven days of discharge from hospital.
Nottinghamshire Healthcare NHS Foundation Trust considers that this data is as described
for the following reasons:
•
•
•
•
•
Data is collected in line with national reporting requirements as set out by Monitor.
Data is collected and analysed by the Trust Applied Information team before being
released on the Trust reporting site.
CPA 7 day follow up rates are scrutinised on a monthly basis at Directorate
meetings and Divisional Business meetings.
Directorate and ward level managers are required to monitor the CPA 7 day rate as
one of part of their duties.
Divisional performance heads are required to sign off CPA 7 data performance
reports before inclusion into the Trust’s monthly Board Report.
Nottinghamshire Healthcare NHS Foundation Trust has taken the following actions to
improve this percentage, and so the quality of its services, by:
•
•
Continuing to work closely with service users and their families in developing
discharge care plans which support patients in a safe transition from inpatient care
to life in the community.
Nottinghamshire Healthcare NHS Foundation Trust has continued to achieve this
target throughout the last three years, remaining consistently above the national
average for levels of follow up care in the community. Nonetheless it remains
committed to continual improvement and will look to improve service provision
relating to follow up care during 2015/ 16.
34
Quality Report 2014/15
7 Day
Follow Up
Nottinghamshire
Healthcare NHS
Foundation
Trust (HSCIC
data)
2014/2015
98.5%
Nottinghamshire
Healthcare NHS
Foundation Trust
(local data taken from
the Rio Clinical
information System )
98.8%
2013/2014
99.2%
99.1%
97.2%
100%
74.5%
2012/2013
98.3%
n/a
97.4%
100%
0%
National
Average
(HSCIC
data)
Highest
Performing
Trust in any
given Quarter
Lowest
Performing
Trust in any
given
Quarter
97.2%
100%
90%
Calculated from 12 months of data, not monthly average performance as shown in Part 3
Crisis Team Gatekeeping Admissions: The data made available to Nottinghamshire
Healthcare NHS Foundation Trust by the Information Centre with regard to the percentage
of admissions to acute wards for which the Crisis Resolution Home Treatment Team
(CRHT) acted as a gatekeeper during the reporting period.
In a crisis resolution context within psychiatric care, a 'crisis' is defined as the breakdown of
an individual's normal coping mechanisms. Crisis Resolution and Home Treatment is an
alternative to inpatient hospital care for service users with serious mental illness, offering
flexible, home-based care, 24 hours a day, seven days a week. These teams act as
gatekeepers to acute in-patient services, and are measured against the 95% minimum
gatekeeping target set by Monitor.
Nottinghamshire Healthcare NHS Foundation Trust considers that this data is as described
for the following reasons:
•
•
•
Crisis Resolution gatekeeping is an embedded and key process within the Trust
before inpatient admission, evidenced through localised record keeping.
Crisis Resolution gatekeeping levels are presented on a monthly basis at Board of
Directors Meetings.
Divisional Performance Heads are required to sign off Crisis Resolution data reports
before inclusion into the Trust’s monthly Board Report.
Nottinghamshire Healthcare NHS Foundation Trust has taken the following actions to
improve this percentage, and so the quality of its services, by:
•
•
Improving the centralised management and recording of Crisis Resolution
gatekeeping performance data through the development of bespoke reporting
systems available on the Trust Rio clinical information system.
Focussing on the data quality of Crisis Resolution gatekeeping at clinical team level
where admission information is recorded onto Rio.
Crisis
Resolution
Nottinghamshire
Healthcare NHS
Foundation Trust
(HSCIC data)
National
Average
(HSCIC data)
Highest
Performing Trust
in any given
Quarter
Lowest Performing
Trust in any given
Quarter
2014/2015
2013/2014
2012/2013
98.0%
100%
100%
98.1%
98.3%
98.2%
100%
100%
100%
33.3%
74.5%
0%
Nottinghamshire Healthcare Trust reported the following which is calculated from 12 months
of data, not monthly average performance as shown in Part 3:
35
Quality Report 2014/15
Re-admission Rates: The criteria as laid out by the Department of Health in regards to
readmission rate reporting in Quality Accounts is based on data collected by the Health and
Social Care Information Centre. This data collection is not directly applicable to mental
health trusts due to the age related criteria not being relevant to mental health services.
Nonetheless readmission rates are of concern to all health service providers including
mental health services, and therefore the figures provided are those based on our own
internal records.
Readmissions of patients to inpatient areas can be extremely distressing, leading to
potentially harmful consequences for patients’ mental and physical wellbeing. NHS
organisations endeavour to keep readmission rates as low as possible; however there can
be a wide variation in readmission rates between similar NHS organisations. These
variations can act as a trigger to look at practice within an organisation or geographical
area. This could in turn help to prevent avoidable readmissions and lead to improved levels
of care.
Nottinghamshire Healthcare NHS Foundation Trust considers that this data is as described
for the following reasons:
•
•
•
•
•
Data is collected in line with Trust reporting requirements.
Instances of readmission within 28 days are investigated to ensure that each case is
clinically appropriate.
Readmission rates are presented on a monthly basis at Board of Directors Meetings.
Readmission rates are scrutinised on a monthly basis at Divisional Business
meetings.
Divisional Performance Heads are required to sign off Readmission data reports
before inclusion into the Trust’s monthly Board Report.
Nottinghamshire Healthcare NHS Foundation Trust has taken the following actions to
improve the percentage and so the quality of its services, by:
•
•
Maintaining a focus on effective and therapeutic relationships between patient and
its services to ensure wellness and reducing readmission.
Enabling patients making the transition from a structured hospital based
environment to the community to have as positive and enabling experience as
possible, providing support to reassure patients around the challenging aspects of
greater personal involvement in the community.
0-15 years is not applicable, 16 years and over, see the table below:
Psychiatric
Re-admission
Rates
(Adult mental
health)
Nottinghamshire
Healthcare NHS
Foundation
Trust (local data
Rio Clinical
information
system)
Nottinghamshire
Healthcare NHS
Foundation
Trust (HSCIC
data)
2014/2015
5.0%
Not Available
2013/2014
5.4%
Not Available
2012/2013
4.0%
Not Available
National
Average
Not
Available
Not
Available
Not
Available
Highest
Performing
Trust in any
given Quarter
Lowest
Performing
Trust in any
given Quarter
Not Available
Not Available
Not Available
Not Available
Not Available
Not Available
36
Quality Report 2014/15
Friends and Family Test: The data made available to Nottinghamshire Healthcare NHS
Foundation Trust by the Information Centre with regard to the percentage of staff employed
by or under contract to the Trust during the reporting period, who would recommend the
Trust as a provider of care to their family or friends.
Obtaining feedback from our staff concerning their role, their leadership, their engagement
with the Trust, their motivation and their advocacy of services is crucial to improving care.
Keogh, Berwick and Francis all express the need for candour and for Trusts to practice
whole-heartedly the growth and development of all staff, including their ability and support to
improve the processes in which they work.
The Friends and Family Test is a simple feedback tool that asks respondents to what
extent they would recommend a particular service to their family or friends. Respondents
answer using a six-point response scale, ranging from “extremely unlikely” to “extremely
likely”.
Nottinghamshire Healthcare NHS Foundation Trust considers that this data is as described
for the following reasons:
•
•
The Family and Friends Test is part of the annual NHS Staff Survey, administered by
independent survey contractors on behalf of the Picker Institute Europe. NHS staff
complete and return their questionnaires directly to the independent contractor, which
means that answers cannot be seen by anyone other than Survey contractors.
From April 2014, the Trust has provided quarterly updates on staff responses to the
question ‘How likely are you to recommend this organisation to friends and family if
they needed care or treatment?’ These responses are reported via the national
UNIFY system, and posted on the Trust website.
Nottinghamshire Healthcare NHS Foundation Trust intends to take the following actions to
improve this percentage and so the quality of its services, by:
•
•
•
•
The data collected will be analysed and reported back to the Divisions and
Directorates. Each Directorate should share the key issues raised and what they are
doing about them, and any action completed with their teams.
Each Division / Directorate will be expected to review the Staff Experience Action
Plan and the Service User / Carer Experience Action Plan together in their
Governance and Compliance Meetings.
By providing the analysis and reporting to directorate, ward or team level we are able
to make strong correlation between the Service User experience and the Staff
experience Friends and Family Test, therefore have the ability to develop service
improvements and also identify best practice.
As an organisation we will act on the information provided; link it to our service user
feedback and experience; learn from the findings, communicate and act on the
learning to achieve continuous and never ending improvement for our service users
and staff.
37
Quality Report 2014/15
2014/2015
Nottinghamshire
Healthcare NHS
Foundation Trust
(National Staff
Survey 2014)
72%
2013/2014
68%
65%
96.4%
33.7%
2012/2013
68%
58%
80%
39%
Family and
Friends Test –
National Staff
Survey
National Average
(National Staff
Survey 2014)
Highest
Performing Trust
Lowest
Performing Trust
60%
85%
38%
Community Mental Health Survey - The data made available to Nottinghamshire
Healthcare NHS Foundation Trust by the Information Centre for the Trust’s ‘Patient
Experience of Community Mental Health Services’ indicator score with regard to a patient’s
experience of contact with a health or social care worker during the reporting period.
The summary of the results for the annual Community Mental Health Survey details how
patients graded different key aspects of their care. These results also enable each of the
Trusts involved in the survey to assess their own findings and develop services accordingly.
With a national response rate of 29% for 2014, the Community Mental Health Survey
Service is both a valued research tool and a robust indicator of how service users rate their
experience of treatment.
Nottinghamshire Healthcare NHS Foundation Trust considers that this data is as described
for the following reasons:
•
•
All samples are collected and checked in line with the process approved by the
Confidentiality Advisory Group (CAG) which provides independent expert advice to
the Health Research Authority (HRA) and the Secretary of State for Health.
Patients who have been selected in the sample are informed on how their
confidentiality will be protected. Details of how we do this are included in the letters
patients receive alongside the questionnaires and in published FAQs that support
each survey. These documents tell patients how we apply data protection and ensure
that personal data are kept confidential.
Nottinghamshire Healthcare NHS Foundation Trust intends to take the following actions to
improve this score, and so the quality of its services by:
•
•
•
•
The Trust will continue to recognise the importance of working to individual strengths
and aspirations, using recovery focussed ways of working.
The Trust will continue to work in partnership with those using services, their carers
(where appropriate), staff and membership, listening to individual lived experience
and seeking to care plan in partnership. Providing as many diverse ways to enable
feedback from those using services and their carers is something the Trust strives to
constantly improve.
The Trust is committed to ensuring people’s experiences of care are positive. All
services are expected to submit an Involvement and Experience report every quarter
detailing how they have used feedback to reflect on people’s experiences and
improve services accordingly.
The Trust has Quality Priorities as well as Strategic Priorities, which continue to be
embedded in all aspects of care provided.
38
Quality Report 2014/15
Patient
Experience of
Community
Mental Health
Services - rating
Nottinghamshire
Healthcare NHS
Foundation Trust
(HSCIC data)
Highest
Performing
Trust
Lowest
Performing
Trust
National average:
patients with a positive
experience of
Community Mental
Health services (HSCIC
data)
2014/2015
7.2 (out of a
possible 10)
7.5 (out of a
possible 10)
6.5 (out of a
possible 10)
66% positive
2013/2014
7.2 (out of a possible
10)
7.6 (out of a
possible 10)
6.6 (out of a
possible 10)
67% positive
2012/2013
7.3 (out of a possible
10)
7.8 (out of a
possible 10)
6.5 (out of a
possible 10)
n/a
Patient Safety Incidents - The data made available to Nottinghamshire Healthcare NHS
Foundation Trust by the Information Centre with regard to the number and, where available,
rate of patient safety incidents reported within the Trust during the reporting period, and the
number and percentage of such patient safety incidents that resulted in severe harm or
death.
A patient safety incident is any healthcare related event that was unintended, unexpected
and undesired and which could have or did cause harm to patients. It is recommended as a
preferred term when considering adverse events, near misses and significant events to
minimise confusion and help the formal reporting of relevant incidents.
The scope of the indicator includes all patient safety incidents reported through the National
Reporting and Learning System (NRLS). This includes reports made by the Trust, staff,
patients and the public. From April 2010 it became mandatory for Trusts in England to
report all serious patient safety incidents to the Care Quality Commission. Trusts do this by
reporting incidents on the NRLS.
A case of severe harm is defined in seven steps to patient safety: a full reference guide,
published by the National Patient Safety Agency in 2004, as “any patient safety incident that
appears to have resulted in permanent harm to one or more persons receiving NHS-funded
care.”
“Permanent harm directly related to the incident and not related to the natural course of the
patient’s illness or underlying condition is defined as permanent lessening of bodily
functions, sensory, motor, physiologic or intellectual, including removal of the wrong limb or
organ, or brain damage.”
The Trust reported 10372 Patient Safety Incidents (PSI) for 2014/2015, of which 59 resulted
in severe harm or death.
Nottinghamshire Healthcare NHS Foundation Trust considers that this data is as described
for the following reasons:
• The Trust has a strong reporting culture in place, evidenced by its position in the
top 20% of trusts in the National Staff survey, 2014, for two key findings relating
to incident reporting: ‘% witnessing potentially harmful errors, near-misses or
incidents in the last month’ and ‘Fairness and effectiveness of incident reporting
39
Quality Report 2014/15
•
•
•
•
•
•
procedures’
The Safeguard electronic reporting system employed by the Trust enables a
rapid and proactive reporting ethos with increased accountability at all levels.
The Trust reports a range of incident data to the monthly Board of Directors
ensuring openness and accountability, reflecting a reporting culture that is
founded on continual learning and improvement through analysis and
openness.
The Trust reports regularly to the National Reporting and Learning System
regarding any incident of patient safety whether actual or potential.
The Trust report any instance of crime, including all violent incidents, to NHS
Protect.
Incidents involving staff absences of 7 days or more or other specified criteria
are reported to the Health and Safety Executive (HSE) under the “Reporting of
Injuries, Diseases and Dangerous Occurrences” Regulations (RIDDOR).
Serious incidents are reported to the Commissioners via the STEIS system and
are investigated fully. Where the investigation highlights recommendations for
change these are converted to action plans and are monitored to completion.
Nottinghamshire Healthcare NHS Foundation Trust has taken the following actions to
improve the following incident rates, and so the quality of its services, by:
•
•
•
•
•
•
Developing a violence and anti-social behaviour reduction strategy which will
include 6 key dimensions with each one having a distinct set of objectives.
Ensuring there is organisational learning from all incidents including serious
incidents.
Improving record keeping ensuring all identified care and treatment is clearly
defined with evidence of involvement of service users in care planning.
Improving the treatment of, recording of, and learning from incidents of pressure
ulcers.
The Trust has grown the range and depth of incident reporting at the monthly
Board of Directors enabling degrees of harm information to be made available at
Directorate, Divisional and Trust level.
Providing a monthly supporting document for the National Safety Thermometer
website published by the Department of Health, to present a balanced view of
the Trust’s performance in relation to four key areas of patient health.
The Trust has adopted a Reportable Issues log and escalates any risk or issue
identified from the range of reporting frameworks and structures employed by the
Trust, to ensure the Board of Directors is kept abreast of any potential risk or
harm.
Data Quality of Degree of Harm Data:
100% of incidents graded as severe harm or death on the Trusts incident reporting system
(Ulysses) are validated to ensure they are graded correctly. This 100% validation is being
extended to all incidents reported as moderate harm as part of the process of implementing
the Duty of Candour which came into effect on 27th November 2014.
An internal audit report published in March 2015 provided a limited assurance opinion,
partly because the quality of the information recorded on Ulysses to describe the incident
did not always support the degree of harm that was selected. This will in part be addressed
with the 100% validation of moderate, severe and death incidents by senior managers. Due
to the number of incidents reported this is not possible for all incidents and therefore
40
Quality Report 2014/15
additional guidance and training will be provided on reporting and grading incidents.
Data released by the National Reporting and Learning System:
Incident Data
Reporting
Periods
Apr – Sept
2014
(NRLS)
Apr– Sept
2013
(NRLS)
Oct 12 –
Mar
13 (NRLS)
Apr – Sept
2012
(NRLS)
Notts HC
Trust incidents
total
(NRLS)
Notts HC
Trust Severe
Harm/
Death
incidents
total
(NRLS)
Notts HC Trust
- Severe
Harm/ Death
incidents total
(NRLS)
National Severe Harm/
Death
incidents as a
% of total
incidents
(NRLS)
National –
highest
level of
Severe
Harm/
Death
incidents
as a % of
total
incidents
(NRLS)
5155
34
0.56%
1.01%
5.97%
0.00%
4465
14
0.31%
1.26%
5.33%
0.00%
4238
12
0.28%
1.32%
4.95%
0.00%
4607
28
0.61%
1.58%
9.43%
0.00%
National –
lowest level of
Severe Harm/
Death incidents
as a % of total
incidents
(NRLS)
The data released by the National Reporting and Learning System (above) is part of a
dataset that provides information on all trusts nationally; this takes a number of months of
collation and preparation, therefore the period April to September 2014 is the most recent
set of data publicly available and has been considered by our External Auditors as part of
their Limited Assurance Process.
Nonetheless Nottinghamshire Healthcare NHS
Foundation Trust submits data on a weekly basis to the National Reporting and Learning
System and has therefore provided an accurate assessment of its performance at a local
level in regard to Patient Safety Incident reporting throughout 2013 / 14.
Data reported by the Trust to the National Reporting and Learning System:
Patient
Safety
Incidents
Reporting
Periods
2014 /
2015
2013 /
2014
2012 /
2013
Nottinghamshire
Healthcare NHS
Foundation Trust –
Rate of Patient Safety
Incidents (number of
incidents divided by total
bed days of care) x 1000
bed days
(Ulysses incident
recording system and Rio
Clinical information
system data)
Nottinghamshire
Healthcare NHS
Foundation Trust
– Number of
Patient Safety
Incidents
Resulting in
Severe Harm or
Death (Ulysses
Nottinghamshir
e Healthcare
NHS
Foundation
Trust – Total
number of
Patient Safety
Incidents in the
Year (Ulysses
Nottinghamshire
Healthcare NHS
Foundation Trust –
Percentage of
Patient Safety
Incidents Resulting
in Severe Harm or
Death (incidents rated
at least severe divided
by total number of
patient safety incidents
in the year) (Ulysses
incident recording
system)
incident recording
system)
incident
recording
system)
28.74
59
10372
0.56%
24.43
38
9343
0.41%
23.1
37
8861
0.42%
41
Quality Report 2014/15
Further Quality Indicators
In addition to the requirement for the Trust’s external auditors to undertake a review of
the content of the Quality Report there is a requirement for two mandated indicators to
be audited. An additional locally agreed indicator is also selected for audit by the Council
of Governors.
The two mandated indicators are:
•
•
Care Programme Approach 7 day follow up (covered in the previous section)
Delayed Transfers of Care (see below)
The locally agreed indicator is:
•
Improving access to psychological therapies (see below)
Delayed Transfers of Care (DTOC)
‘Inpatient services must be conceived as stepping stones for inclusion, not departure
points for exclusion’ (Creating accepting communities, MIND Enquiry, S.Dunn,1999).
Improving discharge pathways from mental health wards is fundamental to promoting
recovery and social inclusion. With the high demand on inpatient beds it is therefore
imperative that delays do not occur for those who are fit for discharge. The Trust
endeavours to ensure that patients undergoing transfer do so with minimal delay. An
explanation of the indicator construction is given on page 57.
* “leave” days excluded from calculation, as per national guidance. Calculated from 12
months of data, not monthly average performance as shown in Part 3
2014/2015
Nottinghamshire Healthcare
NHS Foundation Trust
(local data from Rio clinical
information system)*
4.93%
2013/2014
7.16%
Delayed
Transfers of Care
National
Average
Highest
Performing
Trust
Lowest
Performing
Trust
n/a
n/a
n/a
n/a
n/a
n/a
Improving Access to Psychological Therapies (IAPT)
Improving access to psychological therapies (IAPT) aims to increase the availability of
‘talking therapies’ on the NHS. IAPT is primarily for people who have mild to moderate
mental health difficulties, such as depression and anxiety. Such conditions are treated
using a variety of therapeutic techniques, including cognitive behavioural therapy (CBT)
and interpersonal therapy (IPT). IAPT seeks to use the least intrusive method of care
possible to treat people. This is often called a ‘stepped care model’ - the patient is
generally offered a low intensity therapy in the first instance. An explanation of the
indicator construction is given on page 58.
2014/2015
Nottinghamshire Healthcare
NHS Foundation Trust
(local data from PC-Mis
clinical system)
48.9%
2013/2014
41.7%
Recovery rates
IAPT
Calculated from 12 months of data, not monthly average performance as shown in Part 3
42
Quality Report 2014/15
PART THREE: Review of Quality Performance 2014/15
Overview of Performance in 2014/15
This section provides information on performance against our quality and performance
indicators agreed internally by the Trust and also performance against relevant indicators
and performance thresholds set out in Appendix A of Monitor’s Risk Assessment
Framework. These were not included in the 2013/14 Quality Account as the Trust did not
achieve foundation trust status until 1st March 2015 and this was only a requirement for
foundation trusts.
The Trust has an established Performance Management Framework which includes a
monthly Board Quality and Performance Report (QPR). The content of the QPR is reviewed
and approved each year by the Finance and Performance Committee on behalf of the Board
of Directors. This includes all Monitor targets as defined within their Risk Assessment
Framework, Trust Development Authority (TDA) indicators which were applicable prior to
authorisation as a foundation trust and locally agreed indicators. The TDA indicators will
become locally agreed indicators for 2015/16. This report provides performance information
at Trust and Division level and is structured around CQC’s five domains: Safe, Caring,
Effective, Responsive and Well-Led. Where appropriate benchmarking information is
included in this report however this is an area where the Trust recognises more
benchmarking could be undertaken and this is a priority for 2015/16.
Data Quality
Accurate information is fundamental to support the delivery of high quality care; we therefore
strive to ensure all data is as accurate as possible. As part of our quality governance
improvement plan the Trust introduced a Performance Indicator Assessment Framework
(PIAF) in 2014. Each indicator on the dashboards in the QPR is assessed against five
dimensions of data quality and an overall RAG rating applied which is included as coloured
spots against each indicator on the QPR. Where an indicator has not yet been assessed a
grey spot is used. These dimensions and the definitions of the RAG rating are outline below.
Data Quality
Dimension
Completeness
Timeliness
Definition
Valid data – measures how much of the collected data can be used
Data entry – is all the data readily available at the time of calculation for
the period being measured
Accuracy
Accurate recording of data, consistent interpretation of business rules
when selecting values from lists and accurate calculation method for
indicator construction
Audit
Has an audit, either local, internal or external, been carried out in the
last 2 years and on either the system used to collect the data or on the
specific indicator itself, and if so, what was the result
Validation
Divisions or other departments are monitoring the indicators locally and
flagging up if there's an issue
Indicator Data Quality
Definition
RAG Rating
Blue
Highly Significant Assurance (very robust)
Green
Significant Assurance (good enough)
Amber
Limited Assurance (significant issues)
Red
Very Limited Assurance (systemic issues, minimal
confidence)
43
Quality Report 2014/15
The PIAF also includes a glossary of all indicators which includes the definitions and any
action required where an indicators data quality RAG rating is amber or red to increase the
rating to green. The PIAF is included in the QPR each month and this will continue to be an
ongoing area for development in 2015/16.
The Trust has various information systems in which data is collected from which
performance with local and national indicators is calculated. These include nationally
available systems:
•
•
•
•
•
•
RiO – Clinical information system used by our mental health services from which
data is used for CPA, readmissions, delayed transfers of care, crisis gatekeeping,
early intervention in psychosis and data completeness and outcome indicators
SystmOne – Clinical information used in community services used for community
data completeness indicators
ESR – Electronic staff record for sickness and appraisal rates
Integra – Finance system for turnover and vacancy rates
PC-MIS – for IAPT indicators
Ulysses – for incident and complaint indicators
Some of the data from these systems is extracted into national datasets such as National
Reporting and Learning System (NRLS) and The Mental Health and Learning Disabilities
Data Set (MHLDDS).
In addition the Trust utilises local systems for patient experience, training and clinical
supervision.
Performance against Locally Agreed Quality and Performance Indicators
The Trust has chosen to include performance against all the locally agreed quality and
performance indicators reported to the Board of Directors rather than specifically select three
patient safety, three clinical effectiveness and three patient experience indicators. This was
discussed and supported by stakeholders through the lead Clinical Commissioning Group
and the Council of Governors.
Performance against all these indicators is included in the table below. Indicators which are
governed using national definitions are marked with an asterix*. Where possible we have
included benchmarking information to show how we compare to other NHS organisations.
Each month where there is underperformance, exception reports are included in the QPR
providing a rationale for under-performance and action being taken to improve. Areas for
which there has been underperformance in 2014/15 relating to local indicators include:
•
•
•
•
•
•
Staff Appraisals
Mandatory Training Information Governance
Sickness and Absence
Acquired Avoidable Pressure Ulcers
Clinical Supervision
Safety Thermometer Harm Free Care
44
Quality Report 2014/15
Locally Agreed Quality and Performance Indicators
Domain
Indicator Description
End of
Year
March
2014
End of
Year
March
2015
(month
12 data
only)
(month
12 data
only)
Average
Monthly
Performance
2013/14
Average
Monthly
Performance
2014/15
Benchmarked
performance
97%
n/a
96%
See Page 38
(data from NHS
Staff Survey)
92%
94%
92%
94%
-
65
81
71
70
80%
97.0%
97.5%
94.7%
96.8%
-
3032
1962
1781
2195
-
10.1%
13.8%
9.7%
11.6%
Local Data
Source
Target
Trust on-line
Feedback site
-
n/a
-
Friends and Family Test scores
Percentage from December 2014 onwards
to reflect new NHS England guidance. The
average performance for 2014/15 reflects
December to March 14/15 only. A figure is
not given for 13/14 or April to November
14/15 to prevent inappropriate comparison
Caring
Service Quality Rating %
Complaints - number received
% of patient complaint cases
completed within agreed timescale
Number of responses from Family &
Friends Test
Turnover % (rolling 12 month figure)
Trust on-line
Feedback site
Divisional
complaints
data
Divisional
complaints
data
Trust on-line
Feedback site
Electronic
Staff Records
(ESR)
Well-Led
Total Sickness rate
Electronic
Staff Records
(ESR)
≤4%
4.7%
4.8%
5.0%
5.0%
HSCIC
November 2014
- National
mental health
trust rate - 5.4%
National
Community trust
rate – 5.0%
45
Data
Quality
Rating
Quality Report 2014/15
Vacancy rate %
Annual Reviews (Staff Appraisals)
carried out %
Clinical supervision %
Mandatory training
Mandatory training Information
Governance %
PCPT/IAPT - the Proportion of
people who complete treatment who
are moving to recovery *
Effective
% patients readmitted within 28
days – Adult *
% patients readmitted within 28
days - Older People *
Total number of incidents
Safe
% incidents degree of harm severe or death/catastrophic *
Integra
Financial
System
Electronic
Staff Records
(ESR)
Divisional
performance
dashboards
HR Training
Database
National
Information
Governance
database
PC-Mis
database
Rio clinical
information
system
Rio clinical
information
system
Ulysses
incident
information
system
Ulysses
incident
-
6.6%
8.0%
6.8%
7.9%
95%
82.0%
84.2%
74.8%
82.5%
80%
84.1%
71.6%
81.8%
70.7%
85%
88.1%
90.1%
85.6%
89.4%
95%
89.8%
92.1%
59.8%
63.4%
50%
41.8%
48.3%
42.1%
50.1%
<4%
3.9%
4.3%
7.2%
4.8%
<3%
1.9%
2.6%
0.9%
2.3%
-
1968
2496
1996
2319
-
0.56%
0.44%
0.41%
0.41%
National Staff
Survey 2014 Trust 91%
against a
national average
for mental
health trusts of
88%
46
Quality Report 2014/15
Total number of acquired avoidable
pressure ulcers stages 3 and 4
reported in month
Total number of acquired avoidable
pressure ulcers stages 3 and 4
reviewed post root cause analysis
Safety Thermometer All Harms - %
Harm Free Care *
Responsive
information
system
Ulysses
incident
information
system
Ulysses
incident
information
system
NHS Safety
Thermometer
website
Zero
9
8
13
9
Zero
n/a
n/a
n/a
9
95%
92.9%
93.3%
92.2%
93.0%
CPA - % patients having a review in
last 12 months *
Rio clinical
information
system
95%
97.2%
98.5%
96.0%
93.0%
CPA - % patients HoNOS review in
last 12 months *
Rio clinical
information
system
95%
82.4%
97.8%
79.4%
93.6%
Mental Health Delayed Transfers of
Care % attributable to the Trust
Rio clinical
information
system
≤7.5%
3.2%
2.2%
4.7%
3.1%
HSCIC March
2015 – National
rate 94.0%
HSCIC
December 2014
Trust – 88.1%
National rate
83.8%
HSCIC
December 2014
Trust – 92.6%
National rate
82.7%
47
Quality Report 2014/15
Compliance with Monitor Risk Assessment Framework
As a foundation trust we are required to comply with our terms of authorisation as set out in
Monitor’s Risk Assessment Framework. Performance against these targets is set out in the
table below. The Trust has been compliant with all targets during 2014/15 with the exception
of Care Programme Approach (CPA) 12 Month Review. An explanation for this is provided
below.
CPA 12 Month Review
CPA reviews are recorded on RiO, our clinical information system. Information from RiO is
extracted and submitted to the Mental Health Minimum Data Set (MHMDS). It is this data set
that is used by the Health and Social Care Information Centre (HSCIC) to calculate
performance.
It was identified that the data field submitted to the MHMDS was ‘validated CPAs’. Staff
record CPA reviews on RiO in another field (which is un-validated), following which the
review requires validation. This ensures it appears in the data field used to inform the
MHMDS and subsequently used by the HSCIC to calculate the percentage of patients who
have had a CPA within the last 12 months. CPAs have to be validated within 45 days to
count towards performance and we identified that some staff were unaware of the
requirement to either validate the CPA, or the timeframe in which this had to be undertaken.
The Trust was calculating performance using the un-validated data and this explained the
identified difference between the internally and externally calculated levels of performance.
The Trusts internal performance figure represented the true number of CPA reviews that
have occurred as opposed to those which formally count and therefore the clinical risk of this
underperformance during the year was low.
In June 2014, the methodology for calculating performance in the Trust was amended to
reflect the methodology used externally by the HSCIC. This is to ensure the level of
performance monitored by the trust is aligned to the level of performance monitored by the
TDA and Monitor.
The change in methodology resulted in performance dropping from 96.6% in June to 89.7%
in July. Performance by March 2015 was 98.5%
48
Quality Report 2014/15
Monitor Targets
Domain
Access
Indicator Description
Care Programme Approach (CPA) patients receiving follow-up contact within seven days
of discharge
Care Programme Approach (CPA) patients having formal review within 12 months
Admissions to inpatients services had access
to Crisis Resolution/Home Treatment teams
Meeting commitment to serve new psychosis
cases by early intervention teams
Minimising mental health delayed transfers of
care
Mental health data completeness: identifiers
Outcomes
Mental health data completeness: outcomes
for patients on CPA - new indicator
Certification against compliance with
requirements regarding access to health care
for people with a learning disability
Data completeness: community services Referral to treatment information
Data completeness: community services Referral information
Data completeness: community services Treatment activity information
Local Data
Source
Rio clinical
system
Rio clinical
system
Rio clinical
system
Rio clinical
system
Rio clinical
system
Rio clinical
system
Rio clinical
system
Divisional
Performance
depts
SystmOne
clinical
system
SystmOne
clinical
system
SystmOne
clinical
system
End of
Year
March
2014
End of
Year
March
2015
(month 12
data only)
(month 12
data only)
95%
100%
95%
Average
Monthly
Performance
2013/14
Average
Monthly
Perform
-ance
2014/15
Benchmarked
performance
98.3%
99.0%
98.8%
See Page 35
97.2%
98.5%
96.0%
93.0%
95%
94.1%
100%
98.1%
98.9%
95%
120.8%
120.1%
111.2%
141.9%
≤7.5%
6.1%
4.1%
6.8%
4.9%
97%
99.8%
99.0%
99.7%
99.4%
50%
97.8%
82.1%
96.6%
77.8%
Compli
ance
Compliant
Compliant
Compliant
Compliant
50%
100%
100%
100%
100%
50%
100%
100%
100%
100%
50%
100%
100%
100%
100%
Target
See Page 35
49
Data
Quality
Rating
Annexes
Annex A - Statements of Assurance from Other Bodies
Healthwatch
As the independent watchdog for health and care in the County, we work hard to
ensure patient and carer voices are heard, by providers and commissioners.
We think we have a good working relationship with the Trust. We have regular update
meetings where any issues can be discussed. We have shared some comments with the
Trust and have received timely and useful responses to these.
We are grateful for the opportunity to view and comment on the Quality Report. We
specifically reviewed it in terms of patient and carer involvement.
Positives
Pleased to see that in most cases, last year’s targets have been met, and when not met
plans are in place to improve.
Healthwatch has regular meetings with the Involvement Team, to keep updated on each
other’s work, and find areas where we can work together. We have recently agreed an
Information Sharing Protocol, which will improve the consistency and efficiency of sharing
feedback.
We were glad to see the launch of Millbrook Live, following on from Highbury and Bassetlaw,
to encourage more sharing of patients’ thoughts and suggestions.
Concerns
It is clear that challenges remain and are recognised in, for example, reducing the incidence
of pressure ulcers; and in terms of supervision targets (especially in Health Partnerships).
It is clear, also, that the Trust is monitoring performance on these and on other issues. It is
noted that plans are in place designed to secure performance improvement and we look
forward to future evidence of progress in those directions.
Content
We felt that evidence of greater emphasis on patient and carer engagement would have
been both appropriate and welcome.
Carer and patient engagement are both clearly at the core of Trust plans, yet note that, for
example, nothing is stated about patient or public involvement in putting together the Quality
Report.
We note the list of proposed actions and the stated commitment to continual improvement
and look forward to receiving evidence, in future, of positive progress.
Presentation
In general, this is a relatively clear document, given the requirement to meet national
standards for what is included. We like the coloured charts and use of space. However there
are a few places where it is unclear. Either in terms of definitions of words or phrases, or
numbers.
50
Comments received by Healthwatch Nottinghamshire
Between April 2014 and March 2015, we have collated around 85 comments on the whole
range of mental health services, from Talking Therapy to inpatient treatment.
We did a specific piece of work on mental health, to find out how patients experienced
services, what issues carers were facing and what public perceptions were of services. This
gave us a lot of data, and we are working towards an Insight Project based on these
outcomes. Crisis Support and Carer Support were two of the main threads.
Topics raised in patient or carer comments to Healthwatch:
Communications – between clinicians, with carers, and with patients.
Waiting times to access treatment.
Not feeling listened to.
Crisis support – access and quality.
Equality of access – across parts of County and for British Sign Language (BSL)
users.
Distance to care or bed, and carers difficulty visiting.
Care Plans. Lack of plans or lack of feeling involved in them.
Not being involved in decisions.
Closure of day centres and groups
Transitions – from CAMHS to Adult and from In- to Out- patient.
Lack of continuity.
Ward closures.
Importance of individual staff for support – “she is superb”.
We are pleased to see that these topics are covered by the Quality Priorities for 2015-16. 5 Improving complaints management, 6 - experience of patient, carers and service users
“need to be listened to, communicated with and involved in developing their own plan of
care”, 8 - Timely access to services in a range of locations. 9 - Impact of Cost Improvement
Programmes and 10 - Right number of staff, with the right skills.
We will continue to work with the Trust, to monitor any issues which arise, and listen to
patients and carers about their experiences.
Joint Nottingham and Nottinghamshire Health Scrutiny Committee
The Joint Health Scrutiny Committee for Nottingham City and Nottinghamshire County
welcomes the opportunity to comment on the Nottinghamshire Healthcare NHS Foundation
Trust Quality Report.
The Committee has found the Trust open and willing to engage with Scrutiny during the
year.
The Committee welcomes the Trust’s continued focus on pressure ulcers, particularly since
the Trust was not able to meet any of its pressure ulcer related targets last year. However,
the Committee recognised last year that the targets were challenging and is pleased to see
that no stage 3 or 4 avoidable pressure ulcers have been reported since October 2014.
The Trust’s important work preventing suicide and reducing self-harm was also welcomed by
the Committee.
51
The Committee is pleased to note that there has been no increase in staff sickness related
to physical assaults at work.
The Committee is particularly pleased to see that there have been no never events within
the Trust during 2014/15 and no medication errors have resulted in severe harm or death.
However, the Committee is concerned to see the large number of medication errors (both
prescribing and administrative). The Committee would hope to see a substantial reduction in
the number of medication errors in next year’s Quality Report.
Council of Governors
The Council of Governors has two main general duties:
(i)
to hold the non-executive directors (NEDs) to account;
(ii)
to represent the views of and to account to members of the Trust and the general
public.
With respect to quality assurance, the CoG has formed a Quality and Innovation working
group, consisting of governors and advised by Trust officers. The chair of the Trust’s Quality
& Risk (Q&R) Committee, or her representative, attends this group to assist the governors in
seeking assurance.
For most of 2014-15, the CoG has been acting in shadow form, setting up its own processes
and procedures and developing relations with NEDs and members of the Trust. The CoG
quality group met for the first time in December.
Since December, and more especially since the achievement of FT status in March, the
working group has focused on three tasks:
(i)
seeking assurance on quality performance and advising the CoG accordingly;
(ii)
challenging the chair of the Trust’s Q&R Committee on the Trust’s proposed quality
priorities for 2015-16;
(iii)
seeking assurance on the availability of appropriate resources to deliver the Trust’s
ambitious quality agenda for 2015-16.
We are pleased to report that governors are assured on performance, priorities and
resources and have been provided with evidence to support this assurance.
Patient Safety Collaborative
East Midlands Academic Health Science Network Patient Safety Collaborative has provided
the following statement for inclusion:
East Midlands Academic Health Science Network has established a local Patient Safety
Collaborative whose role is to offer staff, service users, carers and patients the opportunity to
work together to tackle specific patient safety problems, improve the safety of systems of
care, build patient safety improvement capability and focus on actions that make the biggest
difference using evidence based improvement methodologies.
Nottinghamshire Healthcare NHS Foundation Trust is committed to working with the EMPSC
and has pledged to contribute to the emergent safety priories
• Discharge, transfers and transitions
• Suicide, delirium and restraint
• The deteriorating patient
• The older person: focussing on what ‘good safety’ looks like in the care home setting.
52
In addition we pledge to support the core priorities identified below:
• Developing a safety culture/leadership
• Measurement for improvement
• Capability building
Nottingham City Clinical Commissioning Group
NHS Nottingham City Clinical Commissioning Group (CCG) is the lead commissioner for
Nottinghamshire Healthcare NHS Foundation Trust on behalf of a number of commissioners.
In this role the CCG is responsible for monitoring the quality and performance of services at
Nottinghamshire Healthcare NHS Foundation Trust throughout the year.
Our 2014-15 contract and service specifications with the Trust detailed the level and
standards of care expected and how we would measure, monitor, review and manage
performance. Monthly Quality and Contract Review meetings are held with the Trust and it is
through this arrangement along with visits to services and continuous dialogue as issues
arise that the accuracy and validity of this Quality Account has been checked by the CCG.
We acknowledge the hard work and commitment of Nottinghamshire Healthcare NHS
Foundation Trust staff to ensure patients remain at the centre of care. As healthcare
commissioners we are dedicated to commissioning high quality services from our providers
and are encouraged that the Trust are focused on patient safety, patient experience and
clinical effectiveness. Nottinghamshire Healthcare NHS Foundation Trust has worked
constructively with commissioners and other partners to respond to commissioning
intentions and develop integrated care pathways to support the reduction of health
inequalities and improve the health of the local community.
The commissioners noted the outcome of a CQC inspection carried out in early 2014-15
which was Good overall, with an outstanding rating for caring and committed staff. There
were areas of improvement required and the Trust responded quickly to these. In addition,
during 2014-15 the Trust was authorised by Monitor as a Foundation Trust following 12
months of assessment and external scrutiny. This involved a robust examination of the
Trust’s standards and governance procedures.
The commissioners are also assured of the Trust’s commitment to the “Sign up for Safety”
campaign and that six key areas from the campaign have been identified as quality priorities
for the coming year: restrictive practices, suicide and self-harm, assaults and violence,
medication errors, pressure ulcers and falls. Some of these areas are continuations of last
year’s quality priorities where progress has been made but there is scope for further
improvement.
Commissioners are keen to see the monitoring and reporting of progress and achievements
against the quality priorities from the Trust recorded and presented by protected
characteristic. This is to support the CCG in analysing and measuring our equality
performance and provide information about services and how they are being experienced by
our entire population. .
The Trust has demonstrated a commitment to physical healthcare and in particular smoking
cessation and although this hasn’t been chosen as a quality priority for 2015-16, the
commissioners expect to see a continuation of the work undertaken with recent CQUINs on
Physform and the National Schizophrenia Audit. The Trust has a Smoking Cessation Action
Plan that sets out an ambitious target to stop smoking on Trust premises by April 2016. The
commissioners will work with the Trust in 2015-16 to monitor progress in these areas.
53
The Trust has continued to demonstrate high commitment to improving the patient
experience and has included quality priorities around improved management of complaints
and ensuring a consistent positive overall experience of patients, carers, service users and
staff. The commissioners are pleased to see the continuation of these priorities from 201415 into 2015-16 as improving both patient experience and staff satisfaction are high priority
areas for us. The commissioners will continue to monitor the Trust against its targets for staff
training and staff appraisals and recommends that the Trust aligns these targets across all
it’s contracts.
We will continue to work with Nottinghamshire Healthcare NHS Foundation Trust in 2015-16
to assure ourselves of the continual quality of the services provided and to monitor
achievements of targets, indicators and priorities.
54
Annex B – Statement from Directors
Statement of Directors’ Responsibilities in Respect of the Quality Account
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of
annual quality reports (which incorporate the above legal requirements) and on the
arrangements that NHS foundation trust boards should put in place to support the data
quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves
that:
•
the content of the Quality Report meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual 2014/15 and supporting guidance
•
the content of the Quality Report is not inconsistent with internal and external
sources of information including:
o board minutes and papers for the period April 2014 to the date of signing
the limited assurance report
o papers relating to Quality reported to the board over the period April 2014
to the date of signing the limited assurance report
o feedback from commissioners dated 26/05/2015
o feedback from governors dated 20/05/2015
o feedback from local Healthwatch organisations dated 07/05/2015
o feedback from Overview and Scrutiny Committee dated 12/05/2015
o the trust’s complaints report published under regulation 18 of the Local
Authority Social Services and NHS Complaints Regulations 2009,
Complaints and PALS Report 2013/14 reported to the Board on
28/08/2014
o the 2014 national patient survey 18/09/2014
o the 2014 national staff survey 24/02/2015
o the Head of Internal Audit’s annual opinion over the trust’s control
environment dated 19/05/2015
o CQC Intelligent Monitoring Report dated 30/11/2014 and 01/05/2015
(draft)
•
the Quality Report presents a balanced picture of the NHS foundation trust’s
performance over the period covered
55
•
the performance information reported in the Quality Report is reliable and
accurate
•
there are proper internal controls over the collection and reporting of the
measures of performance included in the Quality Report, and these controls are
subject to review to confirm that they are working effectively in practice
•
the data underpinning the measures of performance reported in the Quality
Report is robust and reliable, conforms to specified data quality standards and
prescribed definitions, is subject to appropriate scrutiny and review and
•
the Quality Report has been prepared in accordance with Monitor’s annual
reporting guidance (which incorporates the Quality Accounts regulations)
(published at www.monitor.gov.uk/annualreportingmanual) as well as the
standards to support data quality for the preparation of the Quality Report
(available at www.monitor.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with
the above requirements in preparing the Quality Report.
By order of the board
NB: sign and date in any colour ink except black
56
Glossary and Definitions for Audited Indicators
CPA 7 Day Follow-up
Indicator Description:
100% enhanced Care Programme Approach (CPA) patients receive follow-up contact within
seven days of discharge from hospital
Numerator/Value: The number of people under adult mental illness specialties on CPA who
were followed up (either by face-to-face contact or by phone discussion) within seven days
of discharge from psychiatric inpatient care.
Denominator: The total number of people under adult mental illness specialties on CPA
who were discharged from psychiatric inpatient care.
Target: : ≥ 95%
Additional Information:
Following up someone on care programme approach (CPA) within seven days of discharge
from inpatient care reduces risk of harm and social exclusion and can maintain and improve
access to care.
The indicator is calculated as the proportion of those in Care Programme Approach (CPA)
formally discharged from psychiatric inpatient care who are followed up within 7 days. (This
excludes periods of temporary leave without formal discharge.)
Numerator and denominator clinical information are taken from the RiO clinical information
system.
• ‘Patients discharged’ includes patients discharged to their place of residence, care home,
residential accommodation, or to non-psychiatric care, or to prison.
• The indicator excludes patients who are readmitted within 7 days of discharge.
• The indicator excludes patients who die within 7 days of discharge.
• The indicator excludes patients forcibly removed from the country as a result of legal
precedence within 7 days of discharge.
• The indicator excludes patients transferred to NHS psychiatric inpatient ward when
discharged from inpatient care.
• The indicator excludes CAMHS in-patients (children and adolescent mental health
services).
• Patients are recorded as followed up receive direct face to face contact or a telephone
conversation from the Trust (not text or voice messages or third party e.g. GP or a care
home contact).
• The 7 day period is measured in days not hours and starts on the day after discharge.
Delayed Transfers of Care
Indicator Description: Percentage of secondary mental health patients' occupied bed days
where transfer of care was delayed during the period.
Numerator/Value: The number of secondary mental health patients (aged 18 and over on
admission) per day whose transfer of care was delayed during the period. For example, one
patient delayed for five days counts as five (even when the patient is on leave)
Denominator: The total number of occupied bed days during the period (excluding leave).
Delayed transfers of care attributable to social care services are included.
Target: ≤ 7.5%
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Additional Information:
A delayed transfer of care occurs when a patient is ready for transfer from a hospital bed,
but is still occupying such a bed. Delayed transfers of care (DTOC) (both numerator and
denominator) only includes adults aged 18 and over. Nottinghamshire Healthcare NHS
FoundationTrust data for DTOC entered via the UNIFY system for the Department of Health
national MSitDT (Sitrep) database includes mental health and community patients whose
transfer of care was delayed each month. The DTOC percentage indicator is calculated on
the number of delayed days of transfer in a given period as the numerator, expressed as a
percentage of the denominator - total occupied bed days in the same period, a calculation in
line with current (Sitrep) guidance.
Numerator and denominator clinical information are taken from the RiO clinical information
system.
A patient is ready for transfer when:
[a] a clinical decision has been made that the patient is ready for transfer AND
[b] a multidisciplinary team decision has been made that the patient is ready for transfer
AND
[c] the patient is safe to discharge/transfer.
To be effective, the measure must apply to acute beds, and to non-acute and mental health
beds. If one category of beds is excluded, the risk is that patients will be relocated to one of
the ‘excluded’ beds rather than be discharged.
Improving access to psychological therapies (IAPT) Recovery rates
Indicator Description: Percentage of patients who have completed their treatment whose
outcome score undertaken at the point of discharge demonstrates they are moving towards
recovery.
Numerator/Value: The number of patients in the reporting period whose outcome score at
point of discharge demonstrates they are moving towards recovery.
Denominator: The number of patients who have been discharged from the service in the
reporting period.
Target: ≥ 50%
Additional Information:
Improving access to psychological therapies (IAPT) aims to increase the availability of
‘talking therapies’ on the NHS. IAPT uses a number of well-validated, patient completed
questionnaires to measure change in a person’s mental well-being.
Most of the
questionnaires are administered at each appointment, making it possible to track
improvement by comparing scores over time.
The IAPT Programme includes a measure of recovery which use questionnaire scores for
‘moving to recovery’. This counts the number of people that were above the clinical cut-off
before treatment but below following treatment. An individual is defined as a case if (s)he
scores above the clinical threshold on depression and/or anxiety at pre-treatment. Recovery
occurs if that person subsequently scores below the clinical threshold on depression and
anxiety.
The recovery rate calculation uses the total number of people ending treatment who were
above threshold at start of treatment and have subsequently moved to recovery (as defined
above) as the numerator value and the total number of people were above threshold values
at the start of treatment who have subsequently finished treatment as the denominator
value.
Numerator and denominator clinical information are taken from the PCMIS clinical
information system.
58
Summary of Changes Following Stakeholder Commentary
Nottingham City CCG
Changes made following Trust attendance at the Quality Improvement Committee on 13 th
May 2015 and subsequent written commentary.

Inclusion of Trust commitment to smoking cessation – this is included in the look
forward to 2015/16 section of Quality Priority 6 on page 13.

Commissioners are keen to see the monitoring and reporting of progress and
achievements against the quality priorities from the Trust recorded and presented by
protected characteristic. This is included in the Quality Priority Monitoring section on
page 18.
Independent Auditors’ Limited Assurance Report to the Directors of
Nottinghamshire Healthcare NHS Foundation Trust on the Annual Quality
Report
Independent Auditors’ Limited Assurance Report to the Council of Governors of
Nottinghamshire Healthcare NHS Foundation Trust on the Annual Quality Report
We have been engaged by the Council of Governors of Nottinghamshire Healthcare NHS Foundation
Trust to perform an independent assurance engagement in respect of Nottinghamshire Healthcare
NHS Foundation Trust’s Quality Report for the year ended 31 March 2015 (the ‘Quality Report’) and
specified performance indicators contained therein.
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance (the “specified
indicators”); marked with the symbol
in the Quality Report, consist of the following national
priority indicators as mandated by Monitor:
Specified Indicators
Specified indicators criteria
Percentage of enhanced Care Programme
Approach (CPA) patients who receive followup contact within seven days of discharge
from hospital
Quality Report page 34
Minimising delayed transfer of care
Quality Report page 42
Glossary page 57
Glossary page 57
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in accordance
with the specified indicators criteria referred to on pages of the Quality Report as listed above (the
"Criteria"). The Directors are also responsible for the conformity of their Criteria with the assessment
criteria set out in the NHS Foundation Trust Annual Reporting Manual (“FT ARM”) and the “Detailed
59
requirements for quality reports 2014/15” issued by the Independent Regulator of NHS Foundation
Trusts (“Monitor”).
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether
anything has come to our attention that causes us to believe that:



The Quality Report does not incorporate the matters required to be reported on as specified
in Annex 2 to Chapter 7 of the FT ARM and Monitor’s “Detailed requirements for quality
reports 2014/15”;
The Quality Report is not consistent in all material respects with the sources specified below;
and
The specified indicators have not been prepared in all material respects in accordance with
the Criteria and the six dimensions of data quality set out in Monitor’s “2014/15 Detailed
guidance for external assurance on quality reports”.
We read the Quality Report and consider whether it addresses the content requirements of the FT
ARM and Monitor’s “Detailed requirements for quality reports 2014/15; and consider the implications
for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially
inconsistent with the following documents:

Board minutes for the period April 2014 to the date of signing the limited assurance report (the
period);

Papers relating to Quality reported to the Board over the period April 2014 to the date of signing
the limited assurance report;

Feedback from the Nottingham City Clinical Commissioning Group dated 26/05/2014;

Feedback from Nottinghamshire Healthcare Foundation Trust Quality Report 2014-15
Governor’s Report dated 20/05/2015;

Feedback from local Healthwatch organisations Healthwatch Nottinghamshire Statement May
2015 dated 07/05/2015;

The Trust’s complaints report published under regulation 18 of the Local Authority Social
Services and NHS Complaints Regulations 2009, Complaints and PALS Report 2013-2014
reported to the Board on 28/08/2014;

Feedback from other stakeholders involved in the sign-off of the Quality Report, Joint
Nottingham and Nottinghamshire Health Scrutiny Committee dated 12/05/2014 and East
Midlands Academic Health Science Network Patient Safety Collaborative - Quality Account
Statement (2015) - dated 17/03/2015;

The 2014 National Patient Survey dated 18/09/2014;

The 2014 National Staff survey (full and summary) for 2014 dated 24/02/2015;

Care Quality Commission Intelligent Monitoring Reports dated 30/11/2014 and 01/05/2015
(draft);

The Head of Internal Audit’s annual opinion over the Trust’s control environment dated
19/05/2015 ; and

CQC Inspections reports dated 31/07/2014 for the following services, Acute Admission wards,
Adult Community based services, Child and Adolescent Mental Health services (CAMHS),
Community Health Inpatient services, Community Health Services for Adults, Community health
services for children, young people and families, End of life care, Forensic services, Long stay
services, Perinatal Services, Psychiatric intensive care units (PICU) and health based places of
safety, Rapid Response Liaison Psychiatry, Services for Older People (Mental Health), Specialist
eating disorder service (Mental Health) and CQC - Follow up report - HMP & YOI Doncaster
dated 03/04/2015, HMP Wakefield received dated 20/05/2015 and HMP Nottingham received
dated 20/05/2015.
60
We consider the implications for our report if we become aware of any apparent misstatements or
material inconsistencies with those documents (collectively, the “documents”). Our responsibilities
do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute
of Chartered Accountants in England and Wales (“ICAEW”) Code of Ethics. Our team comprised
assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of
Nottinghamshire Healthcare NHS Foundation Trust as a body, to assist the Council of Governors in
reporting Nottinghamshire Healthcare NHS Foundation Trust’s quality agenda, performance and
activities. We permit the disclosure of this report within the Annual Report for the year ended 31
March 2015, to enable the Council of Governors to demonstrate they have discharged their
governance responsibilities by commissioning an independent assurance report in connection with
the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to
anyone other than the Council of Governors as a body and Nottinghamshire Healthcare NHS
Foundation Trust for our work or this report save where terms are expressly agreed and with our prior
consent in writing.
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on
Assurance Engagements 3000 ‘Assurance Engagements other than Audits or Reviews of Historical
Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE
3000’). Our limited assurance procedures included:








Reviewing the content of the Quality Report against the requirements of the FT ARM and
Monitor’s “Detailed requirements for quality reports 2014/15”;
Reviewing the Quality Report for consistency against the documents specified above;
obtaining an understanding of the design and operation of the controls in place in relation to
the collation and reporting of the specified indicators, including controls over third party
information (if applicable) and performing walkthroughs to confirm our understanding;
Based on our understanding, assessing the risks that the performance against the specified
indicators may be materially misstated and determining the nature, timing and extent of
further procedures;
Making enquiries of relevant management, personnel and, where relevant, third parties;
considering significant judgements made by the NHS Foundation Trust in preparation of the
specified indicators;
Performing limited testing, on a selective basis of evidence supporting the reported
performance indicators, and assessing the related disclosures; and
Reading the documents.
A limited assurance engagement is less 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.
61
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different
measurements and can impact comparability. The precision of different measurement techniques may
also vary. Furthermore, the nature and methods used to determine such information, as well as the
measurement criteria and the precision thereof, may change over time. It is important to read the
Quality Report in the context of the assessment criteria set out in the FT ARM, Monitor’s “Detailed
requirements for quality reports 2014/15 and the Criteria referred to above.
The nature, form and content required of Quality Reports are determined by Monitor. This may result
in the omission of information relevant to other users, for example for the purpose of comparing the
results of different NHS Foundation Trusts.
In addition, the scope of our assurance work has not included governance over quality or nonmandated indicators in the Quality Report, which have been determined locally by Nottinghamshire
Healthcare NHS Foundation Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe
that for the year ended 31 March 2015,



The Quality Report does not incorporate the matters required to be reported on as specified in
Annex 2 to Chapter 7 of the FT ARM and Monitor’s “Detailed requirements for quality
reports 2014/15”;
The Quality Report is not consistent in all material respects with the documents specified
above; and
The specified indicators have not been prepared in all material respects in accordance with
the Criteria and the six dimensions of data quality set out in the “Detailed guidance for
external assurance on quality reports 2014/15”.
PricewaterhouseCoopers LLP
Donington Court,
Pegasus Business Park,
Castle Donington, DE74 2UZ
28 May 2015
The maintenance and integrity of Nottinghamshire Healthcare NHS Foundation Trust’s website is the
responsibility of the directors; the work carried out by the assurance providers does not involve consideration of
these matters and, accordingly, the assurance providers accept no responsibility for any changes that may have
occurred to the reported performance indicators or criteria since they were initially presented on the website.
62