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PAPER
BOD 144/2014
(Agenda Item: 9)
Report to the Meeting of the
Oxford Health NHS Foundation Trust
Board of Directors
26th November 2014
Quality Account 2014/15 Quarter 2 Report on Progress
For: Approval
Executive Summary
This report outlines progress in the second quarter on the eight quality priorities
agreed for 2014/15. Traditionally the Q2 report is made available to external
stakeholders and therefore includes some background to the selection of the
quality priorities. A glossary will be available before it is circulated externally and
the report will be fully formatted.
There remain some gaps in the required data while new systems for collecting
and monitoring data are finalised; however, all indicators have now been
discussed with the relevant directorate(s) and progress will be reported in
subsequent reports.
The ambition behind the objective to develop a quality dashboard is that this data
will be automated via the CUBE and will enable year on year comparison against
key quality indicators at a Trust, directorate and service level – aligning with the
bigger piece of work to establish a register and related indicators for all services
which is being led by the Finance Director.
The Ulysses (Safeguard) incident data is still being reported against the old
divisional structures while the mapping to the new structures continues.
Significant progress has now been made and the adult directorate mapping is
complete.
The analysis of whether our services are safe, effective, caring, responsive and
well led is drawn in part from the quality account data and also from other reports
and activities. The intention is to incorporate data from peer reviews across the
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organisation in the final report. This is the first report to assess our practice and
progress in this way and the Board is invited to suggest ways to improve this
narrative and to identify any gaps in information.
Recommendation
The Committee is asked to note and approve the Quality Account Quarter 2
report for external circulation.
Author and Title:
Tehmeena Ajmal, Head of Quality and Risk
Cameron Geekie, Quality and Risk Information Coordinator
Lead Executive Director: Ros Alstead, Director of Nursing and Clinical Standards
A risk assessment has been undertaken around the legal issues that this paper
presents and there are no issues that need to be referred to the Trust Solicitors.
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Quality Account
2014/15
Quarter 2 Report
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www.oxfordhealth.nhs.uk
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1.
Summary of report
The Quality Account Quarter 2 report is an opportunity to reflect on why we have
selected our eight quality priorities, to outline our progress against each, and to
use this and other information to help us assess the quality of our services using
the five CQC questions.
Our quality account reflects the learning from the national safety enquiries led by
Robert Francis and Sir Bruce Keogh and also allows us to continue working on
areas we have identified are key priorities or where we have not made as much
progress as we would have liked in previous years.
After six months we are making progress in reducing harm to patients in five
main areas; we have implemented a wide ranging remodelling programme; we
are working with patients and carers to develop new outcome measures; and we
are developing standard operating procedures to improve the consistency and
quality of our data. The organisation is proactively using the new CQC standards
to assess and improve service quality and to engage staff in our quality agenda.
Further work is required to involve patients and carers in our care pathways, and
to seek out and respond to patient feedback. We also want to create more
opportunities for staff to tell us about their experience of delivering care and to
work with them to make improvements in the care we deliver to our patients.
2.
Summary of progress against our eight quality priorities
Quality Priority 1: Workforce
The Aston teamwork model is being rolled out to team leaders across the
organisation. We have already exceeded the target for number of leaders
trained. Approximately 85% of those trained felt they were now equipped to lead
improvements in team effectiveness which is below the target of 100%. The
innovation team has also worked with individual teams on developing team
objectives, clarifying team roles, and developing inter-term relationships.
The percentage of staff having an appraisal has risen from 56 to 79% but is still
below the target of 100%. There has been an increase in attendance at courses
for leadership, team and individual skills development compared with the same
period last year.
The Trust continues to monitor staffing levels on inpatient wards. All but eight
wards have challenges meeting staffing levels due to staff vacancies and
sickness but were able to work with sessional and agency staff to ensure at safe
staffing levels on individual shifts.
There was an increase from 6-12% of staff responding to the friends and family
test. They commented positively on how well the Trust listens to feedback, on the
level of training available and their pride in working for OHFT. However, they also
felt under pressure due to staffing pressures and the planned remodelling of
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services. They did not always feel their contribution was recognised and there is
a perception that Oxon based staff have greater access to development
opportunities.
Quality Priority 2: Data quality
The quality dashboard measures/indicators have now been drafted. The next
stage of the project is to test and consult with staff and to review data sources
and data quality.
The work to improve data quality is being coordinated by the Data Quality
Review Group and has established a matrix to monitor and track data
completeness and accuracy.
Quality Priority 3: Service remodelling
There were a number of activities linked to this priority. The service remodelling
has been implemented in adult mental health services and teams are now taking
part in a review to evaluate quality and effectiveness. Leadership teams are
established and extended hours of working has been implemented in adult
mental health services.
Changes are in the process of being introduced in older people’s services,
including the development of locality-based teams to provide multi-disciplinary
care for patients with physical and mental health needs and to create enhanced
working relationships between disciplines. This will include extending hours of
availability and bringing together nursing, geriatric, psychiatric and psychological
care. The co-location of the City community hospital ward and the Fulbrook
Centre is planned for the end of November 2014.
The percentage of patients in settled accommodation and in employment has
remained about the same since Q1. There has been an increase of 2% for
patients involved in setting and achieving goals, but there is still some progress
to be made to achieve the target of 100%.
We do not yet have a complete data set relating to physical health and multidisciplinary assessments and further work is ongoing with the directorate for
older people’s services to make these available for future reports. However, all
patients should now routinely be receiving an MDT assessment including medical
input either from geriatricians or from general practitioners.
Patient forums are now in place in adult mental health services and patient
outcome measures have been developed and are now being used in community
services.
In children and young people’s services the targets relating to increasing health
visitor numbers have been achieved, and they have received extensive training
to support their breast feeding initiatives.
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Satisfaction rates as assessed through the Friends and Family test have
remained approximately the same for urgent care, but has dropped slightly for
community hospitals. This is due in part to an increase in likely to recommend
responses which are excluded from the net promoter calculation.
Quality Priority 4: Staff engagement with the quality agenda
Corporate and directorate governance and quality structures are being reviewed
to align with the new CQC questions and to provide greater assurance of our
progress on quality. Values based recruitment project is at the stage of analysing
160 questionnaires to inform the next stage of the project to develop and trial a
behavioural framework.
Staff are being invited to attend surgeries with Executive directors to share ideas
and concerns as well as being offered opportunities to discuss changes within
their own directorates with their senior managers.
A new risk management approach is being rolled out across the Trust and is
being positively welcomed as an opportunity to strengthen risk management, to
enable better escalation and mitigation of risks, and to involve staff more closely
in identifying and controlling risks. This is linking to the development of the Board
Assurance Framework and Trust Risk Register.
A new whistleblowing policy is being launched in the Trust and concerns will be
fully investigated and monitored by the Executive team. Work is underway in
directorates to create opportunities to gather staff and patient stories of their
experience of the care we provide, including patients using the district nursing
service and a member of staff on an acute mental health ward.
Quality Priority 5: Reducing harm from suicide; pressure ulcers; absence
without leave; violence and aggression and falls
Overall the number of reported incidents dropped in Q2; however, there is a
continuing reduction in the number of serious incidents, and in particular the
number of patients who have died by probable suicide.
Infection control rates remain within set parameters and audits demonstrate good
compliance with infection control guidelines amongst staff.
Staff are continuing to be involved in a range of productives, safer care and
general improvement projects and themes include reduction of harm from falls,
reduction in absence without leave and reduction in harm from pressure damage.
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Prevention of suicide
The suicide awareness project has trained a further four teams and is working
with a range of teams to embed Joiners Interpersonal Theory of Suicide 1 in
everyday practice. There have been no probable suicides in inpatient services
this quarter and two in community mental health services.
Reduction in absences without leave
The number of incidents has reduced by approximately 45% and there was no
harm reported as a result of absence without leave.
Prevention of pressure damage
The number of patients developing avoidable pressure ulcers in our care has
dropped in Q2 which is likely to reflect the work underway to increase staff
competence and training, improved care planning and documentation and closer
working with partner providers to develop more consistent approached to
management of patients at risk of harm from pressure damage. The Braden
assessment tool2 is replacing3 the Walsall tool as part of the Skintelligence work
stream currently being implemented in the Trust. Data on skin integrity
assessments and nutritional status assessments were not available this quarter.
Reduction in harm from falls
The number of falls by 1000 bed days has reduced this quarter as has the
incidence of harm from falls. A number of initiatives are being trialled in wards,
including an increase in falls assessments and more consistent referrals to the
falls teams. This is very well established in community hospitals and currently
being extended to older adult mental health wards. Data was not available this
quarter on patients having a falls risk assessment after 28 days, or a review of
patients’ care plans after a fall.
The Interpersonal Theory of Suicide (Joiner 2005). This theory focuses on how feelings of
burdensomeness and lack of belonging can create a sense of hopelessness and suicidal desire.
This model looks at recognising the point or trigger(s) where desire becomes intent and capability
in order to help staff differentiate between patients who think about suicide (ideation) and those
who are likely to attempt suicide.
1
The Joiner framework is intended to underpin and support existing suicide awareness models,
tools and clinical judgement and has been shared through learning events. It is part of the clinical
risk assessment and management training programme.
2 The primary aim of this tool is to identify patients who are at risk of developing a pressure ulcer
and to determine the degree of risk. The Braden Scale is made up of six subscales, which measure
elements of risk that contribute to either higher intensity and duration of pressure, or lower tissue
tolerance for pressure. These are: sensory perception, moisture, activity, mobility, friction, and
shear. Each item is scored between 1 and 4, with each score accompanied by a descriptor. The
lower the score, the greater the risk.
It is being adopted because it is considered to offer better inter-rater reliability and to enable
OHFT risk assessments to be consistent with Oxford university Hospitals NHS Trust which
currently uses the Braden tool.
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Reduction in violence and aggression
This priority relates to a reduction in the use of restrictive practice, in particular
the use of prone restraint and hyper flexion. The number of prone restraints has
remained steady this quarter, in part due to a small number of patients
presenting with challenging behaviour, high levels of violence and aggression
and a high risk of self-harm.
The new prevention and management of violence and aggression programme
has been drafted and once approved will launch a two year programme to deliver
a new training programme and changes in practice.
Quality Priority 6: Patient experience
Work is progressing to improve information available on the website relating to
patient feedback and actions we have taken to respond to this. All teams are now
collecting patient experience data and local leads are reporting on themes and
actions. The friends and family test is being rolled out across all services.
Quality Priority 7: Developing outcome measures
Discussions have been held with each directorate to identify appropriate services
and pathways to monitor the development of outcome measures. These will
include development of outcome measures in adult and older people’s mental
health services; implementation of co-created outcomes with patients in
community hospital services; development of outcome measures with young
people in speech and language therapy services in Buckinghamshire.
Quality Priority 8: Using the new CQC regulatory framework
A taskforce now meets fortnightly to ensure that all teams understand the new
regulatory framework and are able to apply it to their service. We have visited or
had presentations from Trusts which have already undergone an inspection
using the new framework and this has assisted us in developing our approach.
Peer reviews are now underway in all services and is providing an opportunity to
review a range of data, identify good practice and areas of risk and embed a
shared understanding of quality across the organisation.
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3.
Quality Account 2014/15 Quarter 2 report
OHFT has chosen to use the new five CQC questions to review
and assess the quality of services we provide and to analyse
progress against our eight quality priorities.
Is the service safe?
What is our track record on safety?
Do we learn when things go wrong and improve safety standards as a result?
Do we have reliable systems and practices to keep our patients safe?
How do we assess and monitor safety in real time and react to changes in risk?
How well do we anticipate and plan for potential risks to our services?
We measure safety in a number of ways, through Essential Standards, the
Community Hospitals Assurance Tool, the Safety thermometer, local safety
assessments, clinical audit, reporting and responding to safety incidents and
reporting on national and local standards. In 2014/15 our safety thermometer
results demonstrate a reduction in harm on those measures. We are making
progress on our harm reduction priorities within the quality account (quality
priority 5), with a reduction in reported absences without leave, fewer probable
suicides, fewer avoidable pressure ulcers, a reduction in harm from falls and no
increase in the overall use of prone restraints, despite three wards managing
some complex patients presenting with very challenging behaviour.
As a Trust we have a strong reporting culture for safety incidents and an effective
process for identifying, investigating and learning from serious incidents.
However, there are a number of teams and professions which report few or no
safety incidents and this is an area where we need to do further work. We share
learning in a number of ways, including newsletters, visits to teams, attendance
at governance meetings and running learning events. However, we need to
strengthen feedback to staff and trend reporting and analysis to teams. We also
need to assist them in making sense of a plethora of data and ensuring we are
confident our data is consistent and accurate. Teams have fed back that they
struggle with developing and implementing a large number of action plans and
we are now working with services to integrate and prioritise action planning and
focus on those actions which will make a difference.
Each directorate reviews safety information at a senior management, service and
team level. This is open to scrutiny during the regular directorate performance
reviews with executive and non-executive directors. The Integrated Governance
Committee and quality improvement committees4 provide assurance to the Trust
that we have effective processes in place to deliver a safe service and monitor
progress against our safety and quality priorities. This is reported in turn to the
In January 2015 these committees will be replaced with a new Quality committee and quality
sub-committees organised to reflect the five CQC domains of safe, caring, responsive, effective
and well led.
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Board of Directors at their monthly meetings (which are held in public). The Trust
also has a quality sub-committee comprising Trust governors which acts on
behalf of the governing body to review and monitor service quality and safety in
detail.
The Trust has a range of policies and procedures which are designed to ensure
safe practice. As part of a review of our governance arrangements we are
improving our policy review and approval process to ensure policies are in date
and that staff are able to find policies at the point they require them. In future
policy authors will be asked to assess the usability and clarity of their policies to
ensure staff understand what is expected of them, and can implement policies
appropriately.
We have carried out a complete overhaul of our risk management processes and
teams have engaged very positively with a simpler reporting format and a
strengthened escalation process linking local risk registers with directorate and
corporate risk registers.
We monitor staffing levels in relation to nursing staffing on a weekly basis to
ensure safe staffing levels are available on every shift (quality priority 1) and risk
rate wards which are experiencing challenges with, for example, filling vacancies
or managing sickness absence.
Is the service effective?
Are our patients needs assessed and care and treatment delivered in line with
current legislation and evidence?
How do the outcomes for our patients compare with other services?
How do we make sure that our staff, equipment and facilities enable effective
delivery of care?
How do we support multi-disciplinary working between our services and with
other organisations?
How well do we comply with the mental health act and protect the rights of our
patients who are subject to it and deliver positive outcomes for them?
We are reviewing our clinical audit process to ensure we monitor and report on
audits where improvements are required, that consequent actions are
implemented, and that re-audits show an improvement in practice. We have a
process for reviewing our services against NICE guidance, but along with CAS
alerts we will use the revised local governance structures to ensure a more
proactive approach to responding to these national requirements and alerts. The
research and development committee oversees our innovations in practice and
supports the organisation to identify and make use of evidence-based practice.
Staff are involved in a range of improvement activities delivered through our
productive care, safer care and directorate based improvement programmes
(quality priority 4).
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The medical devices group is working closely with our contracted provider to
ensure we have an up to date register of all medical devices equipment; that
faults or failures are rapidly rectified and, working with local units, that staff are
competent to use medical equipment. This group also oversees business cases
for purchasing or replacing medical equipment. There are relatively few incidents
relating to medical devices. Safety alerts relating to medical devices are
managed through our CAS alert process which assess the relevance of alerts
and requires local services to state whether they are compliant or not with the
safety notice. This is monitored by the services and estates committee.
Staff are required to attend mandatory training which is monitored and reported
on by the HR and workforce group, the quality committee and the Board of
Directors. We also monitor the percentage of staff who have received a review of
the performance and objectives and the opportunities for staff to attend
leadership, skills and professional training (quality priority 1).
Multi-disciplinary working is being promoted through service remodelling (quality
priority 3) which is developing locality based teams for older adult services and
bringing together physical and mental health practitioners. We work in
partnership both to deliver care to patients, and to manage or solve system side
issues or problems (for example delayed discharges of care or management of
pressure ulcers (quality priority 5)
Non-executive directors participate in mental health act hearings and we are
subject to a range of monitoring to ensure we are compliant with the mental
health and capacity acts. This is reviewed in detail by the effectiveness quality
sub-committee on behalf of the Board of Directors. Staff receiving training in their
responsibilities and in the rights of patients and carers in relation to legislation.
Areas for improvement generally relate to documentation and appropriate
information for and communication with patients.
We have training placements for various disciplines at under graduate and post
graduate levels. We work closely with Health Education Thames Valley who
monitor our activity to ensure trainees get appropriate development and
assessment opportunities. Involvement with trainees has a number of benefits - it
assists our future recruitment as trainees often elect to apply for permanent
positions; trainers have to challenge their own practice and encourage fresh
thinking and a questioning approach to our practice; and potential staff are
attracted to our proactive approach to training.
Is the service caring?
Are our patients treated with kindness, dignity, respect, compassion and
empathy?
Are our patients and their carers involved as partners in their care and supported
to make informed decisions?
Do we give our patients and their carers the support they need to cope
emotionally with their care and treatment?
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The Trust uses a range of data to assess whether patients experience our
services and staff as being caring, respectful and compassionate. The friends
and family test is a regular way of capturing patient feedback; however it works
around a series of fixed questions which do not enable a qualitative assessment
of their experiences. We have also introduced a staff friends and family test
including the question “How likely are you to recommend OHFT to friends and
family if they needed care and treatment?”, but response rates are still very low
(quality priority 1). One issue staff raise is that pressures on staffing, heavy
workload, and increased activity and patient acuity is limiting the ability of staff to
spend the time they would like with patients to provide support and reassurance.
A key area of learning from complaints and from serious incidents investigations
is the impact of poor communication, information and involvement in care on
patient experience and all are factors in adverse incidents.
Quality priority 7 reflects our recognition that we need to develop more structured
ways of developing outcomes measures with patients and those close to come;
co-creating a set of outcomes which have value to them and which enable us to
deliver the highest value for investment in our services. The new care clusters for
mental health patients provides some opportunity for this, but we are seeking
creative ways of focusing on outcomes, rather than simply processes or inputs
cross all of our services and care pathways.
Is the service responsive?
Do we plan and deliver our services to meet the needs of different patients?
Do we make sure that our patients can access our services in a timely way?
Do we take account of patients’ needs and wishes throughout their care and
treatment?
Do we routinely listen and learn from our patients’ concerns and complaints?
Adult and older adult mental health services have recently introduced extended
hours during the week and weekend working to provide better access for patients
to our services (quality priority 3). We monitor services against national and local
response times to ensure patients do not have to wait unnecessarily for
appointments, care or treatment. These are monitored internally and through our
contracts with local commissioners. When services fail to meet accepted waiting
times we carry out a root cause analysis and agree a set of remedial actions.
We are implementing a new patient experience strategy which reflects our
awareness that this activity needs further work and investment (quality priority 6).
Building on our positive experience of involving patients and carers in our service
remodelling programme (quality priority 3) we need to make more progress on
more routinely involving patients in decisions about our services and in ways of
measuring their effectiveness. Our governing body comprises a number of
patient and carer representatives and they lead our quality and safety subcommittee which monitors services on behalf of the Council of Governors. The
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Council also defines which measures are subject to external audit as part of our
quality assurance process for the quality account.
Our complaints team supports investigations into formal complaints raised by
patients and those close to them about our services. We also have a proactive
Patient Advice and Liaison Service which visits wards and runs open surgeries to
enable patients to raise concerns at the point at which they are receiving care.
Wards and community teams are running “have your say” forums which enables
staff to receive real time feedback about services and to work with patients to
deal with problems, issues or concerns as they arise.
New and open complaints are reviewed every week by the Director of nursing
and Clinical standards and quality leads/heads of nursing and themes and
lessons learned are shared with teams and with the Board.
Is the service well led?
Do we have a clear vision and strategy to deliver high quality of care and
promote good outcomes?
Do our governance arrangements ensure that responsibilities are clear, quality
and performance are regularly considered and risks identified and managed?
Does our leadership and culture reflect our vision and values, encourage
openness and transparency and promote delivery of high quality care across
teams and pathways?
Do we engage, seek and act on feedback from our patients and their carers, the
public and our staff?
Do we strive continuously to learn, improve, support safe innovation, and ensure
future stability and quality of care?
OHFT has agreed a strategy which includes the strategic objective “Driving
Quality Improvement”. Specific quality priorities are defined in the annual quality
account.
Board meetings are now held in public and we maintain our duty of candour both
to report progress and achievements, and areas requiring improvement and to
reflect on learning from investigations into complaints and serious incidents. Staff
are encouraged to attend surgeries held by the Chief Executive and Executive
Directors to enable them to share concerns and to raise awareness of good
practice in their teams or services (quality priority 4). We organise quality visits
attended by executive and non-executive directors and have a well-functioning
system for peer review (quality priority 8). Directorates reflect on their quality
performance with board members on a regular basis and use this opportunity to
identify future risks to service quality as well as to promote innovations and
progress (quality priority 4).
The Trust has recently reorganised its governance structure to reflect the five
CQC domains and service directorates are similarly reorganising their quality and
governance structures. The new committees and sub-committees will commence
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in January 2015. We have commenced a programme of peer reviews which
enables services to use the five questions to assess their service quality and to
identify risks and areas requiring improvement (quality priority 8).
We have recently reviewed our risk management strategy and have launched a
new approach to identifying and managing risks at all levels of the organisation
(quality priority 4).
Attendance at leadership development events and courses has increased since
the same period last year and we provide a range of opportunities for formal and
informal leadership development. We hold quarterly senior leadership conference
to bring together our senior management teams to debate and discuss a range of
issues and developments. We have also rolled out the Aston teamwork model to
improve team functioning and effectiveness (quality priority 1). Mental health
wards have strengthened their leadership teams and older adults have aligned
physical and mental health services under a single leader to encourage and
promote multi-disciplinary working and more seamless care for the patient
(quality priority 3).
As above we have implemented a patient experience strategy and this is one of
our eight quality priorities for 2014/15 (quality priority 6).
The Trust has invested in skills and capacity to deliver quality and safety
improvement and innovation through our innovation team, our productive team
and our safer care team (quality priority 4). They work with teams and services
and across the Trust to implement safety projects (quality priority 5) and to
spread and sustain best practice.
The Trust has significantly increased its academic profile over the past two years,
an example of which is our membership of the Academic Health Sciences
Network (AHSN). Four of the first five networks being managed through the
AHSN are focused on mental health. We are the highest mental health trust
recruiter of patients into research studies. The local Academic Health Sciences
Centre (a partnership of Oxford University, Oxford Brookes, Oxford University
Hospitals NHS Trust and OHFT) is the only new centre developed in the country
in the past five years. OHFT is currently hosting the CLARHC (Collaborative
Leadership in Applied Health Research) which offers £9 million funding plus £9
million matched funding over five years. We also host the diagnostic evidence
collaborative (DEC) which is our first significant physical health academic
development. These partnerships and collaborations improve our ability to
translate research into clinical practice. This is important because innovation in
healthcare improves care for patients, improves patient optimism and confidence
and improves recruitment and retention of staff. We have set these development
within our research governance process to ensure good and safe practice.
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We have recently approved our organizational development strategy which
includes a commitment regularly to review our organizational development and
leadership development at Board level.
4.
Quality Priorities 2014/15
Our priorities for 2014/15 have taken into account our achievements against our
priorities for 2013/14 (and where we identified further progress was necessary);
issues arising from serious incident investigations and complaints; our
commitment to delivering value in healthcare which focuses on good outcomes
created in collaboration with our patients; and learning from the Keogh report into
high mortality rates in a number of acute trusts and the Francis report following
events at Mid Staffordshire. In particular we have responded to their
recommendations which include
 stronger leadership and accountability (both managerial and clinical) at all
levels of those organisations
 more reliable information on quality, and better use of available data
 listening and responding to staff, patient and carer concerns
 improved staffing levels and development and supervision for staff
We are also using the five CQC questions and key lines of enquiry to assess
whether our services are safe, effective, caring, responsive and well led. We will
test this through work on developing our workforce, improving data quality,
implementing our service remodelling programmes and further integrating
services, continuing work on outcome based care, improving staff engagement
and implementing our patient experience strategy.
While we made some progress in 2013/14 on our harm reduction priorities we
need to do further work on prevention of probable suicides, reduction in harm
from falls, reduction in avoidable pressure damage, a reduction in incidences of
violence and aggression, and reduction in absence without leave from inpatient
mental health units. These have all been included in our priorities, with
associated indicators, for the coming year. Our priorities also reflect the need for
improved clinical and managerial leadership, effective team working with skilled
and engaged staff and access to reliable data.
The eight quality priorities are:
1.
2.
3.
4.
5.
Workforce
Data on quality and quality of data
Service remodelling
Staff engagement
Reduction in harm from falls, pressure damage, absence without
permission, violence and aggression and attempted suicide
6. Implementation of our patient experience strategy
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7. Development of outcome measures
8. Using the new CQC regulatory framework
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Quality priority 1: workforce
Ensuring we have the right number of staff with appropriate training and
experience, supported by effective clinical and managerial leadership, working
effectively within teams. This will support our aspiration to be an excellent
employer, caring for staff, supporting staff development, supporting teams and
individuals to be able to work more effectively, developing our professional
leadership and supporting new interventions. This work will be co-ordinated
through our organisational development strategy. This will enable the service to
be caring, safe, effective, responsive and well-led.
Agreement of quality-focused workforce indicators as part of a wider
quality dashboard by 30 September 2014
The quality dashboard is trialling a number of workforce related measures which
include:
 Sickness absence (%)
 Turnover (%)
 Vacancies as a proportion of establishment
 Number of shifts below minimum staffing levels
 Agency staff bill as a percentage of budget for clinical staff
 Percentage of staff who have completed mandatory training
 Percentage of staff who have been appraised within the last twelve
months
Roll-out of the Aston Teamwork model5 across the organisation to
nominated managers
The Aston Teamwork model has been rolled-out across the organisation to
nominated managers. To date, 15 cohorts of managers have completed day one
of two of the team based working orientation programme being offered since 3 rd
December 2013, with cohorts 1 to 3 having completed day two. Since December
2013, a total of 323 managers have commenced or completed their team based
working learning and practice.
Aston University carried out research into the impact of effective team based working in the
NHS and found that teams working well achieved: improved patient satisfaction; increased
effectiveness and innovation; lower patient mortality; reduced error rates; reduced hospitalisation
and costs; higher staff satisfaction; reduced staff turnover and sickness absence; increased mental
wellbeing of team members
5
This resulted in the Aston University team working development programme, an evidence-based
facilitated programme with a structured set of tools that aims to improve organisational
performance through building effective teams. Dimensions of an effective team include clear
team and individual purpose and objectives; clarity of team member roles; shared values and
goals; ability to manage and make effective use of conflict; enhanced multi-disciplinary working;
and effective communication.
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In addition to the team based working orientation sessions, the three facilitators
offer bespoke support to any team who request it. To date, 53 teams have asked
for and have received support. This support ranges from one-off advice or
coaching, to the team leader/manager about introducing team based working
methods, facilitation of team development sessions and away days, talks to team
meetings, and ongoing facilitation and support for teams with their development.
The principles of the Aston team based working programme have also been
incorporated into other learning opportunities provided by the Improvement team
(including those offered as part of Productive Care and in the Improvement
Champions Development programme). The Improvement team have worked with
other leads in the Trust, aiming to embed the principles into other aspects of the
Trust’s business.
Participants have all been asked four questions:
Has the session improved your knowledge of team based working?
55% reported “a lot”, 40% reported “a bit” and 5% reported “no”
Do you understand the features of effective teams?
90% reported yes, 7% reported “not sure” and 3% reported “no”
Do you believe that you can improve team based working in your area?
86% reported “yes” and 14% reported “not sure”
Do you believe that the Trust will benefit from improving team based working?
85% reported “yes” and 15% reported “not sure”
In objective setting with the delegates, the following themes were noted in their
requirements for learning/support.
 Team development and support in times of change and transition
 Building positive team climates and supporting people under extreme
pressure
 Understanding the Trust strategy for team based working and developing
a common approach and language
 How to set direction and objectives for teams
 How to work effectively with other teams and how sub-teams within an
overall team can work more effectively together
 Practical tools and tips that can be used and cascaded
 Building communication and trust in teams
 Having time out and time to think and reflect
Of the teams that have asked for bespoke support the following themes reflect
the issues they are asking for help with:
 Team performance improvement
 Improving integration of teams/inter-disciplinary working, participation and
team cohesion
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[ PUBLIC ]





Clarity about team identity and purpose and objectives setting support
Improving role clarity and team knowledge and skills sharing
Reducing conflict and improving team relationships and effectiveness
Building positive team climates and working effectively with other teams
Use of formal and informal team effectiveness assessment tools and
leading feedback and development sessions
The Improvement team has exceeded its target for number of managers to be
trained for the year by quarter 2; and has worked with 53 teams across the trust
that have requested more specific support and facilitation.
indicator
Data source
purpose
13/14
Q1
14/15
238
Q2
14/15
295
a) no. of team
Improvement Monitor
178
leaders trained in
and
spread of
Aston teamwork
innovation
skills
principles – target
team
development
250 leaders in
attendance
2014/15
records
86%
90%
86%
b) 100% attendees
reporting they are
equipped to lead
team working
effectiveness
improvements
Maintain existing levels of access to staff training and development,
including clinical practice, improvement skills and professional leadership
The percentage of staff who have received an appraisal within twelve months of
their previous performance review has risen from 56-79%.
The level of attendance at skills development courses (at 2055) is marginally
below that for Q1 (2318), but this is to be expected for the ‘summer leave’ period.
Within this, there is a 50% increase in the attendance at courses for leadership,
team and individual skills compared with the same period last year.
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[ PUBLIC ]
indicator
source
purpose
13/14
baseline
Q1
Performance
Learning
Support staff 100%
development
and
development,
review completed development performance
in last 12 months records
review
(target 100%)
Skills
courses Learning
Ensure staff 8900
attendance
and
develop and
development update clinical
records
and
leadership
skills
Q1
2014/15
Q2
14/15
56%.
79%
2318
2055
(less
training
during
holiday
period
Implementation of the key actions arising from the national staff survey
results to promote staff well-being
All teams and directorates have had the opportunity to review the results from the
survey of their staff. Each directorate is leading on implementing and reviewing a
series of actions in response to feedback they have received. Managers have
discussed the staff survey results with their teams in order to identify the most
pressing concerns and develop local actions to resolve these.
Deliver expected nursing staffing levels on inpatient wards
The table below shows the percentage of shifts which were fully staffed since
May. Of the 34 wards included in this monitoring, eight had no or low level
concerns. Fourteen wards were identified as being at higher risk (with 75% or
fewer shifts fully staffed) and a further twelve were identified as a potential
moderate risk (with 76-89% of shifts fully staffed). The risk rating is currently
being reviewed to ensure it is more sensitive to differentiating between shifts with
actual numbers of staff below expected and those where sessional or regular
agency staff are employed to meet required staffing numbers.
Day
time
Shifts
(Early, Late and Twilight)
Registered
Unregistered
nurses
staff
May 2014
96.20%
94.50%
June 2014
96.9%
97.3%
July 2014
98.7%
96.3%
August 2014
95.1%
93.4%
September 2014 95.6%
93.9%
20
Night time Shift
Registered
nurses
99.50%
95.6%
92.5%
94.9%
95.5%
Unregistered
staff
99.80%
97.7%
98.6%
97.5%
96.4%
[ PUBLIC ]
To mitigate risks associated with staffing levels, wards are taking the following
actions: the number of beds has been temporarily reduced on two wards; staff
who are normally supernumerary to the nurse staffing numbers worked in a
nursing role; staff were borrowed from other wards; staff worked flexibly
sometimes working an extra hour at the beginning or end of a shift, and ‘long
lines of work’ were established with agency staff to improve continuity of care and
reliability of temporary staff.
The main reason wards were unable to staff shifts fully was due to vacancies
related to recruitment difficulties in some geographical areas and in some
specialties which require more strategic attention. Staffing has also been more
challenging over the summer period with more staff wanting to take annual leave
and fewer temporary staff available. The Trust continues to work on solutions to
improve access to temporary staff and to expedite recruitment of new permanent
staff.
The number of adult physical health nursing training commissions has been
increased significantly at Oxford Brookes University and across the Thames
Valley in recognition of the challenges in recruiting adequate numbers of adult
registered nurses. There is a steering group, led by Health Education Thames
Valley, to support the implementation of this increase that we are participating in.
Whilst we actively recruit from the main universities that place nursing students
on our wards, other initiatives are being tried to meet the demand, including
considering requesting an increase in the mental health nurse training
commissions with our link Universities.
Friends and Family staff survey “how likely are you to recommend this
organisation to friends and family as a place to work/if they needed care or
treatment?”
The Staff Friends and Family test was introduced on 1st April 2014 and asked two
questions:
How likely are you to recommend OHFT to friends and family if they needed care
and treatment?
How likely are you to recommend OHFT to friends and family as a place to work?
The results for quarter two were based on a 12% response rate (compared to a
national average of 16%). Quarter 1 had a 6% response rate which led to
changes being made for quarter 2 on how staff received and completed the
survey. For quarter two the surveys were emailed to staff and each member of
staff received a unique password to complete the survey.
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[ PUBLIC ]
The key comments have been summarised below.
Theme
Quality of Care
First hand /
family / friend
experience
Resources
Service
Oxford Health
as an employer
Learning and
Development
Wellbeing
Positive
Staff felt that the Trust was
forward-thinking and well led
with high standards of care,
whilst also being reactive to
feedback.
Experiences were positive with
descriptions of clean wards
with friendly, supportive and
knowledgeable staff
Staff were seen to be well
trained and dedicated to
providing excellent patient
care, who go above and
beyond.
Staff felt that the trust offered a
wide range of services and felt
proud that many were unique
to the trust.
Staff felt that the trust takes an
interest in what staff have to
say and provides them with an
environment which enables
them to deliver quality care to
patients
Great opportunities for
advancement and an
environment that encourages
staff to grow as professionals.
Staff felt that the trust
understands that staff morale
and wellbeing is a core
component of ensuring
effective, high quality care.
Staff felt valued and supported
in their roles.
22
Requires improvement
The quality of care was seen to
be stretched due to understaffing
and many felt that this could be
dangerous to both staff and
patients.
Staff who had used the services
felt that they were rushed through
treatments and were seen as
number rather than an individual.
Although staff were felt to be
capable, they were also seen to
be overstretched with high
workloads and increased
demands
Staff felt that long waiting lists for
treatments meant that many
people do not get the service that
is needed in a timely fashion.
Staff have not felt supported or
communicated effectively by the
trust through the ongoing
remodelling of services.
Many staff felt that opportunities
for development and training
were Oxford focussed.
Staff felt that they worked hard,
but that their work wasn’t
recognised or rewarded.
[ PUBLIC ]
Quality priority 2: data on quality (and quality of data)
Ensuring we have reliable, accurate and relevant data on the quality and safety
of our services. This will enable the service to be safe, effective and well-led.
Develop a quality dashboard
The aim of developing a quality dashboard is to identify a core set of measures
which individually (directly or indirectly) relate to quality of service delivery and,
when taken together, enable the Trust to monitor service quality and identify
services where quality is at risk. Each measure should be relevant and available
at a Trust, directorate and service level (taking into account that some measures
are specific to mental health or to physical health services).
The development of a quality dashboard is being aligned with the broader piece
of work led by the finance directorate to create a register of all services and
related activity and key performance indicators.
The intention is to populate the dashboard with measures which services
currently use to assess quality; that the data is robust (and automated where
possible); and that as much data as possible will be available via the CUBE/data
warehouse. The draft set of measures reflects the existing national and local
quality schedules (contracts) and includes other measures in discussion with
governance and quality leads. As far as possible it is data which is routinely and
easily collected.
The information team is currently “mocking up” the dashboard which will include
ensuring it works “at a glance” (i.e. on a single page); that we have accurate
targets; that we are clear what would justify a red, amber or green rating; that the
data source has been identified; and that services can review and monitor over a
number of months to see any patterns or trends. The draft/outline dashboard will
be discussed with directorate quality and operational leads, and will be tested in
a small number of areas for relevance and usefulness.
A draft mock-up of the operationally focused indicators can be found below,
along with a list of possible indicators to include in the quality, staffing and
finance “sections”.
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[ PUBLIC ]
Operational indicators draft (mock-up of dashboard) EXAMPLE ONLY,
NOT TRUE DATA
Data Indicator
source
Target This June July Aug Sep Oct YTD
month
Percentage of admitted 90.0% 91.5% 92.9%
Service Users starting
treatment within a
maximum of 18 weeks
from Referral
91.5%
Percentage of non95.0% 92.9
admitted Service Users
starting treatment within
a maximum of 18
weeks from Referral
95.9%
92.9%
Sleeping
0
Accommodation Breach
(number of
episodes/number of
patients affected)
0
0
Care Programme
95.0% 96.0% 92.9%
Approach (CPA): The
percentage of Service
Users under adult
mental illness
specialties on CPA who
were followed up within
7 days
Emergency Length of
Stay
Emergency
readmissions
Delayed Transfers of
Care
24
0
1/9 0
0
1/9
96%
[ PUBLIC ]
Quality indicators (draft)
MRSA (number)
CDI (number)
VTE risk assessment %
CPA metrics (risk assessment, crisis
plan)
Friends and family net promoter score
Grade 3 / 4 pressure ulcers – all and
avoidable
Urinary Tract Infections – new
Number of AWOLs
Number of prone restraints
Number of falls by 1000 bed days with
harm
Number of medication incidents with
harm
Number of suspected suicides
Number of SIRIs
% SIRI actions awaiting completion
Number of orange incidents
% incidents awaiting management
review
% complaints responded to within
timeframes
% complaints actions awaiting
completion
Staffing indicators (draft)
number of shifts below minimum
staffing levels
Agency staff bill as a % of budget Clinical Staff
% of staff completing mandatory
training
% PDRs completed within 12 months
Finance indicators (draft)
Income against contract
Expenditure against budget
Delivery of CIPs (%)
Development of standard operating procedures for data quality including
written controls for quality indicators and a standard process for sourcing,
verifying and checking reported data with assigned data leads
The Data Quality Review Group meets every two months to review and monitor
the quality of data recorded and reported at the Trust. The group is responsible
for implementing standard operating procedures for managing data quality in the
Trust. Each directorate has provided details of the reports and process that they
follow to review and improve the quality of data. The group has approved a
standard data quality matrix for use across the Trust to monitor and track data
completeness and accuracy. In addition, an individual health care professional
version of this matrix has been completed (known as My_HCP Dashboard)
providing instance access for health care professionals to data that they have
entered that is incomplete or inconsistent with Trust standards.
In parallel, the information management process at the Trust is being reviewed
and responsibilities for the component parts of the process allocated
appropriately. Asset owners, who will be allocated at a directorate level, will be
required to review, monitor and control the quality of data recorded and reported
at the Trust. The flow chart below shows the desired process flow.
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[ PUBLIC ]
Information Quality
Asset Owners
Data sets
Source Data
Data Warehouse
Asset Owners set
standards for
Config and quality
High Quality data
That has been
checked for:
Completeness,
Timeliness, Quality
of input
KPIs
Meta
data
Measures
Simple calcs
Business
Rules
Quality
Outputs
Logic
Contract
Schedules
Reports
Dashboards
Asset Owners set standards for KPIs, Measures, reporting
calculations, business rules, logic
Data Submissions
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[ PUBLIC ]
Quality priority 3: service remodelling
To continue the service redesign and pathway remodelling programme,
specifically focusing on its benefits in terms of quality and safety. This will enable
the service to be caring, safe, effective, responsive and well-led.
The overall objective for remodelling pathways and services is to develop
high quality health services delivering caring, safe and excellent services
to patients and their families. The objectives for 2014/15 are:
Fully implement a new model of care based on cluster packages6, care
programme approach7 and the recovery star8; ensuring patients and their
families are clear about who is providing their care, what the care is and
what to expect throughout their time in the service; supporting the patient
(and/or family) to set their own goals
In adult services the new model was implemented in April 2014. Work is
continuing with care clustering; all packages have been agreed and the
associated tools for each package are being reviewed.
Staff are regularly attending the Carers Reference Group to understand how the
new model is working from carers perspective and take any feedback back to the
directorate.
A project is now underway to implement the Recovery Star which will begin with
training staff in how to use this; the online tool is being tested in a demo
environment at present.
In older adult services the signed off clusters have been circulated to staff and a
workshop is planned with staff on how they will deliver care and treatment
through the cluster packages.
A workshop for staff on delivery of treatment through cluster packages is being
developed
Indicator or measure
Data
Purpose
of Q1 14/15
Q2 14/15
source
measure
% of patients with a
CPA
Measure quality
11.7%
11.6%
CPA to be in
audit
of life goals as
employment or
part of care
a classification of a mental health service user based on their individual characteristics, condition
and behaviours
7
The Care Programme Approach (CPA) is a national framework for mental health services
assessment, care planning, review, care co-ordination, and service user and carer involvement
focused on recovery.
8
The “Recovery Star” highlights areas to work with individual patients on in identifying and
addressing difficulties that they have with core areas of life. These areas are managing health,
self-care, trust and hope, living skills, identity and self-esteem, special networks, responsibilities,
work, addictive behaviour and relationships
6
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meaningful activity
% of patients with a
CPA in settled
accommodation
planning
Measure quality
78.6%
77.8%
of life goals as
part of care
planning
100% of patients
CPA
Assess levels of 85%
87%
involved in setting and audit
patient
achieving goals
involvement in
setting and
meeting their
personal care
plans
Fully implement the integrated physical and mental health pathways for
older people
Locality teams are currently being established for older people’s services,
bringing together physical and mental health specialities under new heads of
service covering discrete geographical areas.
100% of patients RiO
on older adult
mental health
wards to be
screened using
the early warning
scores and have
physical health
assessment
(PHA) including
VTE
Number of
RiO
appropriate older
adult patients
with comorbidities
receiving an
MDT
assessment
CPA
audit
Quarterly Aligning
physical
and mental
health
needs of
older adult
patients
Quarterly Aligning
physical
and mental
health
needs of
older adult
patients
Q1
VTE 96%
PHA
95.75%
Q2
VTE
assessment
96%
PHA not
available
n/a
not available
Transfer of the Oxford City community hospital to the Fulbrook Centre to
support the integrated model of care
Integrated working is being planned to align with the relocation of City
Community Hospitals to the Fulbrook Centre. The managerial and team
structures have been identified and are in the process of being set up. The move
is planned for the end of November.
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[ PUBLIC ]
Develop, implement and evaluate new staffing models including seven day
working and extended hours
All of the AMHTs are now working across 7 days a week with extended hours.
Work is now underway to see whether consultants can move to 7 day a week
working as well to provide more clinical support and input to the services.
In older adult services staff have been consulted on the proposed changes which
are due to take place in two phases:
Phase 1 is formal organisational change. In Buckinghamshire organisational
change to support the new model of care has been delivered. In Oxfordshire the
organisational change process is being implemented with the completion of
flexible working panels expected by the end of October 2014. In each county
plans are in place for redeployment or redundancy for a small number of
members of staff.
Phase 2 is to establish and embed the new ways of working to deliver the new
model of care. This will involve the delivery of an enhanced duty function and
extended hours/seven day working and streamlined inpatient processes working
closely with partner providers.
Agree and implement model to offer MDT assessment to older adults with
physical and mental health needs
All patients now receive MDT assessment which includes a geriatrician
assessment. We are developing a mental health training package for community
hospitals. Mental health nursing within community hospitals is covered by mental
health staff appointments and integrated community hospital support services
involving collaborative working between the geriatrician, psychiatrist and
psychologist. The Integrated locality teams are exploring how to apply these
principles within the new teams
Further development and agreement of the dementia care strategy with
partners
OHFT has agreed to adopt the Oxfordshire Dementia Plan and support and
implement the recommended actions.
Implement locality and ward based patient and carer forums in adult
services
Patient forums are now in place for each AMHT and inpatient service. These are
being supported by the directorate patient experience lead. The forums have
been advertised on the wards and in the AMHTs as well as information being
sent to GP practices.
The ward forums take the shape of ‘Have your say’ meetings and meet each
week on the wards. Patients are encouraged to participate and raise any
concerns they have.
29
[ PUBLIC ]
There is representation from the wards (modern matrons) attending the AMHT
sessions to provide a link between the services and ensure any concerns /
issues raised in this forum are fed back appropriately.
Work is underway to arrange and implement carer forums more widely across
the service.
Implement patient and carer outcome measures
Patient outcome measures have been developed and are now being used within
the AMHTs. Patients are invited to complete a questionnaire following their care
plan reviews which are then posted to Patient Perspective to ensure
confidentiality; these results are collated by the service that provides monthly
reports to the directorate.
Carers outcome measures are currently under development
Review and develop early intervention in psychosis services
The review of EIS has been completed and a new model has been agreed. The
model now has one team manager across Oxfordshire and Buckinghamshire to
provide continuity between the services; there has also been an enhanced
research function included. The research is being supported by the Oxford
Academic Health Science Network.
Review and develop the complex needs services with CCG leads
The review of the complex needs service is being led by the Head of
Psychological Therapies and is currently focused on scoping and defining the
context, purpose and boundaries of the review.
Implement leadership teams in adult mental health wards
All of the adult inpatient wards have a leadership team in place comprising the
ward-based consultant, modern matron and ward manager; the trio are attending
the Planning for the Future (PFTF) programme to help build a strong leadership
team for the ward. These sessions have been taking place over the last 10
months with experts in the field of leadership attending the workshops to discuss
and education the teams on being effective leaders.
Agree a health plan for every secondary school in Oxfordshire
We have now received a template and guidance from Oxfordshire County
Council commissioners to format the health improvement plans for each
secondary school. The school health nurses (SHN) have been gathering
information on their schools which will feed into this plan. SHNs will now start
working together with school staff, referencing School Development Plans, to
have a health plan agreed with schools, for submission to commissioners by the
end of December.
Increase the number of health visitors in line with the national call for
action
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[ PUBLIC ]
The health visiting service is on track to achieve the target of increased health
visitor numbers by April 2015, and are currently exceeding the target of 123.6
WTE by 2.7 WTE.
Support the breast feeding initiative to promote breast feeding-friendly
areas
All the health visiting teams are receiving training in breastfeeding, with the
requirement to provide evidence of competence in supporting women to
breastfeed. women are able to breastfeed in the drop in baby clinics, and in
most of the sites there is a private space for them if they do not wish to remain in
the public room.
Our infant feeding policy has been reviewed in line with updated BFI standards,
and is now awaiting governance approval before the application for a certificate
of commitment can be submitted. The Nutritional Guidelines for under 5s have
also been reviewed to ensure compliance with the updated standards.
A question regarding infant feeding has been included in the monthly patient
survey (starting end September)
Work has begun on the breast feeding information as part of the health visiting
section of the trust website. http://www.oxfordhealth.nhs.uk/children-and-youngpeople/oxon/health-visiting/
A proforma locality plan has been developed – this will be shared with locality
champions at an update event planned for December.
Three health visitors have come forward to complete the UNICEF ‘Train the
trainer’
course.
This is likely to be run in the early part of next year, and will bring our trainer
team up to eight.
A two day ‘Breastfeeding and relationship building’ training is due to be run in
November and February, with an additional bespoke training for the SCPHN
students. Each course is now full. The curriculum for this training has been
reviewed.
Seventy four practitioners have completed their update training, and are in the
process of completing practical skills reviews and audits.
Another 32
practitioners are booked on for sessions between now and the end of January.
A framework for breastfeeding awareness induction for non-clinical staff has
been developed, this will be rolled out once the updated policy is in place.
Improving patient and carer satisfaction with services
For quarter 2 2014/15 the overall friends and family test results are shown in
graph 2 (n=3732 responses excluding answer options don’t know).
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[ PUBLIC ]
Trust wide FFT Quarter 2 2014/15
2%
2%
5%
Extremely likely
Likely
26%
Neither likely nor unlikely
Unlikely
Extremely unlikely
65%
Extremely
likely
Likely
Neither
Unlikely
likely nor
unlikely
Extremely
unlikely
Community
78.1%
Hospital Wards
n=242
16.5%
2.5%
2.1%
0.8%
Minor
Injury 76.8%
Units n=1652
19%
2.5%
0.6%
1.1%
For quarter 2 the net promoter score for community hospital wards was 62
(compared to 81.7 in Q1 refreshed). The change from Q1 to Q2 is due to an
increase in the number of people responding as likely to recommend which is
excluded from the net promoter calculation and an increase in the number of
people responding unlikely or indifferently to the question. A breakdown by
month and answer option is shown below. There is no particular community
hospital ward identified as not doing well and it should be noted the response
numbers are quite low (242 responses out of 1105 discharges, 22%) even with
two different methods used to offer people a chance to give feedback. For MIUs
the score was 73.9 (compared to 71.3 in Q1 refreshed). Calculating the net
promoter score for patient FFT is no longer supported by NHS England as stated
in the guidance published in July 2014.
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[ PUBLIC ]
Indicator or measure
Improving patient
and carer
satisfaction with
services
(target
improvement on
2013/14 rates)
Data
source
Friends
and
Family
test
Purpose
measure
Quarterly
of Q1 14/15
Ensuring
services
continue to
meet the
needs of
patients/people
close to them
+81.7
CH
+71.3
MIU
Q2 14/15
+62
CH
73.9
MIU
Quality priority 4: staff engagement with the quality agenda
Ensuring a focus on quality from the front-line to the Board, improving quality
management processes, and strengthening links between the Board and staff
directly delivering patient care. This will enable the service to be caring, safe,
effective, responsive and well-led.
Review and align governance processes to further develop a safety culture
where staff notice, respond to and anticipate quality failures
Each operational directorate has been reviewing their quality and governance
structures to allow a greater degree of assurance and to ensure oversight of
quality innovations as well as quality failures. The Older People’s and the
Children and Young People’s directorate have organised their meetings to reflect
the new CQC questions. The Quality and Risk team is working with individual
teams and managers to review the information they receive on Safeguard
incidents to support a renewed focus on the management of incidents and the
use of information to anticipate areas of risk. The intention is to ensure teams
and individuals receive feedback as a result of reporting an incident and
understand what actions have been identified as a result. The Quality and Risk
team is also beginning to monitor those teams where no incidents have been
reported and is discussing these teams with the relevant service manager and
head of service.
The peer reviews, which are being organised to enable teams to assess
themselves against the five questions, brings together a range of different data to
allow a 360 view of each service.
Implement values based recruitment
The 160 questionnaires that were received by interviewees and interviewers are
currently being analysed by students at the Said Business School to enable us to
use the feedback to develop our behavioural framework. The analysis is due to
be completed in early November. The aim is to produce a draft behavioural
framework by the end of November 2014. The second phase of developing
recruitment material will take place between November and January with roll out
of training and implementation in the first quarter of next year.
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[ PUBLIC ]
Identify and deliver opportunities for staff and board members to meet and
discuss quality issues and concerns
A number of surgeries are being organised with executive directors to enable
staff to speak directly to them and raise concerns there are also a number of
opportunities for staff to discuss organisational changes within their own
directorate.
Review and redesign the risk management process across the trust to
develop and embed a risk based approach to quality and safety
The risk management strategy and policy has substantially been rewritten and a
number of staff have been asked to comment on its usability, applicability and
relevance. It is due for final approval in November 2014.
The Board Assurance Framework is now a live document with regular updates
and review at the Board and other relevance committees. The Trust Risk
Register is reviewed regularly by the Executive team and service directors and
functional leads have the opportunity to add or amend risks as appropriate.
The Head of Quality and Risk has met with senior teams and heads of service
across the trust to discuss the use of a new risk register template, and is meeting
with individual managers and teams to support them in starting to use the
template. The response has been extremely positive and teams are developing a
range of ways to ensure it remains a live and active document for them. As an
example, ward managers in the Whiteleaf Centre (adult mental health) are
planning to use the Patient Status at a Glance board to enable a daily review of
risks and concerns shift by shift, which will formally be reviewed on a weekly
basis by the ward leadership team with a view to transferring to the ward risk
register as required. The ward risk registers will be discussed each week with the
service manager and any risks escalated to the head of service as necessary.
Provide opportunities for staff to engage in improvement activities and
projects
Adult Directorate
Productive Care facilitators have been supporting the Oxon and
Buckinghamshire adult mental health wards to achieve accreditation with the
AIMS (Accreditation for Inpatient Mental Health services standards) with specific
focus on a shared medication competency framework and planning for a smoke
free environment. Within the specialised services the Harm Minimisation team
have developed methods of capturing client experience with a new ‘you said, we
did ‘board and by holding a regular drop in brunch club. Woodlands and
Lambourne House have worked on improving the experience of patients
returning from leave and the environment for carers and visitors. Lambourne
House have introduced an electronic document to record accurately patients
returning from leave and have achieved 98% completion. Woodlands secured
funds to improve their ‘airlock’ space and have put in place a photo board of staff,
defining roles and have updated the information leaflets for clients and visitors.
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[ PUBLIC ]
Older People’s Directorate
Community Nursing
There are several ongoing work streams within the directorate with community
services. The Venous Leg Ulcer Pathway has been introduced to a further 30
District Nursing teams, using a visual Patient Status at A Glance tool to highlight
the pathway milestones. Early reporting indicates enhanced healing rates,
improved patient satisfaction and a release in ‘time to care’ for nursing staff by
reducing visit frequency. Nurses have also identified previously undiagnosed
conditions in several patients as a result of the lower leg assessment process.
Community Hospitals
All wards have undertaken the annual sustainability review. The average score
was 64.2 %. A score of 55% or above strongly suggests that improvements
undertaken will embed and sustain. This is an overall improvement on the score
for 2013.
Two community hospitals have been supported with the planned moves to new
premises and this support will continue during and after the moves. Staff have
been looking at ways of delivering person centred care in the new wards with a
focus on safety, privacy and dignity. Away days have been supported including
work on purpose statements, effective team working and managing transitions.
Children and Young People’s Directorate
Children and Young People Directorate Productive Care facilitation has
supported the Productivity project in several areas including the community
dental service.
Cotswold House, Oxford is being assisted with work on the QED (Quality Eating
Disorders) accreditation project. Actions are in progress in looking at information
and communication pre-admission, during stay in unit and upon discharge as
well as the move towards smoke free environment by April 2015.
A comprehensive tool for the Health Visitors SIG’s (Special Interest Groups) has
been developed and is in use. This captures in one place all the evaluations
received from attendees at all the groups run by Health Visitors such as breast
feeding and weaning advice groups. The results can be reviewed by team locality
and across the county wide service.
Bucks SLT (Speech and Language) team for children have re-designed the
pathway and using innovative tools such as internet and phone apps for
accessing advice
Activities for Q3 will include:
 Complete the 15 Steps challenge on Sandford ward for Older Adults
during Dec 14
 Support the Venous Ulcer Pathway PSAG rollout with district nursing
teams through Q3 and Q4 .
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[ PUBLIC ]






Review and embed performance dashboards in Community Nursing
service and Forensic wards, ensuring compatibility for future transfer to
the Business Intelligence Cube.
Support the preceptorship programme for newly qualified nurses and
allied health professionals in Buckinghamshire and Oxfordshire.
Pilot new ‘service improvement tools in practice’ session in Jan 2015.
Support the Productivity project within the Older People’s and Children
and Young People’s directorates.
Continue To support AIMS and QED accreditation
Provide project management support for the ASD pathway in the Children
and Young People directorate.
Implement processes to ensure staff can raise concerns and to monitor
actions taken
The whistleblowing policy has been updated and reviewed and will shortly be
approved. Whistleblowing concerns are monitored by the weekly review meeting.
The investigations are reviewed and monitored by the Executive team.
Implement actions to improve staff wellbeing and motivation at work
The whistleblowing policy has now been agreed by the Trust Board and will be
communicated to all staff and placed on the intranet.
September saw the return of the Pedometer Challenge which had 436 members
of staff taking part and a combined total of over 53,000,000 steps during the
month. As a result, staff felt motivated to walk more, enjoyed the team interaction
and many have now bought their own pedometers.
During August and September we had table-tennis tables from Ping! Oxfordshire
for three weeks at two of our sites (Oxford Business Park and Littlemore Site),
which staff and patients thoroughly enjoyed and felt it was a positive way for
teams to interact and have fun.
Friday 26th September was Macmillan’s Biggest Coffee Morning and thanks to
the generous staff at Oxford Health NHS Foundation Trust we managed to raise
£525.95. Teams from across the trust hosted coffee mornings, cake sales,
raffles, quizzes and more.
The work of the wellbeing group has been shortlisted in the category
“Excellence in Supporting Staff Health and Wellbeing” as part of the Nursing
Times Awards 2014. Results will be announced on 29th October 2014.
Patient & Staff Stories
The directorates are still reviewing which services will capture five patient and
five staff stories (which will therefore be reported in the full quality account
report); however, in each directorate a range of activity has been undertaken
formally to capture individual stories and experiences.
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[ PUBLIC ]
Adult directorate
The directorate patient experience lead
community and acute to capture both
‘stories’. Understanding the experiences
continued development of services and
share how working within or using the
recorded interview or a written narrative.
has been liaising with the teams, both
staff and patient experiences through
of staff and patients is important in the
offers an opportunity for individuals to
service has been for them through a
Our first staff story was recorded on the 30th October. We have also arranged for
two patient stories to be captured in the community though at the request of the
patients, these will be written narratives. Once these stories have been received,
we will be able to share them across the service.
Older people’s services
Three patients consented to be filmed to share their experiences of care within
the district nursing service. Overall the patients were very complimentary and
positive about their experiences. The films have been shared with band 6 team
leaders and managers in two facilitated workshops to identify any learning and
areas for improvement. Two key areas identified are 1) to look at how we can
improve the management of pain within the service and 2) how we can improve
appointment timings in a realistic manner which fits with service provision and
user need. The service will also be developing a service user feedback letter.
The film is on DVD and available for staff or Board members to view. It will also
be shared widely within the district nursing service.
Children and Young people
Awaiting update
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Quality priority 5: reduction in harm
Incident reporting
Overall, the level of incidents reported has seen a slight decrease compared with
last quarter. There have been fewer incidents in Bucks and more incidents
reported in Oxon compared with Q2. Incidents are still being reported using the
old divisional structure while we finalise the new directorate structures (teams,
specialities and lead managers). The Quality and Risk team has now taken on
the coordination of this process to ensure we are able to start reporting for the
new directorates by Q4.
Numbers of reported green and yellow incidents (low/minor injury or property
damage) continue as expected to be the largest numbers of incidents reported
(Chart 1 and Figure 1). The reduction in reporting this quarter is primarily
accounted for by fewer green and yellow incidents. There have been
proportionately slightly higher numbers of orange and red incidents (232 and 17
respectively) but a reduction in numbers of deaths reported. The latter has fallen
to the lowest level over the last six quarters.
Incidents by actual impact
3500
3000
2500
2000
1500
1000
500
0
5.Death
4. Major Injury/Severe Property
Damage
3. Moderate Injury/Moderate
Property Damage
2013/14 2013/14 2013/14 2013/14 2014/15 2014/15
[1]
[2]
[3]
[4]
[1]
[2]
2. Minor Injury/Minor Property
Damage
1. No Injury/No Property Damage
The highest reporters are the services which see the highest number of patients;
however, within these directorates there are teams which do not report any
incidents and we will now be actively monitoring this with service leads. In
particular this relates to a number of community nursing teams, health visitors,
therapies, complex needs services and psychological services, CAMHS learning
disability services, PCAMHS, and some CAMHS teams.
In quarter two fourteen SIRIs have been reported. If the reported numbers
remain at the level seen this quarter then the trajectory would see an end of year
report indicating a reduction year on year over the last three years.
If numbers of suspected or confirmed sucides remain at the current rate over the
remaining year we will be anticipating half the number reported in 2013-14. There
have been three suspected suicides and three unexpected deaths. One was an
inpatient in a low secure ward in Bucks. It likely that this was death by natural
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causes but the cause of death has not yet been released. One was a death of a
patient not in receipt of care and one was the death of a one year old child whose
mother was under the care of health visitors. The latter will go to serious case
review.
Eighty-four percent of SIRI actions have been completed. Of note Community
services in Oxon have reduced their number of outstanding actions from 25% to
10% this quarter. Specialised services have seen an increase in the number of
out of date actions from 6% in quarter one to 47% in quarter two. Actions include
improving communication and handover; increased training for staff; caseload
and skill mix reviews and development of improvement projects.
Infection Prevention and Control
There have been 2 confirmed cases of Clostridium difficile in Q2 in community
hospitals – this was the same patient on both occasions at the same community
hospital, which was peer reviewed as being unavoidable. There have been three
in total since April 2014 (the target is no more than 8 cases).
There were no cases of CDI in mental health.
There were no cases of MRSA and MSSA bacteraemia in the Trust.
There have been 6 cases of E.Coli bacteraemia in Q2.
All cases have had a thorough RCA completed and any learning points identified
and discussed within the service. These infections require mandatory reporting
but do not have a target.
Environmental audits continue to demonstrate good compliance with infection
prevention control standards.
Hand hygiene audits continue to demonstrate excellent compliance of 97.5%.
Bare below the elbows was 99.5%. Hand hygiene in mental health wards is also
continuing bi monthly. The overall compliance score for the hand washing
technique for July and September 2014 was 96 %. Bare below the elbows was
92%.
Outcome 8 Cleanliness and Infection Control is monitored quarterly via the IPCT
and governance team. Overall, areas are demonstrating good compliance with
this outcome, except the numbers of staff trained in infection prevention and
control remain below the target of 100%. There are also some concerns
regarding audit results and decontamination record keeping.
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[ PUBLIC ]
5a: prevention of suicide
Agree suicide awareness and prevention strategies in teams across the
trust and review the impact on practice, benchmarking against other
providers for common indicators
Further training has been delivered to Vaughan Thomas and Ruby ward,
Abingdon Older Adult CMHT, and also physiotherapists in Finchampstead
(Berkshire)as part of our partnership working in that health system.
Reflective practice sessions have taken place with the Emergency Department
Psychiatric Service (EDPS) and Chiltern AMHT with more planned for both
Evaluation questions regarding increased knowledge, understanding, confidence
and usefulness of the theory were answered on a 0-10 Likert scale with
responses ranging from 7 to 10 for all responses.
In the teams where pre and post evaluations have been undertaken an
improvement in all areas has been noted.
Older Adult CMHT (n=9)
level of knowledge
feeling experienced
mean score after
confidence involving carers
mean score before
confidence providing interventions
confidence assessing
0
2
4
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6
8
10
[ PUBLIC ]
Older Adult Ward (n=6)
level of knowledge
feeling experienced
mean score after
confidence involving carers
mean score before
confidence in interventions
confidence assessing
0
2
4
6
8
10
Other developments include:
 the Learning from Incidents team is supporting the use of the interpersonal
theory of suicide and it is to be used as a reflective tool in critical incident
reviews within the serious incident requiring investigation process to
enable staff to critically reflect on cases to enable learning and
subsequent practice improvement.

The safer care team will be working with a small number of trained teams
in 2015 to work on applying the interpersonal theory to practice using
improvement methodology to test, refine and embed safer ways of
working.

Discussion has taken place with Brookes and Bedfordshire universities to
ensure consistency of learning across the professional lifespan and both
universities are in agreement that the interpersonal theory of suicide will
be incorporated into pre-registration training; also that modes of learning
conducive to practice and reflection will be used to build skill and
confidence with students in relation to suicide assessment

A team is working on developing an e-learning package on risk
assessment, specifically suicide and the interpersonal theory will be
incorporated.
Reduction in probable suicides in community and inpatient services
The quality account measures for suicide prevention include days between
probable suicides in individual adult mental health community teams and these
are contained in the table below. The other indicator relates to days between
probable suicide in inpatient services. For all inpatient units except two there
have been no probable suicides in 2013/14 or 2014/15. The days between for
Vaughan Thomas and Lambourne are contained in the table below.
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Days
between
(since
last)
Incident date incidents
North West Bucks
South East Bucks
South East
Prison
IR
Team
Bullingdon
10/05/2014
16/05/2014
03/06/2014
143
137
119
12/06/2014
110
Central West Bucks
North Oxon
07/07/2014
21/09/2014
85
9
Days
between
Incident date incidents
Lambourne House
14/08/2013
Vaughan Thomas Ward 15/01/2014
412
258
Implement recommendations and share learning with safeguarding
children’s boards from OHFT internal report into children’s and young
people’s suicide
No update for Q2
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5b: reduction in the number of missing patients from inpatient services
Review and evaluate absence without leave (AWOL) projects in three wards
No update for Q2
There has been a notable decrease in the number of reported AWOLs in Q2, and
no harm was identified for any patients as a result of absence without
permission.
Indicator
or
measure
Number of
incidents of
absence
without
permission
(target 50%
reduction)
Number of
patients absent
without
permission
(target 25%
reduction)
0 patients to
experience
harm (rated 3,
4 or 5 in
impact) as a
result of being
absent without
permission
Data
source
Safeguard
Purpose
measure
Measure
reduction in
incidence of
AWOLs
of Baseline
13/14
230
Safeguard
Measure
number of
patients
generating
AWOL incidents
Safeguard
Measuring
2
reduction in
harm resulting
from incidents of
absence without
permission
174
Q1
2014/15
77
Q2
14/15
43
41
28
1
(3, 0
moderate
harm)
5c: reduction in the number of avoidable pressure ulcers
Review skin integrity assessment tool and agree options for replacing the
Walsall assessment tool by 31 July 2014
The Skintelligence programme commenced on 23rd October 2014. This
programme utilises methodology from the Institute of Healthcare Improvement
service to help teams undertake local interventions that reduce the harm caused
to patients’ skin as a consequence of pressure.
A total of 31 participants, representing 20 teams from a range of older adult
services have engaged in activities in partnership with local nursing and
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residential homes. They are undertaking projects to assess the effectiveness of a
number of interventions through the use of run charts and ‘Plan Do Study Act’
cycles. These teams are supported to achieve reductions in the incidence of
avoidable pressure damage by being able to discuss problems and raise queries
through a dedicated email address and phone helpline. In addition, face-to-face
support is offered by the Head of Nursing for Older Adults and the Safer Care
Programme Manager.
The Skintelligence programme is just one work stream in the Trust Pressure
Ulcer Prevention Plan. Additional works streams that are progressing include a
partnership with Oxford University Hospitals NHS Trust and work around
documentation, education, and training and competencies.
The Braden pressure damage risk assessment tool is being rolled out in
partnership with Oxford University Hospitals to ensure providers in Oxfordshire
are using the same assessment process; this will ensure greater uniformity in risk
assessment and should provide more consistent management of car . Pressure
damage training has been added to the level four list of Patient and Personal
Safety Training. As a consequence, managers are able to clearly identify and
effectively monitor the competency and training needs of their teams in relation to
pressure damage prevention.
The incidence of avoidable category 3/4 pressure tissue damage remains low
within Oxford Health. The prevalence of all pressure damage has reduced
recently, as indicated by safety thermometer data. However, the prevalence of
new pressure remains high in comparison to the national figures for all NHS
trusts. This highlights the importance of ongoing work with other local providers,
social services, and the independent care sector.
Agree and pilot a set of appropriate and reportable indicators to support
pressure damage harm reduction projects by 30 September 2014
The Fulbrook ward staff have started collecting data and are using a safety cross
to record any skin damage. Sandford are currently at 90 days since any pressure
damage, Cherwell are still collating data, however, they are over 90 days since
any pressure damage.
The random testing of 5 sets of notes to check all have a risk assessment in
place started W/C 27th October and this will happen weekly to establish a
baseline and next steps.
Work has commenced using an initial Ask 5 staff if they know what to do if they
see any pressure damage and how they implement further interventions.
Each ward has already Identified one patient who is at high risk and are testing
out different ways to encourage staff to use the SSKINS model. They are
adapting the notes template and a member of staff has created a poster on
avoiding skin damage to go in the patient’s bedroom as a prompt for staff.
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The older people’s directorate has not been able to report on all the indicators
below for Q2. Currently, while all grade 2 pressure damage is reported as an
incident, a full assessment of avoidability is only carried out for grade 3 and 4
pressure damage.
Indicator or Data
measure
source
Number of
patients
with
avoidable
pressure
ulcers
graded 2-4
(target 0)
Frequency
of
reporting
Safeguard Quarterly
100% of
RiO
patients
managed
by the
district
nursing
service to
have a skin
integrity risk
assessment
100% of
RiO
patients
managed
by the
district
nursing
service to
have a
nutritional
status
assessment
Purpose
Baseline Q1
Q2
of
13/14
2014/15 14/15
measure
Measure 15
49
2
reduction
in
avoidable
pressure
ulcers
Quarterly
Reduce
96%
93%
risk of
(Walsall)
avoidable
pressure
damage
No data
available
Quarterly
Reduce
93%
risk of
avoidable
pressure
damage
No data
available
86%
An additional SIRI was reported in May but relates to an incident in Q4 of 2013/14. It has not
been included in these figures therefore.
9
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5d: reduction in the number of patients harmed by falls
Implement and evaluate a falls harm reduction project in Sandford Ward
No update required until Q3
Rolling out red frames
Cherwell ward have tried a red frame with a single patient with a diagnosis of
dementia and we found patient was attracted to colour and tend to use it better
as compared to the normal grey frame. This was also trialled on Sandford ward
with no difference in concordance with mobility aids and as such had no impact
on patient outcome. The Infection Prevention and Control team have identified a
potential infection control risk with the use of painted’ frames. The Fulbrook
physiotherapist is working with another Trust to look at the purchasing of red
frames, while the Estates teams is attempting to source a suitable paint that
meets the Infection Control requirements.
The safety cross is being used on Amber ward and Cherwell ward as part of the
Productives project). In addition, all patients are receiving physiotherapy
assessment irrespective of mobility issues, which has increased effective
screening; and all patients who have 2 or more falls are now referred to the falls
service.
Agree a set of appropriate and reportable indicators to support falls harm
reduction projects by 30 September 2014
Currently safer care is using the safer care collaborative measure which is:
harm from falls reduced by 50%
The number of reported falls by 1000 bed days has slightly reduced in Q2. Harm
from falls by 1000 bed days has also slightly reduced.
Indicator or
Data
measure
source
Number of
Safeguard
falls/number
resulting in
harm (rated as
3, 4 or 5 in
impact) by
1000 bed days
(target to
reduce to
3.8/0.2 in
mental health
and 8.6/0.2 in
physical
health)
Purpose of
measure
Measure
reduction
in harm
from falls
46
Baseline
13/14
Number of
falls 4.8 MH
(harm 0.3)
and 10.6 PH
(harm 0.3)
by 1000 bed
days
Q1 14/15
321
(10.6/1000
bed days)
of which
16
(0.8/1000
bed days)
resulted in
harm
Q2 14/15
120 or 5.1 MH
13 or (0.6 harm)
187 or 10.5 PH
12 (0.7 harm)
[ PUBLIC ]
100% of
patients in
older adult
inpatient
services to
have a falls
risk
assessment
on admission
100% of
patients in
older adult
inpatient
services to
have a further
falls risk
assessment
after 28 days
% of patients
to have a
review of care
plan after a fall
(target 100%)
100% of
patients to be
referred to
falls service
after 2 or more
falls
RiO
Reduce
the risk
of falls
87.75%
Data
not
availa
ble
92% CH
OAMH data not
available
RiO
Reduce
the risk
of falls
Baseline set
Q1
Data
not
availa
ble
Data not available
RiO
Reduce
the risk
of falls
Baseline set
Q1
Data not
available
RiO
Reduce
the risk
of harm
from
falls
Baseline set
Q1
Data not
available
74% CH
Documentation audit
“If there is a falls risk,
has a care plan been
put in place?”
OAMH 8/27 repeat
fallers = 30%
(range 0-33)
Community hospital
wards 26/37 repeat
fallers = 70%
(range 50-100)
5e: reduction in violence and aggression
Implement a revised training programme for prevention and management
of violence and aggression (PMVA)
The project to review our training in relation to reducing the amount of restraint
has been completed. A costed proposal to update our in house training is
awaiting approval to set up a two year programme of curriculum development,
establishing governance arrangements and re-training of all inpatient staff.
Report on and reduce the number of avoidable prone restraints (where the
person is face down) and use of hyper-flexion (holding the arm to restrain)
There were 412 reported incidents of physical restraint in quarter two. Totals for
the previous four quarters were 293, 338 and 351 and 358. The figure of 412 is
unusual but not unprecedented. On two occasions in the last two years, there
have been more than 400 incidents in one quarter.
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The mean number per month for the last eighteen months is 119. The graph
below shows a fairly steady rate of incidents with occasional peaks and troughs
and a higher than average rate for the past four months.
This number includes three patients who have been restrained multiple times as
a result of challenging behaviour, attempts to self-harm and violence to staff.
Staff in those wards are working proactively with PMVA trainers, specialists and
directorate managers to reduce the incidence and duration of restraint.
The incident form requires a ‘cause group’ to be selected for each incident.
Many different types of cause group were selected but violence and aggression
(62% of all incidents) followed by self harm (21%) were as usual the main
reasons for restraint. The other causes relate to restraints for administering
medication and to prevent absconding. The pattern does not vary from previous
quarters.
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The percentage of restraints recorded as prone has remained steady at 30% in
compared to 26% last quarter (the figures in the previous quarters were 33%,
29% 25% and 22%). The new category of kneeling is rarely selected. The rise in
prone reflects a fall in the use of seated restraint, the other categories remained
constant.
Indicator or
measure
Reduce number
of reported
incidents of
violence and
aggression
resulting in
harm (3, 4 or 5
in impact) by
25%
Number of
(avoidable)
prone restraints
(target towards
0)
Number of
restraints
involving hyperflexion (target
towards 0)
Data
Purpose of
source
measure
Safeguard Measure
reduction in
incidence of
violence and
aggression
Baseline
13/14
28
(incidents
in our
inpatient
units only)
Q1 14/15
Safeguard Measure
reduction in
incidence of
prone
restraints
Safeguard Measure
reduction in
incidence of
hyper-flexion
392 (all
prone
restraints)
94
116/412
1187
22
9/412
49
22 (all
incidents
including
those in the
community)
Q2
14/15
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Quality priority 6: implement patient experience strategy
Ensuring a focus on delivering a positive experience, which meets the needs of
patients and those close to them. This will enable the service to be caring.
Develop a webpage to share feedback and how this has been learned from
and acted upon
Web page specifications have been developed with the communication team and
every complainant has been asked for consent to publish an anonymous
summary of their complaint, outcomes and actions. The web page will also
contain information on friends and family results. Since July the trust has
proactively been responding to and learning from feedback posted on line and
now promotes this as an option for patients and carers wanting to fed back on
their experiences. The new webpage will include a link to Patient Opinion.
90% of teams to be collecting feedback on patient experience feedback and
50% of teams to demonstrate they are listening to and acting in feedback
Every service is collecting feedback with patient experience leads reporting on
themes and improvement actions through the patient experience group and in
reports to the quality committee and Board.
Roll-out of the Friends and Family test across all services
This is on track
Introduce a system for capturing patient and staff stories
There is no update on this for Q2
Agree core domains of patient experience to measure and report on
There is no update on this for Q2
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Quality priority 7: development of outcome measures
Ensuring a focus on how services support patients to manage their condition
and/or recover. This will enable the service to be effective.
Discussions have been held with each directorate to identify appropriate services
and pathways to monitor the development of outcome measures. These will
include development of outcome measures in adult and older people’s mental
health services; implementation of co-created outcomes with patients in
community hospital services; development of outcome measures with young
people in speech and language therapy services in Buckinghamshire.
Quality priority 8: using the new CQC regulatory framework
Ensuring we assess and, where necessary, make quality improvements to our
services to ensure they are safe, effective, caring, responsive and well-led.
Ensure staff across the organisation are familiar with the changes to the
regulatory framework and adapt the Trust’s approach to quality in
recognition of changes in regulation
The Trust has adapted its formal quality governance structure to reflect the new
CQC domains and reporting in future will enable the Trust to assess its progress
against the key lines of enquiry.
A taskforce now meets fortnightly comprising quality leads and heads of service
to organise peer reviews and begin to embed a new way of approaching quality
within teams and services. In addition briefings are taking placed with teams
across all services and disciplines to introduce them to the five questions and
assess how they meet these in practice. Other achievements include:






Good engagement from taskforce members including two representatives
from each Directorate, and representatives from estates, communications,
HR, emergency planning, a link medic and pharmacy.
Members of the taskforce team have visited other trusts and sharing
events to hear about their experiences of being inspected, this has
included Solent, Devon, SW London and St Georges, OUH and BHT.
The Director of Nursing from Devon Partnership NHS Trust came and
spoke to the taskforce team and a wider group of people on 1st Aug 2014
to share their experience.
One of the group sessions at the senior leader’s conference in July 2014
was focussed on the CQC standards, including a presentation from the
Deputy Chief Inspector for Hospitals.
Each of the Directorate SMT groups has been briefed about the new CQC
standards and the inspecting for quality project.
Over 54 presentations have been given to teams and services to raise
awareness about the new standards and the trusts approach to
embedding and monitoring these in practice. Plus some group work was
carried out with consultants at their away day in October.
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











The internal audit to be completed by TIAA into the provision of care for
dying patients across children, adult and older people services is scoped
and due to start in early November 2014.
For each of the core services (identified by the CQC) a lead in each
directorate has been identified to support the taskforce group.
A risk and issue log has been developed by the taskforce group.
A detailed internal communication plan for staff has been developed,
focusing on phase 1 of the project before the inspection date is known.
A finalised model and development of standardised tools for internal peer
review visits. Visits started across the three directorates from October
2014.
Directorates and corporate services have completed a ‘readiness’ selfassessment against information likely to be requested by the CQC for a
data pack about the trust as part of the preparation for their inspection.
A plan has been drafted for setting up and running the coordination centre
for the few weeks before the inspection, during the inspection visit and
afterwards based on an emergency planning approach.
Internal communication plan has been finalised by the taskforce group.
The trust is involved in testing of the new quarterly mental health
intelligent reports to be produced by the CQC. This meant the trust was
able to see the intelligence information held by the CQC about the trust
prior to the reports being published in mid Nov 2014. The trust was
identified as having an overall risk score of 1 out of a possible 114 relating
to DTOC and we have been placed in band 4 the lowest risk band.
The trust’s statement of purpose was updated in Sept 2014 to meet
regulation 12.
A service directory has been developed with details of the team name,
base location, lead contact person and details and opening hours, due to
be finalised in the next month.
An A5 poster has been created to detail key telephone numbers useful for
clinical teams, this will be circulated in mid-Nov 2014.
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