Draft Quality Account 2014/15 - cms.wiltshire.gov.uk 8 - AWP Draft... · referrals, and had more...

0

Note to editors: ALL RED is compulsory wording and cannot not be changed. Please leave red.

Green remains to be updated

Avon and Wiltshire Mental Health Partnership NHS Trust

Draft Quality

Account 2014/15

20 April 2015 Version 1.2

1

Contents

Part 1: Chief Executive’s statement on behalf of the Board

Introducing Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)

Part 2a: Our priorities for improvement in 2014/15

Priority 1: To improve service user and carer experience

Priority 2: To improve the clinical effectiveness of our services

Priority 3: To reduce avoidable harm

Priority 4: To improve the physical health of our patients

Priority 5: To provide services that are compliant with the Care Quality Commission’s (CQC) Fundamental Standards of care

Part 2b: Statements relating to quality 2.1 Review of services 2.2 Participation in clinical audits 2.3 Participation in clinical research 2.4 Commissioning for quality and innovation (CQUIN payment framework 2.5 Care Quality Commission (CQC) registration 2.6 Quality of data 2.7 Safeguarding

Part 3: Our care quality achievements in 2013/14

3.1 National data 3.2 Patient Experience - How we did 3.3 Effectiveness – How we did 3.4 Safety – How we did 3.5 Service user, carer and patient experience 3.6 Learning from incidents 3.7 Patient environment 3.8 Staff survey

Part 4: How we developed our Quality Account

APPENDICES to be developed Appendix A: External assurances and comments

Appendix B: Glossary of terms

Appendix C: Statement of Directors’ Responsibilities

Appendix D: Information by Clinical Commissioning Group Area

Appendix E: More information on quality indicators

2

Part 1: Chief Executive’s statement on behalf of the Board

Our absolute focus is on improving the quality of our care and the services we provide. I am therefore pleased to introduce on behalf of our Trust Board, our sixth Quality Account. This document summarises the quality improvements we have made to the safety and effectiveness of our services and highlights our focus on improving the experiences of those who use them.

The central purpose of our Trust is to provide the highest quality mental healthcare that promotes recovery and hope. This Quality Account describes the progress we have made over the last twelve months and outlines our quality priorities for the coming year. These have been shared with our staff, service users, carers and commissioners, so that everyone is aware of the steps we are taking and the impact we want them to have.

The past year has been one of consolidation but also one with significant challenges for us. We have continued to embed the changes we made to our organisational structure in 2013 with our clinically and locally led service delivery units that are providing services able to develop and respond more quickly to the needs of the local communities served. Our real time quality improvement system has continually evolved to meet the end user’s needs and the support provided to our operational services by our central quality improvement function has been commended.

The Trust has dealt with the increased demands made on mental health services from the communities we serve as well as a national shortage in qualified nursing staff. The impact of these issues is evident in our wards not always having beds available to admit people as close to home as they should be and also some of our wards having to temporarily close beds where we do not have enough qualified people to staff them safely. Additional pressures on the overall health and social care system have contributed to patients being delayed in mental health beds who are ready for discharge because suitable alternative beds have not been available; we are working with our commissioners and local authorities to resolve these issues.

During June 2014 the Trust received an inspection from the Care Quality Commission’s Chief Inspector of Hospitals. The inspection was comprehensive and, as well as identifying areas of good practice and praising our staff for their compassion and caring attitudes, we were notified of areas of significant concern where we were required to make improvements. These priority areas were: the safety of the environment of our inpatient wards, particularly in relation to ligature risk; ensuring safe staffing numbers and improving our systems and processes to ensure organisational action and learning from incidents, reviews or other sources of information.

To make these improvements the Trust implemented a comprehensive plan of action and internally tested our compliance via independent visits and developmental support from specialist staff. In December 2014 the Trust was re-inspected by the CQC to test our improvements and we are pleased that these met the CQCs expectations. In addition to these areas the Trust continues to work on the findings of the CQC report in recognition that we still have more to do to ensure that we have fully embedded the necessary improvements in to our clinical practice and service provision. We are not prepared to stand still. We strive to maintain a culture of continuous quality improvement via ward and team self-assessment, a programme of mock inspections and quality visits and a comprehensive programme of clinical audit.

3

In last year’s Quality Account we set out our Quality Priorities for the year and we are pleased that our work in these areas has progressed well. Our inpatient services were successfully accredited with the Carers Trust Triangle of Care in May 2014 and our community services are ready to apply in May 2015. We have increased the number of service users taking part in the Friends and Family Test service user survey and ensured that our services have listened and responded to this valuable feedback. The physical health of our most seriously ill patients has been a key area of focus ensuring all inpatients receive a thorough physical health check and that we work with GPs and other health professionals to ensure safe and coordinated treatment for both physical and mental health conditions.

In the past year we have continued to achieve against the majority of our contractual and national quality performance indicators as well as delivering successfully the quality improvement incentive schemes agreed with our commissioners, however we know through the experience of the CQC inspection that we cannot be complacent. We must continuously strive to improve what we do. We will check and check again how we are doing, to ensure that we routinely provide safe, clinically effective and caring services.

In the coming year, we have identified a series of quality priorities to build upon our work this year in response to the feedback of our regulators, commissioners, our service users and carers’ and our staff. Our objective is deliver high quality services Trust wide, which are clinically led, locally driven and quality focused and to support this we have set following Quality Priorities for 2015/16:

• We will deliver high quality services Trust wide and aim to achieve a CQC rating of at least ‘good’ across all inpatient, community and specialist services

• We will continue to implement the ‘Safewards Model’ and reduce the need for restrictive interventions and improve the use of positive and proactive approaches to care and above all to improve the safety of our wards

• To provide services that our service users would recommend to their friends and family and continue our work to improve our partnership working with carers

• To improve the clinical effectiveness of our approach to assessment and care planning

• Implement a new electronic patient record and improve how we record our clinical practice

• We will continue our work to make sure that that we give equal attention to the physical health of our service users as we do to their mental health.

Our service delivery units will also be continuing to focus on key local areas for improvement in partnership with their patients, service users, carers and commissioners.

We have maintained open and honest relationships with our local communities, the people who use our services, NHS commissioners, GP Commissioners and local authorities over the last year. We will build on these relationships to ensure that we improve and develop our services in response the needs of our local communities.

I verify to the best of my knowledge that the information in this document is an accurate and true account of the Trust’s quality of services.

Iain Tulley Chief Executive SIGNATURE TO BE INSERTED FOR FINAL BOARD APPROVED VERSION

4

Guidance to help you when reading this document:

1. We have used a “traffic light” system to rate how well we have done against the standards we have set for ourselves. These are:

Red Standard not met / poor result

Amber Standard nearly met / adequate result

Green Standard met / good result

2. We have also used arrows to show the direction of change against target level over the past year as follows:

▲ = Improving

► = No change

▼ = Deteriorating

3. There is an explanation of some terms in the glossary in Appendix B.

5

Introducing Avon and Wiltshire Mental Health Partnership NHS Trust (AWP)

AWP is a major provider of recovery focused mental health services. Our objective is to be the organisation of choice for service users, staff and commissioners alike, providing a comprehensive range of specialist Mental Health services in primary, secondary and tertiary care settings, across our existing geographical area.

We are committed to the delivery of safe, accessible, effective, leading edge, innovative and person-centred services which intervene early and effectively and concentrate on recovery and reablement. We work together with our health and social care partners to provide service users with increased choice in the way they receive support and care which is closer to their homes and to avoid, where possible, disruptive inpatient stays.

AWP provides services for people with mental health needs, for people with learning disabilities combined with mental health needs and for people with needs relating to drug or alcohol dependency. We also provide secure mental health services and work with the criminal justice system.

We operate from more than 100 sites across Bath and North East Somerset (B&NES), Bristol, North Somerset, South Gloucestershire, Swindon and Wiltshire, as well as providing specialist services for a wider catchment extending across the South West.

In 2014/15 the Trust’s community services saw 31,685 individuals from just under 28,879 referrals, and had more than 301,405 contacts with service users (either via the telephone or face to face). In addition, 2,212 people were admitted into our inpatient units for more intensive treatment.

Our turnover in 2014/15 was £198m and we employed an average of 3298 (whole time equivalent) staff from a variety of professional backgrounds including psychiatrists, psychologists, mental health nurses and allied health professionals.

Fundamental to delivering quality services is continuing to embed the principles of the NHS Constitution within the organisation. This constitution sets out rights of patients, public and staff, pledges which the NHS is committed to achieve, together with responsibilities which the public, patients and staff owe to one another to ensure that the NHS operates fairly and effectively.

6

Part 2a: Our priorities for improvement in 2015/16

Our Trust Objective is to deliver high quality services Trust wide, which are clinically led, locally driven and quality focused. Set out below are the priorities we are planning to deliver in the year ahead.

7

Priority 1: To improve service user and carer experience

Description of issues and rationale for prioritising

Understanding the experience of our service users and carers is key to informing how we make adjustments and improvements to our services to meet the needs and expectations of those using them.

The Carers Trust ‘Triangle of Care’ Membership Scheme is a recognised as a way to demonstrate our commitment to working in partnership with carers.

The actions we will take in 2015/16 are set out in the table below:

Improvement Priority

Actions Success measures

To provide services that our service users will be confident to recommend to their friends and family if they required similar treatment.

Development of a new Service User and Carer Involvement Strategy developed in partnership with our service users and carers

Complete an in depth thematic analysis of patient feedback and findings from incident reporting

The use of the Friends and Family Test (FFT) as a mechanism for gathering real-time service user feedback

Improved use of technology to gather service user feedback

Development of survey tools to improve the accessibility of the FFT

Delivery of new strategy endorsed by our Trust-wide Involvement Group

Evidence of actions completed to address themes from thematic analysis

Evidence of local improvement actions in response to the patient and carer experience

90% of our service users will recommend our services via the ‘Friends and Family Test’

Consistent response rates of 15% for community services across all of our service delivery units

To enhance carers experience through improved partnership working and carer support.

We will continue to use the Carers Trust ‘Triangle of Care’ self-assessment improvement tool across the Trust and take forward identified improvement actions

Implementation of our Family Friends’ and Carers Charter

Rolling out carer awareness training across all teams

Simplifying carer recording processes on RiO

Updating and improving carer information on Carers pages of internal and external website

Submission for phase two Triangle of Care accreditation Triangle of care improvement plans in place for 100% of teams and wards XX% of carers asked if they have a carer or person who supports them XX% teams completed carers awareness training

8

Priority 2: To improve the clinical effectiveness of our services Description of issues and rationale for prioritising

Clinically effective care is about providing the right care, at the right time and achieving the right outcome.

We know from our clinical audit programme, patient feedback, incident investigations and our regulators that we can do more to improve our clinical practice in order to achieve the best possible outcomes for our service users.


Improvement Priority Actions Success measures

To ensure that all service users receive a comprehensive assessment including formulation, assessment of risk, and have a clinically effective care plan that is agreed by the service user

Training and development of staff on formulation, assessment and care planning.

The clinical toolkit will be reviewed as per yearly review cycle.

Guidance on recording assessments and formulations for clinicians will be refreshed following the introduction of open RiO.

Checklists for managers will be developed which will enable the review of assessments, formulation and care plans. This will be used monthly.

Development of clinical networks to advise on clinical effectiveness and standards

Audits of the clinical record demonstrate that 85% of records have formulation summary recorded.

95% of service users records include a risk assessment

90% of service users have crisis and contingency plan

85% of service users care plans contain the following elements:

• Statement of need which has been identified during assessment

• Goals

• Interventions with timescales

• Evidence of service user and carer involvement in the development of the care plan

• Are agreed and signed by the service user

To improve the quality of the electronic patient record (EPR) to aid and reflect clinical practice and decision making

Development and agreement of Trust standards for the completion of a good quality patient record

Tailoring of the new EPR to the needs of service users and staff

Implementation of a new EPR

Delivery of training

New records management standards agreed by end of September 2015

85% compliance with monthly audits of the clinical record

Improved scores in staff feedback survey on use of the EPR

9

Priority 3: To reduce avoidable harm Description of issues and rationale for prioritising

Providing services that are safe and free from harm is our highest priority. We know from themes reappearing in our findings from incident investigations that we need to do better to truly listen, learn and act when things go wrong.

‘Sign up to Safety’ is a campaign that aims to make the NHS in England the safest healthcare system in the world, building on the recommendations of the Berwick Advisory Group. The ambition for the NHS in England is to halve avoidable harm in the NHS and save 6,000 lives as a result.

Investigations into abuses at Winterbourne View Hospital and Mind’s Mental Health Crisis in Care: physical restraint in crisis (2013) showed that restrictive interventions have not always been used only as a last resort in health and care. During the coming year we will continue our work to implement the new Department of Health best practice guidance to ensure service user and staff, safety dignity and respect.



Listening to patients, carers and staff, learning from what they say when things go wrong and take action to improve patients’ safety. Our aim is to reduce avoidable harm by 50% in line with NHS England’s ‘Sign up to Safety’ campaign to save lives and reduce harm for patients over the next 3 years.

We will develop and deliver a patient safety improvement plan and set out our actions to meet the Sign up to Safety pledges:

1. Put safety first 2. Continually learn 3. Honesty 4. Collaborate 5. Support

Achieve CQC rating of ‘good’ in the safe domain

8% reduction in falls leading to a fracture

Maintain and improve our position in the top 25% of organisations by the rate of incidents reported.

Evidence of discharging our duty of candour for 100% of serious incidents

90% of actions completed on the Patient Safety Development Plan

To reduce the use and need for restrictive interventions and improve the use of positive and proactive approaches to care

Implementation of Department of Health Guidance ‘Positive and Proactive Care: reducing the need for restrictive interventions’.

Adoption of the 2015 update of the Mental Health Act 1983: Code of Practice

‘Safewards Model’* implemented on

all wards

15% reduction in all restrictive practices

10% reduction in the use of seclusion above 8 hours duration

Improved score for national inpatient survey question ‘Do you feel safe?’

* A model of care designed to reduce the use of restrictive practices such as restraint or rapid tranquilisation.

10

Priority 4: To improve the physical health of our patients


The SMI patient population makes up 5 per cent of the total population but accounts for 18 per cent of total deaths. There is an excess of over 40,000 deaths among SMI patients which could be reduced if SMI patients received the same healthcare interventions as the general population.

We will continue to prioritise work this year to ensure that our highest risk patients receive comprehensive physical health checks whilst in our care and that appropriate action is taken when issues are identified alongside the communication of all identified physical and mental conditions to the GP. The primary aim is to reduce premature mortality, improve patient safety, patient experience and quality of life, through shared communications and coordination of treatments.



*To reduce premature death and improve the physical health condition of severely mentally ill patients and ensure physical health needs are identified and treated.

All patients will receive a comprehensive physical health assessment within 72 hours of admission to a ward

The full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors for patients with schizophrenia in our wards and early intervention (EI) services.

All inpatients will receive a daily assessment of their physical health condition.

Care plans to fully reflect actions to address lifestyle and physical health needs

Meeting 90% (inpatient) and 80% (EI) compliance with the completion cardio metabolic risk factors assessed via the National Audit of Schizophrenia

Improved score for national inpatient survey question ‘Do you feel enough care was taken of your physical health needs?’

XX% of inpatients with physical health assessment within 72 hours of admission

XX% of inpatients receive daily physical health assessment

*Ensuring that discharge summaries and care plans are shared with GPs and include comprehensive information including diagnosis, medications, physical health conditions and recovery interventions.

Development of comprehensive guidance and training for clinical practitioners on the inclusion of diagnosis, medications, physical health conditions and recovery interventions in care plans for inpatients

Meeting 90% compliance assessed by a local audit of care plans

Improved score for national inpatient survey question ‘Do you feel enough care was taken of your physical health needs?’

*Part of the 2015/16 CQUIN (Commissioning for Quality and Innovation) scheme which is where Trusts can earn additional income dependent on the delivery of a set of measured quality improvement objectives. Details are set out at the following link INSERT LINK

11

Priority 5: To provide services that are compliant with the Care Quality Commission’s (CQC) Fundamental Standards of care.


The Government’s response to the Francis inquiry included new measures aimed at improving openness and transparency, and setting minimum standards of care. From April 2015 the Department of Health and CQC have developed a new approach to regulating, inspecting and rating health and social care services based on new Fundamental Standards regulations that set clear standards below which care must never fall.

We have work to do to make sure that we understand the new regulations and to make sure that our services are fully compliant with them. We want to build on our progress last year when we introduced a new approach to continuous quality improvement developing local clinical leadership and accountability but above all we believe that we are beginning to change the culture of our teams and wards to own the quality of the care they provide and to strive to continually improve it.



To ensure that all services are compliant with the CQC Fundamental Standards of care

Self-assessments of compliance at ward and team level

Development of a dashboard to provide information at ward and team level to inform improvement activity

Locally led and independent/peer review quality walk around programme

Mock inspections and independent compliance checks

‘15 steps challenge’ visiting programme

Quality improvement training and specialist support for projects

Quality improvements plans in place for all service delivery units

To receive no CQC compliance actions at inspection across all five key questions:

Is the service:

• Safe?

• Caring?

• Effective?

• Responsive to people’s needs?

• Well-led?

95% of wards are taking part in the self-assessment

20% increase in the number of registered quality improvement projects

12

Part 2b: Statements relating to quality

The Trust’s approach to quality improvement is set out in our Quality Improvement Strategy 2013 to 2017. (Available on our website http://www.awp.nhs.uk/news-publications/publications/trust-strategies/)

The strategy builds on our commitment to be a Trust which is driven by quality, clinically led and which is heavily influenced by the views of patients and carers. Our approach to quality improvement is supported by:

• An organisational environment focused on quality improvement

• A defined ‘Quality Assurance Framework’

• Delivery through quality priorities owned and developed by delivery units and Corporate Directorates.

The plans also seek to improve the systems and processes around quality, including underpinning functions essential for delivering high quality care, such as finance and human resources.

The following statements provide information to show that the Trust is performing to essential standards, that we measure our clinical processes and performance and are involved in national projects to improve quality.

The Board and it’s Quality and Standards Committee receive and review assurance and progress reports on a regular basis.

2.1 Review of services During 2014/15 AWP has provided NHS inpatient and community mental health services organised across eight service delivery units, including:

• Specialised and specialist drug and alcohol services

• Secure services

• Locality led service delivery units across the six local authority areas we serve which provide inpatient and community mental health services to adults.

The Trust has reviewed all the data available to it on the quality of care in the above NHS services. The income generated by the NHS services reviewed in 2014/15 represents 100% of the total income generated from the provision of NHS services by the Trust during 2014/15.

2.2 Participation in clinical audit National Clinical Audit is designed to improve patient outcomes across a wide range of mental health conditions. Its purpose is to engage all healthcare professionals across England and Wales in systematic evaluation of their clinical practice against standards and to support and encourage improvement and deliver better outcomes in the quality of treatment and care. In mental health there are a number of audits run by the Royal College of Psychiatrists Prescribing Observatory for Mental Health (POMH) and the National Clinical Audit and Patient Outcomes Programme (NCAPOP).

13

During 2014/15, one national clinical audits and one national confidential enquiry covered NHS services that AWP provides. During that period AWP participated in 100% of the national clinical audits and 100% of national confidential enquiries in which it was eligible to participate.

The national clinical audits and national confidential enquiries that AWP was eligible to participate in during 2014/15 are set out in table 1 below. The national clinical audits and national confidential enquiries that AWP participated in during 2014/15 are set out in table 1 below. The national clinical audits and national confidential enquiries that AWP participated in, and for which data collection was completed during 2014/15, are listed below in Table 1 alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

Table 1 – Participation in National Clinical Audits

*National Audit Topics that AWP was eligible to participate in

AWP involvement

** Cases submitted /

cases required

POMH 9c Antipsychotic Prescribing for People With a Learning Disability

YES TBC

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

YES TBC

*Table 1: Showing the National Audits the Trust was eligible to participate in, those it did participate in, and the level of completion of data requirements. POMH- Prescribing Observatory for Mental Health (Royal College of Psychiatrists) ** No set number of cases are required

2.2.1 Quality improvement actions from national clinical audit

The reports of four national clinical audits were reviewed by the Trust in 2014/15 and AWP intends to take the following actions to improve the quality of healthcare provided:

National Audit of Schizophrenia

This audit of 84 cases, 14 service user surveys and 12 carer surveys, from 24 teams showed improvements on the previous audit and results were generally better than the national average. Areas for improvement were: use and recording of advance decisions; recording of physical health indicators; recording of smoking cessation advice; antipsychotic polypharmacy rates. Actions on physical health were address through the implementation of the National Mental Health CQUIN. Polypharmacy was addressed by medical directors. Improvement actions around the recording and use of advance decisions remain to be implemented fully.

POMH 4b: Prescribing of Anti-dementia Drugs

This audit of 342 cases from 16 teams showed high levels of compliance with the standards. No improvement actions were required.

14

POMH 12 b: Prescribing for People with a Personality Disorder

Data for 155 service users was returned by 10 teams. Results were acceptable, similar to the national picture but had improved since the previous audit. The main concern was weak documentation of decisions to prescribe antipsychotic medication. No actions were needed beyond sharing results for discussion with the Personality Disorder Network, Medicines Optimisation Group and locality management teams.

POMH 14a: Prescribing for Substance Misuse: Alcohol Detoxification

POMH 14a audited the quality of alcohol detoxification for mental health inpatients needing an unplanned detox. There are 20 to 30 such cases per year in AWP, 15 were audited. Whilst numbers are low alcohol detoxification is dangerous and needs careful management. Areas for improvement: use of breathalisers to determine the stage of detoxification; inclusion of gamma GT in a liver function test; inclusion of some neurological signs in assessments. The Dual Diagnosis Consultant Nurse and Specialist Consultant are reviewing detox protocols to address these gaps.

There were fewer national audits than usual this year as AWP were not eligible to participate in POMH 10c (Prescribing Antipsychotics for Children and Adolescents), and POMH 6c (Assessment of Side Effects of Depot Antipsychotics) was postponed to allow trusts to implement and audit the National Mental Health CQUIN.

2.2.1 Quality improvement actions from local audits

The reports of some 60 local clinical audits were reviewed by the Trust in 2014/15 and AWP intends to take a number of actions to improve the quality of healthcare provided.

AWP-079-15 Positive Caridometabolic Indicators in Schizophrenia (National Mental Health CQUIN) This audit is not on the NCAPOP national list, but was overseen by the National Audit of Schizophrenia. Considerable work was carried out to implement assessment of cardio metabolic risk factors. National data is not published due at the start of 2015/16. This audit looked at the assessment and interventions for smoking, drug use, alcohol use, body mass index, blood glucose and blood lipid levels (8 indicators in total) We reviewed our results locally and compliance was very high with 1306 of 1400 interventions or tests being done. Compliance was 93.3%. Data was returned for 100 of 100 required service users. Of these 88% of service users had all 8 indicators met. Actions were not required, and this work will continue in 2015/16 to our early intervention teams. AWP-077 Transitions Between Oxford Health CAMHS and AWP Adult Mental Health Services & Reaudit of Transition Protocol in Swindon, Wiltshire and BANES CAMHS This audit looked the interface between AWP and Oxford Health Trust in three localities. Oxford Health reviewed 28 patients and AWP 26. Compliance with the protocol was generally high and areas of suboptimal compliance were low risk. Actions were to establish joint clinics, create shared lists of patients over 17 years of age or in early intervention services. These actions have been completed. This audit was highly collaborative and resolved some persistent misconceptions. For example there was a perception that referrals were slow to be picked up and exceeded the four week waiting time limit. However these delays were because of the way referrals were written in advance, asking for care to transfer on the service user’s 18th birthday.

15

2.3 Participation in clinical research

The Trust is committed to research being part of everything we do. We support high quality research into the prevention, treatment and management of mental health problems, addictions and dementia and aim to put research findings into clinical practice wherever possible. AWP ensures we give everyone who uses AWP services, their carer’s and families (as well as our staff) the chance to find out about research they could take part in.

This forms our pledge to make Research for All. In March 2014 AWP became an Everyone Included Trust, which is our way of making sure everyone has the choice to receive information about research.

AWP works with the National Institute for Health Research (NIHR) and the West of England Clinical Research Network (WE CRN). The Trust also collaborates locally with universities and acute Trusts through Bristol Health Partners (BHP), the West of England Academic Health Science Network (AHSN) and the NIHR Collaborations for Leadership in Applied Health Research and Care West (CLAHRC West).

The Research and Development (R&D) department currently supports the Department of Health contract for the National Suicide Prevention Programme grant led by Professor Gunnell at the University of Bristol. It also runs the BEST Evidence in Mental Health clinical question answering service in collaboration with the Cochrane Group at the University of Bristol.

This financial year AWP has participated in 92 research studies (April 2014 to March 2015) of which 51 were National Institute for Health Research (NIHR) adopted studies. 12 of these studies were sponsored by commercial companies. 41 of these were student and non-NIHR portfolio research. AWP continues to act as a Participant Identification Centre for work with RICE (Research Institute for the Care of the Elderly) and now also works with North Bristol NHS Trust on other NIHR studies.

For our last full year of data (April 2013 to March 2014), comparable figures were: 96 active studies in AWP, 45 NIHR studies, 10 sponsored by commercial companies. AWP recruited a total of 978 patients into NIHR studies during this period.

The number of patients receiving NHS services provided or sub-contracted by AWP in 2014/15 that were recruited during that period to participate in research approved by a research ethics committee was 701 (correct at 16 March 2015). This represents a 28% reduction in research participation into NIHR studies, the complexity of the studies has dramatically increased by 18% on last financial year.

2.4 Commissioning for Quality and Innovation (CQUIN) payment framework Two and a half percent of the Trust’s income in 2014/15 was conditional on achieving quality improvement and innovation goals agreed between AWP and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation Payment Framework.

During 2014/15 the Trust CQUIN schemes included a series of initiatives agreed locally for each CCG area along with three nationally set schemes. The Trust achieved measurable improvements and met the target levels aspired to for all of the CQUIN schemes.

Further details of the agreed goals for 2014/15 and for the following 12 month period are available electronically in an additional document which is available from our website: http://www.awp.nhs.uk/news-publications/publications/quality-account/

16

2.5 Care Quality Commission (CQC) registration

AWP is required to register with the CQC and its current registration status is fully registered without conditions.

The CQC has taken enforcement action against AWP during 2014/15.

AWP has not participated in special reviews or investigations by the Care Quality Commission during 2014/15.

Chief Inspector of Hospitals Inspection June 2014

In June 2014 the Trust received a comprehensive inspection, as part of the pilot for the new inspection approach for mental health trusts, led by the CQC Chief Inspector of Hospitals. The Trust was inspected over a period in excess of a week by a team of over 70 individuals.

The report highlighted areas for improvement as well as recognising the kind, caring and responsive approach of our staff and noted their high skills in the delivery of care. The report also highlights examples of good practice including evidence based practice, centres of excellence in specialist services and motivated clinical leadership.

As a result of the inspection the Trust received a report summarising the findings stating that “the trust needs to take significant steps to improve the quality of their services and we find that they are currently in breach of regulations.” Enforcement Actions were issued to the Trust which gave strict timescales for the Trust to make the required improvements.

Set out below are the four key areas covered by the enforcement action:

• Regulation 10 Assessing and mentoring the quality of service provision - in relation to several examples where the Trust could not demonstrate that it had taken appropriate action or learned from previous CQC inspections or when things had gone wrong

• Regulation 15 Safety and suitability of premises - for Fromeside medium secure unit in Bristol, in relation to dirty carpets and ligature points

• Regulation 15 Safety and suitability of premises - for Hillview Lodge acute adult inpatient ward in Bath, in relation to standard of maintenance, décor, cleanliness and lack of privacy and dignity

• Regulation 22 Staffing - for Fromeside, sufficient numbers of suitably experienced staff

In December 2014 the Trust received a follow up inspection to test whether the improvements had been made in these areas. The Trust is pleased to have been informed that the CQC were satisfied that improvements were made to allow the enforcement notices to be lifted.

The report can be found at the following link with full details of the findings. http://www.cqc.org.uk/directory/rvn As a result many actions have been completed and improvements made such as increased recruitment, staffing being more closely matched to capacity and needs, an accelerated anti ligature and replacement and refurbishment programme to deal with estate issues, more training and changes to some of our systems. We are confident that by continuing to work with our commissioners we will strengthen our services and meet the CQC requirements.

At the post inspection quality summit hosted by the CQC and the NHS Trust Development Authority (TDA), the CQC expressed its confidence in the leadership of the

17

Trust to resolve the inspection issues and to take the Trust forward. The solution to some of these historic issues will require a co-ordinated push from the Trust, commissioners and social care colleagues as well as support from the CQC and the TDA.

Our Trust accepts the inspectors’ conclusions and reaffirms its absolute commitment to delivering consistently the required standards.

18

2.6 Quality of data

The Trust has a comprehensive and systematic approach to the management of the quality of data held on its patient information system RiO, which is then used for reporting.

The quality of the electronic patient record is audited monthly via the Trust’s Records Management audit, that requires senior clinicians to review five randomly selected records and to rate them against a series of ten criteria. This is supported by a suite of ‘completeness’ metrics that check that key information is available for all patients accessing services and a further check is undertaken to ensure that staff are entering data into the system in a timely manner. Results for these indicators are reported internally to Board Committee and Board and externally to Commissioners on a monthly basis and team / ward level information is available in ‘real time’ to allow managers to track their performance.

Results are presented in table 2 below. Performance across the quality audit and the completeness metrics remains strong, however 2014-15 has seen a dip in performance for the timeliness of data entry. The underlying causes of this dip are known to the organisation and action is underway to address the issues.

DATA TO BE UPDATED END 14/15

Table 2: Data quality measures Target level

2013/14 2014/15

Records Management: monthly audit (local indicator) 75% 84% 86.5% ��

Data completeness - core fields for patient identification (national indicator)

97% 99.9% 99.9% ►

Data completeness - outcome fields (national indicator) 50% 81.2% 79.9% ▼

Data quality: completion of NHS number (national indicator, new for 2014-15)

99% NA 99.9%

Data quality: completion of ethnic category (national indicator, new for 2014-15)

90% NA 100%

Data quality: completion of risk assessment (local indicator, new for 2014-15)

85% NA 99.9%

Data quality: completion of crisis, relapse and contingency plans (local indicator, new for 2014-15)

85% NA 86%

Data timeliness - system updated in three days of actual event (local indicator)

95% 95.1% 93.2% ▼

The Trust will be taking the following actions to improve data quality:

• Continue to complete the Records Management audit on a regular basis, but reviewing the focus of the audit and the target in year to ensure both remain relevant and are supporting continual improvement in record keeping.

• Completeness metrics for all nine protected characteristics will be provided routinely in 2015/16, driving an improvement in overall completeness allowing for further analysis (meeting the requirements of the Equality Act).

19

Our performance against other key areas of data quality is as follows: The Trust submitted records during 2014/15 to the Secondary Uses Service for inclusion in the hospital episode statistics which are included in the latest published data. The percentage of records in the published data which included the patient’s valid:

• NHS number was 100% for admitted patient care.

• General Medical Practice Code was 100% for admitted patient care. The Trust’s Information Governance Assessment report score overall for 2014/15 was 77% and was graded satisfactory (green). AWP was not subject to the Payment by Results clinical coding audit during 2014/15 by the Audit Commission.

2.7 Safeguarding The Trust continues to regard safeguarding as a key and developing priority to protect the people, their families and the communities we work with.

AWP remains an active member of the safeguarding multi agency partnerships in our area, including Safeguarding Children and Safeguarding Adults Boards, Domestic Violence partnerships, †MAPPA Strategic Management Boards and Contest and Prevent partnerships.

This year there have been further significant developments in safeguarding that have formed the main basis for development work in the Trust including the on-going actions following the Savile reports, changes to the law including the placing of adult safeguarding on a statutory footing and the Supreme Court judgements in relation to Deprivation of Liberty Safeguards for adults under our care, emerging new issues, including female genital mutilation, child sexual exploitation and modern day slavery, as well as lessons from our own internal investigations in to serious incidents.

The Trust has also been involved in working with local authorities, commissioners and local multi agency safeguarding partnerships to develop a range of improvements in practice and policy.

The Trust has implemented procedures, systems and training, with over 900 staff receiving counter terrorism Prevent ‡HealthWRAP training by the end of 2014/15. The Trust has seen a continuing rise in casework in this area.

The Trust safeguarding team saw a continuing rise in safeguarding activity levels and contacts from practitioners in 2014/15 in all safeguarding and public protection processes, with nearly 2000 contacts to the team from practitioners during the year. This is due to increases in safeguarding statutory duties, the number and complexity of safeguarding partnerships, safeguarding governance requirements, serious case review processes and large increases in safeguarding case activity and complexity.

During 2014/15 we have prioritised improvements in the following areas:

† Multi-Agency Public Protection Arrangements (MAPPA) is the name given to arrangements in England

and Wales for the "responsible authorities"

‡ HealthWRAP is the prescribed Home Office/Department of Health training package for Prevent (as a key

part of the government’s CONTEST counter terrorism strategy)

20

• Planning for the implementation of the Care Act 2014, including the new statutory duties and roles , and the change to person centred adult safeguarding

• Planning for the implementation of the new CQC revised regulations on Safeguarding (draft Regulation 13)

• Commencing use of the new safeguarding function within the RiO and ensuring effective recording of safeguarding information in other electronic patient record systems

• Delivering the detailed actions set out in the Safeguarding Children, Safeguarding Adults at Risk, Domestic Abuse, MAAPA, Prevent and Historical Abuse action plans in the Trust.

• Managing the increased demand for safeguarding activity, including safeguarding cases management and enhanced safeguarding governance activity with safeguarding partnerships and commissioners

21

Part 3: Our care quality achievements in 2014/15 The Trust has a robust performance and quality improvement strategy. From Board level to frontline services, quantitative and qualitative information is scrutinised covering the areas of patient experience, effectiveness and safety. Reports are reviewed monthly by the Board, and across the Trust, including external scrutiny by our commissioners and a range of care forums. This approach has helped to systematically improve the quality of services.

Trust’s quality surveillance system, called ‘Information for Quality’ (IQ), reports data at ward and team level up to local area service delivery unit and Trust level. The system reports across seven key domains as an early warning system to identify areas for improvement.

In this section, we describe what we achieved during the year across the areas of patient experience, effectiveness and safety. We describe how have progressed with our quality improvement priorities alongside a series of quality indicators that we routinely use for measuring the quality of services.

For each domain of quality, we have included some measures, as key quality indicators, which show data for the Trust overall. Area level breakdowns to enable local comparison are available in Appendix D and further information on the definitions of the measures used is included in Appendix E.

3.1 National Indicators

Set out in the section below are the national quality indicators that trusts are required to report in their Quality Account.

Additionally, where the necessary data is made available to the trust by the Health and Social Care Information Centre (HSCIC), a comparison of the numbers, percentages, values, scores or rates of the trust are included.

3.1.1 Care programme approach (CPA) seven day follow up

National data - CPA seven day follow up

Data Source

Reporting period (for 3 months in quarter)

National Average

Q4

2014/15

Highest score

nationally Q4

2014/15

Lowest score

nationally Q4

2014/15 Q4 2013/14 Q4 2014/15

Number % Number %

HSCIC 526/536 98.1% TBC TBC TBC TBC TBC

DATA NOT YET AVAILABLE The Trust considers that this data is as described for the following reasons: to add narrative when data available.

The Trust intends to take/has taken the following actions to improve this percentage, and so the quality of its services: To add narrative once data available

22

3.1.2 Admissions to inpatient services have had access to crisis resolution home treatment teams

DATA NOT YET AVAILABLE The Trust considers that this data is as described for the following reasons: To add narrative once data available.

The Trust intends to take the following actions to improve this percentage, and so the quality of its services, by … To add narrative once data available.

National Data - admissions to inpatient services have had access to crisis resolution home treatment teams

Data Source

Reporting period (for 3 months in quarter)

National Average

Q4

2014/15

Highest score

nationally

Q4 2014/15

Lowest score

nationally

Q4 2014/15 Q4 2013/14 Q4 2014/15

Number % Number %

HSCIC 247/257 96.1% TBC TBC TBC TBC TBC

23

3.1.3 Ensuring that people have a positive experience of care

Data is provided for this indicator from the annual Care Quality Commission Community Mental Health Survey. The indicator is a composite, calculated as the average of four survey questions that relate patients’ experience of contact with a health and social care worker.

The Trust considers that this data is as described for the following reasons: The data reflects the Trusts current position as benchmarked against other similar organisations. The score is judged by the CQC as ‘about the same’ compared to other Trusts. Further detail on our results for the national Community Mental Health Survey are detailed in section 3.5.3.

The Trust intends to take the following actions to improve this score, and so the quality of its services, by:

• Using the national Friends and Family Test survey which provides team and ward information on service users’ experience on a monthly basis. This allows quick and focused local responses to specific issues raised and informs Trust wide improvement actions.

• Ensuring that all Local Delivery Units review the quantitative and qualitative community survey data and plan local actions focused on the areas needing improvement.

National Data – Patient experience indicator

Reporting Period

AWP Score

England average

Highest score

nationally

Lowest score nationally

2014 TBC TBC TBC TBC

2013 83.5 85.8 90.9 80.9

2012 85.8 86.5 91.8 82.6

24

3.1.4 Treating and caring for people in a safe environment and protecting them from avoidable harm

Patient safety incident data is collected centrally by the National Reporting and Learning Service (NRLS). Two measures are reported below for the rate of incidents reported per 1000 bed days and the rate of incidents which are categorised as causing severe harm or death.

Please note that the data for the period October 2013 to March 2014 (published in September 2014) is the most recently available due to a delay of six months from when data is submitted to the NRLS to it being published. Further data is expected in March 2015.

National Data – Patient safety incident data

Reporting Period

(6 months)

AWP Score England Average

Highest score nationally

Lowest score

nationally

Number Rate

i) Rate of patient safety incidents reported per 1000 bed days

01/04/11 to 30/09/11

2185 18.74 21.1 86.22 3.06

01/10/11 to 31/03/12

2816 24.16 23.5 86.99 0.00

01/04/12 to 30/09/12

3026 30.19 23.8 70.29 5.44

01/10/12 to 31/03/13

2742 27.4 32.3 99.8 0.00

01/04/13 to 30/09/13

3367 34.47 28.03 67.06 0.00

01/10/13 to 31/03/14

3538 36.22 28.5 58.69 0.00

ii) Rate of incidents reported that caused severe harm or death

01/04/11 to 30/09/11

42 1.9% 0.8% 7.0% 0.1%

01/10/11 to 31/03/12

37 1.3% 1.3% 5.3% 0.0%

01/04/12 to 30/09/12

59 1.9% 1.6% 9.1% 0.1%

01/10/12 to 31/03/13

32 1.2% 1.3% 9.4% 0.0%

01/04/13 to 30/09/13

41 1.2% 1.3% 5.3% 0.0%

01/10/13 to 31/03/14

18 0.5% 1.1% 5.4% 0.0%

Notes *Incident data is reported via the National Reporting and Learning Service. Not all organisations apply the

national coding of degree of harm in a consistent way, which can make comparison of harm profiles of organisations difficult.

25

The Trust considers that this data is as described for the following reasons:

The data concurs with our own data and we are pleased to note the increase in reporting (both in terms of numbers and rate per thousand bed days) between 2011 and 2014. We believe that this is as a result of actions taken to ensure continuous improvement, such as thematic reviews and executive led quality improvement visits both of which have encouraged reporting and promoted a patient safety culture. We note that our percentage of incidents causing severe harm or death is below the national average. We are confident that our criteria for serious untoward incidents is appropriately inclusive and we are assured through the topic specific benchmark work that we undertake that we make every effort to ensure our services are as safe as possible.

The Trust is taking the following actions to improve this percentage rate, and so the quality of its services, by:

The Trust credits the ease of use of its web incident reporting system together with its promotion of a fair blame culture for the improved percentage rate and it plans to further improve through targeted work across services to challenge incident reporting cultures.

3.1.5 Staff Friends and Family Test

Data is provided for this indicator from the annual NHS Staff Survey. The indicator is the percentage of staff who answers were either ‘agree’ or ‘strongly agree’ with the question “If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation”.

The Trust considers that this data is as described for the following reasons:

The question gives us an indication of staff confidence in the quality of care provided. Staff survey results for 2014 are disappointing but not unexpected. Against a backdrop of NHS pressures, CQC scrutiny and criticism, our staff have experienced significant internal change during the year and some have experienced job uncertainty. We have analysed the data from the National Survey as well as conducting a quarterly staff friends and family test surveys.

The Trust is taking the following actions to improve this percentage rate, and so the quality of its services, by: Clear themes emerge from the survey feedback and we have set out our approach to addressing these in section 3.8. .

National Data – National NHS Staff Survey - Friends and Family Test

Reporting Period

AWP Score

England average

Highest score

nationally

Lowest score nationally

2014 47% 66% 93% 36%

2013 48% 65% 94% 38%

26

Patient experience - How we did

Understanding the experience of our service users and their carers is fundamental to the Trust making sure that we provide good quality services. We continuously strive to improve quality in response to service users and carers experiences. Progress with our 2014/15 priorities to improve patient and carer experience Last year, our priority quality improvements for service user and carer experience were:

• To use of the Friends and Family Test service user survey to improve service user experience by taking prompt action at ward and team level in response to regular feedback from service users and their carers

• Using the Carers Trust ‘Triangle of Care’ framework to improve carers’ experience through improved partnership working and carer support.

3.2.1 The NHS Friends and Family Test (FFT)

Aims Actions Success measures 2014/15 Outcome

To improve service user experience by taking prompt action at ward and team level in response to regular feedback from service users and their carers

To share our real-time service user and carer feedback from the ‘Friends and Family Test’ with staff, service users and carers in wards, reception areas and via our service user and carer groups.

We will develop improvement actions in partnership with our service users and their carers.

Evidence of local improvement actions and sharing feedback.

Improved scores for the ‘Friends and Family Test’.

ACHIEVED

Progress 2014/15

All Service Delivery units have evidenced how they are sharing feedback and developing improvement actions in partnership with staff, service users and carers locally.

We have improved our overall survey response rates from 10.2% in March 2014 to 12.5% in March 2015, achieving 14% in December 2014.

The score is based on the percentage of service users who would recommend our services and this has fluctuated over the year around 88 to 90%, moving from 88.8% in March 2014 to 89.7% in March 2015.

National data available for February 2015 shows AWP scoring above average at 90.5% ‘would recommend’, compared to the national benchmark for mental health services of 85%.

Understanding the experience of our service users and carers is key to informing how we make adjustments and improvements to our services to meet the needs and expectations of those using them.

The Friends and Family Test (FFT) survey was introduced to the NHS in 2012 as a single measure to look at the quality of care across the country, promoting the principle that all people should have the opportunity to feed back about their care and treatment.

The FFT is a single question that asks people who use the services whether they would recommend the service to friends and family who need similar care or treatment. In addition it asks them to give the reason for their response; it is these comments that can

27

be used locally to highlight good practice and address concerns much faster than more traditional survey methods.

AWP introduced the FFT ahead of the national schedule as a national early adopter pilot site in 2013 and 2014. In 2014/15 our focus was to improve the use of the FFT in our community teams and to ensure that this valuable feedback was being promptly responded to by our teams and wards.

Engagement with the Friends and Family Test

The key to success of the FFT as a service improvement tool is ensuring the engagement of staff and service users in the process of receiving and responding to the comments received. To do this we have improved our guidance and promotional materials and supported staff in collating and presenting their feedback. Using the ‘you said we did’ format we have used posters in wards and waiting areas but also involved service users and carers in meetings to review feedback and to help plan actions.

We measure this in two ways as shown in Graph 1 and 2 below:

i. Percentage of responses that provide a comment – we have seen an increase over the year from 70% to 79%. This indicates that the majority of services users who respond provide a comment. It gives some indication of the level of confidence that the Trust will listen and act on their concerns. In addition, the majority of feedback received is praise which is motivating for staff. See 3.5.4. for examples of feedback and improvements.

ii. Response rate – this measures the percentage of service users who have responded to the survey out of those who have had a care review or been transferred or discharged from care.

We have improved overall from 10.3% in March 2014 to 12.5% in March 2015 although we have noted a recent fall. Notably our community services have increased from 8.7% March 2014 to 11.3% in March 2015. This is set out in Graph 1 below. We will be continuing in 2015/16 to improve the consistency of the use of the FFT across all service areas.

Graph 1 – Friends and Family Response Rate 2014/15

28

Our Friends and Family Scores

We score the FFT based on the percentage of responses that would or would not recommend our services to their friends or family.

Graph 2 below sets out the range of scores across the year for the percentage who would recommend, this shows a fluctuation through the year with a small overall increase.

From January 2015 national data has been published for all mental health Trusts. In February, AWP performed above the national average; 90.5% of service users would recommend our services, compared to 85% nationally. Fewer AWP service users said they would not recommend AWP services than nationally (AWP 2.9%, national 5%).

When compared to Mental Health Trusts providing similar services, we are one of the top performers for the number of surveys received.

Graph 2 - Friends and Family Scores 2014/15

Note: ‘would recommend’ includes ‘extremely likely’ and ‘likely’. ‘Would not recommend’ includes ‘unlikely’ and ‘extremely unlikely’ Responses not shown were either neutral or ‘don’t know’.

29

3.2.2 Our work with carers and the Carers Trust Triangle of Care


To improve carers’ experience through improved partnership working and carer support.

We will continue to use the Carers Trust ‘Triangle of Care’ self-assessment improvement tool in all services and take identified improvement actions.

Implementation of our Family Friends’ and Carers Charter.

Membership of Triangle of Care.

Evidence of 80% of teams and wards using the toolkit and making improvements.

ACHIEVED

Progress 2014/15

We shall be submitting evidence for our second phase for community teams in May 2015, this will be the accreditation for the work achieved in the past year.

Actions identified by the Triangle of Care have been implemented with positive results, including carer training, streamlined processes for recording carer work on the patient record (RiO) and Advance Care Planning for which carers and staff have co-produced an information pack and training.

In the last year, we have continued our work to improve our partnership working with carers using the Carers Trust ‘Triangle of Care’ toolkit and this will continue into 2015/16. Accreditation for phase 1 of the Triangle of Care was achieved in May 2014.This relates to improved partnership working on acute inpatient units, rehabilitation units and intensive teams.

This scheme is recognised nationally as a way of demonstrating a commitment to working in partnership with carers. All teams and wards have a Carer Champion who has received specialist training and lead the use of the Triangle of Care self-assessment toolkit locally. The toolkit provides a framework based around the six key standards, as below, and supports teams to plan and take actions locally to meet them.

The six key standards of the Triangle of Care

1. Carers and the essential role they play are identified at first contact or as soon as possible thereafter.

2. Staff are ‘carer aware’ and trained in carer engagement strategies. 3. Policy and practice protocols re: confidentiality and sharing information, are in

place. 4. Defined post(s) responsible for carers are in place. 5. A carer introduction to the service and staff is available, with a relevant range of

information across the care pathway. 6. A range of carer support services is available.

30

This past year our focus was on community teams to complete this process and to submit for accreditation in May 2015. Alongside the efforts at local level, the Trust has maintained a Trust wide Carers’ Forum that has led the Trust’s work with carers and partner organisations. In particular the group has advocated for dedicated time for carers work which has been agreed in four localities. It has also overseen the delivery of specialist carer and family training and ensured that all staff receive local training on carer awareness. Four carers from the Carers Forum represent carer views at the Trust Wide Involvement Group. In the National Community Mental Health Survey 2014 there is a specific question on ‘family and carers’:

Have NHS mental health services involved a member of your family or someone else close to you, as much as you would like?

59% said yes, definitely; 25% said yes, to some extent; 14% said no, not as much as they would like. Compared nationally AWP score about the same' as most other trusts for this question. Family, Friends’ and Carers’ Charter

This charter was developed in 2014 through co-production with carers and staff. The Charter contains a series of statements that can be measured, to demonstrate AWP’s continuing commitment to working in partnership with carers. Posters with the standards have been developed for display in reception and waiting areas and leaflets containing the Charter will be given to carers alongside any information that is normally given to them. Details are published on the Trust’s website. Carers are offered the opportunity to give feedback on how well these standards are being delivered.

31

3.2.3 Patient experience indicators The metrics below in Table 3 reflect key measures of quality for measuring patient experience. These indicators are measures of access to services for assessment and how we are making reasonable adjustments to meet the needs of those service users with a learning disability; as well as various other elements of patient experience such as:

• ensuring inpatient accommodation meets the dignity and privacy needs of all sexes

• a score for patient experience from the national Care Quality Commission survey

• a staff survey indicator of how our staff feel about the services they provide

Table 3: Patient experience – how we did

Indicator Standard 2013/14 2014/15

(numerator / denominator

Service users seen for their first appointment within four weeks of their referral

95%

99%

96.4%

(13,222 / 12,741)

►

Compliance to Department of Health standards for eliminating mixed sex accommodation

100%

Compliance

100%

100%

►

Meeting six criteria for access to healthcare for people with a learning disability

All criteria met

Fully met

Fully met ►

NHS patient experience question ‘Overall, how would you rate the care you have received from NHS Mental Health Services in the last 12 months?’

National Average

Achieved Achieved ►

Staff Friends and Family

Score for staff survey question on recommending the provider to friends or family needing care

National Average

3.55

Below average

3.37

Below average

3.33

▼

The poor performance of the staff survey indicator is a key concern of the Trust Board recognising that this is a key indicator of the quality of our services. Further information on staff experience measures and plans for improvement is included in section 3.8. During 2014/15 the Trust has implemented the Department of Health Staff Friends and Family quarterly survey to help us monitor this more regularly.

32

3.3 Effectiveness - How we did Effective services are defined as providing the right care to the right person at the right time.

Progress with our 2014/15 priorities to improve effectiveness

Last year, our two priority areas for quality improvements were to:

• Improve our approach to formulation in our assessment of service users to help our clinical practitioners develop more clinically effective care plans

• To improve the effectiveness of our care pathways and interventions with service users

3.3.1 Improving our approach to formulation

Aims Actions Success measures

2014/15 Outcome

To improve our approach to formulation in our assessment of service users to help our clinical practitioners develop more clinically effective care plans

Training and development of staff on formulation.

Availability of on-line resources through our clinical toolkit.

Audits of the clinical record demonstrate that 85% of records have a formulation summary recorded.

NOT ACHIEVED

February 2015 79.4% of records have a formulation summary recorded

Progress 2014/15

The Trust has completed the planned actions however the success measure does not reflect the desired improvement.

The Trust has developed guidance in the Clinical Toolkit to support staff to develop clinical formulations to inform care planning and intervention. This is available via Ourspace.

Team based training in formulation has started to be delivered by Trust psychologists to support this alongside additional training for individuals delivered during 2014.

The measure above is based on a monthly Records Management Audit for each team which includes a review of records to test if a formulation is present and meets the best practice guidance outlined in the Clinical Toolkit.

Scores for this audit at the beginning of the year in April 2014 were at 80.1%. Through the year there have been fluctuations around this level with our end of year results not showing any consistent improvement for the measure at 79.4% of records reviewed had a formulation recorded.

The Trust will be continuing improvement work in this area as part of the improvement work planned for clinical practice of assessment and care planning.

33

3.3.2 To improve the effectiveness of our care pathways and interventions with service users


To improve the effectiveness of our care pathways and interventions with service users.

Delivery of local area quality and service improvement plans to improve the care pathways and interventions provided to service users.

Successful delivery of local area quality improvement plans.

PARTLY ACHIEVED

Progress 2014/15

During the year our Service Delivery Units have progressed with their local quality plans which were developed to meet the specific needs and priorities of the local health community. We have rated this as partly met because not all of our plans were completed as we had to refocus efforts on the delivery of a improvements to address areas identified by the CQC inspection in June 2014.

Several of the improvement initiatives were part of the Trusts §CQUIN programme agreed in partnership with commissioners. Some examples of the schemes delivered by area are as follows:

• Implementation of ‘Alcohol Use Disorders Identification Test Consumption tool’. This aids the identification of people who would benefit from reducing or ceasing drinking alcohol. (B&NES)

• Improved effectiveness of inpatient stay and discharge planning in partnership with other services (Bristol)

• Transition arrangements with Child and Adolescent Mental Health Care services (North Somerset)

• Autism early intervention (South Gloucestershire)

• Acute hospital dementia assessments (Swindon)

• Review of community mental health services model (Wiltshire)

• Collaborative multidisciplinary risk assessments involving the service user (Medium and Low Secure Services)

§ CQUIN is Commissioning for Quality and Innovation. It is a scheme whereby Trusts can earn additional

income dependent on the delivery of a set of measured quality improvement objectives.

34

3.3.3 Effectiveness indicators

This section demonstrates how we are doing on key measures of effectiveness as set out in table 5.

These measures are indicators for:

• ensuring service users have a timely review of their care

• ensuring assessments are made so that service users are only admitted to inpatient care if no other care in the community is appropriate

• monitoring that we are identifying the expected number of cases of psychosis through early intervention for the population of the health community served.

Table 5: Effectiveness – how we did

Indicator Standard 2013/14 2014/15


Annual CPA review 95% 96% 95.1%

▼

Admissions to inpatient services have had access to crisis resolution home treatment teams

95% 97% 95.0%

▼

Minimising delayed transfers of care <7.5% 6.5%

9.2%

▼

Number receiving early intervention 182 246 261 ▲

The Trust has seen an increase in delayed transfers of care, which is attributed to increasing difficulty in finding appropriate care home placements for service users with highly complex health and social care needs. The Trust is working closely with partner organisations to ensure timely discharge and is hoping to see an improvement in 2015/16.

35

3.4 Safety – How we did

It is not only crucial that services are as safe as they can be, but that we can demonstrate this to ourselves, our partners, our services users and carers and to the public. AWP continues to work hard to ensure that our services are as safe as possible.

Progress with our 2014/15 priorities to improve safety

Last year our priority areas for safety quality improvements were:

• To focus on the physical health of our severely mentally ill (SMI) patients to reduce premature death, improve patient safety, patient experience and quality of life through shared communications and reconciliation of treatments. This was a national CQUIN scheme.

• To reduce the use and need for restrictive interventions and improve the use of positive and proactive approaches to care.

3.4.1 Improved physical health checks including assessment of cardio metabolic risk factors.

People with Serious Mental Illness have much higher morbidity and mortality rates, compared to the general population. It is acknowledged that service users within mental health services do not always receive the physical health care intervention they require and this and the following improvements to communicating with GP was designed to directly tackle this issue.


Reduce premature death in severely mentally ill patients and ensure physical health needs are identified and treated

The full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in inpatients with schizophrenia

Meeting 90% compliance assessed via the National Audit of Schizophrenia.

TBC

Progress 2014/15

The Trust has completed the data collection and submitted data to the national audit team. Locally results have been analysed and compliance is expected to be high. Depending on how the national team calculate overall compliance figure the Trust is expecting to be between 88% and 98%compliant.

The Trust took action to make sure that for those patients with Schizophrenia that an assessment was completed for each of the following key cardio metabolic parameters (as per the 'Lester tool'), with the results recorded in the patient's notes/care plan/discharge documentation as appropriate, together with a record of associated interventions (e.g. smoking cessation programme, lifestyle advice, medication review, treatment according to NICE guidelines or onward referral to another clinician for assessment, diagnosis, and treatment).

The parameters are:

• Smoking status • Lifestyle (including exercise, diet alcohol and drugs) • Body Mass Index • Blood pressure • Glucose regulation (HbA1c or fasting glucose or random glucose as appropriate) • Blood lipids

36

3.4.2 Communication with GPs to improve physical health care and reconciliation of treatments


Ensuring that discharge summaries are shared with GPs and include comprehensive information including diagnosis, medications, physical health conditions and recovery interventions.

Development of comprehensive guidance and training for clinical practitioners on the inclusion of diagnosis, medications, physical health conditions and recovery interventions in discharge summaries for inpatients

Meeting 90% compliance assessed by a local audit of care plans.

TBC

Progress 2014/15

The second and complimentary part of this national physical health care scheme was to focus on ensuring the sharing of appropriate physical and mental health information with GPs.

AWP are aware from previous clinical audits that assessment and care planning of physical health has been poor.

Guidance was issued to staff on the key improvement areas as below, as well as a comprehensive review and rewrite of the Physical Health Policy.

The Trust focused efforts on a standardised system across all wards using the ‘Interim Discharge Summary’ letter. This is the document that is issued to GPs within 24 hours of a patients discharge from a ward. Revisions were made to ensure that the letter template asks for the following items to be completed:

• all primary and secondary mental and physical health diagnosis, including ICD codes; • medications prescribed and monitoring requirements • physical health condition and on-going monitoring and treatment needs • cardio metabolic risk factors with results, interventions and recommended action for the GP.

The Trust is completing an audit of discharge letters in April to provide the evidence of the expected improvements.

37

3.4.3 Reducing the use and need for restrictive interventions


To reduce the use and need for restrictive interventions and improve the use of positive and proactive approaches to care

Implementation of Department of Health Guidance ‘Positive and Proactive Care: reducing the need for restrictive interventions’.

‘Safewards Model’ implemented on all wards.

A reduction in all restrictive practices of 20% over two years.

PARTLY ACHIEVED

Progress 2014/15

The Safewards model is being implemented across the Trust and 31% of wards have implemented one or more of the 10 Safewards Interventions. With the support of commissioners the Trust has recently appointed a Service User Involvement Worker to support the implementation of Safewards and ensure service user involvement.

The programme of work is being managed by the Violence Reduction Work Group and the Trust’s Prevention and Management of Violence & Aggression Training programme (PMVA) has been reviewed and revised accordingly.

Staff guidance and checklists have been developed with full clinical engagement.

The Trust has participated in two national benchmarking exercises in the use of restrictive practices and overall AWP has an average number of incidents of restraint compared to other Mental Health Trusts and lower than average incidents of face down restraint than other Mental Health Trusts. We have scored our progress this year as amber as we do not have reliable data to evidence any progress towards our reduction target.

A revised restrictive practices reporting standard has been developed and this will enable the Trust to provide more detailed information about types of restrictive practices used in the coming year. To date current data collected by the Trust shows an increase in the numbers of reported cases of restraint and seclusion, however this is believed to be a consequence of implementing the ‘Safewards’ programme which highlights the use of restrictive practices and encourages better reporting; this evidences a positive outcome of the work.

38

3.4.4 Safety indicators

This section demonstrates how we are doing on key measures of safety as set out in table 8.

• Care Programme Approach (CPA) 7 day follow up – for ensuring all patients are contacted post discharge when most vulnerable

• How service users felt about the safety of services

• Staff sickness absence: we believe a stable, healthy and consistent staff team makes for a safer and more reassuring service for our service users, carers and visitors

• Maintaining services that are free of the risk of hospital communicated and acquired infections

The Trust has maintained standards to the national expectations for CPA seven day follow up and infection control. With respect to our indicator for patients feeling safe as an inpatient our score remains in the band of about the same as other Trusts but has dipped to below the national average. We have recognised this issue and are therefore prioritising more work this year to improve the safety of our wards.

With respect to sickness the Trust recognises the impact on safety and patient’s continuity of care where there are high staff sickness levels. During the year we have made concerted efforts to reduce levels of staff sickness, particularly by ensuring the effective management and support of individuals suffering from long term sickness alongside developing a staff support programme.

Table 6: Safety – how we did

Indicator Target 2013/14

2014/15


CPA seven day follow up 95% 98% 96.5%

(2,023 / 2,097)

▼

Percentage answering ‘yes always’ to the survey question ‘During your most recent stay did you feel safe?’

National Average

41%

41% 34% ▼

Staff sickness absence data cumulative average over past 12 months

4.6% 4.51% 4.43 ▲

Meeting objectives for the reduction of infections of Clostridium difficile and Methicillin-resistant Staphylococcus aureus (MRSA)

Reduction Achieved Achieved ►

39

3.5 Service user, carer and patient experience

In 2014, we gathered feedback from service users and carers about their experience of care through the national community mental health survey, the annual inpatient survey and regularly via the Friends and Family Test across all our services. Complaints, praise and feedback is received via the Patient Advice and Liaison Service (PALS) and there is further feedback from incident data and CQC inspections and visits.

This information is used to inform our on-going actions to improve quality and the annual priorities for quality improvement.

3.5.1 Patient Advice and Liaison Service (PALS), praise and complaints

2011/12 2012/13 2013/14 2014/15

No of formal complaints 278 302 272 314

No of informal complaints 27 103 88 72

Total 305 405 360 386

Referred to Parliamentary and Health Service Ombudsman

19 21 7 12

PALS cases 1688 1485 1631 1887

Praise received 709 782 849 724

The table below shows the classification of themes arising from complaints and PALS. The classification list has been revised this year and the Trust has adopted the themes used by the Care Quality Commission. Examples of the fields these themes contain have been given in the table, but these lists are not exhaustive.

Five themes from our feedback Complaints PALS

Responsive (includes access to services, responsiveness to referrals and inpatient bed management)

75 360

Effective (includes clinical care, CPA, discharge from services, MHA, physical healthcare)

138 437

Caring (includes attitude of staff, privacy and dignity, communication)

119 387

Safety (includes medication, nutrition, personal safety, safeguarding, personal property)

47 191

Well led (incudes policy and procedure, health records, complaints handling, requests for information, user and carer involvement)

7 512

TOTAL 386 1887

40

3.5.2 Learning from complaints and concerns

The Trust recognises that promoting a culture of openness is a prerequisite to improving service user safety and the quality of healthcare services. We apologise and explain what happened to service users or their representatives when things have gone wrong. We look, where possible, to put things right. Sharing the learning from complaints and concerns helps and informs us to make changes to practice, processes and systems so that the risk of harm or recurrence is reduced. Information from PALS and Complaints cases is used alongside information from incidents and the Friends and Family Test to help the Trust to shape services, to identify ‘hot spots’ and to act as an early warning system for the Trust to identify potential issues.

AWP wants to encourage people to raise their concerns and complaints. PALS carry out ward visits and attend AWP forums (inpatient and community) so they are available to speak to people face to face. This year we have increased our presence on older people’s wards, rehabilitation units and carer groups.

In 2015/16 a user-led panel will be formed to look at how we handle complaints. The aim of this panel is to consider our complaint investigations and to identify when we have got it wrong, when best practice can be identified and reinforced, and how we can improve our systems and in turn improve people’s experience of raising complaints and concerns.

We are also moving to an internet web based system to capture and report on all the praise we receive.

41

3.5.3 National survey findings

Community Mental Health Survey 2014

The Trust is within the expected range for mental health trusts and scored ‘about the same’ as other mental health trusts for all eight sections of the published results of the annual national Community Mental Health Survey. See the table below.

The report is available on the Care Quality Commission website at the following link: http://www.cqc.org.uk/provider/RVN/survey/6 (scroll to second half of webpage).

The majority of scores were close to the average for all trusts. There was an improvement in service users knowing who was in charge of their care. We continue to score well for involving carers, however, we are no longer above average. Some areas for improvement include: information about medication, advice about support for needs such as accommodation and employment, crisis care and making sure that staff changes do not have a negative effect on peoples’ care.

Section heading Score out of

10 for your

trust (2014)

How this score compares with other trusts

Health and Social Care Workers 7.7 Average

Organising care 8.6 Average

Planning care 7.0 Average

Reviewing care 7.6 Average

Changes in who people see 6.6 Average

Crisis Care 6.0 Average

Treatments 7.2 Average

Other areas of life 4.9 Average

Overall views and experiences 7.2 Average

In response to our community survey results and the many service user comments received, our local service delivery units have developed their own action plans, each focussing on a small number of areas where there is scope for improvement. Issues being addressed include:

• Service user access to information about contacting others with lived experience

• Helping service users to understand how different organisations work with each other

• Making sure that people know who is in charge of their care when there is a change.

• Good crisis support, including a review of local resourcing

• Fully involving service users in care planning, so that issues that are important to people in their lives are addressed

• Making sure that service users fully understand the purposes and side effects of medication

42

Inpatient survey 2014

The Trust chose to repeat the national adult inpatient survey for the sixth year since it was first undertaken in 2009. Approximately half of all mental health trusts undertook this optional survey.

This year, most scores improved for interactions with psychiatrists in comparison to last year. Trust wide actions following the 2013 survey have resulted in service users reporting a more positive experience.

Scores also improved compared to last year for people having been contacted by the mental health team since they left hospital. The AWP score (94%) was the highest of all mental health trusts taking part in the survey.

Feedback was less positive than last year for service users’ interactions with nurses. Some comments suggested that lower scores for nurses listening carefully might be related to staff workloads.

Scores were lower than last year for questions about talking therapies. National scores for questions about medication were generally low and AWP scores were average within that range. Service users continue to ask for more ward activities and some were concerned about their safety on the ward.

Locality action plans have picked up a number of issues from the inpatient survey results including:

• Increased local staffing to improve ward activities offered at weekends

• Implementation of the Safe Wards initiative

• Nursing staff having the time to talk to patients

43

3.5.4 Friends and Family Test survey results

Since April 2013, we have received over 12,800 completed surveys from service users across AWP to tell us whether they would recommend our services to friends and family. We received 4524 surveys in 2013/14 and 8320 in 2014/15.

The survey provides immediate feedback to staff about service users’ satisfaction with their current care. Some carers also give us feedback about their experiences. The comments help us to see where we are doing well and where we need to improve. Scores, positive and negative comments and actions in response to concerns raised are regularly displayed in wards and in community waiting areas.

More people chose to comment on their experience of care than last year. The majority of the comments are positive.

The ward is quiet and restful, offering comfortable accommodation ... The staff are always available and very helpful. It is a useful place to recover.

I have received support and understanding and kindness in difficult times just when needed.

Very happy, as a family we don’t know what we

would have done without you.

I really enjoy going to the Active Life Groups,

as I really like the sports and it has boosted my confidence and helped

my social anxiety in meeting other people with similar problems

You learn a lot ... you get back your life and

it’s the best feeling in the world

Didn't listen to me properly.’

‘I didn't get enough one on one time.’

44

Across the Trust, improvements have been made in response to Friends and Family Test feedback. See below for some examples:

• Service users in the Early Intervention service in Swindon said that they would like more group activities. In July, a group of service users were taken to Bournemouth beach for a day out and a rock climbing trip was organised in October.

• Community staff were asked to be more discreet about wearing their identity badges when carrying out home visits.

• A series of complaints and comments about the environment on Juniper Ward in North Somerset were received. Staff decided to act and worked with service users to re paint the ward in their own time.

45

3.6 Learning from Incidents

During 2014/15 our staff reported 9,260 incidents, of which 108 were considered serious. A serious incident is defined as any event or circumstance arising that led to serious unintended or unexpected harm, loss or damage.

Every serious incident is investigated by a senior member of staff to identify the root causes and to share lessons learned to prevent reoccurrence. These investigation reports are quality assured through the Trust’s internal governance processes and also through scrutiny by the Commissioner of the relevant service.

There is close monitoring to ensure the implementation of recommendations arising from SUIs. The themes identified from serious untoward incidents are shown in the chart below.

Examples of actions taken as a result of serious untoward incidents include:

• An extensive programme of anti-ligatures works in in-patient units.

• Improving the safety of garden environments for service users.

• Reiterating to staff that service users and carers should be seen independently of each other and should both be asked about current as well as past abuse.

• Raising the profile amongst clinical staff of neuroleptic malignant syndrome.

11

19

1

7

19

23

7

23

6

3

12

18

8

19

11

2

24

29

15

24

34

10

16

20

9

1

12

87

0

5

10

15

20

25

30

35

01

: A

cce

ss

02

: B

est

Pra

ctic

e A

dh

ere

nce

03

: C

ap

ab

ilit

y

04

: C

ap

aci

ty

05

: C

are

rs/F

am

ily

06

: C

lin

ica

l p

ract

ice

07

: C

om

mu

nic

ati

on

08

: C

PA

09

: D

iag

no

sis/

Fo

rmu

lati

on

10

: D

isch

arg

e

11

: D

ua

l D

iag

no

sis

12

: E

nv

iro

nm

en

t

13

: In

form

ati

on

sh

ari

ng

15

: M

ed

icin

es

16

: M

ult

i a

ge

ncy

arr

an

ge

me

nts

17

: P

ati

en

t C

lin

ica

l C

on

dit

ion

18

: P

oli

cy C

om

pli

an

ce

19

: R

eco

rds

Ma

na

ge

me

nt

20

: R

eso

urc

es

21

: R

isk

Ass

ess

me

nt

22

: S

afe

gu

ard

ing

23

: S

ecu

rity

24

: S

taff

ing

25

: S

up

erv

isio

n

26

: T

rain

ing

27

: A

dm

in s

yste

m c

ha

ng

e

29

: C

ross

Org

an

isa

tio

n L

ink

s

30

: C

risi

s a

nd

Co

nti

ng

en

cy

31

: C

are

Pa

thw

ay

32

: P

hy

sica

l H

ea

lth

care

(bla

nk

)

Themes from Serious Untoward Incidents 2014/15

46

• Implementation of a number of training solutions to further help and support staff in discharging their duties.

Additionally the Trust produces regular Safety Matters Bulletins for staff to share learning from thematic analysis of incidents. There has been a particular focus this year on learning from medication incidents.

3.7 Patient environment

The national framework for the monitoring and assessment of the patient environment is the Patient-Led Assessments of the Care Environment (PLACE). This is a self-assessment framework for the range of non-clinical services which contribute to the environment in which healthcare is delivered in both the NHS and independent/private healthcare sector in England. Participation is voluntary.

These assessments were introduced in April 2013 to replace the former Patient Environment Action Team (PEAT) assessments which had been undertaken from 2000 – 2012 inclusive. AWP volunteered to be one of the pilot sites for mental health services and as a result significant changes were made to the assessment tool. The table below shows the four areas of assessment outlining the national average score and the score achieved by AWP in the last two years.

Please note that as a result of changes made to the assessment methodology and scoring algorithm used to produce the results two of the four domains, comparative analysis of results between 2013 and 2014 is not reliable.

National Average 2014

AWP Score 2013

AWP Score 2014

Change

Cleanliness 97.25% 91.86% 99.41% �

Condition, Appearance and Maintenance

91.97% 87.11% 94.65% �

Privacy, Dignity and Wellbeing

87.73% 89.27% 89.03% �

Food & Hydration 88.79% 92.68% 89.12% �

47

3.8 Staff survey

AWP values the hard work of our staff and their dedication to providing high quality mental health care and we have committed to supporting and developing our staff as a strategic priority.

We maintain regular ‘temperature checks’ on staff experience and wellbeing through the use of a quarterly internal survey that incorporates the Staff Friends and Family test. This complements the annual NHS Staff Survey that seeks response to questions that relate to staff pledges in the NHS Constitution. We invite our entire workforce to respond to both surveys to gain the best insight into staff experience.

Survey results are analysed by Locality as well as providing a Trust wide picture. Results are used to develop and refine plans to improve staff experience of working at AWP. The Trust wide results of the 2014 Annual Staff Survey are reported below.

We were pleased with receive feedback from such a significant proportion of our staff exceeding the national average as shown in the table below:

Response rates for 2013 and 2014

2013 2014

Trust National average Trust National average

48.4%

(1704 staff)

50.8%

51%

(1790 staff)

42%

Positive results evidence improvement in areas where significant focus has been applied. We have increased training and appraisal rates as a means of improving staff skills and confidence to deliver safe, high quality care. The Trust is pleased to see evidence that our emphasis on the reporting of incidents and concerns about clinical practice is reflected in the results. Taken alongside increased reporting of incidents, this survey result evidences a positive reporting culture.

The most recent results are set out in the table below.

48

National Staff Survey Comparative Results 2013 and 2014

Top 5 Ranking Scores Trust

2013

*National average 2013

Trust 2014


% change

% of staff appraised in last 12 months 83% 88% 91% 88% +8%

% of staff receiving health and safety training in the last 12 months

69% 74% 79% 73% +10%

% of staff agreeing that they would feel secure raising concerns about unsafe clinical practice

- - 70% 69%

No

comparab

le

question

in 2013

% of staff having equality and diversity training in the last 12 months

58% 64% 68% 67% +10%

Fairness and effectiveness of incident reporting procedures 3.52 3.52 3.53 3.52 +.01%

Lowest 5 ranking scores Trust

2013


Trust 2014


% change

% of staff feeling pressure in

last 3 months to attend work

when feeling unwell

24% 22% 25% 20% +1%

% of staff receiving job-relevant

training, learning or

development in the last 12

months

82% 81% 77% 82% -5%

% of staff experiencing

harassment, bullying or abuse

from staff in last 12 months

22% 21% 27% 21% +5%

% of staff reporting good

communication between senior

management and staff

31% 31% 26% 30% -5%

Effective team working 3.93 3.83 3.76 3.84 -0.17%

*National averages for mental health and learning disability Trusts

49

Our ambition is to be the best Mental Health Employer in England and as such we take

this feedback from staff seriously. Action is being taken at two levels. At a Trust wide

level the following approaches will target key areas of concern:

• Pressure to attend work when unwell:

Recruitment and Retention Strategy to increase our substantive staff and retain

our existing workforce

An active Health and Wellbeing Programme of work led by our Health and

Wellbeing Manager. This programme provides staff with financial benefits (e.g.

salary sacrifice schemes and retail discount and support to stay well physically

and mentally.

• Availability of job relevant training:

Launch of the Development HIVE, an interactive tool, that allows staff to see the

full range of learning, development and support opportunities available. Major

areas of development in the year ahead include recruiting at least 100 apprentices

and appraisal training to ensure appraisers have the skills, confidence and tools to

deliver an excellent appraisal.

• Bullying and Harassment:

We recently launched a new Bullying and Harassment Policy which clearly defines

bullying and harassment, how to get help and how to report it. A campaign

approach is raising awareness of this throughout the Trust and close partnership

working with Staff Side representatives ensures that the policy is visible and

actively used.

50

To deeply understand the issues behind staff reported bullying and harassment in

the staff survey we have commissioned an independent partner to run

engagement events with staff. The output of this work will help to inform what

further actions we can take to address this concerning issue.

• Senior Leader Communication:

We have launched an accredited leadership development programme in

partnership with the University of the West of England. This will see 160 middle-

senior managers supported to develop leadership competence and confidence.

This programme is complemented by local and national development programmes

offered by the South West Leadership Academy and NHS Leadership Academy.

• Effective Team Working:

Research shows that high performing teams provide safer, higher quality care.

We have launched a major programme of Team based Working that will see every

team in the Trust, clinical and non-clinical, supported to undertake team

development by 31 March 2016. We have partnered with recognised experts in

team development, Aston OD, to deliver this programme.

In order to bespoke the implementation of the programmes described above a Workforce

Development Plan has been developed for each Locality based on specific need. The

implementation of Workforce Development Plans will be closely monitored.

The Board maintains active oversight in all issues relating to our staff through the

Employee Strategy and Engagement Committee. This Committee maintains oversight of

staff survey responses and receives assurance that appropriate action is being taken in

response. The Board is committed to seeing positive change in survey results in the

coming year as evidence of improved staff experience and engagement.

51

Part 4: How we developed our Quality Account

This is the fifth year that NHS Trusts have reported formally on the quality of their services.

Much of this report is set out to meet legal requirements. However we also report on our priorities for improvement which have been agreed in partnership with clinicians, service users and carers.

Our aim has been to produce a true and fair representation of our services, including information that is meaningful, relevant and understandable to our service users, their carers and the public.

Throughout the year, we have had ongoing engagement with service users and carers across the Trust via our existing forums and the Trust Engagement Group. Each service informs their quality improvement activities by gathering service user and carer feedback from a variety of mechanisms: PALS, praise and complaints, annual surveys, real-time surveys, service user and carer representation on Trust groups, focus groups and at special events.

We have continued to develop the use of the Experience Based Design (EBD) approach with resources and trained peer mentors offering support and we have also engaged across the organisation with our staff and clinicians.

The Trust is also grateful to our service users, carers and staff who also commented and contributed to this document.

External assurances and comments

We provided a draft of this Quality Account to the local area team of the NHS Commissioning Board, North Somerset Clinical Commissioning Group as our co-ordinating commissioner, Wiltshire Health and Wellbeing Board, all six local authority health overview and scrutiny committees and local Healthwatch groups and invited them to review the document and provide us with comments.

In the time available, we have responded to these comments wherever possible by adding information or making appropriate amendments while producing our final document. The Trust is grateful to all of the above organisations for helping to verify the content and for their suggestions for improving this document.

The verbatim comments received from the above organisations are available in full in Appendix A of the downloadable version of our Quality Account, including appendices, on our website at http://www.awp.nhs.uk/news-publications/publications/quality-account/

Concluding comments

We very much hope that the information contained in this document is useful and meaningful, reinforcing the fact that providing high quality and safe services is AWP’s highest priority and at the heart of all that we do.

We would value your feedback on this document so we can improve next year’s Quality Account. You can contact us via the details below. Alternatively, if you would like further information, a hard copy of this document, or have any questions, please contact us.

52

Contact us with your feedback or for further information at:

Email: [email protected]

Telephone: 01249 468000

Or write to: Quality Account

Communications Team

Avon and Wiltshire Mental Health Partnership NHS Trust

Jenner House

Langley Park Estate

Chippenham

SN15 1GG

Our full Quality Account, including the following appendices, is available on the Trust’s website http://www.awp.nhs.uk/news-publications/publications/quality-account/

or by request:

Appendices:

A External assurances and comments TO BE ADDED

B Glossary of terms

C Statement of Directors’ Responsibilities TO BE ADDED

D Information by PCT and local authority area TO BE ADDED

E More information on the targets presented in tables TO BE ADDED

An additional document, Commissioning for Quality and Innovation (CQUIN), is also available via the Trust website.

53

Appendix B - Glossary of terms

Assertive outreach A service designed to meet the needs of people with severe mental health problems and complex needs who have difficulty engaging with services and often require repeat admission to hospital. For example: they may have a poor response to treatment, a drug or alcohol dependence, unsettled accommodation or be homeless.

Absent without leave (AWOL)

AWOL is a breach of the Mental Health Act (MHA) where a service user, who is detained under the Act in a hospital, either:

1. Absents them self from hospital without leave granted under Section 17 of the MHA; or

2. Fails to return to the hospital on any occasion at the end of the granted period of leave of absence; or

3. Absents themself without permission from any place where they are required to live in accordance with the condition imposed on the grant of leave of absence.

Accreditation for inpatient mental health services (AIMS)

AIMS is a standards-based accreditation programme designed to improve the quality of care in inpatient mental health wards. It is a comprehensive process of review carried out by the Royal College Royal College of Psychiatrists College Centre for Quality Improvement. It identifies and acknowledges high standards of organisation and patient care, and supports other services to achieve these. Accreditation assures staff, service users and carers, commissioners and regulators of the quality of the service being provided.

Care Programme Approach (CPA)

The process that providers of mental health care use to co-ordinate the care, treatment and support for people who have mental health needs.

Care Quality Commission (CQC)

The CQC is the independent regulator of health and adult social care services in England. It also protects the interests of people whose rights are restricted under the Mental Health Act.

Clinical audits A systematic process for setting and monitoring standards of clinical care. 'Guidelines' define what the best clinical practice should be, 'audit' investigates whether best practice is being carried out and makes recommendations for improvement.

Care Custer A Mental Health Care Cluster is part of a currency developed to support Payment by Results for Mental Health Services. Mental Health Care Clusters are 21 groupings of Mental Health Patients based on their characteristics, and are a way of classifying individuals utilising Mental Health Services that

54

is planned to form the basis for payment.

Clostridium difficile

Clostridium difficile is a bacterial infection that most commonly occurs in people who have recently had a course of antibiotics and are in hospital. Symptoms can range from mild diarrhoea to a serious inflammation of the bowel.

Commissioning for Quality and Innovation (CQUIN)

A payment framework that has been a compulsory part of the NHS contract from 2009/10. It allows all local health communities to develop their own schemes to encourage quality improvement and recognise innovation by making a proportion of NHS service provider’s income conditional on locally agreed goals.

Crisis care This is a short-term, community, intensive service, commonly for adults (16 years and over) with severe mental illness such as schizophrenia, manic depressive disorders and severe depressive disorder. It is delivered by the Trust’s Intensive Teams. Crisis care is provided to those in acute psychiatric crisis of such severity that, without the involvement of a CRHT, admission to hospital would be necessary.

South West Dementias and Neurodegenerative Diseases Research Network (DeNDRON)

The regional branch of DeNDRoN is one of six topic-specific clinical research networks funded by the Department of Health in England. It supports the development and delivery of clinical research in the NHS in the dementias, Parkinson’s disease, motor neurone disease, Huntington’s disease and other neurodegenerative diseases.

Early intervention These teams work with service users and their families to provide expert assessment, treatment and support at an early stage in their psychosis, with a view to being able to minimise its impact on their lives and avoid longer term need for mental health services. Typically service users are aged 14 to 35 and this will be their first episode of psychosis and they will receive up to three years support.

Equality Delivery System

The EDS is a tool for NHS organisations – in partnership with patients, the public, staff and staff-side organisations – to use to review their equality performance and to identify equality objectives and actions. It offers local and national reporting and accountability mechanisms. Further information available at the following link: http://www.eastmidlands.nhs.uk/about-us/inclusion/eds/

Foundation Trust Foundation Trusts are a type of NHS organisation with greater local accountability and freedom to manage themselves. They remain within the NHS overall, and provide the same services as traditional trusts, but have more freedom to set local goals. Staff and members of the public can join their Boards or become members.

Healthwatch Healthwatch England is the independent consumer champion for health and social care in England. Working with a network of 152 local Healthwatch, their role is to ensure that the voices of consumers and those who use services reach the

55

ears of the decision makers. These organisations replace Local Involvement Networks from April 2013.

HoNOS The ‘Health of the Nation Outcome Scale’ is a tool used by mental health clinicians to rate the mental health of service users. It is used before and after treatment so that changes attributable to the treatment or intervention can be measured.

Hospital Episode Statistics (HES)

HES is a national data source that contains details of all admissions to NHS hospitals in England. It includes private patients treated in NHS hospitals, patients who were resident outside of England and care delivered by treatment centres (including those in the independent sector) funded by the NHS. HES also contains details of all NHS outpatient appointments in England.

Information Governance Toolkit

An online tool that enables organisations to measure their performance against information governance standards.

There are several elements of law and policy from which information governance standards are derived. It encompasses legal requirements, central guidance and best practice in information handling, including:

• The common law duty of confidentiality

• Data Protection Act 1998

• Information security

• Information quality

• Records management

• Freedom of Information Act 2000.

Local Involvement Network (LINk)

A LINk is a network of local people, organisations and groups from across the community who want to make care services better. There is one for every local authority area.

Their aim is to provide a stronger voice for local people in the planning, design, commissioning and provision of health and social care services. From April 2013, LINks will be replaced by local Healthwatch organisations.

Medicines reconciliation

The aim of medicines reconciliation on hospital admission is to ensure that medicines prescribed on admission correspond to those that the patient was taking before admission. Details to be recorded include the name of the medicine(s), dosage, frequency and route of administration.

Mencap Getting it right Charter

“Getting it right” is Mencap’s campaign for equal healthcare for all children and adults with a learning disability. By signing the charter, healthcare professionals and organisations are pledging to meet nine standards.

Mental Health Information System (MHIS)

Electronic computer based system for the recording of service user clinical and care records.

56

Mental Health Minimum Data Set (MHMDS)

The MHMDS is a mandatory data return for all NHS providers of specialist adult mental health services. Data from the Trust’s electronic patient records, relating to admissions, appointments, CPA, and some basic demographic information is submitted to the Department of Health on an anonymised basis throughout the year.

Mental Health Research Network (MHRN)

The MHRN supports vital large-scale research which will help to raise the standard of mental health and social care research throughout England. In addition, it acts as a central point of information and reference, connecting service users and carers to researchers and mental health professionals.

NCAPOP The National Clinical Audit and Patient Outcomes Programme (NCAPOP) is a closely linked set of centrally-funded national clinical audit projects that collect data on compliance with evidence based standards, and provide local trusts with benchmarked reports on the compliance and performance. They also measure and report patient outcomes.

The projects analyse data supplied by local clinicians centrally and feed back comparative findings to help participants identify necessary improvements for patients.

National Institute of Health and Clinical Excellence (NICE)

NICE provides guidance, sets quality standards and manages a national database to improve people’s health and prevent and treat ill health.

NICE makes recommendations to the NHS on:

• New and existing medicines, treatments and procedures

• Treating and caring for people with specific diseases and conditions

• How to improve people’s health and prevent illness and disease.

National Patient Safety Agency (NPSA)

The NPSA leads and contributes to improved, safe patient care by informing, supporting and influencing the health sector.

They manage a national safety reporting system receiving confidential reports of patient safety incidents from healthcare staff across England and Wales. Clinicians and safety experts analyse these reports to identify common risks to patients and opportunities to improve patient safety.

National Reporting and Learning Framework

National framework for reporting and learning from serious incidents requiring investigation in the NHS.

NIHR Flexibility and Sustainability Funding (NIHR FSF)

NIHR FSF is a research funding stream designed to help research-active NHS organisations attract, develop and retain high-quality research, clinical and support staff by supporting the salaries of their Faculty members and associated workforce in a flexible manner.

57

Overview and Scrutiny Committee (OSC)

Each local authority is required to have an OSC to scrutinise public services outside its own organisation, including health. It has statutory powers to call in witnesses from local NHS bodies and make recommendations that NHS organisations must consider as part of their decision-making processes. Similarly, there is a requirement on NHS organisations to consult with health overview and scrutiny committees when considering substantial developments or variations to services.

Patient Advice and Liaison Service (PALS)

PALS is an impartial service designed to ensure that the NHS listens to patients, their relatives, carers and friends, answers their questions and resolves their concerns as quickly as possible.

PALS also helps the NHS to improve services and make changes by listening to what matters to patients and their families and friends.

POMH Prescribing Observatory for Mental Health (Royal College of Psychiatrists)

Protected Characteristics

The Equality Act 2010 makes it unlawful to discriminate against people with a ‘protected characteristic’ (previously known as equality strands / grounds).

Specified ‘protected’ characteristics are as follows:

• Age

• Disability

• Gender re-assignment

• Marriage and civil partnership

• Pregnancy and maternity

• Race including national identity and ethnicity

• Religion or belief

• Sex (that is, is someone female or male)

• Sexual orientation

Quality and Healthcare Governance system

In AWP this is a combination of structures and processes from Board to frontline that ensures quality standards are being maintained, including:

• Ensuring required standards are achieved

• Investigating and taking action on sub-standard performance

• Planning and driving continuous improvement

• Identifying, sharing and ensuring delivery of best practice

• Identifying and managing risks to quality of care.

58

RiO RiO is the name of a new electronic patient record system that largely replaces paper records.

RiO ensures that clinical staff have accurate, up to date and secure information available around the clock. It provides real-time information for assessment, care management, progress notes and bed management.

RiO has been fully implemented across all AWP services.

Regulatory framework

A framework or system of rules and requirements that are set out by law in statutory legislation.

Recovery Star The Recovery Star is a key-working and outcomes measurement tool designed to map an individual’s journey towards recovery. It uses a ‘Ladder of Change’ as a framework for service users, supported by their key-worker, to explore key themes in working towards their recovery; managing mental health, self-care, living skills, social networks, work, relationships, addictive behaviour, responsibilities, identity and self-esteem, trust and hope.

Safeguarding A term used in conjunction with measures which are taken to protect, safeguard and promote the health and welfare of children and vulnerable people; ensuring they live free from harm, abuse and neglect.

Safewards The new 'Safewards' model is based on years of research by nursing guru Len Bowers.

The research looked at potentially harmful events such as aggression, rule breaking, substance use, absconding, medication refusal, and self-harm and identified the most effective ways of containing these negative events.

The model identifies a range of feasible interventions which are proved to make a difference for example: using soft words, mitigating bad news, using calm down methods and providing reassurance.

Alongside increasing the use of such techniques, the model drops some of the most disliked interventions such as restraint, rapid tranquilisation and the outcome is that conflict on wards decreased by 14.6 per cent and containment activity decreased by 23.6 per cent.

http://www.safewards.net/model/model-diagram

Scorecards Fully named The Balanced Scorecard, this is a performance management tool that sets out in tabular form, in a single place, all of the targets and standards the Trust must meet and how we are doing against them. It is reported monthly to the Board, Primary Care Trusts (PCTs) and local authorities, and internally to our operational services. It enables everyone to see what our performance is and to target improvements where they are needed. It is supported by

59

weekly internal reports that break performance down to team and ward level.

Serious untoward or adverse Incident (SUI)

Any event or circumstance arising that could have or did lead to serious unintended or unexpected harm, loss or damage.

Essentially serious adverse incidents are those which cause (or have the potential to cause) the most harm either to individuals (staff, service users, visitors, contractors, others) or to the organisation. These include: unexpected deaths; injuries causing major and permanent physical or psychological harm; large-scale theft or fraud; outbreak of Legionnaires disease; major fire or flood.

Social Care Institute of Excellence (SCIE)

SCIE is an independent charity, funded by the Department of Health that identifies and disseminates the knowledge base for good practice in all aspects of social care throughout the United Kingdom.

Strategic Business Units (SBU)

This is a term adopted by AWP to describe the way the organisation has structured the management of its main operational services and areas of business. Each SBU is led by a service director and clinical director.

Strategic Executive Information System (STEIS)

A system for collecting weekly management information from the NHS. We use this system to report all Serious Untoward Incidents (SUIs).

Strategic Health Authority (SHA)

SHAs are responsible for managing the NHS regionally and providing an important link between the Department of Health and the NHS. Ours is called NHS South West. It is responsible for:

• Developing plans for improving health services to meet the needs of the region and ensure national priorities are integrated in to local plans

• Making sure local health services are of a high quality and are performing well

• Increasing the capacity of local health services so they can provide more services.

Thematic review A systematic review of evidence around a particular theme of patient safety such as medication or violence and aggression. The process looks at what can be learnt from reported incidents, issues raised with the PALS service, complaints, claims and our investigations of suspected suicides.

We then compare our Trust to others and look at national guidance and Trust policy on good practice and develop a plan to turn our learning into action.

60

Think family model This is a model of care that asks all professionals such as health, social care, education, criminal justice to ‘think family’ so that there is no ‘wrong door’: Contact with any one service gives access to a wider system of support. Individual needs are looked at in the context of the whole family, so clients are seen not just as individuals but as parents or other family members. Services build on the strengths of families, increasing their resilience and aspirations. Support is tailored to meet need so that families with the most complex needs receive the most intensive support.

Triangle of Care Published by the Carers Trust (formerly The Princess Royal Trust for Carers) and the National Mental Health Development Unit it is a guide and toolkit which emphasizes the need for better local strategic involvement of carers and families in the care planning and treatment of people with mental ill-health.

Western Comprehensive Local Research Network (CLRN)

CLRNs work with their local NHS organisations to support clinical research through funding staff and resources such as information technology and office space.

Whole time equivalent (WTE)

This is a measure used to present staffing numbers. Part time hours are added together to calculate the figure.

Draft Quality Account 2014/15 - cms.wiltshire.gov.uk 8 - AWP Draft... · referrals, and had more...

Documents

Transcript of Draft Quality Account 2014/15 - cms.wiltshire.gov.uk 8 - AWP Draft... · referrals, and had more...