In this section. Welcome to 2 gether NHS Foundation Trust s Quality Report for 2012/13.

Transcription

1 Welcome to gether NHS Foundation Trust s Quality Report for 01/13. The purpose of a Quality Report is to ensure Trust Boards focus on quality improvement as a core function of the organisation. In this section 3 Statement on Quality from the Chief Executive 5 Looking ahead to 013/14 9 Statements relating to the Quality of the NHS services provided 17 Looking Back: A review of Quality in 01/13 39 Statements from our Partners on the Quality Report 45 Statement of Directors Responsibilities in respect of the Quality Report 49 Independent Auditor s Report to the Council of Governors on the Quality Report

2 Part 1. Statement on Quality from the Chief Executive Introduction 3 Quality Initiatives 01/13 3 Quality Initiatives 013/14 3 Part a. Looking ahead to 013/14 Priorities for Improvement 013/14 5 Part b. Statements relating to the Quality of NHS Services Provided Review of Services 9 Participation in Clinical Audits and National Confidential Enquiries 10 Participation in Clinical Research 11 Use of the CQUIN payment framework 1 Statements from the Care Quality Commission 15 Quality of Data 16 Part 3. Looking Back: A Review of Quality in 011/1 Priorities for Improvement 01/13 17 Domain 1: Preventing people from dying prematurely 18 Domain : Enhancing quality of life for people with longterm conditions 18 Domain 3: Helping people to recover from episodes of ill health or following injury 0 Domain 4: Ensuring people have a positive experience of care Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm 7 Summary Report on Quality Measures for 01/13 31 Monitor Indicators and Thresholds for 01/13 33 Quality Indicators for 01/13 33 Community Survey Staff Survey PEAT Assessment Results 011/1 38 Annex 1. Statements from our Partners on the Quality Account Gloucestershire Health, Community and Care Overview and Scrutiny Committee 39 Herefordshire Health, Community and Care Overview and Scrutiny Committee 39 Gloucestershire Local Involvement Network 40 Healthwatch Herefordshire 41 Gloucestershire Clinical Comissioning Group 4 Herefordshire Clinical Comissioning Group 43 The Royal College of Psychiatrists 43 Annex. Statement of Directors Responsibilities in respect of the Quality Report 45 Annex 3. Glossary 46 Annex 4. How to contact us Other Comments, Concerns, Complaints and Compliments 48 Alternative Formats 48 Independent Auditor s Report to the Council of Governors on the Quality Report 49

3 Part 1. Statement on Quality from the Chief Executive Introduction Once again on behalf of the Board and all colleagues within gether NHS Foundation Trust it is my pleasure to present our annual Quality Report. As always, this report is a combination of the collective efforts of many clinical and managerial colleagues across the Trust. Our Quality Report last year identified 4 goals and 34 targets across the five domains of quality as detailed in the 01/13 NHS Operating Framework and NHS Outcomes Framework. Following feedback from service users, carers, our commissioners and LINks, we have streamlined our objectives for 013/14 into 11 goals and 1 targets. In part of this report you will find those detailed goals and targets these are the further improvements we have planned for 013/14. In part 3 you will read how we did against the plans we set out to achieve in our Quality Report last year. Quality Initiatives 01/13 Whilst 01/13 has been a challenging year, our frontline staff backed by our support services have once again continued to deliver improvements in the quality of services we provide. Significant progress was made on the 4 goals and 34 targets we set ourselves, with 4 targets achieved. Progress on the ten targets which were not fully achieved is detailed within the report. We have been privileged to have had the opportunity to provide the full range of a prison Healthcare service into HMP Gloucester. Our team of dedicated and skilled practitioners were acknowledged during a Care Quality Commission (CQC) visit to the prison for their excellent work. HMP Gloucester was one of the seven prisons chosen for closure under the reconfiguration plans by the Ministry of Justice and the service provision ceased at the end of the 01/13 financial year. In June 01, Gloucestershire Substance Misuse Services were tendered by commissioners. We were unsuccessful at tender and service contracts were awarded to Turning Point. Against a backdrop initially of uncertainty and subsequently of knowledge that we would cease being the preferred provider, our practitioners maintained high standards of provision throughout the year delivering some of the best outcomes across the South West of England. From December onwards practitioners worked extremely hard to continue to deliver services and ensure a safe transfer of care to the new provider. This was achieved and we ceased service provision from the end of March 013. Quality Initiatives 013/14 This theme of continuous improvements will continue into 013/14 and is supported by further investment in our inpatient units and our community bases. It will also be evident in the ongoing professional development and increased number of permanent staff working within our working age adult inpatient services. As we commence 013/14, our focus is clear: to work ever closer with service users, carers, commissioners and staff to understand the quality indicators that matter most to them. As a provider organisation we only exist to serve service users and carers. They are experts by experience and throughout the year, much of our learning and subsequent improvements have come from their involvement in service planning and evaluation. We are indebted to their continued support. "Health outcomes matter to patients and the public. Measuring and publishing information on health outcomes are important for encouraging improvements in quality". During 013/14 we will implement ways to help make sure that our adult service users have the opportunity to describe the impact of the interventions they received by completing nationally recognised outcome measures. This will help us to continually understand, from their perspective, the usefulness of the interventions provided and enable us to make any necessary adjustments. It is essential that when individual s access services that they are as safe as possible. We will build upon the learning from our involvement in the South of England Improving Safety in Mental Health Programme to implement change using reliable improvement technologies. The Francis Report and the failings at Winterbourne View have raised question of confidence in the overall care and support system. Every health and social care practitioner, every manager and every Board member must think carefully about the recommendations that have emerged from the lessons from both of these reports to ensure that they have confidence in the local services they provide and access. 3

4 Our clinical leadership is leading our organisational selfreflection and action planning to ensure that we can give everyone confidence, that locally, we have a culture that is conducive to ensure the quality of care we provide and that if concerns arise, that there are effective methods of raising these and that they are acted upon. Our clinicians are highly qualified and experienced. They are trained to critically appraise and utilise emerging evidence on effectiveness, to adopt and adapt best practice and to personalise what they do for the unique circumstances of the individual they are supporting with care and compassion. These attributes will be pivotal in embracing the changes ahead of us effectively. Following the introduction of a Carers Charter in 011, this year service users and clinicians collaborated together to develop our Service User Charter. The charter was launched on World Mental Health Day in October and together with our Carers Charter is a statement of the positive intent to place service users and carers at the centre of everything we do, on every occasion. Overall, the primary goal to which we aspire is to ensure that individuals in our care are safe, obtain the best possible outcomes and when in receipt of services have the experience that we would all wish for a member of our family. As we have stated in previous years our name is a statement of intent; to work together with others. Throughout the year we have benefited from feedback, collaborative discussions, suggestions and challenges from our partners in commissioning, LiNks and shadow Healthwatch as well as other provider organisation colleagues. We are proud to be a part of the NHS. We are also proud that as a Public Interest Corporation we are a membership organisation. Our 7,000 members elect a Council of Governors who play a vital role in ensuring our accountability and connectivity to our local communities in which we serve. We are indebted to our Governors who have given freely of their time energy and skills to assure themselves on behalf of our communities that the quality of services provided is of an appropriate standard. In the coming year, the Trust Board will continue to focus our energy and expertise on ensuring that we consistently deliver and improve the services we provide. This is what our service users and carers deserve; this is what we will work with them and our commissioners to achieve. Shaun Clee Chief Executive gether NHS Foundation Trust 4

5 Part a. Looking ahead to 013/14 This section of the report looks ahead to our priorities for quality improvement in 013/14. We have developed our quality priorities for improvement against the five quality areas described in the NHS Outcomes Framework 013/14. These areas sit under the three key dimensions of effectiveness; user experience and safety and have been approved by the Trust Board following discussions with our key stakeholders. We are aiming to improve outcomes for service users through these actions being mindful that a key national priority is: Health outcomes matter to patients and the public. Measuring and publishing information on health outcomes are important for encouraging improvements in quality NHS Outcomes Framework 013/14 Following feedback from service users, carers, our commissioners and LINks, we have streamlined our objectives for 013/14 into 11 goals and 1 targets. Outcomes will be measured and monitored with the period of time varying from monthly, quarterly or annually depending what we are measuring and how often the data is collected. How we prioritised our quality improvement initiatives The quality improvements in each area were chosen by considering the requirements and recommendations from the following sources: Documents/Organisations: NHS Commissioning Board (Everyone Counts: Planning for Patients 013/14) The Francis Inquiry (February 013) Care Quality Commission (via the Quality Risk Profile and CQC Compliance Reviews at our sites) Department of Health, with specific reference to No health, without mental health (011) Internal inspections Monitor King s Fund report on Quality Accounts National Institute for Health & Care Excellence publications including their quality standards We strongly value working in partnership and have had feedback on our services during 01/13 which has informed our choice of quality improvement initiatives for this coming year. The feedback and contributions have come from: Gloucestershire Local Involvement Network (LINk) Herefordshire Local Involvement Network (LINk) Gloucestershire Health, Community and Care Overview and Scrutiny Committee (HCCOSC) and Council colleagues Herefordshire Overview and Scrutiny Committee and Council colleagues NHS Gloucestershire and the shadow Clinical Commissioning Group NHS Herefordshire and the shadow Clinical Commissioning Group Internal audits South West Mental Health Patient Safety Improvement Programme Trust s Service Experience Committee (comprising of service users and carers) Trust s Governors Trust clinicians and managers The proposed quality initiatives were then considered and agreed by the Governance Committee, which is a subcommittee of the Board and has clinical and managerial representation from across the Trust and is chaired by a NonExecutive Director. This Committee meets formally monthly to consider information relating to quality across all of the services we provide. The priorities for improvement are applicable for services in both Gloucestershire and Herefordshire unless specified, and where they are different it is a reflection of the different quality priorities in each county. 5

6 Progress on the implementation of each of the quality improvement areas will continue to be reported to the Trust Board every quarter. This information will also be shared with our major stakeholders. These targets represent a small sample of the large number of quality initiatives which are undertaken, but are areas which will potentially have a significant impact on safety and quality. In terms of wider initiatives, the Trust remains an active participant in the South of England Patient Safety Improvement Programme for mental health providers and has challenging CQUIN targets in both counties. The Trust has also reviewed the recommendations from the Francis Report into the Mid Staffordshire Trust and identified areas where we have good assurance and issues we plan to focus on for further work. A group of senior clinicians has met to draw up a plan of actions and areas of work and these will be communicated to staff in a series of road shows which will also provide an opportunity for staff to give feedback and make their own suggestions. This alongside our service experience work will hopefully make the organisation more aware of what it is like to work in the Trust or to receive services. Domain 1: Preventing people from dying prematurely Ensuring that premature death in people with serious mental illness and learning difficulties is reduced remains a key priority; we will carry out the following activities: Goal Target Drivers Minimise the risk of suicide of people who use our services 1.1 Reduce the numbers of deaths relating to identified risk factors of people in contact with services when compared data from previous years. National strategy of zero tolerance of preventable harm Gloucestershire Suicide Prevention Strategy and Action Plan Herefordshire Public Health Report Ensure we follow people up when they leave our inpatient units within 48 hours to reduce risk of harm % of adults will be followed up by our services within 48 hours of discharge from psychiatric inpatient care (This is a local target. The national target is that 95% CPA service users receive follow up within 7 days) Local and national priorities Our local target of 95% was not met consistently during 0113 Improve the physical health of patients with mental health problems % of community patients with a serious mental illness will have had an annual physical health check People with schizophrenia and bipolar disorder die on average 5 years earlier than the general population largely because of physical health problems. 6

7 Domain : Enhancing quality of life for people with long term conditions We will continue to focus on outcomes that are important to those living with longterm conditions. The way we will carry out this objective will be to focus improvements upon the following: Goal Target Drivers Improve the experience of people with dementia in Gloucestershire and Herefordshire.1 Improved access to dementia services for Black & Ethnic minority communities through training an agreed number of staff. 70% of an identified group of registered staff will receive this training. (Gloucestershire).. Ensure appropriate and timely reviews of prescribed antipsychotic medication for people with dementia living in a care home through three monthly reviews, providing demonstrable evidence of improvement during Quarter 4. (Herefordshire) Prime Minister s Dementia Challenge (01) enhancing the quality of life for people with dementia. People will feedback to us whether the service they have received has improved their quality of life..3 90% of adults in contact with services will describe the impact of interventions on their discharge through the completion of nationally recognised outcome measures Improve the effectiveness of interventions offered by the Trust Children and Young Peoples Services will use mechanisms to gain feedback on whether the service has improved their quality of life..4 Report on improved outcomes of those who use the service Implementation of the new National Children s Improving Access to Psychological Therapy Local priority for Herefordshire to improve services Domain 3: Helping people to recover from episodes of ill health or following injury Central to the service we provide is achieving the best possible outcomes for people who develop treatable conditions. Specifically, we need to help people recover from illness or injury and prevent conditions from becoming more serious. Actions that will be taken to support this objective include: Goal Target Drivers Ensure appropriate access to psychiatric inpatient care % of people will be seen by the Crisis and Home Treatment Team prior to admission, to ensure appropriate access to inpatients services. Department of Health Outcomes Framework key measure on appropriate access 7

8 Domain 4: Ensuring people have a positive experience of care Quality of care includes the quality of caring. This means how personal care is provided; the compassion, dignity and respect with which service users are treated, and the extent to which they are given the level of comfort, information and support they require. The Trust is implementing the 6Cs (National Nursing Strategy 01) throughout the organisation. In our quarterly reports we will report on our development work in this area as well as focusing upon equality and diversity work and partnership working with voluntary agencies in both counties. Goal Target Drivers Improve service user experience 4.1 Undertake local surveys of both community and inpatient services by asking the following questions and improve on our 01/13 scores. Did you have enough time to discuss your condition, treatment and care? (7%) Did you find talking with a member of your care team helpful? (49%) Did we involve your family and carers as much as you would like? (50%) Has your mental health care service helped you start achieving your treatment goals? (54%) We have identified these questions as they were areas where we achieved a lower score in the 01/13 national Community Patient Survey Improve carer experience 4. Ensure that of carers are offered assessments Implementation of Trust s Carers Charter Domain 5: Treating and caring for people in a safe environment and protecting them from avoidable harm Protecting service users from further harm whilst they are in our care is a fundamental requirement. We seek to ensure a safe environment for service users, staff and everyone else that comes into contact with us. We will achieve this by the following: Goal Target Drivers Minimise the risk of harm to people who use our services 5.1 To reduce the number of serious incidents as a proportion of patients on the trust s caseload to an annual average of 0. incidents per 1000 caseload. (Patient harm serious incidents are reported nationally e.g. pressure ulcers, severe selfharm incidents ) National driver of zero tolerance of preventable harm for people who use NHS services NHS Safety Programme Ensure the safety of patients detained under the Mental Health Act 5. Reduce the number of patients who are absent without leave from inpatient units who are formally detained by 50%. Baseline to be established and confirmed in Quarter NHS Safety Programme 8

9 Part b. Statements relating to the Quality of NHS Services Provided The following section includes responses to a nationally defined set of statements which are common across all Quality Reports. The statements provide assurance that we are providing services according to national standards, measuring and monitoring the quality of care we provide and are participating in and learning from national projects. Review of Services The purpose of this section of the report is to ensure we have considered the quality of care across all our services which we undertake through comprehensive reports on all services to the Governance Committee (a subcommittee of the Board). During 01/013, the gether NHS Foundation Trust provided and/or subcontracted the following NHS services: Gloucestershire Our services are delivered through multidisciplinary and specialist teams. They are: One stop teams providing care to adults with mental health problems and those with a learning disability Primary Mental Health Care services Specialist services including Early Intervention, Crisis Resolution and Home Treatment, Assertive Outreach, Managing Memory, *Prison healthcare, *Substance Misuse and Children and Young People Services Inpatient care Improving Access to Psychological Therapies *Following the closure of HMP Gloucester, the Prison Healthcare service ceased to be a service that we provided from 31 March 013. Also the Substance Misuse Services were transferred to Turning Point from 1 April 013 following a tendering process by NHS Gloucestershire. Herefordshire We provide a comprehensive range of integrated mental health and social care services across the county. Our services include: providing care to adults with mental health problems in Recovery Teams and Older People s teams Children and Adolescent Mental Health care Specialist services including Early Intervention, Assertive Outreach and Crisis Resolution and Home Treatment and Substance Misuse Services Inpatient care Improving Access to Psychological Therapies South Gloucestershire During 01/13, we provided Improving Access to Psychological Therapies services until October 01. gether NHS Foundation Trust has reviewed all the data available to them on the quality of care in all of these NHS services through a systematic plan of quality reporting and assurance that is considered by the Trust s Governance Committee and the Board. The income generated by the NHS services reviewed in 01/13 represents 94.9% of the total income generated from the provision of NHS services by the gether NHS Foundation Trust for 011/1. Participation in Clinical Audits and National Confidential Enquiries During 01/13, two national clinical audits and four national confidential enquiries covered NHS services that gether NHS Foundation Trust provides. During that period, gether NHS Foundation Trust participated in 50% national clinical audits and confidential enquiries of the national clinical audits and national confidential enquiries which we were eligible to participate in. 9

10 The national clinical audits and national confidential enquiries that gether NHS Foundation Trust was eligible and participated in during 01/13 are as follows: National Clinical Audits Clinical Audits National Audit of Psychological Therapies Prescribing Observatory for Mental Health Participated Yes/No Yes No Reason for no participation Voluntary involvement. The Trust was not a member in membership period National Confidential Enquiries National Confidential Enquiries Confidential Enquiry into Maternal and Child Health National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Sudden Unexplained Death of Psychiatric Inpatients Study Confidential Inquiry into the Premature Deaths of People with a Learning Disability Participated Yes/No Yes Yes Yes Yes Reason for no participation The national clinical audits and national confidential enquiries that gether NHS Foundation Trust participated in, and for which data collection was completed during 01/13 are listed below 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. Clinical Audits National Audit of Psychological Therapies No of cases requested No of cases submitted % cases submitted All Not known Report not available. Confidential Enquiries Confidential Enquiry into Maternal and Child Health Not Available Not Available Not Available National Confidential Inquiry into into Suicide and Homicide by People with Mental Illness Not Available Not Available 98.45% Sudden Unexplained Death of Psychiatric Inpatients Study Not Available Not Available 98.31% Confidential Inquiry into the Premature Deaths of People with a Learning Disability Not Available Not Available Not Available The report for the National Audit of Psychological Therapies has not yet been issued and will be available in October

11 The participation in these national audits and enquiries demonstrates that as an organisation we want to learn and benchmark our care against other providers to the benefit of the people who use our services. As a result of participating in the national audits we are: Ensuring an increased focus on the physical health of people diagnosed with schizophrenia Reviewing how more people can access psychological therapy services through our Improving Access to Psychological Therapy service Providing maternal mental health services according to agreed countywide pathways of care During 01/13 the Trust took part in the audit of schizophrenia lead nationally by Rethink. The Trust also participated in the first round of the National Audit of Schizophrenia in autumn 011, the final report of which was published in April 01. gether NHS Foundation Trust is already enlisted to take part in the second round of this audit due to take place during 013/14. Clinical audits of our services Within our services there is a high level of clinical participation in local clinical audits, demonstrating our commitment to quality across the organisation. All clinically led local audits are reported to the Governance Committee in summary form to ensure that actions are taken forward and learning is shared widely. During 01/13, 83 local clinical audits were completed within the Trust. During this process we internally identified 581 recommendations to further improve our practice as part of our commitment to continuous improvement. A further 17 audits were commenced during 01/13 and are due to be completed early in 013/14. An extract from one of our internal audits regarding compliance with the Falls Care Pathway (written incorporating the NICE guidance CG1) identified the following: All inpatients in older people services and learning disability services over the age of 40 were included in the audit. In total 45 inpatients were identified and of the 16 criteria the following scores were identified: 6 (38%) scored 95 compliance (13%) scored 9094% compliance 7 (43%) scored 8089% compliance 1 (6%) scored 7079% compliance Overall score 91% Compliance The audit showed that the Falls risk assessment is routinely covered on admission or as part of the Trust initial assessment and all those assessed as being at risk are being referred for physiotherapy treatment. The areas which scored lower included: Osteoporosis risk Visual impairment Home hazard assessment From the audit findings, recommendations were made to further improve quality and patient experience within this area. Participation in Clinical Research It is important that we report on our participation in research reflecting our commitment to continuously improve the quality of services that we provide. Throughout the last twelve months, we have continued to support the recruitment of service users and staff into research approved by an NHS research ethics committee. During 01/13, there were 4 people recruited (data from the Western Comprehensive Local Research Network WCLRN). The number has decreased from last year (315 recruits) reflecting that there are less recruiting studies on the National Institute for Health Research (NIHR) portfolio, and greater competition. The Trust currently has a total of 6 registered and approved studies in Gloucestershire which includes a mix of clinical and commercial trials, confidential inquiries, service evaluations and student research. Of these studies, 40 were clinical research based in mental health or dementia during 01/13, with the addition of service evaluation or student research projects initiated and coordinated by Trust staff or students. We continue to participate in research that fits with the Trust core values, which means we are focusing closely on research studies that align with our continuing commitment to improving the quality of care we offer and to making our contribution to wider health improvement. Service change within Herefordshire has meant that active research did not take place during 0113 but preparations were made to ensure that research activity can begin during Research Sponsors At the close of 01/13, we have 8 approved NIHR studies recruiting or active in Gloucestershire. Of these, 17 studies are sponsored by Universities, seven sponsors are from the pharmaceutical industry, two are other NHS Trusts and two are charitable organisations such as the Medical Research Council. This highlights the need for NHS organisations, such as ours, to build strong academic links with those Universities who are research active in mental health in order to help build links for site selection. Examples of the breadth of our research portfolio of activity are listed below. Mental Health ECHO: Expert Carers Helping Others a randomised controlled trial of a carer intervention for those with an eating disorder NAlive Pilot: NALoxone InVEstigation Prisonbased Naloxoneonrelease pilot randomised controlled prevention trial: to demonstrate feasibility by recruiting first tenth of 56,000 participants needed to quantify reduction in drugsrelated deaths soon after release DPIM Polymorphisms in Mental Illness: investigating genetic factors involved in schizophrenia, bipolar disorder, alcoholism and autism and exploring possible treatment options 11

12 National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Confidential Inquiry into premature deaths of people with learning disabilities REFOCUS randomised controlled trial: Developing a recovery focus in mental health services in England OASIS: Seroquel XL hospitalevent monitoring study Victims of homicide with mental illness National study of suicide by prisoners Liberty, equality, capacity: the impact of the Deprivation of Liberty Dementias and Neurodegenerative Disease A large randomised assessment of the relative cost effectiveness of classes of drugs for Parkinson s Brains for Dementia Research GERAS: Observational Study of costs and resource use of Alzheimer s disease in Europe PD Rehab Parkinson Disease We continue to receive support funding from the WCLRN via the Research and Development Consortium for Gloucestershire to provide a research infrastructure within the Trust. Use of the Commissioning for Quality & Innovation (CQUIN) framework The national contractual use of CQUINs is to support the essential focus upon quality improvement in the provision of services and incentivise this through specific quality payments. A proportion of gether NHS Foundation Trust s income in 01/13 was conditional on achieving quality improvement and innovation goals agreed between gether NHS Foundation Trust and NHS Gloucestershire, NHS Herefordshire and NHS South West Specialised Commissioning Group (for the provision of low secure mental health NHS services). 01/13 CQUIN Goals Gloucestershire Goal Name Description Goal weighting Expected value Quality Domain Venous thrombo embolism (VTE) Patient Experience NHS Safety Thermometer Telehealth and Telecare Maternal Mental Health Out of County Placements Reduce avoidable death, disability & chronic ill health from VTE Improve responsiveness to the personal needs of patients (Patient Experience) Improve data collection on pressure ulcers, falls, urinary tract infection in those with a catheter & VTE Promote use of this technology to help people live more independently at home Provide a pathway and staff training to better help expectant mothers who are experiencing mental ill health To ensure systems are in place that will allow people to be treated as close to their support networks as possible 5.00% 91,100 Safety 19.00% 346,180 Patient Experience 5.00% 91,100 Safety 10.00% 18,0 Effectiveness 14.00% 55,080 Effectiveness 3.00% 54,660 Effectiveness Medicines Make plans to encourage generic.00% 400,840 Effectiveness management prescribing within Primary care Falls Reduce falls within inpatient settings 10.00% 18,0 Safety Learning Disability Outcomes Develop a tool that captures how interventions result in improvements for the individual or LD population 1.00% 18,640 Patient Experience 1

13 Herefordshire Goal Name Description Goal weighting Expected value Quality Domain VTE Risk Assessment (Prevention) NHS Safety Thermometer Improve responsiveness to the personal needs of patients Making Every Contact Count Pain Assessment Recovery Star To reduce avoidable death, disability and chronic ill health from venous thromboembolism (VTE) Improve data collection onpressure ulcers, falls, urinary tract infection in those with a catheter & VTE Improve responsiveness to the personal needs of patients (Patient Experience) Making every patient contact count through systematic healthy lifestyle advice delivered through frontline staff Implementation of a community and inpatient (Cantilupe) pain assessment tool to improve local assessment To pilot the implementation of recovery star clients of agreed teams 5.00% 17,783 Safety 5.00% 17,783 Safety 18.00% 64,019 Patient Experience 1.00% 4,680 Effectiveness 30.00% 106,699 Effectiveness 15.00% 53,349 Effectiveness Prevention of suicide Implementation of the NPSA community patient suicide prevention through toolkits 15.00% 53,349 Safety Low Secure Services Goal Name Description Goal weighting Expected value Quality Domain Minimum Take Dashboard Shared pathway and recovery and outcomes Implementing a standard secure pathway Secure forensic care pathway feasibility project Aimed at ensuring that implementation and routine use of the required clinical dashboards Introduce and implement a recovery and outcomes based approach to the care pathway, demonstrating recovery orientated practice Introduce and monitor key milestones on the patient pathway to make it efficient and reduce length of stay Implement, review and feedback on MHCT clustering, 5 Care pathway indicators, and reporting feasibility within a clear reporting structure 5% 9,801 Efficiency 5% 9,801 Patient Experience 5% 9,801 Efficiency 5% 9,801 Innovation The total combined potential value of the income conditional on reaching the targets within the CQUINs during 0113 was,301,000 of which,90,000 has actually been achieved. This is different to the figure provided in the final account due to due the year end figure being agreed by commissioners at the end of Quarter In 0111 the total potential value of the income conditional on reaching the targets within the CQUINs was 1,31,000 of which 1,306,500 was achieved. 13

14 013/14 CQUIN Goals 013/14 CQUIN Goals CQUIN goals for 013/14 have been agreed with Gloucestershire and Herefordshire Clinical Commissioning Groups and the National Commissioning Board (for the provision of low secure mental health NHS services). These include: Digital First Initiatives an innovation which aims to avoid unnecessary face to face appointments Increased use of Telecare/Telehealth Technologies using technologies to help people live independently Use of NHS Safety Thermometer a tool to promote, measure and monitor harm free care Patient experience improving the experience that service users have from our services Effective Communication between Secondary and Primary Health improved communication between GPs and specialist services Increased use of Recovery Star tool for promoting service users recovery CAMHS Outcome measure understanding what helps children and young people best Increased use of LD Outcomes measure understanding what helps people with a learning disability best Responsiveness to carers of inpatients making sure that we are listening to and working with carers Carers for people with dementia making sure that we are listening to and working with carers VTE Monitoring and assessing a tool to promote, measure and monitor harm free care Encourage use of generic prescribing in Primary Care working with GPs to promote good use of medicines Physical health of people with mental health problems promoting annual physical health checks Increased access for BME to community services ensuring that equality of access to our services is available to the whole community Payment by Results promoting efficiency, patient choice and best practice Suicide prevention training providing staff with skills to help support people experiencing suicidal crisis Regular review of elderly patients being prescribed antipsychotic medication ensuring appropriate use of medicines Low secure care pathway ensuring the best outcomes for people in our forensic services Provision of Literacy and Numeracy in Low secure unit improving reading and simple arithmetic 14

15 Statements from the Care Quality Commission The Care Quality Commission (CQC) is the independent regulator of health and adult social care services in England. From April 010, all NHS Trusts have been legally required to register with the CQC. Registration is the licence to operate and to be registered, providers must, by law, demonstrate compliance with the requirements of the CQC (Registration) Regulations 009. gether NHS Foundation Trust is registered with the CQC with no conditions. This means that the Trust has continued to demonstrate compliance with the regulations and we are registered to provide the following regulated activities: Assessment or medical treatment to persons detained under the Mental Health act 1983 Diagnostic and screening procedures Treatment of disease, disorder or injury The locations from which the Trust is registered to provide these regulated activities are confirmed on the CQC website The CQC has not taken enforcement action against gether NHS Foundation Trust during 01/13; however compliance actions were required following one of their inspections during this time period. The Trust continues to receive monthly Quality Risk Profiles from the CQC. The Quality Risk Profile published on 4 April 013 declares no risk to compliance with any of the 16 essential standard outcome areas for quality and safety above a High Yellow rating. This is on a scale that increases risk from Low/High red to Low/High Yellow to Low/High Amber to Low/High Red. Low Green being the lowest risk rating and High Red being the highest risk rating. The CQC has monitored the Trust s compliance with its standards by undertaking the following inspections of services during 01/13: Review of HMP Gloucester Prison Healthcare A CQC Inspection of the healthcare provision within the prison took place on 91 July 01, as part of a wider inspection by HMP Inspectorate of HMP Gloucester. The inspection found that the service was compliant in the areas reviewed which included treating people with respect, the provision of safe care which is coordinated, appropriately trained and supervised staff with quality monitoring systems in place. During the inspection prisoners spoken with expressed a high level of satisfaction with the health services offered. One person commented: Charlton Lane Centre They ve really helped me a lot. A CQC inspection of Charlton Lane Centre took place on August 01 as part of the national themed CQC inspections on dignity and nutrition. Charlton Lane provides inpatient care to people with mental health problems as well as physical health problems. The inspection found that people using this service were treated people with respect, provided with safe care and food and drink to meet their individual needs and safeguarded from harm. Comments from patients to the CQC inspectors included: I feel involved in my care and know my rights Staff always maintain my privacy and dignity The inspection found that the recording of care was not compliant with the CQC standards and that this was having a minor impact on patients using the service. A series of actions were taken and following a review by the CQC of information provided to them by the Trust, the service was judged in February 013 as being fully compliant. Review of Westridge Assessment and Treatment Unit An unannounced CQC inspection of this in patient service for people with a learning disability took place on 18 December 01. The inspection found that people using this service were provided with safe care in appropriate environments, were safeguarded from harm, with appropriate levels of staff on duty and quality monitoring systems in place. Relatives told the inspection team that they were happy with the service provided, the skills of the staff and they felt informed and included in the care of those using the service. Mental Health Act monitoring The CQC undertake regular reviews of the use of the Mental Health Act within Trust services The Mental Health Act Commissioner has visited all of our inpatient services in Gloucestershire and Herefordshire and has forwarded to the Trust reports detailing their findings. We have investigated the points raised within the reports and responded to the CQC detailing the actions that have been put in place to correct those issues. All visit reports made by the Commissioner and the Trust responses are scrutinised initially by the Director of Service Delivery and then by the Trusts Mental Health Act Scrutiny Committee. Changes in service registration with Care Quality Commission for 013/14 The CQC have been formally informed of the closure of Her Majesty s Prison Gloucester, and that the Substance Misuse Services in Gloucestershire were transferred to Turning Point from 1 April 013 following a tendering process by NHS Gloucestershire. The Trust s Certificate of Registration with CQC has been updated in relation to the locations from which services are provided. 15

16 Quality of Data Statement on relevance of Data Quality and actions to improve Data Quality Good quality data underpins the effective provision of care and treatment and is essential to enabling improvements in care. gether NHS Foundation Trust submitted records during 01/13 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: 99.8% for admitted patient care (99.1% national); and 99.9% for outpatient care (99% national) the patient s valid General Practitioner Registration Code was: for admitted patient care (99.9%); and 99.9% for outpatient care (99.3% national) gether NHS Foundation Trust has taken the following actions to improve data quality building on its existing clinical data quality arrangements: Putting in place new data quality processes resulting in one report covering all services which is held on a shared system so managers can view information by service, team or clinician Significant increase in the completeness of data capture over and above what has already been achieved throughout 01/13 Setting up a new Clinical Information Reference Committee to support the already established RiO (mental health electronic record) Group to continue the review of data quality Information Governance Toolkit Ensuring that patient data is held securely is essential, as such the Trust complies with the NHS requirements on Information Governance and assesses itself annually against the national standards set out in the Information Governance Toolkit which is available on the Health & Social Care Information Centre website: gether NHS Foundation Trust Information Governance Toolkit Assessment Report overall score for 011/1 was 83% and was graded green (satisfactory). For the 01/13 version of the Information Governance Toolkit Foundation Trusts were again required to achieve a minimum of Level for each of the 45 indicators. At time of submission on 31 March 013, of the 45 key indicators: were at level 3 were at level 1 was deemed not relevant to us This produced an overall score of 83%, which is rated green (satisfactory) The Trust s efforts will remain focussed on maintaining the current level of compliance during 013/14 and ensuring that the relevant evidence is up to date and reflective of best practice as currently understood, and that good information governance is promoted and embedded in the Trust through the work of the Information Governance and Health Records Committee, the IG Advisory Committee and Trust managers and staff. Clinical Coding Error Rate gether NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 01/013 by the Audit Commission. 16

17 Part 3. Looking Back: A Review of Quality in 01/13 A Review of Quality in 01/13 The 01/13 quality priorities were agreed in May 01 and published in the Quality Report, and are accessed through the following link: w.aspx?id=769 The quality priorities were grouped under five broad areas of quality improvements. This section of the report outlines the achievements and progress made in each of the five areas against what we said we would do. It also outlines key service developments which have positively impacted on the care we provide. Significant progress was made on the 4 goals and 34 targets we set ourselves, with 4 targets achieved. The report describes the progress made on the 10 targets that we did not achieve or partially achieved relating to: 1. Smoking cessation referrals in Gloucestershire (1.3). Implementation of an IAPT service for HMP Gloucester (.5) 3. Ensuring improved access to IAPT in Herefordshire (.6) 4. At least 95% of adult Care Programme Approach (CPA) service users receiving followup contact within 48 hours of discharge from psychiatric inpatient care (3.1) 5. Internal service satisfaction survey results (4.1) 6. Achievement of AIMS accreditation in Herefordshire inpatient services (4.4) 7. Reduction in serious harm from falls by 50% (between 01013) 8. Zero unexpected deaths in inpatient units. (5.3) 9. Information being made available from a crisis team to an inpatient unit within 4 hours of admission. (5.4) 10.Service users being discharged with relevant information ( 5.5) Since the start of the Commissioning for Quality and Innovation (CQUIN) scheme commenced, gether NHS Foundation Trust has worked proactively with its commissioners to ensure that the targets that were being set had a positive benefit for users of its service. It is important to us that we use this scheme to aid quality improvements and that it fits into our commitment to constantly strive to improve quality overall. In January 011, NICE (now The National Institute for Health and Care Excellence) released Quality Standard 14 which is focused on service user experience in adult mental health. In this standard they stated that highquality care should be clinically effective, safe and be provided in a way that ensures the service user has the best possible experience of care from the NHS. The way the staff are here makes it feel more equal, from the patient point of view. They make you feel equal, they don t talk down to you. This quality standard describes markers of high quality, costeffective care that, when delivered collectively, should contribute to improving the effectiveness, safety and experience of care for service users in the following ways: enhancing quality of life for people with longterm conditions ensuring that people have a positive experience of care treating and caring for people in a safe environment and protecting them from avoidable harm enhancing quality of life for people with care and support needs ensuring that people have a positive experience of care and support safeguarding adults whose circumstances make them vulnerable and protecting them from avoidable harm This standard has had a direct impact on what CQUINs were agreed and how we delivered them. 17

18 Domain 1: Preventing people from dying prematurely In 01/13 we committed to continue our quality work in reducing the risk of premature death in people with serious mental illness and learning difficulties. We set ourselves three goals with five associated targets, and achieved four targets within this domain. 1.1 Suicide Prevention We aimed to minimise the risk of suicide amongst those with mental disorders through a systematic implementation of sound risk management principles and set ourselves a specific target. Target Year End Achievement To use the National Patient Safety Agency (NPSA) National Suicide Prevention Toolkit for all inpatient units in Herefordshire and Gloucestershire monthly on a sample of patients records.* * This target relates to Wotton Lawn Hospital and Stonebow Unit It is positive to report that the toolkit audit took place in all teams as per the plan and this enabled staff to ensure all patient risk factors are taken account of and learning within in teams To use the NPSA Community Suicide Prevention Toolkit quarterly to audit Crisis & Recovery Teams in Gloucestershire and Herefordshire suicide prevention work 1. Promoting healthier lifestyles We wanted to provide more positive health interventions for our service users relating to smoking and drinking and quality improvements have taken place: Staff in Herefordshire and Gloucestershire have undertaken specific Making Every Contact Count training. 16 staff have been trained at Level 1 and 114 at Level in Herefordshire. This has increased the total number of referrals that have been made to stop smoking services this year to: Gloucestershire: 146 against a target of 170 (Not achieved. This target relates to service users in the community. In 013/14 emphasis will be placed on smoking cessation as part of the physical health check) Herefordshire: 71 against a target of 6 Improving the health of prisoners has been a key objective through accessible primary and mental health services. This has been measured against 3 national prison indicators and at the end of the year before the prison closed the healthcare service was meeting all the indicators. Comments from individuals under our care to CQC inspectors at HMP Gloucester included: "There's no problem with the staff, they are very efficient and sort things out quickly." "They let you speak and I feel like they listen to my opinions." Domain : Enhancing quality of life for people with longterm conditions We continue to be aware that people who have a mental illness or a learning disability need support to live with their longterm condition and we wanted to make more quality improvements to our service that would assist in this area. In this domain, we set ourselves four goals with seven associated targets, and achieved five of the targets..1 Improving services for people with dementia (Gloucestershire) We wanted to improve dementia services within Gloucestershire by providing appropriate assessments of need and ensuring that people were able to access the appropriate services for them. Staff in Gloucestershire have undertaken specific Telehealth and Telecare training. This will help them to be aware of the benefits of Telecare and Telehealth services and promote the use of this technology to help people live more independently at home. The technology includes personal alarms and health monitoring devices. Gloucestershire staff trained: 105 against a target of 83 18

19 . Improving services for people with dementia (Herefordshire) In Herefordshire, reflecting local priorities, we wanted to ensure that service users with a diagnosis of dementia received a thorough pain assessment on admission to hospital and in community teams. Throughout the year we have developed the tool, trained staff and have now embedded it into practice in such a way that all appropriate people are now assessed in this way on admission..3 Improve services for people with a learning disability in Gloucestershire We were concerned that there has been an absence of a tool that that accurately captures how interventions from the Learning Disability (LD) service result in improvements for the individual or population of people using learning disability services. We therefore have worked collaboratively to develop and implement one during the course of this year. Throughout this year we have worked collaboratively and developed a Health Equality framework outcome tool, trained staff, piloted the tool and it has been launched nationally. The scores from within our Trust are showing positive outcomes across all five health equality.5 Improve access to psychological therapy services for the wider populations in Gloucestershire In line with principles outlined in No health, without mental health (011), we wanted to make sure that as many people as possible were able to access and benefit from our Improving Access to Psychological Therapies (IAPT) services in Gloucestershire and Herefordshire. Access and recovery rates have improved throughout the year. We also wanted to establish and implement a children s Improving Access to Psychological Therapies (IAPT) service in Gloucestershire as part of a national pilot. Target To ensure that people in Gloucestershire have improved access to our Improving Access to Psychological Therapies (IAPT) Service determinant areas with further analysis made possible by the developing electronic data capture tool. Overall a net positive 4% change in the impact of the evidence based determinants of health inequalities was achieved across the sample..4 Improve access to services for adults in Gloucestershire To ensure ease of access to our services we wanted to establish and implement a Contact Centre and monitor the benefits for service users and those referring to the service. The Gloucestershire Contact Centre commenced in May 01 providing a referral management function for the North Locality initially. The West Locality commenced using the service on the 16 July 01 and the South Locality service commenced in September. The Contact Centre is continuing to review how systems can be improved and has recently provided access for GP queries related to medication with access to the on call Consultant rota. The service has been positively received evidenced by increased use of the service by GP colleagues. The Contact Centre is now also receiving referrals for the Crisis Teams between 9am5pm. Our IAPT trainees have now completed their course at Reading University, and work is taking place to ensure participation and feedback from children on this. The service is currently developing routine outcome monitoring and developing a Cognitive Behaviour Therapy (CBT) pathway. Prior to HMP Gloucester closing on March , we had also progressed our plans to implement an IAPT service for prisoners within the prison and the service had commenced. With the closure of the prison the target could not, therefore, be realised. Year End Achievement (cumulative) Q1 Referrals 1148 Q Referrals 640 Q3 Referrals 440 Q4 Referrals Improve access to psychological therapy services for the wider populations in Herefordshire In line with No health, without mental health (011) we wanted to make sure that as many people as possible were able to access and benefit from our IAPT services in Herefordshire. At the end of March 013 there had been 943 new cases accepted against a target of 950 so the target was narrowly missed, but nevertheless not achieved. Target To ensure that people in Herefordshire have improved access to Herefordshire IAPT There were also 599 successful completions of therapy against a target of 600; likewise, whilst this was a marginal deficit, the overall target was not achieved. Progress against targets for 013/14 will be reviewed monthly by the Trust s Delivery Committee to maintain a dedicated focus throughout the year. Year End Achievement (cumulative) Q1 Referrals 70 Q Referrals 503 Q3 Referrals 657 Q4 Referrals

20 Domain 3: Helping people to recover from episodes of ill health or following injury We continue to strive to provide a service that is achieving the best possible outcomes for people who develop treatable conditions. Specifically, in 01/13 we wanted to help people recover from illness or injury and prevent conditions from becoming more serious. In this domain, we set ourselves seven goals with eight associated targets, and achieved seven of the targets. 3.1 In order to try to ensure safety of people discharged from our services, we wanted to follow them up within as short space of time as possible, exceeding the set national timescales Target At least 95% of adult Care Programme Approach (CPA) receiving followup contact within 48 hours of discharge from psychiatric inpatient care. Gloucestershire Target (95%) Year End Achievement We did not achieve this target during 01/13 so we will be keeping it as a key target for 013/14. In April 013 we will introduce pre discharge planning forms which will identify who is responsible for completing the 48 hour follow up, and have produced guidance for staff for recording this. This target will be monitored monthly via the Countywide Delivery Committee. Gloucestershire Year end (89%) 89% Herefordshire Target (95%) Herefordshire Year end (70%) 70% This relates to our stretch target of follow up within 48 hours. We have consistently achieved the national target in ensuring that 95% of people on CPA received follow up within 7 days of discharge. 3. To ensure effective and responsive services for people with a first episode of psychosis, we wanted to put mechanisms in place that checked people with a first episode of psychosis were being treated by the appropriate teams Target New psychosis cases will be served by early intervention teams* Target (95%) Year End Achievement Gloucestershire Year end () Herefordshire Year end () * Measure defined by Department of Health national standards 0 4