CORPORATE REPORT. Performance against key targets

Transcription

1 CORPORATE REPORT Performance against key targets

2 Business Plan Review 2014/15 Performance against Key Targets The Commission has five key performance indicators (KPIs) agreed with the Scottish Government. Performance against each of these KPIs is noted below. a) Visit at least 1,900 individual services users b) Complete 30 visits in the unannounced format Most of our visits involved interviewing individuals receiving care and treatment. Sometimes, we were not able to interview the individual, but we still reviewed their case files. Type of visit Target Individuals visited File review Total Visits to individuals subject to AWI powers Individuals seen as part of themed visits Acute enhanced observation Individuals in the community s25-s27 Older people acute admission Individuals seen as part of local visits 450* Individuals subject to MHA powers Individuals subject to AWI powers Individuals subject to CPSA powers Individuals that were informal Individuals, no report completed Other individual visits (Young people, cross border transfer and MWC initiated) Individuals subject to MHA powers Individuals subject to AWI powers Individuals subject to CPSA powers Individuals that were informal Individuals seen as part of monitoring visits SUS 49 CCTO 103 TOTALS *Initially older people acute was 200, this was then dropped to 100. So the themed target became 350 and we increased the number of local visits. 1

3 In total we have reviewed the care and treatment of 2,094 individuals. We met with 32 advocacy workers and 77 relatives/carers during our themed and local visits. We completed 121 local visits, with 30 of these undertaken in an unannounced format (25%) We will produce statistics and analysis on the use of mental health and incapacity legislation on time, within six months of the end of the year The reports were posted on the website on 9 th October The slight delay in posting was to allow us to promote the reports nationally in the media. We will complete and publish four investigation reports by the end of March 2015 During the year we progressed 21 investigations, 12 of which were new. Of these one was published on the website. We remitted eight cases back to local services after initial investigation. In these cases, we expressed concerns and made recommendations to service managers for further internal investigation. In one instance, we looked at the review carried out by local services following which we were satisfied with the outcome. In two cases we were satisfied that there was no deficiency of care. We are continuing to investigate a further nine cases. Although we did not meet our KPI for this year, we completed other work on the investigations guidelines and with other organisations on agreeing a process to identify a lead organisation for investigations. The Board has revised the KPI for 2015/16 to state that we will publish at least two investigations. We will assess samples of our telephone advice and aim for at least 97.5% of all our advice to be accurate During the year there were 5,143 (13/14 4,834) calls allocated to Duty Practitioners as requests for advice. When we audited calls this year, we found that around 10% (12%) of these resulted in information being recorded but no advice being requested or given. We therefore estimate the approximate number of calls requesting advice at around 4,629 (4,254). This year we reduced the number of calls audited by half. accommodate a management audit of visits activity. This was done to 2

4 We audited 205 calls, which is 4.5% of the total requests for advice allocated to duty practitioners. Number of items of advice examined 205 Accurate items of advice 204 (Of which we thought we could have added to the advice given in 10 (5%) cases) Inaccurate items of advice 1 (0.5%) % accuracy 99.5% Target for accuracy 97.5% We have therefore performed better than our target of 97.5%. We will publicly report, within the agreed timescales, the outcome of the recommendations we make to services in 90% of cases Our focussed visits to individuals allow us to make specific recommendations to services. We made 409 recommendations following 125 focussed visits conducted during 1 st January 2014 and 31 st December Note that this is not the same as the number of visits reported during the year 1 st April 2014 to 31 st March 2015 as we allow a 3 month response window from services. a) We were satisfied that services had responded fully to 405 (99.6%) of recommendations. b) We have not yet received responses to two (0.4%) recommendations although we have been in contact with service managers to request this information. Responses were due by 31 st March 2015 and we will take further action in 2015/16. c) We escalated four recommendations (1%), relating to one service as we were not satisfied with the service response. This resulted in a follow up visit and a meeting with the Chief Executive of the Board. d) We have therefore ensured that we followed up all recommendations for which response were due between 1 st April 2014 and 31 st March We have therefore exceeded the performance indicator of 90% by undertaking follow-up action on 99.66% of our recommendations. The fact that these have been fully implemented or resulted in significant service progress demonstrates our effectiveness in influencing service improvements through a targeted, risk based programme of local visits. 3

5 Business Objectives End Year Report Key strategy Development need Responsibility Timescale Progress Status Visits and monitoring Produce three national reports on visits to individuals in services across Scotland providing similar care and treatment Young people in secure care (visits completed in 2013/14) Team C Leader June 2014 Completed Individuals in older people services Individuals in adult acute wards on observation Individuals in community (s25 27) Team B Leader Team A Leader Team C Leader January 2015 revised to June 2015 January 2015 revised to March 2015 March 2015 Currently being written and target to get to Board in June Completed Approved by OMG in May and will go to Board in June Completed This was a pilot and as such it became apparent that it could not be produced as a themed visit report. A report on the pilot with recommended next steps was presented to Board in March. To review the visit programme and consult advisory committee with revisions Team A Leader October 2014, revised to January 2015 Completed Approved by Board in January 2015 Produce overview report of focussed visits for 2013/14 Team A Leader August 2014 Completed. Presented to Board in June

6 Key strategy Development need Responsibility Timescale Progress Status To analyse questionnaires for individuals and service providers we see on focussed visits Team A Leader Oct 2014 & April 2015 Only 5 questionnaires returned during the year. All five very positive To review and make recommendations on questionnaires for other visit areas Team A Leader June 2014 The intention was to do this after first analysis of forms above in October The analysis did not give much information. Given the low response rate the questionnaire will be reviewed and redesigned. To review how to engage carers on all themed and monitoring visits To visit a user or carer group in every Health Board area To ensure that at least 30 focussed visits are in the unannounced format Key performance indicator: to visit a minimum of 1,900 service users during Team A Leader April 2014 In the relevant themed visits we used a standard named person letter to contact relatives/ carers. We saw 77 relatives/carers during our visits Team Leaders March 2015 Completed. We met with 14 groups with 258 people attending Team Leaders March 2015 See KPI report Team A leader March 2015 See KPI report 5

7 Key strategy Development need Responsibility Timescale Progress Status To ensure the publication of two monitoring reports (from visits/ analysis completed during 2013/14) Specified persons approved at Board in May and published July Presented to Board in Specified persons Team A Leader September and published May 2014 October Recorded matters Team C Leader To implement visits for monitoring priorities 2014/15 Suspension of detention Team A Leader March 2015 Completed and approved by Board in May CCTOs Team B Leader March 2015 revised to June 2015 Report being written, target June Board To complete biennial survey of people with learning disabilities subject to MHCT Act 2003 Team B Leader February 2015 Board agreed not to do this but asked that a further proposal about learning disability monitoring be presented to October Board. This resulted in a proposal to monitor T2 forms. Completed an audit of T2 forms for people with learning disability. Learning outcomes to be shared at RCPsych learning disability faculty meeting in May 2015 and DMP annual seminar in November

8 Key strategy Development need Responsibility Timescale Progress Status Key performance indicator: to produce statistics and analysis on the use of mental health and incapacity legislation within 6 months of the end of the year Team B leader September 2014 See KPI report Investigations and casework Develop an annual report of investigation casework, with case studies, for presentation to the Board Key performance indicator: to produce four investigation reports during Revise seven of the current good practice guides Team C Leader August 2014 Completed, presented to Board in September 2014 Team C leader March 2015 See KPI report September 2014 Working with the AWIA in care homes Team C Leader We have received comments from the Justice Department. Carried forward to 2015/16 Mental Health Act care plans Team B Leader Approved by OMG but awaiting response from Mental Health Tribunal Working with independent advocacy Team A Leader Comments received from SIAA. Carried forward to 2015/16 Money matters Team C Leader Completed Supervising and supporting welfare guardians Team C Leader We have received comments from the Justice Department. Carried forward to 2015/16 7

9 Key strategy Development need Responsibility Timescale Progress Status Specified persons Team B Leader Completed Carried forward from 2013/14 Information for general hospitals Team B Leader Consulted with liaison psychiatrists through seconded training doctor. Currently being updated and split into a guide for MHA and one for AWI and scheduled to go to OMG in September 2015 Nutrition by artificial means Team A Leader Completed Safe to wander Team A Leader Approved by OMG in May and currently with publishers Review and improve Excellence into Practice seminars and run programme of seminars throughout the year HOCS Ongoing Four EIPs completed with 90 attendees An EIP for carers held in March in partnership with Carers Trust and Support in Mind. To hold an EIP type event in Orkney or Shetland Team C Leader March 2015 Carried forward to next year To decide on topics for and run series of webinars throughout the year HOCS Ongoing OMG agreed that webinars no longer a priority and no further work planned. Alternative 8

10 Key strategy Development need Responsibility Timescale Progress Status proposals focussing on CPD are under development by Executive Director (Medical) Influence & Empower To develop alternative, more accessible formats for our good practice guides specifically for individuals and their carers. To facilitate the Principles into practice awards in March 2015 Key performance indicator: to maintain an accuracy rate of at least 97.5% in random samples of advice given Continue input into meetings with CEOs of Health Boards To consult with people with learning disabilities on the statement on rights in mental health and learning disability care HOCS November 2014 Consultation event held in November and project rescoped following that consultation. Short topic guides to be produced in June 2015 HOCS March applications for awards received with 15 shortlisted. Successful event held in March Chief Executive Ongoing See KPI report Chief Executive June 2014 Attended meeting in June 2014 HOCS October 2014 This will not happen as a statement of rights has not been agreed as part of the commitment 5 work To work with SHRC and Scottish Government on progressing commitment 5 of mental health strategy Chief Executive Ongoing Logic outcome model developed and consulted on in December Follow up meetings to identify actions to meet the outcomes held with relevant organisations. Final report to be developed during

11 Key strategy Development need Responsibility Timescale Progress Status Contribute to the ongoing work of NPM Chief Executive April 2015 Ongoing. Contributed to NPM and to the annual report annual report and work on de facto detention and seclusion To hold a seminar for medical records HOCS November Completed in March 2015 Management and governance staff Key performance indicator: to report of the outcomes of recommendations made to services within agreed timescales in 90% of cases Review of senior management team roles and portfolios Complete the self assessment of the operation of the Board, Audit Committee and Operational Management Group Implement stakeholder feedback survey on visits Implement action plans, including impact assessments from the equalities scheme Implement the risk management action plan 2014 Team A Leader March 2015 See KPI report Chief Executive June 2014 Approved at Board in September. Recruitment for new post and SW post completed Chair / Audit Chair / HOCS April 2015 Board completed May 2014 Audit committee self assessment completed at November meeting and OMG in May 2015 HOCS September 2014 This was incorporated into the visit review HOCS Ongoing Equalities plan approved at December Board HOCS Ongoing Progress report to Audit committee in June, November and February Implement best value framework HOCS Ongoing Framework approved at Board in June 2014 and progress report to Board in June 2015 Finalise MOU with Scottish Government outlining roles and responsibilities for NCF HOCS June 2014 Completed Approved at September Board 10

12 Key strategy Development need Responsibility Timescale Progress Status Implement corporate governance and other business management arrangements for NCF HOCS August 2014 Updates provided to each Board meeting. Forum remit in standing orders and minutes of Human resources, learning and development Information governance Update and implement HR and learning and development strategy Forum reported to Board HOCS Ongoing Reported to OMG in October with some work outstanding due to NCF commitments. Carried forward to next year Implement biennial staff survey HOCS January 2015 Completed in January 2015 Action plan from results of this and IIP to be completed during 2015 Implement induction programme for NCF staff on business management policies and procedures Implement action plan for records management Set up team and project manage the upgrade to IMP required from changes to MHA HOCS August 2014 Completed with ongoing support from corporate services staff HOCS Ongoing Revised plan approved by NRS. A huge amount of work completed on records management which is an improvement action in the plan approved. HOCS Ongoing First meeting of Scottish Government group held in October. Consultation by SG Oct December. First draft of revised forms completed and currently consulting internally. 11

13 Comparative Data on activity 2014/ / / / / /10 Visits Themed visit reports Local visits (to services) Of which unannounced Number of individuals visited File reviews Total number of individuals review of care and treatment Guardianship visits (included in total visits above) Monitoring MHA forms processed Guardianship and intervention orders processed EDC notifications by phone processed Monitoring reports (including visits or case reviews and numbers are recorded in total number of visits above) DMP opinions Neurosurgery assessments Information and advice Number of recorded telephone calls (includes EDC notifications) Requests for advice Investigations Number of investigations progressed Of which published

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