BEST CARE BY THE BEST PEOPLE. Quality Account 2015/16. Best care by the best people

Transcription

1 BEST CARE BY THE BEST PEOPLE Quality Account 2015/16 Best care by the best people

2 2 Page 2 NELFT NHS Foundation Trust I Quality Account 2015/16

3 Contents Foreword from the chief executive 4 Statement from the chief nurse and 6 executive director of integrated care (Essex) Introduction to the Quality Account What is a Quality Account and why is it important? 8 Development of our quality priorities for 2015/16 8 Quality Account governance arrangements 8 How to provide feedback 9 Part one Introduction to NELFT 1. Description of our services Our values NELFT awards and achievements Our strategic direction Engagement NELFT management structure Equality and diversity Highlights from 2015/16 16 Part two Looking forward Priorities for improvement 2016/ Improvement priority Improvement priority Improvement priority Governors selected local indicator Service user surveys Statement of assurance from the board Participation in clinical audits Participation in clinical research NICE compliance Commissioning for Quality and Innovation 38 (CQUIN) targets 2016/ Registration with the Care Quality 39 Commission (CQC) Data quality NHS number and general medical practice 41 code validity Information governance assessment report Clinical coding error rate 41 Part three Looking back Review of our quality performance in 2015/ Progress against each of our 2015/16 44 priorities 3.2. Serious incidents and complaints feedback Complaints Safeguarding Legionella Benchmarking Monitor risk assessment framework Monitor core indicators Our workforce Commissioning for Quality and Innovation (CQUINS) payment 2015/16 65 Appendix 1a Clinical audits - 66 NELFT participation in national clinical audits and national confidential enquiries Appendix 1b Clinical audits - 67 requirements and actions taken Appendix 1c Falls data 70 Appendix 2 Quality Account 71 governance structure Appendix 3 Third party comments 66 Appendix /16 Statement of directors 85 responsibilities Appendix 5 Auditors limited assurance report 86 governance structure Glossary 89 Useful contact numbers 93 NELFT NHS Foundation Trust I Quality Account 2015/16 Page 3

4 Foreword This is our eighth quality account and I am delighted that we continue to evidence a clearly improving trajectory with new awards for our services, a progressive plan for innovation and a big focus on a new programme of Quality Improvement. Whilst austerity has been a repeated source of concern in public services over the past year, it has not dampened the enthusiasm of our staff as they continue to strive to improve the experiences of our patients and service users. We continue to see national challenges in maintaining standards across the NHS and continued pressure in recruitment in an increasingly competitive environment. Recruitment of high quality staff in the NHS is a challenge for most organisations but retaining good staff is an equal challenge and we have been putting systems in place that support that aspiration. As an organisation we have become much more sophisticated in tracking patient, service user and staff satisfaction and putting in place learning processes which will in time support us in improving what we do. We have invested time and resources into engaging staff in a meaningful way and worked hard to understand where we might learn from them and our patients and service users by using their feedback to change systems, services and processes. We have seen some gains from this in the number of staff returning their annual staff survey questionnaires and areas of improvement in the overall staff feedback although we still have a lot to do. One example of this is that we have changed the leadership systems in the organisation. Clinicians now plan and run the clinical executive and this has been the focus for the development of a new strategy that seeks to move us from good to best. This forum has also been the platform on which we have launched a major programme of systematically developing and managing quality improvement initiatives. In partnership with the London Borough of Barking and Dagenham we have seen significant developments in Care City and this quality improvement programme has received its first major investment award from the wider public service market. This investment has come in the form of its approval as an NHS England technology test bed with a grant award of nearly 2millionn. Care City has also recently succeeded in gaining support for the local area as a designated Health New Town. We have also seen major innovation and new ideas being implemented in nurse rotation, physical health checks in mental health, the integration of health and social care contracts in the London Borough of Redbridge, more integrated care ideas and the new Emotional and Wellbeing Mental Health Services 4 Page 4 NELFT NHS Foundation Trust I Quality Account 2015/16

5 (EWMHS) in Essex, which joined NELFT in November NELFT services have also been cited in national reviews on at least three occasions where they are marked out as being the standard for others to aspire to. Finally, we have seen major awards and recognition for some of our cultural change initiatives such as our Black and Minority Ethnic (BME) network. It would not be possible to list all of the initiatives that NELFT staff are delivering although much can be learned about them through further reading of this account. Most importantly, the evidence above clearly demonstrates that NELFT continues to benefit from the tireless efforts of its professional staff and its total commitment to continuous quality improvement. John Brouder Chief executive To the best of my knowledge the information presented to you in this account is accurate and provides a fair representation of the quality within the organisation. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 5

6 Statement from the chief nurse and executive director of integrated care (Essex) In NELFT our ambition is to provide patients, service users, relatives and carers with the Best care by the best people. Our patients and service users deserve the safest and most compassionate care we can provide, and in doing this it is important to acknowledge our mistakes and learn from them. As chief nurse, I am proud of our on-going achievements and the challenging plans we have set for ourselves over the next year. The Quality Account sets out a number of areas that we need to focus on. These have been influenced and identified by our patients, service users, staff and partner organisations; by listening to their views and comparing ourselves with others we ensure we focus on what matters to the people we serve. For the coming year our priorities are: Working together for service users and patients To embed duty of candour in practice, ensuring we are providing openness and transparency in care delivery. Commitment to quality of care To easily identify patient and service users with a learning disability so to make reasonable adjustments to their care thus improve the quality of care we deliver. Respect and dignity To improve the end of life care experience of people receiving support from NELFT services, ensuring positive outcomes for people approaching end of life, and those that are important to them. The Quality Account is a vital snapshot of our achievements and whilst it shows areas where we have progressed well, there are clearly areas where further improvement is still needed. Key to our success and achievement are our people; particularly as we continuously respond to the changing needs of the health of our communities, the remarkable and welcome improvement in the life expectancy of older people along with a changing social and financial landscape. As a trust, we believe that service user experience is inextricably linked to staff experience. Prioritising engagement and involvement of staff has been central to the work of the NELFT board over the past few years. This year we have developed a Well Together strategy to focus ever more keenly on the wellbeing of our workforce. This includes a number of call to action areas such as recruitment, retention and staff wellbeing. The call to action was to ensure maximum involvement of staff across the organisation who were consulted to seek and develop the solutions. The pressures of work are often relentless but with a truly talented workforce in NELFT, who always give their best to achieve the best, I continue to feel like the most envied of all chief nurses across the country. The Quality Account is our opportunity to share with you not 6 Page 6 NELFT NHS Foundation Trust I Quality Account 2015/16

7 only our achievements but our plans for the year ahead. We remain committed to getting the basics of care right, learning from staff, patient and service user and carer experience and ensuring national best practice is the norm. NELFT is recognised as one of the leading organisations nationally for supporting the BME agenda with our chief executive, John Brouder making a personal commitment to back the introduction of the Fair For Everyone initiative. The initiative s aim is to encourage staff to confront the day-to-day perceptions and behaviours that lead to some people being treated unfairly or less equally. At NELFT the Fair For Everyone initiative is a requirement for all. By investing in the wellbeing and professional development of staff, we invest in improving the patient and service user experience and achieving our ambition of providing high quality, safe, compassionate care. Stephanie Dawe Chief nurse and executive director of integrated care (Essex) NELFT NHS Foundation Trust I Quality Account 2015/16 Page 7

8 Introduction What is a Quality Account and why is it important? Our Quality Account provides a continuous process for us to engage with patients, service users, staff, partner organisations, stakeholders and members of the public in an open, transparent way in order to scrutinise our processes. By doing this, we seek to improve the quality of services we provide year on year and embed those improvements in to our everyday practice. Our Quality Account is an annual report split in to three sections: an introduction to NELFT, our services and our commitment to quality (Part 1) looking forward and setting our priorities for the coming year 2016/17 (Part 2) our progress on 2015/16 priorities (Part 3) Development of our quality priorities for 2016/17 Continuous improvement is a top priority for the trust and our aim is to develop meaningful quality indicators that can be monitored, reported and scrutinised by all. The Quality Account provides a framework where improvement priorities can be developed which reflect local need, but that can also be adopted across NELFT. We have again consulted widely with stakeholders and invited participation in our quality account questionnaire for setting quality priorities for 2016/17. This year saw a 42 per cent rise in the number of overall responses, a significant increase from last year. Responses were across age groups and included a high proportion of NELFT staff responses (58 per cent), demonstrating how important the quality of patient and service user care is to our staff. The collated results from the consultation indicated that NELFT should focus in the coming year on: working together for service users and patients commitment to quality of care respect and dignity Quality Account governance arrangements The chief nurse and executive director of integrated care (Essex) has overall responsibility for the NELFT Quality Account. Production of the Quality Account is the responsibility of the director of performance and business intelligence. Clinical locality leads are engaged to produce the content of the Quality Account by working with clinical staff to shape improvement indicators in line with the priorities identified by stakeholders through the quality questionnaire. Progress reports on each of the quality improvement priorities are reported to each clinical locality s quality and patient safety group bi-monthly and to the quality and safety committee (which is chaired by a non-executive director) half yearly. The chief nurse group oversees the Quality Account process where it is formally reported quarterly and 8 Page 8 NELFT NHS Foundation Trust I Quality Account 2015/16

9 in turn, reports to the executive management team, which then report to the NELFT board. Data quality is assured through NELFT s data quality group and through audit processes (both internal and external). Address: NELFT NHS Foundation Trust Suite 1, Phoenix House Christopher Martin Road Basildon, Essex SS14 3EZ. See appendix 2 for our Quality Account (QA) governance structure. How to provide feedback on this Quality Account We hope you find this report useful and informative. We welcome your feedback on how we can improve our Quality Account next year. If you would like to give us feedback on our Quality Account 2015/16, please contact: Julie Price, director of performance and business intelligence julie.price@nelft.nhs.uk Tel: ext NELFT NHS Foundation Trust I Quality Account 2015/16 Page 9

10 Part one NELFT is a growing organisation serving a population of over 2.8 million across north east London and Essex. Over the last five years, we have continued to work towards our aim in becoming a fully integrated healthcare provider offering a complete pathway across mental and physical health. Our most recent acquisition has been the Emotional Wellbeing and Mental Health Service (EWMHS) in Essex, which provides early intervention, support and mental health services for children and young people. We now employ approximately 6000 staff and have an annual turnover in excess of 350 million. 1. Description of our services NELFT provides mental health and community services for people living in the London boroughs of Barking and Dagenham, Havering, Redbridge and Waltham Forest and people living in Essex. We provide these services in a range of settings including health centres, community hospitals and people s own homes. We work closely with a range of partners to provide the best possible care for patients and service users. NELFT provides mental health and community health services including: services for people experiencing acute mental illness help for children and young people with emotional, behavioural or mental health difficulties care for people with dementia support for people with problems associated with drug and alcohol misuse specialist services for people with a learning disability care and support for people living with long term conditions such as diabetes speech and language therapy health visiting, district and school nursing community dental services many services that in other areas may be provided in hospital, such as blood testing, foot care and children s audiology NELFT provides added quality and value through service developments including: mental health input into long term physical conditions such as diabetes, stroke and lung disease physical health of people with mental problems providing treatment at home and in the community reducing demands on hospital services innovative transformation of health services 1.1 Our values NELFT has a core set of values outlining what is important to our staff and the people who use our services. 10 Page 10 NELFT NHS Foundation Trust I Quality Account 2015/16

11 People first We remember that patients, service users and carers are our top priority, and treat others how we would like to be treated. Prioritising quality We provide the best service possible, following best practice and national developments. Progressive, innovative and continually improving We listen and continually improve our services for the benefit of our patients, service users and carers. Professional and honest We work to create relationships based on honesty, respect and trust, and meet the highest standards of professionalism and confidentiality. Promoting what is possible independence, opportunity and choice We help people achieve the best quality of life possible, giving them the information and support they need. 1.2 NELFT awards and achievements (2015) We pride ourselves on providing the 'Best care, by the best people' and although the majority of our patients and service users tell us they would recommend our services to other people, we are proud this has further been endorsed by winning some high profile external awards. We were delighted our Ethnic Minority Network was named the best in the country when we beat off stiff competition from other public sector and private sector organisations to scoop the Employee Race, Ethnicity and Cultural Heritage Network of the Year at the Inclusive Networks awards. We were named most streamlined trust in core skills at the Streamlining London Awards For many years, staff have commented they repeat training unnecessarily when they move organisations, so we changed this to ensure all appropriate and in-date mandatory training can come with them. The London streamlining project we took part in harmonises mandatory training across 36 trusts to ensure that we train the right people, on the right topics and frequency, for the right amount of time in accordance with the national core skills framework. Nurse consultant Geraldine Rodgers won the prestigious Royal College of Nursing s Nursing Older People award. The Nursing Older People Award is for nurses who have made an outstanding contribution to the care of older people, and who can clearly demonstrate that they have developed initiatives to either support independent living or improve physical and emotional care in care homes or hospitals. Dr Mohan Bhat, director of medical education, was named Psychiatric Trainer of the Year 2015 at the Royal College of Psychiatrists Awards. The award judges said "Dr Bhat has succeeded in transforming the medical education department at NELFT. We have hosted many events throughout this year including: Nurses Day celebration A celebration of the fantastic work our nurses are doing. This year, our Nurses Day was attended by NHS England, chief nurse, Jane Cummings who joined our hundreds of nursing staff. NELFT NHS Foundation Trust I Quality Account Page 11

12 Ethnic Minority Network Conference More than 200 colleagues from across our organisation gathered for the fourth annual Ethnic Minority Network staff conference in November. The conference heard from guest speaker Roger Kline, research fellow, Middlesex University and director, NHS Workforce Race Equality Standard (WRES). Attendees got involved in lively workshops, which centred on 'how does equality and diversity create a competitive advantage for our organisation'. NELFT s Sports and Wellbeing Day Our staff joined our service users, partners, governors and special guest, GB Paralympian Martine Wright - at the tenth NELFT sports, health and wellbeing day in July. The day, which promotes the benefits of good physical health on overall wellbeing was also an opportunity for our people to take part in range of sports including, the popular five-a-side football competition hosted by professional Leyton Orient Football Club referees; rounder s competition; tugof-war and old school sports races. Learning Disabilities Conference Learning Disabilities Week was marked with a conference centred on the theme Future of learning disabilities services, and was a fantastic opportunity to showcase the hard work all our disabilities services do. End of year celebration Hundreds of staff were recognised for their continued hard work at our Make a Difference end of year celebration. The evening also celebrated our Make a Difference winners who have gone above and beyond in their roles to ensure we continue to provide the best care to our patients and service users. Photos clockwise from left Ethnic Minority Network with the Employee Race, Ethnicity and Cultural Heritage Network of the Year award, Nurses Day celebration, Sports and wellbeing day and Geraldine Rodgers receiving the Royal College of Nursing s Nursing Older People award. 12 Page 12 NELFT NHS Foundation Trust I Quality Account 2015/16

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14 1.3 Our strategic direction NELFT stands out as one of a diminishing number of foundation trusts that have been able to maintain their good finance and governance ratings. However, quality remains at the heart of everything we do. In increasingly challenging times we have worked hard to generate plans that are consistent with the Five Year Forward View. We continue our efforts to maintain a strategy that allows us to live within the austerity demands of a future NHS and public service environment whilst continuing to drive up quality. We will continue to: aspire towards treating more people at home and in their local communities integrate across several domains of care and organisational boundaries to deliver the best integrated care options to the people that we serve invest to be the best and to ensure that our staff meet that standard maintain our investment in new technology to optimise both our clinical standards and the efficiency of the services that we deliver Care City is fast developing and evolving as an important partnership creating the drive for technology innovation and community regeneration which must be a cornerstone of future quality development. This will be the test bed in which NELFT, in conjunction with the London Borough of Barking and Dagenham will evolve models that will move us away from paternalistic public services to independently minded communities who are taking back responsibility for their future care and quality of life. This will be evidenced as we progress the Vanguard and Accountable Care Organisation (ACO) models locally. The changes that characterise public services today demand a different more mobile and agile workforce with a wider set of skills and competencies. Those elements of service that serve to add real value such as research and development will continue. Quality improvement has become a mainstream activity across all our services and leadership for the strategic development of quality remains with the clinical executive of the organisation which is chaired and managed by clinicians. Despite the changes nationally and the shifting emphasis for care we fully expect this strategy to continue to improve our position and the service user experience. 1.4 Engagement NELFT works closely with governors and holds a monthly forum which provides governors with the opportunity to meet our NELFT chair and chief executive to discuss key strategic issues. Governors meet with the chairs of the board sub committees in order to better understand the role and work of committees in continually reviewing the quality of the service we provide. We also hold a joint workshop with board members and governors once a year to discuss forward planning. Non-executive directors, regularly visit clinical services to better understand the service provision, and also to meet with staff and service users and hear about their experiences first hand. Governors are also involved in mock Care Quality Commission (CQC) inspections and Patient- Led Assessment of the Care Environment (PLACE) visits, which gives them the opportunity to have a conversation with service users about their experience. The trust communicates with our local population via our website and social media platforms including Twitter, Facebook and LinkedIn which provide a forum for engagement and discussion as well as a means to provide information. A range of public activities and events are open to patients, service users, carers and the local community throughout the year. Printed patient and service user literature is available at all sites providing information about services. Strategic Patient Experience Partnership group Each locality holds a quarterly Patient Experience Partnership group (PEP). These have been established to monitor the quality of patient/service user/carer experiences of services. The chair and vice chair of the PEPs are patients and service user members, with integrated care directors and directors of nursing in attendance. An overarching strategic patient experience partnership group reports directly to the trust board. Key agenda items: Quality Accounts survey reporting and friends and family test safer staffing sign up to safety smoke free 14 Page 14 NELFT NHS Foundation Trust I Quality Account 2015/16

15 NICE guidelines equality delivery system mobile working CQC preparedness locality PEP updates 1.5 NELFT management structure Our operational structure has been formulated according to local authority and Clinical Commissioning Group (CCG) boundaries. This allows the locality directorates to establish close working links with the communities they serve as well as external stakeholders and partners. It also facilitates the ability of teams to better integrate mental health and community health services in our London boroughs and provides a good foundation to be responsive to the differing needs within the diverse population served in Essex. It is expected that this will further enhance the service user experience and allow teams to work more effectively for the service user. The locality directorates are as follows: Barking & Dagenham Havering Redbridge Waltham Forest Basildon and Brentwood Thurrock MHIPAD (Mental Health Inpatient and Acute Directorate) - this directorate has been realigned for 2016/17 to Acute and Rehabilitation services, covering both MHS and CHS in our London boroughs 1.6 Equality and diversity Equality and diversity remains a priority in everything we do. Our aim is to develop a culture which values both its staff and patients and service users and to have processes and systems in place which pro-actively promote equality for all and embrace diversity. The strategic equality and diversity group is led by the executive director of human resources and organisational development. The group aims to help identify steps to improve performance in the area of equality and diversity, which are then addressed and embedded via the London and Essex equality and diversity groups. The aims of the groups are to ensure that services are designed to meet the needs of our staff and of the communities we serve and: ensure our patients and service users, carers, partners and stakeholders are effectively engaged in service provision ensure that our workforce reflects the communities we serve that our workforce is free from discrimination, bullying, harassment and victimisation ensure all staff have the skills and abilities to work with the diverse communities it serves everyone feels assured that the trust is fair to all and values its staff As a public sector organisation we are expected to comply with the legal duties of the Equality Act 2010, which includes publishing four key objectives and monitoring arrangements: We continue to develop and monitor compliance with the completeness of diversity monitoring data for service users across all services. Last year we developed a monitoring tool which has been aligned with the electronic service user records systems, a patient/ service user information leaflet, and posters (both in large print and easy read). This year we will embed these in the electronic records audits cycle to monitor compliance and develop diversity monitoring score card for all services. The ethnic minority staff network strategy has been reviewed and will focus on the development of ethnic minority ambassadors for each of our integrated care directorates and for corporate services, implementation of reverse mentoring and a leadership training course for bands 5-7 (both clinical and non-clinical staff) and expanding the representation of ethnic minority staff on interviewing panels for band 7 posts. Development of strategies for the Lesbian, Gay, Bisexual and Transgender (LGBT) Staff Network group and the Disability Staff Network group. Embed diversity monitoring processes for complaints, incidents and serious incidents reports so as to assess the impact for particular protected characteristics, and to develop specific training needs to equip staff and empower service users. NELFT NHS Foundation Trust I Quality Account Page 15

16 In addition to the four key objectives, NELFT will also concentrate on the following: monitor detentions of service users under the Mental Health Act and admissions to mental health services by the 9 protected characteristics equality impact assessments are carried out for service changes, commissioning of new services, service provision and policies, assessing both the quality and quantity of impact assessments improving access and communication for patient/ service users, for example information leaflets in different formats expanding external networks. NELFT is a member of the following charities, which support the organisation to comply with the equality act, they include; the Gender Trust, ELOP, Stonewall and Enei (Employment Network for Equality and Inclusion) themed review of disciplinary and harassment cases Human Rights Act training for managers The NHS Council for Equality and Human Rights announced the publication and implementation of the Workforce Race Equality Standards and the Equality Delivery System 2 (EDS2), which are now mandatory for all public sector organisations: implement and monitor our compliance with the Workforce Race Equality Standards. carry out a self-assessment of our compliance with the EDS2, to be scrutinised by our stakeholders, service users and carers, voluntary sector organisations, Healthwatch groups and commissioners NELFT equality and diversity action plan is aligned with the requirements of the EDS2 implementation of the NHS Accessible Information Standards, which is not just about information but how we communicate with service users with a disability or a learning disability so that they can be more involved in their health and care this will include developing policy and procedures, changing human behaviours and having robust electronic systems 1.7 Highlights from 2015/16 Barking locality Intermediate care reconfiguration in Barking, Havering and Redbridge (BHR) CCG economy Building on our successful reconfiguration of intermediate care services in partnership with the BHR Clinical Commissioning Groups (CCGs), NELFT has continued to enhance and develop our intermediate care services. The Community Treatment Team (CTT) and Intensive Rehabilitation Service (IRS) supports the planned reduction of our intermediate care bed base in the BHR CCGs, treating more service users in their own homes rather than requiring an admission into an acute or intermediate care bed. In 2015/16, the model has continued to be refined with the implementation of planned reductions in the intermediate care bed base. All intermediate care beds for the BHR CCGs are now located at King George Hospital, in Foxglove and Japonica wards. The transition of the intermediate care beds has been seamless and has had local support from stakeholders and service users. The service has been closely monitored by NELFT and our commissioners evaluate impact and ensure high quality services are provided as an alternative to the previous bed based model. Patient and service user satisfaction rates for all three services remain high and in quarter 3 of 2015/16 our satisfaction rates for these services are summarised below: Intermediate care beds service users expressed their level of satisfaction with the service they received by scoring BHR intermediate care beds service an overall 94 per cent on how likely they were to recommend the service to their family and friends Havering patients rated their satisfaction as 96% Barking and Dagenham patients rated their satisfaction as 92% Redbridge patients rated their satisfaction as 94% 16 Page 16 NELFT NHS Foundation Trust I Quality Account 2015/16

17 Community Treatment Team (CTT) service users expressed their level of satisfaction with the service they received by scoring BHR CTT service an overall 96 per cent on how likely they were to recommend the service to their family and friends Havering patients rated their satisfaction as 100% Barking and Dagenham patients rated their satisfaction as 93% Redbridge patients rated their satisfaction as 94% Intensive Rehabilitation Service (IRS) users expressed their level of satisfaction with the service they received by scoring BHR IRS service an overall 96 per cent on how likely they were to recommend the service to their family and friends Havering patients rated their satisfaction as 93% Barking and Dagenham patients rated their satisfaction as 100% Redbridge patients rated their satisfaction as 94% Havering locality Community health and social care services As reported in our 2014/15 Quality Account, we continue to embed the work we developed last year to enhance Community Health and Social Care Service (CHSCS) in Havering. The CHSCS service which operates across six clusters in Havering is a multidisciplinary team of community nurses, therapists, support workers and administrative staff working at a cluster level to deliver support to service users aligned to a group of GP practices. This work has been further enhanced by the co-location of this service with adult social care; two clusters have co-located in Cranham and Harold Hill. Due to local estates challenges with relocation of other staff to accommodate these moves there has been some delay in the co-location of the service into the final two clusters. This is now due to be completed by June The opening of the Acorn Centre NELFT was aware of the difficulty associated in delivering specialist children s services in Havering and we have been working over the last three years to develop a specialist children s centre in Havering. Previously the lack of a dedicated specialist children s centre in Havering had an impact on service delivery with the range of services being offered over ten locations in Havering with no central point of contact for parents of children with complex needs. The Acorn Centre has been developed with stakeholders, service users, commissioners and parenting groups in Havering to develop the centre which formally opened in July We also worked with patient and service users and parenting groups in a painting competition which resulted in patient and service users art work adorning the walls of the new centre. The principle of the specialist children s centre is to enable a hub and spoke model with the hub being located at the Acorn Centre and outreach clinics or spokes to be delivered at other locations in the borough to support access to these services. The relocation to the Acorn Centre has been further advanced by developing a single referral process for an all specialist children s service in Havering so that GPs, healthcare professionals, social care staff and parents have one point of contact for referrals and we can ensure a more timely and appropriate response to referrals to the service. Barking and Dagenham locality Children s services Targeted children s services in Barking and Dagenham have implemented a Single Point of Access (SPA) to ensure that all referrals are managed on a best place, best person to see them and right priority basis. This has helped to reduce duplication and multiple assessments for children and their families and ensure that children can be seen by the most appropriate professional. Joint clinics are also being run between paediatrics and psychiatry on the autism spectrum disorder care pathway. A range of care pathways are now being integrated into the local offer. In addition,mindfulness NELFT NHS Foundation Trust I Quality Account Page 17

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19 groups for parents have also been set up to support the parenting aspect of care within the services. A transition pathway for children from the Children and Adolescent Mental Health Service (CAMHS) to adult mental health services has been developed and ratified within the trust. This is in response to the need to ensure that young people and their families feel supported in how their care is moved from one clinician to the next and that appropriate joint working can take place so that there is a very clear handover and care plan agreed with managed expectations. This has enabled young people from the age of 17 to be effectively co-worked with both CAMHS and adult workers and has helped young people to get to know the staff over a longer period of time. The Listening Group is a children and young people s participation and engagement group in Barking and Dagenham working in partnership with a local media company to develop a video that supports the training of CAMHS practitioners from the young person s perspective. Adult services One of our Community Health and Social Care Service (CHSCS) won the CCG Partnership award in September 2015 for the work they have done in building community capacity and relationships with local GP s and the network of local providers. Within our mental health services we have employed registered general nurses to support the increase in screening and physical health checks, so that those most vulnerable can receive equal parity for both physical and mental health concerns. This has helped to increase the number of patient and service users who have actively been screened and then received brief interventions and onward signposting or referral for health issues that could affect their life expectancy. The dementia pathway has been reviewed in partnership with Dementia UK, local health services, GPs and the local authorities in the BHR economy area. This has helped to clarify what a service user can expect to receive, when they would receive it and supports the management of expectations for both service users and their carers. This also includes earlier identification of support and access to community and voluntary sector services to enable people to live more active and engaged lives whilst managing the progressive nature of dementia. The memory service for Barking and Dagenham achieved an Excellent Accreditation Award through the Memory Services National Accreditation Programme (MSNAP) accreditation process. Redbridge locality Mental health services Mental health services in Redbridge have seen the development of a central hub for the services based at Mellmead House in Wanstead. Mellmead already was the home to the community recovery and assertive outreach teams, who have now fully integrated into one service. This has allowed people to be supported and treated who have a range of complex mental health needs. The borough access and assessment team is now also accommodated at Mellmead House, allowing people who have mental a health problem to access help and treatment. The co-location of these services has ensured people can access a range of help in one place, for short or longer terms according to their needs. Redbridge has managed the Early Intervention in Psychosis (EIP) service across London. There is a strong evidence base to suggest that the earlier that a person receives intervention for an emerging psychosis, the better the lifetime outcomes will be for them. To this end the Government has introduced waiting time standards that state that by the 31 March 2016, 50 per cent of people who are potentially experiencing a first episode of psychosis should be assessed and allocated a person to co-ordinate their care within fourteen days. By the end of January 2016, 82 per cent of people with first episode of psychosis were allocated to a care co-ordinator within 14 days. Children s services Children s services in Redbridge moved into a new child development centre called Grovelands in Work has continued during 2015/16 to develop an integrated model of care based around clinical care pathways. Redbridge services have successfully introduced three of these pathways and are working to implement the remaining 13. The integrated model development will in time see the CAMHS service currently located at Loxford Hall, move to Grovelands to develop a service that meets the physical and emotional needs of children and young people. Planning permission NELFT NHS Foundation Trust I Quality Account Page 19

20 to extend the Grovelands building has now been obtained and the fully integrated service should be operational by the end of 2016/17. Community health services The community health services in Redbridge have seen a review of the service delivery during 2015/16. This has seen the number of teams reduce from seven to four during the year, enabling NELFT to align the service with the four GP clusters within the borough. This has enabled closer working with some GP s during the year. Throughout the year significant work has been undertaken in preparation for the delivery of an integrated model of health and social care, delivered in partnership with the London Borough of Redbridge. The new service which has been in preparation throughout the year commenced in April 2016, and is based in four new locations, again aligned with the four GP clusters. NELFT is the lead provider in the new partnership known as HASS (Health and Adult Social Services) and will manage the social care staff on behalf of the London Borough of Redbridge. This innovative model of service will lead to people who have a health and/ or social care need being able to access support from one place. The model will also see improvements in working with local GP services, through the development of closer working relationships. Waltham Forest locality Following a successful tender bid by NELFT, the new Waltham Forest falls prevention service came into existence on the 1 October This newly established team provides specialised assessment and treatment for people in the community who have had falls, have a fear of falling, poor balance/ mobility or who are considered to be at risk of falls. The service is easily accessible to all including the public who may have concerns about falling or just need some advice and information on general falls prevention. The multidisciplinary team consists of therapists, nurses, rehabilitation assistants and administration staff who work closely with GPs, other health and social care professionals, plus the voluntary sector. One important area for the team is the education of care home staff and staff within extra care sheltered housing schemes, which tend to have residents who are at high risk of falls and subsequently have numerous London Ambulance Service (LAS) call outs and/or A&E attendances. Within the first three months of the service starting, over 130 staff from these establishments had falls prevention training which staff found very helpful and said that it would change their behaviour when dealing with falls service users. Positive feedback has also been received from other services and voluntary groups as falls prevention was seen to be a gap in community provision in the past. So far, nearly 90 per cent of service users seen by the falls prevention service have seen improvement in their overall balance which in turn will reduce their risk of falls Waltham Forest rehabilitation services inpatient unit is based at Ainslie rehabilitation unit, Chingford. This 32-bedded unit offers adults over the age of 18 who live in Waltham Forest with a Waltham Forest GP multidisciplinary physical rehabilitation in purpose built setting. In 2015/16, this service achieved excellent outcomes in patient care by reducing length of stay from around 35 days to just less than 19 days by facilitating early discharge and continuing rehabilitation in a person s own home on discharge. This resulted in 90 per cent of patients admitted had an improvement in their activities of daily living between admission and discharge from the unit. There were no acquired pressure ulcers on the unit in 2015 (using the modified Barthel index which is an ordinal scale used to measure performance in activities of daily living). In August 2015, the unit had an unannounced inspection by the CQC whose summary findings reflected the high quality services delivered in the unit: The service had agreed referral pathways and procedures in place. Waiting times to access the service were short. Integrated care and joint assessments with allied health professionals were in place. The Ainslie unit was clean, hygienic and well maintained. There were robust arrangements in place to store, manage and administer medicines. Care and treatment records were fit for purpose, appropriately stored and readily accessible to staff. The trust's vision and values were known to and promoted by staff and underpinned the care and treatment delivered on the unit. There was clear leadership of the unit at a local level and corporate level. Patients we spoke with were very positive about the care and treatment they received. 20 Page 20 NELFT NHS Foundation Trust I Quality Account 2015/16

21 The CQC also commented on the Butterfly Scheme which is in operation on the unit where the butterfly symbol is used to identify patients who had been identified with dementia. This acts as a visual prompt to aid staff to provide the best care for patients on the ward with a diagnosis of dementia so care is targeted to effectively manage and meet their needs. Since receiving an excellent report from the CQC, the unit has also been involved in other initiatives/ projects such as the use of a pop up Reminiscence Pods (REMPOD), which work by turning any care space into a therapeutic and calming environment especially for those with dementia. In addition, the unit is involved in the John s story pilot; welcoming carers to remain with dementia patients in hospital for as many hours as needed to offer support. This will enhance the care for patients with dementia and delirium to make it an integral part of care to patient on a daily basis. The service also celebrated Older People Day in October 2015 with the Chartered Society of Physiotherapy, Transport for London, London Borough of Waltham Forest sports development team, and GLL leisure team; a Route Master bus was parked on site for patients and visitors to get on and off as a way of assessing balance and advice on falls prevention, local leisure activities and opportunities were given. NELFT has recently introduced a pilot for the provision of slow stream rehabilitation for more complex patients on the Waltham Forest Rehabilitation Unit in collaboration with Waltham Forest CCG. This pilot started in December 2015 with a view of developing out of hospital pathways that will support the most appropriate people to have effective rehabilitation in a community bed rather than in an acute hospital. Targeted children s services in Waltham Forest have integrated and a single point of access has been created to ensure ease of access to services and to reduce duplication and multiple assessments for children and their families. Joint clinics are also being run between paediatrics and psychiatry on the autism spectrum disorder care pathway. Parenting programmes are also being jointly delivered to promote accessibility. Other examples of innovation include an occupational therapistrun football club for children with disabilities/confidence issues and a tai chi club for children on the physiotherapy caseload. Basildon, Brentwood and Thurrock localities (BB&T) This last year has been very busy in BB&T localities - most of our services have been reviewed to ensure that they are delivering as required and meeting local residents needs. We have strengthened many areas of service in response to feedback from our patients and service users, carers and referrers. Some key examples include: Introduction of a single point of access for all targeted children s referrals. By introducing this service we have simplified the referral process for GPs and other professionals and ensured that referrals are reviewed, triaged and allocated/responded to in a timely manner Issuing an adult consultation (discussion document) during 2015 and holding many staff engagement events to agree a model for adult community services that meets the needs of our local residents and ensures a streamlined pathway. We are at the early stages of implementing the changes including an access and assessment service and integrated community teams that focus on care co-ordination for local residents with complex needs. In addition, we have appointed a joint integrated director role with Thurrock local authority that should see further integration work across health and social care teams in Thurrock. Working very closely with the community dentistry teams in north east London to ensure that all children/adults waiting for care under general anaesthesia have a clear plan in place to reduce waiting times. The integrated sexual health service brought together a number of sexual health services into an integrated model and as part of this development have launched a Facebook page to improve access for, and communication with young people. The page can be found at: SHISthurrock This additional form of access will allow young people to receive sexual health information and updates regarding locally available sexual health services. NELFT were successfully awarded the newly created Emotional Wellbeing Mental Health Services (EWMHS) that covers the seven CCG areas and three local authority areas of NELFT NHS Foundation Trust I Quality Account Page 21

22 Essex. The newly commissioned service across Essex will ensure that the services for children and young people are strengthened. =The new service model is currently being consulted on with staff groups, and we are in the process of running early evening young person events across all CCG areas. Feedback to date is very positive about the proposed changes. NELFT were successfully awarded the pulmonary rehabilitation and home oxygen services across Brentwood, Basildon and Thurrock. These two new services now form part of a new integrated community respiratory model. Service leads and clinicians have worked closely with local GPs and service users in establishing the pathway. Mental Health Inpatient and Acute Directorate (MHIPAD) Much work has been undertaken in MHIPAD in the past year, particularly focussing on staff programmes. Essentially, a stable, well trained workforce that feels valued is key to delivering safe and effective care in our acute mental health services. A number of quality improvement initiatives have been on-going throughout the year and the improvements delivered are significant: Sickness was 8.9 per cent and rising, but is now 4 per cent and reducing. Vacancies were above 18 per cent but have now fallen to 12 per cent with every vacancy accounted for in the recruitment pipeline. Agency controls were not being rigorously applied, resulting in temporary staff being recruited from agencies in 90 per cent of cases, and from the NELFT staff bank in only 10 per cent. Applying controls has seen a shift to 85 per cent of temporary staff being recruited via the NELFT bank, and agency staff only being recruited when a suitable worker through the bank cannot be found. The ratio of leavers to starters has improved significantly. MHIPAD has completed the safe staffing tool audit on the wards to determine the right levels of staffing to reflect the increased levels of acuteness of the service users we now care for. As a result of our endeavours, NELFT s acute care pathway was recommended nationally by Lord Crisp as a good model for out of hospital mental health care. Older Persons Fellowship project This is a quality improvement fellowship project which focuses on the enhancement of the therapeutic environment for both patients and service users and staff to make it more dementia friendly following feedback from service users on discharge who said they felt unsafe whilst on the ward. The acute mental ward has twenty single beds and provides 24 hour care for older adults over the age of 65 years and is based within a specialised mental health building. Service users are admitted from across north east London for treatment. Prior to admission to the ward all the service users are assessed by the older adult home treatment team, and are only admitted if the risks are deemed too high for the service users to stay at home. The service users admitted to Daisy ward have a wide range of mental health problems including dementia, depression, psychotic illnesses, anxiety and bipolar affective disorder. By enhancing the therapeutic environment, a positive impact on service users and staff has been achieved. There has been a validated improvement to service user outcomes achieved 22 Page 22 NELFT NHS Foundation Trust I Quality Account 2015/16

23 through changing behaviour using a systematic change method. Primary successes achieved by early involvement of service users and staff were: incidence of physical and verbal aggression reduced episodes of staff sickness reduced feeling safe on the ward: service users stated they felt extremely safe post-intervention an increased dementia friendly environment reduction in the prescribing of anti-psychotics drugs The aim for the future is to sustain the momentum and reduce further incidents of violence and aggression. NELFT NHS Foundation Trust I Quality Account Page 23

24 Part two In Part 2 of our Quality Account we will outline our planned improvement priorities for 2016/17, including those improvement priorities agreed with our commissioners. Our priorities are organised under the three areas of quality identified through our stakeholder engagement process. Priorities for improvement 2016/17 NELFT has consulted widely with stakeholders, through the Quality Account survey run from October 2015 to the end of January 2016 to inform our quality priorities for the coming year. We have also taken account of progress against last year s priorities, and any that require continued focus will remain as priorities. Those priorities from previous years that have been successfully achieved will become business as usual and embedded in daily practice. Themes from complaints and compliments, as well as patient, service user, carer and staff questionnaires are also taken in to account when setting our quality priorities. The result of our Quality Account survey indicated that our stakeholders wanted us to focus on three improvement priorities: working together for patients, service users, commitment to quality and care and respect and dignity. Each priority has been considered by clinical staff and the chief nurse group and specific areas of quality improvement have been identified. Whilst developing these indicators, we have also ensured that they also allow us to improve in the areas of: clinical effectiveness patient experience patient safety 2.1 Priority 1: Working together for patients Aim: The aim of the duty of candour is to ensure that health service bodies are open and transparent when certain incidents occur in relation to the care and treatment provided to people who use services. The NHS Standard Contract condition 35 makes clear there are two stages to the performance indicator, one at the start of the incident report and investigation, the second at the final point of the investigation process. 10,000 penalties could apply at both stages of one investigation. The trust is clear of its responsibility to promote the professional duty of candour by providing support and guidance and so all incident reporting/investigation training programmes include how to recognise and implement the duty of candour Why we have chosen this priority Duty of candour ensures that health service bodies are open and transparent to the relevant person (as defined by the regulation) when certain incidents occur in relation to the care and treatment provided to people who use services. Here at NELFT we openly support duty of candour and will always strive to be open, honest and transparent. What we are trying to improve We want to ensure that everyone who we see feels that they have been involved in their care and 24 Page 24 NELFT NHS Foundation Trust I Quality Account 2015/16

25 Quality goal (patient safety, clinical effectivenss and patient experience) Area applicable to What do we expect to achieve How progress will be measured How progress will be monitored and reported To ensure duty of candour is embedded in practice ensuring we are providing openness and transparency in care delivery. That 'any patient harmed by the provision of a healthcare service is informed of the fact and an appropriate remedy offered, regardless of whether a complaint has been made or a question asked about it'. The patient record and duty of candour letters will provide additional assurance that professions are exercising the duty in accordance with professional codes. NELFT-wide. A case exploration of the quality of duty of candour will be conducted in Q3. Professional leads will provide a quarterly article to colleagues on the challenges and interpretation of duty of candour. Collation and analysis of data via ICD monthly performance reports. Quarterly reporting to board via monthly performance reporting. The board will review monthly data of performance and be informed of any gaps in assurance that are creating significant risks or issues. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 25

26 2.2 Priority 2: Commitment to quality of care Why we have chosen this priority The quality and care of our service users is paramount to us at NELFT. To demonstrate our continuing commitment to provide the best quality and care, this year we will concentrate on three key areas: mainstreaming learning disabilities through the trust implementing end of life pathway and building a dementia friendly environment continuation of our induction programme to train and assess our Health Care Support Workers (HCSW) against the skills for health/skills for care minimum training standards Aim: Development and implementation of a nonstigmatising logo to easily identify learning disability service users, so reasonable adjustments can be made to their care. What are we trying to improve? To improve and strengthen the electronic system currently in place, making it more user friendly and accessible. Clinical staff need to be able to identify when someone has extra needs in relation to learning disabilities so that necessary adjustments can be made, improving service user care at point of delivery. Quality goal (Clinical effectiveness and patient experience) Area applicable to What do we expect to achieve How progress will be measured How progress will be monitored and reported To pilot a scheme similar to the Butterfly Scheme used for dementia, where we use an agreed logo to flag LD patients, so we can make reasonable adjustments to their care. Initially this would be in the form of stickers/magnets, which could be on the handover board or in patient's folders. NELFT-wide. Q1- Agree logo and work with procurement to identify and manufacture logo for circulation. Q2 & Q3- Trial in a range of clinical areas across NELFT. Q3- Develop an evaluation tool. Q4-Audit the impact on quality of care by audit. An audit will be undertaken to evaluate the impact on quality of care. The pilot will be evaluated quarterly through partient, service user and staff feedback questionnaires which are currently in development. Aim: Improving the end of life care experience of people receiving care from NELFT services. Poor communication and not recognising that people are dying are key themes identified by a parliamentary and health service ombudsman investigation into complaints at end of life, Dying without Dignity. Some health and care professionals are uncomfortable discussing how long someone has to live, and sometimes do not have the skills and confidence to give difficult news or talk about the dying process. Adequate training and continued support is important to help health and care professionals to communicate sensitively and effectively. NICE 2015 What are we trying to improve? Clear and appropriate communication is fundamental to ensuring positive outcomes for people approaching end of life, and those that are important to them. Clinical staff that work within NELFT need to be taught the specific skills of communication with people at end of life and their families, thus improving the quality of care and experience for people at the end of life. 26 Page 26 NELFT NHS Foundation Trust I Quality Account 2015/16

27 Quality goal (Clinical effectiveness and patient experience) Area applicable to What do we expect to achieve How progress will be measured How progress will be monitored and reported To have a NELFT-wide educational session that will be designed, implemented and evaluated during 2016/17. The course will be delivered either as an individual session or as part of existing palliative care training. The session will address managing difficult conversations and access to support mechanisms across NELFT. NELFT-wide. Q1 Scope existing communications training and agree model for NELFT. Agree training plan in partnership with education & training and operational services Identify end of life care link/ champion professionals for all teams. Q2 & Q3 Roll out training to community nurse and ICMs. Review via end of life palliative care education work stream. Review progress via end of life palliative care education work stream report into end of life care overview group. Monitored monthly via DPQSG. Report into the end of life care overview group. Q4 Evaluate outcomes, collate data. Health Care Support Workers (HCSW) certificate programme (carried over from 2014/15 Quality Account) Write report based on outcomes. Review quality audit plan for 2017/18. Aim: To ensure all Health Care Support Workerss (HCSW s) are competent to deliver safe patient care (quality goal clinical effectiveness and patient safety) What are we trying to improve? The care certificate was launched in April 2015, and provides clear evidence to employers, patients, service users and people who receive care that our health or social care workers have been trained to a specific set of standards. It gives everyone the confidence that the HCSWs have the skills, knowledge and behaviours to provide compassionate and high quality care and support. (See 3.1 for progress to date). NELFT NHS Foundation Trust I Quality Account 2015/16 Page 27

28 2.3 Priority 3 - Respect and dignity Why we have chosen this priority A dementia friendly environment is defined as a supporting environment for patients, service users and carers; an environment is created that is easy to understand and more accessible to people who use it (Alzheimer s society 2014), thus enabling person-centred care respect and dignity of our patients and service users. Aim: To have a dementia friendly environment within our inpatient user areas to deliver person-centred care, giving respect and dignity to our patients and service users. What we are trying to improve Following feedback from service users discharged from an acute older persons mental health ward, service users stated on their discharge survey that they had felt unsafe whilst on the ward. Quality goal (Clinical effectiveness and patient experience) Area applicable to What do we expect to achieve How progress will be measured How progress will be monitored and reported To have a dementia friendly environment within our in-patient areas to delivery person centred care, giving respect and dignity of our patients. NELFT MHS service (Inpatients). Q1- Complete dementia environment assessment in five areas in-patient areas (Stage, Cook, Woodbury, Japonica and Foxglove wards) using EHE tool (2014) developed by the Kings Fund for use in care settings. This research based tool has seven sections which aim to explore the ward environment and highlights the areas that may need to be addressed. Q2- Complete dementia assessments in the remaining areas (Waltham Forest, Mayflower, Thorndon ward in Brentwood Community Hospital, and Alistair Farquharson Centre in Thurrock) and pilot a new area for John s Campaign (for the right to stay with people with dementia in hospital. Website: open access to carers for dementia patients.( i.e.no restrictions on visiting times). Q3- Plan workshops which will consist of patients, carers and staff (eight to ten per workshop) to establish the This is me document as part of the care plan. To provide staff with insight on how to know the patients likes and needs (Alzheimer s Society and Champion 2014). Q4- Evaluate how This is me is used in practice as part patients care plan. Improvements on environment assessments through inspection. Reduction of violence and aggression. Carer feedback. This will completed through the dementia sub group of the community of practice for frailty and LTC. Progress will be monitored quarterly. 28 Page 28 NELFT NHS Foundation Trust I Quality Account 2015/16

29 2.4 Governors selected local indicator Rotational nurse competencies (quality goal clinical effectiveness and patient experience) NELFT is encouraging newly qualified nurses to undertake rotational nurse training within the trust in order to build a sustainable clinical workforce and help address vacancy gaps. The rotational nurse programme includes a number of core competencies. The governors wish KPMG to test the validity of core competency achievement so that the programme can be further rolled out on a larger scale (having trialled the programme with three nurses last year). The audit found the following: Registered Nurse (RN) Registered Nurse Mental Health 1 (RNMH) Registered Nurse Mental Health 2 (RNMH) Mental health Ethical Practice a a a Knowledge a a a Process/Care a a a Interventions a a a Physical Health Continence a a Personal care a a a Nutrition a a Observations a a a Pressure area care a a a Specialist placement * a a a NELFT NHS Foundation Trust I Quality Account 2015/16 Page 29

30 The rotational nurse programme includes core competencies that needed to be achieved this includes the following. Rotation per cent required (this is the practitioners own area of practice and preceptorship) Rotation 2 85 percent required (ward based rotation in opposite area e.g. Registered Nurse Adults (RNA) into mental health and RNMH to adult community nursing Rotation 3 50 per cent required (*specialist area e.g. RNA into specialist memory service and RNMH into district nursing) The baseline target for the rotation programme was that 100 per cent of individuals achieve the different levels of competencies. However, the target was not entirely met during the pilot as although all participants achieved the core competencies from their area of registration, one of the rotation nurses did not meet all the competencies for the second and third rotation. This was a small pilot which was set up to develop and test the competencies required for the programme. The competencies were developed as the project unfolded. The competencies could only be achieved if they were available; and in this case the items not achieved were not available at the time of assessment. The recommendation is that this pilot will now be used to further develop this programme and refine the competencies for future participants. The value of the programme was evidenced in other significant ways such as the rotational nurses bringing in quality improvements to the practise areas. Also for the practitioners themselves who have demonstrated that having undertaken the programme have developed their holistic nursing skills and competencies across physical health and mental health, well beyond those of the nurses that had not undertaken the rotation programme. The recommendation is that the information provided by this rotational nurse competency pilot will be used as the baseline which will inform our future recording and monitoring of the programme and its benefits as it is rolled out further across NELFT. 2.5 Service user surveys Friends and Family Test implementation Feedback from our service users is vital to help us understand what we are doing well and what we should improve. The Friends and Family Test (FFT) national guidance has been implemented across all community and mental health services since January We collect FFT data through a variety of methods including paper surveys, feedback leaflets and online surveys. Leaflet style questionnaires and business cards with a web link have been provided to all services across the trust to ensure all service users have the opportunity to give feedback using the FFT. The survey is also available on the trust website. To further improve the quality of service user feedback all clinical services across the trust have been collecting 5x5 survey data on a monthly basis. Each month, a senior member of staff from each service contacts a minimum of five randomly selected service users/ carers by telephone to ask them five key questions about their experience of care, with the first question being the FFT question. How likely is it that you would recommend this service to friends and family if they needed similar care or treatment? Did you find it easy to get care, treatment or support from this service? Did staff introduce themselves to you? Did the service you received meet your expectations? Did you feel you were involved in your care as much as you would have liked? The following three pages give an overview of the trust family and friend questions test results. 30 Page 30 NELFT NHS Foundation Trust I Quality Account 2015/16

31 How likely is it that you would recommend this service to friends and family if they needed similar care or treatment? Survey name Date Survey returns NELFT overall Would recommend Would not recommend Q1 2015/ % 3% Q2 2015/ % 2% Q3 2015/ % 2% Q4 2015/ % 2% Community services Q1 2015/ % 2% Q2 2015/ % 2% Q3 2015/ % 2% Q4 2015/ % 1% Mental health Q1 2015/ % 5% Q2 2015/ % 3% Q3 2015/ % 3% Q4 2015/ % 3% NELFT NHS Foundation Trust I Quality Account 2015/16 Page 31

32 How likely is it that you would recommend this service to friends and family if they needed similar care or treatment? Survey name Date Survey returns Basildon and Brentwood 5x5 overall Would recommend Would not recommend Q1 2015/ % 1% Q2 2015/ % 1% Q3 2015/ % 1% Q4 2015/ % 2% Thurrock 5x5 overall Q1 2015/ % 1% Q2 2015/ % 0% Q3 2015/ % 0% Q4 2015/ % 1% Barking and Dagenham 5x5 overall Q1 2015/ % 2% Q2 2015/ % 2% Q3 2015/ % 1% Q4 2015/ % 2% 32 Page 32 NELFT NHS Foundation Trust I Quality Account 2015/16

33 Survey name Date Survey returns Havering 5x5 overall Would recommend Would not recommend Q1 2015/ % 3% Q2 2015/ % 2% Q3 2015/ % 4% Q4 2015/ % 2% Redbridge 5x5 overall Q1 2015/ % 2% Q2 2015/ % 2% Q3 2015/ % 1% Q4 2015/ % 2% Waltham Forest 5x5 overall Q1 2015/ % 7% Q2 2015/ % 3% Q3 2015/ % 2% Q4 2015/ % 2% MHIPAD In-patient exit Q1 2015/ % 11% Q2 2015/ % 5% Q3 2015/ % 5% Q4 2015/ % 9% HTT exit Q1 2015/ % 2% Q2 2015/ % 4% Q3 2015/ % 0% Q4 2015/ % 5% NELFT NHS Foundation Trust I Quality Account 2015/16 Page 33

34 Nationally required information 2.6 Statement of assurance from the board regarding the review of services During 2015/16, NELFT provided and/or subcontracted 72 relevant health services (provided across multiple localities). NELFT has reviewed all the data available to them on the quality of care in all of these relevant health services. The income generated by the relevant health services reviewed in 2015/16 represents 100 per cent of the total income generated from the provision of relevant health services by NELFT for 2015/16. All the data received ensures the delivery of high quality care and covers the three dimensions of quality: service user safety, clinical effectiveness and service user experience. Quality assurance data is collated and reported in the quality and safety committee dashboard and the performance executive dashboard. This level of monitoring takes place through the quality governance structure within the trust which includes Integrated Care Directorate (ICD) locality performance, quality and safety groups and the sub-groups, directorate performance, quality and safety groups. Risks are reported on the trust-wide risk register and high level risk registers (containing risks scoring 15 and above) are monitored via the ICD directorate performance, quality and safety groups and quality and safety committee. Strategic risks which prevent the trust from achieving corporate objectives are recorded on the board assurance framework which is reported at trust board. To date, data availability has not impeded our objectives however, we continually strive to improve and extend our data capture and the quality of data. 2.7 Participation in clinical audits Participation in national clinical audit and confidential enquiries Our participation During 2015/16, 11 national clinical audits and one national confidential enquiry covered the NHS services provided by NELFT. The national clinical audits and national confidential enquiries that NELFT participated in, and for which data collection was completed during 2015/16, are listed in appendix 1a, 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. Learning from national clinical audits The national audits measure healthcare practice on specific conditions against accepted standards, providing service users, the public and clinicians with a clear picture of the standards of healthcare being achieved for specific specialties. They also give healthcare provider s benchmarked reports on their performance, with the aim of improving the care provided. The national audits are related to some of the most commonly-occurring conditions. The data is supplied by local clinicians to provide a national picture of care standards for that specific condition. On a local level, National Clinical Audits and Patient Outcome Programme (NCAPOP) audits provide local trusts with individual benchmarked reports on their compliance and performance, feeding back comparative findings to help participants identify necessary improvements for service users. The reports of 21 national and trust priority clinical audits were reviewed by NELFT in 2015/16. We will use these reviews to improve the quality of care we provide by taking the actions outlined in the examples of national audit summaries in the table at appendix 1b. Learning from local clinical audits Our clinicians are strongly encouraged to set up local in-depth audits to follow up on national audit findings, based on local quality and safety priorities.104 local clinical audits were registered in 2015/16 and the reports of 36 local clinical audits were reviewed and actions agreed. These actions are outlined in the following sections. Specific outcomes in individual services have included: Mental health inpatient user and acute services Measures to be implemented to ensure all patients at discharge have their physical health monitoring completed and recorded in their medical records. 34 Page 34 NELFT NHS Foundation Trust I Quality Account 2015/16

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36 Results and recommendations to be communicated to primary and secondary care through discharge summaries, helping to improve quality of care. Community recovery team services Increasing awareness for all care co-ordinators to know the process of referring for Cognitive Behavioural Therapy (CBT) and Family Interventions in Psychosis. Health records Increasing the use of existing electronic systems such as RiO and SystmOne and reducing use of paper records in line with National Information Board Personalised Health and Care Integrated community services Identifying further provisions of regular education and training provided to all staff in all boroughs related to the end of life care plan as part of the Priorities of Care. Champions to be introduced in each area to promote the use of end of life care plan. Nutrition and dietetics service Educating and promoting acute staff at transitional clinics and providing regular support to service users through counselling sessions and referral to physiological services Older adults mental health and memory service Highlighting the importance of identifying early dementia and supporting families throughout the disease by enhancing education for staff regarding the Montreal Cognitive Assessment (MoCA) Universal children s services Refresher training sessions to be offered to staff in relation to all children on a safeguarding plan or identified as vulnerable to have their status recorded correctly. Child & Adolescent Mental Health Services (CAMHS) Services to be further developed to provide emotional support to children and young people and identifying effective treatments for children and young people who are self-harming. Health visiting and school nursing services Identifying further training requirements for health visitors to identify risk factors on emotional health and wellbeing for all (new) mothers. Health improvement services Highlighting awareness amongst colleagues regarding the need for improvement of fundamental cross infection control procedures and development of facilities of clinical areas to provide maximum compliance. Clinical audit outcomes and recommendations for 2015/16 Clinical audits within NELFT have resulted in a number of improvements within our range of services and at all stages of the service user pathway. Key themes for outcomes have included: working together for patients commitment to quality of care compassion improving communications between staff and service users meeting mental health needs of service users 2.8 Participation in clinical research Participation in clinical research demonstrates NELFT s commitment to improving the quality of care that we offer and our contribution to health improvement is demonstrated by our participation in clinical research. Active participation in research at NELFT contributes to successful service user outcomes. Similarly, we ensure that clinical staff stay abreast of the latest possible treatments. Our engagement with clinical research also demonstrates NELFT s commitment to testing and offering the latest medical treatments and techniques. A commitment to clinical research leads to better treatments for service users and this is demonstrated by the improvement in service user health outcomes in NELFT mental health and community services. Our involvement in National Institute for Health Research (NIHR) research has resulted in 88 publications over the last three years. This illustrates our commitment to transparency and desire to improve service user outcomes and experience across the NHS. In 2015/16 the number of service users receiving NHS services provided or sub-contracted by NELFT mental health services recruited during that period to participate in NIHR portfolio studies approved by a research ethics committee was 656. The number of service users receiving NHS 36 Page 36 NELFT NHS Foundation Trust I Quality Account 2015/16

37 services provided or sub-contracted by NELFT Community Health Services recruited during that period to participate in National Institute for Health Research (NIHR) portfolio studies approved by a research ethics committee was 88. NELFT Mental Health Services were involved in conducting 35 NIHR clinical research studies from April 2015 to March 2016 and involved in conducting 11 local clinical research studies during the same period. NELFT community health services were involved in conducting seven NIHR clinical research studies from April 2015 to March 2016 and were involved in conducting three local clinical research studies during the same period. A total of 29 NIHR portfolio research studies were active across NELFT s localities between April 2015 and March 2016, of which 22 were newly approved and adopted studies during this period. NELFT is sponsoring the EMPOWER programme grant, which was awarded to the trust following a competitive National Institute for Health Research application process. Work has commenced on the five year research study led by Dr Janet Feigenbaum for which NELFT is the lead site. The aim of EMPOWER is to increase wellbeing and prepare people with problems consistent with a personality disorder for employment through the development and evaluation of a new intervention based on the principles and techniques of Dialectical Behavioural Therapy (DBT). The intervention will target known areas of difficulty for example, managing intense emotions, problematic interpersonal relationships, selfcriticism and poor self-management and will focus on managing these areas specifically in the workplace. NELFT is also sponsor for the RADAR programme grant. This is a six year programme to develop and conduct a trial to assess the benefits and risks of a flexible, supported strategy for anti psychotic dose reduction and possible discontinuation in adults with multiple episode schizophrenia and psychotic disorders. In particular, the research will evaluate effects on social functioning and relapse which was awarded to the trust. Work has commenced on the six year research study led by Dr Joanna Moncrieff for which NELFT is the lead site. Over the course of the year, NELFT Research and Development (R&D) department has been supporting the submission of a variety of grant applications from NELFT clinicians. These include Open Dialogue, led by Dr Russell Razzaque and Active Elders, led by Dr Georgina Charlesworth. Both of these bids are for NIHR programme grant awards with NELFT as sponsor and both have successfully proceeded through to the second round of the application process. The R&D department has also supported the submission of two NIHR Health Technology Assessment (HTA) grant applications. These being PIRAMID led by Dr Georgina Charlesworth and also collaboration with Professor Pasco Fearon (UCL) in supporting his bid for Video- Feedback to Promote Positive Parenting (VIPP), both of which have successfully advanced to the second round of the application process. With NELFT R&D support, Dr Elisa Aguirre applied for and received an award from the Oxford Mindfulness Centre to conduct research into an evaluation of Mindfulness Based Cognitive Therapy (MBCT) intervention for obesity-related eating behaviours in a primary care setting to determine the clinical effectiveness in prevention of relapse or recurrence of depression. Following an application process Dr Elisa Aguirre also received a funding award from the Food for the Brain Foundation. We continue to provide support for grant applications and are currently assisting in the preparation of two NIHR Research for Patient Benefit grant applications. The first being a pilot randomised controlled trial of a behavioural intervention for people with intellectual disabilities, experiencing psychological distress as a result of bullying or victimisation led by Dr Afia Ali. The second being MBCT-EAT for comorbid depression and obesity led by Dr Elisa Aguirre. We look forward to receiving positive feedback for all ongoing applications. Finally the R&D department have facilitated the process of NELFT joining a programme called UK CRIS, which is a Medical Research Council funded programme that aims to deploy the Clinical Record Interactive Search (CRIS) system across ten more trusts in the country. Nationally, NELFT is one of the key trusts involved in the testing and implementation of UK CRIS. It takes an extract of the NELFT NHS Foundation Trust I Quality Account 2015/16 Page 37

38 medical record, pseudonymises all the service user identifiers in the record, and then loads the data into a new database that can be queried both for research and service evaluation/audit purposes. It is hoped that the implementation of UK CRIS will positively impact upon the efficiency of the NELFT research recruitment process thus continuing to develop and build on our successful research portfolio. 2.9 NICE compliance in NELFT Assurance for NICE compliance in NELFT is provided through the trust s NICE guidance dissemination process and the undertaking of NICE-related clinical audits as part of the trust s annual clinical audit programme. An audit of the NICE guidance dissemination and conclusion process carried out in December 2015 showed 100% compliance through the CRG (Clinical Reference Group) process. A more robust dissemination process was introduced in January 2016 which now includes an auditable tracking/monitoring system for the dissemination of NICE guidelines, Quality Standards, as well as Technology Appraisal Guidance (TAGs). During 2015/16, eight NICE-related clinical audits were included in the trust s annual clinical audit programme. The standards for these audits were derived from NICE guidance. Clinical audit topics included re-audits on: Autism in adults (which demonstrated significant improvement in all domains of the assessment especially in recording of risk assessments and incorporating the risk assessment in the risk management plan); Depression in children and young people (also demonstrated further improvements in the comprehensive assessment of children and young people for depression as well as delivery of CBT); Medicines reconciliation (significant improvements were noted in the involvement of a pharmacist in the medicines reconciliation process within 24 hours (weekday) or 72 hours (weekend) of admission). There were four national, NICE-related, Prescribing Observatory for Mental Health (POMH-UK) audit topics included on the annual clinical audit programme for 2015/16: Antipsychotic prescribing in Learning Disability; Prescribing for ADHD in children, adults and adolescents; Prescribing in bipolar disorder; Prescribing in substance misuse. Just as importantly NELFT s CQUIN participation in the 2015/16 CQUIN for mental health under the auspices of the clinical audit and NICE department, in conjunction with the Inpatient Acute Directorate, achieved an impressive 90 per cent compliance with the CQUIN target, reflecting a minimum of 90 per cent compliance with NICE guidance and standards (NICE CG178, QS80) CQUIN targets 2016/17 What is Commissioning for Quality and Innovation (CQUIN)? The CQUIN payment framework enables commissioners to reward excellence by linking a proportion of the income they give to provider organisations such as NELFT to the achievement of national and local quality improvement goals. A proportion of the NELFT income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed between NELFT and our commissioners through the CQUIN payment framework. Monetary total achievement for 2015/16 can be found on page 64. Further details of these goals and goals for the following 12 month period are available on request from: Julie Price, director of performance and business intelligence julie.price@nelft.nhs.uk Tel: ext Address: NELFT NHS Foundation Trust, Suite 1, Phoenix House Christopher Martin Road, Basildon, Essex SS14 3EZ. The total amount of income in 2015/16 conditional upon achieving quality improvement and innovation goals was 5,221K. The CQUIN targets for 2016/17 outlined below build on, and are consistent with, both local and national strategy. Detail not available at time of going to print. 38 Page 38 NELFT NHS Foundation Trust I Quality Account 2015/16

39 2.11 Registration with the Care Quality Commission (CQC) NELFT is required to register with the CQC and its current registration status is that it is registered to carry out the following regulated activities: assessment or medical treatment of people detained under the Mental Health Act diagnostic and screening procedures treatment of disease, disorder or Injury family planning surgical The CQC has not taken enforcement action against NELFT during 2015/16. NELFT has not participated in any special reviews or investigations by the CQC during the reporting period. During the year, the CQC carried out a total of six inspections across NELFT, consisting of: three Essential Standards inspections three Mental Health Act inspections Essential standards inspections/ five key questions There are five key questions the CQC ask of all care services: are they safe? are they effective? are they caring? are they responsive? are they well-led Date Unit inspected Outcome 10/08/15 Waltham Forest rehabilitation unit 20/10/15 Sunflowers Court, Stage ward 21/10/15 Sunflowers Court, Ogura and Titian wards more service user choice regarding the location of physiotherapy sessions promote the use of Friends and Family Test (FFT) ensure service user consent is documented promote service user involvement in their care and planning promote carers/relatives involvement in decision making strengthen the process for the identification of service user risk from ligatures Mental Health Act inspections Date Unit inspected Outcome 17/08/15 Woodbury promote Mental Capacity Act and Deprivation of Liberty training re-inforce the use of the admission pack ensure risk assessments are documented within care plans strengthen the process for the identification of service user risk from ligatures maintain service user progress to support discharge promote service user involvement in their care and planning support service users in their understanding of their rights 3/11/15 Sunflowers Court, Turner ward 12/01/16 Sunflowers Court, Titian ward promote service user involvement in their care and planning support service users in their understanding of their rights Strengthen the assessment for capacity for consent, ensuring outcomes are documented Re-inforce the protocol for service user use of mobile devices e.g. internet, cameras etc. Support service users in their understanding of their rights Ensure physical health checks are documented on the service user record NELFT NHS Foundation Trust I Quality Account 2015/16 Page 39

40 Internal audit - areas for improvement 2.12 Data quality All NELFT staff receive training on how to collect record and report information correctly. Staff are provided with data quality guidance prior to attending training on the Electronic Patient Record (EPR) systems. The uptake of data quality and health record system training is monitored and reported to the Data Quality Action group (DQAG) quarterly and actions taken forward. The NELFT clinical data quality policy has been updated and a data quality strategy has been produced. The trust record keeping policy has also been updated to include records related data quality requirements such as synchronisation of service user demographics details and update to equalities data. Record keeping training now includes more guidance regarding use of electronic records and data quality aspects. The data quality intranet page provides guidance to staff regarding data quality requirements, good practice and the specific data quality responsibilities of all staff. A data quality 'golden rules' document has been developed providing a simple one-page guide to the most important areas that staff need to keep in mind when entering information into any NELFT clinical systems. It covers timescales for entry of information, how contacts must be recorded and how data quality errors can be identified and addressed. This has also been produced in poster form. A data quality section is included within the corporate e-learning module for all staff and the joint data quality / information governance module within the NELFT mandatory training programme has been agreed to become an annual requirement rather than every three years, further informing staff of their responsibilities. A variety of data quality reports are made available to staff with responsibility for cost centres via MIDAS, which is an on-line business intelligence data monitoring tool. This allows staff to monitor a number of data quality issues, such as missing NHS numbers, equalities data and unoutcomed appointments. These are refreshed on a daily basis. Further reports are being made available relating to caseload management and discharge of referrals. Data quality is a standing agenda item at all performance group meetings and monthly updates on data quality issues specific to each integrated care directorate are discussed. These meetings are attended by senior managers, performance staff and business managers. The head of data quality also attends local team meetings to discuss specific data quality issues and their resolution, liaising with systems teams where required. The trust undertakes an annual health records audit to assess data quality and record keeping standards in both electronic and paper clinical records. This informs an action plan for improving data quality and record keeping across the trust. The DQAG meets monthly to discuss the improvement of clinical and non-clinical data quality across the trust. Together with the head of data quality, this group oversees the implementation of the annual Information Assurance Framework (IAF) for key targets reported to the performance executive, including annual spot checks of the data to ensure that data recording and reporting processes are robust. In addition to the above, NELFT will be taking the following actions to improve data quality: improve and monitor the quality and capture of information for the Community Information Data Set (CIDS) improve and monitor the quality and capture of information for the Secondary Uses Service data set (SUS) improve and monitor the quality and capture of equalities data improve the management and accuracy of team caseloads within clinical systems monitor and maintain the quality and accuracy of the information recorded for the Mental Health and Learning Disabilities Data Set (MHLDDS) audit and monitor the accuracy and quality of data recorded for mental health payment by results provide training on data quality and accuracy for mental health payments by results to all eligible clinicians 40 Page 40 NELFT NHS Foundation Trust I Quality Account 2015/16

41 produce quarterly data quality briefing papers informing staff of the importance of good data quality and highlighting good practice implement the data quality strategy monitor the quality of data recorded for the trust s Information Assurance Frameworks (IAF) and identify actions required to improve data quality via the IAF audit cycle Health satisfactory level two target and above on all requirements and is graded as green (satisfactory on all requirements) Clinical coding error rate The MHS business unit was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission NHS number and general medical practice code validity NELFT submitted records during 2015/16 to the secondary uses service for inclusion in the hospital episode statistics, which are included in the latest published data. The percentage of records in the published data, which included the service user s valid NHS number was: 99 per cent for admitted patient care 99.9 per cent for outpatient care The percentage of records in the data which included the service user s valid general medical practice code: 99.7 per cent for admitted patient care 100 per cent for outpatient care 2.14 Information governance assessment report The NELFT information governance toolkit version 13 current submission report overall score for 2015/16 is currently at 70 per cent and has met the Department of NELFT NHS Foundation Trust I Quality Account 2015/16 Page 41

42 42 Page 42 NELFT NHS Foundation Trust I Quality Account 2015/16

43 Part three Review of our quality performance in 2015/16 We chose quality indicators last year that could be adopted NELFT-wide, to enable focus and scrutiny both from our chief nurse group and via operational locality leads. Progress against quality indicators was reported and monitored via monthly dashboards and information cascaded via directorate and locality quality sub groups to each clinical team. This has ensured the quality priorities are cascaded and understood throughout the organisation and that progress against indicators is closely tracked. all our services and to our patients and service users. We are proud of the improvements we have achieved in the last 12 months and of the commitment of our staff in delivering improvements. Delivering such a broad range of services across multiple localities in London and Essex presents challenges, so delivering consistent messages to staff regarding our quality priorities is vital. Our governance processes are such that we can cascade information in a consistent and timely manner, whilst ensuring all levels of staff are engaged. NELFT strives to improve and provide the best possible care for our service users and patients. We have, therefore adopted the same approach this year; NELFT-wide challenging targets that are meaningful across NELFT NHS Foundation Trust I Quality Account 2015/16 Page 43

44 3.1 Progress against each of our 2015/16 priorities Considerable progress has been achieved against the targets NELFT set for 2015/16 and our achievements are demonstrated below. These include a number of indicators which also evidence our commitment to improving our: clinical effectiveness, e.g. roll-out of HCSW certificate programme; development of patient information for indwelling catheters; introduction of a VTE risk assessment to older peoples mental health wards patient experience; e.g., introduction of care makers programme; launching survey asking staff what does compassion mean? ; introducing the question do you feel you were involved in your care as much as you would have liked? to the patient surveys patient safety, e.g., introduction of the pressure ulcer pain tool; improving staff understanding of definitions of falls and harm categories; monitoring adverse events due to staffing levels Whilst we did not meet all the targets we set for ourselves, we are proud of the improvements made to date, and the commitment to quality from all our staff. We will continue to implement our programmes of work and ensure processes are embedded. The tables below provide a summary of progress to date; Priority 1 working together for patients Goal Produce and distribute throughout all NELFT services a patient survey to ask service users 'do you feel you were involved in your care as much as you would have liked?' Continue to seek improvement and maintain high levels of engagement with our patients and service uses on their care. What we achieved The core principle of NELFT s service user experience strategy is that service users and carers should be central to decision making about their treatment and care. We, therefore, decided to include the question 'were you as involved as you would like to have been in decisions about your care and treatment?' in all our service user experience surveys, enabling us to measure whether we are achieving the principles set out in the service user experience strategy and to take action if we are not. The data is provided below. In areas where a higher level of people have responded 'no', the data has been broken down to team level to identify any specific services needing improvement work and this has been sent to relevant Integrated care directors to action. Overall Yes Yes, sometimes No Overall 88% 10% 2% Community health 91% 8% 1% Mental health 83% 13% 4% 44 Page 44 NELFT NHS Foundation Trust I Quality Account 2015/16

45 Priority 2 commitment to quality of care Goal NHS Safety Thermometer - pressure ulcers. Introduction of the use of the pressure ulcer pain assessment tool. NHS Safety Thermometer - VTE. Introduction of a VTE risk assessment to patients admitted to the older peoples mental health wards. NHS Safety Thermometer - UTI's. Development of a patient information leaflet for people with an indwelling urinary catheter. NHS Safety Thermometer - falls. Improve staff understanding of the definition of falls and harm categories as identified by the NHS Safety Thermometer. NHS Safety Thermometer - falls. Ensure the falls leaflet is being provided and ascertain it s use to patients. Safe staffing. <1% of shifts will be reported as an 'adverse events that affects staffing levels' on Datix. What we achieved A validated pressure ulcer pain assessment tool has now been implemented across NELFT. The five teams with the highest number of pressure ulcers recorded on the Patient Safety Thermometer are then audited for compliance with use of the tool. The results are reviewed by the pressure ulcer strategic groups. A validated VTE risk assessment has been implemented in the older people s mental health wards, along with a revised modified early warning score (MEWS) tool and assessment framework for the deteriorating service user. These help alert staff to potential VTE risks and prompt them to take action before a service user becomes seriously unwell. Compliance with this risk assessment has increased over the year to 83 per cent. The matrons are now in charge of monitoring compliance via the safewards initiative. An advice sheet for service users, relatives and carers has been developed which tells them how to access the latest clinical advice. The launch of this leaflet is currently being agreed by the NELFT Catheter Associated Urinary Tract Infection (CAUTI) Strategic group. Training has been provided to staff on the different definitions for harm associated to falls, used in the Patient Safety Thermometer. There has also been an article in the staff weekly communications to help re-inforce the correct use of harm levels. The Patient Safety Thermometer data has been reviewed in the NELFT Falls Strategic group to identify any trends. An audit has taken place over four months gathering service users views and feedback on the service user inpatient falls prevention advice leaflet. The results of this audit are now being collated and analysed and the NELFT Falls Strategic group will review and decide if changes are required to the leaflet. Month Datix shifts Severity April % 29/30 no harm May 2.04% 43/43 no harm June 0.28% 6/6 no harm July 0.71% 15/15 no harm August 0.90% 17/19 no harm September 1.14% 24/24 no harm October 1.14% 24/24 no harm November 0.38% 8/8 no harm December 1.76% 36/37 no harm January % 28/28 no harm February 1.62% 34/34 no harm March 1.71% 36/36 no harm NELFT NHS Foundation Trust I Quality Account 2015/16 Page 45

46 Priority 2 commitment to quality of care (cont.) Goal Safe staffing. 100 per cent of those 'adverse events that affect staffing level' logged on Datix will be reported as 'no harm'. HCSW certificate programme. 90 per cent of all newly recruited HCSW's to be trained within 12 months of joining NELFT. 100 existing HCSW's to be trained per quarter. Set-up HCSW's certificate registar. Recruit project manager and maintain register. What we achieved We have seen an increase in Datix reports about staffing levels over Q4. The majority of these are related to the Essex community hospitals where there has been an issue with recruiting registered nursing staff. The board is aware of this through monthly staffing reporting and there is a robust action plan in place to manage this. All incidents have been rated as no harm. The Care Certificate was launched in April It provides clear evidence to employers, patients and people who receive care that the HCSWs have the skills, knowledge and behaviours to provide compassionate and high quality care. It also offers the opportunity to both new and existing staff to improve and refresh their knowledge. Prior to the launch of Care Certificate, NELFT had commissioned London South Bank University to deliver a two day Fundamentals of Care workshop which maps across to care certificate standards. Since then, 450 staff have attended the workshop. To achieve the certificate, staff are required to complete the following training and are subsequently assessed against the care certificate competencies. statutory and mandatory training fundamentals of care workshop workbooks assessments/observations against the care certificate competencies in working environment Once completed, staff will be entered onto the internal register. 46 Page 46 NELFT NHS Foundation Trust I Quality Account 2015/16

47 Priority 3 compassion Goal Introduce care makers concept to the chief nurses group (CNG) and at the Nurses Day Conference on 13 May Produce and launch an online survey asking staff 'what does compassion mean to the trust? What we achieved The concept of the care makers programme was introduced. CNG suggested NELFT band 1-4 support workers who had completed their care certificate would become the NELFT care makers. There is now six applications undergoing registration with NHS England to create care makers for NELFT. Big Question for Quarter 4 was 'What matters to you?' 1000 leaflets were dissertated across the trust asking staff and patients what mattered to them, so far we have had 132 responses, main themes are health and family on results submitted at this stage. Based on feedback a planned innovation lab for HCA will take place on the 17 May, care makers will be very much part of the workshop, as the trust explored ways to embed the 6cs in the workplace. Patient survey asking 'were you treated with compassion today?' Plan and develop the care makers programme. Results are shared with patient experience team and the Quarter 4 big question results will be shared with the associate director of staff engagement. The care makers programme was created to embed the 6C s across the trust, which represents representing the trust values and strategy for building a culture of compassionate care, and is based around six values: care compassion courage communication competence commitment We have established links with NHS England to help create care makers outside the biannual registration dates. Roll-out the care makers programme throughout the organisation. The care makers have ensured focus on compassion in practice and the 6Cs are fundamental in the delivery of quality service user care. They have championed the voice of the service user and their application to become care makers has shown great talent and expertise in making the 6Cs a reality in practice. At the moment, the trust has now six care makers in place who will inspire and champion person centred care. As the concept is new for this cohort of staff we expect this number to grow steadily going forward. In addition, the trust took a different the approach of asking service users (427) and staff (101) one big question, on one day around compassion. The results and feedback provided an instant response to the question. There was 528 responses staff and 427 service users. The overall results highlight that 90.8 per cent of service users stated they had witnessed or received compassionate care in our trust and 100 per cent of staff who answered the 'Big Question' 'What have you done to make a difference to service user care today?' gave examples and scored their work/acts as compassionate. The question results and the work undertaken during the year, has demonstrated we are an organisation who gives and recognises compassionate care. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 47

48 3.2 Serious incidents and complaints feedback Serious incidents Serious incidents in healthcare are rare, but when they do occur, everyone must make sure that there are systematic measures in place to respond to them. In NELFT, our serious incident policy adopts a systems improvement approach to safety, as promoted by the now defunct National Patient Safety Agency (NPSA). As such, it acknowledges that the causes of incidents are not usually simply linked to the actions of individual staff members. The policy employs a system-wide perspective for the notification, management and learning from serious incidents. NELFT has a dedicated team of trained investigators who use key skills to find the root causes of serious incidents to help minimise the chances of a similar incident re-occurring. All staff apply the principles of being open with patients, services users, carers and family members when things go wrong. This includes saying sorry, keeping everyone informed as to the progress of any investigation and sharing the findings of the investigation report with everyone involved. This year, we have introduced a 3.3 Complaints The trust received 272 complaints during the period of 1 April 2015 until 31 March 2016, compared with 247 in 2014/15. This figure reflects the reportable complaint that was submitted to the Health and Social Care Information Centre (HSCIC) as part of the trust s quarterly KO41a submission.staff members. Complaints received 2014/ /16 Locality Barking and Dagenham Basildon and Brentwood Corporate Havering Mental Health IPAD Redbridge No. % of total No. % of total No. % of total No. % of total No. % of total No. % of total 2015/ % % 9 3.3% % % % 2014/ % % 2 0.8% % % % NELFT responded to complaints within the agreed timescales with the complainant to 65 per cent compared with last year s 53 per cent. The following table shows the source of the complaint, e.g. the patient, service user, directly or their family, carer or friend (with written consent from the partient/service user): Complaints received 2015/16 Who was the complaint made by Total % of total Patient % Parent % Gardian % Carer % Other % Total % 48 Page 48 NELFT NHS Foundation Trust I Quality Account 2015/16

49 process to seek feedback from complainants on their experiences to help us to improve. One of the most important aspects of investigating serious incidents and complaints is to provide the trust with an opportunity to make changes to ensure service is improved. NELFT has developed a two year learning lessons strategy which supports the use of new technologies such as webinars and after action reviews to enable staff across the trust to understand what may have gone wrong and how to improve care. Thurrock Waltham Forest Total Completion of first responses Acknowledging complaints within three working days No. % of total No. % of total % % 99.6% % % % 98% The trust welcomes all forms of feedback to help improve the services it provides. To support this NELFT has recently updated its 'compliments, comments, concerns and complaints leaflets. These leaflets are available in easy read format and children and young people friendly versions. from the complaints across the organisation for the benefit of our patients and service users. To support this, NELFT recruited a new role in the trust, head of serious incidents and complaints NELFT values the opportunity that each complaint brings; to learn, improve and recognises the importance of sharing learning NELFT NHS Foundation Trust I Quality Account 2015/16 Page 49

50 3.4 Safeguarding The NELFT safeguarding team add information in relation to emerging learning points from serious case and learning reviews local and national, to the exception reports shared at the integrated care directorate safeguarding group meetings. This information is also discussed at quality and patient safety meetings, cascaded to frontline staff and expanded upon by safeguarding team member s attendance at operational meetings. The team held two shared learning events/ dissemination of learning regarding outcomes of local/national serious case reviews in 2015, in addition to promoting attendance at similar events delivered by local authorities. The safeguarding annual report outlines the serious case and other learning reviews undertaken by NELFT during the reporting period. The safeguarding team s annual audit programme covers the quality of safeguarding record keeping, supervision, organisations response to domestic violence and child sexual exploitation and contribution to core group and child protection conferences. 3.5 Legionella Apr 15 May 15 Jun 15 Jul 15 Aug 15 Legionella incidences Sep 15 Oct 15 Nov 15 Dec 15 Jan 16 Feb 16 Mar 15 Total NELFT considers that this data is as described for the following reason: there have been no incidences of Legionella recorded on the trust system, Datix. This nil return has been cross checked with the estates team who have responsibility for this aspect of health and safety. 3.6 Benchmarking Themed benchmarking NELFT is a member of the NHS Benchmarking Network (NHSBN) and undertakes themed benchmarking throughout the year across both community and mental health services. During 2015/16, NELFT has provided information to the NHSBN for CAMHS, community hospitals, National Audit of Intermediate Care (NAIC), combined MHS inpatients and community benchmarking, National Mental Health Intelligence Network (NMHIN) mental health profiles. Bespoke benchmarking NELFT publishes benchmarking information on our website each quarter. This enables stakeholders to review NELFT performance against local and national indicators. This information can be viewed using the following link: Performance targets Monitor risk assessment framework Monitor, now known as NHS Improvement since April 2016, the regulator of foundation trusts, require foundation trusts to report a set of quality indicators known as the risk assessment framework which are set out in the table overleaf: 50 Page 50 NELFT NHS Foundation Trust I Quality Account 2015/16

51 Monitor performance framework Indicator Measure Target Qtr Qtr Qtr Qtr CHS A&E - 4 hour waiting time Percentage 95% % 99.90% % 98.10% Data completeness - referral to treatment Percentage 50% 89.00% 88.20% 88.00% 87.60% Data completeness - referral information Percentage 50% 93.00% 93.60% 92.50% 92.50% Data completeness - treatment activity information Percentage 50% % % 99.70% 99.20% Patient Identifier information Percentage 50% 93.67% 94.03% 94.93% 94.26% Patients peferred place of death Percentage 50% 75.14% 78.37% 77.93% 69.70% MHS Care Programme Approach (CPA) - F/U within 7 days of discharge Care Programme Approach (CPA) - formal review within 12 months Admissions to inpatients services had access to crisis/home treatment teams New psychosis cases by early intervention teams Percentage 95% 98.30% 97.10% 99.20% 95.90% Percentage 95% 96.30% 95.80% 96.10% 95.60% Percentage 95% 96.30% 95.40% 99.30% 97.00% Percentage 95% 80.00% 96.40% % % Minimising delayed transfers of care** Percentage 7.5% 4.20% 4.80% 4.90% 6.50% MH data completeness: identifiers Percentage 97% % % 94.00% 99.60% MH data completeness: outcomes for patients on CPA Percentage 50% 97.00% 94.00% 94.00% 87.20% Meeting commitment to serve new psychosis cases by early intervention team Percentage 50% New indicator (from Qtr 4) New indicator (from Qtr 4) New indicator (from Qtr 4) 68.20% Improving access to psychological therapies - patients referred within 6 weeks Percentage 75% New indicator (from Qtr 3) New indicator (from Qtr 3) 97.80% 98.90% Improving access to psychological therapies - patients referred within 18 weeks Percentage 95% New indicator (from Qtr 3) New indicator (from Qtr 3) % % NELFT-wide Certification against compliance with requirements regarding access to healthcare for people with a learning disability Maximum time of 18 weeks from point of referral to treatment in aggregate patients on an incomplete pathway Percentage N/A 100% 100% 100% 100% Percentage 92% N/A 72.00% 73.10% 97.00% ** Delayed Transfers of Care, the auditor KPMG issued a qualified opinion on this indicator as reflected in appendix 5. NELFT has already reviewed the processes in response to KPMG and has in place an action plan to address issues raised. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 51

52 3.8 Monitor core indicators Monitor also require foundation trusts to report performance against a core set of quality indicators using data made available by the health and social care information centre (HSCIC). These mandated indicators are summarised below with each indicator given detailed analysis in the following pages: Monitor performance framework Core Indicators Measure 2013/ / /16 1 The percentage of admissions to acute wards for which the crisis resolution home treatment team acted as a gatekeeper. 2 The percentage of patients on care programme approach who were followed up within seven days after discharge from psychiatric in-patient care during the reporting period. 3 'The percentage of patients aged: (i) 0 to 15 and (ii) 16 or over readmitted to a hospital which forms part of the trust within 28 days* of being discharged from a hospital which forms part of the trust'. 4 The percentage of staff employed by, or under contract to the trust, who would recommend the trust as a provider of care to their family or friends. 5 Patient experience of community mental health services' indicator score with regard to a patient s experience of contact with a health or social care worker. 6 The percentage of patients who were admitted to hospital and were risk assessed for VTE. 7 Cases of c.difficile infection amongst patients aged two or over. Adults. 99.1% 98.3% 98.1% Adults. 97.7% 98.7% 97.9% London CHS. 1.2% 0.9% 1.2% Essex >16 years. 2.2% 1.9% 2.1% London MHS. 7.3% 7.5% 6.6% Percentage. 56.0% 56%** 57.0% Response rate Percentage. 99.1% 97.8% 99.5% All cases Rate per 100,000 bed days Patient safety incidents. Number *** Rate per 100,000 population Patient safety incidents that resulted in severe harm or death. Number *** Percentage. 0.49% 0.45% 0.40% * NELFT reports within 30 days ** Corrected and amended from 60% as published in 2014/15 *** April '15 - Sept '15 verified data only available at time of print 52 Page 52 NELFT NHS Foundation Trust I Quality Account 2015/16

53 1. Admissions to acute wards for when home treatment teams (HTT) acted as gatekeeper NELFT considers that this data is as described for the following reason: both internal and external audits have taken place on a regular basis over the year and no significant issues have been found. NELFT will continue to monitor this indicator closely to maintain the high level of performance and the quality of its services. NELFT considers that this data is as described for the following reason: both internal and external audits have taken place on a regular basis over the year and no significant issues have been found. NELFT will continue to monitor this indicator closely to maintain the high level of performance and the quality of its services. Admissions to acute wards for when home treatment teams (HTT) acted as gatekeeper 2013/ / / / /16 NELFT 99.1% 98.3% 98.1% National target 95% 2014/15 Qtr1 2014/15 Qtr2 2014/15 Qtr3 2014/15 Qtr4 2015/16 Qtr1 2015/16 Qtr2 2015/16 Qtr3 2015/16 Qtr4 National target 95% NELFT 99.5% 100.0% 98.0% 95.5% 96.3% 95.4% 99.3% 97.0% National - England 98.0% 98.5% 97.9% 98.1% 96.3% 97.0% 97.4% 98.2% Neighbouring - East London NHS Foundation Trust Neighbouring - Oxleas NHS Foundation Trust 100.0% 100.0% 99.5% 99.5% 99.4% 98.6% 99.9% 99.7% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.8% Highest 100.0% 100.0% 100.0% 100.0% Lowest 18.3% 48.5% 61.9% 84.3% The local home treatment teams (HTT) provide intensive support for people in a mental health crisis in their own home or community setting. They are designed to provide prompt and effective home treatment, including the administration and monitoring of medication, to prevent hospital admissions and give support to informal carers. Gate keeping means assessing everyone who is referred for admission into hospital and also those that may be suitable for discharge from an inpatient ward who may be able to continue their treatment at home. We want to ensure that as many people as possible are treated at home used appropriately and safely, HTT brings clinical benefits, increased patient satisfaction and reduces pressure on hospital beds. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 53

54 2. Service users on Care Programme Approach (CPA) followed up within seven days NELFT considers that this data is as described for the following reason: both internal and external audits have taken place on a regular basis over the year and no significant issues have been found. NELFT will continue to monitor this indicator closely to maintain the high level of performance and the quality of its services Service users on care programme approach followed up within seven days 2013/ / / / /16 NELFT 98.1% 98.7% 97.9% National target 95% 2014/15 Qtr1 2014/15 Qtr2 2014/15 Qtr3 2014/15 Qtr4 2015/16 Qtr1 2015/16 Qtr2 2015/16 Qtr3 2015/16 Qtr4 National target 95.0% NELFT 98.0% 100.0% 98.40% 98.20% 98.3% 97.1% 99.20% 95.9% National - England 97.0% 97.3% 97.30% 97.20% 97.0% 96.80% 96.90% 97.20% Neighbouring - East London NHS Foundation Trust Neighbouring - Oxleas NHS Foundation Trust 96.3% 98.9% 96.9% 96.9% 97.5% 100% 97.8% 96.5% 97.2% 97.0% 97.6% 97.6% 93.5% 97.3% 99.5% 99.5% Highest 100% 100% 100% 100% Lowest 89% 83% 50% 80% The care programme approach (CPA) is a framework designed to promote the effective co-ordination of care of people suffering from complex mental health issues and are being treated within secondary mental health services such as those provided by NELFT. Service users on CPA who are discharged from inpatient care must be followed up by a mental health professional, preferably face to face but may be by telephone contact directly with the service user within a maximum of seven days from discharge. 54 Page 54 NELFT NHS Foundation Trust I Quality Account 2015/16

55 3. 30 day emergency readmission rate* NELFT considers that this data is as described for the following reason: figures are taken from our electronic patient management systems. The figures represent service users readmitted to one of our inpatient wards within 30 days of being discharged. 2013/ / /16 NELFT London CHS 1.2% 1.4% 1.2% NELFT Essex CHS 2.2% 5.4% 2.1% NELFT MHS 7.3% 11.1% 6.6% Benchmarking data: National average, highest and lowest benchmarking data not available. Data periods not comparable. Over 2015/16, several schemes have impacted on the reduced readmission rates. The commissioning of the new Intensive Rehabilitation Service (IRS) and improved case finding of patients for the rehabilitation pathway has meant that patients are admitted to the rehabilitation pathway appropriately. The London readmission rates are an improving position. During 2015/16, NELFT has implemented the recommendations from Intermediate Care Consultation for Barking and Dagenham, Havering and Redbridge, which has seen three inpatients facilities with variable medical cover converge onto one site improving medical cover which has impacted on the rates of acute transfers and as a result, readmissions. A higher level of acuity is managed on the inpatients wards safely without acute transfers. Falls prevention equipment has been rolled out to support reduction in falls and subsequent harm and transfers to acute and readmissions. The commissioning of the enhanced mental health liaison service for Barking and Dagenham, Havering and Redbridge (BHR) has afforded better mental health support to the BHR community beds. In conjunction with our acute partners at Basildon and Thurrock University Hospital (BTUH), the introduction of the hospital integrated discharge scheme has begun to focus on a more collaborative approach towards effective discharge planning and supporting patients with the most effective pathway into the community utilising the available health and social care services. Another successful scheme has seen the dementia crisis intervention team caring for people in crisis with dementia in their own homes rather than attending the acute hospital. Effective case management and care co-ordination within the community as part of the integrated care teams has also had an impact on reducing readmission rates with the support of long term condition specialist services in the community. *The national indicator states a 28 day readmission rate, however NELFT works and data reports on a 30 day readmission rate NELFT NHS Foundation Trust I Quality Account 2015/16 Page 55

56 4. Staff recommendation of the trust to a friend or relative as a provider of care NELFT considers that this data is as described for the following reason: figures are taken from national NHS staff surveys. Staff recommendation of the trust as a provider of care 2015/16 NELFT 57% National average 67% Highest 75% Lowest 50% Engagement of staff is critical to improving the quality of care provided, and has a strong link to recommendation for treatment; NELFT is committed to improving the experience of staff working across the organisation. The trust has made a one percent improvement on last year s 2014 /2015 figures. This is an improving picture, resulting from the positive actions taken last year and which will continue throughout With the recruitment of the associate director of staff engagement, the role has provided an opportunity for wider engagement and increased communications across the workforce. By working with staff face to face there are opportunities to explore the underlying cause of some of the results of the survey. The staff survey action plan has been driven by frontline staff with a commitment to identify and own the areas highlighted within the survey. The focus is locality specific with review dates and a number of staff have attended workshops to input into the process. Action plans from the staff survey and the engagement agenda in general, will be overseen by the trust clinical executive, joint negotiation and consultation committee and strategic staff health and wellbeing group. 56 Page 56 NELFT NHS Foundation Trust I Quality Account 2015/16

57 5. Service user experience of community mental health NELFT considers that this data is as described for the following reason: results of the community mental health service user survey were released in October This survey was compulsory for all trusts. At the start of 2015, a questionnaire was sent to 850 people who received community mental health services. Responses were received from 271 people at NELFT. A score of 10 would represent the most positive possible reported service user experience. Patient s experience of contact with a health or social care worker 2011/ / / / /16 NELFT score Patient s experience of contact with a health or social care worker 2011/ / / / /16 Overall score Listening carefully to them Taking their views into account N/A N/A Having trust and confidence in the health or social care worker N/A N/A Treated with respect and dignity Being given enough time to discuss their condition or treatment NB. Last year brought change to some of the survey questions and therefore the overall score only provides a true like for like comparison to the previous year 2014/15. No national benchmarking is included for this indicator as the CQC no longer provide a single overall rating for each NHS trust as they believe this would be misleading since the survey assess a number of different aspects of people s experiences. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 57

58 6. Rate of admissions assessed for Venous Thromboembolism (VTE) NELFT considers that this data is as described for the following reason: data is as reported on the NHS Safety Thermometer. The data for NELFT represents community inpatient wards and does not include mental health inpatient wards. 2013/ / //16 NELFT 99.10% 97.80% 99.50% 2015/16 Benchmarking Qtr 1 Qtr 2 Qtr 3 Qtr 4 National Average 96.0% 95.9% 95.5% Highest 100.0% 100.0% 100.0% 100.0% Lowest 86.1% 75.0% 61.5% Whilst the mental health inpatient wards have not been included in this year s audit, an evidence based VTE risk assessment tool was implemented across all the older adult inpatient wards during the third quarter of 2015/16. Therefore, next year both community and mental health older adult inpatient wards will be included in the audit. 7. Clostridium difficile rates (C.diff) NELFT considers that this data is as described for the following reason: data is taken from a positive sample C.difficile rates Target Number Avoidable and attributable 2014/ /16 Target Number Avoidable and attributable Incidences Rate per 100,000 bed days NELFT have a target of nil cases of avoidable and attributable to NELFT for the rate of clostridium difficile (C.diff) infection in service users aged two years and over. This target was met for 2015/ Page 58 NELFT NHS Foundation Trust I Quality Account 2015/16

59 NELFT has taken the following actions to improve this rate, and so the quality of its services, by treating all cases of positive C.diff as per the national guidance reviewing positive cases continuing to work with the wider health economy undertaking post infection reviews to determine how the incidence occurred continuing to provide training for frontline staff on C.diff management and root cause analysis undertaking policy reviews NB. There are currently two cases pending investigation. NELFT is awaiting the outcome of attribution and the results are expected by June NELFT NHS Foundation Trust I Quality Account 2015/16 Page 59

60 8. Patient safety incidents NELFT considers that this data is as described for the following reason: data is taken from National Reporting and Learning System (NRLS) when benchmarking with other trusts and from the local risk management system (Datix) for 2015/16. Patient safety incidents 2014/ /16 (Source: NRLS) 2014/ /16 Paitent safety incidents 2014/ /16 (Apr '15 - Sept '15 only) No. Rate No. Rate NELFT Average mental health trust 4825 N/A** 2587 N/A** Trust 2014/ /16 No. Rate No. Rate Oxford Health NHS Foundation Trust* 7075 N/A** Berkshire Healthcare NHS Foundation Trust* 3578 N/A** * These foundation trusts have a similar MHS/CHS split to NELFT ** This is not supplied by NRLS 9. Service user safety incidents that resulted in severe harm or death NELFT considers that this data is as described for the following reason: data is taken from National Reporting and Learning System (NRLS) Patient safety incidents 2014/ /16 (Source: NRLS) Paitent safety incidents 2014/15 Severe harm Death Total No. % No. % NELFT % % 0.45% Average mental health trust % % 1.03% Benchmarking with trusts comparable to NELFT Oxford Health NHS Foundation Trust* % % 0.82% Berkshire Healthcare NHS Foundation Trust* % % 1.31% Southern Health NHS Foundation Trust highest for incidents coded as severe Black Country Partnership NHS Foundation Trust lowest for incidents coded as severe Penine Care NHS Foundation Trust highest for incident coded as death % N/A N/A N/A % N/A N/A N/A 4527 N/A N/A % N/A Calderstones Partnership NHS Foundation Trust 1708 N/A N/A 0 0 N/A 60 Page 60 NELFT NHS Foundation Trust I Quality Account 2015/16

61 By reporting incidents, staff are contributing to patient safety and quality of care. As in previous years, NELFT continues to report more low and no-harm incidents than those given a moderate or severe grade of harm and incidents of death. NELFT has taken the following actions to improve the quality of incident reporting and so the quality of its services, by: launching an e-learning training package, designed with the provider of the local risk management system embedding the use of the risk module which means that risks and incidents can be linked a comprehensive library of user guides on the intranet a weekly meeting where senior staff review all incidents reported in the previous week so trends, themes and areas of concern can be identified and shared and actions taken forward all incidents involving patients being made available to NHS England much nearer in time to the date of the incident weekly communication with managers who had not recorded their investigation on the system as quickly as expected One recent example where incident reporting and investigations have led to quality improvement is regarding sharing information about children who attend A&E. A member of staff completed an incident form once she became aware that a neighbouring trust was no longer forwarding A&E attendance information to the appropriate health visitors or school nurses. This form was shared with senior management who contacted their colleagues in the trust and this vital flow of information was re-established. NB: Only the first two quarters of the financial year was validated and authorised by the NRLS at the time this document was written. 2015/16 (Apr Sept 2015 data only) Severe harm Death Total No. % No. % % % 0.40% % % 1.04% % % 0.56% % % 1.80% % N/A N/A N/A % N/A N/A N/A 3256 N/A N/A % N/A 1100 N/A N/A 0 0 N/A * These foundation trusts have a similar MHS/CHS split to NELFT NB: Only the first two quarters of the financial year was validated and authorised by the NRLS at the time this document was written. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 61

62 3.9 Our workforce The highest and lowest ranking scores for NELFT in the 2015 National Staff Survey were as follows: Top five ranking scores staff experiencing physical violence from service users, relatives or the public in last 12 months staff satisfaction with the quality of work and patient/service user care they are able to deliver quality of non-mandatory training, learning or development staff agreeing that their role makes a difference to patients/ service users staff reporting errors, near misses or incidents witnessed in the last six months Bottom five ranking scores staff suffering work-related stress in last 12 months staff able to contribute towards improvements at work support from immediate managers recognition and value of staff by managers and the organisation staff experiencing harassment, bullying or abuse from staff in last 12 months Planning and developing the workforce The NHS Constitution sets a clear expectation that staff are provided with training, development and learning. The Five Year Forward View reiterates the need for continual development of the workforce, with new skills and new ways of working. We have had a good record in evidencing this in staff surveys and in the 2015 national survey, we were above average for access to mandatory training, with 99 per cent of respondents stating that they had undertaken training in the last 12 months. The other responses in the field of 'your personal development' showed as mostly comparable to sector averages. Success with our training is also evidenced by our exceeding the 90 per cent target for mandatory training compliance. This benchmarked us as second out of 32 London trusts and the achievement of an award for best overall training organisation. We face an ongoing challenge regarding appraisal activity across the organisation and this remains below target overall. The 2015 staff survey, however, evidenced that 83 per cent of respondents had been appraised within the last 12 months. The STARS system has streamlined the process and allows for real time and consistent reporting across the whole organisation. Monthly reports and targeted support to managers are offered to ensure that appraisals take place, are meaningful and valued and are appropriately recorded. Medical revalidation which brings together information about doctors from a range of sources to help provide them with a complete picture of their practice continues across the trust and maintains full assurance in audit reports. One area where we continue to be particularly active is in improving the systems and processes around recruitment, specifically around the challenges of attracting health care professionals. Following on from last year s national recruitment campaign, we invested in the TRAC recruitment management system. This enables real time tracking of vacancies from advert to appointment. Training for system users and recruiting managers continues at a pace. We continue to participate in recruitment fairs and have streamlined a number of elements of the recruitment process through staff involvement in the Well Together Programme. The apprentice scheme was established and whilst not achieving the target numbers, posts suitable for apprentices have been identified across all localities and corporate functions and there are plans to work with education providers to develop clinical apprenticeships are emerging. We have also implemented a rotational training programme to develop nurses with skills in both mental and physical healthcare, as well as supporting 15 nurses to return to practice. Next year, we will sponsor eight staff to undertaken professional training. Staff engagement and empowering staff We have invested in staff engagement with a dedicated associate director role to develop and implement a strategic approach. We have also invested in exploring ways of engaging more closely and effectively with our medical establishment. Initiatives to involve staff and show how we listen and act, have.included, 'You Said: We Did', 'Breakfast with John' 62 Page 62 NELFT NHS Foundation Trust I Quality Account 2015/16

63 and a revised communications strategy, with weekly and monthly briefing media. A' People Zone' has been created on the staff intranet as a one-stop-shop for all staffing and training related matters. The staff survey results still show relatively low levels of morale, but a greater level of participation at 40 per cent, has shown more staff being willing to be engaged with. The Well Together Programme has involved over 250 staff across all services and disciplines in developing quality improvement plans around a range of workforce management and development practices and processes. The profile of quality improvement has increased, with coaches being trained and a leadership programme involving some 25 managers delivered. Health and wellbeing The health and wellbeing agenda continues to grow, as well as other networks that focus on the diversity of the workforce. We held another successful sports and wellbeing event in summer 2015, which was well received and attended by around 500 staff from all services. Over 1,400 staff participated in the Global Corporate Challenge, which saw 200 teams rise to the challenge of each team member achieving 10,000 steps every day for 100 days. We intend to repeat the challenge in Leadership and workforce development Our approach to leadership development continued, with programmes of work targeting ICDs, AMDs and other leaders at all levels. Relationships continue with local partners and Health Education England in providing a comprehensive range of programmes in the field of leadership development as well as us playing a key role in progressing the community education provider network agenda in Waltham Forest and the BHR economies. Recognising the need for management skills development referred to in relation to staff engagement, Forward Focus a programme for team and deputy team leaders has been run effectively as has a new intensive programme to equip first line managers with people management skills. The development programme for non-professionally qualified staff in bands 1 4 progressed at a pace and has been augmented by the Care Certificate Programme, which has been embarked upon by 450 staff to date. The central panel to approve funding for CPD processed applications from over 200 staff and allocated 87,000 worth of training funds nearly half of what was available in the previous year. The coaching master classes for managers continued to be well subscribed to and the 'unlocking potential' coaching programme to help staff from BME backgrounds develop their career potential was successfully delivered to over 50 staff. That scheme and a further programme to support career development for staff with disabilities are also planned for the forthcoming year. Workforce diversity We are particularly proud of our achievements in this area, with substantial progress in developing networks for BME staff, staff with disabilities and LGBT staff. Further highly successful BME conferences were held and we have received national recognition for our Ethnic Minority Network, as well as being voted by The Economist as one of the top ten global organisations for our approach to equality and diversity. We continue to lead locally in our equalities work and have successfully implemented our Equality Delivery System 2 and Workforce Race Equality Scheme. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 63

64 Percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months (KF19) As an organisation, we are triangulating data from performance reports, staff survey, and staff comments. This will support the steps we will take to design a robust plan of action to manage the survey findings. NELFT considers that this data is as described for the following reason: figures are taken from national NHS staff surveys. In the last 12 months how many times have you personally experienced harassment, bullying or abuse at work from other colleagues? National My organisiation Never % % % % % 73 4% % 22 1% More than % 29 1% Missing Analysis of the data shows harassment, bulling or abuse within all directorates across the organisation. In some instances, staff are reporting more than ten occurrences. This has been noted and the respective directors have been made aware. The survey findings will be discussed over the next six months at executive management and senior leadership teams and each engagement workshop which is locality based. This is to ensure there is a broad awareness around the matter of harassment, bulling or abuse as reported by staff. There are a number of interventions currently in place such as the managers development programme which supports managers through developing their resilience and mindfulness through leadership. Bespoke development packages which are discussed at line management interviews and the relevant development is co-created with both parties. A few examples of this include coaching training to enhance leadership and management skills. Coaching sessions for the manager to ensure there are frameworks available for the manager to discuss personal and professional issues in relation to their role, 360 feedback analyses, to provide an objective view for managers and staff of how they are experienced by others. There will also be a reenergising of the 'preventing bullying and harassment at work creating a culture of respect,' training taking it out of the first line management programme and delivering rolling training across the organisation over the next 12 months to all staff. It is anticipated this intervention will create awareness around the distress which harassment, bulling or abuse causes to all staff and a reminder the trust has a process to manage such behaviours. 64 Page 64 NELFT NHS Foundation Trust I Quality Account 2015/16

65 Percentage of staff believing that NELFT provides equal opportunities for career progression or promotion for the Workforce Race Equality Standard.1 (KF27) NELFT considers that this data is as described for the following reason: figures are taken from national NHS staff surveys Does your organisation act fairly with regard to career progression / promotion, regardless of ethnic background, gender, religion, sexual orientation, disability or age? National My organisation Yes % % No % % Don't know % % Missing The data from the staff survey indicates that 83 per cent stated that NELFT acts fairly with regard to progression and promotion, regardless of the protected characteristics. This means 17 per cent in total either feel that the trust does not act fairly or are not aware of this. One of the key issues highlighted as part of the Ethnic Minority Staff Network strategy is not having processes in place to report on which groups are more likely than others to get promoted or have career progression. Going forward, the equality and diversity manager, in partnership with HR and training and development, is looking at implementing fields on reporting systems to address this and where the report highlights a gap then this would be addressed via access to specific training e.g. leadership skills, coaching or mentoring. This has already been addressed by the Ethnic Minority Staff Network strategy, but needs to be addressed for the other protected characteristics, particularly for LGBT, pregnancy and maternity and disability groups Commissioning for Quality and Innovation (CQUIN) payment 2015/16 A proportion of NELFT s income in 2015/16 was conditional on achieving quality improvement and innovation goals agreed with our commissioners through CQUIN payment framework. The targets agreed were consistent with the delivery of NELFT s strategic objectives and are delivery driven at the team, directorate and board level. Clinical teams monitor their own performance against each CQUIN. This occurs via a number of local forums and through staff supervision. The monetary total for achievement of goals in 2015/16 was 5,491k and the monetary total for achievement of goals in 2014/15 was 5,653k. Detail not available at time of going to print. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 65

66 Appendix 1a National audit/inquiry National Chronic Obstructive Pulmonary Disease (COPD). Prescribing Observatory for Mental Health - POMH 9c Antipsychotic Prescribing for people with learning disability. Sentinel Stroke National Audit Programme (SSNAP). National Audit of Intermediate Care (NAIC). UK Parkinson s Audit (previously known as National Parkinson Prescribing Observatory for Mental Health - POMH 13b Prescribing for ADHD in children, Adults and Adolescents. Prescribing Observatory for Mental Health - POMH 15a Prescribing for bipolar disorder. Prescribing Observatory for Mental Health - POMH 14b Prescribing for Substance misuse National Diabetes Foot Care Audit (NDFA) CQUIN Physical Health Cases submitted 116 service users audited from 4 NELFT sites which participated in the audit (Nationally, 7500 records were submitted by 211 programmes. 91 cases. Continuous on-going audit. Not due to end till March NAIC Audit data submission (bed and home based) Service user Reported Experience Measures (PREM) & Service user questionnaire (SUQ). Bed based: 102 PREM cases. 200 Service user questionnaires. Home based: 99 PREM cases. 136 Service user questionnaires. (Nationally a total of 340 services contributed to the audit and over 12,000 responses from the service user audit and Service user Reported Experience Measure (PREM)). Neurology services Brentwood Community Hospital Total number of cases submitted = 22. Neurology services Elderly Care Long Term Conditions Centre Harold Wood. Total number of cases submitted = 55. Speech and language therapy service Orsett Hospital. Total number of cases submitted = 11. The minimum number of cases required for neurology was 20, and for SLT cases. 289 cases. 20 cases 1 case submitted for service users who had their first assessment before April 2015 (Continuous on-going audit. A minimum of 100 service users will need to have been treated during the audit year) 100 cases National confidential inquiries National confidential inquiry into suicide and homicide 100% 66 Page 66 NELFT NHS Foundation Trust I Quality Account 2015/16

67 Appendix 1b Audit title National confidential inquiry into suicide and homicide for people with mental illness (NCISH) 14/15. The audit aims to monitor people with Mental Illness (NCISH). The National Inquiry will help NELFT by supporting health professionals, policymakers, and service managers with the evidence and practical suggestions they need to effectively implement change. POMH-UK QIP Topic 9c: Antipsychotic Prescribing for people with a learning disability. This audit will monitor compliance with the following standards: Documentation for the indication for treatment with antipsychotic medication; need for ongoing treatment reviewed at least once a year; review of the side effects of prescribed medication at least once a year (including physical health monitoring). Requirements and actions taken The Inquiry method of data collection is similar across all UK countries. Briefly, to identify service users (i.e. individuals in contact with mental health service within 12 months of suicide or homicide). Data are sent to mental health services in each individual s district of residence. Detailed clinical data are obtained for these individuals via questionnaires sent to the consultant psychiatrist. Action taken: 1) A 'service map' to be drawn up of all local substance misuse services across the four London localities especially in light of recent recommissioning of services which should then be cascaded to all I-P and community mental health teams. 2) NELFT to ensure refreshed strategy is reflective of 'Triangle of care' initiative to which the trust will subscribe. 3) NELFT to extend its involvement in the national Open Dialogue trial to disseminate the practice to Waltham Forest, as well as Havering, to further enhance involvement of families throughout the care pathway. A supplementary audit for quality improvement programme addressing the use of antipsychotic medication in people with learning disability. The main practice standards were: 1) The indication for treatment with antipsychotic medication should be documented in the clinical records (Deb, 2006). 2) The continuing need for antipsychotic medication should be reviewed at least once a year (Deb, 2006). 3) Side effects of antipsychotic medication should be reviewed at least once a year. This review should include assessment for the presence of extrapyramidal side effects (EPS), and screening for the four aspects of the metabolic syndrome: obesity, hypertension, impaired glucose tolerance and dyslipidaemia (NICE schizophrenia guideline update CG82, 2009). Inclusion criteria: All service users with a diagnosis of learning disability (LD) could be included, rather than, as in the earlier audits, only those service users with a diagnosis of LD who were prescribed an antipsychotic. Actions taken: 1) All though in general, side effects were documented there were deficits in specifically documenting EPSE, body weight and blood pressure, blood glucose and lipid profile. 2) All prescription of antipsychotic medication should be in line with the NICE guidelines. 3) If a service user is prescribed antipsychotic medication, all reviews should include review of side effects (obesity, hypertension, impaired glucose tolerance and dyslipidaemia) with clear documentation of weight, blood pressure and latest blood test results. 4) Medical teams at all local Community Learning Disability Teams (CDLT) to have access to weighing machines and blood pressure monitoring machines. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 67

68 Appendix 1b (cont.) Audit title UNICEF Breastfeeding Audit. The audit has been designed to help health professionals to support successful breastfeeding and achieve Baby Friendly accreditation. Requirements and actions taken The Baby Friendly Initiative is a worldwide programme of the World Health Organisation and UNICEF. The sample of staff was randomly selected from a list of staff employed from bands 3 - band 7 levels. Every 3rd. member of staff was selected. If not available the next person on the list of the same grade was selected. The sample of parents was randomly selected from a variety of clinics across the borough, 15 breastfeeding mothers and 13 bottle feeding mothers were interviewed. Each person was interviewed with a set of questions supplied by BFI; the interview took approximately 30 minutes per person. The answers were scored against set criteria and uploaded. Actions taken: 1) Core clinical skills need to be revisited along with communication of the key areas to parents as although the staff have evidenced good knowledge in some areas, this is not evident in the information that the parents have shared. 2) Communication and sharing of information between staff and parents needs to be reviewed. 3) Wider discussions on infant feeding are to be reviewed to ensure the full picture of infant feeding is captured including the issues relating to feeding at night, feeding when out and about and feeding on return to work. This would also address issues such as when to introduce food or fluids other than breastmilk. 4) Discussions on the international code for marketing of infant formula should be highlighted as this will reinforce to staff the British law relating to advertising of formula and marketing to parents and staff. A clear understanding of the code will support the knowledge base and confidence in respect of discussions around the formulas and foods that can be advised. 68 Page 68 NELFT NHS Foundation Trust I Quality Account 2015/16

69 Audit title POMH 13b - Prescribing Observatory for mental health: Prescribing for Attention Deficit Hyperactivity Disorder (ADHD) in children, adults and adolescents. The audit will establish current prescribing practice for initiation and maintenance treatment of ADHD in children, adults and adolescents. Standards for the audit have been derived from the NICE Quality Standard on ADHD. The audit outcomes will benchmark the trust on prescribing practice and physical health monitoring of service users with ADHD. Requirements and actions taken The Prescribing Observatory for Mental Health (POMH-UK) runs audit-based Quality Improvement Programmes (QIPs) that focus on discrete areas of prescribing practice. Membership of POMH-UK is open to all NHS, private and not-for-profit providers of mental health services (NHS Trusts/healthcare organisations) in the UK. This report focuses on the re-audit from QIP 13: Prescribing for ADHD in children, adolescents and adults. This was a clinical records-based audit of prescribing for ADHD in children, adolescents and adults who had a recorded clinical diagnosis of ADHD (with or without a comorbid psychiatric diagnosis). A questionnaire/audit tool was sent to Trusts with instructions that copies should be made available to allow clinical teams to audit a sample of service users with a diagnosis of Attention Deficit Hyperactivity Disorder. In addition to the data necessary to measure performance against the clinical practice standards, the following contextual data were collected: 1) Age, gender, ethnicity, severity of ADHD, co-morbid psychiatric diagnoses and care setting. 2) The dose of each oral stimulant medication currently prescribed. 3) Other psychotropic medications prescribed. Actions taken: 1) Physical health monitoring of those service users on established treatment is an area for improvement in both Children and Adolescents Mental Health Services (CAMHS) and Adult Mental Health (AMH). 2) AMH & CYP Community of Practice (CoP) to draw up protocol for maintenance physical health checks for adults receiving treatment for ADHD. 3) AMH & CYP CoP audit sub-group to work with audit department to organise re-audit. 4) All service users, ADHD treatment to be reviewed annually, using standardised rating scales. 5) Height and weight to be measured every six months in children and young people, and recorded on a growth chart. 6) Weight to be recorded every six months in adults. 7) Protocols to be implemented for maintaining physical health checks for adults receiving treatment for ADHD. 8) Further re-audits scheduled in collaboration with the clinical audit and effectiveness department for continuous monitoring of quality. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 69

70 Appendix 1c Falls 2013/ /16 comparative data Falls with harm (percentage) Falls with harm (no. of patients) Falls with no harm (percentage) Falls with no harm (no. of patients) 70 Page 70 NELFT NHS Foundation Trust I Quality Account 2015/16

71 Appendix 2 Quality Account governance structure NELFT board/emt Reports to NELFT board ( Half yearly Stephanie Dawe) Quality and safety committee (Half yearly Stephanie Dawe) Data quality group Chief nurse meeting (Quarterly Julie Price) Basildon and Brentwood LPQSG* (Monthly Service director) Thurrock LPQSG (Monthly Service director) Barking and Dagenham LPQSG (Monthly Service director) Havering LPQSG (Monthly Service director) Redbridge LPQSG (Monthly Service director) Waltham Forest LPQSG (Monthly Service director) Inpatient Acute Directorate LPQSG (Monthly Service director) Basildon and Brentwood DPQSG** (Monthly assistant service director) Thurrock DPQSG (Monthly assistant service director) Barking and Dagenham DPQSG (Monthly assistant service director) Havering DPQSG (Monthly assistant service director) Redbridge DPQSG (Monthly assistant service director) Waltham Forest DPQSG (Monthly assistant service director) Inpatient Acute Directorate DPQSG (Monthly assistant service director) Local Improvement priorities/leads Patient and service user involvement * LPQSG - Locality performance and quality safety group ** DPQSG - Directorate performance and quality safety group NELFT NHS Foundation Trust I Quality Account 2015/16 Page 71

72 Appendix 3 Third party statements Quality Account distributed for comment to: Healthwatch Barking and Dagenham Basildon Havering Redbridge Thurrock Waltham Forest Health and wellbeing boards Barking and Dagenham Basildon Havering Redbridge Thurrock Waltham Forest Local authority Barking and Dagenham Basildon Essex County Council Havering Redbridge Thurrock Waltham Forest Local authority health and overview scrutiny committees Barking and Dagenham Essex Havering Redbridge Thurrock Waltham Forest Clinical commissioning chair groups Barking and Dagenham, Havering and Redbridge (BHR CCG) Basildon and Brentwood Thurrock Waltham Forest NELFT Staff Trust board members Governors 72 Page 72 NELFT NHS Foundation Trust I Quality Account 2015/16

73 Statement from Healthwatch Essex Response to North East London NHS Foundation Trust (NELFT) Quality Account from Healthwatch Essex Healthwatch Essex is an independent organisation that works to provide a voice for the people of Essex in helping to shape and improve local health and social care services. We believe that health and social care services should use people s lived experience to improve services. Understanding what it is like for the patient, the service user and the carer to access services should be at the heart of transforming the NHS and social care as it meets the challenges ahead of it. We recognise that Quality Accounts are an important way for local NHS services to report on their performance by measuring patient safety, the effectiveness of treatments that patients receive and patient experience of care. They present a useful opportunity for Healthwatch to provide a critical, but constructive, perspective on the quality of services, and we will comment where we believe we have evidence grounded in people s voice and lived experience that is relevant to the quality of services delivered by NELFT. NELFT has a Patient Experience Strategy in place to assist in capturing the views and experiences of service users, and the Account describes the methods used to engage with the public. Governors have the opportunity to talk to service users about their experience through mock CQC inspections and PLACE visits. To further improve the quality of services, user feedback is collected by the Trusts innovative clinical services 5x5 survey. The Account demonstrates a learning culture, and describes where action has been taken to improve services. Throughout the Account there are numerous examples that show where NELFT has responded to feedback in order to review/improve services. For example, services in Basildon have been strengthened in a number of areas following feedback from service users, carers and referrers: this includes the introduction of a single point of access for children s referrals and the implementation of a new model for adult community services. It is evident from the account that NELFT has engaged staff and stakeholders around the priorities for 2016/17, through a quality account questionnaire. This received a 42% increase in responses compared to last year, with a high proportion being staff. The priority Commitment to Quality of Care has three aims: the identification of service users with a learning disability who require adjustments, improving end of life care services, and ensuring that all Health Care Support Workers are competent to deliver safe care. Healthwatch Essex notes that it is essential for NELFT to monitor the new EWMHS, and ensure that insight from service users informs and shapes the development of this new model of care. Listening to the voice and lived experience of patients, service users, carers, and the wider community, is a vital component of providing good quality care and by working hard to evidence that lived experience we hope we can continue to support the encouraging work of NELFT. Dr Tom Nutt Chief Executive Officer, Healthwatch Essex May 2016 NELFT NHS Foundation Trust I Quality Account 2015/16 Page 73

74 Statement from Healthwatch Havering NELFT Quality Accounts Healthwatch Havering response Thank you for providing us with the opportunity to comment on the Quality Accounts. As usual we were pleased to see the focus on Quality continuing throughout the proposed plans for this year, albeit that the NELFT team should be proud of their achievement to be one of the only trusts to be able to maintain high rating for finance and governance performance. During last year the development of the Acorn Centre, a specialist children s centre for the care of Havering children, has been a real achievement, this combined with the single point of access referral for GPs and the better access for families should support real improvement in the lives of the children and their families in our borough. During the course of the year, volunteers from Healthwatch Havering carried out Enter and View visits to the Trust's mental health service at Goodmayes Hospital and the Community Rehabilitation Services based at Gray's Court, Dagenham and Foxglove and Japonica Wards, King George Hospital Goodmayes. In every case, the volunteers were welcomed by staff and had the opportunity to discuss service provision in depth with them. Our recommendations have been taken on board by the Trust. Our comments on four priorities The Duty of Candour is a key part of creating an open and transparent discussion between professional staff and the patient and can sometimes be difficult to achieve. We were therefore pleased to see that there will be training and support for professional staff to embed this important aspect of the clinical relationship. Importantly it will be possible to evidence the duty of candour as the patient records will provide assurance that this meets with professional codes Over the last two years we have worked closely with the Trust to improve the lives of service users with learning disabilities. The aim to develop and implement a non-stigmatising log to easily identify learning disability service users, so reasonable adjustments can be made to their care builds importantly on this work. With the leadership of this programme by NELFT it should be possible to achieve for the learning disabled user the same success as has been achieved for members of our community with dementia. We look forward to continuing to work with NELFT on the services and support needed for people with learning disabilities in Havering. 74 Page 74 NELFT NHS Foundation Trust I Quality Account 2015/16

75 Over the last two years we have worked closely with the Trust to improve the lives of service users with learning disabilities. The aim to develop and implement a non-stigmatising log to easily identify learning disability service users, so reasonable adjustments can be made to their care builds importantly on this work. With the leadership of this programme by NELFT it should be possible to achieve for the learning disabled user the same success as has been achieved for members of our community with dementia. We look forward to continuing to work with NELFT on the services and support needed for people with learning disabilities in Havering. End of Life care has been a key priority for Healthwatch Havering and we are very pleased to see the development and implementation of a training programme aimed at health professionals to help and support them with discussing End of Life care issues with services users and their families. It would be helpful to know how this will be included in the overall CCG strategy for End of Life Care. Our recent visits to the newly opened wards at King Georges evidenced a new and very welcome approach to delivering care. The decision to use the Kings Fund programme to undertake a complete dementia environment assessment is both exciting and innovative and we look forward to hearing more about this programme during the year. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 75

76 Statement from Thurrock CCG NHS THURROCK CCG COMMENTARY ON NORTH EAST LONDON FOUNDATION TRUST 2015/16 QUALITY ACCOUNT NHS Thurrock CCG welcomes the opportunity to comment on the annual Quality Account prepared by North East London NHS Foundation Trust (NELFT) as the primary commissioner of the Trust s South West Essex Community Services. As lead Commissioner for the contract and to the best of NHS Thurrock CCG s knowledge, the information contained in the Account is accurate and reflects a true and balanced description of the quality of provision of services. HIGHLIGHTS FROM 2015/16 The CCG commends the Trust s achievements in the Basildon, Brentwood Thurrock localities, including the awarding of the Emotional Wellbeing Mental Health Services and the Pulmonary Rehabilitation and Home Oxygen services. The CCG acknowledges the adult community services consultation undertaken to meet the needs of the local population to ensure a streamlined pathway which is in the early stages of implementation and the appointment of a joint integrated director role with Thurrock local authority to support further integration across health and social care teams in Thurrock. Thurrock CCG will be seeking assurances that the quality of care is maintained during BBCCG would like acknowledge the extensive work undertaken to improve its data quality work. BBCCG will continue to work with NELFT on accessing the details of the Thurrock and BB locality data set as part of the regular Clinical Quality Review Group and other Contract monitoring meetings. PRIORITIES FOR 2016/17 The CCG is pleased to note that the Trust has used stakeholder feedback including themes from complaints and compliments to influence the three priority improvements for 2016/17. Working together for Service Users The CCG is pleased to note that this priority will focus on compliance with the statutory requirements for Duty of Candour and will continue to work with the Trust to achieve this. Commitment to quality and care The CCG is pleased to note that this priority includes; the improvement and strengthening of processes to more easily identify service users with a learning disability to improve the quality of care they receive, improving the end of life care experience and the health care support workers certificate programme. Respect and Dignity The CCG is pleased to note that this priority aims to have a dementia friendly environment within in-patient areas. Vision Statement: The Health and care experience of the people of Thurrock will be improved as a result of our working effectively together. 76 Page 76 NELFT NHS Foundation Trust I Quality Account 2015/16

77 PARTICIPATION IN CLINICAL AUDITS The report provides a detailed account of the Trust s participation in corporate, clinical audit and research programmes. The CCG notes the learning from local clinical audits including Community Recovery Services, Integrated Community Services and health improvement services. The CCGs would like to have seen some reference to NICE compliance as part of this Quality account. CARE QUALITY COMMISSION (CQC) INSPECTIONS The CCG notes that the CQC carried out a total of 6 inspections trust-wide and that no enforcement action was undertaken. However, it is noted that there were no inspections to this locality. PROGRESS AGAINST 2015/16 PRIORITIES The CCG notes the following: Priority 1 Working together for patients The outcomes for Q4 for the patient survey which shows above 91% for community health. Priority 2 Commitment of quality of care The initiatives relating to Patient Safety Thermometer including the development of a pressure ulcer pain assessment tool. The awaited outcomes from the audit on the patient Inpatient Falls Prevention Advice Leaflet which the CCG would welcome sight of. The concerns relating to safe staffing for the local inpatient units which the CCG has been kept appraised of during the year. Progress with the HCSW certificate programme and the uptake of LSBU training. The CCG notes the Trust s disappointment that the target was not met and this will be carried over to 2016/17. Priority 3 - Compassion The progress being made to develop the care makers programme and that there are 6 applications undergoing registration Positive outcomes from both service users and staff from one big question NHS Thurrock CCG is fully supportive of all the priorities identified by NELFT in taking forward the patient safety, effectiveness, experience and involvement agenda and looks forward to working in partnership with the Trust in the forthcoming year. Jane Foster-Taylor Chief Nurse, Thurrock CCG NELFT NHS Foundation Trust I Quality Account 2015/16 Page 77

78 Statement from Thurrock Council Public Health Civic Offices, New Road, Grays, Essex RM17 6SL Thurrock Council Public Health Your Contact: Helen Horrocks Julie Price NELFT NHS Foundation Trust 24 May 2016 Dear Julie NELFT QUALITY ACCOUNT 2015/16 FEEDBACK We have reviewed the document in the areas for Thurrock and note some positives have been highlighted eg the SHIS Facebook page on p15, as well as the EWMHS service awarded across greater Essex. Regarding the priorities for next year, we would welcome these as joining with our drive for integration eg priority 1 working together for service users. Other comments: Section 1.1 on p7 Progressive, innovative and continually improving, and Promoting what is possible independence, opportunity and choice how far the Trust is prepared to go in terms of e-cigarettes? It s welcome to see Smoke Free feature as a key agenda item under section 1.4 on p9 and again what role might e-cigarettes play in this? Section 2.4 on p24 it is good to see patient feedback on infant feeding. We are pleased to see very high family and friends ratings at 98% for Q1-3 for Thurrock, some of the highest. The audit recommendations around safeguarding noted and welcomed on p24. It is very good to see NELFT active in research (p25). Content on p52 is a welcomed consideration regarding reference to skill mix of staff, work on safeguarding activities and participation in serious reviews well noted, actions to be taken as a result of the UNICEF BFI audit are very positive. To improve the lifestyle choices of patient s and understanding of staff it would be good to include Making Every Contact Count training (MECC) for front line staff to enable signposting to preventative services and community opportunities ( 3.8) It will be interesting to see the results of the grant programme MBCT- Eat depression and obesity applications (2.9). Thurrock s community weight management programme has a psychological service (2.9) It is good to see health checks for patients with ADHD and would be good to identify these within all services (p53) Early identification of dementia is part of the NHS health check programme and can lead to signposting onto relevant services. It is great to see the sexual health facebook page, however, in terms of innovative practice and successes on quality there is not much about the new SH website being launched, the completion of the integration this year, dual trained staff improving 78 Page 78 NELFT NHS Foundation Trust I Quality Account 2015/16

79 quality, locality being all in one place, one computer system (test results non paper based) (p15) Regarding 1.1 innovation, we would like to see the plan for increase in the use of LARC We really like the bespoke benchmarking tool (p36) Thank you for the opportunity to comment on the Quality Account report for 2015/16. Yours sincerely Helen Horrocks Lead Strategic Commissioner for Public Health NELFT NHS Foundation Trust I Quality Account 2015/16 Page 79

80 Statement from West Essex CCG Statement from West Essex Clinical Commissioning Group West Essex Clinical Commissioning Group is responsible for the commissioning from North East London NHS Foundation trust (NELFT) the emotional wellbeing and mental health service (EWMHS) which provides early intervention, support and mental health services for children and young people living in all of Essex. The EWMHS service has been managed by NELFT since autumn 2015; the Trust is promoting the service. There is no specific data in the quality account in relation to the quality of this service in the last year as it has not been in place for long. West Essex CCG are looking forward to working with NELFT in the coming years, EWMHS is part of NELFTs other activity including adult mental health and community services. The Trust involved service users and others to assist with setting proprieties for 2016/17, there is also a priority from the Trust Governors. There will clearly be an opportunity in year to include children and young people in discussions about priorities for the following year. The trust has provided information on their governance arrangements for producing the quality account, this helps patients and families understand how this complex document is created. We confirm that we have reviewed the information contained within the Account and checked this against data sources where these are available; it is accurate in relation to the services provided. The explanation by the Trust of why certain data sets are as they are has not been included in this draft version as the benchmarking data has not been added, this will hopefully be corrected in the final version. We have reviewed the content of the Account, it complies with the prescribed information as set out in legislation, by the Department of Health (including some of the new items NHS England requested be considered for this year) and by Monitor. We would also appreciate if the Trust would consider the use of the Crystal mark standard for plain English in future reports. Jane Kinniburgh Director of Nursing and Quality West Essex Clinical Commissioning Group Page 80 NELFT NHS Foundation Trust I Quality Account 2015/16

81 Statement from Waltham Forest Carers Association WALTHAM FOREST CARERS ASSOCIATION LIMITED Waltham Forest Resource Hub (Central), 1 Russell Road, Leyton, London, E10 7ES Telephone: (020) Fax: (020) Registered in England with Charity No Company Limited by Guarantee, Company No info@walthamforestcarers.com 23 rd May 2016 Dear Julie Re: NELFT Quality Account 2015/2016 Waltham Forest Carers Association have been working with NELFT over the past 18 months or so to look at the impact that current mental health service provision is having on carers and those they care for through their Mental Health Support Group. Waltham Forest Carers have been running this group for over 5 years now, identifying issues of concern and areas for improvement within mental health. In addition it has also been used as a forum to invite specialists from within NELFT to come and discuss detailed service provision within the following areas: Psychiatric Liaison Obsessive Compulsive Disorder IAPT Psychological Therapy Community Recovery Access and assessment The role of the Carer, their experience, feedback and information play a key role in assisting our organisation to work on their behalf to improve services for the people they care for. We welcome the quality account produced by NELFT and endorse the process of engaging with "service users, staff, partner organisations and stakeholders in an open and transparent way in order to scrutinise our processes". May we request that "carers" are also included in this process, perhaps they can be added? The 3 priorities which have been set by NELFT can only serve to provide improvements to service provision and we recognise the need to work together for the benefit of service users. Again the input of carers is paramount to this process. Respect and dignity is something we have had much discussion about within the mental health support group and carers are always mindful of the need to reinforce this particularly within front line service provision. We note that you have included within your report, feedback from service users that have influenced your priorities. To that end, we would be grateful if you might consider some of the following points which have also been raised by carers as a result of their direct experiences of mental health service provision in particular. NELFT NHS Foundation Trust I Quality Account 2015/16 Page 81

82 Statement from Waltham Forest Carers Association (cont.) Services at Whipps Cross Hospital: No Private facility for mental health patients within A&E Front line staff - extra training required on how to deal with mentally ill patients Checklist for mental health patients - to include patient s right to an advocate Explanation of any medication issued or administered including any potential side effects Goodmayes Hospital Accessibility, particularly for carers and those being cared for who live in Waltham Forest Facilities being provided need to look at the range of activities and their suitability for all service users Other Issues No safe house to take those with mental illness within Waltham Forest Mental Health needs to be given a higher profile in the borough, similar to what we are now doing with dementia. Whilst these are just some of the issues being raised, the Mental Health Support Group recognises that improvements have been and continue to be made. For example there have been significant improvements for those who attend A&E and need to be assessed by Psychiatric Liaison. There is now a 24 hour cover for the service at Whipps Cross which did not exist previously. The new Access and Assessment emergency walk in service at Thorpe Coombe is also to be welcomed this is a major breakthrough for patients suffering with mental health issues. We will continue to work with NELFT to raise issues of concern and to work together to ensure that the role of the carer is not only acknowledged, but that the role they play can contribute significantly to improvements in overall service provision for people with mental health issues living in Waltham Forest. Yours sincerely Fiona Cronin Chief Executive &Shenaz Mirza (Carers Support Groups Officer) For and on behalf of the Mental Health Carers Support Group Waltham Forest Carers Association. 82 Page 82 NELFT NHS Foundation Trust I Quality Account 2015/16

83 Statement from Waltham Forest CCG Stephanie Dawes Chief Nurse and Executive Director of Integrated care NELFT NHS Foundation Trust Friday 13 May Waltham Forest Clinical Commission Group Response to North East London NHS Foundation Trust Draft Quality Accounts 2015/16 Waltham Forest Clinical Commissioning Group (hereafter WF CCG) welcome the opportunity to review the Quality Accounts provided by North East London Foundation Trust (NELFT), which set out an overview of the quality of care provided by the Trust during 2015/16 and the priorities for 2016/17. This statement has been provided following collaboration with the Director of Nursing, WF CCG Chair and staff of the Quality and Governance team. The Quality Account is a well-structured document that clearly highlights the achievements made against the quality improvements in 2015/16. WF CCG is pleased to note the number of achievements that NELFT have made over the year and that the account is balanced indicating where improvements are still required. This section would benefit from a RAG rating to indicate at a glance how the Trust has performed in relation to quality of care. WF CCG is pleased to note that NELFT took on board the feedback made last year to ensure that the 6 C s is embedded into the care makers programme and reported in the Accounts. NELFT s success with the Waltham Forest Falls Prevention service demonstrates effective partnership working and WF CCG is pleased to note that over 90% of service users have seen an improvement in their overall balance and reduction in falls risk. There has also been substantial work undertaken relating to the timely reporting and investigation of both serious incidents and complaints with improved quality of reports for WF CCG patients and these sections could be enhanced to provide the reader with more detail and celebrate this success. It is noted that NELFT as an organization was not subject to a Care Quality Commission Chief of Hospitals Inspection in 2015/16 but there were 6 local inspections across its services. The Monitor Guidance for Quality Accounts indicates that where there are no current CQC ratings that Trusts set out their own view on the compliance with the five key domains. WF CCG feel his would strengthen the quality account and provide assurance to the reader that NELFT understands its services strengths and weaknesses. Whilst the document is well written it could benefit from the use of more graphics to demonstrate levels of achievement thus making it more reader friendly. WF CCG is particularly encouraged that it has consulted widely with stakeholders to inform their Quality Priorities for 2016/17, whilst remaining cognizant of previous priorities and utilizing feedback from complaints and incidents. WF CCG is fully supportive of these priorities. Priority 1: Working together for service users. This aim focuses on the delivery of the duty of candour to ensure the Trusts statutory and professional responsibility to be open, honest and transparent. The improvement goal is to ensure everyone is involved in NELFT NHS Foundation Trust I Quality Account 2015/16 Page 83

84 Statement from Waltham Forest CCG (cont.) their care and treatment. Having goals focused on the duty of candour may not promote delivery of the priority and ensure inclusive patient involvement. WF CCG would welcome further information as to how those patients not subject to duty of candour will be involved in their care. Priority 2: Priority 3: Commitment to quality and care. WF CCG welcomes the quality goals to improve the quality of care for patients with a learning disability, improve the end of life care experience and ensure all healthcare support workers are competent to deliver safe patient care. Respect and dignity. The quality goal has been developed following service user and carer feedback and focuses on ensuring in patient areas have a dementia friendly environment. Whilst an important quality goal this has a narrow focus for delivering respect and dignity, taking into consideration that a large proportion of care provided by NELFT is delivered outside of an inpatient setting. This goal could be enhanced to be more aspirational and to enable delivery of NELFTS fit for the future and continuous improvement. The priorities are described in the accounts in line with guidance indicating how these will be achieved, however it would be useful to understand timelines and milestones for implementation of projects and to provide clear measurable outcomes to demonstrate quality improvements and improve the Quality Account review of 16/17 next year. WF CCG has reviewed the content of the draft Quality Accounts comparing the content and format as mandated by NHS England Quality Accounts Guidance and Monitor Guidance for Foundation Trusts. WF CCG believes that in order to ensure full compliance with the reporting requirements the Quality Accounts reflect the following requirements; 1. To have data and statements for each Quality Indicator indicated in the mandated sections. This should include the actions being taken by the Trust to improve on results and improve on quality. 2. Information about NELFT s sign up to safety plan as part of the sign up to safety campaign. 3. CQC ratings estimation. 4. An overview of each sites quality performance in more detail. 5. Whether NELFT was or was not subject to a payment by results coding audit. WF CCG would like to thank NELFT in requesting input into the draft Quality Accounts and to give comment on the quality improvements both made and planned for the coming year. We look forward to continuing to work together strengthening matrix working across the health care system and continually improving the quality of care and service so our patients, their family and carers. Yours sincerely Anwar Khan Chair Waltham Forest Clinical Commissioning Group Helen Davenport Director of Nursing, Quality and Governance Waltham Forest Clinical Commissioning Group 84 Page 84 NELFT NHS Foundation Trust I Quality Account 2015/16

85 Appendix /16 Statement of directors responsibilities in respect of the quality report The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts) Regulations to prepare Quality Accounts for each financial year. Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality Reports (which incorporate the above legal requirements) and on the arrangements that NHS foundation trust boards should put in place to support the data quality for the preparation of the Quality Report. In preparing the Quality Report, directors are required to take steps to satisfy themselves that: the content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting Manual 2015/16 and supporting guidance the content of the Quality Report is not inconsistent with internal and external sources of information including: board minutes and papers for the period 28 April 2015 to 24 May 2016 papers relating to Quality reported to the board over the period 28 April 2015 to 24 May 2016 feedback from commissioners dated between 25 April and 24th May 2016 feedback from governors dated 27 January 2016 feedback from local Healthwatch organisations dated 26 May 2016 feedback from Overview and Scrutiny Committee 24th May 2016 the trust s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, dated October 2014 the (latest) national service user survey 27 October 2015 the (latest) national staff survey 16 December 2015 the Head of Internal Audit s annual opinion over the trust s control environment dated 24 May 2016 CQC Intelligent Monitoring Report dated January 2016 (currently the CQC issue quarterly IM reports relating to mental health services) the Quality Report presents a balanced picture of the NHS foundation trust s performance over the period covered the performance information reported in the Quality Report is reliable and accurate there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice the data underpinning the measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review the trust has concerns over the accuracy and completeness of the data on the Delayed Transfer of Care indicator and the Quality Report has been prepared in accordance with Monitor s annual reporting guidance (which incorporates the Quality Accounts regulations) (published at annualreportingmanual) as well as the standards to support data quality for the preparation of the Quality Report (available at annualreportingmanual) The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report. By order of the board Joe Fielder Chairman 26 May 2016 John Brouder Chief Executive 26 May 2016 NELFT NHS Foundation Trust I Quality Account 2015/16 Page 85

86 Appendix 5 Auditor s limited assurance report 86 Page 86 NELFT NHS Foundation Trust I Quality Account 2015/16

87 NELFT NHS Foundation Trust I Quality Account 2015/16 Page 87

88 88 Page 88 NELFT NHS Foundation Trust I Quality Account 2015/16