Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 1 of 49

Transcription

1 Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 1 of 49

2 Contents Part 1: Chief Executive s Statement... 3 Part 2: Priorities for improvement and statements of assurance from the Board Priorities for improvement Our priorities for 2017/ Statements of Assurance Reviewing the Quality of Trust Services Clinical Audit Clinical Research CQUIN (Commissioning for Quality and Innovation) What others say about the Trust Data Quality NHS Number and General Practice Code Validity Part 3: Review of Quality Performance Part 3A: Department of Health Mandatory Indicators Preventing People from Dying Prematurely 7 Day Follow-up Enhancing the Quality of Life for People with Long Term Conditions Ensuring that people have a positive experience of care staff survey Helping people to recover from episodes of ill health during injury Ensuring people have a positive experience of care national survey Patient Safety Related incidents Serious Incidents Duty of Candour Part 3B: Performance against quality improvement priorities Progress against 2016/17 priorities Part 3C: Trust Performance against additional quality performance Indicators Contractual Quality Requirement Goals agreed with Commissioners Access targets and outcomes objectives Patient Environment Service Experience Feedback from Service Users and Carers Feedback from Staff - Staff Survey Staff Health and Wellbeing Part 3D: Statements from the Trust s key stakeholders Part 4 Conclusion Statement of directors responsibilities in respect of the Quality Account Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 2 of 49

3 Part 1: Chief Executive s Statement I am pleased to introduce our Quality Accounts. 2016/17 has been a challenging year for the NHS but as an organisation we have continued to focus on developing the quality of our services. This document outlines our progress against the quality priorities we set last year and what our priorities for improving our services are for the year ahead, Within this context, Dudley and Walsall Mental Health Partnership NHS Trust (the Trust) has had another positive 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 Well Led Framework, 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 been rated Good following re inspection by the CQC, has performed well in the staff survey and continued to achieve targets set nationally for mental health trusts in 2016/17. This is testament to our staff in ensuring we put the quality of the service we provide to patients first. More detail is provided in the key quality improvements delivered by the Trust in 2016/17 and the quality challenges we have set for ourselves for 2017/18. 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: been rated GOOD by the CQC performed exceptionally well in the national NHS Staff Survey the CQC stated that staff throughout the Trust displayed a dedicated and caring attitude towards people who used the services reduced the waiting lists for specialist community services for children and young people The core services inspected were responsive to the needs of the people who used them Leadership across the Trust at a senior management level have continued to develop a new positive culture of leadership. Improved access to psychological therapies through the implementation of a therapeutic hub Improved the quality of clinical supervision and appraisals to support care delivery and practice Investment and focus on nurse development and revalidation and the re-launch of our Professional Nurses Forum E-rostering implemented to support effective staffing on wards Continued to develop the role of Experts by Experience and widen the scope of their work in ensuring that service users and carers have a voice in service improvement New clinical research facility opened that will increase our capability in research and development as well as increasing patient involvement Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 3 of 49

4 Strengthened clinical audit within the Trust and alignment to Trust s Quality Improvement Strategy. Improved our dementia environments and introduced dementia care mapping to support quality improvement Embraced and embedded Duty of Candour at all levels Maintained Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations 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 Chief Executive Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 4 of 49

5 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 2017/18 priorities, considerations were taken against progress made since the last Quality Account which is detailed in Section 3 of this report. During 2016/17, 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 2017/18, 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 that are important to stakeholders and partners. Are a mixture of new areas and those which build on key priorities from 2016/17 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 2017/18 Quality Priority 1: Smoke Free (continued from 2016/17) Rationale for Inclusion Smoking is the largest single preventable cause of morbidity. People with mental health problems smoke significantly more, with levels of about three times those observed in the general public. The Trust is committed to supporting individuals to stop smoking whilst received 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 and children and young people) to be smoke-free by Improvement Initiatives To implement programme for smoking cessation. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 5 of 49

6 Measurement Self-assessment NICE/Public Health Guidance Smoking reduction metrics Quality Priority 2: Person Centered Care / Care Planning Rationale for Inclusion People who use mental health services should have the opportunity to make informed decisions about their care and treatment, in partnership with their health and social care practitioners. Putting person centered values into practice means that you are providing care that is focused on the individual. It demonstrates to the individual that you want to care for and support their recovery. The CQC report and internal monitoring show that whist progress continues to be made further work is required to improve the quality and consistency of person centered care planning. Improvement Initiatives To ensure all care and care plans are person centered. Measurement Performance against care planning standards measured through clinical audit Service user and carer feedback Quality Priority 3: Improving the quality of our record keeping Rationale for inclusion Through feedback from the CQC, internal clinical audits and feedback from service users it has been identified that improvements need to be made to the quality of record keeping to enable greater consistency. The Trust currently has a mix of electronic and paper records, which creates challenges to consistency, however as the trust moves towards an electronic single patient record further work is required to ensure the quality of record keeping is maintained and improved. Improvement Initiatives To improve the quality of clinical records in support of the patient s recovery journey. Measurement Clinical records audit Service user and care feedback AIMs accreditations Quality Goal 4: Ensure organisational learning is embedded and sustained Rationale for inclusion Learning is identified through complaints, claims, audit and third party inspections. If learning is embedded in practice and sustained over time, the likelihood of repeated incidents and other events which can cause harm are reduced. Through feedback from the CQC Inspection and internal quality governance processes it has been identified further work is required to improve embedding lessons process to ensure effective triangulation of information, monitoring of actions taken and ensuring improvements are embedded in practice. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 6 of 49

7 Improvement Initiatives To review and make improvements to the Trusts embedding lessons processes Measurement Monitoring of progress on actions through embedding lessons database Clinical Audit Supportive quality monitoring visits Quality Goal 5: Refocus / Recovery Model Rationale for inclusion Recovery is a concept that recognises people can be in control of their lives despite mental health problems, and can regain a meaningful life despite a mental illness. Refocus is a specific approach to recovery that works with both individual and team attitudes towards recovery practices. Improvement Initiatives Refocus consists of four elements 1. Introduction to implementing Refocus. 2. Recovery workshop specifically geared toward team and individual understanding of recovery. 3. Clinician training in a coaching approach to recovery. 4. Recovery self-assessment team exercises and the development of action plans and implement changes. Measurement Staff training Team self-assessment Progress report against Refocus action plan How will we review and monitor these priorities? Each quality improvement priority identified for 2017/18 will be delivered through the framework laid out on the Trust Quality Improvement Strategy. Progress will be monitored through the Trust quality governance framework and overseen by the Governance and Quality Committee. The Quality and Safety 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 ( ) 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 that 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 National Health Service Authority (NHSLA) Compliance Following a change in approach the NHSLA confirmed there were to be no further standard based assessments after March 2014; however the Trust is still committed to demonstrating Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 7 of 49

8 compliance with these standards as they show an on-going commitment to the proactive management of risk within the organisation. Compliance with these standards and ensuring the on-going suitability of policies pertaining to NHSLA standards continues to be overseen by both the Trusts Policies and Procedures Focus Group and the Trust s Quality and Safety Committee. 2.4 Reviewing the Quality of Trust Services During 2016/17 the Trust redesigned the way in which it delivers its services. Services were streamlined from:- Early Intervention Services Acute Inpatient Services Older Adult Inpatient Services Community Services To:- Early Intervention and Urgent Access Services Inpatient Services (Acute and Older Adults) Community Services The Trust has reviewed the data available to them on the quality of care in these services. The income generated by the NHS services reviewed in 2016/17 represents 100% of the total income generated from the provision of NHS services by the NHS Trust for the reporting period 2016/ 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 NHS Trust Board. The Clinical Audit and Effectiveness Committee may also request specific clinical audit reports as appropriate National Clinical Audits and Confidential Enquiries During April 2016 to March 2017 three National Clinical Audits and one National Confidential Enquiry 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 in 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 2016 to March 2017 are as follows:- Prescribing Observatory for Mental Health (POMH) Monitoring of patients prescribed Lithium. Prescribing Observatory for Mental Health (POMH) Rapid Tranquilisation Commissioning for Quality and Innovation (CQUIN) Improving physical healthcare to reduce premature mortality in people with severe mental illness (PSMI) National Confidential Enquiry into Homicide and Suicide Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 8 of 49

9 The National Clinical Audits that Dudley and Walsall Mental Health Partnership NHS Trust participated in, and for which data collection was completed during April 2016 to March 2017 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) Monitoring of patients prescribed Lithium Yes 97 were submitted 100% of requested sample group Prescribing Observatory for Mental Health (POMH) Rapid Tranquillisation Commissioning for Quality and Innovation (CQUIN) Improving physical healthcare to reduce premature mortality in people with severe mental illness (PSMI) National Confidential Enquiry into Homicide and Suicide Local Clinical Audits Yes Yes Yes 27 were submitted 100% of requested sample group 147 were submitted 100% of requested sample group Criteria Met The Trusts own Quality Priority Audits for 2016/17 were derived from a number of key sources including trend analysis of incidents, complaints, commissioner requests, national best practice guidelines (e.g. NICE) and to gain assurance with regards to newly embedded 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 recommendation arising from these audits is detailed in the table below. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 9 of 49

10 Figure 2: Trust Priority Local Clinical Audits Title of Audit Summary of Actions / Recommendations Monitoring for Following the publication of a Patient Safety Alert relating to Deteriorating deteriorating patients, the Trust completed a clinical audit to assess Patients (NEWS and compliance levels against best practice. This included measuring the Rapid percentage of inpatients that had completed NEWS assessments. A Tranquilisation) NEWS assessment is an early warning score used by medical service to quickly determine the degree of illness of a patient. The results showed high levels of compliance regarding the completion of NEWS assessment. Physical Healthcare (CQUIN) Care Programme Approach (CPA) Patient Searches Key recommendations to support further improvement include:- Further training on calculation of NEWS charts Raising awareness of completing observation documentation relating to rapid tranquilisation consistently Review of rapid tranquilisation documentation by pharmacy Re audit planned for 2017/18 This audit was completed as part of a national initiative to improve physical healthcare for people with severe mental illness. The aim is a comprehensive cardio metabolic assessment and treatment for patients with psychosis. The Trust is awaiting the national results. This continues to be a National Audit for 2017/18. CPA aims to ensure that robust arrangements are in place regarding discharge planning and aftercare of people with serious mental illness. The audit showed that the Trust continues to deliver standards in accordance with national requirements however the audit demonstrated the following areas for improvement:- Consistency in the quality of documentation relating to risk assessments Documentation evidence that risk management plans are shared with appropriate others. Re audit planned for 2017/18 The Trust measured compliance with the Patient Search Policy to ensure that blanket restrictions are not in place and that staff are acting in accordance with the 2015 Mental Health Act Code of Practice when patients return from community leave. The results provided assurance that patient searches were being completed in accordance with Trust Policy, key recommendations for improvements relating to consistency were. Revisiting the process for searching on older adult wards Review of search policy to ensure it reflects policy changes and incorporates audit. Re audit scheduled for 2017/18 Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 10 of 49

11 2.6 Clinical Research The number of patients receiving NHS services provided or sub-contracted by Dudley and Walsall Mental Health NHS Partnership Trust in the period 1 st April 2016 to 31 st March 2017 that were recruited to participate in research approved by a Research Ethics Committee was 183 participants as of the end of March Patients were offered the chance to take part in 19 large scale, high quality, national NIHR Portfolio research studies, 8 of which were new studies opened during 16-17, including randomised controlled trials, epidemiological research and genetic research, as displayed below. 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 through active participation in research. Figure 3: Number of portfolio research studies 2016/2017 Research Study Title Topic Service Line Status DPIM Schizophrenia DNA Polymorphism in Mental Health illness REACT An online randomised controlled trial to evaluate the clinical and cost effectiveness of a peer supported selfmanagement intervention for relatives of people with psychosis or bipolar disorder Tiga Cub Feasibility study of child psychotherapy vs usual treatment for children with difficult behaviour. N-CAT - National survey of Child Anxiety and Treatment access Liaison and Diversion Trial Schemes in England - An evaluation of impact on reconviction, health service utilisation and diversion from the criminal justice system CATCH-uS - Children with ADHD in transition to adult services MOLGEN - Molecular Genetics of Adverse Drug Reactions (Clozapine) Narratives of health and illness for healthtalk online and youthhealthtalk online Personality Disorder, Suicide and Homicide - The management and risk of patients with personality disorder prior to suicide and homicide ALOIS Prospective non-interventional study of patients with mild to moderate Alzheimer s Disease and their caregivers in four European Countries Schizophrenia First Episode Psychosis and Bipolar Conduct disorder Anxiety disorders Service Delivery Service Delivery Genetics Service Delivery Personality Disorders Alzheimer s Disease Adult Mental Health Adult Mental Health Child and Adolescent Mental Health Schools Liaison & Diversion Child and Adolescent Mental Health Adult Mental Health Multiple Multiple Older Adult Mental Health Open Open Open Open Open Open Open Open Open Open FemNAT - Understanding gender differences in disruptive behaviour in children and teenagers EO AD Genetics Detecting susceptibility genes for early onset Alzheimer s Disease LO AD Genetics Detecting susceptibility genes for late onset Alzheimer s Disease PRONIA Personalised prognostic tools for early psychosis management Conduct Disorder Alzheimer s Disease Alzheimer s Disease First Episode Psychosis and Child & Adolescent Mental Health Older Adult Mental Health Older Adult Mental Health Adult Mental Health Open Open Open Open Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 11 of 49

12 Depression ASC UK Learning about the lives of adults on the autism spectrum and their relatives Autism Spectrum Disorder in Adults Adult Mental Health In Set up DIADS Diagnostic Instruments for Autism in Deaf Children Study Autism Service Delivery Child and Adolescent Mental Health In Set up OPNT Bulimia Nervosa Naloxone Spray - Randomised, double-blind, placebo controlled trial evaluating the effects of naloxone hydrochloride nasal spray on eating behaviours in bulimia nervosa Eating Disorders Adult Mental Health In Set up A Survey of mindfulness and self-compassion in IAPT - An anonymous survey of mindfulness, self-compassion, wellbeing and mental health IAPT Service Delivery Adult Mental Health In Set up INTERACT - Therapist Survey and Delphi study CBT Service Delivery Adult Mental Health Closed BSL-IAPT - Modelling BSL-IAPT and Standard IAPT accessed by Deaf people IAPT Service Delivery Adult Mental Health Closed COFI-FU Comparing integrated and functional systems of mental health care follow-up Service Delivery Adult Mental Health Closed MILESTONE Improving transition from child to adult mental health care Service Delivery Adult Mental Health Closed TEQ Developing and testing a tool to measure therapeutic engagement Inpatient Service Delivery Adult Mental Health Closed Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 12 of 49

13 2.7 CQUIN (Commissioning for Quality and Innovation) A proportion of the Trust s income in 2016/17 was conditional on achieving quality improvement and innovation goals agreed between the Dudley and Walsall Mental Health Partnership 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 2014/ / / / /17 CQUIN Schemes Financial Value 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 Value: 1.38m Achieved: 1.325m 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 Value: 1.39m Achieved: 1.365m 8 Schemes: 1. Improving Physical Health Care 2. Improving Health and Wellbeing of NHS Staff 3. Medicines Management 4. Voluntary Sector Working 5. DW-ROM 6. Mental Health MDT Pilot 7. Avoidable MHA Admissions 8. John s Dementia Campaign Value: 1.35m Achieved: 1.23m For the first time the CQUIN schemes have been spread over a two year period, as a result during the Trust will participate in five national schemes with a total value of 1.34m. The schemes cover a range of services including the four quality domains of Patient Experience, Safety, Effectiveness and Innovation. Figure 5: National / Scheme Title Local 1. Improving staff health and wellbeing National 2. Improving physical healthcare to reduce premature mortality in people with National serious mental illness (PSMI) 3. Improving services for people with mental health needs who present to National A&E 4. Transitions out of Children and Young People s Mental Health Services National (CYPMHS) 5. Preventing ill health by risky behaviors alcohol and tobacco National Further details for the reporting period and the following twelve months can be obtained from communication@dwmh.nhs.uk Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 13 of 49

14 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 In November 2016 the Trust received a formal CQC assessment against the CQC s assessment framework. The Trusts report from this visit was published on the 28 th March 2017 and has seen the Trust move from an overall rating of requires improvement to an overall rating for the Trust of good. The assessment noted that the Trust had made improvements to:- The documentation of long-term segregation and the management of blanket restrictions on adult acute wards. Reducing waiting times for specialist community services for children and young people. Ensure that staff were displaying a dedicated and caring attitude towards service users. Provide core services that were responsive to the needs of the people who used them. Develop a new positive culture of leadership at senior management level. Allowing for good staff morale and staff who felt supported in carrying out their roles effectively. Figure 6: March 2017 CQC Findings Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 14 of 49

15 Royal College of Psychiatrists Centre for Quality Improvement (CCQI) Accreditations During 2016/17 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 the 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. 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 7: Number of CCQI Accredited Services in the Trust CCQI Programme Participation by the Trust Electroconvulsive Therapy Clinics 1 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 2016/17 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 Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 15 of 49

16 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 2016/17 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 2016/17. 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 monitors 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 NHS Number and General Practice Code Validity The Trust submitted records during 2016/17 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 99.3%) 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%) 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 NHS Digital IG Toolkit (IGT) is an online system which allows NHS organisations and partners to assess themselves against NHS Digital s 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. Dudley and Walsall Mental Health Partnership NHS Trust Information Governance Assessment Report provides an overall score for 2016/17 of 75%; 95% of all staff received IG training and the Trust s internal IGT audit gave a result of Significant Assurance 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. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 16 of 49

17 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 8: Progress against IG Toolkit Compliance January 2015 Outcome Information Governance Requirement 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 Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national clinical coding standards. The Trust has therefore achieved attainment level 3 February 2016 Information Governance Requirement 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 2 Information Governance Requirement Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national clinical coding standards. The Trust has therefore achieved attainment level 2 January 2017 Information Governance Requirement 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 Training programmes for clinical coding staff entering coded clinical data are comprehensive and conform to national clinical coding standards. The Trust has therefore achieved attainment level 3 Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 17 of 49

18 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 2016/ Part 3B Performance against 2016/17 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 data made available with regard to the percentage of service users discharged from inpatient care followed up within 7 days The Trust has utilised the information available from NHS Digital 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 (CARM) 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: o holding a series of awareness sessions o Issuing daily specific exception reports to operational managers o 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 2016/17 The Trust has performed strongly throughout 2016/17 and managed to achieve 96.3% The table below provides the percentage achievement for the last three years Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 18 of 49

19 Figure 9: 7 Day Follow Up against National Averages and Trust High and Low Scores Indicator Target Full Year 2014/15 Full Year 2015/16 Full Year 2016/17 Q3 2016/17 National Average Q3 2016/17 Lowest Trust Q3 2016/17 Highest Trust 7 Day Follow Up 95% 97% 97% 96% 96.7% 73.3% 100% The graph below provides the monthly percentage achievement in 2016/17. Figure 10: Seven Day Follow Up in 2016/ Enhancing the Quality of Life for People with Long Term Conditions All admissions to acute inpatient services will have had access to crisis resolution / home treatment (CRHT) team The Trust has utilised the information available from NHS Digital 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 embedded with clear guidance on the requirements to record data accurately The Trust has taken the following action to increase access to CRHT team 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 2016/17. The information provided by NHS Digital showed numerators, denominators and percentages Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 19 of 49

20 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 2016/17 with 100% inpatient admissions being gate-kept in 2016/17. The table below provides the percentage achievement for the last three years. Figure 11: Crisis Gatekeeping against National Average and Trust High and Low Scores Indicator Target Full Year 2014/15 Full Year 2015/16 Full Year 2016/17 Q3 2016/17 National Average Q3 2016/17 Lowest Trust Q3 2016/17 Highest Trust Gate keeping of Inpatient Admissions by CRHT 95% 100% 100% 100% 98.7% 88.3% 100% The graph below provides the monthly percentage achievement 2016/17. Figure 12: Gatekeeping Achievement Rates 3.3 Ensuring that people have a positive experience of care staff survey 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 official sample size for Dudley and Walsall Mental Health Partnership NHS Trust was completed questionnaires were returned from this sample. The response rate to the National Staff Survey was therefore 51% (502 usable responses from a final sample of 986). Similar organisations surveyed by Quality Health had a mean overall response rate of 49%. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 20 of 49

21 Figure 13: Staff Survey Survey Year Trust MH/LD Trust Average Question 22b - If a friend or relative needed treatment I would be happy with the standard of care provided by this Trust 55% 59% Question 12d - If a friend or relative needed treatment, I would be happy with the standard of care 60% 60% provided by this organisation Question 12d - If a friend or relative needed treatment I would be happy with the standard of care provided by 60% 59% this organisation Question 12d - If a friend or relative needed treatment I would be happy with the standard of care provided by 62% 60% this organisation Question 21d - If a friend or relative needed treatment I would be happy with the standard of care provided by 65% 59% this organisation Question 21d - Agreed that they would be happy with standard of care for friend / relative 66% 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 Approved contractors provide external assurance of the process. In 2016, the Trust has continued to use the same independent approved contractor to run the staff survey. In 2016 the Trust employed a permanent substantive Staff Engagement Lead in a combined role encompassing the new Freedom To Speak Up Guardian post. They will continue to promote the Staff Survey as well as leading the Staff Friends and Family Test, work with Staff Engagement Champions and managers to support initiatives to further drive staff engagement and standards of care. In 2016 we continued to offer eligible staff both traditional paper surveys and electronic versions which were offered to all staff to complete rather than just a sample. 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 in particular utilise the staff Engagement Champions drawn from a variety of locations and services during 2016, to help understand any issues, and to seek staff feedback on possible solutions/remedies. These are planned to continue for Staff Engagement Lead is working with Heads of Service to review Staff Survey results by Service Line to enable a more detailed understanding of the challenges and opportunities specific to their areas, and will be working with them to create bespoke action plans. 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. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 21 of 49

22 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 and work with Heads of Service will be included in action plans, 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 in latest SFFT in March 2017 to a new high of 84%. 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 NHS Digital to enable meaningful comparison. 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 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 Trust has closely monitored this indicator and year end results show a rate at 10.9% against an aspirational Trust target of 10%. The table below provides the percentage achievement for the last three years. Figure 14: Readmission Rates Indicator Target Full Year 2014/15 Full Year 2015/16 Full Year 2016/17 Readmission Rate <10% 8.9% 8.2%% 10.9% Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 22 of 49

23 The graph below provides the monthly percentage achievement 2016/17. Figure 15: Trust Readmission Rate in 2016/ 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, 2014 and 2015 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 2016 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? Figure 16: Patient Experience Performance Dudley and Walsall Mental Health Partnership NHS Trust Experience of Care Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 23 of 49

24 Figure 17: Survey Overall Experience Health and social care workers Figure 18: Benchmarking against other Trusts How this score compares with other Trusts Based on patients responses to the survey, this trust scored 8.1/10 Listening for the person or people seen most recently listening carefully to them About the same 7.6/10 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 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 our 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 has been developed and is currently being 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. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 24 of 49

25 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. 3.6 Patient Safety Related incidents The Trust has obtained data from NHS Digital 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 19: 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 st October st March Middle 50% 1 st April th September Middle 50% 1 st October st March Middle 50% 1 st April th September Middle 50% Figure 20: Patient Safety related incidents None Low Moderate Severe Death Total 1 st October st March st April th September st October st March st April th September % 39.2% 3.1% 0.4% 2.0% % 44.3% 1.2% 0.0% 1.3% % 45.7% 0.9% 0.0% 0.6% % 44.8% 1.6% 0.1% 0.3% ,043 Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 25 of 49

26 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 21: Reported Incident 2016/ Reported Incidents / Serious Incidents 2016/17 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 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. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 26 of 49

27 3.8 Duty of Candour 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 the financial consequences of 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 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. There have been 13 cases during 2016/17 where the process for Duty of Candour has been applied. Figure 22: Number of Trust Incidents / Complaints where the Duty of Candour process has been followed Total Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar 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 2016/17. 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 2016/17 priorities Quality Goal 1: Smoke free Rationale for Inclusion Smoking is the largest single preventable cause of morbidity. People with mental health Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 27 of 49

28 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 PHE should support all mental health inpatient units and facilities (for adults, children and young people) to be smoke-free by Progress against Priority The Trust has commenced preparation to move towards being smoke free by March To achieve this steering a group involving key stakeholders has been established including representation from Experts by Experience and Dudley Stop Smoking Services. The Trust has also engaged with other NHS organisations who have implemented a smoke free environment to learn lessons for successful implementation and is working in partnership with Black Country Partnership Foundation Trust It is proposed this continues to be a Quality Priority for the Trust in 2017/18 Quality Goal 2: Dementia care initiative Rationale for Inclusion To deliver a dementia care improvement plan which will include partnership working with third sector and voluntary organisations. To further build on previous quality improvement priorities and CQUINS to promote a person centered approach to dementia care delivery including dementia care mapping. To continue to implement the Department of Health strategy for national dementia care (Prime Minister s challenge on Dementia 2020) further developing partnerships across the health economies e.g. learning from and working with third sector. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 28 of 49

29 Progress against priority During 2016/17 the Trust has continued to focus on improving dementia care in line with emerging best practice standards. Key quality improvement initiatives have included:- Formation of Dementia Steering Group led by the Head of Service to oversee work plan. Implementation of Dementia Care Mapping (DCM) on dementia inpatient wards. DCM is an evidence based observational tool. It usually involves one or two trained mappers sitting in areas such as a lounge or dining area and observing what happens to people with dementia over the course of a typical day. A map of care is then produced against best practice standards. These enable improvement to be made. A programme of remapping is in place to enable on-going quality improvement. The Trust has now trained 6 dementia care mappers. Mental health Nurse practitioner for Care Homes has started to introduce Dementia care mapping in care homes as a quality improvement tool. Implementation of enhanced dementia training programme for inpatient staff. Improvements made to the environments of both dementia care wards in line with national best practice standard for dementia friendly environments. This has included improved dementia friendly signage, sensory materials, lighting, sensory room. 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 2016/17 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. Progress against priority The Trust continually improves the quality of clinical documentation. During 2016/17 the Trust has:- Strengthened its approach to person centred care planning through the introduction of newly published national best practice standards by the Care Coordination Association on Person Centred Care Planning Introduced a revised rolling programme of clinical audit to monitor and improve standards Professional Nurse Forum held a targeted spotlight session on record keeping Amended inpatient paperwork to enhance person centred approach to care planning The Trust acknowledges it has further improvements to make the quality of clinical records, which will be enhanced by the introduction of a Trust wide electronic patient Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 29 of 49

30 record. It is proposed that both person centred care planning and record keeping remain a key focus the Trust in 2017/18. 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 Progress against priority The Trust has continued to streamline pathways and processes to support the patient s journey through their care. During 2016/17 this has included:- Mental Health Assessment Service Bringing together Crisis, Urgent Care and Early Access into one 24/7 service to provide a seamless service with standardisation across the whole team and time span Simplified pathways for both referrer and patients to navigate Introducing a single point of entry for routine referrals through primary care mental health Separating Crisis from Home Treatment to provide clarity on roles and functions Home Treatment Aligning Home Treatment with the in-patient wards so that it truly becomes the ward in the community Work is in progress to clarify and strengthen the gate keeping function and provide in-reach and timely step down Working with commissioners to identify alternatives to admission Pathways and interface with a number of teams is being reviewed and developed as a part of this programme of work Outpatients A review of outpatients has taken place and work is now in progress to implement a more efficient and effective service that promotes recovery, partnership working with primary care and standardisation across services. This includes developing a set of standards which includes discharge criteria. An operational policy will also be developed and implemented Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 30 of 49

31 Older Adult Services Developing alternatives to admission such as crisis and home treatment and a reduced reliance on beds A review of pathways, particularly out of hours has been a feature of this work with the older adult teams aligning with the adult service pathways Quality Goal 5: Improving the service user 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 user s experience of care. This is being achieved by focusing on:- Discharge pathways Communication processes Appointment processes Consistency of workers Strengthening links with primary care Strengthening service interfaces to improve patient experience Progress against priority Current processes on communication and appointments have been reviewed and discussions are in progress to identify potential and actual blockers and make improvements Both Dudley and Walsall CCGs are supporting the Trust in developing relationships with primary care to overcome obstacles to recovery and discharging patients back to primary care Mental Health as part of the wider Multi-Disciplinary Teams are being piloted in Dudley with GPs and are due to be rolled out across all GPs. This provides a forum and an interface between primary and secondary care to help GPs manage patients in primary care and help Consultants to discharge patients back to primary care Work has commenced with the Community Recovery Service teams to review their role, function, and capacity to enable an increased focus on patients who have complex needs. Pathways and interfaces with others teams, both internally and externally are being reviewed with an increasing focus on shared care with primary care and the development of protocols Discharge criteria has been developed to assist staff in decision making Primary care mental health have been in-reaching into outpatients to review patients on clusters 1-3 which are for people with milder mental health problems, to offer treatments in IAPT (Improving Access to Psychological Therapies) or help facilitate discharge to primary care if appropriate Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 31 of 49

32 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 Contractual Quality Requirement Goals agreed with Commissioners For 2016/17, the Trust monitored 26 contractual Key Performance Indicators (KPIs). Both Dudley CCG and Walsall CCG decided to monitor each month a majority of the KPIs reported in the previous financial year, which was in line with the national reporting requirements. The table below shows the performance levels achieved for the KPIs where thresholds were finalised in the year. Figure 23: Contractual KPI s Performance in 2016/17 Contractual KPIs Target Achieved 1 Referral to Treatment Time Incomplete >92% 95% 2 7 day follow up on Inpatient Admissions >95% 96.3% 3 Delayed Transfers of Care (All Reasons) <7.5% 1.9% 4 Completion of NHS Number on MHSDS >99% 99.7% 5 Completion of Ethnicity Code on MHSDS >90% 91.3% 6 Copies of Care Plans (CPA caseload) >95% 95.2% 7 Number of Home Treatment episodes by Crisis Teams (Walsall CCG) Percentage of people experiencing a first episode of psychosis >50% 71.2% 9 The proportion of people that wait six weeks or less from referral to their first IAPT treatment appointment >75% 87.4% 10 The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment >95% 98.8% 11 Completion of IAPT Minimum Data Set outcome data >90% 98.2% 12 IAPT DNA Rate <13.1% 7.5% 13 The proportion of users on CPA who have had a review within the last 12 months >95% 95.9% 14 Proportion of in-scope patients assigned to a cluster >95% 95.6% 15 IAPT People who receive psychological therapies Dudley-6227 Dudley attending one session only Walsall-4328 Walsall IAPT people who have successfully completed treatment 17 Memory Assessment Service - Face to face initial assessment to be made within 20 days 18 The proportion of users with a valid ICD10 diagnosis code recorded. (Dudley CCG) >50% Dudley 58.8% Walsall 49.1% >95% 91.1% >95% 92.1% 19 Proportion of patients within cluster review periods >95% 83.2% 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 Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 32 of 49

33 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 Access targets and outcomes objectives The Trust routinely reports performance against a nationally developed outcome framework (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 2016/17 (as shown below). Figure 24: National Indicators 2014/ /17 National Indicators 2014/ / /17 Target = 95% Target = 95% Target = 95% 7 Days Follow Up Achieved = 97% Achieved = 97% Achieved = 96% Minimising Delayed Transfers of Care (All reasons) Target < 7.5% Achieved = 1.6% Target < 7.5% Achieved = 0.4% Target < 7.5% Achieved = 1.9% Gate keeping of Inpatient Admissions by CRHT Target = 95% Achieved = 100% Target = 95% Achieved = 100% Target = 95% Achieved = 100% Referral to Treatment - Incomplete Data Completeness Identifiers Data Completeness Outcomes The proportion of people that wait 6 weeks or less from referral to their first IAPT treatment appointment The proportion of people that wait 18 weeks or less from referral to their first IAPT treatment appointment Percentage of people experiencing a first episode of psychosis Target = 92% Completed = 95% Target = 97% Achieved = 99.8% Target = 50% Achieved = 96.2% N/A N/A N/A Target = 92% Completed = 97% Target = 97% Achieved = 99.7% Target = 50% Achieved = 96.4% Target = 75% Achieved = 94.2% Target = 95% Achieved = 99% Target = 50% Achieved = 71.4% Target = 92% Completed = 95% Target = 97% Achieved = 99.3% Target = 50% Achieved = 96.2% Target = 75% Achieved = 87.4% Target = 95% Achieved = 98.8% Target = 50% Achieved = 71.2% Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 33 of 49

34 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 2016 assessments were completed on all hospital sites between March and May This information, along with all other PLACE assessment data was subsequently collated together to create the PLACE 2016 Action Plan. Summary Results The table below shows the Trust s scores against national results from For two of the domains the Trust scores above the national average. Four domains indicate improvements required; Cleanliness, Condition, Appearance and Maintenance, Dementia and Disability. It should be noted that the Disability domain was scored for the first time in 2016, and further discussions about the Trust actions need to take place in the context of the Trust s overarching capital programme and priorities. Figure 25: National PLACE scores v Trust results Domains National Average Trust Average Year Cleanliness 97.25% 97.60% 98.05% 99.67% 99.18% 97.30% Condition Appearance and Maintenance 91.97% 90.10% 93.34% 92.26% 86.02% 87.79% Privacy, Dignity and Wellbeing 87.73% 86.00% 84.20% 85.95% 88.36% 86.62% Food and Hydration 88.79% 88.50% 88.19% 87.97% 84.02% 89.01% Dementia 74.51% 75.22% 78.82% 66.36% Disability NEW % 69.46% Comments Below in two domains Below in two domains Below in four domains 2014 Data Trust Scores >1% below national average for year 2015 Data <1% below national average for year 2016 Data > National average for year Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 34 of 49

35 Figure 26: National PLACE scores 2016 vs Trust average and by site Results are provided for four domains:- National Average Trust Average Cleanliness Condition, Appearance and Maintenance Privacy, Dignity and Well-being Food Dementia Disability 98.05% 93.34% 84.20% 88.19% 75.22% 78.83% 97.30% 87.79% 86.62% 89.01% 66.36% 69.46% BLX 97.95% 93.06% 83.33% 88.11% 77.58% 83.89% DPH 97.70% 86.90% 87.96% 89.57% 62.14% 69.60% BFH 96.88% 86.26% 87.25% 89.10% 64.08% 64.16% 100% 95% 90% 85% 80% 75% 70% 65% 60% Cleanliness Condition Appearance and Maintenance Privacy, Dignity and Wellbeing Food and Hydration Dementia Disability NEW 2016 Bloxwich DPH BFH National Average Trust Average 3.13 Service Experience 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 2016/17 74% of the 1824 people asked, responded with likely or extremely likely. The full results are shown below. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 35 of 49

36 Figure 27: Friends and Family Test Data Community Mental Health Survey 2016 overall satisfaction score The Annual Community Mental Health Survey 2016 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 30% (249 usable responses received from a basic sample of 850). 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 crisis care and support for wellbeing. Mostly the Trust was rated within the intermediate 60% and top 20% of all 49 trusts surveyed in 2016 by Quality Health. There have been significant improvements in responses regarding Crisis Care services, in comparison to the previous year s survey and the national average. The Trust are higher than the national average for patients knowing who to contact out of hours in a crisis situation and this is within the top 20% of all Trusts. The Trust scored 10% higher than the national average for patients stating they definitely got the help they need when they contacted the team. In one area the Trust is within the lower 20%. This is where users feel they have not been given an explanation about changes in who they see. The overall impression is that services have been improving and in support and wellbeing the Trust rates very highly with the users who completed this survey. Service users were asked how they would rate their experience of our services overall and 72% of respondents rated their experience as good or very good. The challenge will be to maintain, and if possible, improve even further the ratings already achieved. 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. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 36 of 49

37 Inpatient Mental Health Survey 2016 overall satisfaction score The Annual Mental Health Inpatient Survey 2016 was conducted independently for the Trust by Quality Health and a questionnaire was sent out to around 362 people who received inpatient mental health services. The response rate was 27% (91 usable responses from a usable sample of 333). Overall out of the 40 scored questions the Trust was rated mainly within middle 60% of all 19 Trusts surveyed in 2016 by Quality Health. The Trust scored within the upper 20% of Trusts for service users saying that they were always listened to carefully by their psychiatrists. The Trust has seen an improvement in scores around service users feeling that staff took their family/home situation into account when planning their discharge and around delays in discharge. However the Trust does fall into the lower 20% of scores on just under a third (12) of the questions. Areas identified where improvements can be made relate to food; provision of talking therapy; activities; care of physical health problems; contact following discharge and. The Trust is using feedback from the survey to inform quality improvements Compliments and Complaints 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, complaints training and promoted throughout the Trust. During the period April 2016 to March 2017, we received a total of 150 formal complaints, 37 of which were withdrawn or closed. We responded to 50 cases within the target timescale; 24 cases remain open, 20 of which were still within target at the time of writing. Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 37 of 49

38 Figure 28: Compliments and Complaints data There were 150 formal complaints and 411 compliments received during April 2016 to March 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 (411) 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: The best experience I have ever had in any NHS Mental Health service in the UK I have been attending the feeling better group; it has helped me with my anxiety. I have enjoyed the course thoroughly. Also Kings Hill Centre is clean and have lovely staff who are very helpful and understanding. I cannot thank them enough for their help. There are two members of staff who have been visiting me weekly for over a year. They were always kind and considerate and I feel supported. I would find it difficult if I did not receive this support Just wanted to thank you from the bottom of our hearts for all your efforts on my daughter s behalf. We were all quite overwhelmed at the review and I felt that we did not fully express our appreciation to you for the work that you have done. My daughter knows I am writing to you so please accept thanks from all of us for your care and diligence A member of staff has always shown professionalism, but more importantly seems to genuinely care about my mom. She is always positive and speaks in a caring way. She is also always open to my questioning and answers as honestly as she can. She has been a point of contact for us during a worrying and difficult time; we feel she is supporting us as a family unit I would like to thank you and the team for all the attention and help I have received. I hope and pray I will continue to improve. The staff in the hospital were all so pleasant and helpful and I thank them for their hard work and dedication. I am grateful for the care I have received. Not enough praise is given to such a dedicated team Since this member of staff was assigned to my case she has been nothing but supportive and helpful right from the start. She reacted quickly to my situation and with her excellent care and assistance it Dudley and Walsall Mental Health Partnership NHS Trust Quality Account 2016/17 Page 38 of 49