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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 DRAFT Page 1 of 42 26 April 2012 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. DRAFT Page 2 of 42 26 April 2012 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 DRAFT Page 3 of 42 26 April 2012 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. DRAFT Page 4 of 42 26 April 2012 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. DRAFT Page 5 of 42 26 April 2012 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 DRAFT May Jun Jul Aug Sep Oct Page 6 of 42 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 DRAFT Page 7 of 42 26 April 2012 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 DRAFT Page 8 of 42 26 April 2012 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. DRAFT Page 9 of 42 26 April 2012 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. DRAFT Page 10 of 42 26 April 2012 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 DRAFT Page 11 of 42 26 April 2012 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. DRAFT Page 12 of 42 26 April 2012 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. DRAFT Page 13 of 42 26 April 2012 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 standards have now been devised and a specific audit is to be piloted across MH and LD inDRAFT Page 14 of 42 26 April 2012 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. DRAFT Page 15 of 42 26 April 2012 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. DRAFT Page 16 of 42 26 April 2012 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 DRAFT Page 17 of 42 26 April 2012 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. DRAFT Page 18 of 42 26 April 2012 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, DRAFT Page 19 of 42 26 April 2012 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. DRAFT Page 20 of 42 26 April 2012 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 DRAFT Page 21 of 42 26 April 2012 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 DRAFT Page 22 of 42 % 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. DRAFT Page 23 of 42 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 DRAFT Page 24 of 42 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. DRAFT Page 25 of 42 26 April 2012 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 DRAFT Page 26 of 42 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. DRAFT Page 27 of 42 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. DRAFT Page 28 of 42 26 April 2012 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. DRAFT Page 29 of 42 26 April 2012 DRAFT Page 30 of 42 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 DRAFT Page 31 of 42 26 April 2012 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. DRAFT 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 DRAFT Page 33 of 42 26 April 2012 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 DRAFT 95% Page 34 of 42 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 DRAFT Page 35 of 42 26 April 2012 Annex C - Statements from the Local Involvement Network, Health Overview & Scrutiny Committee and our commissioners [To be inserted] DRAFT Page 36 of 42 26 April 2012 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 DRAFT Page 37 of 42 26 April 2012 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 DRAFT Page 38 of 42 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. DRAFT Page 39 of 42 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. DRAFT Page 40 of 42 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] DRAFT Page 41 of 42 26 April 2012