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Contents Part 1... 3 Statement and Introduction from the Chief Executive... 3 Services Provided... 6 Part 2... 8 Looking Forward - Improving Quality in 2016/17... 8 Part 3... 9 Looking Back 2015/16... 9 Part 4... 23 Other Achievements 2015/16... 23 Part 5... 26 Statement from Tower Hamlets CCG... 27 2
Part 1 Statement and Introduction from the Chief Executive I am very pleased to introduce the second Quality Account for Compass Wellbeing CIC. As high quality service delivery is at the heart of everything we do, we are delighted to have this opportunity to demonstrate our commitment in this area and describe the improvements we have made throughout the year. As a dynamic social enterprise we focus on transforming our services, bringing together physical health and emotional wellbeing, with a focus on prevention and early intervention, in line with our social mission: To improve wellbeing in the communities we serve, creating change to improve outcomes for clients, families, organisations and communities; building on their strengths and resilience, so that people can live life to the full We recognise that partnership working is essential to the delivery of quality and that paying attention to sustaining good relationships with our partners and service users is key, as is listening to and learning from their feedback. Compass Wellbeing Partnership Model Fostering Innovation to Improve Quality Tower Hamlets CCG & London Borough of Tower Hamlets Strong Communication Safeguarding Voluntary & Community Sector Compass Wellbeing Partnership Community Services & Adults GP Care Group & Primary Care Sharing Information & Learning Community & Patient Engagement 3
Our approach to Quality At Compass Wellbeing we believe that HOW we do things is as important as WHAT we do. We pay attention to the way in which the whole organisation functions, always seeking to improve the effectiveness of what we deliver. We aim to ensure that the infrastructure the organisation provides effective management, tight organisational systems, enabling staff to focus on and provide high quality services. Just as relationships with our stakeholders are important to us, so is building trusting relationships inside the organisation. Listening to staff and treating each other with compassion and understanding is the bedrock of our culture and we are open to and interested in continuous change. We collect and analyse data to help us make decisions on quality and we continuously work to address any problems and challenges by developing our understanding of the issues and engaging with key staff to come up with solutions and deliver change. Driving Quality Improving Outcomes Delivering to specification Quality Performance Attention to detail Listening and compassion Utilising Infrastructure 4
Our Quality Account will firstly outline the services we provide, highlighting our priorities and commitment for continuous improvement for 2016/17, review our key achievements from 2015/16 and finish with feedback from our key stakeholders. I confirm to the best of my knowledge and on behalf of the Board and all the Executive Directors that the information provided in this document is accurate. We would like to thank our staff, clients and stakeholders for their contribution to this quality account. Lucy Marks Chief Executive Officer 5
Services Provided We provide services commissioned by Tower Hamlets CCG and the London Borough of Tower Hamlets. Our staff Our staff provide services through the following teams who work collaboratively in order to deliver our social mission. Psychology & Counselling Improving Access to Psychological Therapies Team (IAPT) This service is part of the national drive to increase access to evidence based psychological therapy services for common mental health problems. Our staff provide Cognitive Behavioural Therapy (CBT) interventions for mild to moderate mental health problems for adults aged 18 upward Practice based Psychology and Counselling Team Primary Care Psychologists and Counsellors work in General Practice providing consultation to GP s regarding complex clients as well as assessment and treatment services for adults aged 18 upward who may need more specialist help Children s Centre Adult Psychology Team This service provides psychological therapy for pregnant women and their partners and for parents of children under 5 years. The service targets parents who are experiencing anxiety and depression through a combination of individual and group work. This work has been commissioned by the Local Authority Disability and Health Counselling Team The Disability and Health Counselling team provide specialist counselling for individuals, carers and families with acquired or congenital disabilities, sensory impairments or long term conditions Asian Counselling Service This service provides counselling in Bengali/Sylheti, for the Bangladeshi community in Tower Hamlets 6
School Health Service The service is responsible for delivering public health programmes and interventions to improve health outcomes for school aged children and young people (5-19yrs). This includes reducing childhood obesity, under 18 conception rates, prevalence of sexual health problems and promoting emotional health and wellbeing and the management long term conditions This service is commissioned by the London Borough of Tower Hamlets Family Nurse Partnership We are delighted that we won the contract in April 2016 to deliver this service that provides intensive support for vulnerable teenage parents, until their child is 2 years old This service is also commissioned by the London Borough of Tower Hamlets 7
Part 2 Looking Forward Improving Quality in 2016/17 What will we do? Priority areas agreed with our commissioners Improve access for older adults and BME communities, monitoring changes in access data Continue to share data with GP networks to track levels of referrals and ensure adequate access across the borough Work with secondary care talking therapies services, CMHT s and commissioners to ensure pathways are clear and any blockages are managed Participating in a review of all talking therapies led by the CCG Evaluation of the primary care perinatal and under 5 s psychological therapies service, and working with the CCG and ELFT to establish need and future service model for perinatal mental health in the borough Evaluation and monitoring of new services for patients with chronic depression, eating disorders and stable psychosis and bipolar disorder in the context of the New Primary Care Mental Health services Other Priority areas include Procuring and implementing a new electronic Incident/Risk Management system for the whole organisation Establishing a New Website, making it easier for service users and partners to understand what we are doing, make referrals, providing a more interactive platform Developing our work with service users and identifying particular priority areas 8
Part 3 Looking Back 2015/16 Priority areas we have been working on Section A: Patient Safety Domestic Violence Training In line with last year s plan we have provided all staff in Psychology and Counselling, with a one day Domestic Violence training. This has been delivered by local highly specialist practitioners in the field, who were also able to ensure staff were clear about local pathways to support best practice in managing safeguarding and safety for staff and service users. The feedback from staff was very positive. Safeguarding We are now an organisation that provides Family Nurse Partnership, School Health Services and Psychology and Counselling, we have therefore been reviewing our Safeguarding procedures and policies in both services under one umbrella. We carried out a Safeguarding audit for the Local Safeguarding Children s Board for the whole organisation and have reviewed and updated our Safeguarding protocols ensuring that we have closer working relationships with the Community Health services Safeguarding Team, who provide regular Safeguarding supervision for School Nurses. We are currently updating our Safeguarding Policy, with input from the Community Health Services Safeguarding Team. Duty Management Following feedback from staff we increased capacity for Duty management, enabling those members of staff who are dealing with clinical risk issues to have rapid access to the right advice and support. With the growth in the service our current system is once again at full capacity and we will be reviewing this and rethinking how we go forward. 9
Section A: Patient Safety (continued) Incident Reporting and Complaints In 2015/2016 there were no incidents reported and no formal complaints were made against the service. However, the following themes arose in the concerns were raised about the service: Patients A small number of patient raised concerns when we have recommended another service and not taken them on for therapy. We have arranged face to face meetings with these patients with very senior clinicians so that they have an opportunity to express how they were feeling and talk through the decision in a sensitive way. In all cases patients have felt heard and understood and have not wanted to make a formal complaint. We will be monitoring this going forward and will then decide if there is anything in our processes that needs changing A number of patients have raised concerns about the lack of reception staff at Steele s Lane Health Centre. We have been in discussion with Barts Health NHS Trust, who are responsible for this. We are currently in negotiation with them about how reception is provided. GPs Two GPs raised concerns about how we communicate to them about risk issues. We offered to meet both to talk this through further. We have been reviewing our procedures, but we also need to clarify with the GP community more formally how we manage risk together. 10
Section B: Clinical Effectiveness Our quality priorities for clinical effectiveness in 2015/16 focused on the ultimate aim of improving clinical outcomes for patients. This involved rolling out case management, increasing group supervision for staff and carrying out research on why patients drop out of treatment, as well as interrogating our outcome data to provide information about where we can improve. In the past year our clinical outcomes for clients receiving treatment in our service have improved from 44.8% to 50%. We are delighted with this progress and that we have now reached the Performance Indicator set by NHS England. We will not be complacent and wish to see this number increase further. 60% 50% 40% 30% 20% 10% 0% Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015-16 2014-15 Recovery Average for 2015/16 = 50% Recovery Average for 2014/15 = 44.8% Recovery Average for 2013/14 = 43.3% To achieve our goals we did the following: 1. Rolled out case management approach in IAPT The case management approach is designed to help the clinician and client make sure that clinical interventions are based on best practice, are jointly decided with the client and are rooted in a shared formulation of the client s difficulties. Following the pilot of this approach in the IAPT service we have started using it in the Practice based Psychology and Counselling Team and will continue to roll it out for all staff over the coming year. 11
2. Increasing group supervision We now provide specialist supervision for staff working with couples and perinatal mental health. We have started monthly group supervision for the Practice Psychologists and Counsellors in order to provide opportunities to learn from more senior experts and develop skills through sharing good practice. 3. Research project on why clients drop out Our data indicates that the majority of clients who attend all their sessions, have the best outcomes. We therefore wanted to understand more about why patients drop out. A small scale research project was carried out with clients who had dropped out of treatment. This was completed through telephone interviews. The data has not been fully analysed but preliminary results point to the following themes: mismatch between client's expectations and what they were offered ( I felt it wasn't relevant ; wasn't what I wanted ) waiting times We will wait for the full data analysis to come back, but our preliminary thinking is that we need to: build stronger agenda matching with clients, into our case management ensure we keep our waiting times to 6 weeks 4. Actively interrogating outcome data and tracking original allocation decision We strongly believe in the importance of clinicians working in partnership with the data analysts from our Corporate Team. We now have a rich data set which we use to help us shape and track the decisions we make. The data analysts provided support to the clinical leads for IAPT to actively interrogate our outcome data, tracking patients who did not do so well in therapy, and looking at the original allocation decision which led to the treatment plan agreed with the client. Our hypothesis that we tested out was that when a poorer clinical decision was made at allocations, the outcome for the patient would be worse. 5. Results from Dynamic Interpersonal Therapy research trial The data from the research trial, carried out in partnership with the Tavistock and Portman NHS Trust for Dynamic Interpersonal Therapy (DIT), a short-term psychoanalytic treatment for depression, has not yet been analyzed. Once the findings have been made public we will be in a position to report on them. 12
Section B: Clinical Effectiveness (continued) Priority Area: Improving Waiting Times In line with what we agreed with our commissioners last year we focussed our attentions on bringing down waiting lists for patients, because this is what both they and referrers told us they wanted us to do. What we said we d do By March 2016, 75% of people referred to the IAPT programme begin treatment within 6 weeks of referral, and 95% begin treatment within 18 weeks of referral Compass Wellbeing commits to ensuring that waiting times for the practice psychology and counselling service are in line with the targets What we achieved We employed more staff to clear the waiting list backlog, and also employed permanent staff to stay on top of waiting lists. We achieved the waiting time targets for IAPT, which means 75% of people are seen in 6 weeks We employed more staff and brought the waiting lists down to an average of 9 weeks over the year. We were not able to bring this down further and have done some preliminary analysis on what the blocks are This includes: Long wait times in the Psychological Therapies Service in Secondary Care, this means we are continuing to see some patients who we should be discharging Lack of agreement about referral pathways and referral process with CMHTs and drug and alcohol services, this means we are spending considerable time managing these referrals, and liaising with colleagues from other services, which is not efficient Further action to take this forward next year: We will be meeting with Clinical Leaders from East London Foundation Trust to come up with solutions to the blockages in the pathways, and working with the CCG on their review of Talking Therapies 13
We will build on the telephone support pilot for patients who are waiting, to ensure patients receive regular calls to let them know about waiting times and review risk We will be progressing our extended hours plan, offering more capacity for individual and group therapy in the evenings We will look at what can be done to increase phone lines in our admin office so that patients are more likely to be able to get through We have developed a centralised waiting list management process for IAPT CBT therapy. This involves systematically carrying out telephone support. We will carry out a review and this will inform decisions about rolling it out further We now provide evening groups, triages and individual sessions on 3 evenings a week and have therefore considerably increased our capacity for extended hours. We will continue to increase our extended hours work We have employed another member of staff in the admin office to increase our capacity to answer phones. We are currently scoping putting in a new phone systemunfortunately this has taken longer than we expected 14
Section B: Clinical Effectiveness (continued) Priority area: New Specialist Services We developed three new clinical services based in primary care as a pilot to fill a gap in service provision for patients with eating disorders, chronic depression and stable psychosis or bipolar disorder. What we said we d do We will provide talking therapies to patients with stable psychosis or bipolar disorder We will provide talking therapies to patients with chronic depression We will provide talking therapies to patients with eating disorders What we achieved We have developed services in each of the three areas and have recruited to new posts This has been a very creative process and we believe the way in which we are delivering these services is pioneering and innovative The services will be closely evaluated and the value and benefits they provide for patients will be tracked throughout this coming year 15
Section B: Clinical Effectiveness (continued) Priority area: Data Quality Increasing data quality was identified as a key area of improvement in 2015-16. In order to achieve this we have created a variety of monthly checks to ensure clinicians are inputting data correctly and held training sessions with all areas of the service. It can be seen from the table below that we have managed to consistently improve data quality throughout the year. In March-16, the average data validity was 82%, so we have made good progress and have reached the national average. We will continue to work on this area. Please note, this data quality is only for our IAPT service, because only the IAPT data is uploaded to HSCIC. Overall Data Validity (%) Overall Data Validity (%) Apr-15 May-15 Jun-15 Jul-15 Aug-15 Sep-15 74% 74% 72% 74% 74% 78% 2015-16 Average Oct-15 Nov-15 Dec-15 Jan-16 Feb-16 Mar-16 78% 81% 82% 82% 83% 83% 82% 16
Section B: Clinical Effectiveness (continued) Priority area: BME communities In order to increase access for BME communities, and particularly the Bangladeshi community, we now have two dedicated Bengali speaking community development workers who are carrying out workshops in the community to extend our reach and raise the profile of our services. This will continue to be a priority area for us to work on next year. The total number of patients discharged from BME communities in 2015-16 was 1409 which is an increase of 21% compared to 2014-15 data. Approximately 29% of patients seen were from BME communities in 2015-16. A breakdown of the ethnicities of these patients is show below: Table: Ethnic group of all patients seen African Any other Asian background Any other Black background Any other ethnic group Any other mixed background Any other White background Bangladeshi White British Caribbean Chinese Indian Irish Missing Not stated Pakistani White and Asian White and Black African White and Black Caribbean # % 106 2.19% 77 1.59% 24 0.50% 122 2.52% 90 1.86% 666 13.74% 902 18.61% 1800 37.14% 107 2.21% 53 1.09% 111 2.29% 92 1.90% 460 9.49% 66 1.36% 53 1.09% 31 0.64% 21 0.43% 65 1.34% Total 4846-17
Section B: Clinical Effectiveness (continued) Priority area: Older Adults The tables below provide information showing numbers of patients that have been referred and seen who are aged 65 or over, during the past year. # % Total Referrals Received 168 - Total Entering Treatment 112 66.7% The type of treatment that these patients were offered is shown below: # % Offered Step 2 Treatment 19 17.0% Offered Step 3 Treatment 20 17.9% Offered Step 4 Treatment 35 31.3% Referred back to GP 3 2.7% Referred to Other Service 18 16.1% Declined Treatment 10 8.9% Service Not Appropriate 2 1.8% Awaiting Allocation 5 4.5% Total 112 - We will be working on a plan to significantly increase the numbers of patients over 65 accessing our service over the next year. When we feedback to GP networks about their referrals we will be raising the older adults agenda with them and this will form one strand of our plan. We will also be building on links we have already established with a number of voluntary sector organisations who work with older adults and will work in partnership with them to find ways to increase access. 18
Section B: Clinical Effectiveness (continued) Future Developments Further work we will be doing to make sure waiting list management is sustainable: We have been working with an organisation that provides digital mental health interventions to agree a blended model which will involve providing a digital offer alongside our direct face to face clinical offer. We will roll this out in the coming year Development of a central booking system for CBT therapists to ensure we use clinician time as efficiently as possible. Again, this will be rolled out in the coming year Other areas commissioners asked us to work on 1. We will communicate with primary care at network level, sharing access data with them. We have been tracking referrals per GP practice in Tower Hamlets. We have not yet shared this data with practices, but will be doing so in the coming year 2. We will improve access for older adults and BME communities, and increase marketing of our services for patients whose first language is Bengali/Sylheti. We agreed with commissioners that we would provide information about numbers of referrals we receive for older adults and BME communities across both our IAPT service and our Practice Psychology and Counselling service, we will use this as a baseline to track numbers of referrals in the coming year. 19
Section B: Clinical Effectiveness (continued) Staff Experience We recognise that our greatest asset is our staff. Safe, compassionate, effective care for patients relies on staff being well managed so they are clear about their role, engaged in decision making and change and feeling respected and supported, as well as having the right level of supervision and training to enable them to fulfil their responsibilities. We agreed last year that we would put in place supervision groups and we have done this (see page 12). We also agreed that we would carry out a redesign of the service structure and this is now complete. We have gone out to consultation with staff and are currently making some final changes following that process, before we go in to the implementation phase. 20
Section C: Patient Experience What Patients Say About Us? Findings from Patient Experience Questionnaire We asked our patients to complete post therapy experience questionnaires for our IAPT service and Practice Psychology and Counselling Service. The results shown in the tables below indicate that clients have a very positive experience of our services. Table: IAPT End of Treatment Questionnaire Did staff listen to you and treat your concerns seriously? Do you feel that the service has helped you to better understand and address your difficulties? Did you feel involved in making choices about your treatment and care? On reflection, did you get the help that mattered to you? Did you have confidence in your therapist and his/her skills and techniques? At All Most of Times the Time Sometimes Rarely Never 94.8% 5.2% 0.0% 0.0% 0.0% 76.3% 22.2% 0.5% 1.0% 0.0% 84.5% 13.9% 1.5% 0.0% 0.0% 82.5% 14.9% 2.1% 0.0% 0.5% 89.7% 9.8% 0.5% 0.0% 0.0% Table: Practice Psychology and Counselling End of Treatment Questionnaire Did staff listen to you and treat your concerns seriously? Do you feel that the service has helped you to better understand and address your difficulties? Did you feel involved in making choices about your treatment and care? On reflection, did you get the help that mattered to you? Did you have confidence in your therapist and his / her skills and techniques? At All Times Most of the Time Sometimes Rarely Never 97.1% 2.2% 0.7% 0.0% 0.0% 76.3% 20.9% 2.9% 0.0% 0.0% 82.0% 12.2% 5.1% 0.0% 0.7% 80.6% 16.5% 2.9% 0.0% 0.0% 91.4% 7.9% 0.7% 0.0% 0.0% 21
Section C: Patient Experience (continued) Patient Testimonials Comments on our IAPT service: I feel so grateful for what feels like being given my life back. The support and treatment I have received has been amazing, I can only say that I truly believe I have the tools now to lead a happy and normal life. Eternally grateful Considering last year I wanted to end my life, to now, where I wouldn't even dream of it, I cannot fault anything. Words can't describe how helpful and life changing it has been Absolutely fantastic - very pleased. I achieved all of my goals. I feel very confident and with my strategies in place to handle my depression better. Thank you ever so much. Lots of appreciation And Practice Psychology and Counselling service: After each session I felt better about myself and stronger in a way I can't say enough about how this process has changed my life, for the better, and supported me to become who I am Very happy to have signed up at a time I felt very isolated and lonely with no one to talk to. During my sessions I felt I was understood, listened to and sympathized with, which mattered a lot to me. I now feel able to open up to people more and trust that they do care I was very nervous at first, feeling like I had a problem that was not normal and maybe crazy. Johanna has helped me to understand why I felt like that and convinced me that I am normal. I will always be grateful. Thank you :) [client drew smiley face] 22
Part 4 Other Achievements 2015/16 1. Entering treatment In 2015-2016 a total of 4765 people entered treatment in our service against our target of 4,759. The graph below shows the number of patients entering into treatment for this financial year in comparison to last year s data. In total, the number of patients entering treatment has been higher than last year, an increase of 1.7%. 500 450 400 350 300 250 200 150 100 50 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015-16 2014-15 The total number of self-referrals has also increased (see below), by 23.2% when compared with 2014-15. The option to self-refer has been important for patients as well as our Commissioners. 200 180 160 140 120 100 80 60 40 20 0 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 2015-16 2014-15 23
2. Perinatal and Under 5s service We carried out a service user telephone survey for our perinatal and under 5s psychological therapies service, commissioned by the local authority. We asked about satisfaction with the service and their experience. Levels of satisfaction with the service and self-reported improvement and change To what extent were you satisfied with the services you received? 93% To what extent do you feel the service helped you in managing your difficulties? 88% How would you rate the improvement or change you have made as a result of using this service? 77% The main themes that parents talked about are listed below: A positive impact upon their parenting and relationship with their infants/children Positive changes in family relationships, in particular with spouses and partners Working through their own difficult childhood experiences, which became difficult to ignore as they became parents themselves Better stress management and self care resulting in being more attuned to other s (infant s) needs Feeling listened to and understood by the therapist helped parents overcome stigma and talk honestly about their difficulties without the fear of judgement Here are some of the things they said: I m less concerned about my baby looking perfect or being a certain way. I can cope more with others opinions in terms of my child crying, looking unclean etc. My bond with my baby is stronger. I learned that it took time to get used to him and understand his needs 24
Massive impact. I was in a place where I didn t know how I was going to get through my pregnancy. I didn t know how I was going to get into parenthood As someone who found it difficult to even leave the house before the sessions began, I am now going out a lot more and feeling a lot less anxious. I have learned to love myself a lot more 3. Empowering Young Mind s Programme We are half way through a two year programme to enable School Health staff to promote mental health and emotional wellbeing with Children and Young People. This involves a training and transformational change project. The training focuses on training in communication skills, attachment and how to identify and start conversations about mental health issues and enable children and young people and their parents to take up help. Our starting point is that staff need to feel contained and listened to in order to really listen and respond to children and young people. We have therefore built in reflective practice sessions. Some of the things staff have said they will be doing differently following the training: ensuring the environment is right for listening more acknowledgment of children s feeling being more empathic to angry parents reflecting on difficult conversations 4. Developing our partnership work We have continued to work on our partnerships with other organisations. We have been working closely with the newly established GP Care Group in Tower Hamlets and were asked by them to deliver reflective practice/supervision in their successful bid to provide the Health Visiting contract for Tower Hamlets We have now started to be involved in the Vanguard Programme, and have made a commitment to working with other local providers and commissioners on the 0 to 19 pathway, particularly given we provide the School Health and Family Nurse Partnership services 25
Feedback from local GP Tower Hamlets has a young, diverse, deprived and sometimes challenging population. As a GP and a commissioner I realise how important it is to give our child population the best start in life and a very significant contribution to this comes through supporting the mental health of children and families. In my experience Compass achieves this by providing a sensitive and bespoke service that is accessible in the community, often working with and supporting families who have multiple social, psychological and physical problems. To do this well the service also has to engage with other professionals who provide care for families. Compass has a history of this and in particular has supported and supervised Health Visitors caring for women with post-natal depression as well as providing close liaison with GPs. Ongoing commitment is demonstrated by Compass' successful bid to provide the Family Nurse Partnership model and co-provide Health Visiting Services in Tower Hamlets. They have also been proactive in the drive to provide innovative and integrated models of care such as the multi-specialty community provider pilot (Vanguard) in Tower Hamlets. Dr Neil Douglas Clinical Lead Child Health, CCG 26
Part 5 Statement from NHS Tower Hamlets CCG NHS Tower Hamlets Clinical Commissioning Group (CCG) welcomes the opportunity to review the Compass Wellbeing Quality Account and to provide this statement. We have worked closely with Compass Wellbeing to review quality, performance and improve services for the population of Tower Hamlets. In 2015-16 the CCG worked with Compass Wellbeing on designing services to support primary care mental health service provision with the organisation being commissioned to provide eating disorders, depression and psychosis and bipolar disorder services. We confirm that we have reviewed the information contained within this Quality Account and compared the data provided against available sources. We congratulate Compass Wellbeing on their good work driving clinical outcome improvements with recovery rates meeting the 50% NHS England target by the end of 2015/16 and we recognise the commitment to build on this work with the ambition to see further improvements with this standard in 2016/17. We are pleased to note that Compass Wellbeing has focused on meeting waiting time standards meaning 75% of people are seen within 6 weeks and we note the commitment for 2016/17 to ensure access to services is good across the borough alongside increasing access for older adults and BME communities. The commissioners are pleased that Compass Wellbeing has maintained its focus on improving data quality for the IAPT service; having reached the national average for data validity, but agrees that this area will require further attention in the year ahead to address on-going differences between local and HSCIC data. We agree with the priorities identified by Compass Wellbeing for 2015/16 within the Quality Account; however, the quality account could have been clearer regarding how views and feedback from patients and staff were used to inform these priorities. It is noted that a priority area for 2016/17 is developing our work with service users and identifying particular priority areas and we look forward to learning of developments over the year ahead. There are some areas where we believe further or more detailed information is required to meet the guidance. These areas are: 27
More detail as how progress of the priority areas will be reported and what organisational capacity and capability there is to deliver these More detail on how Compass Wellbeing has participated in audit and clinical audit and how the findings have been used to drive quality improvement We are committed to working with Compass Wellbeing and we are pleased that Compass Wellbeing will be working with commissioners as we take a multi-agency review of all psychological talking therapies across the borough. 28
Our response to NHS Tower Hamlets CCG We are grateful for the CCG s comments and continued encouragement for our commitment to raising the quality of the services we provide Below is a response to the two areas where they consider more detailed information is required to meet the guidance: 1. More detail on how progress of the priority areas will be reported and what organisational capacity and capability there is to deliver these We currently have a robust performance management system that integrates management and reporting and has delivered on IAPT KPI s. This system is continuously evolving to meet our reporting needs. The key priority areas will be integrated into our current system and will include objectives, targets and timelines. Our clinical lead will work closely with our performance lead to monitor outcomes as part of the integrated system for quality and performance. We will be developing a quality dashboard for managers, supervisors and corporate team members in order for the key priority areas to be monitored routinely and reported regularly. This will enable the organisation to track progress on the priority areas and report as necessary to our Commissioners. We have assigned a Director lead to each of the priority areas, and there will be both a clinical operational lead and lead from our corporate team, who will work together to develop and deliver the objectives set from an accountability perspective. We have been developing the skills and capacities of the corporate team over the last year, to ensure that we have a strong infrastructure to deliver these new developments. 2. More detail on how Compass Wellbeing has participated in audit and clinical audit and how the findings have been used to drive quality improvement. We have carried out two clinical audits this year using the audit cycle methodology, including developing audit criteria, measuring performance against agreed standards, implementing change and sustaining improvement a) Outcome data audit, involving measuring performance on use of standards set for allocation decision (see point 4 on page 12) Two clinical leads for the IAPT service carried out the audit with the support of the corporate team. The key finding was that when the standards were not adhered to 29
clinical outcomes were poorer. Feedback was given to staff by their manager on adherence to allocation decision standards and staff support and training was put in place to enable learning to take place for the future. Data was gathered again on outcomes on two further occasions and increasing rates of good decision making at allocation leading to better outcomes were observed. b) An audit of data quality was carried out (see Data Quality section on page 16) This was led by a member of the corporate team and the clinical operational lead for psychology and counselling. Standards set for data completeness by NHS England were used. Two training sessions were put in place for staff as well as protected time to complete their patient data. This resulted in a significant improvement in data completeness. However, when the data completeness was measured in March 2016 it was clear that we need to continue training and support for staff in order to improve further, and will be continuing to carry out audits in this area. 30
Listening to feedback on this report We would like to thank all the stakeholders, clients and staff who gave their feedback on our services that enabled us to see where we could make improvements in what we do and how we do it. Our thanks also to the staff involved in producing this document. We will listen to feedback on this report and use it for developing quality improvement priorities for 2016/17. We welcome feedback from all readers on this report and our work on our quality priorities. If you would like to give us your thoughts on this report, or get involved in the development of next year s report, please contact: Lucy Marks, CEO Compass Wellbeing CIC Steels Lane Health Centre 384-398 Commercial Road London E1 0LR info@compasswellbeing.co.uk 31
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