Quality summary report:

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1 Quality summary report: Learning Disability Services CLCH Quality Report Jan Dec 2011 Service exact name Community Learning Disability Services Barnet, Kensington and Chelsea, Hammersmith and Fulham and Westminster Address line 1 Emergency/Crisis and Planned Short Breaks and Respite Services Alison House (AH) and Kingsbridge Road (KBR) Address line 2 Town/city County Postcode No. beds Website Main telephone Completed by Maisie McKenzie Senior Manager Approval Julie Harris Insert role

2 CLCH Quality Report 2011 Summary report for Learning Disabilities Directorate Service area Specialist Learning Disabilities Boroughs Barnet Kensington & Chelsea Hammersmith & Fulham Westminster CQC statement of purpose for this service The Community Learning Disability Services in our four boroughs of Barnet Hammersmith and Fulham, Kensington and Chelsea and Westminster are joint a partnership across Central London Community Healthcare (CLCH), and the respective local authorities London Borough of Barnet, London Borough of Hammersmith and Fulham. Royal Borough of Kensington and Chelsea and Westminster City Council (WCC) and respective Mental Health Trusts, Barnet and Mental Health Trusts (Barnet and Enfield and Central and North West London Mental Health Trust. The service users who access the service are aged18 and above. Services now see an increasing number of young people in transition between the ages of 16 to 21 years as they move from children s to adult services. All service users must meet an eligibility criteria as recognised by an IQ of below 70 and significant impairment in their functional ability of daily living. The service does not provide inpatient/ bedded services but works closely with our emergency short breaks and respite services at Kingsbridge Road and Alison House in Kensington and Chelsea. Service type: Community Learning Disabilities Services and Emergency Short Breaks and Planned Respite Services In addition to our community LD services, CLCH provides Short Breaks Services (planned & emergency/crisis) Alison House provides men and women with learning disabilities aged 18 to 65 with a short respite break away from home. KBR provides 4 beds for adults with learning disabilities who have complex needs, including autism, challenging behaviour and/or mental health needs. Both Alison House & KBR are used by Westminster & RBKC service users. The services provided aim to meet each

3 person s physical, emotional, cultural, religious needs and to help them further their hopes and dreams. We recognise that each person is different. Our key workers endeavour to personalise the service to accommodate each guest s individual needs, ensuring care plans are up to date and reflective. We have a strong focus on service user engagement and empowerment, offering opportunities for service users to explore the local community and make new friends. Alison House caters for clients with challenging & complex health needs- including enteral feeding, intermittent urethral catheterisation, nasogastric feeding and the administration of suppositories. Both Alison House & KBR offer a flexible service responding to family/carer needs which are staffed 24 hours/ 7 days a week. The emergency/crisis service at KBR has 7 beds in 2 flats. Services users will be in distress or whose current living situation is at risk due to factors that may include an increase in challenging behaviour which has become unmanageable in their home environment, mental health issues (not people detainable under the Mental Health Act 1993), family or placement breakdown, other health issues. An emergency/crisis is defined as an unforeseen circumstance which means the individual s usual living arrangements cannot be maintained. Both KBR and Alison House are registered with the Care Quality Commission and had unannounced visits in Both were fully compliant. All people using these bedded services will be 18 or over and have a learning disability, they may also have: autistic spectrum disorder challenging behaviours Mental health Physical disability Sensory impairment Dementia Service type: Community based service for people with a learning disability

4 Planned Short Break bed based services Emergency/Crisis bed based service Care home with nursing provision Registered Activities: 1. Accommodation for persons who require nursing or personal care 2. Treatment of disease, disorder or injury 3. Diagnostic and screening procedures Overall summary of quality performance and next steps Since the report was written last year the three inner London services are part of the wider Tri Borough Transform Learning Disability Services and integrate with CLCH. The aim of the service is to 1) Form the foundations upon which Learning Disability Services can develop over the next 5 years and create a new service model which will utilise existing resources, systems and ways of working as effectively and efficiently as possible - become unified, but not uniform 2) Identify ways of improving outcomes for service users and carers. 3) Work collaboratively with key stakeholders Our services are committed to continuing to progress against the quality improvement plans within their services and these are overseen by the respective Clinical Governance Forums in each service. The aim of short breaks planned & unplanned bedded services is: Care Provision. All care is provided within a framework of Clinical Guidelines, Policies and Procedures. There is a dedicated Operational Policy and Statement of Purpose and also an accessible Service User Guide for short break services. There is a rolling programme to ensure that these are up to date. A further programme of standardisation of protocols is in development. Clinical risk management. We continue to develop a culture of reporting and learning, based on Fair Blame, Learning from Experience and Being Open. Incident reporting & management and raising concerns policy is in

5 place. The CLCH learning from experience group meets monthly to review cases and share the learning/ target improvement projects. Short breaks services operate an online incident reporting and management system (Datix). All staff are aware of and able to report untoward events and near misses. Quality Accounts. The service participates in the PREMs programme, the results of which are included in the CLCH quality accounts. Compliments and complaints regarding the service are reported to the PALS team who provide guidance on management and central collation of data. The learning is used to improve service delivery. Transition/Partnership Working. We support service users going through transition from children services into adult care services (joint referral form & transition pack). Service users are provided with information to make a valid & informed decision to receive care and treatment. Verbal consent is obtained prior to conducting any physical examination, administration of medicines, diagnostic test, clinical procedure or personal care. Provisions are made for chaperones/ advocates and the use of translators/ interpreters. Staff act as the service user s advocate, facilitating the service user s own choices with regard to care whilst promoting independence and self-care. Staff enable service information on which to base decisions, within the context of the service user's individual plan and risk assessment and risk management plan. Care plans and risk assessments incorporate activities supported by partner organisations e.g.-westminster Society Outreach and WLDP Day Services. The service works in close collaboration with local community stakeholders for supporting guests to access community-based provisions, social services, private carers, case managers and GPs to plan and implement integrated care pathways. Both Alison House & KBR attend the Transition Sub- Group held in K&C. Summary Our CLCH organisation wide approach to quality, safety & effectiveness is threefold: The service user is central to all organisational and service activities;

6 Continual improvements to service quality and delivery are made in a safe, effective, timely, efficient, accessible and equitable manner for all service users and staff; The organisation supports staff in their quality, safety & effectiveness endeavours by supporting structures and processes to review, plan, implement & monitor quality & safety. A committee structure supports and reviews the framework to ensure quality, safety & effectiveness is overseen & owned by service leads and executive staff. The service user safety & quality and risk management committees have the lead role in providing this function and oversee the activities of specialist subcommittees such as: Infection prevention & control Medicines Management Safeguarding (adults & children- linking with borough based structures) Product review & medical devices Flu & business continuity Fire health & safety Information governance Safety Overview We aim to make our service as safe as possible at all times. Safety In May 2001, the BBC Panorama programme broadcast its investigation into the appalling care and treatment of patients at Winterbourne View, an assessment and treatment service provided by Castlebeck Care (Teesdale) Ltd. Following the broadcast, a number of actions were put in place to provide assurance for people with learning disability in London.

7 Community Learning Disability Services in partnership with local commissioners were required to provide: a one-off snapshot data collection on all NHS funded placements, both within borough and in out of area, for people with learning disabilities.. Safeguarding Adults Self-Assessment and Assurance Framework was also completed by provider services in order to provide assure to local commissioners that robust safeguarding governance systems are in place. As joint teams, all Reg 37 s and safeguarding are recorded using both CLCH and LA recording and reporting processes Under our safeguarding commentary for Short Breaks Services CQC Self-Assessment Framework we ensure: a) All staff are CRB checked on initial employment and via an on-going programme lead by the human resources department. b) All staff are required to attend annual mandatory training that includes consent to treatment, mental health & capacity and safeguarding adults & children. c) All staff participate in clinical and/or 1:1 supervision and discusses challenging cases/ raise concerns with line management. CLCH has specialist safeguarding adult s leads who act as sources of expertise, advice and supervision. All services work closely with the Safeguarding specialists in the relevant local Key achievement s this year We identified the following safety improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: Emergency Short Breaks Our CQC Review of compliance document (evidence) dated September 11 (for KBR) & November 2011 (for Alison House) highlights key achievements made last year. Our overall judgment both KBR and Alison House met all the essential standards of quality and safety Learning Disability Performance and Self-Assessment Framework, requesting all London Learning Disability services to feedback on a number of targets. Community Learning Disability Services

8 Learning Disability Performance and Self-Assessment Framework, requesting all London Learning Disability services to feedback on a number of targets. One target specifically looked at safety of people with learning disabilities who are in services that the NHS commissions or provides. Key results Total incidents Jan-Dec 2011 by category Total incidents Jan-Dec 2011 by severity Degree of harm Low Minor Medium High Catastrophic

9 Level of reporting: In this service, incidents are recorded in most cases Near misses are recorded in every case Themes arising: The services work with Service Users who present with severe challenging behaviour. Staff have access to Behaviours Support Services within their teams or PROACT-SCIPr-UK training which is a whole approach to working with individuals who present with these issues. The focus is on early intervention and establishing the function of behaviour in order to devise a suitable behaviour support programme to encourage consistency of management and to enable learning for the individual. Physical Intervention is very much a last resort and is only taught if required. Safety Action Expected completion Named lead Improvement date Actions for 2012 Our key priorities this year July 2012 Head of Service for are to ensure to ensure that the Tri Borough all areas of safety are Learning Disability incorporated in to a joint Services in clinical governance plan conjunction with within all four boroughs. Maisie McKenzie Safeguarding Adults have been key areas of priority, MCA and DOLS Effectiveness Overview We aim to achieve the best possible outcomes for service users and carers

10 To do this, we regularly check to see that we are delivering care and treatment according to best practice standards, and we increasingly look to measure and improve clinical and patient reported outcomes. Learning Disability Services have a range of Clinical Governance meetings in order to ensure that the team is effective which is being reviewed as part of the tri borough arrangements The team does however engage in the audit process. There are number of on-going audit projects Audiology Screening Clinics for People with a Learning Disability Dementia and people with learning disabilities Audit of Activity Recording Time Within a New Team Structure The use of Therapy Outcome Measures (TOMs) in Learning Disability Occupational Therapy. Examining the pathways between local mental health services for people with learning disabilities and their carers in the Royal Borough of Kensington and Chelsea Outcomes of health checks for people with learning disability Oropharyngeal dysphagia: Assessment practice patterns for Speech and Language Therapists Oropharyngeal Dysphagia: Assessment Practice Patterns for SLTs Identifying the economic consequences of autism, the pathways and outcomes for users with a Learning Disability and Autism. Audit of Dementia screening and care for clients of learning disabilities service Key achievements this year We identified the following clinical effectiveness improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them 1) Assessment of the number of individuals with autism in Kensington and Chelsea, services available to them and the cost of care packages for those with autism and a learning disability. Microsoft Office Word Docu Clinical audit LD Team.docx

11 Reason for carrying out the project: To identify individuals with autism who are accessing services and to analyse the cost of their care in order to inform service development. This audit therefore aims to identify the prevalence of autism with those individuals who access the community learning disability team, the cost of their care packages, and what services are available to them currently within the local area. Methodology: 1) Survey period: 1 year data sample 2) Target sample size: 34 3) Final sample size: 34 4) Response rate: N/A 5) Sampling approach: all relevant cases known to the team. 6) How the data was collected: Review of patient records, online survey of national statistics and population projections. Results: The Community Learning Disability Team has currently identified 34 (7% of total estimate), individuals with ASC and LD, which is 414 less than the projected estimate. This may be because some people with ASC may never come to the attention of services as having special needs, because they have learned strategies to overcome any difficulties with communication and social interaction and found fulfilling employment that suits their particular talents. A significant number of people are also unlikely to be diagnosed with ASC. A study of Westminster patients with an Autistic Spectrum Condition (ASC) known to their GP shows that diagnosis falls off dramatically after teenage years. The costs of the cases identified by the CLDT were analysed using the one world software programme. Results are detailed in table 3 below. Table 3. Projected LD and ASC costing April April 2011 Total Cost Continuing Care Cost Average cost per case 2,159,978,92 1,347, 195,87 63, The total cost of care packages for the identified individuals was 2,159,978,92

12 per year. 62.4% of this is funded through continuing care packages at a cost of 1,347, 195,87 per year. The average cost of care for someone with ASC is 63, per year. Summary of Results and conclusions Current population data indicates that the number of individuals coming into adult services with a diagnosis of autism will increase substantially over the next 19 years. Based on the current cost of health and social care packages for people with both a learning disability and autism, it is likely that future costs will rise and that there will be a further strain on services to meet the needs of the most complex cases. Similarly, whilst there are a number of services currently available for people with autism within the locality, the increased prevalence projection may indicate that new services will need to be commissioned in the future to adequately support those complex individuals who present with more than one diagnosis. The projected increased numbers of people with autism in the future may also indicate a greater need to provide specialist training in autism for main stream services which these people will access. Early identification and transitional planning for the most vulnerable people should also be made a service priority. Recommendations and Quality Improvement Actions Action Implemented by Date Agree local pathways for people with autism LA Pathways complete. Awaiting confirmation Further enhanced training for services providing support to people with LD and ASC. CLDT On-going Continue to provide information and signposting for everyone with an LD and ASC, including Carers. CLDT On-going Further awareness raising of autism and LD. CLDT On-going

13 Key results Patient Reported Outcome Measures (PROMs) We are meeting with the teams to discuss the PROMS for 2012/13. These are multi-disciplinary teams working under the integrated governance of both the Local Authority and CLCH so the development of the PROM for each team will take some time Clinical Audit Participation in Trust-wide audits during 2011 The Learning Disabilities service contributed to the CLCH trust-wide health records audit. Three boroughs were involved and audited the following number of records: Barnet 11 Kensington and Chelsea 10 Hammersmith and Fulham 10 Westminster 0 Audit of Dementia screening and care for clients of learning disabilities service. Main findings of this audit: o Team members had better awareness of dementia and the signs to referrer for dementia screening which resulted in an increased referral rate. Outcomes of health checks for people with learning disability. Main findings from this audit o New illnesses were discovered as a result of the Cardiff Health Check o Medication was reviewed and changed for some patients. o Patients mentioned that the Health Check help them know their GP and have a relationship with them confident in GP. o GPs with largest number of registered Learning disability patients were more successful in completing health checks. NICE compliance

14 For CG20 - service had moderate compliance with this guidance. Actions completed, Feb.2011: 1. Update policy, protocol 2. Clear understanding of prescribed treatment and communication between community learning disability service and specialist neurology services NICE related education for staff has been organised with the aim to improve quality of the service (if any, including BMJ e-learning). Some related to LD free modules are available on- line What the patients say about the outcomes of their care and treatment The CQC Review of Compliance for KBR reported: People spoken with liked staying at learning disability flats. People said that they were able to decide how to spend their time at the home and staff are available for support is they need it. We observed staff talking with people and encouraging them to do things for themselves, for instance, making a drink in the kitchen. We observed people being treated with dignity and respect. Clinical Effectiveness improvement actions Action PROMS Westminster is currently in the process of developing a guidance and template to support the implementation of an accessible Patient Reported Outcome Measure (PROM). The guidance should assist practitioners to provide the appropriate settings/conditions to encourage service users to understand and be involved in their treatment planning and goal setting across CLCH. It is hoped that this will encourage the development of new skills and increase service user compliance. Whilst it will be used within learning disability services, the tool will also be utilised across all CLCH services for vulnerable groups Expected Named completion lead date 2012 Service lead

15 Experience Overview We care about treating everybody with kindness, dignity and respect at all times. Community Learning Disability Services are a partnership of 3 agencies spanning health (community and mental health) and social care, roles and responsibilities overlap. We worked to develop PREMS tool in order to capture the experience of service users and carers of our services. The paper copy of the PREMS were used in all of the four services across CLCH with the electronic tablet form for service users and carers piloted in the Hammersmith and Fulham Service. Compliance with using the PREMS tools consistently is still an area that needs to be worked during Both AH and KBR hold regular coffee mornings for the families of the people using the service PREMS have been sent to the families using the planned short breaks service and to service users/families using the emergency crisis service at KBR. Key achievement s this year We identified the following patient experience improvement actions in our 2010 Quality Report. This section outlines the progress we have made on each of them: Westminster Community Learning Disability Services: 1) To assess how to improve the service so people do not feel that they receiving a poor service completed service changes i.e. accessible information developed for both Community and Bedded services as a result 2) Review complaints and address the nature of the complaints completed all reviewed in partnership with complaints team 3) Record unsolicited verbal compliments at team meetings and encourage staff to report them.- completed all complaints and compliments sent on

16 to complaints team 4) Report compliments and complaints to CLCH and PALS - as above Kingsbridge Road Emergency Crisis and Short Breaks Service. 1) Review short break service carer questionnaire completed coffee mornings and involvement in the PREMS pilot this year 2) Continue to explore ways of gathering data from service users completed coffee mornings with service users and carers 3) Ensure compliments received by the service are forwarded to PALS completed these are sent on to the team on a monthly basis. Patient survey results Question Result for this service Trust-wide average Patient surveys (known as Patient Reported Experience Measures PREMs)

17 % patients/carers rating overall experience good or excellent % patients saying they were definitely involved in planning their treatment % patients saying they were always treated with dignity & respect % patients saying they definitely understood explanation 100% 93% 80% 56% 100% 92% 60% 88% % patients satisfied with waiting time 80% 74% Action for 2012/12. Although over all we are pleased with the results for 2010/11, we would like to look at ways to capture data from both more independent service users who do not have support from a carer/family member yet still access our services. Extend the pilot of the tablet IT solution to cover both bedded and community teams. Both the bedded and in community learning disability teams will focus on providing different ways of explaining care as only 60% of service users understood their explanation ie look at easy read resources to explain their care in these settings. Learning disabilities PREMs results of additional questions asked Responses Responses Number printed Response received Response rate (%) 31.1 Community Learning Disabilities Service Kingsbridge Road / Alison House Community Learning Disabilities analysis

18 Site/Delivery Delivery N % Clinic Domiciliary 3 60 Bedded Group School Not recorded 2 40 Is it easy to contact the service user s clinician/case worker? Was the service user given the opportunity to address all concerns? Was the service user given enough time to make decisions about their care? Has the treatment helped the service user? Yes to Yes Not some No definitely recorded extent What could we do better/was there anything that could be improved? NOTHING TO IMPROVE - VERY GOOD Does the service user have a long-standing physical or mental health condition? N % Yes 4 80 No Not recorded 1 20 PREM methodology The following table summarises the number of patients that responded to a

19 PREM this year, and shows this as a percentage of all referrals during the survey period (August December 2011). Our aim was to achieve a representative view of patient feedback, so we set out to survey or all patients. PREM volume targets Total (Aug-Dec 2011) Number of patients who responded to a PREM 5 Total new referrals % of new referrals who responded to a PREM Target % of respondents Target achieved? Compliment s and Complaints Compliments and Complaints Number of compliments Jan 2011 Dec 2011: 1 in total B, you and your team did a great job in providing stable and supportive environment for r, while we worked out how best to support Roy following the incident. The reports you and your staff provided were also I think, vitally important in helping convince the various Judges we have been in front of, that the incident was completely out of character, and that r was far too vulnerable to be considered for any form of custodial sentence. Number of complaints Jan 2011 Dec 2011: 3 in total The concerns raised were in relation to general care of service users whilst in our care. All three complaints were investigated; safeguarding alerts were raised in line with our local and national practice. All three issues were resolved with service users and carers. Patient user groups and focus groups Use this section to describe any on-going patient user group involvement or specific patient focus groups that you have run in the service this year (Jan Dec 2011) Westminster Within Westminster we have had two focus groups over the last 12 months for

20 service users with learning disabilities, support staff and carers to feedback about their experiences of accessing CLCH health services. The feedback has been utilised to identify what reasonable adjustments services should be making to ensure equal access for people with learning disabilities. The Westminster Learning Disability Partnership Board Health Sub Group meets quarterly and is well represented by CLCH staff. This group is another mechanism for receiving feedback regarding service access and sharing good practice. Other qualitative feedback The Psychology service within the Kensington and Chelsea Learning Disabilities identified the need to find out form their service users their views on the service. Thus a service-user satisfaction questionnaire for the psychology service in the Community Learning Disabilities Team was designed in July A draft of the questionnaire was presented to the psychology team for comments. A cover letter was created introducing the questionnaire to potential participants which was made accessible. The service-user satisfaction questionnaire was also made accessible. Twelve cover letters were sent to potential participants inviting them to take part in the survey. A telephone call was made within two weeks of sending the letter to answer any questions the service users may have and arrange a meeting if they agreed to take part. Eight individuals agreed to take part. Report on psychology service-us Demographic information: Servicer user Gender Age Ethnicity 1 Female 48 White British 2 Female 28 White British 3 Female 43 White British 4 Male 46 White British 5 Male 37 Mixed - other 6 Female 22 White - other 7 Male 39 Chinese

21 Overall summary and conclusions: Most participants spoke positively about the psychology service, feeling that they are or have been listened to by the psychologist they are working with and that the work done together is or has been helpful to them. They are therefore generally satisfied with the service they are receiving. The two individuals who either did not answer most of the questions or did not appear to understand the questions being asked had seen a psychologist at least four months ago and could not remember the reason for seeing a psychologist or the work they had done together therefore they could not offer much feedback. It may be important to take the timing of completing the satisfaction questionnaire with a service user into consideration. It should ideally be completed within a few weeks following the end of therapy. In those cases where an individual is in long-term therapy, it may be useful to complete the questionnaire after 6 months and/or after a year commencing therapy CLCH Our engaging People Strategy uses LD Short Breaks Services (Alison House) as a case study for best practice, highlighting areas of patient and public involvement. What the patients say All participants were happy with the work they are or were doing with a psychologist. All respondents except one agreed that the psychologist had told them about the treatment and work they were going to be doing together initially, and felt the psychologist listened to their needs. One individual reported they could not remember. When asked whether they felt that the psychologist had understood what they wanted, all but one respondent felt the psychologist had. They knew the psychologist had understood because they listen when you talk, if I say things she understands what I m saying, he d try to explain and give me some praise, and he writes things like my thoughts Patient Action Expected Named experience completion lead Improvement date Actions To continue to participate in the pilot of the tablets to On-going Senior capture service user experiences of the services. March 2012 manager Learning Disabilities

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