Qu Q a u l a ilt i y t y Ac A c c o c u o n u t n

Transcription

1 Quality Account

2 CONTENTS Statement from the Chief Executive 3 Page Statements from our Service Users 4 Summary of Priorities 6 Summary of Performance 7 Performance Review - Safety 8 Performance Review - Clinical Effectiveness 10 Performance Review - Patient Experience 12 Priorities for Improvement Quality Statements 16 Statements from Stakeholders 18 2

3 STATEMENT FROM THE CHIEF EXECUTIVE This has been a groundbreaking year for Barnet Enfield and Haringey Mental Health Trust (BEH) with significant advances in our quality assurance systems which have led to clear and demonstrable improvements to clinical care. The process of publishing our first Quality Account in 2010 gave us the opportunity to review and strengthen our systems for monitoring and improving quality across the Trust. Through 2010/11 we have been putting in place a systematic and integrated system of monitoring quality across Trust services, the result of which forms the basis of this Quality Account. The Trust s Lead Nurse Compliance Unit is now well established. The Compliance Unit employing the sixteen Key Outcomes in the Care Quality Commissions regulatory system as a frame of reference, has been carrying out a rolling programme of inspections of both inpatient and community teams. Through a process of standard setting, staff training and regular monitoring, the Lead Nurses have been assisting all service areas to attend to the fundamentals of sound and effective mental health care. In addition, an ongoing monthly self declaration process has been developed with individual care teams and clinicians setting service specific standards and self assessing their own performance. These self reported scores are spot checked by the Trust s Clinical Audit Team in order to maintain the integrity of the self assessment system. All results are benchmarked and subject to a trend analysis. The Trust has continued to invest in 2010/11 in its Patient Experience Tracker system. The Doctor Foster s system which has been deployed with great success on the inpatient units, has now been supplemented with the roll out of the Meridian system across community teams. These systems are allowing managers at all levels of the Trust to monitor the quality of patient experience in real time. In addition to these systems the Trust has also been carrying out a rolling programme of Privacy and Dignity audits on the Trust s inpatient units; these audits involve both semi structured interviews and the observation of staff-patient interaction. Teams are able to view their own performance in comparison with the performance of other teams across the Trust in both the Patient Experience Tracker systems and in the Privacy and Dignity audits, thus encouraging competition. The Trust has also carried out postal surveys of users of both inpatient and community services as part of the CQUIN programme, achieving most of the demanding improvement targets on patient experience set by commissioners. Intelligence gathered through the Trust s internal quality assurance systems coupled with feedback from the Care Quality Commission s Mental Health Act inspection programme are fed into both corporate, directorate and local governance structures allowing for action to be taken immediately where concerns are identified and also for best practice to be shared and celebrated. Through the application of these systems in 2010/11, the Trust has achieved significant improvements in both the quality and rigour of the care process and in the levels of satisfaction for those who use Trust services. In the year ahead these new systems of monitoring quality of care and driving up standards will continue to be refined as we implement extensive transformations of services across the Trust. The Trust has recently merged with Enfield Community Services (ECS), and we have reconfigured our community based mental health teams in order to establish community teams that specialise in the treatment of different conditions. We will be opening new services including crisis houses and wellbeing clinics, whilst expanding services for personality disorders and early intervention in psychosis. We are not complacent and we will not be sitting on our laurels. There is always room for improvement. However, we are confident that the ongoing application of the quality assurance processes we have developed and embedded in the past year provides an accurate account of the quality of our services, and will ensure that the care we provide in the year ahead continues to meet the high standards our current Service users have come to expect. Maria Kane, Chief Executive 3

4 You Said...We Did STATEMENTS FROM OUR SERVICE USERS BEH holds a monthly Service User and Carer Strategy Group, where clinicians, managers, and executive directors work directly with the community we serve to better understand how we can improve our services. This year we made progress working collaboratively with our service users and carers to achieve the priorities they brought to this group. These included training of clinical staff delivered by service users, improving the customer service provided by front-line staff, and involving service users and carers in the recruitment process. Working Together - Service user-led training for staff In many ways the training which became known as Working Together What gets in the way of engaging with service users, reflects the journey of how the training was commissioned. There had been a degree of discontent within the three service user groups, Barnet Voice for Mental Health, EMU (Enfield Mental Health User Group) and HUN (Haringey Mental Health User Network) in the way we were being asked to contribute to training. Outside organisations were asking for our experiences which someone else was then going to incorporate into their training! We felt side-lined! Through the person of David Robinson, Director of Nursing, Barnet, Enfield and Haringey Mental Health Trust not only listened but asked us to work with the Training Department to deliver some training of our own across the whole Trust. So, did we achieve our aim of working and thinking together with mental health professionals across the Trust in exploring what gets in the way of involving service users in their care? Did the professionals who participated go away with an increased understanding of the importance of their role in the interaction with service users; an increased understanding of what service users find helpful within that interaction; and an increased understanding of overcoming the obstacles within that interaction? In many ways only time will tell. Certainly, out of the 97 staff who took part 94% said that they found the workshop either useful or very useful in understanding what service users find helpful in interactions with them. 68 % of the staff that they had gained something that they might use in their practice and/or take back to their team, with another 27% saying this was a possibility. From the comments we received there was a lot of positivity, tinged with concerns of how the lack of time, resources and too large a workload gets in the way of engaging in a meaningful way. Nevertheless, the very nature of the workshops service users and staff working together to improve care, as equals, looking together at problems, and how to overcome them - mirrored the best way to engage with service users. As someone said, Do with the service user, not to. - Elsie Lyons, Barnet Voice 4

5 Improving Customer Service - Star Wards and TalkWell I've been a very 'high maintenance' and even more grateful user of BEH's inpatient and outpatient services for the last 6 years. The opportunity to reciprocate in some way helps me feel less of a drain on the NHS, and the Trust has been very responsive to using the resources I've produced through the (St Ann's inspired!) Star Wards project I set up. For example, TalkWell is a practical guide for ward staff on the crucial and complex issue of conversations with patients, and this has been energetically adopted by BEH. An interesting example of collaboration was when my psychiatrist/therapist and I both ran sessions at a training morning on TalkWell for both inpatient and community staff. BEH is impressive in implementing 'Patient Power'! - Marion Janner, Service user and creator of STAR WARDS Reflections on interview panels My new life began after I was discharged from a psychiatric ward where I had been an inpatient for a total of 11 months. During that time I was introduced to Barnet Voice for Mental Health. I later became an active member, working to open the eyes of people who look after us when we need help, from the service user point of view! When I felt well enough and was asked to sit on a trust interview panel I took the opportunity to improve my self-esteem and to find out if the prospective members of staff are people service users could trust. My experience as a panel member has been very good. I am always well respected by other panel members. Service user interview panel members always ask questions relating to the service user point of view. I found that the interviewees usually come prepared for the questions presented by the Trust staff, but they find my questions are very challenging. Once I went to sit on an interview panel and a member of staff came to open the door for me. He recognized me from his own interview a few months earlier. He confessed that, among all the questions he had on the day, my questions were interesting and challenging. - Mohammed Ibrahim, Barnet Voice 5

6 SUMMARY OF PRIORITES Where were we last year? Follow-up on our priorities The Trust set quality account priorities for 2010/11 on the basis of identified areas requiring improvement as indicated by a combination of self audits and external agency feedback. These are in the three domains which must be covered by all quality accounts; patient safety, patient experience and clinical effectiveness. Priorities for Improve the involvement of detained patients in decisions about their care. (pg 10) met Improve physical health of mental health Service users (pg 9) met Implement outcome measures to monitor effectiveness of treatment. (pg 8) partial Priorities for Where are we going? Our priorities for The indicators for have been set with the recognition that the Trust must be a learning organisation. As such we must be responsive to our own internal audit findings and the reports we receive in year from external agencies. Where we continue to need to develop, monitor or grow, the Trust will maintain the same priorities or build on them so that they can be seen to fruition. 6 Patient Experience - Improve and monitor the impact of therapeutic engagement (pg 13) Safety - Improve communication with GPs (pg 13) Clinical Effectiveness - Improve focus on patient identified care goals (pg 13)

7 Where are we now? SUMMARY OF PERFORMANCE Patient Safety day follow up after discharge from inpatient care (pg 9) % % Risk assessment carried out within 7 days of admission to inpatient care (pg 9) 92% 99% Improvements in number of safety incidents reported per month (pg 8) 276 PM 369 PM Patient Experience Service users report they are being treated with dignity and respect in inpatient and community services (pg 13) 79% 86% Service users are involved in decisions about their care and treatment (pg 12) 77% 97% Service users are provided with information about their care and treatment (pg 14) 54% 69% ECS: Overall patient satisfaction (pg 13) N/A 90% Clinical Effectiveness Service users are assessed using mandatory HoNOS PBR clustering tool (pg 11) 48% 97% Inpatient service users are offered physical health checks on admission (pg 11) 80% 99% Outcome measures are implemented to measure effectiveness of treatment (pg 10) partial partial 7

8 PERFORMANCE REVIEW Patient Safety Improving incident reporting and reviewing focus on this? What was our What did we achieve? All NHS Trust are required to report incidents of harm, violence, or errors which could have a potentially negative impact on patients, visitors or staff. National reports have shown that BEH has been on the low end of the reporting scale compared with other mental health Trusts. Given the expectation that all trusts will have a similar number of errors and level of violence, this suggested that BEH needed to improve its culture of identifying and learning from incidents. To increase the level of reporting incidents and near misses by 30-50%, with a 30% percent increase being viewed as partial improvement. The graph below shows the number of incidents reported by quarter from 09/10 to date. With average reporting rates of 829 in and 1107 in , we have improved reporting by 34% Incidents reported by quarter Q1 09/10 Q2 09/10 Q3 09/10 Q4 09/10 Q1 10/11 Q2 10/11 Q3 10/11 Q4 10/11 To improve our capacity to learn from incidents, BEH has joined the LIPS programme (Leading Improvement in Patient Safety) run by the NHS Institute for Innovation and Improvement. This programme guides team leaders to develop plans for patient safety improvements and share learning across the Trust. In the early stages of the programme BEH was awarded first prize among participating mental health trusts for our efforts to involve front line staff in creating real change on the wards. The Trust has developed a quarterly Saving Lives newsletter to highlight our success with LIPS and other lessons learnt from incidents and promote awareness about incident reporting. The LIPS programme has since gained increased participation from team leads and has a gathering influence across Trust services. What needs to improve? continue to While our target improvement has been partially met, BEH remains in the lower reporting scale of mental health Trusts. In we expect to achieve a further 30-50% improvement on rates of reporting. Recent updates of our incident reporting system have enhanced functionality which will improve the ability of teams to review and reflect on the incidents they report. Incident performance reports will be continually monitored through clinical governance and scrutiny meetings. 8

9 7 Day follow-up focus on this? What was our What did we achieve? Research has shown that patients discharged from inpatient mental health services are at the greatest risk of relapse or self harm in the first seven days following discharge. Follow up care provided within this period has been shown to greatly reduce both readmission and mortality rates. Our target is to provide follow up care within 7 days of discharge to 100% of patients. The following chart is based on performance data including all patients discharged from inpatient services in % Compliance with 7 day follow up 100.0% 99.8% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.7% 100.0% 100.0% 80% 60% 40% 20% 0% Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 What needs to improve? continue to While high levels of compliance have been maintained, there was a slight dip in compliance in May and January. Teams and individual clinicians now have access to view up to date progress on performance targets for all patients on their caseload. 7 day follow-up is being actively managed and monitored by teams through the daily review of discharge activity. Performance is also monitored through the weekly exception reports, monthly service line performance meetings and at Board Committee level. Risk Assessments completed in 7 days of admission focus on this? What was our It is essential for the safety of our patients that an assessment of past and current risk behaviour is carried out as soon as possible. All patients should have a completed risk assessment within 7 days of admission to inpatient care. Target has been set at 95% to account for potential delays due to compliance with assessments. What did we achieve? The following graph shows compliance for all inpatients by month. 100 Risk Assessment Completed in 7 days Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 What needs to improve? continue to It is essential that the process of completing risk assessments is thorough, and informs decisions about the care provided to the patient. These assessment should also be a continuous process, updated as new information becomes available, and as the patients condition improves. Monitoring of the risk assessments and related documents has been expanded to encompass an evaluation of the quality and continuity of risk assessment. This will be monitored through the ward and community quality assurance process, and reported back to teams and to all clinical governance and scrutiny meetings. 9

10 Clinical Effectiveness Patient Reported Outcomes focus on this? What was our What did we achieve? In 2009 the Trust considered a range of assessment tools to evaluate the effectiveness of treatment modules. These tools included CORE (Clinical Outcomes for Routine Evaluations) for use with Psychological Interventions; QIDS-SR (Quick Inventory of Depressive Symptomatology 16 point); CORC (Child and adolescent mental health service Outcome Research Consortium evaluations); and a psychosis self-assessment tool. It was agreed that CORE provided the most standard, wellvalidated tool to compare and contrast local service provision and benchmark our services nationally. CORE has been in use in psychological therapy services across the Trust. In Enfield Community Services a menu of outcome tools have been developed and are in use in services including physiotherapy, podiatry, nutrition and dietetics, lymphoedema service, and adult speech and language therapy. Our target was to improve the statistically reliable improvement CORE scores by 10% from baseline figures and introduce a standardised patient reported outcome assessment tool in ECS services. The following table shows the prevalence of statistically reliable change in patients receiving psychological therapies in compared with A total of 119 cases were included in , and 209 cases were included in In 2011, 62% of cases reported statistically reliable improvement compared with outcomes in which 53% of cases showed improvement. CORE Outcomes % 34% 4% % 45% 2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% statistically reliable improvement no change statistically reliable deterioration The following table displays results from April September 2010 for 249 patients in four ECS services; speech and language therapy, podiatry, nutrition and dietetics, and physiotherapy. 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% ECS Patient Reported Outcomes 96% 91% 97% 97% symptoms improved resume daily routine manage symptoms understanding of condition What needs to improve? CORE Net is an online database used to record outcome measures of therapy and was rolled out across selected business units within BEH in February The system is currently being used in three of our seven service lines, and all remaining service lines will start implementing CORE within the coming year. Enfield Community Services plan to develop the use of PROMS across other services within the ECS Service Line. continue to CORE net results will be available to individual clinicians and managers, and will be reported through clinical governance groups. Findings from ECS patient reported outcomes will be shared with relevant staff groups. The data for the outcomes agreed with commissioners are shared with them on a quarterly basis as part of the Balanced Scorecard for ECS. 10

11 Improving Physical Health focus on this? What was our What did we achieve? BEH recognises that physical health has a significant impact on mental health. Helping our service users to improve their physical health is a priority for this Trust, as well as the health community at large. To provide an initial physical health care assessment within 72 hours of admission to all of our inpatients. The target was set at 95% to account for potential delays due to compliance with assessments. The following graph shows that the Trust has made steady progress throughout the year in reaching this target (based on compliance for all inpatients by month). 100 Health Checks Offered 95 % What needs to improve? continue to 80 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 To compliment the high level of performance of physical health screening on admission Trust services need to improve communication with GPs at discharge and continue to build on the work throughout in relation to maintaining physical wellbeing of community service users. Community teams will be monitoring physical health checks by requesting brief summaries of care from GPs upon referral and at CPA reviews. Community teams will audit compliance with physical health checks through the community quality assurance audit programme and report through the clinical governance structure on a monthly basis. HoNOS PBR focus on this? What was our What did we achieve? All Mental Health NHS Trusts are currently in the process of moving towards a system of payment by results. In the past, NHS Trusts agreed block contracts with commissioners. Under payment by results the money received by NHS trusts directly relates to the number of interventions or activity provided. In order to integrate into this system, all mental health trusts must assess each patient using HoNOS PbR. HoNOS assessments will allow trusts to demonstrate change in a patient s overall functioning after a particular intervention has been completed. We are contractually obligated to assess 80% of all patients eligible for CPA by the end of March The following graph shows compliance for all inpatients by month. 100 HONOS Carried Out 90 % Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 What needs to improve? continue to While we have exceeded our targets for , there is more work to be done to prepare the Trust for payment by results. The Trust is working to establish a series of care packages which will ensure that all service users are offered care which meets national standards and is consistent across geographic areas. The completion of HoNOS assessments will continue to be monitored through performance reports. Systems are in development to allow for monitoring of outcomes based on the development of care packages. Progress around this programme of work will be reported on a quarterly basis throughout the year to the Board. 11

12 Patient Experience Patient involvement in care Detained and Informal Patients focus on this? What was our What did we achieve? Following a National NHS Community Mental Health Service Users Survey in 2010, the Trust scored below the national average regarding the planning and reviewing of care, including patient involvement in the care planning process. This was identified as an area in need of improvement by the Care Quality Commission Mental Heath Act (MHA) Assessments as well as through internal audits. The Trust responded by making service user involvement in care one of the primary service improvement targets for the year. Our target is 90% compliance with all standards of patient involvement. We have employed a number of tools to collect data to monitor performance in these areas. Patient involvement in care planning is monitored through patient feedback surveys, ward quality audits, and consent to treatment compliance audits. A number of initiatives to improve practice have been implemented including the distribution of Wellness and Recovery Packs for all Service users, and enhanced MHA training for staff through e-learning, policy summary documents, team leader events, posters, newsletters and RiO recording templates. The following graphs shows compliance for all inpatients by month.: % % 100 Involvement in Medication Decisions Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar Involvement in Care Planning Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 The following table shows compliance with consent to treatment MHA regulations: MHA consent audit compliance Prior to 3 month rule (s58) 98% On admission 92% On change of meds 90% On monthly basis 90% What needs to improve? continue to To maintain clinical focus on this target, the Trust brought together all team leaders to consult and agree on implementing improvements in these areas. Standards of practice and methods for recording good practice were agreed and communicated across all services. The use of team leader away days to drive improvement with this standard has proved very effective. Team leader events are now held at regular intervals throughout the year to target improvement in a variety of topics as issues of concern arise. Patient involvement in treatment planning has become a standard item on all quality assurance audits, and is monitored monthly in all services. Reports are circulated through clinical governance groups and scrutiny meetings. 12

13 Privacy, Dignity and Respect focus on this? What was our What did we achieve? It is essential that service users are treated with privacy, dignity and respect. BEH carries out a service user led audit of privacy, dignity and respect in all of our inpatient units, using observation and patient and visitor interviews. Ongoing patient experience surveys carried out in wards and community teams include questions relating to dignity and respect. To achieve 80% service user satisfaction. The following graph shows results from the service user-led Privacy, Dignity and Respect Audit. A total of 88 interviews were conducted in The following graphs show results from patient feedback surveys. A total of 13,678 inpatient responses and 455 community responses were received in Overall Satisfaction with Privacy, Dignity and Respect Dementia Wards Crisis Wards Non-psychotic Wards Treated with dignity and respect - Community Treated with dignity and respect - Inpatients Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 M ar Apr-10 M ay-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 M ar-11 What needs to improve? continue to While patient feedback scores in relation to dignity and respect have improved over the course of the year, observation audits have shown some areas where there is room for improvement. Monitoring will continue through both surveys and observation audits. Survey results are reported to managers, clinical governance groups and scrutiny committees on a monthly basis. Observation audits are reported on a quarterly basis through clinical governance and scrutiny committees, but any concerns identified on the day of the audit are addressed directly to ward managers. Service user satisfaction in Enfield Community Services focus on this? What was our What did we achieve? Enfield Community Services carries out a programme of Service user surveys twice yearly. Each service designs a localised survey tool based on the services they provide, with a single standardised question regarding the overall satisfaction with the service provided. To maintain consistently high rates of patient satisfaction of at least 90%. As this is the first year that data for Enfield Community Services has been included in the Trust s Quality Account, the reported figures for 2010 to 2011 are regarded as a benchmark. In April, 15 services were audited, with 675 respondents. In October, 25 services were audited, with 671 respondents. April 2010 October 2010 How satisfied were you with the service you received 91% 90% What needs to improve? continue to Enfield Community Services have maintained high rates of patient satisfaction. In the coming year surveys systems in this service line will be integrated into the patient experience tracker system used elsewhere in the Trust. Reports are produced and actioned by individual teams and distributed to ECS service line. Future reports will be amalgamated within the Trust-wide clinical governance reporting structure. 13

14 Patient Experience Information to patients and Carers focus on this? What was our What did we achieve? The Trust encourages service users to take an active role in improving their mental and physical health. Information about mental illness, medication and the choices available to service users is crucial to empowering patients and those who care for them to become actively involved in decisions about their care and treatment, as well as taking personal steps toward recovery. To achieve a 10% improvement over national surveys scores reported in 2010, regarding patient satisfaction with information provided. The Trust is aware that a large amount of information is available to service users and carers, and has taken steps to provide this information in a format that is consistent across the Trust. Diagnosis and medication information is available to clinicians and the public on our Trust website: We have also developed a Wellness and Recovery pack, which provides service users and carers with information about the service, along with a recovery focused tool and diary in which Service users can record their goals and experiences. The following graph shows patient satisfaction scores from a postal survey of community and inpatient service users carried out in in comparison with the previous year s national surveys. A total of 383 responses were received from the inpatient and community national surveys carried out in A total of 325 responses were received for the surveys. 80% Satisfied with Information Provided 70% 75% 60% 50% 40% 30% 65% 43% 63% 09/10 10/11 20% 10% 0% community Inpatient What needs to improve? continue to While satisfaction with information provided has met improvement targets, it is clear that more work is needed to ensure that patients understand and are satisfied with the information provided to them, particularly in inpatient settings. We will continue to monitor this standard through patient surveys and report through clinical governance, scrutiny committees and Service User and Carer Strategy Groups. 14

15 PRIORITIES FOR The following Priorities for Improvement in have been agreed in consultation with our service users, carers, clinicians, and partner agencies: Improve therapeutic engagement focus on this? What is our plan and Therapeutic engagement is core to the development of positive working relationships between clinicians and service users. By developing better communication and understanding, service users and their care team can work more effectively toward improved health outcomes. Our plan is to ensure that all our teams partake in Productive Ward and Community initiatives so that engagement time measures are consistently monitored and displayed. This will enable the extrapolation of compliance percentages from Productive Measures tables. We are aiming for an 80% compliance rate by year end. Protected patient engagement time will monitored through monthly quality assurance audits and patient surveys. Improve communication with GPs focus on this? What is our plan and Feedback from our stakeholders focused strongly on the need to improve communication with GPs. Collaborative provision of health care between all providers is essential to ensure better health for our service users. The Trust is working to ensure that communication at the point of discharge or transfer of care is both timely and meets the needs of other care providers. The Trust will work with commissioners and GPs to develop agreed standards of physical health information to be provided from GPs at the point of referral and at care reviews. Target: 25% improvement in compliance with discharge and transfer standards. Compliance with communication of discharge and transfer arrangements will be audited on a quarterly basis. Improve focus on patient identified care goals focus on this? What is our plan and To develop the use of Patient Reported Outcomes (PROMS) in mental health services, it has been agreed that goals should be set on an individual level by users of mental health services. Every care plan should include at least one personal goal identified by the service user. Progress toward achieving personal goals will be a mandatory element of every care review. Wellness and Recovery packs are currently offered to all service users and can be used to help identify personal goals. Clinical staff will receive further guidance on supporting the use of Wellness and Recovery packs. Target: 90% of service users have individually identified care goals addressed in their care plans. Patient identified care goals will be monitored through monthly quality assurance audits. 15

16 16 QUALITY STATEMENTS During Barnet Enfield and Haringey Mental Health NHS Trust provided eight NHS services in seven service lines. BEH has reviewed all the data available to them on the quality of care in all eight of these NHS services. The income generated by the NHS services reviewed in represents 100% of the total income generated from the provision of NHS services by BEH for National Audits During Barnet Enfield and Haringey Mental Health NHS Trust participated in all national clinical audits applicable to the services provided by the Trust. Details and outcomes of national clinical audits and national confidential enquiries that BEH was eligible to participate in during are as follows: Psychological Therapies Data collected for 94 cases. Awaiting report. Falls and Bone Health service questionnaire completed Schizophrenia registered. Data collection to commence in August Prescribing Observatory for Mental Health: Topic 1: Prescribing high dose and combined antipsychotics an adult acute and psychiatric intensive care wards - Data collected for 168 cases Topic 2: Screening for Metabolic Side Effects of Antipsychotic drugs in patients treated by assertive outreach teams Data collected for 39 cases. Topic 7: Monitoring of patients prescribed lithium - Data collected for 73 cases. Topic 8: Medicines reconciliation - Data collected for 85cases. Topic 9: Use of antipsychotic medicine in people with Learning Disabilities - Data collected for 67 cases. Topic 10: Use of antipsychotic medicine in CAMHS - Data collected for 17 cases. Topic 11: Prescribing antipsychotics for people with dementia - Data collected for 180 cases. National Audit for Continence care - Awaiting report. Local Audits The reports of 31 local clinical audits were reviewed by BEH in For full reports of local audits visit our website by following the link below: priorities_and_performance/clinical_gov/clinical_governance/ audit_reports BEH intends to take the following actions to improve the quality of healthcare provided: Physical Health Checks - Director of Nursing/ Commissioners to Agree standards around gender specific screening for long-stay wards by Discharge/Transfer - Director of Nursing/ RIO transformation team to provide standardised template discharge letters on RIO with agreed content required by GPs. Privacy Dignity and Respect Audit Department to continue ongoing monitoring and local reporting. Lone Working Facilities Department to update lone working policy to include specific protocol for monitoring staff movements. Quality Assurance Audit Department to liaise with team leads to roll out to all services by Patient Experience Audit Department to expand programme to include community teams by 2011 following service reconfiguration. Hygiene Code Audit on Magnolia Unit - Infection Control Consultant Nurse and Magnolia Unit Manager to ensure all patients are screened for MRSA within 24 hours of admission by re-auditing monthly. Foam Mattress Audit Magnolia Unit - Consultant Nurse to replace mattresses not fit for purpose by August National Cleaning Standards - Audits to be carried out monthly by the facilities manager and reported back to infection control committee. CQC Barnet Enfield and Haringey Mental Health NHS Trust is required to register with the Care Quality Commission and its current registration status is currently registered. BEH has no conditions to its registration. The Care Quality Commission has not taken enforcement action against BEH during 2010

17 2011. BEH is not subject to periodic reviews by the Care Quality Commission. BEH has not participated in any special reviews or investigations by the CQC during the reporting period. Research Barnet, Enfield and Haringey Mental Health NHS Trust has a strong tradition in supporting research; it continues to have research as core to the provision of high quality and innovative care for its patients. The Trust actively participates and supports research generated by its own clinicians as well as researchers from outside the organisation as well. Our research activities are facilitated through most of our services with the Trust participating in a range of studies using different methodologies including, large-scale evaluative clinical trials to determine the effectiveness of new treatments whether developed within or outside of the Trust. The number of patients receiving NHS care provided by BEH in 2010/11 that were recruited during that period to participate in research approved by a research ethics committee was 233 (externally funded studies). BEH was involved in conducting 27 clinical research studies approved by the ethics committee that related to mental healthcare provision during 2010/11; 16 funded and 11 unfunded. In 2010 we received a letter of commendation from the Director of the Mental Health Research Network for our high level of recruitment. Peer-reviewed publications have resulted from our involvement in NIHR research, which demonstrates our commitment to the dissemination of research findings as well as a desire to improve patient outcomes and experience across the NHS. CQUIN A proportion of Barnet Enfield and Haringey Mental Health NHS Trust income in was conditional on achieving quality improvement and innovation goals agreed between BEH and Barnet, Enfield and Haringey PCTs through the Commissioning for Quality and Innovation payment framework. Further details of the agreed goals for and for the following 12 month period are available in the following document on our website: as/5.2c%20performance%20report%20march%202011v3.pdf. Hospital Episode Statistics Barnet Enfield and Haringey Mental Health NHS Trust submitted records during 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: 98.5% for admitted patient care; and 99.1% for out patient care. The percentage of records in the published data which included the patient s valid General Medical Practice Code was 100% for admitted patient care; and 99.3% for out patient care. Information Toolkit Barnet Enfield and Haringey Mental Health NHS Trust score for for Information Quality and Records Management, assessed using the Information Governance Toolkit was level two. ECS are reporting as part of NHSE s submission, as required in Connecting for Health guidance. Following a meeting between BEH Records Manager and ECS, it has been agreed that ECS report as a service line in an integrated submission in 2011/12. Payment By Results Barnet Enfield and Haringey Mental Health NHS Trust was subject to the Payment by Results clinical coding audit during the reporting period by the Audit Commission and the error rates reported in the latest published audit for that period for diagnoses and treatment coding (clinical coding) were 20%. 17

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