Quality Account 2016/17

Subtitle / Description of Report / Document Date of Report / Document

Statement & Introduction from the Chief Executive

I am very pleased to introduce this Quality Account for Starfish Health and Wellbeing (CIC).

Starfish Health and Wellbeing believes that when we come together with a shared

vision of the future, a shared understanding of the way to achieve it and a shared

commitment to values of contextual understanding, co-operation, compassion and

resilience, we can achieve our goals.

The future we see:

• Embraces psychological difficulties as lesser or more extreme experiences on

a continuum;

• Recognises the pivotal role of the individual and the vital importance of the

contextual elements of their life in recovery;

• Sees the therapist as an invaluable guide and supporter on the road to

recovery;

• Sees all other staff, support, volunteers, peer mentors and associates as

being critical factors in our continued success;

• Values the essential role of transition support through social engagement to

facilitate community integration and recovery;

• Understands the value that can be added using technology to support, extend

and enhance psychological services.

This year we have worked to refine and embed our values with our staff and the

people we serve.

This year’s Quality Account has been produced openly and honestly in order to

describe the progress we have been making, where there are areas for some

improvement and state our priorities or next year.

We always want to listen to people from the communities we serve and

commissioners in order to improve the services we deliver. We would like to thank

our staff, clients and stakeholders for their ongoing hard work and support, as well as

the help we’ve received in identifying our strengths and priorities.

To the best of my knowledge all the information in this document is accurate.

Iain Caldwell Chief Executive Officer

Services Provided by Starfish Health and Wellbeing

IAPT Services Starfish Health and Wellbeing are commissioned by Cannock Chase CCG

Hartlepool and Stockton CCG, South Tees CCG, and Stafford and Surrounds CCG

to provide:

Primary Care therapy service Improving Access to Psychological Therapies (IAPT).

This services is part of the national drive to increase access to evidence based

psychological therapy services for common mental health problems.

“I was worried about coming and what to expect but was made to feel at ease and in a safe environment for the issues we discussed.”

Primary Care Service

Starfish Health and Wellbeing are commissioned by GP First to improve low level

support for patients within Primary Care. The focus of this service is to create

capacity within the current Primary Care teams; reduce dependency on GP’s, reduce

the prescribing of SSRI’s; navigate and signpost patients to the most suitable

services within the shortest time period to ensure the pathway for the patient is as

seamless as possible.

Social Hubs

Starfish Health and Wellbeing are commissioned by Wolverhampton City Council

to provide community based, preventative Social Hubs.

The purpose of the service is to improve and maintain the mental wellbeing of adults

which helps to prevent them from (re-)entering higher level/statutory services

wherever possible by promoting: independence; empowerment (choice and control)

and personal resilience skills for those who have/have had or who are at risk of

mental ill-health.

Art Studio Starfish Health and Wellbeing successfully secured a grant to help set up an art

studio, “The Startrium”, which provides a range of creative arts and activities that will

improve people’s quality of life and emotional wellbeing through providing a stable

and friendly environment in which to express their creativity.

What do you feel the Startrium offers for you?

“Peace of mind”

“A platform to meet people with the same difficulties as me”

“I feel better meeting new people. They are very funny and helpful too. Any

problems from the past, the workers helped me lots:

“It gives me something to get up for in the morning and I like art”

“Time out for socializing with new people. Helping to improve my confidence,

getting out of the house and keeping me busy”

“It offers an environment in which likeminded people can gather”

“It helps me relax and have time for myself. It gives me confidence to talk to

people and I am developing my art skills”, “This group gives me time for me. It

helps me to get up on a morning and get motivated to do something”, “My life is

very busy and can be hard work at times. The group helps me relax”

“A life”, “Something to look forward to; to get up for. This is light and friendly

within the group”, “We enjoy the chat and relationships within the group”,

“The Monday and Tuesday sessions are the highlight of my week”, “If I'm totally

honest, I was not leaving the house and was struggling with the groups, but I feel

calmer in this group. The group are so friendly and staff make you feel welcome”

I can talk to them about issues and the help I need.

Looking Back Over the Past 12 Months

• Patient Safety

• Clinical Effectiveness

• Service User Experience

• Information Governance

......................................... 18

Patient Safety

Serious Untoward Incident

We are very sad to report that unfortunately at one of our services we had someone

who took their own life.

On reviewing this case, the person had discussed specific issues and depression

and had followed their treatment plan as highlighted in the Initial Assessment. The

person had shown improvement with depressive symptoms and was engaging in

further work to address this further. No risk had been identified through sessions or

through outcome measures.

All risk protocols were reviewed by the Area Clinical Governance Group and all staff

had undertaken the Connecting with People training. This training in suicide and self-

harm mitigation is informed by evidence-based principles. It is designed to increase

the quality and consistency of evidence-based assessments and improve the

organisation’s approach to clinical governance. The training aims to increase

empathy, reduce stigma and enhance participants’ ability to compassionately

respond to someone who has suicidal thoughts or are at risk of self-harming.

The programme covers the following areas:

• Suicide prevention

• Self Harm reduction

• Emotional resilience

• Compassion at work

On Duty Management

Over the past 12 months Starfish Health and Wellbeing has reviewed our On Duty

Rota. As a result of this process we have made more supervisors available at peak

times to provide advice and help for any clinician advice to deal with risk issues. We

have provided further training and additional supervision for duty managers in order

for them to feel more supported in carrying out this task.

Auditing Risk Records

As part of our continuing improvement a number of audits have taken place in all

areas of the services. Auditing risk records have been a priority for the past 12

months. Individual training has been given to staff to improve the quality of recording

and re-audits have taken place to ensure compliance.

“It's been life changing for me and the help I've had has made such a difference to

all of my life.”

“I can't thank you enough. It's been enlightening. I didn't think it was possible to feel

this different in just this many weeks.”

“Referral through my GP was quick and the appointments were easily arranged to

suit my childcare needs”

Clinical Effectiveness

Starfish Health and Wellbeing’s team has put every effortt into improving clinical

outcomes in line with national targets. (The national target for outcomes is a 50%

recovery rate for patients with anxiety and depression who start treatment above

caseness).

Over the past 12 months’ our recovery rates have ranged from above 49% to 71%

for all our IAPT services.

Over the past 12 months’ reliable improvement rates have ranged from 58% to 71%

for all IAPT services.

Review of data quality and outcomes

Over the past year we have set up weekly meeting where data quality and outcomes

are reviewed. This has enabled the management team to identify where the service

is going off track and those areas on which we need to focus to improve.

Self Audits, Case Management and Supervision

Over the past 12 months the process of Self Audits, Case Management and

Supervision improved. This has ensured a focus on high quality data and improved

outcomes.

• Self Audits: These are monthly operational review functions that are carried

out by clinicians to ensure that case records and notes are up to date and all

administration tasks relating to cases are also up to date and complete.

• Case Management: This is an operational review session with a supervisor to

ensure case records and notes are up to date and to identify any clients who

have attended a number of appointments but not shown improvement or have

deteriorated, to ensure these cases are reviewed in clinical supervision.

• Supervision: This is a clinical meeting to talk through cases - identified

through the case management process - where there has been no

improvement or where a client’s condition has deteriorated.

Service User Experience

Patient Experience Questionnaires (PEQ)

We ask people to complete post-therapy satisfaction questionnaires for all our IAPT

services.

End of Service PEQ

Satisfaction Rating

Completely Satisfied

Satisfied Neither or

dis-

Satisfied

Not

Satisfied

Not at all

Satisfied

Number of

each rating

1031 70 10 0 0

Starfish Health and Wellbeing would like to improve PEQ completion rates for the

coming year in services where rates have been low.

Service Reviews

As part of Starfish Health and Wellbeing’s attempt to ensure service users are

actively involved in planning and evaluating the organisation’s services each service

undertakes annual service reviews by service users. These reviews are carried out

by people with direct experience of using the service. This gives service users the

opportunity to talk about their experience and an opportunity to generate ideas for

improving the service.

Complaints

Starfish Health and Wellbeing records all incidents and complaints that present to

each service. All complaints are taken to the Area Clinical Governance Group for

review and analysed for common themes. Action plans are instigated where needed

to enable the service to develop and learn from any mistakes.

Out of the 9847 people entering treatment there was a total of 13 complaints

received.

Main categories of complaints:

• Appointments being cancelled at short notice because staff sickness;

• Unwillingness to complete MDS or difficulties completing MDS;

• Unable to offer a service because our service does not operate in an area.

Information Governance

Over the last 12 months Starfish Health and Welling has reviewed and updated our

Information Governance Framework. This was to ensure a closer alignment of the

Framework to the IG Tool Kit, which brings together related initiatives concerned with

improving the security, processing, quality and handling of information. The

Framework ensures compliance with the Data Protection Act 1998, the Freedom of

Information Act 2000, and the Human Rights Act 1998 plus the common-law duty of

confidence. It also incorporates the NHS Code of Confidentiality; Information

Security Assurance, Information Quality Assurance and Records Management and

underpins the NHS Care Record Guarantee.

All staff were trained in the updated Framework and audits have been completed to

ensure compliance and understanding.

“I felt listened to and was given the chance to talk about how I felt without being

rushed even though I find talking about my feelings very difficult to do.”

Improving Quality in 2017/18

Starfish Health and Wellbeing’s Priorities for The

Coming Year

Our priorities for the next 12 months will be:

• Staff Wellbeing

• Increased referrals

• Working with people with long-term conditions

Staff Wellbeing

A staff survey was carried out in December 2016. An action plan has been developed from the survey feedback and key areas identified to work on for the coming year:

• Review management and leadership skills within the organisation, look for

gaps and develop a new staffing structure.

• Improve communication by setting up a monthly briefing document from

management and governance meetings and disseminate through team

meeting and emails with questions to feed back to meetings.

• Improve working environment, complete a deep clean, hire a new cleaner

refurbish kitchens.

• Set up a new worker benefits scheme, as few staff have used the old scheme

Increased referrals

Starfish Health and Wellbeing will support the increase in referrals which is set out in

the NHS Five Year Forward Plan which states that “By 2020/21 there will be

increased access to psychological therapies, so that at least 25% of people (or 1.5

million) with common mental health conditions access services each year”.

In the next year our service will offer the option of self-referral. This is important for

patients as well as our Commissioners because national data shows that outcomes

are generally better for patients who have self-referred. We will be continuing to work

on increasing self-referrals next year by promoting the service and by making use of

our new leaflets.

National Objective 2016/17 2017/18 2018/19 2019/20 20/21

At least 25% of

people with common

MH conditions access

psychological

therapies each year.

15.8% 16.8% 19% 22% 25%

Total number of

people accessing

treatment

0.96m 1.02m 1.16m 1.37m 1.5m

Working with people with long-term conditions

Long-term conditions (LTC) are now a central task of the NHS. Addressing these

needs requires a partnership with patients over the long term rather than providing

single, unconnected ‘episodes’ of care. As a result our services need to be

integrated around the patient. With this in mind staff will undergo training in LTC and

a new pathway will be designed with physical health teams to offer an integrated

approach.

These new services will be co-located with primary and community care, ensuring

more convenient and tailored treatment and relieving pressure on General Practice.

“Fantastic service. Felt as though I was listened to and understood and given

techniques to continue improving.”

“I am thankful for the help from the service, couldn't ask for a better outcome. I look

forward to the future”

“A service tailored to suit individuals and takes into account people's opinions.”

“Everyone involved was friendly and supportive and explained everything

thoroughly. Thank you very much.”

“It has opened my eyes to the outside world and that my feelings are not unique. I

was frightened of "old age" and what my life was becoming. I feel now more able to

face the future.”

“Very helpful, first class help”

“Expert advice helped me realise what I have”

External Quality Reviews

Over the next 12 months Starfish Health and Wellbeing will undertake 2 quality reviews:

1. Accreditation Programme for Phycological Therapy Service (APPTS).

The APPTS is a new accreditation programme that works with psychological

therapies services in the UK whose primary function is to provide psychological

therapies to improve the psychological wellbeing of adults in the community.

This programme includes a two-month self-assessment, an independent service

user survey, an independent staff survey and an external peer review. All information

will be then assessed by the programme board.

2. ISO 9001:2015, the international standard specifying requirements for quality

management systems.

The ISO is a quality management system (QMS) is a formalised system that

documents processes, procedures, and responsibilities for achieving quality policies

and objectives. A QMS helps coordinate and direct Starfish Health and Wellbeing’s

activities to meet client and regulatory requirements and improve its effectiveness

and efficiency on a continuous basis.

Quality management systems serve many purposes, including:

• Improving processes

• Reducing waste and inefficiency

• Lowering costs

• Facilitating and identifying training opportunities

• Engaging staff

• Setting an organisation wide direction

Starfish Health and Wellbeing will recieve an external audit from the ISO assessors

to take place in June 2017 to assess if we continue to meet the standards necessary

to hold the ISO Quality Mark.