South West London and St George’s
Mental Health NHS Trust
Quality Account
2014/15
Contents
Part 1: Chief Executive’s statement on the quality of our services
4
Part 2: Looking forward - Priorities for improvement 2014/15
7
Looking forward - Quality Account priorities for 2015/16
9
Looking forward - CQUIN goals for 2015/16
10
Part 3: Looking back - Review of quality performance 2014/15
11
Review of Quality Account priorities 2014/15
11
Looking back - Progress against the core quality indicators 2014/15
25
Looking back - Evaluation of current practice against the findings of the Francis Inquiry and
Winterbourne Review 2014/15
27
Looking back - Safeguarding Vulnerable Adults 2014/15
28
Looking back - Safeguarding Vulnerable Children 2014/15
28
Looking back - Statements of quality assurance from the Board 2014/15
29
Information on the review of services
29
Looking back - Participation in Clinical Audits and Quality Improvement activity 2014/15
29
Looking back - Participation in clinical research 2014/15
34
Statements from the Care Quality Commission 2014/15
36
Data quality 2014/15
38
NHS number and general medical practice code validity 2014/15
39
Information governance toolkit attainment levels 2014/15
39
Information governance personal data loss 2014/15
39
Clinical coding error rate 2014/15
39
Complaints 2014/15
40
Freedom to Speak Up 2014/15
41
Compliments 2014/15
41
Serious Incidents 2014/15
43
Comments from stakeholders
45
Amendments following comments from stakeholders
59
Feedback
59
Glossary
60
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Annex - Statement of Directors Responsibility in Respect of the Quality Account
62
Independent Auditors’ Limited Assurance Report
63
Appendix 1: Quality Account Priorities 2015/16
67
Appendix 2: Francis and Winterbourne Report action plan
82
Appendix 3: Review of Quality Account Priorities 2014/15
83
Appendix 4: Review of CQUIN Goals 2014/15
96
Appendix 5: Participated audits 2013/14
113
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
3
Part 1: Chief Executive’s statement on the quality of our services
I am delighted to present South West London and St George’s Trust’s Quality Account for 2014/15.
The purpose of these accounts is to report publicly on what we have achieved over the last twelve
months in terms of making progress against our stated quality goals. The accounts also look ahead to
our quality priorities for the next twelve months and summarise how we expect to manage and
monitor them.
The Trust has worked with the local CCG’s, staff, service users, carers and commissioners in order to
establish the Quality Account priorities. The initial themes were discussed further at the Clinical
Quality Commissioning Reference Group (CQRG) and then developed into indicators using
information provided by the Trust clinical leads. The draft report was sent out to CCGs, Health
Overview and Scrutiny Committees (HOSCs), Local Healthwatch, the Service User Reference Group
and sub committees of the Trust Board.
I am very pleased to report that we have met and bettered our targets for several quality initiatives
since we published our last set of Quality Accounts in June 2014. I think this illustrates that we have
made a steady improvement and continues our pursuit of achieving high standards of quality across
the organisation. This is an impressive track record, especially considering the current state of mental
health in the UK, which presents us with so many challenging clinical and financial challenges.
According to the Centre for Mental Health Annual Report 2012 one in four of us has a mental health
condition at any one time and around half of people with lifetime mental health problems experience
the first symptoms before the age of 14.
In terms of finance mental ill health has an economic and
social cost of £105bn a year for the UK, and mental illness accounts for 23% of the total burden of
disease but only 13% of NHS spending. The impact of mental health on physical health is also telling
with untreated mental ill health adding approximately £10 billion a year to the cost of physical health
care for people with long-term conditions.
With this in mind the Trust continues to be committed to the provision of consistent, high-quality, safe
services and aims to continually improve the treatment and care we provide for service users, carers
and staff. Part of our commitment to quality is the development of our five year quality strategy, which
articulates three broad quality objectives; Safety, Clinical effectiveness and Patient experience. We
have also ensured that these three themes align with the five high level national domains for
improvement specified in The NHS Outcomes Framework 2014/15.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Quality governance is not a corporate function. Our aim is for it to be embedded in all aspects of the
Trust’s activities and to make sure it is everyone’s responsibility from front-line clinicians to porters,
facilities staff and IT. Over the past year we have undertaken two assessments which have
highlighted the ongoing commitment to quality in the Trust.
Chief Inspector of Hospitals
In June 2014 the Trust received feedback following an inspection by the Chief Inspector of Hospitals
(CiH). The findings from the inspection reflected positively on the Trust and recognised the hard work
and dedication of our staff. Overall, the CQC found that staff were ‘compassionate’ and services were
‘safe and well-led’. The CQC praised staff saying they were ‘caring and had a good approach to
patient care and interacted positively and compassionately with people’. Inspectors also noted that
much of the care delivered followed best practice guidance.
As a Trust, we are grateful to the inspectors for their root and branch examination of our services and
for recognising the excellent work provided by our caring and professional staff. The inspection was
tough, but very fair and gave us the extremely valuable opportunity to examine the services we
provide and look at how we can make them better for patients, carers and our staff.
The Inspectors ‘judged that services were safe. There were systems to identify, investigate and learn
from incidents. Staff at all levels of the organisation said that there was an open culture that supported
them to report and learn from incidents. The Trust’s board had a focus on quality and this was
reflected across the organisation.’
The Chief Inspector of Hospitals reported that ‘the majority of patients and carers we spoke to
described staff as caring and compassionate. Whilst we were on the wards we saw staff treating
people with dignity and respect.’
The Inspectors acknowledged that ‘without exception, the people we spoke with were confident that
the new chief executive and the Trust’s board were able to provide the leadership and governance
required.’
As an organisation we are very aware that there is a great deal of work still to be done and we are
ready to meet the challenges ahead. We have already begun working to implement robust action
plans on the areas of improvement highlighted by the Chief Inspector of Hospitals.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Monitor Quality Assessment
In January 2015 the Trust was assessed by Monitor against our quality governance framework in
order to ensure that the Trust has a robust approach to governance for quality.
These types of
Monitor assessments were introduced in 2010 in response to the Francis Report.
The assessment conducted by Monitor involved a series structured interviews at, and below, board
level to assess the arrangements for managing clinical risks, ensure ongoing improvements in
standards of care and through 1 to1 interviews, staff focus groups, meeting observations. Monitor
assessors spoke with a number of different groups of staff across the five boroughs. The evidence
gathered was used to assess the Trust against the governance framework (MQGF). The Trust has
worked with this framework for the last two years, both self-assessing itself against the criteria and
being independently assessed on two occasions by KPMG.
This provided us with another opportunity to demonstrate the progress we have made as well as
giving us an insight into areas where we still need to make improvements. The assessment has
resulted in the Trust being referred by the TDA to the next stage of the foundation trust application
process.
The Trust’s sub-group to the Board, Quality Assurance and Safety Assurance Group has signed off
these quality accounts. To the best of my knowledge the information presented in this report is
accurate.
Thank you to everyone who is helping keeping quality at the top of our agenda, and for their
unswerving commitment to turning our vision into positive action.
David Bradley
Chief Executive
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Part 2: Looking forward - Priorities for improvement 2014/15
At South West London and St George’s (SWLSTG), we want to demonstrate the highest possible
standards of quality and professionalism in everything we do. This applies in all our interactions with
service users and our wider stakeholders and, additionally, across all our day to day processes and
procedures, be they clinical or non-clinical.
We want the exemplary calibre of our people and our performance to be apparent at all times – and
where there are any aspects of our work that need improving, we want to strive to identify and
enhance these as efficiently and cost effectively as possible.
In addition to our service users and their carers, the Trust serves numerous customers and provides
services to many different stakeholders. These include CCGs, GPs, local authorities and our own
staff. We make a point of constantly monitoring what our stakeholders think so we can act on what
they say.
The Trust has been working with local authority partners to prepare for implementation of the Care
Act 2014 which came into force on 1st April 2015. Trust wide dissemination of information about the
Act to date has focused on key, overarching messages particularly emphasizing that this is not just a
change in law and policy, but an opportunity for a cultural shift in care and support. This shift is
towards more prevention, better support for carers, encouraging the use of social networks, personal
and community assets to enhance self- management and self-reliance whilst also introducing new
national eligibility criteria and capping care costs (from 2016). New duties of cooperation between
agencies will be important for ensuring integrated responses to people needing diverse services
across South West London. An ongoing programme of training and review of key policies and
protocols is underway.
With all these aims and ambitions in mind, we have collated our quality strategic planning under three
key quality themes:

clinical effectiveness

patient safety

patient experience
These, in turn, accommodate the five overarching domains identified by the NHS Outcomes
Framework 2014/15 setting out the high-level national outcomes that the NHS should be aiming to
improve:
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Domain 1: Preventing people from dying prematurely
Domain 2: Enhancing quality of life for people with long-term conditions
Domain 3: Helping people to recover from episodes of ill health or following injury
Domain 4: Ensuring people have a positive experience of care
Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable
harm
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Looking forward - Quality Account priorities for 2015/16
This section of the Trust’s Quality Account outlines the priorities identified by the Trust to improve the
quality of our services in 2015/16. The Trust has identified these priorities in partnership with staff
(including senior leader at the monthly Trust Leadership Conference), service users, carers and
Clinical Commissioning Groups (CCGs). The Trust commenced its consultation on the quality
priorities for 2015/16 in December 2014 by seeking views on quality themes from each CCG,
SWLSTG staff, service users and carers.
The themes identified by the CCGs were:
•
Coordinated Inpatient Discharge Planning (2 year indicator)
•
Service Responsiveness and Web Consultations
•
Physical Health – Physical Health Handbook, Diabetes and Obesity, Food and Nutrition (year 2 of
a two year indicator commenced in 2014/15)
•
Learning Disabilities (LD) (year 2 of a two year indicator commenced in 2014/15).
These initial themes were discussed further at the Clinical Quality Commissioning Reference Group
(CQRG) in February 2015 and then worked up into potential indicator ideas using information
provided by the Trust clinical leads for Crisis Planning, Discharge Summaries, Physical Health,
Learning Disabilities, the IT Project Manager for Web Consultations and the Trust Commissioning for
Quality and Innovation (CQUIN) Lead.
In summary the quality improvements for 2015/16 are:
Clinical Effectiveness

Refining and improving Trust inpatient discharge standards

Continuing to improve the identification and experience of service users with learning disabilities
and by making appropriate adjustments to treatments currently available.
Patient Safety

Improving the physical health of hospital inpatients by ensuring appropriate physical health
information is available for service users, carers, friends and family members and by monitoring
Diabetes and Obesity.
Patient Experience

Improving the Trust standards and procedures for promoting innovative methods of
communication for service users in the community and GPs.
For further detail on specific targets throughout the year please refer to Appendix 1.
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Looking forward - CQUIN goals for 2015/16
The Trust’s CQUIN indicators were agreed with our commissioners and sit under the three domains of
quality: safety, effectiveness and patient experience. Each CQUIN goal must be measurable, using a
defined indicator.
CQUIN Indicators for 2015/16 being pursued by the Trust:

Carers and Families – Triangle of Care (2 Year CQUIN)

Mental Health Tariff – Care Packages and Programme of Audit

Medicines and Physical Health (M&PR) Reconciliation at CPA Review and Discharge and
Medicines Compliance in the Community (2 Year CQUIN)

CAMHS – ‘You’re Welcome’

Improving Physical Healthcare to Reduce Premature Mortality in People with Severe Mental
Illness (SMI) – Cardio Metabolic Assessments and Communication with GPs (Summaries of
Care)

Smoking Cessation
For further detail on each CQUIN please refer to Appendix 2.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Part 3: Looking back - Review of quality performance 2014/15
Review of Quality Account priorities 2014/15
This section of the Trust’s Quality Account provides information on the quality of services provided in
2014/15 and reports on our progress against the 2014/15 quality account priorities. The Trust
identified these priorities in partnership with staff, service users, carers and commissioners. The Trust
selected priorities for safety, service user experience and clinical effectiveness.
A proportion of the SWLSTG’s income in 2014/15 was conditional on achieving quality improvement
and innovation goals agreed between the Trust and Commissioners for the provision of NHS services,
through the Commissioning for Quality and Innovation payment framework (CQUIN). The seven
CQUIN areas (and measures) for 2014/15 were:

Staff and Service User Friends and Family Test (FFT)

Safety Thermometer

Improving Diagnoses in Mental Health (Physical Health)

Feedback for Improvement - Community

Four Factor Model / Cluster Assessment

Crisis Plans

Safe, Managed Discharges
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Overview of Trust performance with 2014/15 Quality Account priorities
Indicator
April 2014 starting
position
Year-end
performance
2014/15
Target
Clinical Effectiveness
Priority 1: Crisis
Plans
Indicator 1
Two Crisis Plans
a) 30% of people on CPA to have a collaboratively developed crisis plan
were developed in
uploaded onto RiO
2013/14: a full Crisis
b) 15% of people NOT on CPA to have a collaboratively developed crisis plan
Plan
(Advance
uploaded onto RiO
Directive) and a
c) Trust to complete quarterly quality audit of crisis plans. Audit report to be
summary
Crisis
submitted to commissioners
Plan.
d) 60% of new, collaboratively developed crisis plans to be categorised as
These
were
‘adequate’ or above following Q1 audit
implemented at the
end of the year.
Indicator 2
By July 2014, 34% of Trust to complete quarterly audit of crisis plans and of clinical progress
CPA and 15% of non notes/care plans to demonstrate evidence that the crisis plan was accessed
CPA service users and followed. Audit report to be submitted to commissioners and should include
had a collaboratively any reasons for not following certain aspects of a person's crisis plan during
developed
crisis treatment spells in HTT or inpatient wards.
plan. 94% of these Q2
were rated as being Indicator 1
of ‘adequate’ quality. a) 40% of people on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
b) 25% of people NOT on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
c) Trust to complete quarterly quality audit of crisis plans. Audit report to be
submitted to commissioners
d) 70% of new, collaboratively developed crisis plans to be categorised as
‘adequate’, of which 40% are to be categorised at ‘good’ following the Q2
audit
Indicator 2
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Successfully
Achieved

Successfully
Achieved

Trust to complete quarterly audit of crisis plans and of clinical progress notes /
care plans to demonstrate evidence that the crisis plan was accessed and
followed. Audit report to be submitted to commissioners and should include any
reasons for not following certain aspects of a person's crisis plan during
treatment spells in HTT or inpatient wards.
Q3
Indicator 1
a) 50% of people on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
b) 40% of people NOT on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
c) Trust to complete quarterly quality audit of crisis plans. Audit report to be
submitted to commissioners
d) 80% of new, collaboratively developed crisis plans to be categorised as
‘adequate’, of which 50% are to be categorised at ‘good’ following the Q3
audit
Indicator 2
Trust to complete quarterly audit of crisis plans and of clinical progress notes /
care plans to demonstrate evidence that the crisis plan was accessed and
followed. Audit report to be submitted to commissioners and should include any
reasons for not following certain aspects of a person's crisis plan during
treatment spells in HTT or inpatient wards.
Indicator 3
CAMHS to look at how to incorporate the collaboratively developed crisis plans
process into CAMHS. Implementation recommendations to be submitted to
commissioners.
Q4
Indicator 1
a) 60% of people on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
b) 45% of people NOT on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
c) Trust to complete quarterly quality audit of crisis plans. Audit report to be
submitted to commissioners
d) 90% of new, collaboratively developed crisis plans to be categorised as
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Successfully
Achieved

Successfully
Achieved

‘adequate’, of which 60% are to be categorised at ‘good’ following the Q4
audit
Priority 2: Learning Information not
Disabilities
previously collected
Indicator 2
Trust to complete quarterly audit of crisis plans and of clinical progress notes /
care plans to demonstrate evidence that the crisis plan was accessed and
followed. Audit report to be submitted to commissioners and should include any
reasons for not following certain aspects of a person's crisis plan during
treatment spells in HTT or inpatient wards.
Q1
a) Identify an Executive Lead for mental health & learning disabilities
b) Revise the membership and terms of reference for the Mainstreaming LD
Group.
c) Produce LD Awareness Protocol (to include awareness of Autism and
Asperger’s) to increase identification of individuals with learning disabilities
who use mainstream services.
d) Trust’s Medical Director and Director of Nursing and Quality Standards to
commission a Trust wide baseline audit using an audit tool based on the
Green Light Toolkit. This audit should establish:
• how many service users in mainstream services have already been
identified as having LD
• how many of these identified service users have been referred to the
Trust’s LD service for a) consultation / advice or b) assessment or c)
intervention.
• how many of these identified service users
have management
strategies that relate to their learning disabilities recorded in their clinical
record.
Q2
a) Develop eLearning training package This training package will include:
• basic awareness of learning disabilities
• screening questions
• referral pathways
• basic knowledge of reasonable adjustments
• information on how mainstream mental health services can be
adjusted for LD service users.
- Information on resources including easy read
b) Wards and teams to identify LD Champions.
Q3
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Successfully
Achieved

Successfully
Achieved

Successfully
a) Launch of eLearning package to all staff
b) LD Champions to have completed LD eLearning package
c) The Trust to hold an LD Learning Event to promote awareness, embed
learning across the Trust, and support the training.
Q4
a) For those service users in mainstream mental health services that have
been identified to have LD:
• 25% to have a clear, co-produced LD management plan recorded in their
clinical record and have their care plan in an accessible format.
• 25% to have evidence in their clinical record of liaison / consultation with
the Trust’s LD services.
b) Trust’s Medical Director and Director of Nursing and Quality Standards to
commission a year-end audit using the audit tool developed in Q1.
c) Audit report to be produced. This report should include:
• lessons learned
• recommendations for improvement
• uptake of eLearning training.
d) Gaps identified by the Q4 audit to be worked into year two of the two year
action plan to improve the identification process for service users with
mental health issues and learning disabilities within the Trust.
Achieved

Successfully
Achieved

Patient Safety
Priority 3: Physical
Health (Diabetes,
Observations of
Vital Signs and
Falls)
Information not
previously collected
Q1
Diabetes
a) The Trust will complete a quarterly audit of diabetes management plans.
These audits will seek to demonstrate evidence that 10% of service users
with identified Diabetes have a care plan including a support management
plan including information on lifestyle, diet, nutrition, medication advice and
access to primary care.
The audit reports will be submitted to
commissioners and will aim to record demonstrable progress.
Observation of vital signs
a) The Trust will develop a plan to monitor and electronically record
inpatients’ vital signs using the NEWS format on a daily basis
Falls
a) The Trust will update the Falls policy to in line with NICE guidance
b) The Trust will audit incident data on falls and submit a report to include:
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Successfully
Achieved

•
•
•
•
numbers of falls
level of harm
practice
against standards and recommendations for improvement
Q2
Diabetes
a) The Trust will complete a quarterly audit of Diabetes management plans.
These audits will seek to demonstrate evidence that 20% of service users
with identified Diabetes have a care plan including a support management
including information on lifestyle, diet, nutrition, medication advice and
access to primary care. The Trust will submit these audit reports to
commissioners.
Observation of vital signs
a) The Trust will produce a ‘Daily Observation of Service Users’ Vital Signs’
training package for staff
b) The Trust will agree an appropriate recording process for daily vital signs
data and will include these in the training package
Successfully
Achieved

Falls
a) The Trust will develop a Falls eLearning package
b) Inpatient wards will identify a Falls Champion
c) The Trust will audit incident data on falls and submit a report to include:
• numbers of falls
• level of harm
• practice against standards and recommendations for improvement
Q3
Diabetes
a) The Trust will complete quarterly audits of Diabetes management plans.
These plans will set out to demonstrate evidence that 30% of those with
identified Diabetes have a care plan including a support management plan
including information on lifestyle, diet, nutrition, medication advice and
access to primary care. The Trust will submit these audit reports to
commissioners.
b) The Trust will develop an eLearning package on Diabetes management.
Observation of vital signs
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Successfully
Achieved

a) The Trust will roll out ‘Daily Observation of Service Users’ Vital Signs’
training to staff
Falls
a) Trust wide learning event on falls will take place to educate staff about
risks, prevention, common hazards and good practice using incidents
subject to Root Cause Analysis as examples from which to learn.
b) The Trust will audit incident data on falls and submit a report to include:
• number of falls - it is expected that the number of falls should reduce
throughout the year as a result of this Quality Account indicator and
evidence should be included to demonstrate that the number of falls
has fallen from Q1
• level of harm
• practice against standards and recommendation for improvement
Q4
Diabetes
The Trust will complete quarterly audits of Diabetes management plans.
These plans will set out to demonstrate evidence that 40% of those with
identified Diabetes have a care plan including a support management plan
including information on lifestyle, diet, nutrition, medication advice and access
to primary care. The Trust will submit these audit reports to commissioners.
Observation of vital signs
a) Staff to monitor and electronically record inpatients’ vital signs using the
NEWS format on a daily basis
Falls
a) Trust to audit incident data on falls and submit a report to demonstrate:
• a reduction in the number of falls reported for the year
• reduced levels of harm
• lessons learned
Successfully
Achieved

Patient/Carer Experience
Priority 4: GP
Interfaces and
Education
Information not
previously collected
Q1
Kinesis
a) Commence Kinesis pilot in Wandsworth Community and Rehabilitation
Services and Wandsworth Home Treatment Team.
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Successfully
Achieved

Q2
Kinesis
a) Continue pilot in Wandsworth Community and Rehabilitation Services and
Wandsworth Home Treatment Team
b) Commence pilot in Wandsworth Age Related Services.
GP Satisfaction survey
Electronic survey (e.g. Survey Monkey or similar) for GPs to be designed and
produced to establish GPs’ level of satisfaction with the service and contact
information provided, communication and liaison, the advice received from
our services and any mental health related educational requirements.
Q3
Kinesis
a) Continue pilots in Wandsworth Community and Rehabilitation Services,
Wandsworth Home Treatment Team and Wandsworth Age Related
Services.
GP Satisfaction survey
Send out satisfaction survey to GPs.
Q4
Kinesis
a) Produce and submit year-end report to commissioners on Kinesis GP
system. This report should include information on:
• system usage figures
• benefits realisation
• cost effectiveness of the system
• lessons learned
GP Satisfaction survey
a) Analyse the results of the GP satisfaction survey.
b) Produce a survey results report. This report should include information on:
any gaps identified by GPs relating to their satisfaction of the service and
contact information provided, communication, liaison structures, the advice
received from our services or any mental health related educational
requirements, recommendations for improvement.
Priority 5: Service
User, Carer,
Friends and Family
Patient Opinion
Information not
previously collected
Q1
a) Develop communications plan to promote Patient Opinion Trust wide. This
should include:
• The production and rollout of Patient Opinion ‘starter’ training for staff
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Successfully
Achieved

Successfully
Achieved

Successfully
Achieved

Successfully
Achieved

Experience
• Internal and external publicity
• A press launch.
b) Co-produce and launch a Patient Experience Strategy.
Q2
a) RTF CQUIN Q1 report to be made available on the Trust website
b) FFT Staff CQUIN Q1 report to be made available on the Trust website
c) Implement communication plan for Patient Opinion.
d) Progress report on the promotion of Patient Opinion. This report should
include:
• Examples of feedback received and appropriate action plans
• Examples of changes made in response to feedback and their
outcomes
• Figures on the number of people posting feedback on the site
regarding SWLSTG
• An update on the success of the promotion work and
recommendations/ideas for improvement going forward
e) Patient Experience Strategy implementation plan to be signed off.
Q3
a) RTF CQUIN Q2 report to be made available on the Trust website
b) Continue to implement communication plan for Patient Opinion
c) Progress report on the promotion of Patient Opinion. This report should
include:
• Examples of feedback received and appropriate action plans
• Examples of changes made in response to feedback and their
outcomes
• Figures on the number of people posting feedback on the site
regarding SWLSTG
• An update on the success of the promotion work and
recommendations/ideas for improvement going forward
d) Patient Experience Strategy implementation to begin.
Q4
a) RTF CQUIN Q3 report to be made available on the Trust website
b) RTF CQUIN Q4 report to be made available on the Trust website during
Q1 of 2015/16
c) FFT Patient CQUIN Q4 report to be made available on the Trust website
during Q1 of 2015/16
d) Report on progress of Patient Experience Strategy implementation
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Successfully
Achieved

Successfully
Achieved

Successfully
Achieved

e) Year-end feedback report to be produced to demonstrate service user and
CFF satisfaction with Trust services. This report should be co-produced
by the project managers for RTF, FFT and Patient Opinion and include:
• Quotations and vignettes from service users, carers, friends and family
members gathered using all the Trust feedback systems.
Quotations and vignettes from staff on the feedback systems and changes
that have been made as a result of feedback received from all systems.
For further details on each priority please refer to Appendix 4.
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Overview of Trust performance with 2014/15 CQUIN priorities
CQUIN
Indicator
Implement staff FFT to all Trust departments, teams and
wards. Submit a one off report to commissioners by 31 July
2014 on responses and necessary actions plans
Year-end performance
Implementation of Patient FFT, incorporating it into existing
Trust Real Time Feedback systems
Successfully completed
Staff and
Service User
Friends and
Family Test
(FFT)
Pilot the Patient FFT for community teams with seven existing
RTF kiosks. Add the Patient FFT to the RTF on-line survey
to make the opportunity available for community service
users to respond. Submit an implementation progress report
to commissioners
(Patient
Experience)
Submit monthly data as required by the national submission
timetable
Produce a year-end report including:
• Examples of action plans, based on feedback received in
response to FFT follow-up question, to improve service
user experience of services
• List of feedback themes
• Lessons learned (implementation and stakeholder
engagement)
Collect and submit monthly Safety Thermometer screening
data for falls, pressure ulcers and Urinary Tract Infections
(UTI) (for those with catheters) for older people’s inpatient
wards
Safety
Thermometer
(Patient Safety)
Audit incident data quarterly on falls and submit an audit
report to commissioners. Report to include recommendations
on how to:
• reduce harm caused by falls
• reduce the number of falls occurring
• (Q3) confirmation that NICE guidance has been
implemented or submission of an action plan in respect of
this with timetable
• (Q3) Confirmation that NPSA Rapid Response guidance
has been implemented or submission of an action plan in
respect of this with timetable.
Submit a year-end report exploring if the Safety Thermometer
work has had an effect on identified harms or hazards
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
Successfully completed


Successfully completed

Successfully completed

Successfully completed

Successfully completed

Successfully completed

Successfully completed

21
Indicator 1
Cardio Metabolic Assessment for patients with psychoses,
including Schizophrenia
Demonstrate, through the National Data Collection Exercise,
full implementation of appropriate processes for assessing,
documenting and acting on cardio metabolic risk factors in
patients with psychoses, including schizophrenia.
The results recorded in the patient's notes/care
plan/discharge documentation as appropriate, together with a
record of associated interventions according to NICE
guidelines or onward referral to another clinician for
assessment, diagnosis, and treatment e.g. smoking
cessation programme, lifestyle advice and medication review.
Improving
Diagnoses in
Mental Health
(Physical
Health)
(Patient Safety)
Successfully completed

The following cardio metabolic parameters (as per the 'Lester
tool' and the cardiovascular outcome framework) are
assessed:
• Smoking status
• Lifestyle (including exercise, diet, alcohol and drugs)
• Body Mass Index
• Blood pressure
• Glucose regulation (HbA1c or fasting glucose or random
glucose as appropriate)
• Blood lipids
The audit sample must cover all relevant services provided by
the provider.
Indicator 2
Summaries of Care
Completion of a programme of local audit of communication
with patients’ GPs, focusing on patients on the CPA.
Audit CPA Review Letters, Discharge Summaries and other
correspondence with GPs to ensure that the holistic CPA
components have been communicated.
The Q2 and Q4 local audits must cover a sample of patients
in contact with specified services for more than 100 days and
who are on the CPA.
Demonstrate that for 70% (Q2) and 90% (Q4) of patients, an
up-to-date summary of care (communicated via CPA Review
Letters, Discharge Summaries and other correspondence)
has been shared with the GP. This should include the holistic
components set out in the CPA guidance:
a) ICD codes for primary and secondary mental and
physical health diagnoses.
b) Medications prescribed and monitoring and adherence
support plans.
c) Physical health condition(s) and ongoing monitoring and
treatment needs.
d) Recovery interventions including lifestyle, social,
employment and accommodation plans where necessary
for physical health improvement.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
Successfully completed

22
Feedback for
Improvement Community
(Patient
Experience)
Trust to submit RTF systems community implementation plan
to commissioners as part of the Q1 report. This should
include dates of:
• Technical system implementation
• Staff and service user training on how to use the RTF
systems
• Go live dates for each community area included in the
implementation
• Process for review and improvement
• Lessons learned and improvements made to date by any
community teams / services already using RTF systems
Submit a progress report on use of RTF systems in Home
Treatment Teams (following implementation in Q2 2013/14).
Report to include a list of themed feedback received to date.
Submit quarterly progress updates on implementation. These
should include action plan for any community team / service
that has successfully completed their implementation of the
RTF systems. Action plans should include:
• List of themed feedback from service users and CFF
• Planned actions to address any issues or reasonable
requests
• Target dates and named responsible person for
completion of each action
• Lessons learned
Submit Q1 and Q3 reports to clinical and classical
commissioners on cluster assessment within the Trust.
Reports should:
• Set out details of the Four Factor model and its use
•
(Clinical
Effectiveness)

Successfully completed

Successfully completed

Reviews the effectiveness of the Trust’s care packages
for a quarter for each cluster to demonstrate:
i) The % of service users where changes in their total
Health of the Nation Outcome Scales (HoNOS) score
met the criteria for reliable, clinically significant change
(reliable improvement and deterioration) following a
cluster episode
i) The % of service users where changes occurred but
they did not meet the criteria for reliable change
(improvement and deterioration) following a cluster
episode
i) The % of service users where there was no change at
all in their total HoNOS scores following a cluster
episode.
Four Factor
Model / Cluster
Assessment
Successfully completed
Q2 - Trust to host a cluster assessment (HoNOS) event for
staff and commissioners to feedback the initial findings of the
cluster assessment outcomes.
Successfully completed

Successfully completed

Q4 - Submit final report to commissioners including:
•
•
•
•
Implications for commissioners
Variance (between teams) and its causes
Aspects of outcomes that are more able to be affected by
changes in practice
Next steps
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
Successfully completed

23
Indicator 1
Continuation of quarterly quality audits as per 2013/14 but
also having a target for the number / proportion of
collaboratively developed crisis plans for each quarter - rising
baseline i.e. significantly increase the number without
compromising quality.
Training for staff to continue throughout the year.
•
Crisis Plans
(Clinical
Effectiveness)
30% (Q1), 40% (Q2), 50% (Q3), 60% (Q4) of people on
CPA to have a collaboratively developed crisis plans
uploaded onto RiO
• 15% (Q1), 25% (Q2), 40% (Q3), 45% (Q4) of people NOT
on CPA to have a collaboratively developed crisis plans
uploaded onto RiO
• Trust to complete quarterly quality audit of crisis plans.
Audit report to be submitted to commissioners
• 60% (Q1), 70% (Q2), 80% (Q3), 90% (Q4) of new,
collaboratively developed crisis plans to be categorised
as ‘Adequate’ or above following Q1 audit
Indicator 2
Audits to be undertaken on a quarterly basis of clinical
progress notes / care plans to demonstrate evidence that the
crisis plan was accessed and followed with any reasons for
not following certain aspects of a person's crisis plan during
treatment spells in HTT or inpatient wards.
There could also be feedback systems developed for service
users (e.g. RTF) at discharge from HTT / inpatient wards to
assess satisfaction levels with how their crisis plan was
followed or not.
Trust to complete quarterly audits of crisis plans of clinical
progress notes / care plans to demonstrate evidence that the
crisis plan was accessed and followed. Audit reports to be
submitted to commissioners and should include any reasons
for not following certain aspects of a person's crisis plan
during treatment spells in HTT or inpatient wards.
Indicator 3 (one-off report submission)
(Q3) CAMHS to look at how to incorporate the collaboratively
developed crisis plans process into CAMHS. Implementation
recommendations to be submitted to commissioners.
Safe, Managed
Discharges –
Community
(Clinical
Effectiveness)
(Q1) - Produce a quality standard for community discharge
summaries. This template should include a section for
completion when people disengage with services. This
should be achieved by co-producing with GPs, service users,
carers and Trust staff and taking into consideration
recommendations made in the 2013/14 Q3 Community
Discharge Summary Audit Report
Successfully completed

Successfully completed

Successfully completed

Successfully completed

Trust to improve
communication
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
24
of community
discharge
summary
information
between primary
and secondary
care.
This work will
ensure that GPs
receive
appropriate
information and
the process of
discharge
summary
production is
made more
efficient for
clinicians.
Produce and implement a pre-populated discharge summary
template in RiO for use by staff
Successfully completed

(Q2, Q3 and Q4) - Audit the quality standard discharge
summary template produced in Q1 and report results to
commissioners including any lessons learned.
Successfully completed

Further detail can be found in Appendix 5.
Looking back - Progress against the core quality indicators 2014/15
The table below details the Trust’s performance against the core set of indicators for 2014/15. All Trusts are
required to report against these indicators using a standardised statement set out in the Quality Account
regulations. Some of the indicators are not relevant to all Trusts, and we have therefore only included
indicators that are relevant to the services that the Trust provides.
Data has been sourced from both the Health and Social Centre (HSCIC) and from the Trust internal data
management system, Pulse, and will be referenced accordingly.
Indicator
Care Programme Approach (CPA) seven day follow-ups
Target
95%
Successfully
Achieved
What is being monitored? The proportion of patients on CPA who
were followed up within seven days after discharge from psychiatric
inpatient care

97%
Source:
Trust Pulse
The Trust has met this indicator for the last two years. Breaches are
reviewed at the monthly Directorate Performance Review meetings.
Crisis Resolution and Home Treatment (CHRT) gatekeeping for
inpatient admissions
What is being monitored? The proportion of admissions to acute
wards that were gate kept by the CRHT teams
The Trust has met the gatekeeping requirement for two years now
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
2014/15
performance
95%
Successfully
Achieved

99%
Source:
Trust Pulse
25
and there has been increasing numbers of people who can be treated
at home, rather than having to come into hospital during a crisis. The
Trust aims to invest further in the Home Treatment functions to ensure
that there is greater access to this important clinical support
This requires all contacts be face to face for this measure “unless it
can be demonstrated that face-to-face was not appropriate or
possible”.
30 day emergency readmissions
What is being monitored? The percentage of patients readmitted to a
hospital which forms part of the Trust within 30 days of being
discharged
The SWLSTG mental health trust intends to take the following actions
to improve this percentage, and so quality of its services, by reviewing
individual readmissions and reviewing the reasons for admission on
an individual basis to assess to see if improvements can be made to
the service user care pathway to avoid readmissions.
‘Friends and family’ test
Less
than
7.5%
4.0%
Source:
Trust Pulse
N/A
What is being measured? The proportion of staff that completed the
staff survey that ‘agreed’ and ‘strongly agreed’ with the statements:
How likely are you to recommend this organisation to friends and
family if they needed care or treatment?
66%
How likely are you to recommend this organisation to friends and
family as a place to work?
54%
The SWLSTG mental health trust intends to improve this percentage
even further by engaging with staff around delivering better outcomes
for our patients for improvement through the ‘Listening into Action’
initiative that is currently in operation across the Trust., and supporting
directorates to engage with staff regarding their local friends and
family test, staff survey and Listening into Action Pulse check result
Patient experience of community mental health services
Source:
NHS Staff Friends
and Family Test
2014/15 Quarter 4
N/A
The 2014 Community Survey questions were substantially
redeveloped in order to reflect changes in policy, best practice and
patterns of service. Therefore results are not comparable to results
from previous years’ surveys.
The Trust was rated as ‘average’ by the CQC based on the results of
this survey. The overall response rate achieved by the Trust was
26% in comparison to the national average of 29%.
The Trust rated in the top 3 of other London Mental Health Trusts
about questions relating to ‘other areas of life’ where questions were
asked whether they have had help with or advice with finding support
for physical health needs / financial advice or benefits / work /
accommodation; supported to take part in activities locally; involved
family / friends as much as they would like; whether staff understand
what is important in their life; and whether mental health services help
them to feel hopeful about the things that are important to them.
Rated Average
Source:
The “overall” rating
by the Care Quality
Commission from
the 2014 national
community service
user survey.
The Trust rated poorly when asked questions about Crisis Care,
specifically whether they know who to contact out of hours and when
they tried to contact them whether they got the help they needed.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
26
The response to the question about whether service users have been
given information about getting informal peer support is the one
response in the survey where we as a Trust score about the same as
other Trusts in England.
The survey was analysed and outcomes reviewed by the Trusts
Leadership Group and an action plan put in place for areas of
development and this is being monitored through governance
processes.
Patient safety incidents resulting in severe harm or death
Rate of Patient Safety Incidents per 1000 bed days
N/A
33.63 - Count of
incidents 2,120
% of Patient Safety Incidents reported that resulted in severe harm or
death (April – September 2014)
0.6% - Count of
Incidents 13
SWLSTG continues to provide appropriate training and supports
teams to learn from these incidents.
Source:
NRLS data
01/04/14 – 30/09/14
Looking back - Evaluation of current practice against the findings of
the Francis Inquiry and Winterbourne Review 2014/15
Following the publication of the Mid Staffordshire NHS Foundation Trust Public Inquiry in 2013, the Trust
conducted a baseline evaluation determining the current practice at South West London and St George’s
Mental Health Trust against the recommendations from the Winterbourne View Report and the Francis
Inquiry.
The Winterbourne Serious Case Review (SCR) was published in the summer of 2012. In December 2012,
the Department of Health published the Winterbourne View Review multiagency Concordat – a programme
for action. In its wake, the Local Government Association set up a Joint Improvement Partnership (JIP) to
coordinate and drive action nationally, across the social care and health sectors. Safeguarding adults
boards have been asked to produce and implement local plans to ensure the safety and wellbeing of
people in institutional care in their localities. The Trust has taken an active part in local Boards’
Winterbourne Action Plan (and the Trust has shared our plan with local Safeguarding Boards).
Findings from both the Francis Inquiry and Winterbourne Review were collated, analysed, and presented in
a report to the Quality and Safety Assurance Committee (QSAC) in September 2013, February and
November 2014. Analysis of the baseline assessment revealed that many of the recommendations
proposed by Winterbourne and Francis represent good practice and are already in place at South West
London and St George’s Mental Health Trust. Additional work will be led and mainstreamed through the
established governance structures and processes within the Trust.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
27
The Trust continues to pay sufficient and consistent attention to our governance systems, intelligence
gathering, the management culture and building better direct relationships with service users and their
families in order to mitigate the risk of the failures of care found in Mid Staffordshire and Winterbourne
View. The Trust can demonstrate that Quality is a driving force however this is increasingly difficult,
particularly as finances are undeniably constrained and the management and regulatory system ultimately
requires financial balance alongside high performance in terms of patient care.
Outstanding actions are at Appendix 3
Looking back - Safeguarding Vulnerable Adults 2014/15
The Safeguarding Adults Quality Account targets in 2013/14 raised the profile of adult safeguarding further
across the Trust and helped to embed effective, consistent governance systems and structures into
frontline and management practice across the Trust. The Trust has built on this foundation throughout
14/15. Most recently this has included focus on the implementation of the ‘Making Safeguarding Personal’
guidance – to ensure people receiving safeguarding services can stay in control as much as possible and
have an outcome they want. We have also been working with local authorities on meeting the requirements
of the Care Act and its associated guidance.
The Trust has also been working to fulfil the recommendations from nationally reported hospital abuse
scandals involving celebrities particularly Kate Lampard’s Department of Health ‘Lessons Learned’
report. These actions are aimed at preventing such incidents from occurring again. Policy, practices and
performance have all been subject to review and revision to ensure the highest standards are maintained.
Looking back - Safeguarding Vulnerable Children 2014/15
During 2014/15, the Trust has further developed the quarterly data provided to the 5 Local Safeguarding
Children’s Boards. This is now provided consistently for each borough as detailed below. Safeguarding
children training figures are now also provided quarterly. These indicators are currently being developed
for internal trust reporting and scrutiny:

% of adult service users who have regular and significant contact with children and are recorded

Number CAMHS clients referred from Liaison Psychiatry with a risk score for self-harm

Number of children attending A&E due to self- harming/attempted suicide/alcohol harm

Number of young people referred to CAMHS during this quarter

% of Young people referred to CAMHS as an emergency seen within 24 hours (number and
percentage)

% of Young people referred to CAMHS for an urgent appointment seen within 7 working days (number
and percentage)
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
28

Number of young people assessed through the 136 Suite (place of safety in Springfield Hospital for
people found in a public place who may have a mental disorder - can only be accessed with police
powers).

Percentage of cases to CAMHS offered an initial assessment within 8 weeks of initial referral (shown
as number and percentage)
Looking back - Statements of quality assurance from the Board
2014/15
Information on the review of services
During 2014/15 the Trust provided inpatient and community mental health services under four management
teams: Kingston and Richmond, Sutton and Merton, Wandsworth and Specialist Services.
Our service areas include:

Adults of working age mental health

Older people’s mental health

Child and adolescent mental health

Mental health services for people with learning disabilities

Drug and alcohol services (Richmond, Sutton & Merton)

Increasing Access to Psychological Therapies Services (IAPT - Wandsworth, Sutton & Merton)
The Trust provides a number of specialist national services including obsessive-compulsive disorder (OCD)
/ body dysmorphic disorder (BDD), forensics services, eating disorder and deaf services for children,
adolescents and adults.
The Trust reviews the data available on the quality of care in all of these NHS services as part of ongoing
governance processes and will continue to do so as the Trust prepares to apply for FT status. The income
generated by the NHS services reviewed in 2014/15 represents 100% of the total income generated from
the provision of NHS services by the Trust for this period.
Looking back - Participation in Clinical Audits and Quality
Improvement activity 2014/15
In preparation for the Chief Inspection of Hospitals (CiH) inspection in March 2014 the Trust carried out two
programmes of quality improvement. The Trust chose to drive quality improvements through a range of
measures including strengthening local quality governance at team and directorate levels and by
monitoring local improvements through conducting an annual cycle of quality improvement reviews and
audits. Two of these quality improvement measures were the 15 Steps visits challenge and the peer
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
29
review audits, the aim was to identify and address any issues of concern and in particular to help identify
issues at risk of not being compliant with the 16 CQC essential standards. Both processes are
unannounced and are complimentary to each other but are quite different in approach, style and time
commitment.
The 15 steps challenge is a national programme based on the premise that one can tell a lot about the
quality of care provided on a ward or team base within 15 steps of entering the service setting. The
emphasis is on first impressions, rather than a detailed inspection into care plans and medical records and
should take no more than 30 minutes to complete the visit with an additional 15 minutes allocated to
complete the associated documentation and feedback to the ward/team. Executive Directors and NonExecutive Directors, senior staff and others not employed by the Trust (Hospital Managers,
Commissioners, Health Watch Volunteers, carer and service user representatives) participated in the 15
step visits.
Peer review is a practice-focused process and is under-taken using a coaching and supportive approach. It
is seen as a key indicator for quality assurance, and measures the standards of the delivery of care in
clinical services against CQC outcomes. Peer reviewers as with 15 step visit teams comprised of mixed
communities of clinical staff, hospital managers, commissioners, and volunteer groups such as Health
Watch, experts by experience and carer representatives.
Care planning as a theme has been identified as an area for further development within the 15 Step
challenge and Peer Review quality improvement programme with focus mainly centred on quality of care
plan documentation where variability has been evidenced across the spectrum of teams, including Inpatient
units, Community Mental Health Teams and resource centres that have under taken these processes.
During October to December 2014, 42 Peer Reviews were completed within the Specialist Services and
Kingston & Richmond Directorates and almost 40 15 Step visits were completed predominantly within the
Sutton & Merton, Wandsworth and CAMHS Directorates.
Areas of significant improvement include good examples of continuous capacity and consent recording on
RiO though this remains on the corporate audit programme since further improvement is needed as
evidence by CQC MHA monitoring visits findings. The Mental Capacity Act Action Plan for December 2014
– March 2016 was agreed at November 2014 Quality And Safety Assurance Committee. The action plan
includes actions to address training needs, improved online guidance and supervision practices and the
development of Trust and Directorate lead roles.
During 2014/15 the Trust participated in 4 national audits relevant to NHS services provided by South West
London and St George’s Mental Health NHS Trust.
1. National Clinical Audit of Schizophrenia
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
30
2. National Clinical Audit of Psychological Therapies for Anxiety and Depression
3. National Audit of the implementation of NICE public health guidance for the
4. National Audit POMH-UK
During 2014/15 SWLSTG participated in 100% of national clinical audits and 100% of national confidential
enquiries in which it was eligible to participate
The Trust did not have any ‘never events’ in 2014/15.
The Corporate Clinical Audit Programme included in addition to the national audits noted earlier a full range
of audit activity developed and ratified by the Compliance and Clinical Practice Standards Group with
consideration of CQC concerns, national audit requirements and learning from serious incidents,
complaints and claims. The Integrated Governance Group approved the programme in January 2014 and
the Quality and Safety Assurance Committee ratified the programme in February 2014.
The Trust
conducted the following local audits during 2014/15 to determine the degree of practice compliance against
local and national policy standards:
1. Mental Health Act/ Consent and Capacity
2. Rapid Tranquillisation
3. Medicines Code (Including Controlled Drugs)
4. Physical Health; Inpatient and Community standards
5. Care Planning; Inpatient and Community standards
6. Observation and Intensive Engagement practice
7. Quality of Risk assessments (Inpatient and Community)
8. Search Policy
9. Triangle of Care
Appendix 6 outlines the national clinical audits and national confidential enquiries that South West London
and SWLSTG participated in, or reviewed, during 2014/15.
SWLSTG reviewed four national clinical audits in 2014/15. Below are some of the actions the Trust has
taken, or intends to take, to improve the quality of healthcare provided as a result of these findings.
The Trust reviewed the report from the Health and Work Development Unit on Promoting public health in
the workplace. This was a follow up to the 2010 National Audit of the implementation of NICE public health
guidance for the workplace. The Trust has seen significant improvements, in particular the Trust’s smoking
cessation and physical activity programmes. Since the re-audit was conducted in October 2013, there has
been a focus on engaging staff to improve their lives at work, through the work of the Trust’s Listening into
Action (LiA) Team. LIA conversations highlighted the need for a more coordinated approach to
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
31
health and wellbeing which in turn has led to prioritisation of workforce health and wellbeing as an Enabling
Our People Scheme (EOP). The Trust is therefore committed to developing a Workforce health and
wellbeing (HWB) strategy and action plan. The staff survey results also highlight progress and areas
requiring further attention that can negatively impact on staff health and wellbeing. Issues likely to reinforce
health and wellbeing where the Trust performs better than national average include clear job objectives,
presenteeism, and reasonable adjustment. However the survey also highlights those areas likely to
negatively impact on staff health and wellbeing and where the Trust is performing less well than the
average. These include e.g. violence and aggression from staff, discrimination from service users and
relatives and work pressure.
The plan going forward for the development of the HWB Strategy and action plan will be to:

Adopt the Healthy Workplaces Charter as the basis for framing priorities, seeking charter accreditation.

Adopt Dame Carol Black’s complimentary PHRD Pledge H7- mental health

Conduct the HWB survey that is aligned with the Charter and also incorporates Unison’s stress survey,
piloting first with LiA Sponsor Group (March 2015)

Undertake an LiA health and wellbeing solution styled conversation with staff and involving key
stakeholders.(April 2015)

Draw on e.g. sickness absence, most recent annual staff survey findings and internal social inclusion
networks

Develop a communications plan to support the health and wellbeing work stream.

Develop and ratify a Health and Wellbeing Strategy and action plan (May 2015)
The Trust subscribes to membership of POM-H (UK) which supports the implementation of NICE guidelines
to help clinical teams monitor and improve the quality of their mental health prescribing. POMH-UK audit
reports were reviewed by the Drugs and Therapeutics Audit sub-group and the findings and
recommendations circulated Trust-wide. The Trust performance with respect to POMH-UK audits was
mixed.
Prescribing anti-dementia drugs POMH-UK Topic 4b: re-audit findings were published in April 2014. The
key finding was that the sample size was small at 10% as opposed to 100% previously. Trusts were asked
to include patients who had a clinical diagnosis of dementia whether or not they were prescribed an antidementia drug. In some cases, the evidence for practice recommendations fell short of supporting an audit
standard, i.e. being applicable in 100% of cases.
Action plans have been developed to address areas where performance falls short of the standards with
respect to:

the use of medicines with a high cognitive burden in people with dementia
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
32

ensuring patients with relevant cardiovascular risk factors (sick sinus or heart block) are not exposed to
AChE inhibitors

checking pulse rate to assess early tolerability of AChE inhibitors
Prescribing antipsychotics for children and adolescents POMH-UK Topic 10c First supplementary audit
report published in March 2014 found that there are potential areas, that the Trust might wish to address,
given its benchmarked performance against the practice standards. Specifically, the Trust is invited to
reflect over local practice and systems with respect to:

The quality of pre-treatment screening. Without baseline measures, it is difficult to interpret later
assessment and ascertain the side-effect burden associated with antipsychotics.

Assessment of side-effects in children and adolescents with neurodevelopmental disorders. Local
systems may be required to ensure adequate side-effect monitoring in this group of patients.

Continued physical health and side-effect monitoring to ensure this does not drop off over time.

Shared care arrangements for antipsychotic prescribing and monitoring with primary care.

The diagnosis of movement disorder. This is critical to the development of a treatment plan, given that
there are distinct therapeutic interventions for each of the extrapyramidal side-effects.
POMH-UK Topic 14a Prescribing for substance misuse: alcohol detoxification. The Trust hosted the
London POMH-UK conference on October 29th where the audit findings were presented. The POMH-UK
event was opened by David Bradley CEO and was closed by Dr Emma Whicher Medical Director for the
Trust. Priority areas for action included;

Increase awareness of the importance of assessment for Wernicke’s.

Thiamine should be prescribed parenterally

Consider different blood tests for specific conditions

Relapse prevention medication should be considered

Breath alcohol tests should be routinely completed before the start of detoxification

Train people to use standardized assessment tools

Support all staff to be confident in delivering brief interventions

Provide information about a range of services post discharge
Sutton and Merton IAPT and Wandsworth IAPT both participated in the National Audit of Psychological
Therapies (NAPT) which was established to assess and improve the quality of NHS-funded psychological
therapy provision for people with anxiety and depression in England and Wales. The baseline (2011) and
the second round of NAPT evaluated the same aspects of quality - access, appropriateness, acceptability
and outcomes. In general the Trust fared favourably against national standards. However findings were
below the national average in standards relating to NICE guidelines and information provided to service
users about their choice of treatment options. Action plans have been developed to address all
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
33
areas of concern identified in the audit.
The Trust participated in the second round of the National Audit of Schizophrenia (NAS2). The National
Audit of Schizophrenia (NAS) is an initiative of the Royal College of Psychiatrists' Centre for Quality
Improvement (CCQI).
Participating in the NAS enables the Trust to assess the quality of treatment offered to people with
schizophrenia living in the community. NAS2 audit reports were reviewed in the Compliance and Clinical
Practice Standards Group. The findings and recommendations were circulated trust wide. The Trust’s
performance when compared to others nationally was mixed with very few returns from service users.
Although monitoring of Physical Health risk factors was about average in the Trust when compared
nationally, it was still below what should be provided. Availability and uptake of Psychological Therapies
was above average for the Trust but it was also below what should be provided.
Action plans have been developed to address priorities for improvement. It has been agreed to complete an
internal audit; using the NAS patient questionnaire, to gain further information about the experience of care
provided by South West London and St Georges Mental Health Trust for people with psychosis or
schizophrenia.
Looking back - Participation in clinical research 2014/15
The Research & Development Department is making significant strides in expanding its research
capabilities, and by forging strong and mutually beneficial partnerships, the department has also developed
the commercial dimension of its research portfolio as well as innovation, to secure its position as a major
player within the local healthcare economy.
Most recently, the department has grown in both operational capacity and stature, following a redesign of
its infrastructure and Committee, leading to the establishment of a Clinical and Academic Hub (CAH). This
was the outcome of a proposal submitted to, and ratified by the Medical Director, which envisaged future
measures to:

implement an R&D business model which protects the integrity of the Trust ledger and attracts interest
from commercial research sponsors;

embeds a culture of innovation which aligns closely with research, education and training for all
stakeholders; and

resolve emergent operational and strategic challenges.
The CAH encompasses a wide scope of mental health research within the Trust and, through its Clinical
Research Units, remains dedicated to the provision of teaching in mental health and subspecialties.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
34
This in turn culminated in the foundation of two discrete Clinical Research Units (CRUs), the first in
Psychiatry of Old Age and Neuropsychiatry (CRU-POAN) which was created in Autumn 2013, and the
second in General Psychiatry and Allied Disciplines (CRU-GPAD), formally launched in November last
year.
Under the leadership of the R&D Director Dr Robert Lawrence, Trust R&D has been reconfigured to
emerge as an expanding business entity, characterised by robust leadership, a strategy of dissemination
and multidisciplinary engagement. This new structure operates in close alignment with the Trust Innovation
Strategy, with clear objectives to ensure that R&D remains a self-sustaining business entity underpinned by
robust principles of research governance, commercial viability, and clinical excellence.
Most notable
among these are:

the integration and implanting of nursing expertise within core R&D functions - currently there are three
seconded clinical research nurses who support key research activity and provide invaluable support to
colleagues involved in national portfolio (multi-centre) and commercial studies;

he promotion of integration throughout the numerous research disciplines, especially psychology and
occupational therapy;

the cultivation of strong working relationships with the local research network, industry and
commercially sponsored research (such as drug trials).
The underlying ethos of the new R&D is to focus on quality, breadth of and feasibility of any pending
studies, in order to ensure that the translation of research into improved patient treatment is as smooth and
efficient as possible. The strategic ‘fit’ of any proposed R&D initiatives are thus assessed to ensure that
they align closely with the Trust’s objectives, and collectively constitute a conceptual framework for the
revised and integrated R&D strategy.
The synergy created by this newly fostered environment of multidisciplinary engagement has enabled the
fruitful development of numerous coalescent themes with expertise from numerous partner institutions.
Following a two-year application process, a joint team of researchers has been awarded a 5-year £1.95
million National Institute for Health Research Health Technology Assessment (NIHR HTA) programme
grant to manualise, pilot and trial a peer worker intervention (ENRICH: enhanced discharge from inpatient
to community mental health care). This is the largest grant awarded to the Trust in over seven years and
unites investigators from the Trust, SGUL, and City University London. The programme will also produce
detailed guidance for implementing the ENRICH intervention so that all Mental Health Trusts can employ,
train and support Peer Workers to enhance discharge. It is the first prestigious NIHR programme grant to
be awarded to the Trust and enhances its R&D profile considerably.
The CRN-led local performance metrics bear witness to this inexorable expansion: the year to date total for
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
35
patient recruitment (April-February) into clinical research studies currently stands at 225.The Trust portfolio
currently comprises 41 active studies, of which:

8 studies are educational training projects at Masters level or higher;

28 are national multicentre portfolio studies;

5 are locally generated, unfunded or stand-alone pilot studies.
Further, there are currently 12 members of clinical staff who are involved in portfolio research across
mental health subspecialties including neuropsychiatry, dementias, perinatal mental health, addictions and
allied disciplines such as occupational therapy. The number of clinical drug trials adopted over the last year
has also risen exponentially, with Pharmacy providing support to 5 interventional multicentre trials.
The critical mass of research activity and the resultant upsurge in associated income is further underscored
by an initiative launched by the R&D department to increase active engagement in research by service
users, carers and the wider public. Last year the department agreed to fund the activities of the PEER
group (Peer Expertise in Education and Research), a group of service users and carers with a lived
experience of mental health issues who are interested in becoming actively involved in research at SGUL
and the Trust. This ongoing commitment by the department has enabled the group to offer more
involvement opportunities, provide adequate support and training and develop ground-breaking areas for
the Trust such as user-led research.
By applying critical foresight, and remaining committed to principles of Best Practice, Best Value and
Innovation, the position of Trust R&D at the forefront of healthcare provision is assured and will remain as
such, while keeping improvements in patient health care at the heart of its activities.
Statements from the Care Quality Commission 2014/15
South West London and St George’s Mental Health NHS Trust is required to register with the Care Quality
Commission (CQC). The Trust was registered with the CQC without compliance conditions on registration.
South West London and St George’s Mental Health NHS Trust has been registered to carry out the
following regulated activities (activities undertaken by the Trust that require registration):

treatment of disease, disorder or injury

assessment and medical treatment of persons detained under the Mental Health Act

diagnostic and screening procedures
Between March/April 2014 and March 2015, the CQC conducted inspections at the following registered
Trust sites:
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Site
CQC Compliance Inspections
Mental Health Act Monitoring
Inspections
Springfield
CIH Inspection – 17-21 March 2014, report Wisteria - August 2014
Hospital
published May 2014
Ward 2 - October 2014
Crocus Ward - October 2014
Aquarius - October 2014
Bluebell - December 2014
Turner - December 2014
Burntwood Villas - January 2015
Queen
Mary’s CIH Inspection – 17-21 March 2014, report Lavender - August 2014
Hospital
published May 2014
Laurel Ward - February 2015
Tolworth Hospital
CIH Inspection – 17-21 March 2014, report N/A
published May 2014
Community
Inspection of CTO: Understanding and use of Norfolk Lodge - September 2014
procedure, July 2014
Westmoor House - September
2014
The CQC has not taken enforcement action against the Trust during 2014-15; however, the Trust has three
areas of non-compliance with moderate impact and has completed all agreed actions against these:
1.
Regulation 9 HSCA 2008 (Regulated Activities); Regulations 2010; Care and welfare of people who
use services. The planning and delivery of care does not meet the service user’s individual needs or
ensure their welfare and safety. Comprehensive management plans were not consistently being
put in place for people using the service where a risk to themselves or others had been identified.
This was a breach of Regulation 9(1) (b), 9(2).
2.
Regulation 13 HSCA 2008 (Regulated Activities); Regulations 2010; Management of Medicines.
People were not protected against the risks associated with medicines because the provider did not
have appropriate arrangements in place to record medicines administered. The reasons why
sedative drugs prescribed ‘as required’ were given were not recorded in people’s records. This
means that we could not be assured that people were being given their medicines appropriately and
consistently. This was a breach of Regulation 13
3.
Regulation 9 HSCA 2008 (Regulated Activities); Regulations 2010; Care and welfare of people who
use services. This regulation was not being met as patients were not always cared for in an
environment that assured their safety and welfare. Many clinical areas had mixed sex wards. This
meant, in the acute admission wards, CAMHS wards and older people’s service, people did not
always receive the care they required and their privacy and dignity was not always maintained. This
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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means there was a risk that the environment was not effective in ensuring the privacy and dignity of
people was maintained. This was a breach of Regulation 9.
In March 2014, South West London and St George’s Mental Health Trust was a pilot site for the new CQC
inspection and regulatory process for mental health trusts. The inspection report is available at:
http://www.cqc.org.uk/sites/default/files/new_reports/AAAA0638.pdf
Further information about the Trust’s performance against the CQC Essential Standards for Quality and
Safety is available at: http://www.cqc.org.uk/provider/RQY South West London and St George’s Mental
Health NHS Trust has not participated in any special reviews or investigations by the CQC during the
reporting period.
Data quality 2014/15
The Trust has unified most of the data collection processes, to ensure that almost all clinical information we
use is derived from the electronic clinical record (RiO). The information can therefore be easily monitored
for accuracy, helping to ensure that the information is current, comparable and correct.
This coherent system is the cornerstone of efforts to assure data quality and means by which the
information used to plan, monitor and control the quality of services is as accurate as possible.
The performance measures are based on the electronic clinical record, with no need for additional data
entry. Therefore the quality of information is directly linked with the quality of the clinical record and the
provision of care and support.
South West London and St George’s Mental Health Trust will be taking the following actions to improve
data quality:

The Trust benchmarks strongly on inpatient data quality in comparison to many other mental health
Trusts, but will focus on ensuring the information in the Mental Health Minimum Data Set (MHMDS) is
prioritised, especially the new data required for the mental health tariff.

Data quality is reported by team and individual on an ongoing basis but is reviewed at the monthly
performance meetings and is reported to the Board.

“My dashboard” is an easy to use personal dashboard which supports the management of data quality
throughout the organisation. Each clinician will be able to easily see how their data quality supports the
provision of an accurate and reliable clinical record.
The Dashboard is being developed further
currently and a new CAMHS Dashboard will be rolled out in 2015/16.

Further work will be carried out with teams to identify who should record what information on the clinical
record in order to further streamline recording and avoid duplication.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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
A clinical audit on data quality is completed annually to check that the information is accurate. The Trust
can easily check the information contained in an individual data field, but it is more difficult to ascertain
the quality of the record or whether the necessary information is contained in free text fields.

The Trust receives additional assurance via external audit on specific performance areas.
Grant
Thornton audited seven day follow up and face to face gate keeping in 2014/15.
NHS number and general medical practice code validity 2014/15
South West London and St George’s Mental Health NHS Trust submitted records during 2013/14 to the
Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which publish information on
data quality. The percentage of records in the published data at Month 10 2013/14:
•
Which included the patient’s valid NHS number was:
-
•
99.7% for admitted service user care (compared to a national average of 99.1%)
Which included the patient’s valid General Medical Practice Code was :
-
100% for admitted patient care (compared to a national average of 99.9%)
Information governance toolkit attainment levels 2014/15
SWLSTG met the deadline for submission of its annual Information Governance Toolkit score for 2014/15.
The Trust achieved an overall score of ‘satisfactory’ for the fourth year running. The Trust scored Level 2
or higher in all of the 45 requirements.
Information governance personal data loss 2014/15
Personal data loss risk is managed by the Trust’s Information Governance Group and overseen by the
Senior Information Risk Officer (SIRO). During 2014/15, 57 minor incidents were reported to the
Information Governance Group. Only one was recorded as a Serious Incident in which a filing cabinet
containing patient health records was discovered in a building which once occupied by CMHT staff. This
was reported to the Department of Health and the Information Commissioner’s Office (ICO).
Clinical coding error rate 2014/15
South West London and St George’s Trust was not subject to a formal Payment by Results clinical coding
audit during 2013/14 although the Clinical Coding policy was reviewed with no significant . The Trust has
continued to focus on the coverage of clinical coding of primary and secondary diagnosis for inpatient
episodes of care. During the financial period 2013/2014, the figure for completed primary diagnosis was
*96.6%, against a national average of 99.3%. (*Source SUS Data Quality Dashboard)
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On the quality of Clinical Coding, in 2013/2014 the Trust was audited for the accuracy of Clinical Codes for
inpatient episodes, The Trust scored over 95% accuracy for primary diagnosis, and over 80% for
secondary diagnosis on a random sample of 100 records. This was translated to Level 3 in the respective
annual Information Governance Toolkit, which is the highest possible score in this category for that
particular requirement.
Complaints 2014/15
We take all our complaints very seriously and consider them to be a valuable feedback mechanism.
Listening carefully to the concerns, we endeavour to everything possible to resolve them and respond to
complainants. We aim to learn from what has happened and make demonstrable improvements to the
service where appropriate.
During 2014/15 the Trust has embedded further the Patient Experience Team that was established in
2013/14.
This marked a change in the way complaints were handled in that team are managerially
separate to the Directorates and work in a corporate context, investigations are independent to the service,
the team are able to challenge information received during the course of the investigation and reach
conclusions that are objective and impartial.
This is not a replacement to a completely independent
investigation from outside the Trust but represents considerable improvement.
Clinical advice is also
sought by the team about practice and learning issues from a clinician within the team.
The Patient Experience Team continues with its quality review structure in place to ensure that complaint
responses cover all points raised, are clinically appropriate and resolves the complaint as far as possible.
Engagement with both complainants and their families regarding the quality focussed approach to
complaint handling has been a key feature this year as has further engagement with staff to support
investigations and embed identified learning.
This has resulted in an increase in the number of
compliments about the Patient Experience Team which include being prompt, providing clear responses,
being proactive, supportive and sympathetic. This approach formed the basis of the team being shortlisted
and then announced Runner Up in the Patient Experience National Network Awards 2014 in January 2015.
The Team has two Key Performance Indicators (KPIs); 75% all written responses sent to the complainant
within 25 working days and 75% all complaints acknowledged with 3 days. Both have been achieved this
year.
During the period 1 April 2014 to 31 March 2015 we received 423 complaints which is a slight increase
from the previous year figure of 406. We continue to improve the quality of resolution and our responses to
complainants and of the 423 complaints received in the year, only five were referred to the Ombudsman for
independent review which is a reduction from nine referrals last year. Two cases remain open for a
decision, two were not upheld, one was partially upheld.
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In terms of themes, communication and information to patients remains a key theme and has prompted the
design of Trust wide Customer Services training by the introduction of behavioural principles of
communication and for the first module three scenarios have been identified as potential areas pressure
points in communication: First, the introduction and welcoming of patient on admission; secondly,
communicating with families when the patient has not given or refused consent to share information and
thirdly when preparing a patient for discharge.
A Complaints Annual Report will be prepared in accordance with Regulation 18 of The Local Authority
Social Services and National Health Service Complaints (England) Regulation 2009.
Freedom to Speak Up 2014/15
On 11th February 2015, Sir Robert Francis published his review into whistleblowing and creating an open
culture in the NHS – ‘Freedom to Speak Up’. The report outlines what staff, employers, unions and national
bodies told the review team and also includes research outcomes, international comparisons and examples
of current good practice. The Trust has agreed an action plan for 2015/16 to implement the
recommendations from the review, which will strengthen our current processes for staff who raise
concerns, and will include details of the concerns raised and subsequent learning from these within the
Quality Account for 2016/17.
Compliments 2014/15
Compliments received about the Patient Experience Team include the following:

‘Really helpful and supportive’

‘The response has answered all my questions; I am very pleased with the response, thank you’

‘I am glad that you acknowledged my letters, would you be able to handle my case? You sound to
have a lovely manner.’

‘…from both of you all I have experienced is moral and practical support. It is heart-warming when
you visited us, it did not feel persecutory at all. In fact it felt like you just wanted to know the truth’

‘Thank you very much for your full and clear response to my complaint regarding the care of my
daughter. I am satisfied with your response.’

‘I appreciate very much the speed with which you have responded to our concerns’.

‘Thank you so much for letting me know so quickly. As ever you are efficient and reliable, as my
previous experience with you has showed.
The Trust values positive feedback and received 897 compliments this year were received via letters,
emails, cards and Real Time Feedback Kiosks on the Trusts wards.
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41
Lilacs ward
“I just wanted to say thank you for looking after me during my time on Lilacs Ward- with care and
compassion and kindness. I have been able to talk, rest, be cared for, reflect and sleep without judgment,
something I desperately needed. I thank you all for doing an amazing job in a very pressured environment,
I have so much respect for your jobs.”
Prudence Skynner Family Group
“We can't speak highly enough about the Family therapy team at Springfield. we have told many friends
about the difference they have made. We are so grateful to [staff names] and all of the other
therapists/students and admin team. We all have our struggles but this has been a significant help to our
relationship and marriage.”
Teddington, Twickenham and Hampton Elderly CMHT
“I want to express my thanks to you and your colleague for all the care and consideration my wife and I
have experienced over the last two years. When I was first referred to you, a consultant psycho-geriatrician,
my reaction was 'I'm only 74'! However you quickly reassured me and over numerous consultation you
have greatly enabled me to work through my difficulties and brought me back to normality, Having [staff
name] present at our meetings was a great help and it allowed her to reinforce strategies that you
proposed. Your sweet smile at the end of each session as progress was made was most comforting. the
regular home visits and phone calls from Karen played a most important part in my recovery. Her pleasant
confidence was much a part of her very professional approach”.
Adolescent Assertive Outreach Team and Sutton CAMHS
‘I am writing to tell you about the excellent care my son [name] was given by the adolescent outreach team
and Sutton CAMHS. The AAOT were like a life line to [patient name] and us as a family. We were looked
after. D was given excellent care by the teams, they developed a good rapport with him and with us. They
were sensitive, caring and always very professional. I was always able to contact them if I needed to...
Every member of the team was excellent and gave my son a very high standard of care. As a result my son
stabilised. Although he is still recovering and continues to improve step by step, I believe that he achieved
this stability through the care of the AAOT and Dr [name]’
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Serious Incidents 2014/15
2014/15 has been another successful year in managing serious incidents and have continued the trend of
no overdue (Strategic Executive Information System) STEIS reports and has met the targets relating to the
quality of reports submitted to Kingston CCG.
The Trust continues to work collaboratively with Kingston CCG and maintains an open approach to
discussing incidents of concern on a weekly basis which has led to a joint approach in deciding which
incidents are added to STEIS and those that can be investigated at a local level.
April to March 2014/15 there have been 43 incidents added to STEIS. The Trust is not an outlier in the
number of Serious Incidents reported in the year when compared to other mental health Trusts.
The Trust has made significant improvement in incident reporting in terms of patient safety incidents
reported to the National Reporting Learning System (NRLS). The Trust is currently an average reporter
when benchmarked against the cluster and at the last publication of data (October to March 2014) the Trust
reported 24.46 patient safety incidents per 1000 bed days. The National Reporting Learning System
(NRLS) published the Trust data at the end of April this covers the period 1 st April 2014 to 30th September
2014. This report highlights further improvement in reporting of patient safety incidents for the Trust. The
Trust reported 2,120 Patient Safety Incidents (rate of 33.63/1000 bed days) during this period an
improvement from (24.46/1000 bed days) previously.
In 2014/15, South West London and St George’s Mental Health Trust have continued to strive to embed
learning across the Trust. This included a quarterly schedule of learning events. A number of risk alerts
have been circulated including those received through cross-Trust learning.
The top 3 reported categories for 2014/15 were Suspected Suicide (9), Attempted Suicide (9), and
Unexpected death (8).
There were two reported homicides in 2014/15 which the Trust is currently
investigating.
Trust wide actions arising from incidents, safeguarding cases and complaints continue to be monitored by
the Serious Incident Governance Group. The Trust has also developed its structures to ensure that local
actions are monitored at the Directorate Clinical Governance Groups.
A new Mortality Committee met for the first time in February 2015. This meeting now takes place quarterly
with the membership consisting of the Medical Director as Chair, Clinical Directors, Head of Quality
Governance, Patient Safety Manager, Patient Safety Manager Pharmacy, Heads of Nursing Inpatient and
Community and the Serious Incident Lead Investigator. The aim is to review and collate mortality,
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
43
homicide and self-harm data, identify themes, review the national picture and develop learning and actions.
There were no reported Never Events.
What else have we done?

The Trust has met the contractual requirements under the Duty of Candour and implemented
Regulation 20 effective from November 2014.

Updated and reviewed all Trust wide Clinical Policies.

Produced quarterly reports on themes and learning.

Review incidents on a daily basis to provide support to staff and encourage a proactive approach to risk
management.
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Comments from stakeholders
To ensure transparency and partnership involvement SWLSTG sent the draft Quality Account for comment
to key stakeholders including local Healthwatch, Health Overview and Scrutiny Committees (HOSCs) and
Clinical Commissioning Groups (CCGs).
_____________________________________________________________________________________
Sutton Scrutiny Committee
Statement and comments on South West London and St George’s Mental Health NHS Trust Quality
Account 2014/15
Sutton Scrutiny Committee is pleased to comment on the South West London and St George’s Mental
Health NHS Trust Quality Account 2014/15
The Committee understands that, in creating this Quality Account, the Trust is bound by certain rules
surrounding the presentation and structure of information. However, unfortunately, our overall impression of
this Account was that it was extremely difficult to understand – both in general and in comparison to the
Quality Accounts we have reviewed from other trusts. The Committee was concerned that the Account had
not been written with sufficient consideration for its audience, as it would be very difficult for any ‘layperson’
to use this document to draw coherent conclusions about the Trust’s progress towards its quality priorities.
With respect to the presentation of priorities and targets, the Committee felt that further clarification was
needed in terms of the relationship between the Quality Account priorities, the ‘core quality indicators’ and
the CQUIN goals. Even with background knowledge of the operation of NHS Trusts to provide context,
Committee members found that the presentation of these three disparate sections was confusing, and left
us without a clear overall sense of the Trust’s performance.
In terms of the Quality Account priorities themselves, the Committee’s impression was that the number of
priorities established (five for 2014/15 and four for 2015/16) seemed rather low; we would welcome
clarification of the rationale behind this. Moreover, while we appreciate that efforts have been made to
include operational information about the targets (in the tables on page 12 onwards), we found the amount
of detail somewhat excessive. The detail regarding how each priority has been measured by quarter,
indicator, and ‘sub-indicator’ would perhaps have been more useful if presented as an appendix which
readers could reference as necessary. Presented in the middle of the document, this information was hard
to digest, contributing to the difficulty of forming a clear understanding of the Trust’s progress. Ironically, we
also found that this section lacked detail in terms of how and to what extent the 2014/15 Quality Account
priorities had been met; the information in Appendix 4 would have been useful here, as it provides a much
clearer narrative of the Trust’s performance.
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The Committee perceived a need for further explanation regarding some specific target areas. For
example, with respect to Quality Account priority 3 (Physical Health), it would be helpful to have some trend
information regarding falls, and also more clarity in terms of the relationship between the reporting target
and the actions that will follow from the reporting. Regarding the complaints target, the Committee initially
felt that the goal for responses and acknowledgement rates (75% all written responses sent to the
complainant within 25 working days and 75% all complaints acknowledged with 3 days) could have been
more ambitious. We appreciate that 75% may have been chosen to reflect the anticipated high proportion
of complex and sensitive complaints (due to the nature of the Trust’s work). However, if this is indeed the
rationale behind this target, we would be grateful for some benchmarking data from other Trusts within the
same sector.
Throughout our reading of the Account, the Committee felt that more background information about the
Trust would have been helpful, in order to provide context and generally make the narrative thread of the
document more accessible. Specifically, we would ask the Trust to provide data about the number of
patients using their services in any given period (eg. data on usage trends over three to five years). Without
setting these broad parameters, it is difficult to draw coherent analysis from the Account; for example, with
respect to the core quality indicator ‘patient safety incidents resulting in severe harm or death’ the
Committee found the 0.3% statistic difficult to interpret without the context of the number of service users.
Finally, the Committee was somewhat concerned that the Account focused too heavily on the Trust’s
achievements and lacked depth in terms of discussion of problems and challenges – for example, with
respect to the areas of non-compliance with CQC requirements, we would have liked to see more specific
examples of how the Trust is addressing these issues. However, we are of course pleased that the Trust
has met all of its priority targets for 2014/15, and acknowledge that they have made progress in several
areas.
Overall, the Committee feels that our relationship with the Trust would benefit greatly from more frequent
communication. Specifically, we would be keen to be involved when the Trust engages with key partners in
discussions about future priorities (as described on page 9 of the Account). The Committee would also be
happy to contribute to quality assessments on a more practical level (we have discussed the possibility of
being involved with ’15 Steps’ visits in the future). The Committee appreciates the Trust’s evident
willingness to consider these options for further engagement, and looks forward to developing our
relationship during 2015/16.
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Commentary
on
South
West
London
and
St
Georges
Mental
Health
NHS
Trust
Quality Accounts 2014 – 2015
Healthwatch Richmond welcomes the account and is pleased to see that all the priorities set out from
2014/15 were achieved. We acknowledge the progress which the Trust has made during the reporting
period in correcting many of the problems which it faced at the start of the period.
Healthwatch Richmond finds that the format is not particularly user friendly, forcing the reader to
compare and cross-reference sections to gain a full picture. The report is also extremely repetitive,
although this may be due to the nationally prescribed requirements. If the audience is meant to be wider
than commissioners and regulators, this should be addressed in future. We also found that there is little
supporting evidence within the body of the report to demonstrate what the Trust achieved against their
targets. We would appreciate seeing more detail both on the many achievements of the previous year, as
well as on the areas of improvement that will be a focus going forward.
We acknowledge the progress that has been made on service feedback and congratulate the Trust on
their recognition in the Patient Experience Network Awards. We were pleased to see the Trust’s
approach and focus to manage and learn from serious incidents and are also pleased to see that some
progress has been made with staff engagement: however it is important that this is maintained and we
were surprised that it was not listed as a priority for 2015/16.
We recognise that it is a challenge for the Trust to deliver services across five different boroughs and
work with five local authorities but we are disappointed that there have been no pilots of service
improvement in the borough of Richmond. We also were disappointed by the level of engagement with
GPs especially outside the Wandsworth area, demonstrated by the low response to the survey in priority
3. We hope these issues will be resolved in the near future.
We welcome the continued focus on coordinated discharge, physical health, learning disabilities and
communication with GPs.
Nonetheless, we would appreciate seeing clearer targets for the future
priorities. We note that there is e-training available to staff on learning disabilities: however, the report
was not clear on the proportion of eligible staff who had undertaken the training. Additionally, it would
be helpful to understand why there are no plans for the use of web consultations with GPs. We are
delighted that research funding has been secured for the peer worker programme to support the
discharge process and look forward to seeing the benefits of this for service users as the research
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47
progresses. Additionally, we congratulate the Trust in developing an impressive research department
that will benefit patients locally and nationally in the longer term.
We are very pleased that a comprehensive project around discharge is being developed and we welcome
the Trust's commitment in looking at the reasons for readmission. It is pleasing to note that there is a
focus on helping to ensure that appropriate care is given before discharge and that proper discharge
procedures are followed, and we look forward to supporting the Trust through this work.
We are pleased that some focus is being given through the CQUIN targets to CAMHS service improvement,
especially as the Trust has restructured its CAMHS services in the past year. The transition to adult
services is a particularly crucial area to improve patient experience and is where many young people feel
let down. Healthwatch Richmond will be conducting surveys to test service user and carer experience of
these services during 2015 and we hope to be able to make a positive contribution to the work of the
Trust through our findings.
Healthwatch Richmond is run by Richmond Health Voices
Regal House, 70 London Road, Twickenham, TW1 3QS. 020 8099 5335.
Charity no. 1152333
Registered as a Company in England & Wales No. 08382351
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South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Wandsworth Adult Care and Health Overview and Scrutiny Committee
Statement and comments on South West London and St George’s Mental Health NHS Trust Quality
Account 2014/15
The Mental Health Trust has made some significant improvements over the past year. Staff views of the
Trust as a place to work and receive care have become more favourable, and are now approximately
middle-ranking amongst Mental Health Trusts. Reporting of patient safety incidents has increased, with a
corresponding reduction in the proportion of incidents leading to severe harm or death.
It is also
commendable that the Trust has achieved its targets for acknowledging and responding to complaints.
The Trust has undertaken considerable programmes of work in relation to the priorities set out for 2014/15
in the previous year’s Quality Account. It is notable that all of the priorities are shown as having been ‘fully
achieved’, and this is supported by evidence that the detailed programmes of work set out under the
indicators have been implemented. However, the process-focussed nature of the indicators used means
that this does not necessarily show whether the aims of the priority have been fulfilled. For example:

The priority on crisis plans is shown as having been fully achieved, and this is evidence by the
proportion of clients with Crisis Plans uploaded onto RiO and audit assessments of the quality of
these plans.
However, elsewhere in the Quality Account it is noted that, within the national
community mental health service user survey, the Trust performed poorly on the questions relating
to Crisis Care;

The priority on interface with GPs is also shown as having been fully achieved, and the GP
satisfaction survey planned for Quarter 4 has indeed been conducted. However, only 16 GPs out of
124 responded to the survey and, of those, only 6 (less than 5% of the original sample) indicated
that they were satisfied or very satisfied with the services provided by the Trust.
The priorities proposed for 2015/16 are generally welcome. However, the indicators proposed are again
very process-focussed and it is strongly suggested that the Trust should set out some clearly defined
outcome measures that will indicate whether the activity described has resulted in improvements for service
users and carers.
Whilst previous Quality Accounts have included and reported on priorities around adult and child
safeguarding, these do not feature in the Quality Account priorities for either 2014/15 or 2015/16. It is
important that this should not lead to a loss of focus on these areas. In particular, it is important that the
Trust develops staff awareness on child safeguarding. This extends beyond children who are direct users
of the Trust’s services and needs to encompass children’s vulnerabilities when their parents have mental
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
54
health problems, including their role as young carers and the emotional aspects of living in a household
affected by mental disorder and/or domestic violence and/or drug and alcohol problems.
Wandsworth Clinical Commissioning Group
As an Associate Commissioner, Wandsworth Clinical Commissioning Group (WCCG) attends the Clinical
Quality Review Group for South West London and St Georges Mental Health NHS Trust and has agrees
with the priorities identified for 2015 / 2016.
We acknowledge that there have been challenges relating to the Improving Access to Psychological
Therapies Programme during 2014/ 2015 particularly in relation to the access targets and waiting times.
WCCG has been actively involved in ensuring improvement in relation to IAPT performance. In addition
WCCG will continue to focus on monitoring the National Audit of Psychological Therapies Action Plan.
WCCG realise that there are challenges in respect of the provision of community services and access to
community services. As such we will continue to work with the Trust and associate commissioners to
support the transformation of community services to strengthen treatment and care and support for patients
and their families at home.
WCCG would like to see a focus on strengthening the pathway to ensure that the Trust meets its National
mandated targets in relation to Early Intervention in Psychosis
Whilst recognising there has been a comprehensive action plans as a result of the CQC visits during 2014
/2015 we would like to see accelerated progress in relation to care planning and risk assessment. In
relation to that we would have like to have seen a clearer action plan against the elements identified by the
CQC requiring improvement although this is blended into the range of actions stated.
It was extremely encouraging to see the continued push to raise the agenda and implementation on parity
and the engagement and access to lifestyle interventions. The reference to and significance of engaging
with physical co-morbidities is welcomed and should be stepped up. Despite this the completeness within
the report was a little lacking omitting to refer to IAPT delivering on long term condition care and also the
lack of weighting towards the significance of smoking and the actions against that for example.
We note also the outcomes of the friends and family test (FFT scores both for treatment and a place of
work. Despite the FFT being a high level marker for action there is clearly a significant amount of work to
be done in both these domains. It is particularly disappointing that only 54% would recommend the Trust as
a place to recommend for work. Mental Health is a challenging area to work in and experience care and we
would also strongly suggest that extensive work needs to be done on this domain. This in itself would
ensure higher quality service, better retention, retention and recruitment of a consistently skilled
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
55
workforce and improve the quality of work environment of those working in the Trust. These are all critical
enablers to an effective, high quality organisation.
It is also noted that crisis care was noted as “poor” and WCCG would also strongly recognise this and as
for the response to the CQC actions would want to see an accelerated programme to work on this. This has
been a joint discussion between provider and WCCG already, which will continue to be a priority as is the
work to enhance the capability and capacity of the Home Treatment Teams.
Brief comments on Quality Account 2015-16 from a family carer
I would like to submit a brief comment from the perspective of a family carer, and a participant in various
activities for the Mental Health Trust and my local CCG.
The Quality Account (QA) is a valuable document. It is good that SU&Cs are consulted about setting some
of the priorities and invited to comment on the final document. Even though this still falls a long way short
of co-production it is a good step in the right direction.
Performance, achievement and quality assurance will always be a “work in progress” in a large and diverse
mental health trust. There will always be room for improvement. As a carer, I find it reassuring that so
much detail and evidence about processes and performance are placed in the public domain and that the
evidence itself is subject to rigorous external audit. This helps service users and carers, lay members of
the board of governors etc., to engage constructively in the more detailed work with the Trust that goes on
throughout the year to improve services. This is the real value of the QA for us.
I am not going to read the QA from cover to cover. However it is clearly signposted so I can find the areas
which interest me. Although a bit “wordy” in places and rather repetitive it is clearly written and reasonably
free of jargon. However this is not a document for the casual reader, or for service users, carers, staff and
members of the public who are not closely involved in the Trust’s work as a whole, but who have a general
interest in what is going on.
It is impossible to meet all stakeholders’ requirements (which may be incompatible) in a single document. I
think there is a real challenge for the Trust to think about who the QA is for and, in particular how to convey
its key messages – most of which are positive and encouraging to the people who most need to hear them.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Richmond upon Thames’ Health Services Scrutiny Committee response to South West
London and St. George’s Mental Health NHS Trust Quality Account
Following on from the meeting held on Monday 11th May 2015, to discuss South West London and St.
George’s Mental Health NHS Trust’s (SWLSTG) Quality Account, we welcome the opportunity to provide
additional input, as the London Borough of Richmond upon Thames (hereinafter ‘LBRuT’) is determined to
champion the interests of its residents by playing a full and positive role in ensuring that the people living
and working in the LBRuT have access to the best possible healthcare and enjoy the best possible health.
The Report:
We congratulate you on this well-written and well-evidenced document. In particular:

The traffic light system was employed well and made the report accessible to the public. However,
at times, the Account was particularly text-heavy and difficult to digest. The inclusion of a summary
section, to capture the key messages, would be helpful in addressing this.

The engagement undertaken with a range of stakeholders to develop the priorities for 2014/2015
and 2015/2016 was appreciated. However, it was felt that a succinct methodology explaining the
engagement process and how the priorities were determined would be useful.
It is evidenced within the report that SWLSTG achieved all of the priorities set for 2014/2015, an
achievement to be commended. The LBRuT particularly noted the Trust’s accomplishments in the following
areas:

The Trust’s ongoing work with external partners to align local services to improve the expanding
‘Strengthening Families’ programme. This is an important priority within the Council and we would
want to see the improvement of interfaces continue as a priority for the Trust.

The progress made in improving the identification of service users with mental health conditions
who have a learning disability within local mainstream services (Priority 2). The associated
enhancement of staff knowledge in the understanding of issues related to mental health and
learning disabilities is noted and the LBRuT agree that these measures will help improve the quality
of the support offered to patients with learning difficulties.

The success of Priority 3 (Physical Health – Diabetes, Observation of Vital Signs and Falls) is
highlighted and ongoing work to continue the improvements in these areas are welcomed by the
LBRuT.

The panel appreciated the progress made on the Public Health initiatives in particular significant
improvements, in the Trust’s smoking cessation and physical activity programmes. The panel also
welcomed the inclusion of the Healthy Workplace Charter as the basis for framing priorities in the
Health and Wellbeing strategy and action plan going forward and ultimately seeking charter
accreditation.
Suggestions
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Whilst we appreciate that the version provided is a draft and the final version is yet to be approved, we
have a number of points we wish to raise and a number of suggestions we wish to see incorporated in the
final version, as we believe that these will further highlight the hard work and commitment which has taken
place to improve the quality of services at the South West London and St. George’s Mental Health NHS
Trust. These are as follows:

We recognise that with the Trust that addressing delayed transfers of care and discharge planning
should be a priority for 2015/2016, as this is an ongoing area of concern for residents. We
acknowledge that a lot of work has already been undertaken by the Trust to develop transfer
programmes and that, moving forward, the work will have a focus on developing GP relationships,
the quality of information available about the patient and the timeliness of transfers and discharge.
The LBRuT welcomes this approach and encourages the Trust to develop the important interfaces
between services, especially those with primary mental health care, drugs and alcohol services and
the voluntary sector.

Further to this point, we note that improvements in the handover during patient transfer and
discharge would be well received. We welcome the Trust’s desire to develop a two-way handover
system and work on communicating with primary care services.

We noticed that the Trust was reported as average by the CQC on Patient experience of community
mental health services and will endeavour to improve this rating going forward.

An error was noted on page 31 of the report where the 4 audits in which the trust participated during
the time period are listed. The statement at number 3 seems to be incomplete.

We noted that Children and Young People (CYP) do not feature in your priorities but are aware
about the importance of these services for our population. It might be useful to include them under
the quality initiatives section outside the specific priorities.

We acknowledge that a great deal of work done to develop the Mental Health Outcomes Framework
resulting in specific outcomes for Richmond residents. The framework aims for a holistic service, to
be delivered through multiple providers and we would encourage the Trust to further engage with its
external partners, to help align the services and provide this support. Similarly, the Outcomes Based
Commissioning (OBC) framework captures in depth the perspective of Richmond patients and we
would expect that the Trust takes account of this Inclusion of the two frameworks in the Quality
Account would be helpful as it represents very valuable feedback about what is important for
Richmond residents.
Conclusion
Our aim is to ensure that your Quality Account reflects the local priorities and concerns voiced by our
constituents as our overall concern is for the best outcomes for our residents. Overall, we are happy with the
QA, agree with your priorities and feel that it meets the objectives of a QA – to review performance over the
previous year, identify areas for improvement, and publish that information, along with a commitment about
how those improvements will be made and monitored over the next year.
We also hope that our views and the suggestions offered are taken on board and acted upon and we are kept
informed of your progress.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
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Amendments following comments from stakeholders
The Trust welcomes the statements received and thanks stakeholders for their comments. The Trust will be
responding to those who provided a statement.
Feedback
South West London and St George’s Mental Health Trust would welcome feedback on our Quality Account
2014/15.
If you would like to provide feedback or make suggestions for the content of future reports, for example,
possible priorities for 2016/17, please contact the Director of Nursing and Quality Andrew.Clough@swlstgtr.nhs.uk
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
59
Glossary
Abbreviation
Definition
A&E
Accident and Emergency
ACF
Acute Care Forum
ADHD
Attention Deficit Hyperactivity Disorder
ARBD
Alcohol Related Brain Damage
BDD
Body Dysmorphic Disease
BP
Blood Pressure
CAMHS
Child and Adolescent Mental Health Services
ccb
CCGs
Calcium Channel Blockade
Clinical Commissioning Groups
CFF
Carers Friends and Family
CHD
CLRN's
Coronary Heart Disease
Comprehensive Clinical Research Network
COPD
CPA
Chronic Obstructive Pulmonary Disease
Care Programme Approach
CQC
Care Quality Commission
CQRG
CQUIN
Clinical Quality Commissioning Reference Group
Commission for Quality and Innovation
CRHT
Crisis Resolution and Home Treatment
CROM
Clinician rate outcome measure
CRU-POAN
DenDRoN
Clinical Research Unit in Psychiatry of Old Age and Neuropsychiatry
Dementias & Neurodegenerative Diseases Research Network.
DOF
Diabetes, Observations of Vital Signs and Falls
DOH
Department of Health
EDT
Electronic Data Transfer
EMC
Executive Management Committee
EME
Efficacy and Mechanism Evaluation
FFT
HoNOS
Friends and Family Test
Health of the nation outcome scales.
HOSCs
Health Overview and Scrutiny Committees
HSCIC
Health and Social Centre
HTT
IAPT
Home Treatment Team
Improving access to psychological therapies
IGR
Integrate Governance Report
KPIs
L(S)CLRN
Key Performance Indicators
London (South) Comprehensive Local Research Network
LD
Learning Disability
LiA
LINks
Listening into Action
Local Involvement Networks
LSCB
London Safeguarding Children Board
MaPSaf
Manchester Patient Safety Framework
MHMDS
Mental Health Minimum Data Set
NAPT
National Audit of Psychological Therapies
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
60
NAS
National audit of Schizophrenia
NEWS
National Early Warning System
NHS
National Health Service
NICE
NIHR
National Institute for Health and Care Excellence
National Institute for Health Research
NMC
Nursing and Midwifery Council
NPSA
National Patient Safety Agency
OCD
Obsessive Compulsive Disorder
PALS
PHA
Patient Advice and Liaison Service
Physical Health Assessment
POM-H
Prescribing Observatory for Mental-Health
PPI
QIP
Patient and Public Involvement
Quality, Innovation, Productivity and Prevention
QOF
Quality Outcome Framework
QSAC
R&D
Quality and Safety Assurance Committee
Research and Development
RATE
Risk Assessment Training and Education
RCP
RiO
Royal College of Physicians (RCP
The Trust’s electronic clinical and patient record system.
RTF
SAM
Real Time Feedback
Safeguarding Adult Manager
SCA
SIRO
Smoking Cessation Advisor
Senior Information Risk Officer
STEIS
SURG
Strategic Executive Information System
Service User Reference Group
SUS
Secondary Uses Service
SWLSTG
South West London and St George's Mental Health NHS Trust
UTI
Urinary Tract Infection
VTE
Venous Thrombosis
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Annex - Statement of Directors Responsibility in Respect of the
Quality Account
The Directors are required under the Health Act 2009, National Health Service (Quality Accounts)
Regulations 2010 and National Health Service (Quality Account) Amendments Regulation 2011 to prepare
Quality Accounts for each financial year. The Department of Health has issued guidance on the form and
content of annual Quality Accounts (which incorporate the above legal requirements).
In preparing the Quality Account, directors are required to take steps to satisfy themselves that:
The Quality Accounts present a balanced picture of the Trust’s performance over the period covered:

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are
working effectively in practice;

the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, is subject to
appropriate scrutiny and review; and the Quality Account had been prepared in accordance with
Department of Health guidance.
The Directors confirm to the best of their knowledge and belief they have complied with the above
requirements in preparing the Quality Account.
By order of the Board
Date: 4th June 2015
Chairman
Date: 4th June 2015
Chief Executive
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Independent Auditors’ Limited Assurance Report
INDEPENDENT AUDITOR'S LIMITED ASSURANCE REPORT TO THE DIRECTORS OF SOUTH WEST
LONDON AND ST GEORGE'S MENTAL HEALTH NHS TRUST ON THE ANNUAL QUALITY ACCOUNT
We are required to perform an independent assurance engagement in respect of South West London and
St George's Mental Health NHS Trust’s Quality Account for the year ended 31 March 2015 ('the Quality
Account') and certain performance indicators contained therein as part of our work. NHS trusts are required
by section 8 of the Health Act 2009 to publish a quality account which must include prescribed information
set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service
(Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account)
Amendment Regulations 2012 ('the Regulations').
Scope and subject matter
The indicators for the year ended 31 March 2015 subject to limited assurance consist of the following
indicators:

the percentage of patients on Care Programme Approach (CPA) followed up within seven days of
discharge from psychiatric inpatient care, as reported on page 25 of the Quality Account; and

the percentage of admissions to acute wards that were gate kept by a Crisis Resolution and Home
Treatment Team, as reported on page 25 of the Quality Account.
We refer to these two indicators collectively as 'the indicators'.
Respective responsibilities of directors and auditors
The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year.
The Department of Health has issued guidance on the form and content of annual Quality Accounts which
incorporates the legal requirements in the Health Act 2009 and the Regulations.
In preparing the Quality Account, the directors are required to take steps to satisfy themselves that:

the Quality Account presents a balanced picture of the Trust’s performance over the period covered;

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance
included in the Quality Account, and these controls are subject to review to confirm that they are
working effectively in practice;

the data underpinning the measures of performance reported in the Quality Account is robust and
reliable, conforms to specified data quality standards and prescribed definitions, and is subject to
appropriate scrutiny and review; and

the Quality Account has been prepared in accordance with Department of Health guidance.
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63
The Directors are required to confirm compliance with these requirements in a statement of directors’
responsibilities within the Quality Account.
Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has
come to our attention that causes us to believe that:

the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;

the Quality Account is not consistent in all material respects with the sources specified in the NHS
Quality Accounts Auditor Guidance 2014-15 issued by the Department of Health in March 2015 ('the
Guidance'); and

the indicators in the Quality Account identified as having been the subject of limited assurance in
the Quality Account are not reasonably stated in all material respects in accordance with the
Regulations and the six dimensions of data quality set out in the Guidance.
We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations
and to consider the implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Account and consider whether it is materially
inconsistent with:

Board minutes for the period April 2014 to May 2015;

papers relating to quality reported to the Board over the period April 2014 to May 2015;

feedback from the following named stakeholders involved in the sign off of the Quality Account:
Sutton Scrutiny Committee; Healthwatch Richmond; Healthwatch Wandsworth; Kingston Health
Overview Panel; Wandsworth Adult Care and Health Overview and Scrutiny Committee; and
Wandsworth Clinical Commissioning Group;

the latest national patient survey dated 2014;

the latest national staff survey dated 2014;

the Care Quality Commission’s Intelligent Monitoring Report dated November 2014;

the Serious Incidents and Complaints Summary reported to the Trust's Quality and Safety
Assurance Committee in January 2015;

the Head of Internal Audit’s annual opinion over the trust’s control environment as reported to the
Audit Committee on 26 May 2015; and

the draft annual governance statement submitted to the NHS Trust Development Authority on 23
April 2015.
We consider the implications for our report if we become aware of any apparent misstatements or material
inconsistencies with these documents (collectively the 'documents'). Our responsibilities do not extend to
any other information.
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This report, including the conclusion, is made solely to the Board of Directors of South West London and St
George's Mental Health NHS Trust. We permit the disclosure of this report to enable the Board of Directors
to demonstrate that they have discharged their governance responsibilities by commissioning an
independent assurance report in connection with the indicators. To the fullest extent permissible by law, we
do not accept or assume responsibility to anyone other than the Board of Directors as a body and South
West London and St George's Mental Health NHS Trust for our work or this report save where terms are
expressly agreed and with our prior consent in writing.
Assurance work performed
We conducted this limited assurance engagement under the terms of the guidance. Our limited assurance
procedures included:

evaluating the design and implementation of the key processes and controls for managing and
reporting the indicators;

making enquiries of management;

testing key management controls;

analytical procedures;

limited testing, on a selective basis, of the data used to calculate the indicator back to supporting
documentation;

comparing the content of the Quality Account to the requirements of the Regulations; and

reading the documents.
A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The
nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited
relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information,
given the characteristics of the subject matter and the methods used for determining such information.
The absence of a significant body of established practice on which to draw allows for the selection of
different but acceptable measurement techniques which can result in materially different measurements
and can impact comparability. The precision of different measurement techniques may also vary.
Furthermore, the nature and methods used to determine such information, as well as the measurement
criteria and the precision thereof, may change over time. It is important to read the Quality Account in the
context of the criteria set out in the Regulations.
The nature, form and content required of Quality Accounts are determined by the Department of Health.
This may result in the omission of information relevant to other users, for example for the purpose of
comparing the results of different NHS organisations.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
65
In addition, the scope of our assurance work has not included governance over quality or non-mandated
indicators which have been determined locally by South West London and St George's Mental Health NHS
Trust.
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that,
for the year ended 31 March 2015:

the Quality Account is not prepared in all material respects in line with the criteria set out in the
Regulations;

the Quality Account is not consistent in all material respects with the sources specified in the
Guidance; and

the indicators in the Quality Account subject to limited assurance have not been reasonably stated
in all material respects in accordance with the Regulations and the six dimensions of data quality
set out in the Guidance.
Grant Thornton UK LLP
Grant Thornton House, Melton Street, Euston Square, London, NW1 2EP
3 June 2015
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Appendix 1: Quality Account Priorities 2015/16
Clinical Effectiveness
Theme
Coordinated Inpatient Discharge Planning
Intended
Outcome
This two year theme aims to improve the quality and coordination of discharge planning for
inpatient service users.
This indicator aims to:
Rationale
 Ensure that best practice standards of discharge planning are applied across inpatient
settings
 Provide high quality and comprehensive information and support for service users
leaving inpatient settings
 Make best use of electronic systems to support discharge processes.
The CQC raised coordinated discharge planning as an issue for concern for the Trust in the
Intelligence Monitoring Report December 2014.
The Acute Care Project Group (part of the Trust’s Transformation Programme) conducted
an evidence scan that identified a lack of pro-active planning of discharge arrangements
and oversight of the discharge process as a whole.
Facilitated discharge is considered a key element that needs to be addressed in order for
the Trust to safely ensure all adult acute wards are 18 bedded wards as recommended by
the RCN and Royal Collage of Psychiatrists.
Action
National initiatives such as the ‘Triangle of Care’ approach increasingly promote family and
carer involvement as a central component of effective and coordinated discharge. This is a
2015/16 CQUIN.
Indicator 1: Discharge Standards (Q1 only)
Refine and improve Trust inpatient discharge standards to ensure standardisation and
learning from best practice across Trust wards
Indicator 2: Ward Information Packs
Develop and implement a comprehensive discharge support and information element in
ward packs for Adult Acute wards to facilitate discharge
Target
Indicator 3: Task Management System
Publicise and engage staff with the Discharges Task List and Task Management System on
My Dashboards. Refine processes and systems to ensure staff are able to make best use of
the systems available
Q1
Indicator 1
 Review the Trust inpatient discharge standards for Adult Acute wards. The process of
updating the standards should include appropriate staff, service user and CFF input
 Co-produce updated Trust inpatient discharge standards for Adult Acute wards. These
standards should include a standardised ECR recording process at discharge for staff
and reference to primary/secondary care interfaces
 Launch the updated inpatient discharge standards for Adult Acute wards
Indicator 2
 Co-produce, with appropriate staff, service users and CFF from Adult Acute wards, a
discharge support and information element for ward packs to support discharge in Adult
Acute wards
Indicator 3
 Produce usage guidelines for staff for the Discharges Task List and Task Management
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System on My Dashboards
 Launch and implement usage guidelines in Adult Acute wards
Q2
Indicator 1
 Conduct an audit of ECR discharge recording and submit an audit report. This report
should include:
- A review of ECR data for patients discharged in Q2
- Lessons learned
- Recommendations for improvement
Indicator 2
 Distribute and implement the usage of the discharge element of ward packs across Adult
Acute wards at the start of Q2
 Collect feedback during Q2 on the discharge element of ward packs from Adult Acute
wards (staff, service users and CFF)
 Collate feedback and submit a progress report at the end of Q2. This report should
include recommendations for improvement based on the feedback collected
Indicator 3
 Monitor and review uptake of the Discharges Task List (DTL) and Task Management
System (TMS) processes on Adult Acute wards. Produce and submit a report, to
include:
- DTL and TMS usage
- Lessons learned
- Recommendations for improvement
Q3
Indicator 1
 Implement recommendations for improvement from Q2 ECR audit
Indicator 2
 Refine/update the discharge element of ward packs based on feedback collected in Q2
and distribute updated versions to adult Acute wards
 Produce plan to expand ward pack discharge element work to other Trust wards
 Commence design work for discharge support and information element of ward packs for
other Trust wards. The design process should include input from relevant stakeholders
(staff, service users and CFF) from these other wards
Indicator 3
Implement recommendations for improvement from Q2 review of DTL and TMS usage
Q4
Indicator 1
 Conduct an audit of ECR discharge recording and submit an audit report. This report
should include:
- A review of ECR data for patients discharged in Q4
- Lessons learned
- Recommendations for improvement
Indicators 1, 2 and 3
 Produce and submit a year-end report. This report should include progress to date
based on feedback from key stakeholders, lessons learned and recommendations
regarding the implementation of:
- Ward packs
- Updated discharge standards and implementation of standardised ECR recording
- Changes to DTL and TMS processes

Reporting
Gaps identified by the year-end report will be used to inform the focus for Year 2 of this
two year action plan to improve quality of coordinated discharge planning in the Trust
Progress for this target will be monitored by the Quality Improvement Programme, who will
provide quarterly updates to the Executive Management Committee, Trust Integrated
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Governance Group and commissioners via the CQRG. This project has been assigned a
Senior Responsible Officer, Clinical Lead and Project Manager
Patient and GP Experience
Theme
Service Responsiveness and Web Consultations
Intended
Outcome
This indicator has been designed to promote innovative methods of communication to
improve service responsiveness for service users in the community and for GPs when
contacting the Trust.
The March 2014 CiH Inspection found that some people served by the adult community
teams had raised concerns about the responsiveness of the service. Service users said
they sometimes found it difficult to contact staff and would not always receive a call-back
when they requested one.
Rationale
This has also been raised by clinical staff as a key line of enquiry.
There are new and innovative methods of communication that have been piloted in Trust
teams and externally, including the use of web based consultations, which could be refined
and developed further to support improved responsiveness.
Action
A priority for the Trust, as outlined in the clinical strategy (2015-2020) is that by 2020 the
Trust will be working more effectively with GPs.
Indicator 1: Trust standards
Update and refine Trust standards and procedures for responsiveness in Trust teams, to
include:
- Expected time frames for returning calls when service users contact community
teams
- Appropriate methods of communication
Indicator 2: *Web consultations
Co-produce, pilot and implement web consultations for service users, and for clinicians and
GPs
Target
*NB: There is currently a Trust pilot underway for the use of Skype with service users until
July 2015 at which point it will be reviewed whether the pilot continues. There are no current
plans for the use of web consultations with GPs
Q1
Indicator 1
 In collaboration with community team staff, service users, carers, friends and families
(CFF) and the Patient Experience Team, review and update Trust standards for
responsiveness in Trust teams as part of community teams’ operational policies
 Launch, implement and promote updated responsiveness standards for community
teams
Indicator 2
 In conjunction with the IT Web Consultations Pilot project manager, produce user
guidelines and support materials for staff and service users for web consultations
 Provide group and 1:1 training sessions for staff, as required, on the usage of web
consultations
 Pilot the use of web consultations between community team staff and service users in
Jubilee Health Centre (Sutton) and in Deaf services
 Collect feedback throughout the quarter from service users and clinicians on the
effectiveness and usability of web consultations using a survey method
Q2
Indicator 1
 In collaboration with the Patient Experience Team, obtain feedback from service users
and staff to establish adherence to the new responsiveness standards. This should be
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
69
Reporting
done by reviewing any related complaints
 Produce and submit a report including recommendations for improvement
Indicator 2
 Provide on-going support for staff in pilot teams regarding web consultations
 Collate and write up feedback from service users and staff on pilot use of web
consultations. Submit an interim report to commissioners to include:
- Usage figures
- Benefits, challenges and solutions found
- Lessons learned
- Recommendations for improvement
 Incorporate recommendations for improvement from Q2 feedback report into Trust policy
and protocol for web consultations
 Produce an implementation plan to extend the web consultations pilot to include other
community teams and GPs
 Produce web consultations usage guidelines and support materials for GPs
 Start engaging other teams and GPs in preparation for pilot extension to commence in
Q3
Q3
Indicator 2
 Hold a session in Q3 with staff and service users to share learning and explore the
barriers and facilitators to engagement for web consultations. This event should also
serve as an engagement opportunity for GPs invited to join the pilot
 Produce an event summary write up and submit report to commissioners at the end of
Q3
 Commence web consultations in additional teams and GPs, providing support as
required
 Collect feedback from service users, clinicians and GPs as to the effectiveness and
usability of web consultations using a survey method
Q4
Indicator 1
 In collaboration with the Patient Experience Team, obtain feedback from service users
and staff to establish adherence to the new responsiveness standards. This should be
done by reviewing any related complaints
 Produce and submit a report including recommendations for improvement
Indicator 2
 Submit a year-end report and recommendations for commissioners around the use of
web consultations in improving service responsiveness and engagement with service
users and GPs. Report to include:
- Levels of uptake
- Benefits and disadvantages
- Feedback from clinicians, service users and GPs
- Links to national findings and policy recommendations, and the Trust’s clinical
strategy 2015-2020
Progress for this target will be monitored by the Quality Improvement Programme, who will
provide quarterly updates to the Executive Management Committee, Trust Integrated
Governance Group and commissioners via the CQRG. This project has been assigned a
Senior Responsible Officer, Clinical Lead and Project Manager
Patient safety
Theme
Physical Health (Year 2 of a two year indicator commenced in 2014/15)
Intended
Outcome
To continue the Trust’s work on integrating mental and physical health care at every level to
ensure ‘parity of esteem’.
The physical health theme will follow the second year of its two year strategy to improve the
monitoring and treatment received by our inpatient service users with regards to physical
health.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
70
Rationale
The national mental health strategy ‘No Health without mental health’ (2011) outlined good
physical health as one of six key objectives to improve outcomes for people with mental
health problems.
‘Parity of esteem’ is outlined in the Trust’s clinical strategy as a key priority for the next 5
years (2015-2020). It is essential that service users receive a high quality of care to optimise
both their mental and physical health.
Action
Target
People with severe mental illness are in some cases 3-4 times more likely to die
prematurely from the key physical health diseases compared with the population as a whole
(RCP report 2013: Whole-person care: from rhetoric to reality- Achieving parity between
mental and physical health).
Indicator 1: **Physical health handbook
This indicator will focus on co-producing a physical health handbook for inpatient service
users.
Indicator 2: Diabetes
Following the development of the diabetes e-learning package in 2014/15, the Trust will roll
out the package amongst appropriate Trust clinical staff (target group to include staff RN
and doctors CT1&2).
Indicator 3: Obesity, food and nutrition
The indicator will focus on refining the obesity pathway, educating staff and updating the
methods for supporting patients with dietary plans.
Q1
Indicator 1
 Establish a physical health steering group to oversee development of the physical
health handbook and undertake a review of existing patient information and leaflets
created to date
 Undertake a consultation exercise with service users and key staff regarding the
requirements for the handbook and feedback on existing patient information
Indicator 2
 Plan and deliver coordinated launch of e-learning diabetes package developed during
Year 1. This will be developed in line with a communications strategy to promote and
educate staff around the package, using online and offline promotional materials
 Commence roll out of e-learning package to appropriate clinical staff
Indicator 3
 Establish a review group to refine and improve the Obesity Pathway, in line with the
updated Nutrition and Food Policy.
 Produce recommendations to improve the recording of information on the ECR
 Implement changes to Obesity pathway and make updates to food record charts
 Undertake a baseline audit of the quality of recording for a subset of patients identified
as being obese.
 Submit audit report to commissioners. This report include evidence of:
- Dietary plans
- Height, weight and BMI recording
- Lifestyle advice and links to support in the community
Q2
Indicator 1
 Produce first draft of the physical health handbook based on consultation with key
stakeholders and send out for feedback
Indicator 2
 Continue roll out of e-learning package to appropriate clinical staff
 Audit the number of staff who have completed the e-learning package during Q1 and
Q2
 Produce and submit report to commissioners. This report should include:
- Feedback received on the package
- % of relevant staff who have completed the package
- Recommendations for future developments
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71
Indicator 3
 Hold training and awareness sessions on obesity, food and nutrition for relevant staff to
increase skills and co-working between therapy and nursing staff
 Collect feedback from sessions and produce and submit a session summary report
 Incorporate learning from initial training sessions into refining plans for delivery of
sessions in Q3
Q3
Indicator 1
 Produce updated version of the physical health handbook based on feedback received
from key stakeholders in Q2
Reporting
Indicator 2
 Continue the roll out of e-learning package to appropriate clinical staff
 Audit the number of staff who have completed the e-learning package.
 Produce and submit a report to commissioners. This report should include:
- Feedback received on the package
- % of relevant staff who have completed the package
- Recommendations for future developments
Indicator 3
 Continue to hold training and awareness sessions for relevant staff to increase skills
and co-working between therapy and nursing staff.
 Collect feedback from sessions and produce and submit an event summary report
 Update system recording processes on the ECR for height, weight and BMI
Q4
Indicator 1
 Launch handbook and distribute to all inpatient wards
 Promote handbook and encourage distribution to all inpatients
Indicator 2
 Continue the roll out of e-learning package to appropriate clinical staff
 Conduct year-end audit of the number of staff who have completed the e-learning
package
 Review the quality of diabetes recording against a baseline from 2014/15 to
demonstrate improvements. Submit a report to commissioners
Indicator 3
 Undertake a year-end audit of the quality of recording and interventions for patients with
obesity
 Submit audit report to commissioners to show the improvements to quality and
interventions for people with identified obesity. This audit report should include evidence
of:
- Dietary plans
- Height, weight and BMI recording
- Lifestyle advice and links to support in the community
Progress for this target will be monitored by the Quality Improvement Programme, who will
provide quarterly updates to the Executive Management Committee, Trust Integrated
Governance Group and commissioners via the CQRG. This project has been assigned a
Senior Responsible Officer, Clinical Lead and Project Manager
Clinical Effectiveness
Theme
The Trust will continue the two year action plan to improve the identification of people
with mental health issues and Learning Disabilities and make adjustments to
treatments currently available.
Intended
Outcome
To build upon on the foundation of good practice achieved in year 1 of the Quality
Account; to continue to improve the identification of service users with mental health
issues who have a learning disability (LD) within local mainstream services, with a
specific focus on sub-groups such as CAMHS and deaf services.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
72
To continue to improve Trust wide understanding of Mental Health & Learning
Disabilities which in turn will improve the identification of this group and the support
offered to those service users who have a LD.
In year 2 to have specific targets around the identification and support for individuals
who have Autistic Spectrum Disorders (ASD), to ensure continuous improvements to
care in line with the Autism Act (2010) and the Think Autism Strategy (2014).
Rationale
for this
priority
The Department of Health policy ‘Protecting Patients from Avoidable Harm’ (March
2013) details that actions should be taken to learn from mistakes made with particular
reference to the Winterbourne View scandal: ‘People with learning disabilities (LD),
autism or mental health problems will get more support in the community rather than in
hospital, where appropriate.’
Local progress against the Monitor standards to facilitate access of people with learning
disabilities into mainstream mental health services requires improvement, and in light of
this the Trust aims to improve the service that is received by mental health service
users with LD in mainstream services, as per ‘Closing the Gap: Priorities for essential
change in Mental Health (Department of Health).
Under the Autism Act (2010) and the Think Autism Strategy (2014), the Trust has a
legal requirement to ensure clear pathways of care for people diagnosed with Autism,
which should include involvement of friends and family. The Trust must also ensure that
staff are provided with suitable training and resources to improve awareness.
Action
Indicator 1: Resource Development
We will build databases and online resources to support staff and service users and
ensure best practice learning. This will include Hospital Passports for people with
Learning Disabilities going into hospital.
Indicator 2: Training and Engagement with staff, family and friends
With a focus on ASD, events and engagement activities will take place for staff, CFF
and service users, including a targeted Trust-wide LD Awareness Week.
Target
Q1
Indicator 1
 The mainstreaming learning disabilities in mental health group will meet to review
the LD protocol and amend screening criteria to reflect use with specific subgroups such as CAMHS / Deaf services

Review and update the LD Hospital Passport based on feedback from staff, CFF
and service users, to reflect needs of service users within the Trust

Produce an audit tool that assists in identifying individuals who are not being
recorded under disabilities section and submit tool to commissioners for
information

Build a database of reasonable adjustments to serve as a repository for good
practice examples
Q2
Indicator 1
 Develop an online resources page / learning forum for the LD Champions to be
included as part of the new Trust website. Online resources page to include:
-
Database of reasonable adjustments
Audit tools for screening LD
LD pathways and protcol
Easy read information
Resources on Autism awareness
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73
Indicator 2
 Hold a session for LD Champions to specifically look at:
-
Support for individuals with ASD
Easy read care plans
Launch of updated Hospital Passports, to ensure they are used when an
individual meets the screening criteria in the Trust protocol
Submit a write up of the Q2 LD Champions’ session to commissioners. The report
will include:

-
Numbers attended
Feedback from staff
Feedback from carers and family
Recommendations for future engagement and training sessions
Q3
Indicator 1
 Plan, coordinate and deliver a re–launch of the Trust’s LD e-learning package to all
clinical staff to increase numbers of staff who have completed basic awareness
package

Submit a progress report regarding the uptake of the Hospital Passport in the
Trust. Include feedback from staff, CFF and service users
Indicator 2
 Produce a summary of QA progress to date, to be published in Trustwide article for
staff, service users and external stakeholders

Hold an ASD awareness session for Trust staff

Hold a Trust-wide LD Awareness Week:
-
Include service user stories
Feature interviews with LD Champions making a difference and showing they
have improved their practice in response to the needs of people with autism / LD
Accounts from carers, friends and family
Q4
Indicator 1
 Monitor the number of clinical staff Trust wide that have completed the LD elearning package. Compare with baseline against previous year
Indicators 1 and 2

Audit and submit a report of individuals who have LD recorded as a disability on
the ECR to demonstrate a 10% improvement in the following criteria against
performance in 2014/15:
-
Of the identified individuals, the proportion who have had reasonable
adjustments offered
- The number who have been offered easy read materials
 Submit a summary report of the two year LD quality account theme. The report will
include key audit findings, progress areas, activities and events, lessons learned
and recommendations for continuous improvement. Include a plan for integration
of quality account work into Trust business as usual from 2016 onwards
Reporting
Progress for this target will be monitored by the Quality Improvement Programme, who
will provide quarterly updates to the Executive Management Committee, Trust
Integrated Governance Group and commissioners via the CQRG. This project has been
assigned a Senior Responsible Officer, Clinical Lead and Project Manager
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74
CQUIN and description
Indicators
Intended outcome
Carers and Families – 1.
Triangle of Care
(2 year CQUIN)
Working more effectively
with families, friends and
carers of people using
mental health services
has been an increasing
priority for the Trust over
recent years
National
clinical
guidance
increasingly
promotes family and
carer involvement as
central to good care and
better outcomes (e.g.
NICE
guidelines
on
schizophrenia)
Co-produce a comprehensive Carer, Family
Year 1
and
Friend*
Identification,
Information
Provision, Support and Involvement Protocol i) To
improve
and
(meets Standards 1, 3, 5 and 6). This protocol
standardise
the
should include guidance on confidentiality and
identification
and
sharing information
provision
of
2. Identify and engage appropriate named staff
information,
advice
(roles) to have responsibility for carers (meets
and
support
for
Standard 4)
carers, families and
3. Develop new ECR functionality and produce
friends of service
staff guidelines for indicator workflow and
users. To enable their
fields for indicator data capture for intended
involvement in the
outcomes i) and ii)
Triangle of Care, to
4. Produce or source a suitable Carer
improve
their
Awareness, Engagement and Involvement
wellbeing
and
Training package (meets standard 2) for staff
satisfaction with Trust
(including process guides, information and
services
support tools for staff). This training should
include:
ii) To
develop
and
- details on how to record carer data
commence
(including identification, carer engagement
implementation
and
strategies and support offered) on the new
evaluation
of
a
Trust ECR system
standardised
family
- equip relevant staff with the skills to deliver
inclusion
support
i) and ii)
pathway with initial
5. Identify, engage and prepare pilot teams for
roll out of training
focus
on
young
6. Develop a CFF ToC involvement and service
people’s and adults’
satisfaction monitoring process and tool. This
psychosis services***
process and tool should enable the Trust to
monitor and report on:
Detailed
pathways
- Levels of CFF engagement in the ToC
and
interventions
(and
- Frequency and nature of CFF involvement
the evidence base)
with the ToC
with regard to families
- Improvements in CFF wellbeing and
satisfaction with Trust services
of
people
with
7. Complete training of relevant staff in pilot
psychosis will be the
teams. Complete training and supervision for
focus of Year 1 of this
staff who will deliver family work intervention
2 year CQUIN target
for people with psychosis
8. Implement use of CFF ToC involvement and
service satisfaction monitoring process and The Trust would expect
tool for pilot teams
this CQUIN to enable
9. Staff in pilot teams to be capturing the required progress on the six
data and recording it accurately on new ECR standards of the Triangle
system
of Care (ToC)
10. Produce and submit a CFF ToC involvement
and service satisfaction report
11. Commence use of ‘Experience of Care Giving
Inventory’ for ii) and develop standard,
automated reports and audits to be used for
quality evaluation
12. Submit an implementation progress report to
commissioners. This report should include:
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
75
13.
14.
15.
16.
Medicines & Physical
Health
(M&PR)
Reconciliation at CPA
review and discharge
and
medicines
compliance
in
the
Community
(2 year CQUIN)
Reconciliation
of
medicines and physical
health
checks
at
discharge.
This
stretching CQUIN aims
to change both the
content of documents
containing
M&PR
information and practice
across
the
whole
organisation
1.
2.
3.
4.
5.
6.
7.
8.
9.
- Standard, automated report example
- Audit tool to be used in Q4
Demonstrate improvement against the current
KPI for assessments being offered for eligible
carers of CPA service users in Kingston,
Richmond
and
Merton
(Sutton
and
Wandsworth are exempt from this indicator as
they are not integrated into the service):
- 50% to have been achieved by the end of
Q3
Conduct process quality audit (using audit tool
produced in Q3). This audit should cover Q3
and Q4
Produce and submit year-end progress update
report to commissioners. This report should
include:
- Data captured by standard automated
reports
- Results of Q3/Q4 process quality audit
- CFF ToC involvement and service
satisfaction data and feedback
- Lessons learned
- Recommendations for improvement (to be
implemented in Year2)
Demonstrate improvement against the current
KPI for assessments being offered for eligible
carers of CPA service users in Kingston,
Richmond
and
Merton
(Sutton
and
Wandsworth are exempt from this indicator as
they are not integrated into the service):
- 60% to have been achieved by the end of
Q3
Recruit required staff to deliver Year 1 of the
CQUIN
Audit current documents and process to
establish baseline data
Submit baseline data, collected on quality of
existing documents and information given to
patients and GPs, to commissioners
Additional promotion of the Trust’s existing
website and intranet ‘Choice and Medication’
pages and Medicines Advice Line to staff and
service users (screen savers, comms etc.)
One off service evaluation to establish the %
of FP10 prescriptions written that are
dispensed.
Report to be submitted to
commissioners
Develop Standard Operating Policy (SOP) for
process (informed by Q1 audit findings) and
submit to commissioners for information
Develop accreditation process for Pharmacy
Staff and submit process documents to
commissioners
Produce Assistance Tool and supporting
materials for staff, to provide them with the
necessary skills to carry out the M&PR SOP
Conduct 1:1 training sessions with individual
clinicians across the Trust in M&PR at CPA
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
To provide independent
and
balanced
information to service
users,
their
carers,
family and friends which
empowers
them
to
participate in medication
treatment decisions
To ensure patients are
fully informed regarding
their medicines (sideeffects, offered written
information, choice of
treatment),
ensure
appropriate
physical
health checks have been
done or arrange for them
to be done, check
adherence,
ensure
accurate information on
medicines and physical
health
have
been
communicated with GPs
and acted upon where
needed
76
review and discharge process based on
individual needs
10. Clinician engagement and promotion of new
SOP and Assistance Tool
11. Audit clinical impact of implementation of new
M&PR at CPA review and discharge SOP.
Impact to be measured using standard risk
rating of interventions methods. Audit of one
month of interventions made during M&PR at
CPA review and discharge using audit tool
developed based on audits conducted on
M&PR from inpatient setting (based on NICE
and NPSA guidance)
12. Audit report to be submitted to commissioners.
Audit report should include:
- Lessons learned
- Recommendations for improvement for the
SOP and Assistance Tool based on audit
results and feedback from clinical staff
13. Trust to have implemented a process for
telephoning service users 5 days after
inpatient discharge to ensure medicines
compliance and that the service user has all
the
necessary
details
required
and
understands all the information. The process
with be audited (using the SNOMED function
on the ECR and a brief audit report will be
submitted to commissioners
CAMHS
Welcome
-
You’re
The Department of Health
‘Quality criteria for young
people
friendly
health
services’, which is referred
to as ‘You’re Welcome’,
sets out principles to help
commissioners and service
providers to improve the
suitability of NHS and nonNHS health services for
young
people
(DoH
website 26.01.15)
1.
2.
3.
4.
The Trust will implement
the
‘You’re
Welcome’
quality criteria for Local
CAMHS services/teams
5.
6.
7.
The CAMHS CQUIN Project clinical leads will
complete the required DoH self-assessment
Self Review Tool during the first half of Q1 (by
mid-May 2015) for all Trust Local community
CAMHS teams/services.
The outcome of the self-assessment process
will inform the work/improvements required
throughout year 1 of this CQUIN in order to
achieve accreditation by the end of Q1,
2016/17
Summary of self-assessment outcome and
feedback to be submitted to commissioners in
an end of quarter report. This report should
include recommendations for improvement
A ‘You’re Welcome Steering (Project Group)
will be established to deliver the work required
to achieve these CQUIN indicators. This
Group will include the CAMHS Participation
Lead
(when
recruited),
CAMHS
commissioners, a representative from Health
Jury and appropriate clinical and service
user/young people representatives
The project clinical lead and Group will
commence work with young people to codesign and co-produce a variety of publicity
and information materials for ‘You’re Welcome’
Where
available,
national
promotional
materials produced by the DoH can also be
used
Appropriate, existing Trust materials may also
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
Resolve any identified
barriers to meeting the
standards of care set out
in care planning and
physical health in relation
to
treatment
with
medicines
Amend the Discharge
Summary
to
reflect
accurate information on
medicines and physical
health
and
request
authorisation from the
author to send to the
patient and GP
To
implement
the
‘You’re Welcome’ quality
criteria in all Local
CAMHS services/teams
within the Trust to enable
Trust Local CAMHS
services/teams
to
become more ‘young
people friendly’
To
work
towards
achieving
‘You’re
Welcome’ accreditation
by the end of Q1,
2016/17
77
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
be used and/or refreshed for inclusion
Submit a selection of draft promotional
material examples to commissioners for
information
Complete co-production of publicity and
information materials for ‘You’re Welcome’ and
distribute to all Local CAMHS services/teams
These materials will be in a variety of
languages and formats and be easily
understandable by young people including
those with learning disabilities, physical
disabilities or sensory impairments. During
Q2, produce versions of the agreed publicity
and information materials in appropriate
formats (e.g. Easy Read) and additional
languages, as required by the population
served by the Local CAMHS teams/services
using translation services where required.
Submit examples to commissioners
Develop and implement a collection of
CAMHS web pages on the Trust website
specifically designed to provide general
CAMHS information (including the ‘You’re
Welcome’ quality criteria) and links to other
relevant information for service user, carers,
friends and family
The Project Group will co-produce a suite of
training and support tools for staff to build the
capability of health workers, especially those
who are the first point of contact with
adolescents, to respond effectively to their
needs. Please refer to the ‘You’re Welcome’
guidance for the elements which should be
covered by the training
This training suite may include existing training
material developed by the Trust or DoH
England / Royal Colleges of General
Practitioners and of Paediatrics and Child
Health’s
e.g.
http://www.elfh.org.uk/programmes/adolescenthealth/more-information/
Submit examples of training and support
materials to commissioners for information
90% of all appropriate Local CAMHS staff to
have completed the training package and be
using the support tools by the end of Q2
A process to monitor the completion of ‘You’re
Welcome’ training all relevant Local CAMHS
staff in supervision will be in place. Submit
details of the implemented process to
commissioners in the Q2 report
Trust to host a CAMHS ‘You’re Welcome’
launch event for stakeholders: staff, service
users, carers, friends and family members
Complete an audit of 17 year old service users
to establish potential commissioning gaps
when these service users make the transition
to Adult services
Submit audit report to commissioners. This
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78
20.
21.
22.
23.
24.
25.
Improving
Physical
Healthcare to Reduce
Premature Mortality in
People with Severe
Mental Illness (SMI)
To ensure that service
users with SMI have
comprehensive cardio
metabolic
risk
assessments,
the
necessary treatments
and the results are
recorded and shared
appropriately with the
patient and the treating
clinical teams. Patients
with SMI
for the
purpose of this CQUIN
are all patients with
psychoses,
including
schizophrenia, in all
types of inpatient units
audit report should include:
- Information
to
highlight
potential
commissioning gaps
- Recommendations/proposals for any follow
on work
Co-produce a system/process to ensure that
young people are regularly involved in
monitoring and evaluating patient experience.
This should include:
- Young peoples’ groups and forums
- Real Time Feedback (RTF) collection
methods for CAMHS
- 15 Steps Visits
Submit a brief overview of the system/process
to commissioners for information
Implement the system/process agreed in Q3
Collate the responses/feedback collected
during Q4 and produce a report for submission
to commissioners. This report should include:
- Examples of feedback received
- Examples
of
action
plans
and
recommendations for improvement based
on the feedback received
- Lessons learned
The Trust will refresh its procedure for
preparing young people for the transition from
health services designed for children and
young people to adult health services,
consistent with current DoH guidance. This
updated procedure should include specific
guidance for the needs of young people with
long-term health needs and be informed by the
results of the Q3 audit
Submit a copy of the refreshed procedure to
commissioners for information
This CQUIN supports
and facilitates closer
working
relationships
between
specialist
mental health providers
and primary care through
the routine use of the
NHS
numbers,
the
sharing of physical and
mental health diagnoses
and
treatments,
communicated between
the specialist mental
health clinicians and the
person’s GP, and with
the service user. It has
the capacity to lead to
reductions in relapse,
crisis
presentations,
avoidable
admissions
and
length
of stay
Indicator 1 (Full details still TBC by National
through
addressing
the
Guidance or commissioners)
impact
of
untreated
Cardio Metabolic Assessment for patients with
In 2015/ 2016, this CQUIN in essence, remains
similar to the 2014/2015 CQUIN, but has
additional, proven effective implementation
methods embedded. This decision was
reached, having examined the evidence of the
current national baseline from the National
Audit of Schizophrenia 2014 (NAS) and the
current evidence of implementation of the
2014/15 CQUIN, consulted with an expert
reference group, and reviewed the successful
implementation approaches of the top
performing providers in the NAS. Most
commissioners and providers consulted, fed
back that services are now beginning to make
real progress in putting in place the necessary
infrastructures and training for successful
implementation, and that consistency of the
CQUIN would enable more rapid progress.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
79
commissioned from all
sectors,
and
the
community
early
intervention psychosis
services.
There is an excess of
over 40,000 deaths,
which could be reduced
if SMI patients received
the same healthcare
interventions as the
general population. [1].
NHS
England
has
committed to reduce
the 15 to 20 year
premature mortality in
people with psychosis
and
improve
their
safety
through
improved assessment,
treatment
and
communication
between clinicians.
There
are
robust
national
NICE
and
professional standards
of care for people with
psychoses. NICE Health
Technology
Assessments
(HTAs),
NICE guidelines and
Quality
Standards
provide clear standards.
However, the 2012
Schizophrenia
Commission, and the
National
Audit
of
Schizophrenia
2012,
which
audited
a
community CPA sample
of over 5,000 service
users, found that less
than 29 % of patients
receive
the
basic
annual physical health
checks and ongoing
monitoring
support.
The recently published
second round of the
national
audit
of
schizophrenia (NAS 2,
2014) confirms that
standards
are
improving slowly to
33% being assessed
psychoses, including Schizophrenia
1. Demonstrate, through the National Data
Collection Exercise, full implementation of
appropriate
processes
for
assessing,
documenting and acting on cardio metabolic risk
factors in patients with psychoses, including
schizophrenia.
2. Look at the results recorded in the patient's
notes/care plan/discharge documentation as
appropriate, together with a record of
associated interventions according to NICE
guidelines or onward referral to another clinician
for assessment, diagnosis, and treatment e.g.
smoking cessation programme, lifestyle advice
and medication review
3. Collect audit data.
The following cardio
metabolic parameters (as per the 'Lester tool'
and the cardiovascular outcome framework) are
assessed:
- Smoking status
- Lifestyle (including exercise, diet, alcohol
and drugs)
- Body Mass Index
- Blood pressure
- Glucose regulation (HbA1c or fasting
glucose or random glucose as appropriate)
- Blood lipids
physical morbidity
recovery.
The audit sample must cover all relevant services
provided by the provider
Indicator 2 (Full details TBC by National
Guidance or commissioners)
1. Completion of a programme of local audit of
communication with patients’ GPs, focusing on
patients on the CPA.
2. Audit CPA Review Letters, Discharge
Summaries and other correspondence with
GPs to ensure that the holistic CPA
components have been communicated. Local
audits must cover a sample of patients in
contact with specified services for more than
100 days and who are on the CPA
1. Demonstrate that an up-to-date summary of
care (communicated via CPA Review Letters,
Discharge
Summaries
and
other
correspondence) has been shared with the GP
(% targets still TBC by National Guidance or
commissioners at time of writing, 22.04.15).
This should include the holistic components set
out in the CPA guidance:
e) ICD codes for primary and secondary mental
and physical health diagnoses.
f) Medications prescribed and monitoring and
adherence support plans.
g) Physical health condition(s) and ongoing
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
80
on
and with variable levels
of responsive treatment
instituted.
Additional National
Indicator – Still TBC by
commissioners at time
of writing (02.06.15)
h)
monitoring and treatment needs.
Recovery interventions including lifestyle,
social, employment and accommodation plans
where necessary for physical health
improvement.
Information not available at time of writing
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
Information not available
at time of writing
81
Appendix 2: Francis and Winterbourne Report action plan
Action plan to address the recommendations outstanding from the Francis
Report
Recommendation
Action
Ensure isolation and closed cultures of Develop a plan to maximise nurse’s
inpatient
care
are
systematically experience
and
professional
recognised and addressed. The culture of development by rotating staff between
acre on all wards and in all community different areas
teams needs to be dominated by a
commitment to highest standards and staff
who perceive this is not upheld know
where and how to report an issue
As part of a mandatory annual A Continuing Professional Development
performance appraisal, each Nurse, portfolio for registered nurses is being
should be required to demonstrate in their developed to complete as evidence
annual learning portfolio an up-to-date towards their NMC annual registration.
knowledge of nursing practice and its Pending guidance from the Nursing and
implementation. Alongside developmental Midwifery Council (NMC).
requirements,
this
should
contain
documented evidence of recognised
training undertaken, including wider
relevant
learning.
It
should
also
demonstrate commitment, compassion
and caring for patients, evidenced by
feedback from patients and families on the
care provided by the nurse. This portfolio
and each annual appraisal should be
made available to the Nursing and
Midwifery Council, if requested, as part of
a nurse’s revalidation process. At the end
of each annual assessment, the appraisal
and portfolio should be signed by the
nurse as being an accurate and true
reflection and be countersigned by their
appraising manager as being such.
Healthcare
providers
should
be A cultural barometer framework has
encouraged by incentives to develop and been drafted based on the Department
deploy reliable and transparent measures of Health's interpretation of the Chief
of the cultural health of front-line nursing Nursing officer six C’s for Mental Health
workplaces and teams, which build on the Nurses. A plan to pilot this will be
experience and feedback of nursing staff developed.
using a robust methodology, such as the
“cultural barometer”.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
and Winterbourne
Timescale
Commence
March
2015.
Review
September 32015
A Steering Group
will meet for the
first time in April
2015
Incorporated into
the Kings Fund
Collective
Leadership
programme
commencing April
2014.
82
Appendix 3: Review of Quality Account Priorities 2014/15
Improving quality and service delivery continues to be at
the heart of everything we do. CQUIN* and Quality
Account indicators are designed to promote good clinical
practice and are important drivers for change and
improvements
in
safety,
effectiveness
and
patient
experience.
*Commissioning for Quality Innovation (CQUIN) is a national framework for locally agreed quality improvement schemes
Quality Improvement
Programme (QIP)
The Quality Improvement Programme manages the
delivery of annual quality improvements across the Trust
and covers the local CQUIN and Quality Account
indicators.
Working together to make quality the target
For 2014/15, it maintained a 100% record
throughout the year and achieved all the Quality Account
and Local CQUIN indicators. The Local CQUIN indicators
for 2014/15 were worth over £2.26m of income for the
Trust.
Over the past few years, the Local CQUIN and Quality Account indicators have helped to refocus the Trust
in a number of key areas.
They have changed the culture of inpatient care towards physical health by making staff ‘physical health
aware’ from the moment they meet a new service user (for instance Safety Thermometer, Physical Health
Assessments projects). The overall profile of physical health has been raised throughout the Trust and
staff are now benefitting from more accurate physical health information about their patients, resulting in
improved patient safety and clinical effectiveness.
The projects have brought the Trust closer to primary care with improved integration and communication
(for instance Safe, Managed Discharges, Ongoing Physical Health, Kinesis and GP Satisfaction
projects). Acknowledging the importance and relevance of the information going to GPs, and the need for
clarity and brevity, has made staff think more carefully about how their input will affect patients’ safety in
both secondary and primary care environments.
The nature of the indicators encouraged co-production and inclusiveness across departmental and multiagency boundaries (for instance Crisis Planning, Safe, Managed Discharges, Physical Health and
Feedback for Improvement). This collaborative working, with service users, clinicians and management or
corporate staff addressing issues together, has cultivated a mutual acknowledgement of expertise.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
83
As service user networks become more important in supporting people and building better partnerships,
listening to and responding to feedback will help shape the way services are formed and improved. It will
enhance two-way communication between staff and service users, carers, family members and friends,
resulting in empowerment and the sharing of best practice.
Embracing technology and innovation (for instance the new Real Time Feedback dashboard, increased
functionality on electronic Smoking Cessation Form system with service user progress charts and work on
transferring information securely to GPs) has facilitated openness and information sharing between staff
and patients. Streamlined processes have made it easier for all stakeholders to be involved, share ideas
and access information.
By bringing clinical leadership into the delivery of the service improvements, the whole Trust has
galvanised into making practise changes. Clinicians have been involved at every stage from identifying
possible projects to leading the delivery of the Quality Account and CQUIN programmes. This clinical
involvement in the end-to-end process has made the indicators clinically relevant at a local level which
increased clinical and medical engagement.
This has contributed to making quality and performance
improvements which are truly embedded and sustainable long term and not just target driven in the short
term.
Priority 1: Crisis Planning
Priority
To ensure that service users who experience a crisis in their mental health receive
appropriate, tailored treatment that they have been involved in planning.
To link with the CQUIN target for 2014/15 to increase the number and the quality
of crisis plans to ensure that during treatment in Home Treatment Teams or acute
inpatient wards the crisis plan is accessed and followed.
To improve the quality of our crisis plans by working with the Trust wide Care Plan
Steering Group to audit care plans and crisis plans of service users who have had
a Care Programme Approach (CPA) review in the previous quarter.
To complete quarterly audits of crisis plans and of clinical progress notes/care
plans to determine if there is evidence that the crisis plan was accessed and
followed during treatment spells in Home Treatment Teams or acute inpatient
wards.
Target
By end of Q4:
a) 60% of people on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
b) 45% of people NOT on CPA to have a collaboratively developed crisis plan
uploaded onto RiO
c) Trust to complete quarterly quality audit of crisis plans. Audit report to be
submitted to commissioners
d) 90% of new, collaboratively developed crisis plans to be categorised as
‘adequate’, of which 60% are to be categorised at ‘good’ following the Q4 audit
e) Trust to have completed quarterly audits of crisis plans and of clinical progress
notes / care plans to demonstrate evidence that the crisis plan was accessed
and followed.
f) CAMHS to have looked at how to incorporate the collaboratively developed
crisis plans process into CAMHS and implementation recommendations to
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
84
have been submitted to commissioners
April 2014
starting position
Two Crisis Plans were developed in 2013/14: a full Crisis Plan (Advance
Directive) and a summary Crisis Plan. These were implemented at the end of the
year. By July 2014, 34% of CPA and 15% of non CPA service users had a
collaboratively developed crisis plan. 94% of these were rated as being of
‘adequate’ quality.
Rationale for
this priority
The development of an individually tailored crisis plan for each service user is
essential to enable healthcare providers, working within different services, to be
able to deliver cohesive and appropriate care. For example, should a service user
present in A&E, a member of the psychiatric liaison team would immediately be
able to access and implement the service user’s crisis plan and ensure
personalised, effective care despite having no prior knowledge of the individual.
Wherever possible, it is important that service users and mental health
professionals work together to develop crisis plans in order to ensure that service
users’ views are properly reflected. It also facilitates more autonomy for service
users and improves their collaborative partnership with mental health
professionals.
National Institute for Health and Care Excellence (NICE) guidance (2011) and the
Mental Health Crisis Care Concordat: Improving outcomes for people
experiencing mental health crisis (2014) both outline important quality measures
indicting whether, and to what the degree families and/or carers should be
involved.
In a recent audit of care plans for SWLSTG (March 2014), findings indicated that
some 21% of care plans involved the service users’ social support network to a
‘great extent’, while the majority of care plans were created without any
involvement from the service users support network. Where appropriate, we want
to ensure that friends and family are involved more closely in decisions about the
services provided to those they care about.
Getting better support in a crisis
72% of people on CPA (Care Planning Approach) and 48% of non CPA patients now have a
collaboratively developed crisis plan on RiO. 94% of crisis plans are now being rated as ‘Adequate’ or
above in quality, with 71% of these being rated as ‘Good’ or ‘Excellent’ in quality.
Training for staff on recovery focused care planning and crisis plans was added to the Trust’s Recovery
College Training Programme at the beginning of 2014/15 and, to further progress, we are continuing to
focuse on ensuring that crisis plans are put into effect during a person’s home treatment or stay on an
inpatient ward.
Priority 2: Physical Health – Diabetes, Observation of Vital Signs and Falls
Priority
Improving the physical health of hospital inpatients by monitoring Diabetes,
Observations of Vital Signs and Falls, to better integrate mental health and
physical health care at every level
Target
Diabetes
 Complete quarterly audits of diabetes management plans. These audits will
seek to demonstrate evidence that, by the end of Q4, 40% of service users
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
85
with identified Diabetes have a care plan including a support management plan
including information on lifestyle, diet, nutrition, medication advice and access
to primary care.
Observation of vital signs
 To develop and implement a plan to monitor and electronically record
inpatients’ vital signs using the NEWS format on a daily basis.
 Produce and roll out a ‘Daily Observation of Service Users’ Vital Signs’ training
package for staff and agree an appropriate recording process
 Staff to be monitoring and electronically recording inpatients’ vital signs using
the NEWS format on a daily basis by the end of Q4
Falls
 To update the Falls policy to be in line with NICE guidance
 To develop and roll out a Falls eLearning package
 For Inpatient wards to identify a Falls Champion
 Hold Trust wide learning events on falls to to educate staff about risks,
prevention, common hazards and good practice using incidents subject to
Root Cause Analysis as examples from which to learn
 To audit incident data on falls and submit quarterly reports to commissioners
April 2014
starting position
New projects - Information not previously available in this format
Rationale for
this priority
The document issued by the Department of Health; Closing the Gap: Priorities for
essential change in Mental Health, specifically focuses on integrating physical and
mental health. It is essential that service users who have been admitted to our
wards feel, and are, safe and that they receive a high quality of care to optimise
both their mental and physical health.
Let’s get physical
Physical health learning events took place in October and December 2014 and new physical health
monitoring leaflets were launched in November.
Harm free care and falls
The Trust submits monthly Safety Thermometer data directly from its Electronic Incident Reporting
system and for 2014/15 there was a specific focus on the falls element of this work for the Trust’s Falls
Quality Account indicator.
An audit report produced in Q4 showed significant improvements to the reporting and recording of falls
information across the year, with increased adherence to Trust policy for post falls’ interventions.
Levels of harm remained low throughout the year, and a slight reduction in the number of falls was reported
from Q1-Q4 For further information please refer to the Safety Thermometer section in Appendix 5.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
86
Observations of vital signs & diabetes
The physical health team focused on training staff in core physical health skills and the observation of
vital signs using the National Early Warning Score (NEWS). The team also developed an e-learning
package on how to recognise and monitor signs and symptoms of diabetes.
The Quarter 4 audit revealed that 50% of inpatient service users with identified diabetes now have an up to
date (<3 months) and complete diabetes specific health care plan, with 66% having a specific diabetes
support management plan, and 56% with specific advice on lifestyle, diet, nutrition and medication advice
(target 40%). A further 22% (n=7) had partial or incomplete care plans recorded.
Of the 23 patients who did have a partial or complete diabetes care plan in place, 74% (n=17) included
information around diet and nutrition. 26% (n=6) of audited patients did not have diet and nutrition advice
indicated on the care plan. The data also showed that 83% (n=19) of care plans included advice around
medication, and a further 13% (n=3) had partial medication information available. In only one case was
there no medication advice included in the care plan.
Stacked bar chart to show the number of patients with care plans that included lifestyle advice
around diet and medication (n=23)
0%
Care plan includes diet and
nutrition advice
20% 40% 60% 80% 100%
6
17
No
Partial/incomplete
Yes
Care plan includes medication
advice
1 3
19
An Observation of Vital Signs audit was carried out in Q4 which showed that staff are now using the NEWS
format to monitor inpatients’ vital signs on a daily basis.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
87
Pie chart to show the proportion of clients that had NEWS charts available (N=50)
16%
4%
No
Partial/not up to date
Yes
80%
Over the course of the year, a number of activities took place to support the training of staff to ensure
confidence in undertaking the NEWS:

A Training Needs Analysis (TNA) tool was sent out to all wards in July 2014 to identify the current
levels of training received by all inpatient staff members

A refreshed training package for NEWS was created for internal training sessions

Training sessions were delivered between October and December 2014. This included training in
NEWS as part of wider physical health events for the Quality Account, specific ward based NEWS
training, and three day physical health skills training for qualified (Band 5 and 6) staff, delivered in
conjunction with Kingston University. In total, 80 staff members were registered to attend training
sessions.
Priority 3: GP Interfaces and Education
Priority
Improving interfaces with primary care and providing education for GPs on Mental
Health. To streamline services provided to service users by improving
communication between primary and secondary care.
 Pilot the Kinesis GP system in Wandsworth and review the performance to
produce a proposal for piloting Kinesis GPs in the other 4 Boroughs
 Conduct a GP satisfaction survey to audit GPs’ satisfaction with the liaison
systems
Target
 Pilot the Kinesis GP system in Wandsworth and review the performance to
produce a proposal for piloting Kinesis GPs in the other 4 Boroughs
 Conduct a GP satisfaction survey to audit GPs’ satisfaction with the liaison
systems
 Submit reports in Q4 to commissioners
April 2014
starting position
New projects - Information not previously available
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
88
Rationale for
this priority
To ensure high quality patient care, it is important to improve communication
between primary and secondary care services. To ensure that GPs are provided
with information they need, when they need it, it is essential that communication
between clinicians is more personalised, timely and joined-up.
Kinesis GP is a web based software system that directly links GPs to hospital
specialists for rapid access to expert advice. This system has been in operation in
Wandsworth for over 18 months built around acute Trusts. Kinesis GP allows
hospital specialists, covering a wide range of clinical specialities to provide
education and feedback to GPs. Requests are running at 5-10 per day from 30
active GP practices users with 80% of these requests answered within 24 hours.
Getting better connected with our partners
GP survey
We sent a survey out to all GPs asking them how satisfied they are with Trust services and the quality of
information we provide. The survey was sent out by email to 124 GPs across the Trust’s five boroughs at
the start of November 2014 (Q3) and remained open until the 31 December 2014 for completion.
There were a total of 16 respondents who completed the GP satisfaction survey.
Survey respondents represented the Trust’s five boroughs, however half (n=8, 50%) of the respondents
were located in one borough, Wandsworth. Three respondents were from the borough of Kingston (19%),
with two each from Richmond and Sutton (12.5% respectively). Only one respondent (6%) was from
Merton.
Survey results indicated reasonable levels of satisfaction with the Trust’s services overall, with specifically
high levels of satisfaction around the quality of care and discharge information sent to GPs by the Trust
about patients.
The bar chart below shows that the majority of respondents were satisfied with Trust services for both
patients and GPs, with over 80% in both cases indicating they were fairly satisfied, satisfied or very
satisfied.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
89
Stacked bar chart to show overall satisfaction level of GPs with Trust services (n=15 for
question one; n=14 for question two)
0%
20%
1
5
How satisfied are you with the
services
provided by the Trust for your
patients?
40%
60%
80% 100%
7
2
Very satisfied
Satisfied
Fairly satisfied
How satisfied are you with the
Trust services provided to you as
a GP?
Not satisfied
1
5
6
2
Kinesis
GP practices across Wandsworth piloted Kinesis during 2014/15, accessing specialist mental health
advice from named Trust consultants, in adult community, rehabilitation and home treatment and IAPT
teams, who respond to messages within 24 hours.
The data from the end of year audit shows that responsiveness within 24 hours was high, with 77% (n=62)
of messages being responded to within the 24 hours as expected. 22% (n=18) were responded to outside
of the time frame and there was one “not applicable” response, where the GP closed the message before
the consultant could respond.
Priority 4: Learning Disabilities (LD) – 2 year indicator
Priority
Improving the identification of service users with mental health issues who have a
learning disability (LD) within local mainstream services
To improve trust wide understanding of Mental Health & Learning Disabilities LDs
which in turn will improve the identification of this group and the support offered to
those service users who have a LD
Target
 To initiate a two year action plan to improve the experience of people with
mental health issues and LD and make adjustments to treatments currently
available.
 To revise the membership and the terms of reference of the current Trust
Mainstreaming LD Group to ensure that this important theme has appropriate
leadership within the Trust.
 Wards and teams to identify a LD champion to promote awareness & good
practice locally.
 To produce a protocol on LD, Autism and Asperger’s syndrome increase
awareness and identify service users with Learning disabilities within
mainstream services.
 To develop and roll out an eLearning awareness training package and
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
90
resource materials in conjunction with St George’s Hospital Medical School.
 Ensure that teams have access to key information for service users in an Easy
Read format.
April 2014
starting position
New project - Information not previously available
Rationale for
this priority
The Department of Health policy ‘Protecting Patients from Avoidable Harm’
(March 2013) details that actions should be taken to learn from mistakes made
with particular reference to the Winterbourne View scandal: ‘People with learning
disabilities (LD), autism or mental health problems will get more support in the
community rather than in hospital, where appropriate.’
Mental health services do not always provide good services for people with LD.
Progress against the Monitor standards to facilitate access of people with learning
disabilities into mainstream mental health services has been slow. Staff generally
have limited LD knowledge and awareness. In light of this, the Trust aims to
improve the service that is received by mental health service users with LD in
mainstream services as per ‘Closing the Gap: Priorities for essential change in
Mental Health (Department of Health).
Learning Disabilities are everyone’s business
This year, a new Learning Disabilities (LD) Awareness Protocol and bespoke e-learning package was
launched to support staff in how best to work with our patients that have learning disabilities.
Uptake of the e-learning training shows that 75 Trust staff booked to complete the e-learning package that
was launched in Q3. Of these, 56 had successfully passed the course. The year-end audit showed that
71% of service users with identified learning disabilities had clear management strategies available, with a
further 17% (n=13) having a partial or incomplete strategy available. 100% had evidence of contact with
the Trust’s specialist LD services (target 25%).
Pie chart to show the proportion of audited patients (N=75) with a clear management strategy for
learning disability included in the care record
12%
No
17%
71%
Partial
Yes
The audit also ascertained whether there was evidence of the service user having flexible appointments to
allow for longer consultation, if it was required.
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
91
Pie chart to show the proportion of cases there was evidence of the service user having flexible
appointments to allow for longer consultation (N=75)
5%
No
23%
Partial
Yes
72%
Comparison across quarters shows a significant improvement in the proportion of patients where there is
evidence of flexible appointment times being provided. In Q1, only 34% of audited patients had partial or
total evidence of flexible appointments, whereas in Q4 it was 95%.
Bar chart to show comparison of the proportion of cases with easy read materials and flexible
appointments offered in Q1 compared with Q4 (%)
95
100
80
60
60
Q1
43
34
40
Q4
20
0
Easy read materials
Flexible appointments
Priority 5: Service User, Carer, Friends and Family Experience
Priority
Using feedback systems to improve the experience of service users and carers,
friends and family.
To encourage service users and carers, friends and family (CFF) to comment on
their experience of mental health services in order for the Trust to identify areas
for improvement.
Target
 The CQUIN for Real Time Feedback (RTF) will report quarterly and these
reports will be made available on the Trust website. These reports will include:
- updates on the progress of the implementation of RTF systems across the
Trust’s community teams
- examples of RTF action plans (formed in response to feedback received)
from community teams
- themed feedback (from both RTF and FFT)
- lessons learned
 The CQUIN for FFT will report to commissioners in Q1 and Q4. These reports
will be made available on the Trust website.
 The Quality Account will focus on the promotion of Patient Opinion, the
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
92
implementation of a new Patient Experience Strategy and the integration of all
feedback systems.
Quarterly progress reports will be submitted to
commissioners.
April 2014
starting position
New project - Information not previously available
Rationale for
this priority
Understanding the experience of service users and CFF is crucial in informing the
Trust about areas of good practice and areas for improvement for its services to
meet the needs and expectations of those using them.
This is outlined in ‘Closing the Gap: Priorities for essential change in mental
health (Department of Health (DoH)). By ensuring the voices and views of patients
and CFF are heard we can learn about potential service improvements. Use of
feedback mechanisms can drive change and continuous improvements in the
quality of the care that mental health service users receive.
Options for people to provide feedback in the Trust include Real Time Feedback
(RTF), the Family and Friends Test (FFT) Care Connect and Patient Opinion. RTF
and the FFT are CQUIN indicators for 2014/15 and Care Connect is now in
operation. However, Patient Opinion, which is an important new feedback source
to enable honest and meaningful conversations between service users and staff,
has only recently been implemented and requires further promotion.
Tell us what you really think
Friends and Family Test
The Staff Friends and Family Test (FFT) was implemented in June 2014 and is now carried out
quarterly by Picker. In June, 63% of responders told us they were either extremely likely or likely to
recommend the Trust if they needed care or treatment and 66% indicated that were either extremely
likely or likely to recommend the Trust as a place to work.
The Patient Friends and Family Test (FFT) was integrated into existing Trust Real Time Feedback
systems and launched in December for use by patients at the point of discharge and CPA Review.
Postcards have now also been introduced on some wards to give patients a choice of how to respond
to the nationally driven FFT questions. For additional information, please refer to Appendix 5.
Feedback for improvement / Service user experience
Following the successful introduction of Real Time Feedback (RTF) systems for inpatient wards in
2013/14, the systems were expanded to incorporate community teams at the start of 2014. Feedback
can be given by service users, carers, friends and family members using co-produced surveys
accessed via kiosks, tablets, an on–line tool and paper questionnaires and over 20,800 responses
have been received to date.
This valuable information is being used to drive quality improvements across all services and staff
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
93
continue to develop “You Said, We Did” boards and posters to share and promote service
development action plans based on feedback they have received.
At the end of 2013/14, an Easy Read version of the RTF survey, the first electronic survey of its kind in
mental health, was implemented for CAMHS, Older People and Deaf Services. For additional
information, please refer to Appendix 5.
Patient Opinion
Patient Opinion was added to the Trust’s feedback systems in April 2014. Since then, 34 feedback
posts have been made, 23 of which have been positive.
In the last year, Patient Opinion has been integrated into the work of the Trust’s Patient Experience Team,
who were runners up for the Patient Experience Team of the Year Award at the Patient Experience
Network Awards in Birmingham on the 11 March 2015.
Graph showing postings on Patient Opinion up until 12 March 2015
14
12
10
8
Positive
Negative
6
Total
4
2
0
Q1
Q2
Q3
Q4
“‘Patient Opinion is an important resource for all our services. It
allows us to hear what our service users and carers are really
experiencing when they utilise our services and provides us with with
opportunities for us to truly co-produce our services. ”
Jeremy Coutinho
Manager, Trust Recovery College
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“We provide benefits advice for service users and often receive thanks
and compliments from them. Whilst this is obviously nice to hear, we
believe it is important that there is somewhere they can comment
anonymously and so we promote the use of Patient Opinion. The
quote below is from an anonymous service user”.
“It’s a refreshing change that there is somewhere that I can explain
what has happened to me and I can tell people of the good and not so
good things that happened. It may not change a lot but it allowed me to
get it off my chest and made me feel better”
Dave Coughlan
Team Coordinator, Welfare Benefits Team
“I encourage all my clients to feedback using
Patient Opinion, it’s an ideal platform for my
clients as it’s anonymous and easy to access.
It also enables clients to make informed
decisions about their care and that’s great for
patient choice.”
Nick Chamberlain-Kent, Team Manager
Wandsworth Early Intervention Service
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Appendix 4: Review of CQUIN Goals 2014/15
CQUIN
Indicator
Implement staff FFT to all Trust departments, teams and wards
Year-end
performance
Successfully
completed

Staff and Service
user Friends and
Family Test (FFT)
The goal of the Friends
and Family Test is to
improve the experience
of service users in line
with Domain 4 of the
NHS Outcomes
Framework.
One off report to commissioners by 31 July 2014 on responses
and necessary actions plans
Implementation of Patient FFT
Successfully
completed

Successfully
completed

Produce a year-end report including:
 Examples of action plans, based on feedback received in
response to FFT follow-up question, to improve service
user experience of services
 List of feedback themes
 Lessons learned (implementation and stakeholder
engagement).
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
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Staff and Service user Friends and Family Test (FFT)– specific achievements in 2014/15
Responses to Patient FFT question – January
Responses to Patient FFT question – February
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Responses to Patient FFT question – 1 March to 11 March
Feedback themes (free text comments to FFT follow up question)
The feedback received to date can be categorised into the following themes
Food
Television
/
activites
Environment
Feedback
Themes
Visitors
Leave
Contact
with
medical
staff
Lessons learned - implementation and stakeholder engagement
1.1. This section highlights what has gone well and not so well during the Patient FFT implementation so
far.
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The postcards given to some of the wards when their RTF devices were broken proved to be
popular with both staff and patients
Further planned improvements
Updated postcard designs are being explored as part of a plan to implement them across all the
inpatient wards and community teams
Feedback from one of the wards on an improvement which can be made to the current
postcard design to make it clearer to service users how to complete them has been
incorporated into the proposed new designs
One of the inpatient wards has engaged particularly well with the Patient FFT process
Further planned improvements
The ward manager of this ward will be invited by the clinical lead to become a FFT champion
and become involved with staff engagement on the other wards
Excellent action plans have been produced and followed through by one of the ward managers
Further planned improvements
A template and usage guidelines based on this ward’s work will produced and highlighted and
shared with other staff as an exemplar of good practice to be replicated
‘You Said, We Did’ posters will be produced for this ward so the feedback and action plans can
be publicised to service users
Now that the number of FFT responses is starting to increase, automated user-friendly reports
have been set up on the Trust’s My Dashboards system. This will enable ward and team
managers to share feedback received and improvement plans with both staff and service users
and should improve engagement with the FFT survey
Further planned improvements
The automated reports will be publicised across all Trust wards and community teams along
with usage guidelines for staff and examples of how the information can be used to engage
service users
The uptake of Patient FFT by service users continues to be slow
Improvement plan
Continue to promote the FFT with posters, flyers and one to one encouragement by discharging
clinicians for people to complete the survey
The FFT clinical lead and Trust CQUIN Lead are liaising with another hospital Trust to benefit
from their implementation lessons learned. A meeting is also being set up to look at the system
which they are using to see if it would be a suitable addition to the Trust’s existing suite of tools
Safety Thermometer
This indicator is to be
based on the National
Collect and submit monthly Safety Thermometer screening data
for falls, pressure ulcers and Urinary Tract Infections (UTI) (for
those with catheters) for older people’s inpatient wards
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NHS Safety
Thermometer.
To monitor falls,
pressure ulcers,
Venous Thrombosis
(VTE) and urinary tract
infections (for those
with indwelling
catheters) for older
people who are on an
Inpatient ward under
the care of the Trust
and to put in place
improvement
programmes to
respond to any harms
or hazards identified.
Put in place improvement programmes to respond to any harms
or hazards identified
Collect and submit data by completing monthly Safety
Thermometer screening on Older Peoples Inpatient wards under
the care of the Trust
Audit incident data on falls and submit quarterly audit reports to
commissioners. Reports to include recommendations on how
to:
 reduce harm caused by falls
 reduce the number of falls occurring
 (Q3) confirmation that NICE guidance has been
implemented or submission of an action plan in respect of
this with timetable
 (Q3) Confirmation that NPSA Rapid Response guidance
has been implemented or submission of an action plan in
respect of this with timetable
Submission of year-end report exploring if the Safety
Thermometer and falls audit work has had an effect on identified
harms or hazards.
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Successfully
completed

Successfully
completed

Successfully
completed

Successfully
completed

100
Safety Thermometer– specific achievements in 2014/15
The findings of the report show a number of improvements in terms of the reporting and quality of recording
of information regarding falls on older adults wards. A number of strategies have been implemented during
2014/15 which may have contributed to the reported improvements:
 NICE guidance and NPSA Rapid Response guidance have been integrated into the Trust’s policy and
clinical practice, and Post Falls’ Best Practice Guidance has been issued following development by the
Falls Working Group.
 Falls champions were invited to learning events during Q3, which highlighted accountability for managing
physical health amongst Trust patients and supported staff to be clear around their responsibilities with
regards to the management and recording of falls.
 In each quarter, the Safety Thermometer joint clinical leads have compiled a list of all incomplete Falls
Care Plans and service users for whom no Falls Care Plan has been completed. These have been
submitted to each ward manager for immediate action.
With regards Falls Assessment Risk Screens, the picture has improved significantly on Azaleas ward, with
100% of all reported falls now having Risk Screens available. By contrast, data from Crocus ward has
shown a reduction across quarters 2-4, however overall the proportion of falls with risk screens across both
wards has improved from 68% in Q2 to 81.5% in Q4.
Bar chart to show the comparison of the proportion (%) of cases where risk screens were fully or
partially completed (Q2-Q4)
100
88
100
80
80
60
67
56
63
Q2
%
Q3
40
Q4
20
0
Azaleas
Crocus
Comparison of the proportion (%) of cases where care plans were fully or partially completed (Q2Q4)
100
84
90
80
83
71
70
60
%
53
50
40
40
Q2
Q3
33
Q4
30
20
10
0
Azaleas
Crocus
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Comparison of the proportion (%) of cases where Trust policy was partially or fully followed (Q2-Q4)
120
100
89
92
86
76
80
%
96
67
Q2
60
Q3
Q4
40
20
0
Azaleas
Crocus
Similarly, with respect to Falls Care Plans, the findings show a general improvement in the number that are
being completed, with an average of 36.5% of falls having care plans in Q2 compared with 77% in Q4.
Finally, the data shows that in an increased number of cases, staff are shown to be following Trust policy
either partially or completely. In Q2, in an average of 78% cases Trust policy was followed, rising to 91% in
Q4.
With regards the other areas of the Safety Thermometer CQUIN, the data shows limited examples of where
there have been pressure ulcers reported, but the data suggests that action plans and interventions were
used where appropriate. A range of strategies support continued improvements to practice, including the
provision of training and procurement of suitable equipment for patient use.
With regards, catheter care, UTIs and VTEs, there have been no reported incidents over the reporting
period, which may reflect a genuine lack of incidents or may relate to required improvements in monitoring
of these conditions on older adult’s wards.
The findings of the auditing process will be shared, to ensure staff are aware of the improvements that have
been made and the continued improvements that are required.
Regular spot audits on RiO notes will continue to be carried out by the ward managers and modern matrons
for the two older people wards, as well as the Physical Health care manager, to ensure that Falls
Assessments are being carried out correctly.
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Indicator 1
Demonstrate, through the National Data Collection Exercise, full
implementation of appropriate processes for assessing,
documenting and acting on cardio metabolic risk factors in
patients with psychoses, including schizophrenia.
Improving diagnosis
in mental health
(Physical Health)
To support NHS
England’s commitment
to reduce the 15 to 20
year premature
mortality in people with
psychosis and improve
their safety through
improved assessment,
treatment and
communication
between clinicians.
For 2014/15 this
CQUIN focuses on all
patients with
psychoses, including
schizophrenia, in all
types of inpatient beds,
intensive community
teams in all sectors i.e.
early intervention
teams, assertive
outreach and
community forensic
teams. However,
providers are
encouraged to extend
the processes
developed to meet this
CQUIN for the benefit
of all patients.
The results recorded in the patient's notes/care plan/discharge
documentation as appropriate, together with a record of
associated interventions according to NICE guidelines or
onward referral to another clinician for assessment, diagnosis,
and treatment e.g. smoking cessation programme, lifestyle
advice and medication review.
Successfully
completed
Collect audit data. The following cardio metabolic parameters
(as per the 'Lester tool' and the cardiovascular outcome
framework) are assessed:
 Smoking status
 Lifestyle (including exercise, diet, alcohol and drugs)
 Body Mass Index
 Blood pressure
 Glucose regulation (HbA1c or fasting glucose or random
glucose as appropriate)
 Blood lipids

The audit sample must cover all relevant services provided by the
provider
Indicator 2
Completion of a programme of local audit of communication with
patients’ GPs, focusing on patients on the CPA.
Audit CPA Review Letters, Discharge Summaries and other
correspondence with GPs to ensure that the holistic CPA
components have been communicated.
The Q2 and Q4 local audits must cover a sample of patients in
contact with specified services for more than 100 days and who
are on the CPA.
Demonstrate that for 70% (Q2) and 90% (Q4) of patients, an upto-date summary of care (communicated via CPA Review
Letters, Discharge Summaries and other correspondence) has
been shared with the GP. This should include the holistic
components set out in the CPA guidance:
- ICD codes for primary and secondary mental and
physical health diagnoses.
- Medications prescribed and monitoring and adherence
support plans.
- Physical health condition(s) and ongoing monitoring and
treatment needs.
- Recovery interventions including lifestyle, social,
employment and accommodation plans where necessary
for physical health improvement.
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completed

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Physical Health – specific achievements in 2014/15
Trust Physical Health Learning Events have been taking place for staff throughout the year at Springfield
and Tolworth Hospitals covering Physical Health monitoring, specifically the observation, measuring and
recording of vital signs, diabetes and falls. These events have been well attended and new physical health
monitoring leaflets were launched in November.
Laurel Ward also held a ward Physical Health
event in November covering a variety of aspects
of physical health care, awareness and selfmanagement.
“Attending a physical health workshop organised by Chris
O’Connor motivated me to organise this event on Laurel
Ward; the management supported me and all staff
endeavoured to provide a good input that reflected their
particular area of expertise.”
Bucci, Occupational Therapist, Laurel Ward
“I learnt about body max index, balanced diet and
keeping my room cool, dark and quiet for a good
night’s rest. The staff were professional and the
atmosphere was nice.”
Service user, Laurel Ward
There is now greater awareness from inpatient staff about the importance of supporting physical health in
patients with psychosis and improvements in monitoring is being demonstrated through regular review of
documentation (NEWS charts and Rio records) by the physical health leads.
Weekly ‘on ward’ exercise therapy and pharmacy session/clinics has greatly facilitated service users and
staff in accessing physical health information and support.
Information about physical health and healthy living is available through the Trust website and a focus on
healthy living is evident through the group programmes on inpatient units.
Since work began as part of the Physical Health CQUINs in 2013/14, improvements have been made in
physical health monitoring and recording, in particular, the completion of physical health assessments within
24 hours of admission to an inpatient ward. The majority of wards now achieve 100% for both this and
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repeat assessments every six months for long stay patients
Cardio Metabolic Assessments
The Trust took part in a national data collection exercise facilitated by the Royal College of
Psychiatrists. The December 2014 audit focused on all inpatients with psychoses, including
Schizophrenia, to demonstrate that cardio metabolic parameters such as body mass index, blood
pressure, glucose and smoking cessation are recorded on RiO.
With regards to assessment and documentation of cardio metabolic risk factors, the analysis shows
generally good performance. The number of patients for whom assessment was carried out and
documented was especially high for smoking (97%), weight (92%), BP (97%), alcohol (95%) and
substance misuse (94%). Results were lower, however, for lipids (66%) and glucose (64%). Please
see examples below.
The Trust Physical Health and CQUIN teams have developed a number of training packages and guidelines
on assessment and documentation of cardio metabolic risk factors and the implementation of these has led
to significant improvements in performance and quality of care provided. To maintain continuous
improvement, guidelines and pathways should continue to be developed and reviewed by these teams.
1%
Smoking status
2%
Current smoker
39%
58%
Ex smoker/non
smoker
Refusal to
provide info
Not documented
Blood pressure (BP)
3%
BP documented
97%
Refusal to provide
information
The smoking status was recorded for 97% of all the
service users. 58% (n=58) were smokers and 39%
were not.
Of the 58 identified smokers in the sample, 23
received one or more smoking intervention.
24 smokers refused any intervention meaning that
81% were offered an intervention for their smoking
Out of the 100 people in the sample, all had their
blood pressure (BP) recorded except three who
had refused on more than one occasion to have
their BP taken.
77 people were considered by their clinician to not
require any interventions for hypertension. Of the
remainder, 20 people received one or more
intervention, two refused any interventions and
information about interventions was not
documented for one person. Therefore, 96% of
those requiring treatment for BP issues were
definitely offered interventions to combat
hypertension.
95% of people in the sample had information on
their alcohol intake recorded on RiO.
Of the 29 people recorded as alcohol drinkers, the
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alcohol usage of ten units was considered by
clinicians to be harmful or hazardous (Figure 5).
Five of these people received one or more
interventions, three refused and information was
not documented for two people. Five other people,
even though their alcohol usage was not
considered to be harmful, received interventions.
Drinking alcohol when admitted to
hospital (or within last 12 months)
5%
Yes
29%
No
66%
Not documented
Weight
2%
6%
Weight documented
Not documented
92%
Refusal to provide
information
Of the 100 people in the sample, 50 were recorded
as having no intervention needed to combat weight
gain/obesity. Of the 50 people needing
interventions, two refused and information was not
documented for eleven.
78% of those who needed them were offered
interventions and 37 people received one or more
interventions.
Summaries of Care
This national indicator required local audits of communication with patients’ GPs. These audits looked
at CPA review letters and other correspondence to evidence that information on ICD10 codes,
medications prescribed, physical health conditions and recovery interventions is shared with primary
care.
% of questions fully completed overall for Quarter 4
% of Questions answered - All services
Yes
Q1 - ICD10 Codes for primary and secondary MH
diagnoses
No
N/A
98%
2%
Q2 - ICD10 Codes for primary and secondary PH
diagnoses
92%
7%1%
Q3 - Medications prescribed and monitoring and
adherence support plans
92%
6%2%
Q4 - PH condition(s) and ongoing monitoring and
treatment needs
84%
14% 2%
Q5 - Recovery interventions where appropriate for
PH improvement
84%
16%
The Trust achieved 84% or above (‘Yes’ plus ‘N/A’ scores) for each of the elements of the indicator, scoring
an average of 91% across all the audit questions and thus achieving the required 90% target.
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106
Feedback for
improvement –
Community
Trust to submit RTF systems community implementation plan to
commissioners as part of the Q1 report. This should include
dates of:
 Technical system implementation
 Staff and service user training on how to use the RTF
systems
 Go live dates for each community area included in the
implementation
 Process for review and improvement
 Lessons learned and improvements made to date by any
community teams / services already using RTF systems.
Use (RTF) systems to
improve overall service Submit a progress report on use of RTF systems in Home
user and carer, friends Treatment Teams (following implementation in Q2 2013/14).
and
family
(CFF) Report to include a list of themed feedback received to date.
experience of Trust
community services.
Submit quarterly progress updates on implementation. These
should include action plan for any community team / service that
has successfully completed their implementation of the RTF
systems. Action plans should include:
 List of themed feedback from service users and CFF
 Planned actions to address any issues or reasonable
requests
 Target dates and named responsible person for
completion of each action
 Lessons learned
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Successfully
completed

Successfully
completed

Successfully
completed

107
Feedback for Improvement - Community – specific achievements in 2014/15
Following the successful introduction of Real Time Feedback (RTF) systems for inpatient wards in
2013/14, the systems were expanded to incorporate community teams at the start of 2014. Feedback
can be given by service users, carers, friends and family members using co-produced surveys
accessed via kiosks, tablets, an on–line tool and paper questionnaires and over 20,800 responses
have now been received to date.
This valuable information is being used to drive quality improvements across all services and staff
continue to develop “You Said, We Did” boards and posters to share and promote service development
action plans based on feedback they have received.
At the end of 2013/14, an Easy Read version of the RTF survey, the first electronic survey of its kind in
mental health, was implemented for CAMHS, Older People and Deaf Services.
“On 15 Steps visits to in-patient units, service users tell us one of
the most important ways they have of commenting on the quality of
care is through RTF, they like the freedom to do it when they want
and the immediacy of the response by Ward Managers.”
Modern Matron, Governance Team
“We all benefit from getting things fed
back”
“It’s great to have the facility of giving
feedback”
Seacole Ward, service user feedback on RTF
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108
To support Trust LD and deaf
service users to give feedback
a video has been added to
RTF devices.
Ward and team managers also
now receive automated weekly
email alerts direct from the
RTF system advising them:
 If they have not received
any feedback via their RTF
device for seven days
 If they have comments
waiting to be acknowledged
or actioned
During Quarter 4, there have been a total of 612 responses across Trust services, of which 146 were
received from community teams. Of the 146 responses received, 40.41% fell into the patient opinion
category, 28.08% were compliments, 1.37% were opinions from parents or carers, 7.53% were concerns
and 22.60% were non applicable (i.e. comments that were not actionable).
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Submit Q1 and Q3 reports to clinical and classical
commissioners on cluster assessment within the Trust. Reports
should:
 Set out details of the Four Factor model and its use
 Reviews the effectiveness of the Trust’s care packages for a
quarter for each cluster to demonstrate:
Four Factor Model /
Cluster Assessment
Mental Health is the
only health or social
care speciality that
currently has no
outcome measures.
ii) The % of service users where changes in their total Health
of the Nation Outcome Scales (HoNOS) score met the
criteria for reliable, clinically significant change (reliable
improvement and deterioration) following a cluster episode
ii) The % of service users where changes occurred but they
did not meet the criteria for reliable change (improvement
and deterioration) following a cluster episode
ii) The % of service users where there was no change at all
in their total HoNOS scores following a cluster episode.
Successfully
completed

*The Four Factor Model is a clinician rated outcome measure
(CROM) which can be used across all the payment by results
clusters for working age and older adult mental health service.
Q2 - Trust to host a cluster assessment (HoNOS) event for staff
and commissioners to feedback the initial findings of the cluster
assessment outcomes.
Successfully
completed

Q4 - Submit final report to commissioners including:
 Implications for commissioners
 Variance (between teams) and its causes
 Aspects of outcomes that are more able to be affected by
changes in practice
 Next steps
Successfully
completed

Four Factor Model / Cluster Assessment – specific achievements in 2014/15
The majority of changes shown in the Q4 report demonstrated lower scores for each domain following
completion of care episode, with the exception of twenty eight instances (35%), two of which occur in the
cognitive impairment clusters (18-21). In none of these instances are the increased post treatment scores
statistically significantly different to pre-treatment scores i.e. none of the average cluster scores represent
deterioration.
Fifty two (65%) instances have change scores indicating improvement. Twenty six (33%) of those had a
statistically significant improvement Across the clusters, emotional well-being is the factor with the highest
number (eight) of significant improvements, followed by personal well-being (seven), social wellbeing (six)
and finally severe disturbance (five).
Clusters 5, 7, 14, 20 and 21 showed significant improvement across three factors. These clusters include
service users with high levels of symptoms and disability.
For the cognitive impairment clusters (18-21), there was no significant deterioration in any of the measures
and some indications of improvement in some of these clusters in social wellbeing, emotional wellbeing and
‘severe disturbance’. This suggests significant gains following treatment for people with organic conditions
Overall, the results across all boroughs suggest that, for discharged service users, twelve of the clusters (5,
7, 8, 10, 12, 13, 14, 15, 18, 19, 20 and 21) show statistically significant positive effect sizes in one or more
of the four domains reported, with emotional wellbeing showing significant improvement most often.
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110
Indicator 1
Continuation of quarterly quality audits as per 2013/14 but also
having a target for the number / proportion of collaboratively
developed crisis plans for each quarter - rising baseline i.e.
significantly increase the number without compromising quality.
Training for staff to continue throughout the year.
Crisis Plans
1. 30% (Q1), 40% (Q2), 50% (Q3), 60% (Q4) of people on CPA
to have a collaboratively developed crisis plans uploaded
onto RiO
2. 15% (Q1), 25% (Q2), 40% (Q3), 45% (Q4) of people NOT on
CPA to have a collaboratively developed crisis plans
uploaded onto RiO
3. Trust to complete quarterly quality audit of crisis plans. Audit
report to be submitted to commissioners
4. 60% (Q1), 70% (Q2), 80% (Q3), 90% (Q4) of new,
collaboratively developed crisis plans to be categorised as
‘Adequate’ or above following Q1 audit
Successfully
completed

Crisis planning was
identified as an area of
weakness in the 2012
community
service
Indicator 2
user survey.
Audits to be undertaken on a quarterly basis of clinical progress
notes / care plans to demonstrate evidence that the crisis plan
was accessed and followed with any reasons for not following
certain aspects of a person's crisis plan during treatment spells
in HTT or inpatient wards.
There could also be feedback systems developed for service
users (e.g. RTF) at discharge from HTT / inpatient wards to
assess satisfaction levels with how their crisis plan was followed
or not.
Trust to complete quarterly audits of crisis plans of clinical
progress notes / care plans to demonstrate evidence that the
crisis plan was accessed and followed. Audit reports to be
submitted to commissioners and should include any reasons for
not following certain aspects of a person's crisis plan during
treatment spells in HTT or inpatient wards.
Indicator 3 (one-off report submission)
(Q3) CAMHS to look at how to incorporate the collaboratively
developed crisis plans process into CAMHS. Implementation
recommendations to be submitted to commissioners.
Successfully
completed

Successfully
completed

Crisis Plans – specific achievements in 2014/15
In Q4, the Trust needed to ensure that 50% of people on CPA and 40% of people NOT on CPA to have a
collaboratively developed crisis plans uploaded onto RiO. 90% of collaboratively developed crisis plans to
be categorised as ‘Adequate’ or above in quality. 60% of these to be categorised as ‘Good’. At the end of
Q4, 72% of people on CPA and 48% of people not on CPA had a Collaborative Crisis Plan uploaded onto
RiO. 71% of completed Collaborative Crisis Plans were rated as ‘Good’ or above.
The Q4 audit found that the quality of completed Collaborative Crisis Plans was good:
 n=11 (6%) were rated as poor
 n=42 (23%) as adequate
 n=64 (36%) as good
 n=62 (35%) as excellent in quality
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Trust to improve communication of community discharge
summary information between primary and secondary care.
This work will ensure that GPs receive appropriate information
and the process of discharge summary production is made more
efficient for clinicians.
Safe, Managed
Discharges
Adequate and timely
communication will
ensure safe, managed
discharges from
community services. It
will support high quality
care and patients’
safety in both
secondary and primary
care settings.
(Q1) - Produce a quality standard for community discharge
summaries. This template should include a section for
completion when people disengage with services. This should
be achieved by co-producing with GPs, service users, carers
and Trust staff and taking into consideration recommendations
made in the 2013/14 Q3 Community Discharge Summary Audit
Report
Produce and implement a pre-populated discharge summary
template in RiO for use by staff
(Q2, Q3 and Q4) - Audit the quality standard discharge summary
template produced in Q1 and report results to commissioners
including any lessons learned.
Successfully
completed

Successfully
completed

Successfully
completed

Safe, Managed Discharges – specific achievements in 2014/15
Following the great improvements to inpatient discharge summaries last year, new community and
Home Treatment Team discharge letter templates and guidelines have been co-produced with input
from patients, carers, GPs, community consultants and commissioners.
Quarterly audit results have showed an enhancement over the year in the quality of discharge
information being sent to GPs and patients.
The areas which showed the greatest improvement from Q3 to Q4 were ‘reason for discharge’ (shown
below) and the contact details/demographics box being fully completed. This rose from 65% to 82% for
community teams and to 100% for Home Treatment Teams.
Pie charts showing the increase in performance for question 9 from Quarter 3 to Quarter 4
Quarter 3
Quarter 4
Q9 - Reason for discharge stated?
Q9 - Reason for discharge stated?
0%
0%
8%
17%
Yes
Yes
No
No
N/A
83%
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
N/A
92%
112
Appendix 5: Participated audits 2013/14
National Clinical Audits
Coordinating Body
Number
of
Cases Number of Registered
Submitted
Cases Required
National Clinical Audits participated in and for which data collection was completed during period 2014/15:
National Audit of
Royal College of
1543 (Sutton and Merton
N/A
Psychological Therapies
Psychiatrists
Improving Access to
Psychological Therapies
(IAPT))
1182 (Wandsworth IAPT)
National Audit of
Royal College of
92
85/100
Schizophrenia
Psychiatrists
Promoting Public Health in
Health and Work
N/A
N/A
Development
Unit
the Workplace
POMH-UK Topic 10c Royal College of
73
N/A
Prescribing antipsychotics
Psychiatrists
for children and
adolescents
POMH-UK Topic 4b –
Royal College of
258
N/A
Prescribing anti-dementia
Psychiatrists
drugs
POMH-UK Topic 14a
Royal College of
22
N/A
Prescribing for substance
Psychiatrists
misuse: alcohol
detoxification.
National Clinical Audits reviewed during 2013/14:
Promoting Public Health in
Health and Work
N/A
N/A
Development
Unit
the Workplace
National Audit of
Royal College of
1543 (Sutton and Merton
N/A
Psychological Therapies
Psychiatrists
IAPT)
1182 (Wandsworth IAPT)
National Confidential Inquiries:
National Confidential
University of
Last available response rate received March 2014
Inquiry into Suicide and
Manchester – The
was 95%
Homicide by People with
Centre for Suicide
Mental Illness
Prevention
South West London and St George’s Mental Health NHS Trust: Quality Account 2014/15
113