2006/07 Clinical Governance Annual Report. Learning the Lessons

Transcription

1 Learning the Lessons

2 Contents Foreword 4 Executive Summary 5 Patient Safety 6 Clinical and Cost Effectiveness 9 Governance 12 Patient Focus 16 Accessible and Responsive Care 19 Care Environment and Amenities 23 Public Health 26 Modernising Clinical Governance 29 2

3 Learning the Lessons St George s Hospital, Stafford 3

4 Foreword We have seen a number of exciting landmarks in the past year in our continued growth as a leading provider of health services. Our Clinical Governance achievements played a vital part in the successful application to integrate with Shropshire Adult Mental Health and Learning Disability services. As the first NHS Foundation Trust of our kind to expand in this way, we are now Learning the Lessons of even more exciting and innovative New Ways of Working. Clinical Governance achievements also enabled us to: Declare full compliance with Standards for Better Health including developmental standards. Maintain Level 2 accreditation against the Clinical Negligence Scheme for Trusts. Deliver an Integrated Care Pathway to meet the physical healthcare needs of service users. The Pathway has been recognised locally as good practice and is being used to inform practice locally and nationally. This report has been structured around the seven domains of Standards for Better Health, and illustrates the progress made with Clinical Governance as well as future plans. The Trust strives to provide the highest quality and widest range of services possible. Relationships with local partners are valued highly for their contribution to the health and social care of service users and carers and partnerships are key components of our mutual governance strategy. Members, Commissioners, Patient and Public Involvement Forums and Local Authority Overview and Scrutiny Committees also have a vital role and we look forward to further strengthening these relationships. Service users, carers and members are a valued source of ideas and joint working enables us to challenge practice and foster improvements. During we introduced the eighth principle to develop our commercial competence and last year we delivered leadership training to improve the management of business aspects of services, helping us to deliver financial performance, better understand the needs of our communities and agree priorities with our partners for service development. There have been improvements in the access to services as well as their responsiveness. The clinical and cost effectiveness of services has been supported by a newly appointed Chief Pharmacist. Our performance management arrangements continue to move us further toward Integrated Clinical, Corporate and Mutual Governance. This document should be read alongside Trust and Business Plans, Assurance Plans, Risk Registers, Medicines, Infection Control, Risk Management and Trust Annual Reports and our Clinical Governance Pocket Guide. Action plans can be found in our Business and Performance Plans. We hope you will enjoy and learn from this report and we extend our thanks to all those who have helped the Trust on its journey so far. Roger Evans Neil Carr Joe Wall Non Executive Director Chief Executive Associate Director Clinical Effectiveness 4

5 Executive Summary Clinical Governance is at the core of everything we do. It has been a constant focus in the journey to expand the Trust. This document describes how we will continue to assure our clients of our robust governance. As a Learning Organisation we: learn from things that go wrong have learnt to proactively assess and manage risks use our learning to develop our services and staff learn from the experiences of others and share the lessons we have learned Clinical governance highlights from 2006 include:- Our collaboration with children, young people and carers to design That Place a new multi-agency centre in Burtonon-Trent The 6th annual Clinical Governance Conference Strengthening our close working relationships with Shropshire adult mental and learning disability services with the joint aim of further improving the quality of services across South Staffordshire and Shropshire and continued compliance at Level 2 with the recently updated national NHS Litigation Authority (NHSLA) Mental Health and Learning Disability standards Effective links between link Risk Management and Clinical Effectiveness A new Integrated Care Pathway to support the physical healthcare of people with mental heath needs A high rating for our services on the national Mental Health Patient Survey. Our services have improved, with fewer cancelled appointments, more consistency in staffing appointments and staff who listen carefully to what patients say and treat them with dignity and respect. We have also learnt where we need to continue to improve the most involving patients more in decisions about their care, providing more information about medication, care reviews, care plans and local support groups and providing more help with work related activities. Services being rated as Good by the Healthcare Commission This report provides evidence of the unprecedented levels of collaboration and mutual governance we have achieved with service users and partners. A selection of initiatives led by Directorates are contained throughout this report but they are too numerous to include them all. However, they are described in detail within Directorate business and performance plans available from public folders or on request. We have learnt the importance of collaboration and require Integrated Governance to be fully effective. This means having the right structures and processes in place, including managerial and clinical leadership with accountability, organisational culture, systems and working practices. We continue on this journey and recommend this approach to you. 5

6 Patient Safety 6 The Pharmacy, Shelton Hospital, Shrewsbury

7 Keeping patients safe Local and national reports of major investigations in healthcare have found many adverse events to be due to failures in systems and processes rather than individual factors. Appropriate systems are at the core of safe services alongside positive action to correct failures. The Trust has systems in place to ensure that medicines are handled safely and securely, and to review and learn from errors if they occur. Patient safety notices, alerts and other communications issued by the national Safety Alert Broadcast System (SABS) and Medicines and Healthcare products Regulatory Agency (MHRA) are implemented within the required timescales. Good practice is supported by systems to minimise risks associated with the acquisition and use of medical devices in accordance with guidance issued by the Medicines and Healthcare products Regulatory Agency (MHRA). Reusable medical devices are properly decontaminated in appropriate facilities. Waste is properly managed to minimise all potential risk to people and the environment. Steps to minimise the risk of healthcare associated infection to patients have been taken, guided by the following documents:- The Code of Practice following publication of the Health Act 2006 Winning Ways (Department of Health 2003) A Matron s Charter: An Action Plan for Cleaner Hospitals (Department of Health 2004) Revised Guidance on Contracting for Cleaning (Department of Health 2004) Audit Tools for Monitoring Infection Control Standards (Infection Control Nurses Association 2004). The Staffordshire Risk Collaborative, chaired by the Associate Director Clinical Effectiveness, promotes joint working specifically related to the management of clinical risks. The Collaborative has 5 main work streams:- Policy, procedures, processes Learning the Lessons Suicide prevention Training and education Communication The training and education work stream oversees the provision of joint clinical risk management training initiatives, including an advanced course that takes account of the findings of reports such as the National Confidential Inquiries and is recognised by NIMHE (National Institute for Mental Health England) as good practice. These initiatives are having a real and beneficial impact; the 3-year average level of suicide in South Staffordshire has once again reduced from 7.2 per 100,000 population in 2005/6 to 6.67 in 2006/7 well below the last known national average and already below the national target for the year 2010 (7.3 per 100,000 population). We ensure employees continue to learn by having the necessary training and supervision to safely deliver services. Our state of the art Learning Centre in Stafford is the hub of a wide learning network with teleconferencing facilities to Burton-on-Trent and Tamworth. What we have done Produced quarterly reports and a Risk Management Annual Report to encourage learning from risks and incidents. Updated our procedures for reporting and managing serious incidents including how we define the incidents, how we inform, involve and share reports with service users and carers, and when a review should include external expertise. Serious incidents are reported as appropriate to Strategic Health Authorities, commissioners, the National Patient Safety Agency (NPSA) and the Health and Safety Executive. These are analysed to identify and learn from root causes. Fully implemented The National Institute for Mental Health England (NIMHE) Suicide Prevention Toolkit. Defined and implemented effective processes for identifying, reporting, learning from and taking action on vulnerable adult and child protection issues. Criminal Records Bureau (CRB) checks are conducted for all staff and students with access to patients and relatives in the normal course of their duties. This provides an important safeguard in ensuring that the people we employ can be trusted to work with vulnerable people. 7

8 Further developed e-learning to improve convenience, access, flexibility and costeffectiveness of training courses. Improved arrangements to ensure staff receive and learn from mandatory safety training. Further improved our guidance on physical healthcare assessments for patients and we are currently undertaking more training to ensure staff learn more about the standards required. Put in place systems to ensure we contribute to year on year reductions in MRSA within inpatient wards. Due to robust infection control procedures there have been no reported cases of cross infection in the Trust s inpatient areas. Systems were updated to effectively manage the risks associated with Clostridium difficile and the job descriptions for all staff now include their responsibilities for infection control. Reviewed our medicines policies and are piloting a new safer medicines prescription and administration card. We will continue to monitor and learn from any errors that arise and expect to see a reduction in this in Improved systems for recording observations of patients in the Forensic Mental Health Service. Implemented a new tool, developed last year with NIMHE, for checking that our wards and departments remain safe Continued to learn from patients and carers who are asked to disclose information vital to patient safety such as whether patients are pregnant, use alcohol or drugs, or suffer from an allergy. Ensuring we continue to improve In order to uphold patient safety we will review: Arrangements for the co-ordination, ratification and review of specific clinical procedures, pathways and guidelines including risk assessments. A new medicines management strategy and a programme of work with clearly defined objectives to further improve practice and safety in this area. More than 50 policies related to many of the above patient safety issues and will learn from the experience of Shropshire staff as well as those based in South Staffordshire. Information to help patients learn more about conditions and treatment choices and update arrangements for ensuring the quality of such information National confidential enquiry reports as they are published and other reports recommended by external assessors to ensure we learn and develop from these. A Falls Prevention Policy will be developed in line with recommendations in the national report on Slips, trips and falls in hospital (National Patient Safety Agency, 2007). This will include work to improve consistency in the use of the FRASE Falls Assessment Tool. With support from the League of Friends we are purchasing Hip Protectors that will significantly reduce the risk of injury during a fall. A published review of recent suicides indicated a need to focus in particular on patients with Dual Diagnosis and those with Severe Mental Illness who disengage from services. We will further review our systems and processes for managing the associated risks and ensure a recently developed Dual Diagnosis Policy is fully implemented. In line with new requirements, we are developing and delivering new systems for child protection training to all staff and incorporating this within new starter induction programmes. Implementation of the new national Standards for Secure Care is now underway and the Forensic Mental Health Service audits of Security, Absconding and Substance Misuse have led to plans to develop/review some policies and practice. Secure services face a significant challenge in the aftermath of the Barrett Inquiry, which criticised the responsible clinical team for giving undue weight to patient preferences and less emphasis on the principles of sound risk management. Policies have been updated to ensure that clinical teams within the Directorate are supported to maintain their fidelity to the recovery model without discharging responsibility in terms of public protection. 8

9 Clinical and Cost Effectiveness Shelton Hospital, Shrewsbury 9

10 Effective services for patients and the public 10 Clinical Effectiveness is about doing the right thing the right way - health care based on sound evidence providing effective clinical outcomes. Cost effectiveness is about getting the most beneficial effect from resources available. Achieving the balance is essential for good governance. We use this approach to achieve health care benefits that meet individual patient needs. The patient s whole journey means they receive services from other agencies so we work extensively with partners to ensure that individual needs are met across organisational boundaries. Integrated care is facilitated through, for example, joint NSF working groups leading to service and practice development and the development of shared policies and guidance such as those on Depression, Care Coordination, Person Centred Planning, Assessment of Mental Capacity, Child Protection and the Protection of Vulnerable Adults. To support learning and development and other aspects of their work all staff are able to access appropriate supervision in accordance with Trust policy which takes into account national guidance from the relevant professional bodies. Standards for Better Health (Department of Health, 2006) Developmental Standard D2a states: Patients receive effective treatment and care that conforms to nationally agreed best practice, particularly as defined in National Service Frameworks, National Institute for Health and Clinical Excellence (NICE) guidance, national plans and agreed national guidance on service delivery. The Trust has a good level of compliance with most of the practice guidance in the NICE Guidelines, National Service Frameworks (NSFs) and other national policy listed in the Healthcare Commission criteria. Where gaps exist action plans are being implemented to address these (Assurance Report for the Trust Board, April 2007). When planning and delivering care we learn from nationally agreed best practice as defined in NSFs, national plans and standards. We play an active role in local interagency planning groups responsible for developing services in line with NSFs. We conform to the procedures for the adoption of NICE technology appraisals. This work is guided by our Clinical Effectiveness Strategy and our learning is enhanced through clinical audit and local surveys of patient and carer views. Clinicians are closely involved in prioritising, conducting, reporting and acting on clinical audits and participate in reviewing the effectiveness of clinical services through evaluation or research. We recognise that it is also vital to listen to the views of patients and carers in our clinical audit and effectiveness programme and we do this in a number of ways by including patient/carer involvement in project work and by providing patients and carers with the opportunity to feedback about services provided. The Trust s approach to clinical audit means that a project is not complete until the lessons learned have been implemented through a managed action plan formed as part of the audit cycle. What we have done Reviewed the Service Level Agreements in place with acute Trusts and other NHS providers in order to improve services and cost effectiveness. Engaged a wide range of clinicians with many reviewing and managing the introduction of new guidance. Clinicians are supported by senior staff and support teams including clinical audit, effectiveness and performance teams. Adopted an integrated care pathway approach to bring together standards, evidence and clinical experience from clinicians, other agencies, patients and carers. Developed and implemented pathways for managing Depression (sources of information for patients and carers); Alzheimer s Disease (medicines management); Attention Deficit Hyperactivity Disorder (pre and post treatment checklists, information for parents and schools); Electro Convulsive Therapy (Royal College of Psychiatrists consent to treatment form); Physical Health assessment and management (new integrated care pathway); Epilepsy (for people with learning disabilities).

11 Audited practice against NICE guidance. The Annual Health Check Declaration of full compliance with the Standards for Better Health on clinical effectiveness was assured by evidence and learning from 65 clinical audit, effectiveness and service development projects. All consultant medical staff, ward and senior managers were provided with copies of full audit reports, NICE guidance and materials to support full implementation. Reports for many of these projects are available through our website at: goodpractice/cad/abstracts.asp Clinical leadership was further developed by the innovative Going the Extra Mile (GEM) leadership training program. Senior nurses are taking a greater leadership role in Essence of Care, Infection Control, Wound Management and Hospital Cleanliness as well as leading Nursing Strategy developments within Clinical Directorates. Twenty projects with patient/carer involvement were conducted last year, with 31 projects conducted to provide service users and carers with the opportunity to feedback on services. Clinical audit and effectiveness projects identified over 200 improvements to services including:- Privacy and Dignity - new bathroom facilities have been installed in wards, new furnishings, development of privacy and dignity guidelines for staff in older peoples mental health wards Record keeping agreement of a new integrated records structure for the Trust. Forensic Directorate developed a new care planning framework incorporating the Evidence Based Rehabilitation Philosophy Safety of patients/clients with mental health needs access to named nurse sessions to discuss individual safety issues on adult inpatient mental health wards, Child and Adolescent Mental Health Service (CAMHS) teams have introduced a Risk Assessment process. Communication with patients and carers adult inpatient mental health units developed a Carers Pathway in collaboration with the Carers Group To help ensure that patients receive clinically and cost effective medicines we have appointed a Chief Pharmacist and support staff. Ensuring we continue to improve Our highest local priorities for improvement relating to developmental standard D2a are: Improving the availability of psychological therapies Implementing the Physical Healthcare Pathway Further developing and implementing a local solution for electronic health records Continuing to participate fully in the review of Care Programme Approach systems and processes and to support implementation of the new arrangements across Shropshire and Staffordshire Implementing systematic measures such as Health of the Nation Outcome Scales (HoNOS) Projects will continue to be implemented to deliver the improvements identified through audit. A robust and well planned forward project programme will be introduced focusing on further deployment of the following guidance: Dementia NICE Guidance; Core treatments in Schizophrenia; Guidance for staff and patients on the management of self harming behaviour; Chronic Depression; Depression in children and young people. A pilot project in Tamworth is being conducted to test a software package for computerised cognitive behaviour therapy (CBT) in collaboration with the Care Services Improvement Partnership (CSIP) and the Social Fund. We will also review the transfer processes for patients with physical health needs to and from general hospitals. We will continue to improve medicines management and related costs supported by implementation of our new medicines management strategy and a programme of work with clearly defined objectives to further improve practice. Training related to care pathway developments will be supported by further developments in cost effective e-learning initiatives. A Mental Health Assessment Pathway will be developed. All teams directly engaged with the delivery of care services will be required to demonstrate that they are continuing to apply the Essence of Care standards in their practice and are learning from benchmarking themselves against other services. 11

12 Governance 12 The Brockington Unit, St George s Hospital, Stafford

13 Governance assuring patients needs are met Clinical governance is a vehicle for continuously improving the quality of patient care and maintaining high standards. It enables us to recognise, learn from and replicate good clinical practice and ensure lessons are reliably learned from failures in standards of care. Governance extends to managerial and clinical leadership and accountability, as well as the culture of an organisation, systems and working practices that ensure that probity, quality assurance, quality improvement and patient safety are central components of all activities. Including internal and external partners and stakeholders, and having the right structures and processes to assure that happens, is what we refer to as Mutual Governance. To manage the complex environment in which we operate, our partnership working and Clinical Governance Strategy have helped us to develop an effective model to ensure Clinical Governance is For Real in South Staffordshire: Governance across the Trust is driven by the principles of Mutual Governance, introduced to build and strengthen respect and robustness within internal and external partnerships. These arrangements are underpinned by the Assurance Framework. Assurance Plans and Risk Registers are developed at both Trust and Directorate level and support learning and development. The Clinical Effectiveness and Risk Sub- Committee has responsibility for the coordination of clinical effectiveness and risk management activities to protect and preserve the human and physical assets of the Trust and of those who come into contact with it. The Committee: Explores any issue or activity that may identify, evaluate, reduce or transfer risk including the need to engage in risk financing (i.e. Insurance). Ensures that procedures are regularly reviewed in order to ensure learning and continuing effectiveness. Committee membership includes a Non-Executive Director chair, Executive Directors and representation from all Clinical Directorates. 13

14 14 What we have done Raises the level of awareness and accountability for Clinical Governance throughout the Trust, supported by Clinical Effectiveness and Risk Coordinator operational groups which undertake the detailed work and secure clinician ownership from all Clinical Directorates. Our structures and processes include our Business Development Sub-Committee and are designed to ensure the wider aspects of Governance are addressed and integrated through Mutual Governance. The Human Resources and Organisational Development and Finance and Performance Sub-Committees and the Audit Committee lead and monitor aspects of our work and ensure we remain true to our principles. The Trust has a history of excellent financial governance and year on year achievement of financial targets is evidence of robust planning, monitoring and in-year management of resources. This is supported by systematic clinical and financial risk assessments and management (including compliance with the original controls assurance standards) to identify potential risks, effectively manage and/or involve others for those outside our control before they can cause harm or loss. Involvement of our Patient Advice and Liaison Service (PALS) is having a real impact on how we learn lessons and is leading to improvements in services. When formal complaints arise there is evidence that we take these very seriously and work by our Service Relations Department, in partnership with staff working in the relevant areas, has again demonstrated real learning and improvements to services. The Trust meets existing national performance requirements reflected in its current Annual Health Declaration of compliance against the relevant Developmental Standards and the entire set of Core Standards for Better Health. We were awarded a rating of Good in the last NHS Performance ratings and learnt that we had become the employer of choice for our colleagues in Shropshire. Reviewed Directorate plans and delivery as part of the Trust s performance review. The Trust s Assurance Plan and Risk Register is monitored and reviewed by the Clinical Effectiveness and Risk Sub-Committee to the Trust Board (which functions as our Clinical Governance Committee) and a report is presented to the Trust Board bi-monthly highlighting any significant areas of risk. Actively supported all employees to promote openness, honesty, probity and the efficient use of resources. This culture contributed to our receiving the Improving Working Lives Practice Plus award. Developed a nationally renowned Clinical Governance Pocket Guide to support staff to do their jobs as well as capture new learning and developments. Recognised the contribution and value of staff across the organisation - good working practice is celebrated at conferences such as the Clinical Governance for Real Conference and the annual Prescribing Conference. Staff are enabled to raise any concerns through the Chief Executive and Chairman s Road Shows and Performance management sessions are held every 6 months with clear agendas and written feedback. Staff are encouraged to become involved in national working groups. Supported and involved staff in organisational and personal development programmes as defined by the relevant areas of the Improving Working Lives standard at Practice Plus level Ensured that staff members from black and minority ethnic groups have opportunities for learning and other personal development. The development of a local Black & Minority Ethnic Staff Network has received consistent and encouraging support. Policies on the Care of Patients from Ethnic Minority Groups, the Use of Interpreters, Equality and Diversity and an Inter- Agency Vulnerable Adults Policy provide staff with detailed guidance. Protected everyone involved with research by complying with the requirements of the Research Governance Framework for Health and Social Care and ensuring the lessons learned are shared through a programme of Research Seminars Challenged discrimination and promoted equality and respect for human rights in accordance with current legislation and guidance.

15 Provided examples of good practice, learning and changes as a result of complaints and PALS cases in our Risk Management Annual Report. Provided learning events to support senior members of staff to take a lead role in investigating and resolving complaints and PALS issues. Implemented innovative local PALS standards enabling us to fully respond to PALS concerns in a timely manner (over 95% within the standard of 25 working days), reduce the number of concerns raised through the PALS service by almost a third and increase the number of compliments more than 4 fold. Adopted systems to ensure that records are managed in accordance with the NHS Information Authority s information governance toolkit. Ensured that essential employment checks are undertaken for all new staff and that staff are recruited in accordance with legislation and as a result of workforce planning. Provided mandatory training, including induction programmes and ongoing opportunities for staff to participate in professional and occupational development. Adopted systems to ensure that all staff abide by relevant codes of professional practice. Staff must participate in workbased learning programmes necessary to the work they undertake, including locum and agency staff. Ensuring we continue to improve Governance arrangements will continue to progress, in particular we will expand our learning through recent developments in some of our Directors roles and the Membership Council related to our integration with Shropshire based services. Work will continue with partners to address the implications of the Draft Mental Health Bill and secure full implementation of the Mental Capacity Act. Delivery of the current programme of learning events associated with our innovative Clinical Governance for Real Month will be completed. Optimum safe staffing levels for all services will be set and clear guidelines will be produced for staff to adopt when staffing levels cause concern. Staff roles will be further developed in line with the national New Ways of Working initiative and supported by a new Nursing Strategy. Further work to scan old paper records into an electronic format will be undertaken to improve access for staff and reduce storage costs. An information system to evidence and learn from progress will be introduced enabling staff to cross reference their work with national standards and provide reports and evidence submissions for external assessments in a cost effective manner. Sharing and learning with recently integrated Shropshire Mental Health and Learning Disability services will continue. Current work includes: Coordinating Clinical Governance activity between services Establishment of further specialist services 15

16 Patient Focus 16 Castle Lodge, Telford

17 Patients at the centre of what we do Clinical Governance requires a culture that ensures the service interacts with the people it provides for and effective healthcare services that do things with, not to, people. The Picker Institute conducted 450,000 interviews with patients over a period of 12 years and identified eight dimensions of care that are important to patients: Respect for their values, preferences and expressed needs Information, communication and education Involvement of family and friends Co-ordination of care Continuity and transition Emotional support Physical comfort Access to care To provide quality services, we must meet the healthcare needs of our patients, carers, commissioners, other partners and the general public. At every level we must listen to them when designing and delivering services. Health care must be provided in partnership with patients and others important to their care. The Heart of the Trust Scheme was launched in January 2004 and encourages Service User and Carer Associates to work alongside the senior team, contributing an operational perspective to the role of the Service User/Carer Sub- Committee. All Associates have experience either as recent users of Trust services or as carers and contribute to learning and other work of the Trust. The scheme s success was rewarded in September 2005 when it won a UK-wide award for excellence in healthcare human resources management. To ensure our services are inclusive we provide suitable and accessible information on services provided and in languages and formats relevant to our service population. The Trust provides patients, and where appropriate, carers (including those with communication or language support needs) with accessible information on the patient s individual care, treatment and after care. This includes care plans, copies of correspondence sent to other care professionals, and, if detained, about their rights under the Mental Health Act A recent audit confirmed our compliance with Information Governance standards that state that staff using and disclosing patient s personal information must act in accordance with the relevant legislation including: Confidentiality: NHS code of practice (Department of Health [DoH] 2003) The Data Protection Act 1998 Protecting and using patient information: a manual for Caldicott guardians (DoH 1999) The Human Rights Act 1998 The Freedom of Information Act 2000 The Landmark Supported Employment Scheme scooped a prestigious Remploy Interwork Leading the Way Award in for its positive approach to employing disabled people. The same year our Landmark Scheme also won the regional Training and Support Provider award after meeting strict criteria on the way it recruits and trains disabled employees, in addition to the support and opportunities it provides them. Community Teams work in close partnership with non-statutory agencies, for example, Making Space and MIND and have links with a variety of employment facilitators including Options, Connexions, Job Centre Plus and Inspirations The Mental Health Improvement Partnership Value Based Workforce work stream has also: Stimulated service user involvement in recruitment and selection and in introducing new staff into services Increased employment opportunities for Service Users (Landmark scheme) Implemented Values based training and learning for staff Implemented Wellness Recovery Action Planning groups that provide information about choice, access to services, care coordination, recovery, and the need for service users to be leading practice. 17

18 18 What we have done Taken steps to ensure that all staff members treat patients, carers and relatives with dignity and respect at every stage of their care and treatment. Induction includes training sessions on customer care and staff are provided with instruction and guidance to ensure they act in accordance with equalities legislation. Worked closely with Professor David Seedhouse to implement the Values Exchange. Software has been installed so that all staff can access case studies and collect, compare and learn about values. Ensured that Associates contribute to the strategic management and development of the Trust, and that the role is adopted by Service User and Carer Governors alongside other Governor Members. Adopted systems to identify areas where dignity and respect may have been compromised. Updated PALS and Complaints information Are You Satisfied? We are Here to Help! Put processes in place to ensure that valid consent is compliant with national standards. Provided information to patients, including those with language and/or communication support needs, on the use and disclosure of confidential information for patients. Offered patients a choice of food in line with the requirements of a balanced diet and in accordance with the six key requirements of the Better Hospital Food programme (NHS Estates 2001). Following a tasting session attended by patients, staff and Governor Members, plans are being finalised to introduce major changes to our current provision. Made improvements to normalise mealtimes, improving the dining environment and preventing interruptions by professionals during mealtimes. Patients have access to food and drink 24 hours a day in accordance with the requirements of the Better Hospital Food programme (NHS Estates 2001). Menus have been reviewed by patients, making them easier to understand. Developed a Books on Prescription initiative in partnership with the local Primary Care Trust. Two complete sets of the recommended books are held at our libraries in Stafford and Lichfield which can be accessed by staff and service users. Adopted integrated care pathways with clear choice and information points. Spring Meadow Therapy Unit have refined the locally developed Recovery orientated approaches benchmark using the Essence of Care framework. Increased the focus within Community Teams on Recovery. Support Time and Recovery Workers are supervised and have good results getting people who have Severe Mental Illness into self sufficiency and recovery. Focussed on getting people back into meaningful occupation with the Head of Occupational Therapy involved in a Back to Work scheme. Worked with other agencies to develop an Advanced Directives policy and guidance for people thinking about making such a directive. Taken account of current research into religion and spirituality, particularly the importance of addressing the wider spiritual needs of patients. Service improvements to address these needs have been made alongside a new strategy. Ensuring we continue to improve We will continue to strive to improve patient experience and provide services we would be proud to use ourselves. The Great Expectations project to examine the experience of admission to an acute adult inpatient ward will provide crucial data and action plans will be put into place to ensure learning. Women s Services will be reviewed and developed. Service users will continue to be facilitated to be involved and represented in our membership scheme. A range of learning and development opportunities will be offered to recognise and meet the different needs of individual Governor Members. The information provided to service users will continue to be reviewed. Facilities and Estates modernisation and service improvements will continue to address national/ local priorities to enhance patient/user experience. For example, our Facilities Manager is continuing to work with representatives from various groups, including patients, to improve the provision of food and Housekeeping Services on the wards. Students will be expected to select a topic for study that will be useful and relevant to the Trust, based on current local and national priorities. A list of topics that are almost all patient focussed will be produced to guide students in this selection. A local patient survey will be commissioned to invite all of our patients to comment on those issues highlighted in the national Mental Health Patient Survey. Results will be broken down to team level.

19 Accessible and Responsive Care That Place, Burton 19

20 Access for and responding to patients 20 The best services in the world are of no use to a person who cannot access them and access to services is a key concern for patients and carers. Once services have been accessed, they must be responsive, timely, offer choice and prevent unnecessary delay. We are working hard to ensure that this is the experience for all service users. Our Eating Disorders care pathways have been identified as best practice across the West Midlands by the Specialised Services Agency and our Prison In-reach services were successful in obtaining sponsorship from the Department of Health for a Second National Prison Conference to share learning across the country. The Trust listens to the views of patients, carers and the local community, including those facing barriers to participation, to learn about their priorities when designing, planning, delivering and improving healthcare. A further example of how we strive to involve staff, service users and carers in joint learning activities is provided by the Annual Clinical Governance Conference. Once again this year the Conference benefited from the input of service users and carers as both speakers and delegates:- Neil Carr, our recently appointed Chief Executive opened our 6th conference. Neil gave an inspiring presentation on Learning from the Past: Not Living in it and described how events in history led to the division of services to meet different health needs. This was a timely reminder of the inter-play between physical and psychological illnesses that corresponded with the launch of the Trust s new Integrated Physical Healthcare Pathway Marion Janner, a mental health service user and Director of Bright, was instrumental in developing the nationally renowned STAR Wards initiative. She graphically and skillfully portrayed what it was like to develop a serious mental illness and outlined what was really important to patients. Marion helped delegates to consider how vitally important it was that patients participate in self-management of symptoms and treatment, have a culture of patient mutual support, a programme of daily activities and good community ties. Cathy Riley, our new Chief Pharmacist gave a presentation titled Medicines Management Everybody s Business? She talked about the importance of good practice in prescribing, dispensing, administering, ordering and procuring medicines then focussed on the importance of compliance, helping delegates understand the importance of good information and choices. The Conference was attended by a full range of staff from all levels of the Trust as well as partner organisations. Evaluation questionnaires collected at the end of the Conference indicated that sessions were well presented, informative, interesting and had helped delegates to consider practical changes to services. We are also working with service users and carers at Directorate level. For example the Forensic Mental Health Services Directorate has an established Service User Involvement Strategy, a Carers Group and ongoing work involving service users in Service Developments that is growing. The Engage Service offers a provision for a hard to reach population of young offenders across the Staffordshire area. Engage with offenders between the ages of years, working closely with a wide range of services across the statutory agencies as well as the voluntary sector. The service has been established on inter-agency principles with a partnership group overseeing its operational functioning and strategic development. It offers a full range of services including direct work with the young people individually and/or with their family. The service also works closely with the professionals involved in the care of young people offering consultation support at regular events across the county including a rolling programme of training events. We have taken steps to ensure that all members of the population we serve are able to access services and to exercise choice in access and treatment, where appropriate, and we ensure that this is offered equitably.

21 What we have done Introduced a new four week rolling programme of therapeutic activities in Perinatal services, including a staff handbook for guidance. Provided de-escalation facilities at Margaret Stanhope Centre in Burton and the George Bryan Centre in Tamworth, providing greater patient privacy and dignity as well as improved security. Opened a Forensic Mental Health Services Intensive Care Unit with 6 intensive care beds. Reconfigured our In-Reach Intensive-Support Team (IRIS) as a Care Home Link Team in order to meet the needs of older people with behaviour that challenges. Identified current gaps in services and how to address them. Appointed a clinical psychologist to improve access to psychological therapies. Also hosting a Staffordshire University accredited course in Cognitive Behavioural Therapy (CBT) to improve access to this talking therapy in line with national recommendations. Developed a CBT Supervision Network via the CBT course to ensure standards for course trainees Appointed an additional Community Mental Health Nurse to work with people from ethnic minority groups Developed a Pre-therapy Programme in the Forensic Mental Health Service to engage service users at an early stage in therapeutic activities. Improved care pathways by increasing liaison and working practices between teams when transferring patients. One example is the improved coordination and delivery of care through a new Dual Diagnosis clinical pathway which will assure appropriate care for patients with mixed mental health and substance misuse issues Developed standard assessment documentation within Adult Community Mental Health and Social Care Teams to link into the Staffordshire-wide Care Coordination process and reduce the unnecessary duplication of patient assessments. Supported the work of voluntary groups such as the Carers Association to implement Alzheimer s Café s for people with dementia and their carers Learned more about reducing waiting times and implemented monitoring systems with early alerts if waiting times are rising; electronic booking systems for appointments; re-offering cancelled appointments; implementing New Ways of Working and role redesign and the Choice and Partnership Appointment (CAPA) system. Following integration with Shropshire based services, the Forensic Mental Health Service now has the expertise of forensic and rehabilitation specialist teams, enhancing the effectiveness of patient pathways. Incorporated service user involvement in the Children s Council. Patients and public have been involved in Peri-Natal Mental Health Service, Eating Disorder Service and Mental Health Prison In Reach Service re-design, development and improvement Patients in Specialist Services now have a choice of assessment, admission date, therapy, date/time of appointment, gender of therapist. Improved our reputation as a service provider of Mental Health Prison In Reach Services providing better support and closer working with prison primary healthcare staff. Re-designed a clear Acute Care Pathway to ensure that patients with emergency health needs are able to access care promptly and with appropriate priority. Provided an integrated care system in the Children s Directorate based on the needs of children and young people with complex problems and to provide seamless care. 21

22 Ensuring we continue to improve An audit and register of Cognitive Behaviour Therapy skills within the Trust is complete to first draft stage and will be consolidated. Mental Health services have accepted proposals for service redesign to increase staff resource dedicated to provision of psychological interventions. This incorporates New Ways of Working and clarity of pathways. Pathway reviews - Crisis Pathway, Early Facilitation of Discharge, Care Co-ordination - will address patient choice. There are key opportunities for Learning Disability Services including the development of new business cases to meet the increasing health needs of the population of people with learning disabilities. These include age related conditions; long-term conditions; epilepsy and mental health needs. Day Opportunities will be reviewed and a new strategy implemented. A clear consultation strategy Ensuring Real Engagement will build on the foundations of service user involvement, extending involvement to a wider community. The Service Development Strategy To Develop Services Together identifies what services we are proposing to develop in the future and how we move forward. The Mental Health Improvement Partnership Programme Advocacy to Exercise Choice and Value Based Work Streams will continue to focus on patients and carers needs. 22

23 Care Environment and Amenities Shelton Hospital, Shrewsbury 23

24 Safe, healthy places for patients The majority of our contact with patients and carers takes place within their own homes but there are times when either admission to hospital or an outpatient clinic visit is needed. Care must be provided in environments that promote patient and staff well-being and respect for patients needs and preferences. To optimise health outcomes for patients they need to be designed for the effective and safe delivery of treatment, provide as much privacy as possible, be well maintained and clean. We ensure compliance with the Disability Discrimination Act through policy development, staff training and adjustments to the physical environment. These improvements have been achieved through comprehensive disability access audits of all our premises followed by the completion of an improvement programme. We minimise the health, safety and environmental risks to patients, staff and visitors wherever possible. We do this in accordance with health and safety at work and fire legislation and the Management of Health, Safety and Welfare Issues for NHS staff (NHS Employers 2005). The Trust provides a secure environment, in accordance with NHS Estates building notes and health technical memoranda and takes account of A professional approach to managing security in the NHS (Counter Fraud and Security Management Service 2003) and other relevant national guidance. To support us in this work the Trust has appointed a new Security Management Specialist as part of our wider Risk Team Safety issues addressed include the protection of lone workers, manual handling and use of equipment and we respond to concerns as they arise. The Trust has taken steps to provide services in environments that are supportive of patient privacy and confidentiality including the provision of single sex facilities. The Trust is compliant with Department of Health guidelines on safety, privacy and dignity in Mental Health Units. We have done a tremendous amount of work to address this area using the Essence of Care framework, beyond just single bedrooms. Each in-patient facility makes a regular report on their progress on improving standards to the Deputy Director of Nursing. Care is provided in well designed and well maintained environments that meet the national specification for clean NHS premises as indicated in our ERIC and Patient Environment Action Team (PEAT) assessment results and Healthcare Commission Performance Management Indicators. A Basic Care Network for Shropshire and Staffordshire benefits from the leadership shown by Facilities and Estates which includes national initiatives and linking with clinical teams. Over the last year, a team has been working with the King s Fund on a project to Enhance the Healing Environment. Norbury House was chosen as patients from across the whole of the Trust are admitted to this area. Following a successful presentation to the King s Fund, the scheme gained approval and the King s Fund released monies early in the New Year which allowed us to complete that work. The work of our Facilities and Estates team was recognised by the Health Estates and Facilities Management Association (Hefma) when the team received Good Practice Awards for Strategy and Strategic Management and was awarded Facilities Team of the Year. 24

25 What we have done Ensured that patients have their own room, often with en-suite facilities. Developed a Map of Life for patients with dementia used on wards to identify individual needs, likes and interests. Provided patient information boxes in rooms that include information regarding the ward, their treatment plans, advice sheets and associated information, e.g. medication, Mental Health Act, and are lockable to promote confidentiality. Constructed seclusion rooms at Margaret Stanhope Centre in Burton and the George Bryan Centre in Tamworth in line with national guidelines. Completed building modifications in Horninglow Clinic in Burton to improve patient and staff safety/security, completed improvements to Norbury ward, refurbished New Burton House and White Lodge kitchens. Constructed a Forensic Mental Health Services Intensive Care Unit. Opened a new multi-agency centre in Burton-on-Trent; That Place. Updated the Facilities & Estates Strategy and Rationalisation Plan. Completed the NIMHE Environmental Audit of all in-patient areas to help minimise the risk of suicide attempts. Provided staff training and a comprehensive range of policies covering all the key issues, including protecting Trust physical assets and those of patients, staff and visitors. Ensuring we continue to improve Work on a Service & Estate review will be completed to clearly identify the Clinical and General Service Requirements for today along with plans/aspirations for the future. The redevelopment of Shelton Hospital in Shropshire is a major aspect of the Estates Strategy development, pulling together development requirements within the Trust and current/ potential links, with Health & Social and Private Partners. We are currently improving accommodation for the Lichfield Child and Adolescent Mental Health Services on the Holly Lodge site. There is now agreement to develop the following facilities for patients: a sensory room on Baswich ward; Developments to Chebsey and Brocton Houses and Kinver Ward. Clinical teams will continue to be offered advice and consultancy from a range of clinical and corporate support teams including Clinical Audit, Clinical Effectiveness, Performance Development, Finance, Human Resources, Facilities and Estates, Corporate Administration and professions such as Nursing. These teams are able to focus on application of the evidence and techniques required to improve the quality of services and practices, bringing about improvements to the experience of staff, patients and carers. 25

26 Public Health 26 Silk banner created by service users

27 Maintaining People s Health Helping people to maintain their health eases the pressure on the health system, is far preferable to treating people who have already become ill and reduces distress. Programmes and services must be designed and delivered in collaboration with all relevant organisations and communities to promote, protect and improve the health of the population served and reduce health inequalities between different population groups and areas. We continually strive to narrow health inequalities, promote, protect and demonstrably improve the health of the community served. This is evident throughout our Mental Health Improvement Partnership Implementation Plan. Prevention is also a cornerstone of the Staffordshire Risk Collaborative. The Trust actively works with partners to improve health and narrow health inequalities, including by contributing appropriately and effectively to nationally recognised and statutory partnerships. These include the National Prescribing Centres Medicines Management Collaborative, the local Mental Health Partnership Board, and the local Crime and Disorder Reduction partnerships. The Children s Directorate supports local antibullying initiatives and health promotion for emotional wellbeing and mental health via school based and primary health worker CAMHS involvement. Intensive Fostering is one of only 3 national pilot schemes. They are meeting all targets and on course for regional roll-out in The Trust implements policies and practice to support healthy lifestyles among the workforce. These include meeting the needs of staff experiencing pregnancy and parenthood in terms of taking leave and health and safety considerations. We have undertaken a number of Healthy Lifestyles Initiatives for employees including stress management, healthy eating and exercise supported by policies such as Positive Mental Health at Work, Alcohol and Drugs and Addictions. We have also introduced policies and guidance on obesity and have recently updated our policy on creating a smoke free environment to ensure new legal requirements are in place. The Trust has access to public health expertise to meet its strategic and operational roles. In relation to Infection Control we have to meet the following requirements:- Have a Director of Infection Control Produce and publish an Annual Report Have written implementation plans The Trust has up to date and tested plans to deal with incidents, emergency situations and major incidents and works with key partner organisations in the preparation of, training for and annual testing of major incident plans. 27

28 What we have done Started to operate a Primary Care Service within our Forensic Mental Health Services to address the difficulty patients have in attending community based services. Work is ongoing to develop the operational policy and its associated strategy. The primary care nurse, supported by a lead nurse for primary care from West Midlands Strategic Health Authority, is monitoring service users in accordance with the Quality and Outcomes Framework Indicators. Smoking cessation interventions for service user groups are beginning in preparation for the implementation of the legislation banning smoking from designated rooms within inpatient units from July 1st Enabled patients and staff to access gym /sports facilities on both Stafford and Shropshire sites. Paediatric psychology won an award for the obesity clinic designed to help children lose weight. Contributed to PCT Local Development Plans and associated actions that are informed by the PCT Director of Public Health priorities for their local community. We were actively involved in producing the vision for better healthcare across Shropshire & Staffordshire. Supported the local PCT to develop the new hospital in Lichfield. Collected, analysed and disseminated information on the health needs of the local population to support disease prevention and health promotion requirements of national service frameworks and national plans. In addition to the Staffordshire wide Clinical Risk Management Training Initiative other examples of initiatives include: the Thinking Ahead Project Partnership with Staffordshire Education Authority, local schools and the Schism theatre group to address mental health promotion in schools; Early intervention in psychosis audit and service specification; and infection control initiatives including action plans to meet all standards. Utilised health action planning with users of learning disability services to encourage them to maintain a healthy lifestyle. Asked all team leaders to routinely record the smoking status of all adult inpatients. Developed and tested clear plans identifying our role in all types of major incidents. Ensuring we continue to improve A number of learning events are planned, including a presentation of the Depression map developed last year to senior people in local PCTs and an infection control open day planned for June 20th The Developmental Neurosciences and Learning Disabilities Directorate have agreed a Strategy with all agencies which has identified funding over the next three years for the enhancement of specialised community teams. Diagnostic and Treatment Centres will offer a one-stop shop for individuals able to access services with not only mental health professionals but also primary care workers, social services, education and housing. It is envisaged this multi-agency approach will become a model of good practice and true integration. Rehabilitation Services based on the recovery model will further develop to enhance the quality of life for service users, reduce the use of acute admission beds, facilitate health promotion activities and reduce stigma. Stronger links, collaborative working, sharing good practice and joint initiatives across the Staffordshire and Shropshire health and social care economy will continue to develop as a way of making best use of resources. Stronger service partnerships with Staffordshire Social Services will be sought. For children, the Education Department is also a vital and authoritative partner with whom we aim to further develop our relationship. There are representatives on all the sub-groups of the Staffordshire Partnership Board and strong links have been made with other agencies. These include the Healthy Living Centre Health net developed in partnership with the Local Authority and Primary Care Trust. The Trust will continue to work with PCTs to achieve the longer-term vision of high quality, effective responsive services. We will support General Practice to achieve National Service Frameworks, the performance measures identified in Better Metrics and other health targets. 28

29 Modernising Clinical Governance The Marches, Shelton Hospital, Shrewsbury 29