Dudley and Walsall Mental Health Partnership NHS …...Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2015/16 Page 3 of 49 New values launched supported by

Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2015/16 Page 1 of 49

CONTENTS

PART 1: CHIEF EXECUTIVE’S STATEMENT .................................................................................................................... 2

PART 2: PRIORITIES FOR IMPROVEMENT AND STATEMENTS OF ASSURANCE FROM THE BOARD ............................... 4

2.1 Priorities for improvement ................................................................................................................................ 4 2.2 Our priorities for 2016/17 ................................................................................................................................. 4 2.3 Statements of Assurance .................................................................................................................................. 6 2.4 Reviewing the Quality of Trust Services ............................................................................................................ 7 2.5 Clinical Audit...................................................................................................................................................... 7 2.6 Clinical Research.............................................................................................................................................. 10 2.7 CQUIN (Commissioning for Quality and Innovation)....................................................................................... 11 2.8 What others say about the Trust .................................................................................................................... 12 2.9 Data Quality .................................................................................................................................................... 13 2.10 NHS Number and General Practice Code Validity ........................................................................................... 14

PART 3: REVIEW OF QUALITY PERFORMANCE............................................................................................................16

Part 3A: Department of Health Mandatory Indicators............................................................................................. 16 3.1 Preventing People from Dying Prematurely – 7 Day Follow-up ...................................................................... 16 3.2 Enhancing the Quality of Life for People with Long Term Conditions ............................................................. 17 3.3 Ensuring that People have a positive Experience of Care – staff survey ......................................................... 19 3.4 Helping people to recover from episodes of ill health during injury .............................................................. 20 3.5 Ensuring People have a positive experience of care - national survey .......................................................... 21 3.6 Patient Safety Related incidents ..................................................................................................................... 23 3.7 Serious Incidents ............................................................................................................................................. 24 3.8 Duty of Candour – Cases ................................................................................................................................. 25 Part 3B: Performance against quality improvement priorities ................................................................................ 27 3.9 Progress against 2015/16 priorities ................................................................................................................ 27 Part 3C: Trust Performance against additional quality performance Indicators ...................................................... 35 3.10 Contractual Quality Requirement Goals agreed with Commissioners ............................................................ 35 3.11 Monitor – Access targets and outcomes objectives ....................................................................................... 36 3.12 Patient Environment ....................................................................................................................................... 37 3.13 Service Experience .......................................................................................................................................... 38 3.14 Feedback from Service Users and Carers ........................................................................................................ 41 3.15 Feedback from Staff ........................................................................................................................................ 42 3.16 Staff Health and Wellbeing ............................................................................................................................. 43 Part 3D: Statement from the Trust’s key stakeholders. ........................................................................................... 44 Statement of directors’ responsibilities in respect of the Quality Account ............................................................. 47


Part 1: Chief Executive’s Statement

2015/16 has been another challenging year for the whole healthcare system, with the ongoing implementation of NHS reforms and ensuring quality remains at the heart of services.

Within this context, Dudley and Walsall Mental Health Partnership NHS Trust (the Trust) has had another productive year with a continuing high focus on quality, led by the executive director of operations and nursing and the joint medical directors, supported by rigorous and regular reporting to provide assurance to the Board.

The Board’s Quality and Safety Sub–Committee meets monthly to review and maintain effective systems for quality governance, risk management and patient safety. More broadly the Trust also uses the Quality Governance Framework, on a quarterly basis, as a live mechanism to self-monitor and assure the Board of the robustness of its quality governance systems and processes.

We therefore welcome the opportunity to present the annual Quality Account to demonstrate our continued commitment to delivering high quality care and ensuring quality is at the heart of the organisation. It is particularly pleasing to be able to confirm that the Trust has continued to achieve targets set nationally for mental health trusts in 2015/16, delivered the Commissioning for Quality and Innovation (CQUIN) schemes, and retained ‘registration without conditions’ with the Care Quality Commission. More detail is provided in the key quality improvements delivered by the Trust in 2015/16 and the quality challenges we have set for ourselves for 2016/17.

On a practical level, the Trust firmly believes that the delivery of high quality services is an integral part of everyday practice and is “everyone’s business”. In support of this, during the last year the Trust has:

Completed the delivery of our current Quality Improvement Strategy and developed a further five year strategy for quality improvement

Maintained Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations

Introduced “Hello, my name is…” campaign that embeds the importance of a warm welcome, familiarity and a friendly face

Dementia pain management tool - improves the way we manage pain in patients with dementia

Improved access to psychological therapies through the implementation of a therapeutic hub

Improved patient and staff experience relating to the impact of incidents in relation to their perceptions and feelings of safety

Improved the quality of clinical supervision and appraisals to support care delivery and practice

Launched our falls care bundle

Maintained a gold star in Triangle of Care - a programme that aims to improve support and information for carers and as recognition of carers as key partners in care

Investment and focus on nurse development and revalidation and the re-launch of our Professional Nurses Forum

E-rostering launched to support effective staffing on wards

Increased number of Experts by Experience to 11 to widen the scope of their work in ensuring that service users and carers have a voice in service improvement


New values launched supported by a behavioural framework that underpins the way we work

New clinical research facility opened that will increase our capability in research and development as well as increasing patient involvement

Strengthened clinical audit within the Trust and alignment to Trust’s Quality Improvement Strategy

Received national recognition for equality and diversity work

Improved our dementia environments and introduced dementia care mapping to support quality improvement

Embraced and embedded Duty of Candour at all levels

As Chief Executive of the Trust, I can confirm that, to the best of my knowledge, the information contained in this Quality Account is accurate. The Statement of Directors responsibilities summarises the steps taken to develop this Quality Account and external assurance is provided in the form of statements from our commissioners. The report of an external audit undertaken by Grant Thornton UK LLP is included in the Quality Account.

Mark Axcell

Acting Chief Executive


Part 2: Priorities for improvement and statements of assurance from the Board

2.1 Priorities for improvement

This is the forward-looking section of the Quality Account. It details the improvements planned for the next year and explains why the priorities have been chosen. When identifying the 2016/17 priorities, considerations were taken against progress made since the last Quality Account which is detailed in Section 3 of this report.

During 2015/16, the Trust embraced an ambitious agenda for quality improvement which has been delivered through the Quality Improvement Strategy. The Trust will continue this journey during 2016/17, and has identified five quality improvement priorities through a process of reviewing services and working with stakeholders, and by looking at the Trust’s performance against national and local quality indicators.

These quality priorities are especially pertinent as barometers for service quality as they:

Reflect the vision and current priorities for the organisation

Are distributed across the CQC domains Caring, Responsive, Effective, Well-led, Safe

Represent both local and national agendas

Include priorities that are important to our service users and their carers

Include priorities that are important to our staff

Include priorities important to stakeholders and partners

Are a mixture of new areas and those which build on key priorities from 2015/16 and are applicable to services being developed as part of the Trust’s vision

For each of the quality priorities a delivery strategy has been developed to track the performance against improvement initiatives at all levels from ward to board. Progress against these priorities will take place through quarterly integrated ‘Quality Reports’ presented to the Quality and Safety Committee and Trust Board.

2.2 Our priorities for 2016/17

Quality Priority 1: Smoking Cessation Rationale for inclusion

Smoking is the largest single preventable cause of morbidity. People with mental health problems smoke significantly more, with levels about three times of those observed in the general public.

The Trust is committed to supporting individuals to stop smoking whilst receiving NHS Care as this is seen as a significant opportunity to support individuals and reduce smoking.

The Trust recognises that by prioritising smoking cessation it will be supporting people with mental health problems who are at greater risk of poor physical health get access to prevention and screening programmes. As part of this, NHS England and Public Health England should support all mental health inpatient units and facilities (for adults, children and young people) to be smoke-free by 2018.

Improvement Initiatives

To develop and deliver an implementation programme for smoking cessation

Measurement

Self-assessment NICE /Public Health guidance


Smoking reduction metrics Quality Goal 2: Dementia care initiative Rationale for inclusion

During 2015/16 the Trust focused on ensuring best practice guidelines are being delivered within our dementia services. This has included the introduction of a Dementia Care Mapping programme which provides a continuous quality improvement programme for our inpatient dementia services.

During 2016/17 the Trust has agreed to continue to focus on the implementation the Department of Health strategy for national dementia care (Prime Minister’s challenge on Dementia 2020) This will include the delivery of a dementia improvement plan which specifically includes further developing partnerships across the health economy and working with the third sector.

Improvement initiatives

To deliver a dementia care improvement plan which will include partnership working with third sector and voluntary organisations.

Measurement

Delivers against dementia improvement plan

Dementia care mapping Quality Goal 3: Improving the quality of our clinical documentation Rationale for inclusion

The Trust is committed to the provision of high quality clinical records to support the recovery of service users. During 2015/16 the Trust has identified through feedback from service users, CQC feedback and peer reviews, that there is a need to continue to improve the quality and monitoring of clinical records. It is envisaged this will support the Trust moving towards a full electronic record.

Improvement initiative

To improve the quality of clinical records in support of the patient’s recovery journey

Measurement

Clinical records audit

Quality Goal 4: Demystifying care pathways Rationale for inclusion

During 2015/16 the Trust has mapped out and produced three patient pathway maps for CAMHS, Adult Services and Older Adult Services. These patient pathways identify the access and exit points into our teams spanning the Trust. They were produced following mapping exercises across the teams involving clinicians and service users.

2016/17 the patient pathways maps are utilised to:

Further demystify pathways for service users and stakeholders through dissemination of pathways and development of leaflets for service users

Support the Trust preparation for the implementation of electronic records



To produce maps of our clinical pathways in a format that is clear, accessible, and transparent to enable stakeholders to navigate our services.

Measurement

Stakeholder survey

Quality Goal 5: Improving the service experience of our recovery pathways in the community Rationale for inclusion

Following feedback from service users through the Trust’s Service Experience Desk (SED) the Trust has identified that improvements can be made to the Trusts recovery care pathways to improve service users experience of care.


Discharge pathways

Communication processes

Appointment processes

Consistency of workers

Strengthening links with primary care

Strengthening service interfaces to improve patient experience Measurement

Service user feedback

Clinical audit How will we review and monitor these priorities?

Each quality improvement priority identified for 2016/17 will be delivered through the framework identified in the Trust Quality Improvement Strategy. Progress will be monitored through the Trust quality governance framework and overseen by the Governance and Quality Committee. The Governance and Quality Committee and Trust Board will receive quarterly updates on progress and also any required exception reports.

2.3 Statements of Assurance

The aim of the following sections (2.4 - 2.10) is to provide information to the public which will be common across all Quality Accounts, thereby enabling people to gain a more informed and transparent view about what different healthcare organisations have reported.

The statements in this section offer assurance from the Trust Board to the public that the Trust is:-

Performing to essential standards

Measuring our clinical processes and performance

Involved in national projects and initiatives aimed at improving quality


2.4 Reviewing the Quality of Trust Services

During 2015/16, the Trust provided NHS services through four service lines:

Access and Acute Services

Older Adults Services

Early Intervention Services

Community Recovery Services

The Trust has reviewed the data available to them on the quality of care in all four of these services.

The income generated by the NHS services reviewed in 2015/16 represents 100% of the total income generated from the provision of NHS services by the NHS Trust for the reporting period 2015/16.

2.5 Clinical Audit

Clinical Audit is a quality improvement cycle that involves measurement of the effectiveness of healthcare against agreed and proven standards for high quality, and taking action to bring clinical practice in line with these standards improving the quality of care and health outcomes. (HQIP ‘New Principles for Best Practice in Clinical Audit’ - Radcliffe Publishing, 2011).

As part of the Clinical Governance Agenda, the Trust has a comprehensive Clinical Audit programme that is delivered as part of the annual audit programme. This is monitored by the Quality and Safety Committee on behalf of the NHS Trust Board. The Clinical Audit and Effectiveness Committee may also request specific clinical audit reports as appropriate.

2.5.1 National Clinical Audits and Confidential Enquiries

During April 2015 to March 2016, four National Clinical Audits and the one National Confidential Enquiries covered NHS services that Dudley and Walsall Mental Health Partnership Trust provides.

During that period the Trust participated in 100% of National Clinical Audits and 100% of 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 the Trust was eligible to participate in during April 2015 to March 2016 are as follows:

Prescribing Observatory for Mental Health (POMH) Prescribing for ADHD in children, adolescents and adults

Prescribing Observatory for Mental Health (POMH) Prescribing for bipolar disorder

Commissioning For Quality and Innovation (CQUIN) Improving Physical Healthcare in Inpatients

Safeguarding Children Section 11 Audit

National Confidential Enquiry into Homicide and Suicide


The National Clinical Audits and National Confidential Enquiries that Dudley and Walsall Mental Health Partnership Trust participated in during April 2015 to March 2016 are as follows:

Prescribing Observatory for Mental Health (POMH) Prescribing for ADHD in children, adolescents and adults

Prescribing Observatory for Mental Health (POMH) Prescribing for bi polar disorder


Safeguarding Children Section 11 Audit


The National Clinical Audits that Dudley and Walsall Mental Health Partnership NHS Trust participated in, and for which data collection was completed during April 2015 to March 2016, 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.

Figure 1 National Clinical Audits

Audit Title Participation % Cases Submitted

Prescribing Observatory for Mental Health (POMH) Prescribing for ADHD in children, adults and Adolescents

Yes 50 were submitted

(2 teams)

Prescribing Observatory for Mental Health (POMH) Prescribing for bi polar disorder


(18 teams)



100% of sample group

Safeguarding Children Section 11 Audit Yes Not applicable: This is a national

audit of Trust processes


Yes Criteria met

2.5.2 Local Clinical Audits

The Trust own Quality Priority Audits for 2015-2016 were derived from a number of key sources including trend analysis of incidents, complaints, commissioner requests, national best practice guidelines (i.e. NICE) and to gain assurance with regards to newly embed processes and to ensure embedded quality processes were safe and effective. A selection of audits commissioned to support these processes and the key findings or recommendations arising from these audits are detailed in the table below.


Figure 2 Trust Priority Local Clinical Audits

Title of audit Summary of actions/recommendations

Abbey Pain Scale

(Local CQUIN)

To introduce the use of the Abbey Pain Scale in patients admitted to hospital with a diagnosis of dementia. 50% of patients diagnosed with dementia experience regular pain, evidence states that despite this, current assessment and treatment of pain in this patient group is inadequate. In addition to the discomfort and distress caused by pain, it is frequently the underlying cause of behavioural symptoms, which can lead to inappropriate treatment with antipsychotic medications.

The audit showed that the Trust was compliant with all of the CQUIN requirements and the use of the Abbey Pain Scale was embedded in practice.

Physical Healthcare (CQUIN)

Cardio Metabolic Assessment and Treatment for Patients with Psychoses. To demonstrate full implementation of appropriate processes for assessing, documenting and acting on cardio metabolic risk factors in inpatients with psychoses.

Delirium

(NICE TA)

Overall, the Trust is showing good overall compliance against the following standards;

Standard 1 – assessment of risk factors: 100%

Standard 2 – assessment of indicators of delirium: 98%

Standard 3 – interventions to prevent delirium: 89%

Standard 4 – diagnosis: 100%

Falls Audit

This audit is the first audit carried out since the introduction FRACT assessment tool that replaced the FRASE tool. There is no direct comparable evidence between the tools, however after reviewing the previous FRASE audit, the overall picture gives an indication that falls care has generally improved in Older Adult Services. This audit was completed on Older Adults wards only. A key recommendation for future audits will be that Adult wards are included.

Anxiety

(NICE CG113)

The results of this NICE compliance audit were of a good standard, compliance in all areas was high. A key issue from this audit is one of documentation not always being complete, however, this is a relatively small sample size and it would be difficult to draw more specific conclusions. A key recommendation from this audit is to complete part 2 of this audit, compare the findings and combine both audits to give an overall picture of a larger data sample. (Forward Audit Plan 2016/17)

Care Programme Approach

This is an annual audit conducted with our community teams.

Overall, compliance was good with Trust and national standards, however, more work needs to be done with regards to evidencing reviews. CPA is part of the 2016/17 Forward Audit Plan.

Medication Safety

(CQUIN)

Medication Safety Thermometer Submission and Improvement

Improving the use of medicines and assurance that hospital pharmacy standards are in place so that patients receive a high quality pharmacy service.

The Medications Safety Thermometer is a national tool with a four step process that measures error and harm from error.


2.6 Clinical Research

During 2015/2016 the Trust has participated in 10 portfolio based research projects.

The number of patients receiving NHS services provided or sub-contracted by the Trust in the period 1 April 2015 to 31 March 2016 that were recruited during that period to participate in research approved by a research and ethics committee was 268 (against a target of 220).

Participation in clinical research demonstrates the Trust’s commitment to improving the quality of care we offer and to making our contribution to wider health improvement. The Trust supports clinical staff to stay abreast of the latest treatment options and active participation in research.

The Trust was involved in conducing 10 portfolio research projects including randomised controlled trials, service evaluations, epidemiological research and genetic research, as displayed in Figure 3.

Figure 3 Portfolio research studies at the Trust (2015/2016)

Research Study Title Topic Service Line Status

DPIM Schizophrenia – DNA Polymorphism in Mental Health illness

Schizophrenia Adult Mental Health

Open

REACT – An online randomised controlled trial to evaluate the clinical and cost effectiveness of a peer supported self-management intervention for relatives of people with psychosis or bipolar disorder

First Episode Psychosis and Bipolar

Adult Mental Health

Open

NCISH – National confidential enquiry into suicide and homicide

Suicide Adult Mental Health

Open

COFI-FU – Comparing integrated and functional systems of mental health care follow-up

Service Delivery

Adult Mental Health

Open

MILESTONE – Improving transition from child to adult mental health care

Service Delivery

Adult Mental Health

Open

FemNAT - Understanding sex differences in disruptive behaviour in children and teenagers

Conduct Disorder

Child and Adolescent Mental Health

Open

AD Genetics – Detecting susceptibility genes for early onset Alzheimer’s Disease Alzheimer’s

Older Adult Mental Health

Open

PRONIA – Personalised prognostic tools for early psychosis management

First Episode Psychosis and Depression

Adult Mental Health

Open

TEQ – Developing and testing a tool to measure therapeutic engagement

Inpatient Service Delivery

Adult Mental Health

SUD – Sudden death in psychiatric inpatients and the relationship with psychotropic drugs

Not set Adult Mental Health

Open


2.7 CQUIN (Commissioning for Quality and Innovation)

A proportion of the Trust’s income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between the Dudley and Walsall Mental Health Partnership NHS Trust and the commissioners through the Commissioning for Quality and Innovation (CQUIN) framework. CQUIN is a national initiative which aims to embed demonstrable quality improvements within the commissioning cycle for NHS healthcare.

The CQUIN scheme indicators, financial values and performance for the past three years are summarised below.

Figure 4 Historical CQUIN Performance 2012–2016

2013/14 2014/15 2015/16

CQUIN Schemes

6 schemes:

1. NHS Safety Thermometer

2. NET Promoter (FFT)

3. Making Every Contact Count

4. Medicines Management

5. Reducing Falls in Older People Mental Health

6. Undertake Agency for Healthcare Research and Quality’s (AHRQ) Patient Safety Culture

7 schemes:

1.Friends & Family Test

2.Safety Thermometer

3.Physical Health Check

4.Medicines Management

5.Recording Duration of Untreated Psychosis

6.CAMHS Transition Protocol

7.Improving Diagnosis Recording

6 schemes:

1. Dementia Pain Management

2. Physical Health Check

3. Urgent Emergency Care – Reducing MH A&E attendances

4. Medicines Management

5. Enhanced Carers Support

6. DW-ROM

Financial value

Value: £1,368,634

Achieved: £1,368,634

Value: £1.38m

Achieved: £1.325m

Value: £1.39m

Achieved: £1.365m

For 2016/17, the Trust has agreed nine CQUIN schemes with a total value of c£1.4m. The schemes cover a range of services including the four quality domains of Patient Experience, Safety, Effectiveness and Innovation.

Figure 5 2016/17 CQUIN Schemes

Scheme Title National / Local

1. Improving physical healthcare to reduce premature mortality in people with severe mental illness (PSMI)

National

2. Improving Health and Wellbeing of NHS Staff National

3. Medicines Management Local

4. Voluntary Sector Working Local

5. Dudley and Walsall Recovery Outcomes Model (DWROM) – Adults & Older People

Local

6. Mental Health MDT Pilot Local

7. Avoidable Mental Health Act Admissions and Standardising Care Plan Local

8. John’s Dementia Campaign Local

Further details for the reporting period and the following twelve months can be obtained from [email protected]

mailto:[email protected]


2.8 What others say about the Trust

As a provider of NHS services, the Trust is monitored and regulated by a variety of external bodies and arrangements. This regulatory framework helps to ensure that the Trust provides services which are of the highest quality, well-managed and make appropriate use of resources.

Statements from the Care Quality Commission (CQC)

The Trust is required to register with the Care Quality Commission and the Trust has no conditions attached to its registration. Through the Trust’s quality governance processes the Trust identifies guidance issued by the Secretary of State which relates to chapter 2 ‘ Registration in Respect of Provision of Health and Social Care ‘of the Health Act 2009, and act and acting upon it appropriately. As such Dudley and Walsall Mental Health Partnership NHS Trust have no conditions attached to their registration.

In February 2016 the Trust received a formal CQC assessment against the CQC revised assessment framework. The Trust is awaiting the outcome of the assessment.

The most recent formal CQC feedback that the Trust received was following an assessment it had in February 2014 as a pilot site for the first wave of the new CQC Mental Health Chief Inspector of Hospitals inspection visits. The CQC inspection report was published on 16 May 2014 and identified many areas of good practice, these were:-

There was good practice in the leadership of the trust; the non-executive directors and theChair were particularly strong

The Trust’s quality and governance systems were seen as robust and ran through the trust at every level. The leadership of governance and quality was outstanding

Learning from incidents and the embedding lessons programme meant that changes in practice in the inpatient areas and community teams were evident, and staff understood why

Safeguarding processes were embedded across all of the teams in the trust and the application of the Mental Health Act across the services was good. People were lawfully detained and had their rights read to them at the appropriate times

Experts by experience were introduced and used at all levels in the Trust

The trust worked well with other local stakeholders, such as the local authorities and the clinical commissioning groups

The Trust has a robust approach to learning from incidents and ensuring this was embedded in practice across all levels

The most recent CQC intelligent Monitoring report, issued in February 2016 identified no risks against key indicators and no elevated risks.

During 2015/16 the Trust has also received a number of CQC MHA visits. The Trust has returned provider action statements in relation to these visits and has developed robust action plans to ensure that issues are resolved.

Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations

During 2015/16 the Trust has continued to participate in CCQI National Quality Improvement projects managed by the Royal College of Psychiatrists. This is a voluntary national improvement and development programme which aims to raise standards of care in mental health services. CCQI accreditation is a nationally recognised indicator of high quality services which support continuous quality improvement.


The Trust has achieved CCQI accreditation for:

all of its working age adult inpatient wards via the Accreditation for Inpatient Mental Health Services programme

both of its Electro-Convulsive Treatment (ECT) Services via the Electro-Convulsive Therapy Accreditation Scheme

three of the four older peoples’ inpatient wards via the Accreditation for Inpatient Mental Health Services – Older People and its memory service via the Memory Services National Accreditation Programme

The figure below shows the number of CCQI accredited services in the Trust.

Figure 6 Number of CCQI Accredited Services in the Trust

CCQI Programme Participation by the Trust

Electroconvulsive Therapy Clinics 2 ECT clinics (100%)

Working Age Inpatient Wards 5 wards (100%)

Older People’s Inpatient Wards 3 wards (75%)

Memory Clinics 1 service (100%)

2.9 Data Quality

Good quality information underpins the effective delivery of care and is essential for measuring and monitoring improvements in quality and performance. The Trust has made significant improvements to its performance management and reporting framework, and has taken a number of actions to improve data quality.

The Trust has a well-established Contract Activity Review Meeting (CARM). This meeting is held at the start of each month to discuss and review the previous month’s data, before it is presented to the Finance and Performance Committee, to Commissioners at the Contract Review, Clinical Quality Review Meetings and then at Board. CARM is now an established governance mechanism for the Trust that involves operational and information staff.

The function of CARM has been further developed during 2015/16 to help raise the profile of information in the Trust and to drive data quality improvements.

In particular, this forum has been extended and is now used to:

Monitor progress against the Data Quality Improvement Plan

Review all submitted reports to monitor performance against target

Co-ordinate Exception reports and remedial action plans to achieve operational service compliance

Authorise submission of performance related data to any external organisations

Standardise data definitions

Explore emerging performance challenges

Commission work covering more detailed analysis and forecasting

Help managers understand the financial impact and implications of changes in the level of activity.

In 2015/16 the Trust refreshed its Data Quality Improvement Plan (DQUIP) which aims to ensure that all strategic, operational and clinical decisions are made on the basis of good information drawn from robust data.


The DQIP was endorsed by Management Executive Team and the Finance and Performance Committee, and implementation has continued throughout 2015/16.

New processes have been put in place to track and monitor all data quality checks and exercises. The scope and purpose of each data quality process is agreed centrally and the results are documented to ensure that a clear audit trail of checks and changes is maintained.

The Performance Department monitor other Data Quality Reports. These include Blank Team Referrals, Floating Referrals, Duplicate Referrals, Appointments with no Outcomes, Daily Demographic checks, Monthly Batch Trace files cross referencing GP Practices and Deceased Records.

2.10 NHS Number and General Practice Code Validity

The Trust submitted records during 2015/16 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data which included the patient’s valid NHS number was:

99.8% for Admitted Patient Care (national 99.2%)

99.7 % for Outpatient Care (national 99.4%) The percentage of records in the published data which included the patient’s valid General Practice medical code:

99.9% for Admitted Patient Care (national 99.9%)

99.8% for Outpatient Care (national 99.8%)

2.10.1 Information Governance Toolkit Attainment Levels

Information Governance (IG) refers to the systems and processes the Trust has in place to safely and effectively manage all types of information. The HSCIC / NHS England’s IG Toolkit (IGT) is an online system which allows NHS organisations and partners to assess themselves against Department of Health Information Governance policies and standards. It also allows members of the public to view participating organisations. Trusts are required to assess themselves annually against the standards in the toolkit. By March 2016 the Trust attained 78% compliance against the toolkit.

Dudley and Walsall Mental Health Partnership NHS Trust Information Governance Assessment Report provides an overall score for 2015/16 of 78%; 95% of all staff received IG training and the Trust’s internal IGT audit gave a result of ‘Significant Assurance’.

2.10.2 Clinical Coding Error Rate

Clinical Coding compliance applies to inpatient records to ensure that diagnosis and procedures are coded correctly and consistently across the Trust. Clinical Coding is part of the Information Governance (IG) Toolkit requirements where the accuracy of coding must be maintained at a given level to achieve level 2 or 3 within the Toolkit.

The Trust has completed several external clinical coding audits. The table below shows positive progress against compliance with the IG toolkit over the last three years:


Figure 7 Progress against IG Toolkit Compliance

Outcome

December 2013 Achieved

Information Governance Requirement 11-514 - An audit of clinical coding, based on national standards, has been undertaken by NHS Classifications Service approved clinical coding auditor within the last 12 months

Attainment level 3

Information Governance Requirement 11-516 - Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national standards

Attainment level 3

January 2015 Information Governance Requirement 12-514 - An audit of clinical coding, based on national standards, has been undertaken by a Clinical Classifications Service (CCS) approved clinical coding auditor within the last 12 months.

The Trust has therefore achieved attainment level 3

Information Governance Requirement 12-516 - Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national clinical coding standards.


February 2016 Information Governance Requirement 12-514 - An audit of clinical coding, based on national standards, has been undertaken by a Clinical Classifications Service (CCS) approved clinical coding auditor within the last 12 months.


Information Governance Requirement 12-516 - Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national clinical coding standards.



The data made available with regard to the percentage of service users discharged from inpatient care followed up within 7 days

Part 3: Review of Quality Performance

This section provides information related to the quality performance of the Trust’s services. External sources of data have been used to provide the public with as much benchmarking information as possible.

This part of the Quality Account is presented in four sections

1. Part 3A – Performance against Department of Health (DOH) Mandatory Indicators, which Trusts are required to report against in their Quality Accounts for 2015/16.

2. Part 3B – Performance against 2015/16 Quality Improvement Priorities

3. Part 3C - Performance against additional Quality Performance Indicators chosen by the Trust including National and Contractual KPIs

4. Part 3D - Statement from the Trust’s key stakeholders.

Part 3A: Department of Health Mandatory Indicators

The NHS (Quality Account) Amendments regulations (2012) defined a set of core quality indicators, which Trusts are required to report against for their Quality Accounts from 2013/14 onwards. The Trust’s position against all relevant indicators for the last two years is shown in the following sections.

3.1 Preventing People from Dying Prematurely – 7 Day Follow-up

The Trust has utilised the information available from the Information centre and the Trust considers that the data is as described for the following reasons:

Staff are aware of their responsibilities regarding data quality through regular communications and team meetings. In addition, all national, local and internal quality indicators are reviewed and data validated at the Contracted Activity Reporting meeting with representation from all Trust areas.

Robust data quality monitoring and validation processes and procedures are in place and embedded along with clear guidance on the requirements to record data accurately.

The Trust has taken the following actions to improve this percentage, and the quality of its services, by:

holding a series of awareness sessions,

Issuing daily specific exception reports to operational managers

Strong leadership provided by senior operational staff to ensure that the clinical importance of this indicator was understood.

This continued to be an important area for the Trust in 2015/16.

The Trust has performed strongly throughout 2015/16 and managed to achieve 97%.

The table below provides the percentage achievement for the last three years.


All admissions to acute inpatient services will have had access to crisis resolution / home treatment (CRHT) team

Figure 8 7 Day Follow Up need to add national lowest and highest

The graph below provides the monthly percentage achievement in 2015/16.

Figure 9 Seven Day Follow Up in 2015/16

3.2 Enhancing the Quality of Life for People with Long Term Conditions

The Trust has utilised the information available from the Information centre and the Trust considers that the data is as described for the following reasons:



Indicator

Target Full Year 2013/14

Full Year 2014/15

Full Year 2015/16

Q3 2015/16 National Average

Q3 2015/16 Lowest Trust

Q3 2015/16 Highest Trust

7 Day Follow Up

95% 99% 97% 97% 96.9% 50% 100%


The Trust has taken the following actions to improve this percentage, and so the quality of its services, by:

Issuing monthly exception reports to operational staff.

Strong leadership provided by senior operational staff to ensure that the clinical importance of this indicator was understood. This continued to be an important area for the Trust in 2015/16.

The information provided by the Information Centre showed numerators, denominators and percentages for all admissions to acute inpatient services and how many were gate-kept by CRHT Team.

This has been an area of consistent strong performance throughout 2015/16 with 100% Inpatient Admissions being gate-kept in 2015/16.


Figure 10 Crisis Gatekeeping need to add national lowest and highest

Indicator

Target

Full Year 2013/14

Full Year 2014/15

Full Year 2015/16

Q3 2015/16 National Average

Q3 2015/16 Lowest Trust

Q3 2015/16 Highest Trust

Gate keeping of Inpatient Admissions by CRHT

95% 100% 100% 100% 97.4% 61.9% 100%

The graph below provides the monthly percentage achievement 2015/16.

Figure 11 Gatekeeping Achievement Rates


3.3 Ensuring that People have a positive Experience of Care – staff survey

The Trust has utilised the information made available by the Information Centre with regard to the results based on a sample of the workforce surveyed as part of the 2011, 2012 and 2013 staff surveys, (the 2013 Trust response rate was 56%, i.e. 329 respondents from sample of 588).

The Trust’s performance against this question was as follows.

Figure 12 Staff Survey

Survey

Year Trust

MH/LD Trust Average

2011 Question 22b - ‘If a friend or relative needed treatment I would be happy with the standard of care provided by this Trust’

55% 59%

2012 Question 12d - ‘If a friend or relative needed treatment, I would be happy with the standard of care provided by this organisation’

60% 60%

2013 Question 12d - ‘If a friend or relative needed treatment I would be happy with the standard of care provided by this organisation’

60% 59%


62% 60%


65% 59%

The Trust considers that these percentages are as described for the following reason:-

As previously recommended, the Trust used an independent approved contractor to run the staff survey on behalf of the Trust in 2011-2015. Approved contractors provide external assurance of the process.

In 2015, the Trust has continued to use the same independent approved contractor to run the staff survey.

We also employed an independent contractor as a Staff Engagement Lead since April 2014 who focused energy promoting the staff survey as well as leading the Staff Friends and Family Test.

For the first time in 2015, 50% of eligible staff were offered the survey online and 50% using traditional paper survey and rather than a sample surveyed all eligible staff as we had done in 2014. This exceeded the requirements as we did not use just a sample of staff.

The percentage of staff employed by, or under contract to, the Trust during the reporting period who would recommend the Trust as a provider of care to their family and friends


The Trust has taken the following actions to improve this percentage, and so the quality of the services provided:

The Trust has held focus groups and staff engagement sessions, using an independent contractor, involving variety of staff from various locations and services to help understand any issues, and to seek staff feedback on possible solutions/remedies.

Senior management continue to attend areas outside of their usual remit, to improve the visibility to staff on the ground and to enhance engagement and communication Trust-wide.

An action plan was developed that encompasses recommendations from the staff survey, CQC inspection and focus groups. This will ensure an overarching approach and support pan-trust implementation, as appropriate.

The Trust will be taking the following actions to improve this percentage, and so the quality of the services provided:

Outputs/recommendations from the focus groups and staff engagement sessions have been included in the action plan, as appropriate.

The Trust launched the Staff Friends and Family Test via its intranet, in May 2014, and have monitored these throughout the year, drilling down into the free text comments as to why people answered the way they did. This has seen staff stating they would recommend the Trust as a place for treatment/care to friends and family increase from 72% to 79% within one year.

3.4 Helping people to recover from episodes of ill health during injury

Readmission rates

The Trust has utilised information made available from the Trust’s information system OASIS as the information was not accessible from the Information Centre to enable meaningful comparison.

The Trust considers that the data is as described for the following reasons:



The Trust has taken the following actions to improve this percentage, and so the quality of its services, by:

Developing processes and procedures, to agreed parameters, with clinical staff to ensure validated readmissions figures were reported internally and externally.

Establishing robust reporting through the Trust’s data warehouse dashboard to enable services to view the level of readmissions.

Strong leadership provided by senior operational staff to ensure that the clinical importance of this indicator was understood.

The percentage of patients readmitted to hospital which forms part of the Trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period.


The Trust has closely monitored this Indicator and year end results shows a compliance rate at 8.2% against an aspirational Trust target of 10%.


https://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/

Figure 13 Readmission Rates

Indicator Target 2013/14 2014/15 2015/16

Readmission Rate <10% 6.6% 8.9% 8.2%

The graph below provides the monthly percentage achievement 2015/16.

Figure 14 Trust Readmission Rate in 2015/16

3.5 Ensuring people have a positive experience of care - national survey

The Trust has utilised the information available from the Information Centre in relation to the 2013 and 2014 Community Patient Survey. To determine the Trust’s performance against this indicator, the mean score achieved against the following three questions has been calculated from the 2015 survey of people who use community mental health services:

Extract from survey – Section Health and Social Care Workers:

1. Did the person or people you saw listen carefully to you?

2. Were you given enough time to discuss your needs and treatment?

3. Did the person or people you saw understand how your mental health needs affect other areas of life?

The Trust’s patient experience of community mental health services indicator with regards to a patient’s experience of contact with a health or social care worker




Figure 15 Patient experience

Performance Experience of Care

2015

Dudley and Walsall Mental Health Partnership NHS Trust

7.8

Figure 16 Survey Overall Experience

Figure 17 Benchmarking against other Trusts

How this score compares with other Trusts Based on patients’ responses to the survey, this trust scored

8.3/10

Listening

for the person or people seen most recently listening carefully to them

About the same

7.8/10

Time for being given enough time to discuss their needs and treatment

About the same

7.2/10 Other areas of life for the person or people seen most recently understanding how their mental health needs affect other areas of their life

About the same

The overall score is the average of the domain scores, which is taken as the experience of care score.

We consider the percentages are as described for the following reasons:

The Trust used an independent approved contractor to run the Community Patient Survey on behalf of the Trust in 2011- 2015

2015 figures for the lowest and highest scoring Trust are provided by the CQC

We have taken the following actions to improve this score further, and the quality of the services:

Improved the visibility of our Service Experience Desk (PALS and Complaints) to better support service uses, carers and staff

Patient Reported Experience Measures (PREMS) survey will be deployed across all teams. The survey has been developed for benchmarking teams and service lines against CREWS standards. PREMS are used to understand patients’ views on their experience while receiving care


In response to the Francis inquiry into the failings of Mid Staffs NHS Foundation Trust, the Parliamentary and Health Service Ombudsman, Local Government Ombudsman and Healthwatch England committed to developing a user-led “vision” of the complaints system and produced a report entitled “My Expectations for Raising Concerns”. This report presents the vision/framework that was created and the findings of the primary research with patients, service users, frontline staff and stakeholders that lay behind it. There are five main areas to the framework which the Trust aims to follow and achieve which has been incorporated into the SED induction programme.

The Trust Development Authority (TDA) has issued a new toolkit that allows Trusts’ to measure patient experience consistently. It comprises of a Patient Experience Development Framework, which is a self-assessment tool, and a Patient Experience Headline Tool, and together these have been designed to enable Trusts to benchmark performance against service lines, as well as promoting discussion at a senior level to improve patient experience.

The Department of Health have recently issued a new toolkit that allows Trusts’ to measure patient experience consistently. This is described in more detail along with the Trust’s results in section 3.3.5.

3.6 Patient Safety Related incidents

The Trust has obtained data from the Information Centre which utilises data from the National Reporting and Learning System (NRLS) from which national benchmarking data is scrutinised by the Trust to monitor performance.

The figures below are taken from the last four half yearly feedback reports from the NRLS who collect information regarding all patient safety related incidents within the Trust and offer a comparison against similar organisations, As a mental health provider we are placed into a cluster group alongside 56 other mental health organisations.

Figure 18 Patient Safety Related incidents Submitted to the NRLS

Number of Incidents per 1000 bed days

Median – per 1000 bed days

Percentile of 56 other reporters within mental health cluster

1 October 2013 - 31 March 2014 29.35 26.71 Middle 50%

1 April 2014 – 30 September 2014 24.51 32.82 Middle 50%

1 October 2014 - 31 March 2015 26.73 31.10 Middle 50%

1 April 2015 – 30 September 2015 30.97 38.62 Middle 50%

Figure 19 Level of Patient Safety Related incidents Submitted to the NRLS, for the last four reporting periods

None Low Moderate Severe Death Total

1 October 2013 - 31 March 2014 366 309 35 2 12

724 50.6% 42.7% 4.8% 0.3% 1.7%

1 April 2014 – 30 September 2014 405 272 40 2 7

726 55.8% 37.5% 5.5% 0.3% 1.0%

1 October 2014 - 31 March 2015 447 317 25 3 16

808 55.3% 39.2% 3.1% 0.4% 2.0%

1 April 2015 – 30 September 2015 447 372 10 0 11

840 53.2% 44.3% 1.2% 0.0% 1.3%


3.7 Serious Incidents

The Trust takes a very rigorous approach to incident reporting and has in operation an excellent reporting culture across the organisation. The Trust is fully committed to learning from serious incidents and has a very robust embedding lessons procedure in operation to ensure that all actions identified through the investigation of serious incidents are fully implemented.

Figure 20 Reported Incidents 2015/16

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

2015 2016

Serious Incidents 2 8 6 4 3 4 1 1 3 4 3 6

Trust Incidents 250 328 319 325 328 272 285 292 350 288 309 319

0

50

100

150

200

250

300

350

400

Reported Incidents / Serious Incidents 2015/2016

Serious Incidents

Trust Incidents

The Trust considers that this data is as described for the following reasons:

Incident reporting is a central component to risk management within Dudley and Walsall Mental Health Partnership NHS Trust and all incidents have been managed according to the Trusts ‘Incident, Near Miss and Serious Incident Reporting Policy

All incidents are recorded on ‘Safeguard’ which is the Trust’s Integrated Risk Management System, for which staff receive training and on-going support

The Trust is considered to have a good reporting culture and that all incidents are reported in a timely manner, with regular training provided to all staff and managers

The organisation also recognises the importance of having robust process for the investigation of Incidents, Complaints and Claims. This is done through the use of Root Cause Analysis Techniques that can be used to identify any key areas of learning for the organisation and identifies any systems failures, key events, human errors and areas for improvement.

The Trust submits its Quality report to the Commissioner Quality Review meeting on a monthly basis for external scrutiny. This process acts as an independent scrutiny check and would highlight any issues such as underreporting or trends in respect to the quality of services provided.


The Trust has taken the following actions to further improve this:

Duty of Candour – The Trust has ensured that the Duty of Candour is embedded within the Trusts serious incident processes and has ensured wherever possible that service users and carers are involved in the process and outcome

The Trust has recently undertaken a review and subsequent restructure of its Quality and its Compliance and Safety Teams. The restructure has led to closer working between Compliance and Safety and Safeguarding teams and has integrated clinical audit and Research and development within the portfolio of the Quality Team

3.8 Duty of Candour – Cases

In the wake of the Francis Inquiry into the failings at Mid Staffordshire NHS Foundation Trust, the Department of Health has introduced a contractual duty of candour that requires NHS organisations to be open and honest with patients and their families about patient safety incidents. As such the Trust has implemented procedures that ensure the regulations are met and financial consequences on non-compliance are avoided. These include:

1. Reviewing all potential moderate harm or above incidents and documenting on the Safeguard system, the decision making process around any decisions regarding whether Duty of Candour is applicable

2. We offer and provide the service user and other relevant person(s) all necessary support and relevant information regarding the incident

3. As soon as possible but always within 10 days of the incident we notify ‘relevant persons’

This must be verbal and face to face (unless the service user/relevant others decline)

This must provide all facts known at this time regarding incident,

This must include an appropriate apology

This meeting must be documented and a follow up letter must be sent to the relevant person

4. Within 10 days of the investigation being signed off by the organisation, the service user /relevant person to be offered feedback and a copy of the investigation report (this should be the full report not altered/revised)

5. Any refusal by relevant person/service user to meet or receive information must be fully documented

The Trust approach:

Duty of Candour procedures have contributed to the further development of a patient centred model of care.

There has been a robust procedure developed for identifying incidents that fall within the set criteria and follow up has been consistent.

Incident data has been processed and followed up to give assurance that the process for Duty of Candour has been followed and evidenced.

Systems have been developed to capture the Duty of Candour data and information and will provide statistics to support the process. Further support and training is required for staff to use the systems to their full effect.


There is evidence collated from the “none” Duty of Candour incidents that a positive culture exists around being open. This is clear by the amount of notifications that are completed on the electronic incident forms and also from the written nursing notes.

Comparisons have been discussed with other Trusts and there is a level of assurance that the interpretation of the legislation and the development of processes are consistent amongst the mental health organisations.

All incidents that are rated moderate and above have been reviewed further to confirm the level of harm sustained and the level of contact the service user had at the time with Trust services. This information was then escalated to Trust directors for a decision regarding whether Duty of Candour procedures apply.

There have been 14 cases during 15/16 where the process for Duty of Candour has been applied. All of these cases were also investigated as serious incidents

Figure 21 Number of Trust Incidents / Complaints where the Duty of Candour process has been followed

2015 2016 Total

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

1 4 3 2 1 1 0 1 0 0 0 1 14


Part 3B: Performance against quality improvement priorities

This section of the Quality Account demonstrates the significant improvements made against the nine Quality Improvement Priorities for 2015/16.

The progress against the priorities and the associated action plans were monitored by the Quality and Safety Committee and the Trust Board.

3.9 Progress against 2015/16 priorities

Quality Goal 1: Enhance care and compassion through the introduction of ‘Hello My Name Is’ initiative Trust wide

Rationale for Inclusion

The Trust is committed to ensuring staff are deliver compassionate care. ‘Hello My Name Is’ initiative is a national campaign to remind healthcare staff about the importance of introductions in the delivery of care. It is about the beginning of a therapeutic relationship and building trust and supports the delivery of compassionate care. The Trust wants to embrace this National initiative to further develop and embed the 6 C’s – caring, compassion, communication, courage, competence, commitment.


To sign up as a Trust to the national initiative and implement a local delivery plan.

Measurement

Satisfaction levels of service users and carers that feel staff introduce themselves

Progress against a locally agreed action plan to support the implementation of the ‘Hello My Name Is’ campaign’

Progress against priority

The Trust has achieved its ambition of fully embedding the campaign into everyday business. The concept of the initiative was initially launched at the Trusts leadership event including the use of pledge cards and a manager’s pack for leads to implement in their teams. Electronic signatures have been utilised along with staff lanyards as part of the Trusts values.

The Trusts Experts By Experience completed an audit during their regular visits asking patients, carers and visitors if staff have introduced themselves to them. The results are positive showing 81% of service users and carers stating that a staff member introduced themselves when they first met them.

The Trust will continue to monitor the embeddedness of this campaign during 2016/17 supported by Experts by Experience.


Quality Goal 2: Improve trust processes for managing Did Not Attends (DNAs)


The Trust has identified the need to improve the management and processes for DNAs this has been identified through a number of sources including coroner’s recommendations, embedding lessons from incidents, service user and carer feedback. The aim of the initiative is to improve patient safety and the efficiency and responsiveness of clinical processes.


To develop and implement a revised policy and underpins clinical process for the management of

DNAs including quality metrics.

Measurement

Monitoring of DNA rates through internal quality key performance indicator

Feedback form service users


This priority enabled some focused work around some of the reasons and possible solutions to the Trust’s DNA statistics.

We conducted a baseline for some service areas that had reported high levels of DNA’s to identify the possible causes and explore some possible solutions.

We found that some GP surgeries had higher reported levels of DNA’s in comparison to others of similar demographics.

We developed a ‘Keeping your appointment’ leaflet explaining the cost of DNA’s to our patients in both missed opportunities to engage with patients that required the service and financial.

We telephoned the patients that had DNA’d to ascertain the reason and if there was anything that we could have done to enable them to keep their appointment. The reasons were very diverse and where possible these will be accommodated within our service provision.

We created an ‘opt in’ process for patients to contact to the service prior to be given an appointment to determine the patient’s knowledge and understanding of why they were referred to determine their willingness and commitment to attend for treatment.

Following this work, the Trust is now reviewing its DNA Policy to reflect the learning from this priority and will be using that knowledge to enable other service areas to improve their rates.


Quality Goal 3: Improve the quality of dementia care through dementia mapping


During 2014/15 the Trust focused on ensuring best practice guidelines are being delivered within our dementia services. This has included taking on board the recommendation from the Care Quality Commission Inspection visit to the Trust in February 2014. Dementia care will continue to be a priority for the Trust in coming year with a focus on introducing ‘Dementia Care Mapping that has been recommended by the National Institute for Health and Clinical Excellence, the Social Care Institute for Excellence, the Audit Commission and the Commission for Health Improvement as a method for improving care practice for people with dementia and promoting person centred care.


To introduce Dementia Care Mapping programme across our inpatient dementia services that results in local improvement plans and benchmarking of practice.

Measurement

Dementia care mapping results for each participating ward and improvement plans


Dementia Care Mapping is an observational tool and a process, which is designed to help staff to consider and improve the quality of care for people living with dementia. When carrying out observations or a ‘map’ a Dementia Care Mapper/s will observe between one and eight people living with dementia. What they write down examines the experience of care from the perspective of the person with dementia.

In 2015/16 the Trust made mapping a Quality Improvement Priority, six mappers were identified from across both boroughs and undertook training at Bradford University. Dementia Care Mapping was further promoted throughout the Trust via internal communications channels and the Trusts website.

The mapping identified a number of themes which focussed on the importance of the following:

Offering a balanced and flexible range of activities, especially vocational activities and creative activities, in order to enhance patient wellbeing, mood and engagement

Knowing each patient as an individual and how life story work and memory resources can potentially enhance our understanding of people’s individual needs, preferences and abilities

All staff coming into contact with patients on our wards having an understanding of personhood and feeling comfortable with intuitively employing person centred approaches during their interactions with patients

Staff using positive, encouraging and empowering language during interactions with patients and colleagues

Enhancing certain times of the day such as meal times and visiting times to provide a more enriched experience to patients and their visitors

Identifying and responding to patients who might be experiencing pain but who are unable to specifically articulate their unmet needs

The Future of mapping includes, the implementation of the action plans, further Dementia Care Mapping repeated on a six monthly basis as recommended by Bradford University and in addition mini maps on individual patients in order to inform care plans and enhance person centred care for individuals.


Quality Goal 4: To improve the quality of clinical supervision and appraisals to support care delivery and practice


The Trust has identified though embedding lessons from serious case reviews, Care Quality Commission recommendations and staff feedback the requirement to further improve and embed the quality of supervision and appraisal processes.

The Trust views supervision as a critical element in ensuring the provision of high quality mental health care and treatment across its services. Supervision is viewed as fundamental to the safeguarding of standards of performance and practice by providing a framework within which line management accountability is discharged, decision making and risk management takes place, expertise is developed and where effective delivery of quality care for all services users is placed at the heart of the process.


Implementation of revised Supervision and Appraisal Policy including quality monitoring.

Measurement

Clinical Audit to measure compliance against policy

Progress against Priority

Considerable progress has been made against this Quality Improvement Priority for Appraisal and Clinical Supervision. Face to face interviews, staff engagement focus groups and one to ones were carried out with managers and clinical leads across the Trust about staffs’ attitudes to Clinical Supervision and Appraisal to identify potential barriers. This enabled the development of improvement plans.

During 2015/16 the following has been achieved in relation to supervision and appraisals

Supervision

The Trusts supervision policy had been revised and is accessible to staff via the intranet

Clinical supervision training reviewed and being rolled out across the Trust with two cohorts completed and a third group near completion

Awareness raising sessions embedded within nurse development programme

Clinical Supervision arrangements are now incorporated into appraisal returns in the new appraisal policy to capture yearly information about individual supervision arrangements

A central Clinical Supervisor register is in the process of being developed for the Trust and will be maintained by Workforce Development

A web page is currently being developed for Clinical Supervision to further promote and embed across the Trust

A centralised system across the trust for the recording of supervision is being developed to enhance local monitoring

Clinical supervision audit is on the Trust Forward Audit Plan for 2016/17

Appraisals

New appraisal policy developed and now ratified and implemented

Improvement plan developed which has led to improved compliance with appraisal (Board target set at 85%)


90% of staff participating in the 2015 Staff Survey indicated that they have received an appraisal in the last 12 months compared to 83% in 2014

To ensure continuation and maintenance of the improvement plans the group continue to meet to drive and embed changes

Quality Goal 5: To demystify care pathways to ensure transparency and ease of understanding for services users, carers and stakeholders about our services


Following feedback from our service users, carers and commissioners the Trust is committed to undertaking a quality improvement initiative to further demystifying our care pathways. This will enable greater transparency and ease of understanding of the services we deliver and how they interface.

Improvement Initiative

To produce maps of our clinical pathways in a format that is clear, accessible, and transparent to enable stakeholders to navigate our services.

Measurement

Monitoring of complaints

Incident reporting

Stakeholder survey


We have made progress with this priority and over the past 12 months have mapped out and produced three Patient Pathway Maps for CAMHS, Adult Services and Older Adult Services.

These patient pathways identify the access and exit points into our teams spanning the Trust. They were produced following many mapping exercises across the teams involving clinicians and service users.

It has been agreed by the this priority will rollover the 2016/17 to ensure the pathways utilised to assist service users and stakeholders navigate our services and also support the implementation of electronic clinical records across the Trust.

Quality Goal 6: To improve the management and monitoring of long term physical conditions


The Trust has identified the requirement to further improve the quality of managing long term physical health conditions. This is underpinned by National publications ‘Living well for Longer, No Health Without Mental Health, Closing the Gap and the National Audit of Schizophrenia which promote the improvement in the early detection, monitoring and effective management of long term conditions for people long term mental health conditions.



To develop in partnership with key stakeholders and implement a local plan across the Trust services for the management and monitoring of long term physical health conditions.

Measurement

Clinical Audit to measure practice against clinical standards and pathways


Positive on going progress has been made with this Quality Improvement Priority. The physical healthcare group continues to oversee this project alongside other physical healthcare initiatives.

The development and ratification of the trusts overarching physical health care policy

Wellbeing plan currently under development incorporating, healthy lifestyles, smoking cessation to address elements of cardio metabolic risk factors

Diabetes policy developed and out for consultation

Agreement for joint working with CCG long term condition leads to ensure the Trust effectively utilises health economy long term condition pathways

CQUIN requirements relating to cardio metabolic risk factors incorporated into physical healthcare agenda

Physical health care audit against policy standards forms part of the trusts forward audit plan for 2016/17

Quality Goal 7: To improve patient and staff experience relating to the impact of

incidents and the management in relation to their perceptions and feelings of safety


During 2014/15 the Trust focused on ensuring best practice guidelines are being delivered in the management of violence and aggression including least restrictive practice principles. Feedback from both and patient surveys have identified further work the Trust needs to undertake to improve patient and staff experience relating to the impact of incidents and their perceptions and feelings of safety.


To introduce an improvement plan informed by staff and service user feedback.

Measurement

Post incident analysis of patient and staff experience


Good progress has been made against this Quality Improvement Priority. A review of the staff attitudes audit and training needs analysis has been undertaken with themes identified. In addition a review of 12 months incident data has been conducted in order to further identify any trends. Patient survey on feelings of safety has been carried out by the Trust’s Experts By Experience and a subsequent improvement plan has been developed and implemented.

MAPA skills workshop, dedicating time to reflect from reported incidents, concentrating upon the impact of teamwork, communication and confidence.


Introduction of a Restrictive Intervention Champion/ Ambassador in each ward setting to promote the use of early intervention, to identify and feed back to the MAPA trainers any behaviours of concern or repetition.

Re-launch of the crisis development model in the form of a care plan to place emphasis on early detections in changes of behaviours and how to respond on an individual basis.

Re-launch of the “coping model” debrief tool in the form of a guide to conducting and recording a formal debrief process both for staff and service users.

Preceptor ship with the newly qualified nurses, all inpatient staff to complete MAPA training with in the 12 month period, plus 1 day workshop to look at confidence building and incorporate the crisis development model into the existing care planning session as well as the coping debrief model.

Student nurses, to offer introductory session on the trust ethos and value base when working with aggression/violence

Communication, intranet page under development to provide a database for information on best practice.

Information sharing, development and introduction of the MAPA® patient/relative information leaflet explaining what MAPA® is why it sometimes must be used, explaining the aims and safety considerations of it.

In addition the Trusts Restrictive Practice Reduction plan has also been developed and monitored via the Least Restrictive Practice Group.

Quality Goal 8: To improve access to psychological therapies through the implementation of a therapeutic hub


During 2014/15 the Trust focused on improving inpatient activities which was informed by service user, Commissioners and Care Quality Commission feedback. To ensure the Trust has a sustainable, person centred and evidence based approach to the delivery of therapeutic interventions and activities the Trust is in the process of developing a therapeutic hub. This will enhance the progress made during 2014/15.


The Therapeutic Hub will draw together all of the multidisciplinary psychological skills under one virtual roof. By moving towards a more unified approach to planning and delivering psychological care in the Trust will clearly demonstrate effectiveness through specific psychological performance measures

It will ensure that expertise only available in one part of the service will become accessible across the locality.

Measurement

Compliance against local psychological therapies performance metrics

Dudley and Walsall Recovery Outcome measure



Positive on going progress has been achieved against this Quality Improvement Priority.

Development of the Therapeutic Hub policy and criteria

Capacity tool developed capacity of all team members established at year commencement and now linked to contractual activity and target

Programmes in place and subject to continual review

Development of Service information leaflets circulated across the organisation

Training needs identified for 2016/2017 on-going based on the service requirements in line with commissioning intent


Part 3C: Trust Performance against additional quality performance Indicators

This section of the Quality Account aims to provide a selection of indicators chosen by the Trust to demonstrate a holistic view of quality across the services provided. The Trust has included contractual and national key quality indicators and a selection of quality indicators the Trust uses to monitor the quality of the services provided.

3.10 Contractual Quality Requirement Goals agreed with Commissioners

For 2015/16, Dudley and Walsall CCGs respectively stipulated 27 and 28 contractual Key Performance Indicators (KPIs), which were reported on a monthly basis. The table below shows the performance levels achieved for the KPIs where thresholds were finalised in the year.

Figure 22 Contractual KPI’s Performance in 2015/16

Contractual KPIs Target Achieved

1 Referral to Treatment Time – Complete 95% 98%

2 Referral to Treatment Time – Incomplete 92% 97%

3 7 day follow up on Inpatient Admissions 95% 97%

4 Delayed Transfers of Care (All Reasons) <7.5% 0.4%

5 Completion of NHS Number on MHSDS 99% 99.8%

6 Completion of Ethnicity Code on MHSDS 90% 92.2%

7 Completion of IAPT Minimum Data Set outcome data 90% 97.8%

8 Copies of Care Plans (CPA caseload) 95% 95.3%

9 Number of Home Treatment episodes by Crisis Teams (Walsall CCG)

608 681

10 Percentage of people experiencing a first episode of psychosis

50% 71.4%

11 Improved Access to Psychological Therapies – People who receive psychological therapies – attending one session only

Dudley-6227 Walsall-4328

Dudley - 6641 Walsall – 6094

12 IAPT – people who have successfully completed treatment

Dudley-50.5% Walsall-50.4%

Dudley – 55.2%

Walsall – 50.4%

13 The proportion of people that wait six weeks or less from referral to their first IAPT treatment appointment

75% 94.2%

14 The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment

95% 99%

15 Completion of IAPT Minimum Data Set outcome data 90% 97.8%

16 The proportion of users on CPA who have had a review within the last 12 months

95% 95.5%

17 The proportion of users with a valid ICD10 diagnosis code recorded.

85% 67.2%

18 Proportion of in-scope patients assigned to a cluster 95% 94.5%

19 Proportion of initial cluster allocations adhering to red rules

70% 61.6%

20 Proportion of patients within cluster review periods 95% 65.2%

The Trust’s overall performance against the commissioners’ KPIs is very positive and has improved throughout the year.

Significant improvements have been made in data quality and the Trust meets regularly with commissioners to discuss performance and quality.


The Trust is fully aware of areas it needs to improve and is working closely with commissioners to achieve this.

3.11 Monitor – Access targets and outcomes objectives

The Trust routinely reports performance against the national outcome framework and Monitor’s access targets and outcomes (a single integrated measure of service quality and performance) to the Management Executive Committee, Finance and Performance Committee and Trust Board each month. The report summarises previous, current and target GRR ratings and highlights any risk areas.

The Trust has improved or maintained performance in all areas against the national metrics in 2015/16 (as shown below).

Figure 23 National Indicators 2013 – 2016

National Indicators 2013/14 2014/15 2015/16

7 Days Follow Up Target = 95%

Achieved = 98%

Target = 95%

Achieved = 97%

Target = 95%

Achieved = 97%

Minimising Delayed Transfers of Care (All reasons)

Target < 7.5%

Achieved = 3.2%

Target < 7.5%

Achieved = 1.6%

Target < 7.5%

Achieved = 0.4%

Gate keeping of Inpatient Admissions by CRHT

Target = 95%

Achieved = 100%

Target = 95%

Achieved = 100%

Target = 95%

Achieved = 100%

Referral to Treatment – Complete

Target = 95%

Completed = 99%

Target = 95%

Completed = 99%

Target = 95%

Completed = 98%

Referral to Treatment - Incomplete

Target = 92%

Completed = 98%

Target = 92%

Completed = 95%

Target = 92%

Completed = 97%

Data Completeness Identifiers Target = 97%

Achieved = 99.7%

Target = 97%

Achieved = 99.8%

Target = 97%

Achieved = 99.7%

Data Completeness Outcomes Target = 50%

Achieved = 95.6%

Target = 50%

Achieved = 96.2%

Target = 50%

Achieved = 96.4%

The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment

N/A N/A Target = 75%

Achieved = 94.2%

The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment


Achieved = 99%

Percentage of people experiencing a first episode of psychosis


Achieved = 71.4%


3.12 Patient Environment

According to NHS England, “Good environments matter”. The expectation is that every NHS patient should be cared for with compassion and dignity in a clean and safe environment and that if patients believe that standards fall short then they should be able to hold the service and its management to account.

The annual Patient Led Assessment of the Care Environment (PLACE) was introduced in early 2013 and replaced PEAT (Patient Environment Action Team).

The Trust PLACE 2015 assessments were completed on all hospital sites between March and May 2015. This information, along with all other PLACE assessment data was subsequently collated together to create the PLACE 2015 Action Plan.

Summary Results

The table below show the Trust’s scores against national results in between 2013-2015. For three of the domains the Trust scores above the national average. Two domains indicate improvements required, ‘Condition, appearance and maintenance’ and ‘Food and hydration’. It should be noted that the ‘dementia friendly domain’ was scored for the first in 2015 and further discussions about the Trust actions need to take place in the context of the Trusts overarching capital programme and priorities.

Figure 24 National PLACE scores vs. Trust results 2013-2015

The table and graph below show the Trust’s PLACE 2015 scores only and compares them against the national results, along with the scores achieved by each site Whilst the aggregated Trust scores are exceeding national scores in some areas, cleanliness, privacy dignity and wellbeing and dementia, this analysis reveals the Trust has further work to improve its environments across all the hospital sites and across all domains.


Figure 25 National PLACE score 2015 vs. Trust average and by site

3.13 Service Experience

Understanding Service Experience is important to the Trust in order to ensure that our services are developed and improved to meet service users’ needs through listening to peoples’ experiences and views, responding comprehensively to feedback and demonstrating what has been improved as a result. The following are a selection of indicators chosen by the Trust as important measures of patient experience.

3.13.1 Friends and family test – net promoter

Introduced in April 2012, the Friends and Family Test (FFT) asks patients whether they would recommend the NHS service they have received to friends and family who need similar treatment or care. This means patients are able to give feedback on their experience of our services, giving us a better understanding of the needs of our patients and enabling improvements.

The Trust implemented this test in 2013 as part of a CQUIN scheme. People being discharged from community services were asked “How likely is it that you would recommend this service?”

In 2015/16 71% of the 1,931 people asked, responded with ‘likely’ or ‘extremely’ likely. The full results are shown below.


Figure 26 Friends and Family Test Data

3.13.2 Community Mental Health Survey 2015 overall satisfaction score

The Annual Community Mental Health Survey 2015 was conducted independently for the Trust by Quality Health and a questionnaire was sent out to around 850 people who received community mental health services. The response rate was 32% (270 usable responses received from a basic sample of 835), which is higher than the Quality Health National Response Rate of 29%.

The results were positive and a good indication of the levels of satisfaction of our service users, with our Trust scoring higher than the national average in many areas, in particular, around organising, planning and reviewing care and treatment, and knowing who to contact in a crisis.

The Trust is among the top 20% of Trusts surveyed by Quality Health for many questions including patients feeling that they are treated with dignity and respect. Service users were asked how they would rate their experience of our services overall and 70.5% of respondents rated their experience as ‘good’ or ‘very good’.

Areas for action focus on maintaining the positive feedback and in addressing some areas for improvement - triangulating findings with other patient experience methods to identify key themes. In response to the findings the Trust has highlighted four main themes to be more fully investigated and managed, such as changes who people see/continuity of care, other areas of life (including supporting service users with accommodation, benefit advice, help with finding work), crisis care and access to talking therapies/ involvement in decisions about medication and in deciding treatment. We will examine the scores on overall experience and drill down data to look for areas of care which are scored low and for any pockets of poor ratings from different groups or locations.

3.13.3 Compliments and Complaints 2015/16

In addition to our focus on quality, we recognise that sometimes people’s experience of our services is not always as positive as we would hope. In October 2007, the Health Service Ombudsman published ‘Principles for Remedy’ as an overall good practice guide for public bodies in dealing with complaints.


Our complaints policy is based around these principles which are:

Getting it right

Being customer focused

Being open and accountable

Acting fairly and proportionately

Putting things right

Seeking continuous improvement

In response to the Francis inquiry into the failings of Mid Staffordshire NHS Foundation Trust, the PHSO, LGO and Healthwatch England committed to developing a user-led “vision” of the complaints system and produced a report entitled “My Expectations for Raising Concerns”. This report presents the vision/framework that was created and the findings of the primary research with patients, service users, frontline staff and stakeholders that lay behind it. There are five main areas to the framework which the Trust aims to follow and achieve and has been incorporated into the SED induction programme and promoted throughout the Trust. During the period April 2015 to March 2016, we received a total of 139 formal complaints, 38 of which were withdrawn or closed. We responded to 43 cases within the target timescale; 28 cases remain open, 20 of which were still within target at the time of writing.

Figure 27 Compliments and Complaints data

There were 139 formal complaints and 321 compliments received during April 2015 to March 2016. The number of complaints received is relatively small compared to the number of patients we see and treat each year.

Over the last twelve months we are pleased to say we have received a large number of compliments (321) from people who have accessed our services, highlighting cases where the quality of our services has been recognised and appreciated. The Service Experience Desk (SED) feature “On a Happy Note” highlights the positive comments made by service users about their care by posting a selection of experiences from service users on the Trust Intranet every month.


Some examples of what people have said about our services are demonstrated below:

Three weeks ago I was ready to die, I didn’t want to be here anymore and I felt nothing and nobody could change that. Three weeks later and still currently in hospital, I am looking at discharge and going home to my family. I have met new people, made new friends and blossomed into the person I am now. I am stronger and more able, positive and fighting back. I want to live, I want to survive. This is all possible because I have a wonderful supportive family and a fantastic team of doctors, nurses and healthcare assistants around me to aid my recovery. Thank you each and every one of you.

My therapy has been instrumental to my on-going recovery. This combined with the mindfulness techniques gained in the course I took part in. I am confident that the therapy has been of great benefit to me and others around me and for the first time in my life I know I have the tools to enable me to be strong in the future. All members of North CRS team have been fantastic – kind, helpful, non-judgemental and a real asset to the mental health service. I would like to offer my gratitude to all that have been involved in my care.

I cannot compliment the doctor enough, her passion for her job and her patience is excellent. She truly cares for patients and I would be in a very dark place without her.

I have found the counselling service provided to be most beneficial to me, life changing in fact. Over the past few months I have become a different person, which I have only been able to achieve by following the counsellor’s advice and using the tools that I have been shown. Thank you for making me a more relaxed, calm and happy person.

I just wanted to say a massive thank you for changing my life for the better. Three months ago I would never have thought I could be where I am today. I owe it all to you, thank you.

The care is not really big enough for the thanks I have for you but I wanted to thank you for doing your job so well. Whilst you have just been doing your job you have just been giving me my life back. I look forward to my future. You have given me skills that now make my life much easier Thank you from the bottom of my heart.

My daughter has made amazing progress. I feel every session with CAMHS has been beneficial to her. I can’t fault any of the treatment she has received. I would also like to say how fantastic the practitioner has been not only for my daughter but also for me. CAMHS is an invaluable service for children who need extra help and support.

During the past four months the doctor has played an important role in the progress made by my husband, whilst in both the Bloxwich and Manor Hospital. I would like to say that I have never experienced a doctor quite as dedicated. His dedication and professionalism goes beyond expectations from any doctor. He is the doctor everyone would want if they were ill. From my observations his patients are not just patients to him. They feel they are so important to him and he will do everything possible to aid their recovery.

We would like to thank you all very much for the care and support you have given dad during his time with you. Initially, he wasn’t convinced that he would benefit from attending but we have noticed a big change in him, and the fact he feels sad about leaving is a testament to your caring, friendly and skilful staff. He tells us of the good laughs he has each week – not to mention the lovely meals. You provide a wonderful service. Thank you all very much.

3.14 Feedback from Service Users and Carers

Over the past twelve months our 10 Experts by Experience (EBEs) have been significantly involved in raising awareness of Trust activities and gaining valuable feedback from service users and carers. We have also gained essential and valuable feedback via informal concerns and comments from the Service Experience Desk and patient surveys.

Here are just a few of the selected actions that have been carried out as a result of feedback from those who use our services, their relatives and carers.

Figure 28 You Said - We Did

You Said: We did:

I would like more information and advice about benefits, housing or finding work

Provided all teams with leaflets and posters highlighting how to access advice and support. Staff are working with our Experts by Experience to raise awareness of the support and signposting we can offer

I am not always sure who is looking after me, staff don’t always introduce themselves

We have introduced “Hello my name is…” that encourages all our staff to introduce themselves to patients, carers and visitors

It’s not clear who I need to contact to raise Posters have been put up in all sites and staff from the


a concern or make a complaint complaints team have been visiting services to raise awareness. A new form has also been launched a new form on our website

I have dementia and often suffer from severe pain but I don’t think staff notice this

We have introduced a pain monitoring tool that will help staff to be able to better manage pain experienced by patients admitted to hospital with a diagnosis of dementia

I miss my dog Team organised ‘dog therapy’ where a dog comes in with an owner and patients can interact with the pet. A popular therapy sometimes used with patients who are living with memory problems

I don’t feel that there is much rotation of the menu

Staff worked with the catering staff to offer more choice and variation

3.15 Feedback from Staff

The Trust has once again encouraged its staff to participate in the annual staff survey as it values the opinions of its staff. There was a 49% return with 461 staff completing a survey. This was significantly better than the national average response rate of 41%. In addition to this a Staff Engagement Lead was recruited externally who has agreed a detailed Action Plan with the Board following 26 staff engagement focus groups in 2014 and 13 follow up focus groups in 2015. The topics of the focus groups related to staff engagement and culture and a key measure has been the 2015 Staff Survey and the Staff Friends & Family Test.

A number of actions to allow staff the opportunity to be heard such as the introduction of Staff Engagement Champions (whose role it has been to be a communication channel between staff feedback generally and to provide views on new initiatives and existing/refreshed policies , such as the appraisal policy and the sickness policy). The number of Engagement Champions has increased from 12 to 27 since it was introduced in June 2014 and staff have stated they believe this is a great channel to seek and offer feedback. Workplace Advisors (whose role is to provide staff a place to go if they have any concerns around bullying and harassment, whistleblowing or any staff concerns, where they might prefer not to go through current channels).

The 2015 Staff survey showed an improvement in many areas from the previous year as shown below, noting there had been many improvements in 2014 from the previous year too so this shows a significant positive shift. Indeed, according to the Listening Into Action blog of 7 March 2016 they said “Congratulations to Dudley and Walsall Mental Health Partnership NHS Trust for being the top ranked Mental Health and Learning Disability Trust this year according to NHS staff responding to the National Staff Survey results”. This was using comparison with improvements against our own 2014 results and the national average for other Mental Health Trusts.

For information the Trust was top nationally against 2 of the 32 Key Findings, Top 3 in 10 of the Key Findings and Top 5 in 17 of the 32 Key Findings measured against other Mental Health Trusts.


Figure 29 Staff Survey Data

Areas showing improvement from the previous year:

90% of staff have had an appraisal/review in the last 12 months (up from 83%)

60% of staff said they look forward to going to work (up from 55%)

55% of staff said they had come to work when not feeling well enough which is a significant improvement from 67% in 2014

93% of staff said they felt the organisation acted fairly when it comes to career progression/promotion regardless of ethnic background, gender, religion, sexual orientation, disability or age (up from 89% and against a national average of 85%)

80% of staff said they left their appraisal feeling valued against a national average of 74%

77% of staff agreed they were satisfied with the support they get from their immediate line manager (up from 73%)

However, the results also highlighted some areas where improvement could be made as shown in the table below.

Figure 30 Staff Survey Improvements

Key areas for improvement within the 2015 staff survey:

5% more staff they had felt pressure from their line manager and 8% more had put themselves under pressure to come to work when feeling unwell

6% less staff stated they had reported bullying, harassment or abuse from either a colleague or service user than the previous year

9% less staff then the national average stated that the Trust values had been discussed in their appraisal

These results form part of the action plan that will be addressed throughout 2016/17.

3.16 Staff Health and Wellbeing

The wellbeing of our staff continues to be of paramount importance to us as we recognise that this has a direct impact on clinical outcomes and the experience of patients. It is therefore important that our staff are energised, motivated and healthy.

We have refreshed our Health and Wellbeing Programme by introducing a senior - led committee to include champions from across the Trust, which also presents another opportunity to engage with staff over an issue which is important to them. This Committee will lead the refreshment of the Health and Wellbeing Strategy due this year.

Health and wellbeing programmes include activities linked to our health priorities such as resilience, eye sight tests for headaches and physiotherapy for musculoskeletal issues but more importantly they are supposed to be fun so we have included activities such as pilates, laughing yoga and mindful meditation. All of the activities in the programme are linked in some way to our sickness reasons and also national priorities such as smoking and obesity.

This year one of the key areas of focus has been assisting staff and managers to get staff back into the workplace, particularly in the instance of long term sickness, by providing extra help and support of a health and wellbeing co-ordinator supported by the health and wellbeing programme.

Staff health and wellbeing is also a wonderful mechanism for staff engagement as it is easily accessible and understanding and most of all, fun.


Part 3D: Statement from the Trust’s key stakeholders.

We approached the following stakeholders to comment on the Quality Account:

Dudley CCG

Walsall CCG

Dudley Healthwatch

Walsall Healthwatch

Dudley Health and Wellbeing Board

Walsall Health and Wellbeing Board

Dudley Health Overview and Scrutiny Committee

Walsall Health Overview and Scrutiny Committee

The Trust is pleased to have received the following commissioner feedback responses

Dudley CCG

Walsall CCG

The Trust will endeavour to incorporate the comments into on-going quality improvements and welcomes opportunities for continued partnership working. The full responses are detailed below


Walsall Clinical Commissioning Group (CCG) has reviewed the 2015/16 Quality Account for Dudley and Walsall Mental Health Partnership Trust.

The Quality Account reflects the progress made by the Trust during 2015/16 in a number of areas and the CCG acknowledges the achievement in the contractual key performance indicators as detailed in the Quality Account. The CCG will continue to seek assurances and support the Trust where applicable in relation to those key performance indicators which weren’t achieved during 2015/16.

We are encouraged with the progress made in relation to staff engagement and the positive impact this work has had on their staff survey results. The initial work commenced with reducing Did Not Attends is also encouraging and we welcome the ongoing development of this work.

Looking forward to 2016/17 the CCG acknowledges the priorities Dudley and Walsall Mental Health Partnership Trust has identified and will continue to support the trust in achieving these priorities.

The CCG has also identified the following areas for further emphasis and improvement for 2016-17:

Older adults services

Reducing staff vacancy rates

Staff appraisals

Walsall CCG will continue to work in partnership with the trust throughout 2016-17 to support them in delivering the priorities highlighted in the Quality Account and any action plans following the publication of the Care Quality Commissions inspection report.

Sally Roberts Director of Governance, Quality and Safety Walsall CCG

Dr Raj Mohan Medical Director Walsall CCG


Dudley Clinical Commissioning Group (CCG) provided the following feedback:

RESPONSE TO DUDLEY AND WALSALL MENTAL HEALTH TRUST QUALITY REPORT 2015/16

The CCG is pleased to respond to the quality account outlining the activity carried out by Dudley and Walsall Mental Health Trust" We note the Trust's continued focus on quality of care remains at the heart of services. Throughout the report there is evidence of collaboration and patient involvement alongside the commitment to enhance the services to adults with mental health difficulties. We are pleased that the feedback from service users, stakeholders, and staff forms the backdrop to the quality account report. Further the Trust has demonstrated the ability to make appropriate use of resources whilst continuing to deliver a high quality service. During 2015, the Trust introduced a range of services to support a five year quality improvement strategy which serves to focus on key issues.

The CCG notes that the Trust has worked hard to embed a number of key priorities to include improving the quality of dementia care through dementia mapping which is an area of great significance to the Dudley population. Additionally, the work being done to demystify care pathways is an area for sustained focus and is of vital importance to simplify the experience of the service user.

The CCG is encouraged to note that a constructive developmental programme is in place as part of the specialist service provision which is underpinned by national publications (No Health Without Mental Health).

Within the 2015/16 staff survey, the Trust is able to celebrate the achievement of being one of the top mental health and learning disability Trusts. The CCG is encouraged by the national recognition received by the Trust for its work to promote equality and diversity.

Where gaps in provision of care have been identified the Trust has been responsive, demonstrating they are listening to service users such as Experts by Experience, which has also served to highlight areas requiring improvements; an example of this is the therapeutic hub.

The CCG notes that data collection remains a challenge although the Trust has made progress towards the introduction of a more effective IT system including a commitment to ensuring clinical records are accurate and accessible in a timely way to all clinicians. We note the Trust has demonstrated a commitment to clinical audits, and will need to adopt a systematic process outlining the gains from these within an improvement cycle.

Visits have taken place to D&WMHT by commissioners from the CCG to review the work being delivered to support the management of young people who have needed to be managed by skilled clinicians in a safe environment. Visits have served to provide insight into the daily challenges being experienced by staff, and demonstrated the flexibility offered by the Trust to provide high quality care for some of our most vulnerable young people with complex mental health needs.

The CCG recognises that further work will need to be done to improve the environment for patients across all sites. We are supportive of these plans and view this as evidence that the Trust is committed to providing a comprehensive and positive patient experience.

Paul Maubach, Chief Executive Officer, Dudley CCG


Statement of directors’ responsibilities in respect of the Quality Account

The directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the National Health Service (Quality Accounts) Regulations 2010 (as amended by the National Health Service (Quality Accounts) Amendment Regulations 2011).

In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

• The Quality Accounts presents a balanced picture of the 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, and is subject to appropriate scrutiny and review

• The Quality Account has been prepared in accordance with Department of Health guidance.

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

Documents

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