Download introduction - Southern Health NHS Foundation Trust

DRAFT
Quality Account
2011/12
Contents
INTRODUCTION................................................................................................................................ 2
Statement on quality from the Chief Executive................................................................................................ 3
HOW WE HAVE PERFORMED AGAINST OUR PRIORITIES AND WHAT WE PLAN TO
DO IN THE FUTURE TO DELIVER IMPROVEMENTS IN THE QUALITY OF OUR
SERVICES ............................................................................................................................................ 3
Priority 1: Improving Safety - how we performed against the commitments we made .................................... 6
Other safety initiatives implemented to improve patient safety in Southern Heath in 2011/12 ...................... 8
Preventing and learning from serious incidents ................................................................................................ 9
Priority 2: Improving Clinical outcomes - how we performed against the commitments we made ................ 11
Other initiatives to improve clinical outcomes implemented in Southern Health during 2011/12 ................. 12
Priority 3: Improving patient experience - how we performed against the commitments we made .............. 14
Other initiatives implemented to improve patient experience in Southern Health during 2011/12 .............. 16
Care Quality Commission inspections ............................................................................................................ 19
Our plans for delivering quality improvements in 2012/13 ............................................................................ 21
Proposed 2012/13 indicators ........................................................................................................................... 21
STATEMENTS OF ASSURANCE FROM THE BOARD ............................................................. 22
Review of services ............................................................................................................................................ 22
Clinical audits and national confidential enquiries .......................................................................................... 22
Clinical research ............................................................................................................................................... 23
CQUIN framework ............................................................................................................................................ 24
CQC registration and actions ............................................................................................................................ 25
Quality of data .................................................................................................................................................. 25
SOUTHERN HEALTH’S APPROACH TO QUALITY ................................................................. 26
Board leadership .............................................................................................................................................. 26
Assurance and Governance .............................................................................................................................. 26
Workforce development .................................................................................................................................. 26
Organisational Learning ................................................................................................................................... 27
Measuring quality............................................................................................................................................. 27
National performance indicators ..................................................................................................................... 27
Stakeholders involved during the preparation of this report. ........................................................................ 28
ANNEXES ........................................................................................................................................... 29
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INTRODUCTION
It is my pleasure to introduce Southern Health NHS Foundation Trust’s (Southern Health)
Quality Account for 2011/12. This has been an eventful first year for Southern Health and
one that has brought many changes and challenges. However throughout the year the
Board’s commitment to ensuring we provide services of the highest standards to our patients
has been constant and we have continued to place great importance on ensuring the Trust
delivers quality care, support and treatment.
Like last year, we hope this report will help the public, patients, our care partners and
stakeholders to understand:



What Southern Health has done well in relation to standards of care and the quality of
the services we provide
What improvements in the quality of our services have been made since the 2011/12
Annual Quality Account
The Trust’s priorities for improvement for the coming year.
This report has been prepared in accordance with the Health Act 2009 and the NHS (Quality
Accounts) Regulations 2010 and, as required by these guidelines, has core sections:
Section 1 (this section): A statement by myself as the accountable officer for Southern
Health NHS Foundation Trust summarising our view of quality and declaring my, and the
Board’s, accountability for the reports content.
Section 2: How we have performed this year against the priorities we identified in our
2010/11 Quality Account and what the Trust plans to do to deliver improvements in quality of
services in 2012/13.
Section 3: Statements of assurance from the Board - this section is nationally mandated
and is directly comparable with other Trusts’ Quality Accounts
Section 4 - Information chosen by Southern Health to demonstrate the approach and
commitment to quality
Section 5 - Annexes
A Detailed performance against 2011/12 local indicators
B Integrated Performance Reports
C Statements from stakeholders
D Statement of directors’ responsibilities in respect of the Quality Account
E Jargon buster
F Feedback form including how you can get involved with the Trust
Our staff, our biggest asset
Throughout the year our staff have been steadfast in their dedication to providing the best
care possible. On behalf of the Board I’d like to take this opportunity to publicly thank and
pay tribute to all of our staff for their tireless hard work and commitment in meeting the
needs of our patients.
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Statement on quality from the Chief Executive
The content of this report is consistent with internal and external information presented to
and agreed by the Southern Health Board and its subcommittees in 2011/12 and these
include:
 Quality Accounts presented to Board
 Compliance Reports presented to Assurance Committee
 Clinical Audit Reports presented to Assurance Committee
 Internal & External Audit Reports presented to the Audit Committee
 Complaints Reports presented to the Assurance Committee
 Board & sub-committee papers and minutes
We have shared this report with the following and their feedback is included in annex A:
 Our commissioners
 Hampshire Local Involvement Networks (LINks)
 Hampshire Health Overview and Scrutiny Committee
This Quality Account will, I believe, demonstrate the professionalism and dedication of the
Southern Health staff throughout the year. Our staff have continued to embrace the quality
agenda driven by a desire to provide high quality, safe services which improve the health,
wellbeing and independence of the people we serve.
Whilst I am rightly very proud of the continuing improvements we have seen this year, we
must ensure that all of our services deliver the standard of quality required by service users,
their carers and our commissioners. During the year Southern Health and the Care Quality
Commission identified a number of services that were not delivering the quality of service
that is expected. The Board of Southern Health took immediate and robust actions and has
either addressed or has a plan in place to address the concerns raised. Details of the
concerns and Southern Health’s actions are provided in section 2.
It is important readers of this report can have confidence the data and information presented
in this report is accurate, robust and reliable. Southern Health conforms to NHS data quality
standards and these have been subject to appropriate review and scrutiny. On behalf of the
Board I am therefore pleased to confirm that to the best of my knowledge the information
contained in this document is accurate.
I hope you find our Quality Account an interesting and informative read and we would like to
hear your thoughts including suggestions about what you would be interested to see in next
year’s Quality Account. To share your views, please fill in the form at the back or contact
Julie Jones on 023 8087 4678 or email julie.jones@Southern Health.nhs.uk.
Please get in touch; we look forward to hearing from you.
Signed…………………………
Katrina Percy
Chief Executive
Date: [xx] June 2012
HOW WE HAVE PERFORMED AGAINST OUR PRIORITIES
AND WHAT WE PLAN TO DO IN THE FUTURE TO
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DELIVER IMPROVEMENTS IN THE QUALITY OF OUR
SERVICES
In 2011 our predecessor organisations Hampshire Community HealthCare and Hampshire
Partnership Foundation Trust published their Quality Accounts. These set out the specific
priorities for quality improvement for Mental Health and Learning Disabilities (MH and LD)
and Integrated Community Services (ICS), which were framed around the three dimensions
of quality identified by Lord Darzi. These are summarised below.
Priority 1: Improve
safety
Priority 2: Improve
clinical outcomes
Priority 3: Improve
patient experience
Priorities for MH and LD
Chosen because safety is our
priority, so that avoidable deaths
and avoidable harm remain
avoided.
Chosen because service users
should drive the design and
delivery of our care.
Chosen to ensure we always do
the right thing at the right time
for the right service user to
achieve the right outcome.
Performance in MH and LD to be measured via: Service user assaults on staff
 Falls in inpatient and
TQtwentyone (social care)
units
 Service users with completed
risk assessments
 Record of allergies on service
users prescription charts
 Pressure ulcers (grade 2 or
above) arising after
admission
 Service users with a physical
health assessment
 Length of stay in inpatient
units
 Medication reconciliation
 Unexpected deaths
 Service users state they have
help to get or maintain
employment, to obtain
benefits or support
 Service users with recorded
employment status on their
notes
 Service users state they had
a care review meeting and
have been offered a copy of
their care plan
 Unpaid carers who state they
rate their contact with the
Trust as ‘good’.
Priorities for ICS
We will continue to improve the
early detection and response to
clinical deterioration in hospital
and in the community
We will improve the way we
identify people nearing the end
of their life and ensure
appropriate care planning and
care pathways are in place to
support them to die in their
place of choice
We will improve how we
communicate and share
relevant information with and
about our patients with others
such as GPs, hospitals, and
nursing homes, etc, to provide a
more joined up service
Performance in ICS to be measured via: Serious incidents about
 Percentage of appropriate
patients whose deteriorating
condition was not identified
 Audit of Modified Early
Warning Score (MEWS)
service users on an End of
Life care pathway
 Patient/ Carer Experience
Survey
 Patient Safety Walkabouts
 Audit the use of the
Liverpool Care Pathway
 Audit the use of
communications tools e.g.
Situation, Background,
Assessment
Recommendation (SBAR)
 Discharge Audit
 Patient Experience Survey
We identified and developed our priorities from what we had learnt about our services and
the views of service users and staff.
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In this section we have provided details of how we have performed in each of the Trust’s
priorities and have highlighted some of the work undertaken to achieve improvements. The
performance against each individual indicator is provided in annexe A.
We have also set out how we are performing against other local and national indicators and
provided some case studies as examples of some of the initiatives that we have introduced
to improve the quality of services we offer
It is important to emphasise – as many of our staff did when we consulted with them – these
were not the only areas we focused on. There were many other areas where we did, and will
continue to, make improvements but these are the priorities to which we publicly declared
our commitment to improving.
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Priority 1: Improving Safety - how we performed against the
commitments we made
The Trust identified a number of areas for improving in 2011/12 to enable the delivery of
safer care to our patients and service users and to ensure that staff are safe when delivering
care. The Trust committed to:
 Reducing the number of assaults against staff and patients
 Reducing the number of service user falls in inpatient units and care settings
 Ensuring that risk assessments are carried out for service users
 Improving the recording and reconciling of medication
 Reviewing the numbers of unexpected deaths for MH and LD users to better
understand the health of our service users
 Improving the early detection and response to clinical deterioration of patients in
hospital the community through early warning tools and appropriately skilled staff
 Undertaking robust, regular patient safety walk rounds
Some examples of the work we have undertaken to achieve the above are set out below –
there is more detailed analysis in annex A.
Reducing the number of assaults against staff and patients
Southern Health is committed to improve the quality of care by reducing preventable
assaults to staff, service users and visitors. We have looked at incidents of violence and
identified actions which have included





Designing training courses to meet the specific needs of a particular service and running
them locally to improve uptake and attendance
Our security and safety experts have looked at the buildings and environment so we can
make units safer.
We have provided detailed information at a service level to enable local teams to
develop service specific improvements and identify themes.
All local services have designed specific action plans to reduce their numbers of violent
and aggressive incidents. These are monitored through divisional governance forums.
The introduction of Productive Wards programme has contributed to the reduction in
violent and aggressive incidents within in-patient units. This programme is to be rolled
out across all MH and LD units in 2012/13.
As a result there has been a downward trend in the overall number of incidents compared to
last year. The majority of reported incidents (60%) are graded as the least severe i.e. verbal
abuse, pinches, scratches predominantly within Older Peoples Mental Health (OPMH)
dementia services (see graph below) This area will remain a priority for 2012/13.
No. of incidents
Violence and agression incident in 2011/12
200
175
150
125
100
75
50
25
0
Apr
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May
Jun
Jul
Aug
Sep
Oct
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Nov
Dec
Jan
Feb
Mar
26 April 2012
Reducing the number of service user falls
Service users and governors identified falls as a key priority for 2011/12. This was due to the
number of falls in some Older People’s Mental Health inpatient units and our TQtwentyone
service (our social care service) that resulted in fractures or injuries.
During the year there has been significant work undertaken to reduce falls in particular in
OPMH. Staff have looked at why there were high numbers of falls and then developed a
comprehensive plan to reduce them. This has included more detailed assessments to
ensure early identification of those at risk of falling and what to do to reduce risks as well
new staff training programmes.
As a result of this work the Trust has seen a continued reduction in the number of falls in
these services. There was a total of 1,055 falls in the year which is a 9.3% decrease
compared to the previous year. This has been reinforced in the annual audit of inpatient falls
which shows improvements in our assessment and management of patients at risk of falls
across all of our services.
We have set ourselves a robust target for further improvement in this area for 2012/13.
Improving early detection and response to clinical deterioration of patients in hospital and the
community
At Southern Health we recognise that increasingly unwell patients are being cared for in our
hospitals and by our community teams. To ensure they receive the right care it is essential
that our staff have the skills, tools and competencies to effectively assess and monitor
patients so that early warning signs of possible deterioration are identified and acted upon
quickly.
Modified Early Warning Scores have two aims: to help staff recognise patients who may become
critically ill and to give clinical staff good information to make decisions through a series of triggers.
The Modified Early Warning Score (MEWS) measures a patient’s vital signs and these are converted
into a score. If the scores reach a certain threshold a senior nurse/clinician and or a doctor must be
contacted to assess the patient.
We implemented the MEWS tool in our community hospitals and community teams and as a
result of this pilot we revised the tool in late 2011. A MEWS Audit was undertaken in
September 2011 and overall results demonstrated compliance. A detailed action plan has
been developed to address any gaps identified. There are monthly checks of MEWS activity
presented at local governance groups.
Monitoring of the number of serious incidents involving undetected clinical deterioration during
2011/12 showed that there had been one incident during quarter two but none for the other three
quarters.
We are currently adapting the tool to suit all Southern Health services to ensure that
regardless of setting, any deterioration in a patient’s physical condition is rapidly recognised
and acted upon. We will implement the new tool across all services during 2012/13.
Patient safety walkabouts are where Trust matrons conduct monthly safety walk rounds.
They are regularly joined by senior colleagues and members of the board. These walk
rounds look at the environment, patient safety and satisfaction as well as staffing and many
other aspects of safety and experience.
In late 2011 we developed a dashboard that provides a picture of how wards are performing
in the key areas above. MH and LD services are currently adapting the Matrons walkabout
tool to address the key safety issues relevant to service areas. The walkabout tool
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dashboard will be rolled across mental health and learning disabilities services in 2012/13. It
will also be introduced in community settings.
In addition to the environmental assessment performed during the walk rounds, all MH and
LD sites are inspected as part of the Patient Environment Assessment Tool audits. MH and
LD continues to achieve strong results, above 95%, across all its sites
Other safety initiatives implemented to improve patient safety in Southern
Heath in 2011/12
Patient Safety Thermometer
In 2011/12 all of Southern Health’s community hospitals ‘signed up’ to the Patient Safety
Thermometer – a national campaign which measures and seeks to reduce the number of
‘harms’ that patients suffer when in hospital. The thermometer measures, on a given day
the number of falls, blood clots, pressure ulcers and urinary infections associated with
catheters.
Measures at our community hospitals have demonstrated the incidence of these harms is
relatively low. In 2012/13 we will develop measures so that we can accurately monitor these
measures in our community teams.
National Safety Alerts
The Department of Health Central Alerting System (CAS) enables alerts and urgent patient
safety specific guidance to be distributed via a NHS-wide central alerting system. CAS alerts
are an important mechanism to help providers learn lessons from each other and to improve
the quality of care they provide and should be actioned rapidly by NHS organisations.
During 2011/12 112 alerts were issued nationally of which 36 were relevant to Southern
Health. The table below summarises the alerts issued this year.
Number
issued
Number
actioned
within
deadline
Number being
implemented
at 31/03/12
Medical Device Alert
99
92
7
0
National Patient Safety
Agency
3
2
1
0
Estates Alerts
10
7
3
0
Total
112
101
11
0
Type of alert
Number
actioned or
implemented
in breach of
deadlines
Southern Health has implemented 101 alerts issued within the Department of Health’s
stringent deadlines. The remaining 11 alerts being implemented are not in breach of their
implementation deadlines. Furthermore, South Central SHA was the only SHA in the country
to report nil outstanding CAS alerts as at 6 March 2012.
Safeguarding
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Safeguarding encompasses Southern Health’s responsibility to work in partnership with
other agencies to prevent the abuse and neglect of vulnerable adults and children and to
deal with it effectively if it does occur. The Trust is a member of Local Safeguarding Boards
for Children and Adults and the Multi Agency procedures.
The Trust is committed to ensuring adequate preventative measures are in place to reduce
the risk of abuse, which include appropriate policies, staff training, supervision, management
and leadership arrangements and clearly defined professional boundaries. An appropriately
skilled workforce is considered key to reducing risk and in the year 4,911 of staff accessed
training to identify those at risk, incidents of abuse and mechanisms for reporting their
concerns.
All alerts are investigated and the Trust seeks to learn lessons thereby reducing risk.
Examples in 2011/12 where alerts or partnership working have led initiative to reduce risk
include:


Secure medication boxes are supplied to service users to enable safe storage of harmful
medications out of the reach of children.
Full engagement with Multi Agency Risk Assessment Conferences and information
sharing allowed preventative strategies to be put in place to keep adult service users and
children safe in respect of managing high risk domestic violence cases.
Infection control
Southern Health has very low rates of Healthcare Acquired Infection (HCAI) and has
consistently reduced the incidence of Clostridium Difficile year on year – delivering greater
reduction than required.
Our Infection Control team have also implemented a number of initiatives such as closer
monitoring of urinary catheters to promote safer care and reduce infection. The positive
benefits of this will be recordable through the Patient Safety Thermometer work stream.
Preventing and learning from serious incidents
Serious incidents
These are rare and unintended events that can cause significant harm or distress. If it
happens as a result of failure in care or treatment, we want to understand why and how, and
to make sure it doesn’t happen again. We do this by
 Making sure staff know what to do in the event of a serious incident
 Running training courses for investigating officers
 Looking at root causes of incidents and identifying actions which will make a
difference
 Holding panels to discuss serious incidents with staff involved and senior managers.
This provides a constructive forum to discuss root causes, review action plans and
share learning.
 Audits of a number of action plans so we know improvements have been made and
learning from incidents has been shared
The table below shows the number and type of serious incidents reported by Southern
Health in 2011/12 and in 2010/11 by the Trust’s predecessor organisations.
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Serious Incidents
No. of incidents
2010/11
236
250
200
2011/12
167
150
100
55
50
26
24
14
31
35
35
8
12
7
11
9
23
2
Other
Information
Governance
Safeguarding
Serious incidents
Service user
deaths
Falls
Pressure ulcers
Infections
0
Never Events
‘Never Events’ is the term for serious patient safety incidents considered largely preventable
if good practice and preventative measures available in the NHS have been implemented.
Southern Health has had one reported Never Event in 2011/12 relating to a retained swab
post operatively. At the time of publishing this Quality Account the circumstances of the
incident are being investigated. Whilst deeply regrettable the Trust is determined to learn
from the incident and is awaiting the outcome of the investigation.
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Priority 2: Improving Clinical outcomes - how we performed against
the commitments we made
In 2011/12 as in previous years, we set ourselves challenging and aspirational targets which
support improved clinical outcome for patients. These were chosen in areas where our
services have the potential to make a positive impact on patient care, either alone or in
partnership with health or social care partners. We have monitored and reported to the
Board our performance against these throughout the year. These included
 Management of pressure ulcers
 Physical health care assessments for mental health service users
 Length of inpatient stays on mental health units
 Appropriate care planning and care pathways are in place to support patients to die in
their place of choice
Some examples of the work we have to achieve the above undertaken are set out below.
Management of pressure ulcers
This indicator was developed specifically for the MH and LD inpatient services to reduce the
number of pressure ulcers developed by service users whist within our units.
The numbers of pressure ulcers increased from 11 in the previous year to 14 in 2011/12.
Within MH and LD the numbers remain small with most occurring in OPMH. MH and LD
have now established protocols with ICS Tissue Viability teams to receive advice and
information on prevention and management of pressure ulcers.
It is also an important area of work across all our services, in community hospitals and for
community teams managing physical health. Southern Health has been working towards a
reduction in incidences of pressure ulcers of 30% for community teams and 80% in
community hospitals.
Intentional Rounding was introduced in our Community Hospitals this year. This is a simple
process that ensures each and every patient is seen and checked by a member of the
nursing team at least every two hours. The patient’s position is changed to reduce the risk of
pressure ulcers.
As a result of this initiative we celebrated the fact that Fordingbridge Hospital had reached a
milestone in February 2012 where it had been 12 months since a Grade 3 or 4 pressure
ulcer had been acquired by someone in our care. In the coming year this initiative will be
rolled out to community teams.
A revised version of this indicator will be adopted for the coming year 2012 to take into
account our breadth of services and set targets for improvement.
Physical health care assessments for mental health service users
The physical health of people with serious mental illness and/or learning disabilities can be
poorer than that of the general population. It is therefore vital that we are aware of any
physical healthcare needs so we can ensure that they are addressed. This indicator was
selected following feedback from service users.
This has also been identified as an area for improvement from CQC inspections As a result
a specific MH and LD training needs analysis has been completed for staff and a tiered
training approach has been implemented to ensure that MH and LD staff are competent to
assess, monitor and implement required interventions in relation to physical health needs.
Southern Health will be providing a broader physical health training schedule across all
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services to increase knowledge, skill and competencies across all professional groups.
AMH in-patient units have introduced weekly physical health clinics for all service user and
will be auditing compliance in 2012/13.
End of Life Care
In 2011 Southern Health approved an End of Life Strategy for the organisation that
encompassed all of the quality outcomes we are required to meet. Central to this is patients
dying on an appropriate care pathway that enables them to die in their place of choice.
There were 80% of patients dying in their preferred place of death in 2011/12. This was in
excess of our aim of 70% and the 76% recorded in 2010/11.
In order to ensure that patients at end of life are placed on an appropriate care pathway such
as the Liverpool care Pathway of the Dying – we have rolled out additional training not just
for SHFT staff but in partnership with our hospice and social care colleagues.
Other initiatives to improve clinical outcomes implemented in Southern Health
during 2011/12
Older Peoples Partnerships
The Trust has established the Portsmouth Older People Partnership that involves Trust staff
working with staff in the acute sector.
When service users arrive at the Queen Alexandra hospital they are seen as soon as
possible by a consultant geriatrician. Early assessment by a consultant enables a timely
assessment of all of their needs and has been shown to improve outcomes as well as
reducing time spent in hospital.
National Institute for Health & Clinical Excellence Guidance
The National Institute for Health and Clinical Excellence (NICE ) is responsible for providing
national guidance on promoting good health and preventing and treating ill health. During
2011/12, NICE issued 96 pieces of guidance of which 27 were assessed as being relevant to
Southern Health, and these are currently being implemented across the Trust.
Implementation and compliance with NICE clinical guidelines has been monitored as part of
our 2011/2012 Clinical Audit Programme and below are examples of how they have helped
us improve the quality of care we provide to patients:
CG 94 Unstable angina: The early management of unstable angina - this guidance
ensures that patients presenting with unstable angina (Recurring chest pain) are diagnosed
and treated appropriately on admission to hospital and that they are provided with
information on their condition.
 Improved Doctors’ usage of scoring systems to predict the outcome for patients and
categorise risk to decide on management of patients with suspected angina
 Led to pathway being available to all junior doctors to ensure they are aware of how to
manage patients presenting with unstable angina
 Led to the development and provision of an information leaflet to be available for patients
on cardiovascular risk factors
PH25 Prevention of cardiovascular disease: this guidance makes recommendations on
how to prevent cardiovascular disease in the general population
 Audit identifies risk factors for cardiovascular disease and is designed to ensure they are
documented in the patient notes
 Following previous audits this audit demonstrated improvements in documentation which
improved the care patients received in this area.
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
The results overwhelmingly suggest that actions as a result of previous audits had a
beneficial impact on the documentation.
Developing Southern Health Outcome Measures
There are many measures used in the NHS to assess the performance of NHS
organisations and the impact of care upon patients and service users. In the past, these
have tended to focus upon activity or processes, for example how often does a nurse
provide a particular treatment, or how many staff on a ward are following an agreed process.
These measures do not always relate to what matters to patients, services users and their
carers or families.
At Southern Health we are working to change the way we look at the care we provide by
looking at ‘outcome’ focused measurement. What this would mean is rather than focus upon
a specific piece of care provided, for example a leg ulcer dressing, we want to shift the
emphasis to what we want to achieve for that patient, for example rapid healing of ulcers to
support maximum function and quality of life for each individual.
The Trust will continue to use the measures and indicators it is required to provide to
regulators, commissioners and the Board, as these ensure the Trust is providing a safe,
reliable service. However, the Trust will utilise the required measure and indicators
alongside other information provided by its teams so to provide a better picture of how care
provided relates to outcomes.
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Priority 3: Improving patient experience - how we performed
against the commitments we made
Southern Health identified a number of priorities related to improving the patient experience.
These focused on:
 Service users should drive the design and delivery of their care
 Ensuring service users need are not assumed or overlooked through having robust care
plans and information
 Improving how the Trust communicates and shares relevant information, with and about
patients, with others to provide a more joined up service and in particular using
structured tools for handover and discharge.
 Implementing the productive series across inpatient and community services
 Obtaining feedback from service users on their experience and responding promptly to
their concerns
Involving service users in the design and delivery of care
The Trust involved service users and carers in staff recruitment. Once they have completed
training service users and carers participated in the appointment of staff to the Trust. They
were involved in developing job descriptions and short listing of candidates through to
interview of staff.
Working with our service users in this way helps the Trust to ensure only staff with the
values we demand are appointed. It also supports service users and carers by offering them
the opportunity to get involved in an area of work they may not have considered in the past.
Working with service users and carers in this way is a nationally recognised initiative and in
2011/12 Southern Health offered the Strategic Health Authority the option to participate. The
SHA accepted the opportunity and now works with service users and cares in this way as
part of the Management Trainee programmes.
Additionally to improve our understating of our services from a service user perspective
service directorates routinely involve patients in focus groups and also ask patients to write
diaries of their experiences.
Examples in the year where the views of service users has led to changes in the design of
services that Southern Health provides include Adult Mental Health and Older people’s
Mental Health services.
Older People’s Mental Health – Service users, carers and other key stakeholders
expressed the wish to see the development of community based services. This led to a
proposal to develop community based services and reduce the number of in-patient beds at
the Tom Rudd Unit, Moorgreen Hospital. The vacated space at the Tom Rudd unit is
currently being re-designed and will accommodate people with learning disabilities with
services planned to commence from mid 2012.
Adult Mental Health – Southern Health, along with NHS Hampshire, undertook a
programme of engagement and established with service users’ their vision for future
services. This was used to inform a proposal to further develop ‘hospital at home’ and
community based services whilst reducing in-patient beds at The Meadows in Sarisbury
Green and Woodhaven in Calmore.
Involving service users in care planning
MH and LD services have been completing a care plan and risk assessment weekly audit
over the last 6 months to demonstrate compliance and service user involvement. Care plan
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patient and community teams in May 2012. This audit will enable specific improvement plans
to be implemented focusing on collaborative care planning, clear links with risk assessment
and progress recording.
This work has resulted in a significant improvement in the care planning process and overall
quality improvement evident in CQC internal and external inspections.
Improving communication with others
A discharge summary is a report of the events of a patient’s time in hospital. It is the most
important tool available to ensure there is continuity in a patients care when they are
discharged from hospital into the care of a GP, community team or to another hospital. A
standard discharge summary was introduced during the year and audited to ensure all
relevant information is completed and made available.
An audit of the use and completeness of the new Hospital Discharge Summary found good
overall compliance with discharge summary completion. A few minor gaps were identified
and services have developed local action plans to address these. Key actions across
services have also been identified and an action plan developed
Productive Series
The NHS Institute for Innovation & Improvement’s Productive Community Series helps front
line teams improve quality and productivity. Southern Health teams won awards from the
Strategic Health Authority for their innovation and progress.
To date 28 community teams and 8 community hospital wards have taken part in the
Productive Series and the initiative is on target to achieve 100% participation of community
teams by October 2012.
Just one of the ‘modules’ community teams are working towards is ‘Working better with our
key care partners’ which will enable to achieve our goals around communication with other
providers and stakeholders.
Mental health services are also undergoing the productive series in both inpatient and
community settings. To date there are fewer teams involved than our community services
but the number of teams involved are set to increase in 2012/13.
Service user feedback
Southern Health has introduced patient and service user experience surveys across all
services in order to measure its performance in meeting patient’s and their carer’s needs
and to identify aspect of care where the Trust could improve. By using a number of standard
questions the Trust can measure customer service delivered across the range of Trust
services.
To increase survey response rates the Trust has developed a number of ways in which
patients and their carers can provide feedback of their experiences including:
 Web-based surveys
 The holding of workshops involving groups of service users
 Computer based interactive symbol based surveys
 Service users themselves collecting the information from others,
Computer based interactive surveys are designed to increase feedback from adults with
learning disabilities and our adolescent services and the involvement of service users to
collect feedback from other service users has proven to be very effective in our social care
and learning disabilities services.
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Patient experience surveys
The results of the 2011 NHS Community Mental Health Services User Survey were
encouraging with 81% of people who took part rating the care they had received over the
previous twelve months as either ‘excellent’, ‘very good’ or ‘good’. This compared to 79%
last year. This result places the Trust just outside the top 20% of all Mental Health Trusts for
overall satisfaction with care.
The survey was designed to obtain feedback from a representative sample of people
accessing adult mental health services, including older adults. 850 people aged 16 and over
who had used the Trust’s mental health services in the previous year, were invited to take
part. The response rate was 37%, this is up from 33% last year and is comparable to many
other Trusts.
The Trust’s performance was more positive than that of other mental health Trusts nationally
in certain important ways; for example, in respect of service users being given (or offered) a
written or printed copy of your NHS care plan, having the number of someone from your
local NHS Mental Health Service that you can phone out of office hours, receiving support
from someone in NHS mental health services in getting help with finding or keeping work
(e.g. being referred to an employment scheme).
The survey also showed that overall we were ‘about the same’ as other Trusts in every other
area. Action plans have been developed by AMH and OPMH to address those areas where
it has been identified, alongside input from service user and carers, improvements could be
made and these are available on the Trust website or via the communications and
engagement team. Progress with implementation is monitored by the Trust-wide Patient
Experience Group and by our commissioners (Southampton, Hampshire, Isle of Wight and
Portsmouth PCT Cluster).
The survey results, as well as current improvement plans, are available on the Trust website.
Other initiatives implemented to improve patient experience in
Southern Health during 2011/12
Implementing Recovery Through Organisational Change (IMROC)
IMROC is a 3 year programme funded by the Department of Health and delivered through a
partnership between the Centre for Mental Health & the Mental Health Network of the NHS
Confederation. Southern Health was delighted to be selected as one of only six pilot sites for
the programme.
As a pilot site we receive expert advice and consultancy from a number of key leaders and
authors in the recovery field and have access to learning sets and networking opportunities
with other sites across the country. Our participation in the programme has been timely in
developing the culture and practice we expect to be delivered through our service redesign.
We define recovery not in the clinical sense of ‘cure’ or the elimination of symptoms but
rather as the ability to live a meaningful life even with the continued presence of illness or
distress. This definition of recovery comes from the narratives of service users and, as such,
is grounded in shared experience of maximising opportunity, meaning, and life chances
alongside the symptoms of mental illness. Recovery is not an intervention and we cannot
‘make people recover’ – our responsibility is, therefore, to create environments in which
service users are supported and enabled in their own recovery.
We have a track record in Adult Mental Health of training and supporting individual staff to
deliver recovery focused care and we see evidence of this across the services we provide.
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Through the IMROC programme, however, we are proactively working to make sure that the
whole organisation supports staff in the delivery of this care to their service users.
Our IMROC work streams include:







Developing measures that tell us how far service users believe we are supporting them
in their recovery
Increasing the availability and supporting service user leadership of training
Developing a recovery education centre for staff and service users and carers
Developing resources to support staff in clinical practice
Reviewing policies and procedures
Changing how we think about risk assessment and management
Transforming our workforce through the addition of peer support workers to teams
We are excited to participate in the IMROC programme and the opportunities it provides to
increase the quality and recovery focus of the care we provide through embedding change
throughout the organisation.
Established a network of a Rapid Assessment Units
Rapid Assessment Units enable patients to be seen quickly, usually within 48 hours, without
the need for referral to an acute hospital. The units provide a range of units including x-rays,
scans, medication and blood transfusions
Self-referral
In 2011/12 Southern Health introduced self-referral by patients and service. The use of selfreferral avoids the need to see a general practitioner for occupational therapy, physiotherapy
and podiatry services
Supporting service users
All patients should be treated with compassion, dignity and respect in a clean, safe and well
managed environment. Southern Health views excellent customer service as integral to
achieving these standards.
The Trust has a dedicated Customer Services Team which is the first point of contact for
patients and members of the public who require advice or information about any of our
services. The Customer Service Teams have the combined role of Patient Advice & Liaison
(PALS) and complaints management and support both staff and patients.
In 2011/12 the Trust received 342 complaints from patients and over 800 written
compliments and letters of thanks. The majority of compliment letters were about staff
attitude and clinical care.
Key complaints themes were clinical care, staff attitude and communication. Below are just
a few examples of how complaints and concerns have been used to help us improve
services
Complaint
Service improvement
A patient complained about the
wheelchair service; they had
exceeded their weight limit in their
wheelchair but had not informed the
wheelchair service of this. This
resulted in an accident linked to their
wheelchair breaking down.
Client was provided with a new power assisted
wheelchair with an increased weight limit.
There were changes relating to paperwork sent to
clients, advising them to regularly check their
weight and inform the wheelchair service of any
change that might affect the weight limit of the
wheelchair and require a client re-assessment.
All clients now have a weight check by staff
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A patient needing to use the dental
service was too heavy for the dental
chair
A client with a severe learning
disability needed assistance to keep
still during the administration of a
general anaesthetic
rather than relying on the client telling the staff
their weight, this ensures greater accuracy
A dental clinic has now been kitted out with
specialised furniture and equipment suitable for
heavier patients, this involved structural changes
to the surgery to enable to equipment to be fitted
A Clinical Holding Policy has now been
developed and approved clinical holding training
has taken place within the service, this was
provided by a specialist training provider
Of the 342 complaints received in 2011/12, the Trust has been made aware of 5 people who
went on to complain to the Parliamentary and Health Service Ombudsman. 2 of those
required no further action, one required local resolution and two are outstanding. In addition,
there has been one upheld from a complaint made in 2009.
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Care Quality Commission inspections
In 2011/12, through a combination of external review and our own internal assessments
Southern Health identified that the quality and safety of some aspects of our services
needed to be improved. During 2011/12 Southern Health was inspected by the Care Quality
Commission (CQC) on 16 occasions and 7 of these inspections lead to 14 compliance
actions where CQC identified we were not meeting essential standards. These findings and
our own assessment of our assurance processes led to our Monitor Governance Rating
moving from Green to Amber/Red.
Areas identified included



Risk assessments and care planning – bespoke risk assessment and care planning
training has been developed and delivered; new standards have been implemented and
weekly spot-check audits carried out to monitor effectiveness.
Staffing levels – a skill mix review was carried out and clear standards put in place; staff
vacancies were filled; a revised induction programme was developed for temporary staff;
and internal bank system was development.
Safeguarding and Mental Health Act (MHA) – policies were reviewed, updated and
communicated to staff; bespoke training was developed and delivered to the clinical
teams; staff handovers were improved as part of Productive Ward programme; and
weekly spot-check audits were carried out to monitor effectiveness.
The Trust tackled these issues quickly and effectively and is now working to further
strengthen its governance systems. A Quality Assurance and Improvement Programme has
been established reporting to the Assurance Committee and the Board. The programme
has focussed on:






Responding to CQC findings, agreeing and co-ordinating action plans to address their
concerns
The collation and triangulation of a wide range of quality and safety information to ensure
early identification of issues and strong performance management
A programme of unannounced visits by a dedicated inspection team and re-inspections
of areas with independent representatives and external experts
The identification of areas of good practice to share across other services
The identification of leadership and organisational development requirements
A review of the governance infrastructure and to provide assurance to the Board around
quality
We asked Deloitte’s to undertake an independent quality assurance review with
recommendations for the future structures, they reported in February 2012 and we will roll
out the recommendations in 2012/13.
We will continue our Quality and Improvement and Assurance programme into 2012/13 and
by June our mock inspection programme will have conducted un-announced visits across all
of our services. The Trust will embed learning from this programme and will further develop
new quality and governance processes.
There are currently 4 compliance actions outstanding in two sites and action plans are being
implemented.
As a result of the actions taken the Trust has regained its green governance rating.
Mock CQC inspections
The Trust set up a mock inspection team in December 2011 and after a period of induction
and planning the mock inspection programme commenced in January 2012. It is a
comprehensive, unannounced programme of visits to all sites, including community teams,
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to assess compliance against the CQC Essential Standards of Quality and Safety. The
inspection process is based on the format used by CQC for their inspections and Southern
Health developed its own inspection tools for each Outcome inspected.
The core mock inspection team comprises of clinicians from mental health, learning
disabilities or community services background. A wider pool of inspectors and observers has
been drawn from staff across the Trust and key stakeholders such our commissioners. Staff
are encouraged to take part so that they gain the necessary skills to carry out peer review
inspections in the future.
The mock inspection programme has been used to identify and celebrate areas of best
practice across the Trust as well as highlighting areas which need to be improved. It has
been invaluable in assuring the Board and stakeholders that we are meeting the CQC
Essential Standards of Quality and Safety and that any gaps are being addressed. It has
raised awareness of CQC with staff and how service users should be at the centre of
everything we do. Due to the way in which our inspections mirror those of CQC, the
programme has also been cited by other trusts as good practice which they would like to
adopt.
As of end March 2012, 128 inspections had been carried out by the mock inspection team.
These covered all service types across the Trust and represent a third of all our sites and
services.
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Our plans for delivering quality improvements in 2012/13
Quality priorities and local indicators for 2012/13
The Trust’s priorities in 2011/12 were based upon:




What patients have told Southern Health about what they think of Trust services and
where it should focus attention
What our Governors have told us is important to them
What staff have told the us is important to them
What has been learnt about the quality of services and where improvements are required
Southern Health and its stakeholders consider that the Trust should continue to seek
improvements in the services it provides based upon improving patient safety, clinical
outcomes and patient experience. As such they will remain the Trust’s priorities in 2012/13
with progress of our performance being monitored by the Trust’s Assurance Committee.
Proposed 2012/13 indicators
After engagement with stakeholders to gain their views on the indicators they consider to be
priorities for the coming year the Trust Board has approved the follow indicators. The Trust
will monitor these indicators and report its performance against them in its 2012/13 Quality
Report.
Improving Patient
Safety
Improving Clinical
Outcomes
Improving Patient
Experience
Incidents involving
patient violence to
reduce by 10% by April
2013
100% adequate risk
assessment, use of
evidence based practice
to reduce risk and reduce
the number of new
pressure ulcers (grade 2
and above) developing
during admission
100% of in-patients with a
physical healthcare
assessment
100% of correct
medication reconciliation
(i.e. agreement of the
medications brought in
by service users and
prescribed in MH&LD
units)
Number and percentage
of patients identified to be
at the end of their life
(within 1 year) who are
on an End of Life Care
Pathway
Introduce INSPIRE as formal
PROM tool to approx 50
service users to set baseline
and then roll out across AMH
100% of patients where
there was appropriate
use of an early warning
scoring system
Number/ percentage of
shift handovers where
structured handover tool
in use
100% of service users have a
care plan that has evidenced
to be developed with them
and / or their main carer
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STATEMENTS OF ASSURANCE FROM THE BOARD
This section contains a number of mandated declarations Southern Health is required so
that its performance may be directly compared to that of other NHS trusts.
Review of services
During 2011/12 Southern Health NHS Foundation Trust provided and/or sub-contracted 47
NHS services.
Southern Health NHS Foundation Trust has reviewed all the data available to them on the
quality of care in 47 of these NHS services.
The income generated by the NHS services reviewed in 2011/12 represents 100 per cent of
the total income generated from the provision of NHS services by Southern Health NHS
Foundation Trust for 2011/12.
Clinical audits and national confidential enquiries
During 2011/12 3 national clinical audits and 3 national confidential enquiries covered NHS
services that Southern Health NHS Foundation Trust provides.
During 2011/12 Southern Health NHS Foundation Trust participated in 33% of national
clinical audits and 100% national confidential enquiries of the national clinical audits and
national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Southern Health NHS
Foundation Trust was eligible to participate in and did participate in during 2011/12 are as
follows:
Eligible
Participat
ed
National confidential enquiry into peri-operative care


National confidential enquiry into cardiac arrest


National confidential enquiry into suicides and homicides


National audit: Schizophrenia


National audit: Parkinsons

x
National audit: End of life care

x
National Audit/Confidential Enquiry Title
It was considered that there was insufficient time between the receipt of the results of the
2010/11 Parkinsons audit in May 2011 to allow for any gaps identified to be addressed prior
to being required to sign up for the 2011/12 audit. In 2011/12 Southern Health has worked to
address any gaps and plans to participate in 2012/13.
Southern Health was unable to register in time to take part in the End of life care audit.
However the Trust adapted the audit tool and conducted a local audit.
The national clinical audits and national confidential enquiries that Southern Health NHS
Foundation Trust participated in, and for which data collection was completed during
2011/12, 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.
National Audit/Confidential Enquiry
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% of required cases
26 April 2012
submitted
National confidential enquiry into peri-operative care
100%
National confidential enquiry into cardiac arrest
100%
National confidential enquiry into suicides and homicides
100%
National audit: Schizophrenia
59%
41% of completed audit tools in respect of the Schizophrenia national audit were not
received within the required timescale for submission. The Trust is seeking improvements in
the internal process for the completion and return of audit tools to allow the submission of
100% of required cases in all future national audits and confidential enquires that the Trust
participates in.
The reports of 42 national clinical audits were reviewed by the provider in 2011/12 and
Southern Health NHS Foundation Trust intends to take the following actions to improve the
quality of healthcare provided:




To ensure all appropriate information is included in the risk assessment at Forest Lodge,
there will be monthly checks and updates of risk assessments.
To ensure all service users have a physical health review within 7 days of admission on
Hawthorns 2, a prompt within the admission checklist has been devised reminding all
qualified staff to ensure required fields within the physical health monitoring assessment
is completed as soon as practical.
To ensure the temperature of the drug refrigerator is recorded daily on Beech Ward, it is
to be documented in the diary as a daily routine and as a reminder.
To ensure all applicable staff attend the Trust Infection Control training, the Becton
Centre sent a letter to all staff to request they complete online training by the 15/12/2011.
Clinical research
Research is a critical component of successful NHS provider organisations, ensuring that
clinical practice is based upon the latest evidence. All patients and service users receive the
opportunity to take part in research. It is also a key element of the continuing development
of staff, providing stimulating opportunities for professional and personal growth.
Southern Health aspires to:
• Embed a culture in the organisation that enables every patient the opportunity to
participate in Research
• Embed clinical and health services research, and the use of evidence, into every day
clinical practice within Southern Health
• Be seen as a leader and host to research relevant to mental health, LD and community
care practice,
• Encourage a research culture, studentships and practitioner researchers within Southern
Health
• Attract national and regional research funding, ensuring the Trust can continue to deliver
significant and relevant research for Southern Health into the future
The Research & Outcomes Department supports research in a number of disease areas,
mostly across mental health conditions including depression, psychosis and borderline
personality disorder. The department is a world leader in research in culturally adapted
cognitive behaviour therapy and its feasibility in ethnic minority groups. Previously the
emphasis has been upon mental health research but the team is now developing research
into more community based care, such as continence care, leg ulcer care, and evaluations
of our mental health and integrated community services.
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26 April 2012
The Memory Assessment & Research Centre (MARC) runs clinical trials in dementia. The
majority of these trials are investigating how effective new drug treatments are, although
some trials look at other aspects associated with Alzheimer's such as depression and
sickness behaviour. MARC is one of the leading centres in Europe for dementia research.
South Coast DeNDRoN is one of seven local research networks which are placed
throughout the UK, and is hosted by Southern Health NHS Foundation Trust.
Southern Health hosted 90 clinical research studies (50 portfolio and 40 non portfolio) during
2011/12 involving approximately 145 clinical staff. The number of patients receiving NHS
services provided or sub-contracted by Southern Health NHS Foundation Trust that were
recruited during that period to participate in research approved by a research ethics
committee was approximately 510.
Over the last three years, approximately 150 publications have resulted from our
involvement in NIHR research, which shows our commitment to transparency and desire to
improve patient outcomes and experiences across the NHS. Engagement with clinical
research demonstrates the Trust’s commitment to testing and offering the latest medical
treatments and techniques.
CQUIN framework
A proportion of Southern Health NHS Foundation Trust income in 2011/12 was conditional
upon achieving quality improvement and innovation goals agreed between Southern Health
NHS Foundation Trust and any person or body they entered into a contract, agreement or
arrangement with for the provision of NHS services, through the Commissioning for Quality
and Innovation payment framework. Further details of the agreed goals for 2011/12 and for
the following 12 month period are available online at: http://www.monitornhsft.gov.uk/sites/all/modules/fckeditor/plugins/ktbrowser/_openTKFile.php?id=3275
In 2011/12 income totalling £0.886million was conditional upon the Trust achieving quality
improvement and innovation goals, of which payment of £0.772 million was received.
Commissioner
Schemes
Available
£
Hampshire
Southampton
Specialist
Commissioning
Locally Developed Schemes
1. Dementia: Improving the support and education to
the wider health system in the recognition,
assessment and referral of people with dementia.
2. Outcomes: Research and analysis to quantify the
effect of intervention for specific mental health
conditions
3. Recovery: quantifying the implementation of recovery
plans and assessment of their effectiveness
National schemes
Medium and Low Secure Services
1. Recovery planning:
a) Sharing the development of recovery plans with
service users and carers
b) Joint staff and service user reports on the
progress being made on a) above.
2. Use of the Essen Scale assessing therapeutic
climate
3. Length of Stay: Assessment and analysis to support
plans for reduction of Length of Stay
4. 25 hours meaningful activity-provision of meaningful
day time occupation outside of clinical therapy
Achieved
£
%
470,644
382,937
81
143,305
116,600
81
272,000
272,000
100
Adolescent Inpatient Service
1. HoNOSCA: All patients will be assessed on
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26 April 2012
admission and discharge using HoNOSCA to
determine their health and social functioning. The
provider will demonstrating an improvement in
HoNOSCA scores for 80% or more cases over a 6
month period
2. Information: To review and improve the information
provided to young people who are assessed and/or
held under the Mental Health Act.
Total
885,949
771,537
87
CQC registration and actions
Southern Health NHS Foundation Trust is required to register with the Care Quality
Commission and its current registration status is registered in full with no conditions. The
Care Quality Commission has not taken enforcement action against Southern Health NHS
Foundation Trust during 2011/12.
Southern Health NHS Foundation Trust has not participated in any special reviews or
investigations by the Care Quality Commission during the reporting period.
Quality of data
Southern Health NHS Foundation Trust submitted records during 2011/12 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: 99.5% for admitted patient care;
99.8% for outpatient care; and 93.1% for accident and emergency care.
- which included the patient's valid General Practitioner Registration Code was: 100% for
admitted patient care; 100% for outpatient care; and 100% for accident and emergency care.
The Trust’s performance in 2011/12 exceeded national targets.
Southern Health NHS Foundation Trust Information Governance Assessment Report overall
score for 2011/12 was 73% and was graded Green.
Southern Health NHS Foundation Trust was not subject to the Payment by Results clinical
coding audit during the reporting period by the Audit Commission.
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SOUTHERN HEALTH’S APPROACH TO QUALITY
Southern Health’s approach to quality supports the Trust’s overall aim of providing high
quality, safe services which improve the health, wellbeing and independence of the people
we serve. We are committed to meeting essential standards and also to using robust
evidence as the basis of improving care. Our work on customer standards and experience
has given us robust feedback on our care from those who use our services. In addition we
have used research, evidence based care and a focus on outcomes to improve the
effectiveness of our services.
In order to deliver safe care, improved clinical outcomes and a better experience for service
users we have developed an approach to quality that ensures robust systems and processes
are in place, that there is a strong culture of innovation and learning and that our workforce
has the right knowledge and expertise to deliver high quality care. Our approach to quality is
led from the Board
Board leadership
The Board’s vision for quality is aligned with the Trust’s strategic vision, core values and
business strategy. At each Board meeting Directors have reviewed measures which indicate
how the organisation is performing in relation to quality, safety, clinical performance, finance
and workforce. At each Board meeting held in 2011/12 the quality and safety indicators set
out in annex B were openly discussed and the Trust’s performance scrutinised.
All non-executive directors take an active and challenging role at the Board and all Board
subcommittees. Non- executive directors lead a number of subcommittees that focus on
quality and governance such as the Assurance Committee which oversees clinical
governance, including quality, safety and risk on behalf of the Board. The Board has been
clear throughout the year that nay examples of poor quality or performance must be tackled
swiftly and purposefully. There is evidence that appropriate action is well underway. The
Assurance Committee ensures that evidence of lessons learned is demonstrated and an
effective approach to the identification and mitigation of risk is in place.
Assurance and Governance
The Trust has commenced the process of standardising and strengthening the infrastructure,
systems and procedures across the Trust following the merger. This has included external
and internal reviews of risk management, assurance and governance as well as inspections
of our clinical services. Implementation of the recommendations will continue during
2012/13.
Workforce development
We know that sustainable quality improvement will not be delivered just by improving
processes and controls. We have therefore developed a comprehensive workforce
programme that encompasses staff appraisal and personal development. Appraisals are
based on a set of competencies focused on quality and professional standards as well as
leadership competencies.
Our personal development programmes ensure that we support staff to deliver high quality
care, develop strong leadership skills and that we nurture talent within our own organisation.
We also recognise and reward individual and team innovation and achievement through our
Star Awards programme.
Southern Health ensures its staff are equipped with the core skills and knowledge they need
to deliver high quality care through a comprehensive staff training programme which
incorporates essential (statutory and mandatory) training, clinical competency based courses
and developmental opportunities. Levels of attendance are routinely monitored and where
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26 April 2012
levels fall below acceptable thresholds strategies for improving attendance have been put in
place.
Organisational Learning
Southern Health is implementing a programme of work to ensure that we learn from the
wealth of information and feedback we have about our services. Using information from
complaints, incidents, audits, inspections and performance indicators, we have identified key
service and organisational themes. These have influenced the selection of some of our
quality indicators for 2012/13. We will continue to monitor implementation plans and share
learning and good practice across the Trust.
Measuring quality
The Board cannot rely on an annual account of quality as its sole mechanism for assuring
itself about the quality of services provided within the Trust. Therefore at each monthly
Board meeting a broad set of quality indicators is reviewed and monitored.
The Quality Account is made publically available as part of the published Board papers.
Annexe B shows the indicators the Board has used in 2011/12 and provides the year-end
position statement.
Along with patient and staff feedback we have used these indicators and what they have told
us about the quality of our services to help us identify priorities and areas for improvement
set out in Part 2a of this report.
National performance indicators
The local quality indicators are not the sole indicators that are monitored by the Trust in
respect of the quality of services that it provides. Annexe B provides the list of indicators,
including the national mandated indicators, which are monitored by the Board via the
integrated performance and governance dashboards and are not reported elsewhere in this
document. Annex B shows the year-end position, i.e. as at 31 March 2012.
In 2011/12 Southern Health met or exceeded all required performance targets and
thresholds except for:
Complaints responded to within the prescribed timescale: due to delays in conducting
investigations and resourcing issues Southern Health responded to 47% and 71% of
complaints within set timescale, in MH&LD and ICS respectively, against the performance
target of 80%. Additional resources have been allocated to support the Complaints and
Patient Advice and Liaison Services (PALS) team. Additionally the Complaints and PALS
team is currently working with divisions, in respect of the allocation and investigation of a
compliant, to improve the Trust’s response time.
Number of mixed sex accommodation breaches: 10 mixed sex accommodation breaches
were recorded in the year against a target of nil. All breaches related occurred in early
2011/12. Action was taken to ensure that there was clinical justification and no further
breeches have occurred and no financial penalties have been levied against the Trust.
Percentage of child population receiving a primary birth visit: Southern Health achieved 84%
against the target of 85%. This was due to data recording and reporting issues which
resulted in the under-recording of the Trust’s performance. An action plan that was
implemented by Children’s Services, assisted by the Trust’s information team, and as a
result more accurate performance data was reported and by February 2012 the Trust’s
performance was above the target.
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26 April 2012
Stakeholders involved during the preparation of this report.
Stakeholders involved in the development of our priorities and measures included:
• Staff
• Service users and carers
• Governors
• Commissioners
• Southampton and Hampshire Local Authorities (via the HOSC) [to be requested]
• Southampton and Hampshire Local Involvement Networks (LINks) [to be requested]
All the stakeholders listed above were also given opportunities to contribute to and
comment. The Quality & Safety Committee considered the stakeholders comments and used
this information to select the final list of measures to be used.
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Annexes
Annex A – Detailed performance against 2011/12 local indicators
In section 2 the Trust summarised the key improvement and initiatives that were delivered to
deliver improvements in the quality of service and support that we provide to our service
users and their careers. The information gave details of the performance of a number of
indicators. The full list is and performance assessment against each individual indicator is
detailed below.
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26 April 2012
Southern Health NHS FT
Quality indicators: improving experience
Description of indicator
The number of new pressure ulcers (grade 2 and
above) developing during admission
Actual
Actual
Actual
2009/10
2010/11
2011/12
3
11
14
No of
pressure
ulcers
15
10
Com m entary
The number of pressure ulcers w ith MH and LD remain small w ith most occurring in
OPMH. MH and LD have now established protocols w ith ICS Tissue Viability teams to
receive advice and information on prevention and management of pressure ulcers.
5
0
2009/10
2010/11
2011/12
Data source: Safeguard report
Description of indicator
% of service users w ith a physical healthcare
assessment
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
3.7%
% of
service
users
40%
30%
Com m entary
20%
This is a new indicator in 2011/12 and no comparative data is available in prior years.
The data is being collected in the year to be used as a baseline for future comparison.
The low numbers recorded on Trust electronic notes do not reflect the number of
physical health assessments carried out and held as paper notes on the w ard. During
2012/13 electronic reporting w ill be improved.
10%
AMH
Description of indicator
Length in days of service user stay (excluding
leave)
0%
MH&LD
Total
Mean
Mean
2011/12
2011/12
61
67
LD
SS
Data source: RiO patient record system
Not shown graphically
From January 2011 the data for measuring length of stay w as based upon RiO patient
records system and is not compatible w ith data previously used to calculate length of
stay. The length of stay is required to be recorded and reported by the Trust as
standard monitoring and therefore this indicator w ill not continue as a Quality Account
indicator.
Number and percentage of patients identified to be at
the end of their life (w ithin 1 year) w ho are on an
End of Life Care Pathw ay
OPMH
OPMH
Com m entary
Description of indicator
AMH
Actual
Actual
Actual
2009/10
2010/11
2011/12
Data source: RiO patient record system
% of
patients
50%
N/A
18%
42%
40%
30%
Com m entary
A new End of Life Strategy has been w ritten. The new Liverpool Care Pathw ay
version 12 is being used and training rolled out across services. An audit of End of
Life care w ithin the ICS community teams and hospitals show ed staff felt confident on
the w hole in dealing w ith service users at the end of life. In September 2011 all teams
in Community services participated in an SHA-led audit on uDNACPR w hich show ed
good areas of practice and some areas of learning. Local multidisciplinary End of Life
groups are meeting on a regular basis.
Description of indicator
Actual
Actual
Actual
2009/10
2010/11
2011/12
20%
10%
0%
2009/10
2010/11
Data source: Data Warehouse
% of
patients
100%
Number/ percentage of patients w ho die in their
preferred place of choice
N/A
76%
80%
75%
50%
Com m entary
Continually 80% of patients are dying in their preferred place, w here that preferred
place is know n. We are still looking at how w e evaluate and improve numerators and
denominators to ensure w e are capturing as many patients as possible and w ork is
progressing on this through EoL Committee.
25%
0%
2010/11
2011/12
Data source: Data Warehouse
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Southern Health NHS FT
Quality indicators: improving experience
Description of indicator
Actual
Actual
Actual
2009/10
2010/11
2011/12
% of
service
users
100%
% of service users w ith recorded employment status
N/A
N/A
58.4%
80%
60%
Com m entary
40%
This is a new indicator in 2011/12 and no comparative data is available in prior years.
The data is being collected in the year to be used as a baseline for future
improvements.
20%
0%
MH&LD
Total
AMH
OPMH
LD
SS
Data source: RiO patient record system
Description of indicator
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
69.0%
% of service users w ho state that in the last 12
months they have received help to get or maintain
employment.
Com m entary
Not shown graphically
The national patient survey report 2011 show ed that 69% of responders indicated
they had received help in getting or maintaining employment. This score puts the Trust
in the top 20% of Trusts for this indicator.
Data source: National Patient's Survey
Description of indicator
% of service users w ho state that in the last 12
months they have received help to obtain financial
support / benefits
Com m entary
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
68.0%
Not shown graphically
The national patient survey report 2011 show ed that 68% of responders indicated
they had received help in getting financial advice or benefits. This score puts the
Trust close to the top 20% of Trusts for this indicator.
Data source: National Patient's Survey
Southern Health NHS FT
Quality indicators: improving effectiveness
Description of indicator
% of service users w ho state that in the last 12
months they had a care review meeting to discuss
their care plan
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
78.0%
Com m entary
Not shown graphically
The national patient survey report 2011 show ed that 78% of responders indicated
they had a care review meeting to discuss their care plan. Data is also being collected
on RiO, the electronic patient record system, w hich w ill be used to establish a baseline
for future improvements. Weekly care plan audits/spot checks have been carried out
betw een September 2011- April 2012. This has demonstrated a significant
improvement in completed care planning and review at care review forums. Care plan
standards have now been designed to include care review s and is being piloted
across 9 inpatient sites w ith the aim to roll out across all inpatient sites by June 2012.
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Page 32 of 42
Data source: National Patient's Survey
26 April 2012
Southern Health NHS FT
Quality indicators: improving effectiveness
Description of indicator
% of Service users w ho state they had been given
or offered a copy of their care plan w ithin the last 12
months.
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
74.0%
Com m entary
Not shown graphically
The national patient survey report 2011 show ed that 74% of responders indicated
they had been given or offered a care plan w ithin the last 12 months. This score puts
the Trust close to the top 20% of Trusts for this indicator. Data is also being collected
on RiO, the electronic patient record system, w hich w ill be used to establish a baseline
for future improvements. Care plan standards have now been designed to include
care review s and is being piloted across 9 inpatient sites w ith the aim to roll out
across all inpatient sites by June 2012.
Description of indicator
% of unpaid carers that state that they rate their
contact w ith the Trust’s services as ‘good’
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
N/A
Com m entary
Not shown graphically
This indicator, chosen by carers for inclusion in 2011/12, w as intended to be the
baseline to measure future performance and the source of the data being the Carer's
survey. No question w as included in the 2011 Survey that asked unpaid carers to rate
their contact w ith the Trust. The content of the survey is developed by carers and the
Trust is engaging w ith them so that future surveys ask unpaid carers to rate contact
w ith Southern Health.
Description of indicator
Audit of the new Hospital Discharge Summary in all
community hospitals
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
60.7%
Com m entary
Number/percentage of community care teams taking
part in the Productive Community Series
Actual
Actual
% team
2009/10
2010/11
2011/12
N/A
N/A
72.7%
Com m entary
Number/ percentage of shift handovers w here
structured handover tool in use
Data source: Internal audit of compliance
Not shown graphically
The Productive Series initiative commenced in November 2010 w ith the target of each
of the 33 community teams commencing the initiative by end of October 2012. To date
24 teams have commenced the initiative and it is on target for all teams to be involved
by the target date. Furthermore, teams from the Trust w on aw ards from the SHA for
their innovation and progress.
Description of indicator
Data source: Carer's Survey
Not shown graphically
An audit of use / completeness of the new Hospital Discharge Summary w as
completed in all community hospitals. Good overall compliance w ith discharge summary
completion w as noted w ith 60.7% demonstrating 80% compliance. A few minor gaps
w ere identified and services have developed local action plans to address these. Key
actions across services have also been identified and an action plan developed.
Description of indicator
Data source: RiO patient record system
Actual
Actual
Actual
2009/10
2010/11
2011/12
N/A
N/A
90.5%
As part of the monthly matron w alkaround the matron checks that SBAR, a structured
handover tool, is used to conduct handover. Data collection commenced in November
2011 w ith data continuing to be collected as a baseline for future improvements and
monitoring. A review of documentation is underw ay that w ill further support the use
of SBAR as a handover and more general communication tool.
Data source: Quarterly return
Not shown graphically
Data source: Data Warehouse
All data is governed by national standard definitions
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Annex B – Southern Health’s Governance and Performance
Dashboard
March 2012
###
Target
% of patients experiencing a delayed transfer of care within a Mental
Health Inpatient facility
7.5%
97%
% of patients receiving a 7 day follow up
95%
97%
% of patients receiving a 12 month review
Performance Corporate Indicators : Monitor Quality Outcomes
5.0%
95%
% gatekeeping compliance for inpatient admissions
92%
90%
100%
EIP new referrals
n/a
99.5%
Mental Health Minimum Data Set - Identifiers
99.0%
60%
Mental Health Minimum Data Set - Outcomes
50%
15
Infection Control (Community C Difficile)
n/a
5
Infection Control (Community MRSA) *
n/a
n/a
Access to Care : Learning Disabilities
n/a
97%
Access to Care : Admitted 23 week wait
95%
97%
Access to Care : Non admitted 18 week wait
95%
YTD Act
YTD Vol
Trend
2.1%
607
p
96.7%
2,270
q
97.4%
20,468
p
98.1%
1,364
p
119.2%
183
p
99.6%
976,791
p
69.0%
80,826
q
#REF!
n/a
p
#REF!
n/a
t
G
n/a
n/a
97.8%
5,267
p
100.0%
18,452
q
99.7%
19,541
p
97%
A&E attendances completed within 4 hours
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95%
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26 April 2012
Combined MH&LD and ICS Dashboard
March 2012
Target
Threshold
Year To Date
Service
Access to Care : Learning Disabilities
6/6
5/6
G
MH & LD
CRHT episodes (% planned v actual)
100%
n/a
123.1%
MH & LD
EIP diagnosis (% planned/actual)
100%
n/a
104.9%
MH & LD
Assertive Outreach caseload (% planned/actual)
100%
n/a
104.2%
MH & LD
B
n/a
B
MH & LD
Outcome and Operational indicators
Best Practice for People with a Learning Disability (Green Light Toolkit)
Ethnic Coding (% data completed/total)
1
1
94.1%
MH & LD
A&E median time to treatment < 60 minutes
50
60
2358.3%
ICS
A&E unplanned re-attendances
4%
5%
3.4%
ICS
A&E attendances left without being seen
4%
5%
0.9%
ICS
Emergency Admissions per '000 population (reporting 1 month in arrears)
1.26
n/a
#VALUE!
ICS
Excess Bed Days per '000 population (reporting 1 month in arrears)
0.87
n/a
#VALUE!
ICS
% End of Life patients dying in their preferred location
60%
50%
68.7%
ICS
% Rapid Response within 2 hours
90%
80%
80.7%
ICS
Smokers quitting (% planned v actual) (1 quarter in arrears)
100%
90%
98.4%
ICS
% Child population receiving a primary birth visit
90%
85%
83.6%
ICS
C Difficile infections
5
n/a
0%
MH & LD
MRSA infections
2
n/a
0%
MH & LD
C Difficile infections
15
n/a
7
ICS
MRSA infections
5
n/a
4
ICS
Number of episodes of absence without leave (reporting 1 month in arrears)
66
n/a
40
MH & LD
Number of mixed sex accommodation breaches
0
n/a
0
MH & LD
Quality assurance questionnaires
90%
80%
95.7%
MH & LD
Complaints responded to within timescale
90%
80%
47.2%
MH & LD
Safety indicators
Customer satisfaction and quality indicators
Number of mixed sex accommodation breaches
0%
n/a
10
ICS
Quality assurance questionnaires
90%
80%
97.5%
ICS
Complaints responded to within timescale
90%
80%
70.6%
ICS
Achieving target
Achieving monitor or internal threshold
Failing monitor or internal threshold
* Removed from Monitor compliance framework (19th September 2011) for Foundation Trusts without a centrally set MRSA objective
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26 April 2012
Annex C - Statements from the Local Involvement Network, Health
Overview & Scrutiny Committee and our commissioners
[To be inserted]
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Annex D – Statement of directors’ responsibilities in respect of the
Quality Account
The directors are required under the Health Act 2009 and the National Health Service
(Quality Accounts) Regulations 2010 as amended to prepare Quality Accounts for each
financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of
annual Quality Accounts (which incorporate the above legal requirements) and on the
arrangements that foundation trust boards should put in place to support the data quality for
the preparation of the Quality Account.
In preparing the Quality Account, directors are required to take steps to satisfy themselves
that:
 the content of the Quality Account meets the requirements set out in the NHS
Foundation Trust Annual Reporting Manual 2011-12;
 the content of the Quality Account is not inconsistent with internal and external sources
of information including:
o Board minutes and papers for the period April 2011 to June 2012
o Papers relating to Quality Accounted to the Board over the period April 2011 to
June 2012
o Feedback from the commissioners dated [XX/XX/20XX]
o Feedback from governors dated [XX/XX/20XX]
o Feedback from LINks dated [XX/XX/20XX]
o The trust’s complaints report published under regulation 18 of the Local Authority
Social Services and NHS Complaints Regulations 2009, dated [XX/XX/20XX];
o The latest national patient survey dated 09/08/2011
o The latest national staff survey 20/03/2012
o The Head of Internal Audit’s annual opinion over the trust’s control environment
dated [XX/XX/20XX]
o CQC quality and risk profiles dated [XX/XX/20XX]
 the Quality Account presents a balanced picture of the NHS foundation trust’s
performance over the period covered;
 the performance information reported in the Quality Account is reliable and accurate;
 there are proper internal controls over the collection and reporting of the measures of
performance included in the Quality Account, and these controls are subject to review to
confirm that they are working effectively in practice;
 the data underpinning the measures of performance reported in the Quality Account is
robust and reliable, conforms to specified data quality standards and prescribed
definitions, is subject to appropriate scrutiny and review; and the Quality Account has
been prepared in accordance with Monitor’s annual reporting guidance (which
incorporates the Quality Accounts regulations) (published at www.monitornhsft.gov.uk/annualreportingmanual) as well as the standards to support data quality for
the preparation of the Quality Account (available at www.monitornhsft.gov.uk/annualreportingmanual)).
The directors confirm to the best of their knowledge and belief they have complied with the
above requirements in preparing the Quality Account.
By order of the Board
..............................Date............................................................Chairman
..............................Date............................................................Chief Executive
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Annex E - Jargon buster
AMH - Adult Mental Health – a directorate within the Trust that delivers services to working
age adults.
CCGs - Clinical Commissioning Groups - groups of GPs that will, from April 2013, be
responsible for designing local health services In England.
CFSMS - NHS Counter Fraud and Security Management Service - launched in April 2003
and has policy and operational responsibility for the management of security in the NHS.
CIP - Cost Improvement Programme. [definition required]
Commissioners - organisations that fund local health and social care
CQC - Care Quality Commission – the regulator for health and adult social care services in
England
CQUIN - Commissioning for Quality and Innovation - a mechanism for encouraging quality
improvement via incentives.
FMEA - Failure Mode and Effects Analysis - a proactive risk management approach.
HCHC - Hampshire Community Health Care - now the Integrated Community Services (ICS)
part of the Southern Health NHS Foundation Trust
HPFT - Hampshire Partnership NHS Foundation Trust - now the Mental Health, Learning
Disability and Social Care part of the Southern Health NHS Foundation Trust
HoNOS - Health of the Nation Outcome Scale – a tool to measure if the treatments and
therapies we provide make a positive difference to service users lives
Hospital at home - Hospital at Home is an acute home-based programme in which eligible
older patients are taken home by a multidisciplinary team that can provide state-of-the-art
acute care services. [check definition]
HOSC - Health Overview & Scrutiny Committee – a committee of elected members of the
local authority who have responsibility for scrutinizing and approving proposals for change in
health service provision.
HSE - Health and Safety Executive: -the national independent watchdog for work-related
health, safety and illness. They are an independent regulator that aims to reduce workrelated death and serious injury.
ICS - Integrated Community Services - the part of Southern Health NHS Foundation
Trust which was formerly Hampshire Community Health Care.
LCFS - Local counter fraud specialist - each NHS trust in England has a LCFS attached to it
with the aim of reducing fraud to a minimum.
LINks - Local Involvement Networks – an independent organisation with responsibility to
represent service users, carers and the local population.
MH&LD - Mental Health and Learning Disabilities services - the part of Southern Health
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26 April 2012
NHS Foundation Trust which was formerly HPFT.
MHMDS - Mental Health Minimum Data Set - national statistics all mental health trusts
contribute to.
Monitor – Monitor is the independent regulator of foundation trusts. It authorises and
regulates NHS foundation trusts and supports their development, ensuring they are wellgoverned and financially robust.
NICE - National Institute of Health and Clinical Excellence – an independent organisation
that provides national guidance on the promotion of good health and the prevention and
treatment of ill health.
NIHR - National Institute for Health Research- an independent organisation with
responsibility for research in the NHS.
NRLS - National Reporting and Learning System - a national database of patient safety
incidents managed by the National Patient Safety Agency.
NHS - National Health Service.
OLDT - Oxfordshire Learning Disability NHS Trust.
OPMH - Older Persons Mental Health - a part of the Hampshire Partnership NHS
Foundation Trust that delivers services to people aged 65+.
PCT - Primary Care Trust - a type of NHS trust which may commission primary, community
and secondary care from providers.
PFI - Private Finance Initiative - one of a range of government policies designed to increase
private sector involvement in the provision of public services.
P&HSO - Parliamentary and Health Service Ombudsman – P&HSO undertake independent
investigations into complaints about government and the health service.
PPP - a government service or private business venture which is funded and operated
through a partnership of government and one or more private sector companies.
QIPP - Quality, innovation, productivity and prevention - QIPP is a large scale
transformational programme for the NHS, involving all NHS staff, clinicians, patients and the
voluntary sector and will improve the quality of care the NHS delivers whilst making
efficiency savings which will be reinvested in frontline care.
RIDDOR - Reporting of Incidences, Diseases and Dangerous Occurrences Regulations RIDDOR places duties on the Trust as an employer (the Responsible Person) to report
serious workplace accidents, occupational diseases and specified dangerous occurrences
(near misses).
Service redesign or transformation – changing how we provide our health and social care
services.
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26 April 2012
SHA - Strategic Health Authority – the main purpose of a SHA is to ensure both that there is
a continuing improvement in the health of the local population and that local healthcare
services are directed to meet its needs.
SHFT - Southern Health NHS Foundation Trust. Formed in April 2011 by the merger
Hampshire Partnership NHS Foundation Trust and Hampshire Community Health
Care.
SHIP – [definition required]
SIRI - Serious Incident Requiring Investigation – such as unexpected death, medication,
errors, grade 4 pressure ulcers.
The Trust - Southern Health NHS Foundation Trust.
Third sector organisation - an organisation in the voluntary sector.
TQtwentyone – the name of the Trust’s social care service that provides services for people
with learning disabilities and people with mental health needs.
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26 April 2012
Annex F – Feedback and involvement form
Quality Account Feedback Form 2011/12
Use this form to tell us what you think about this report and what you would like us to include in our
report next year.
1. Who are you?
Member of staff
Patient or family member/carer
Governor/ Member of the Trust
Other please specify:
2. What did you like about this report?
3. What could we improve?
4. What would you like us to include in next year’s report?
5. Are there any other comments you would like to make?
6. Are you interested in becoming a member of Southern Health Foundation Trust? If so please
provide your name and address:
Thank you for taking the time to read this report and give us your comments.
Please email or post this form to:
Julie Jones, Associate Director – Governance,
Maples
Tatchbury Mount
Calmore
Southampton
Hampshire
SO40 2RZ
Or email: [email protected]
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