1Who we are. Who we are Welcome from the Chief Executive Officer. Our vision, values & aims Services we provide.

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2 Livewell Southwest is one of the largest social enterprises in England delivering health and social care services, and employing over 3,000 staff. 1 Who we are Welcome from the Chief Executive Officer. Our vision, values & aims Services we provide. 2 Our priorities for quality improvement 2016/17 Our aims & plans for improvement. Audits, data quality & information governance Review of our quality priorities for 2015/16 What has been achieved against our aims? Patient experience Positive & proactive care Incident reporting. Quality indicators Statements from stakeholders We are a forward thinking organisation delivering a unique and growing range of services across Plymouth, South Hams and West Devon as well as some specialist services for those living in other parts of Devon and Cornwall. We work as part of the NHS family, in a similar way to GPs, dentists and pharmacies. 1Who we are follow us on follow us facebook livewellsouthwest 2

3 Statement from Steve Waite, Chief Executive Officer 5 Our Aims 1 A recognised employee led organisation Welcome to our Quality Accounts for the year 2015/16. As a social enterprise providing publicly funded health and social care services we are required to publish a Quality Accounts every year. This document that sets out our vision for high quality services, highlights what we have achieved and what our priorities are for the next 12 months. Since our organisation was established five years ago, we have grown substantially from our beginnings and roots as an NHS organisation. The year covered by this Quality Accounts (2015/16) saw a period of particularly exciting change for our organisation with the integration of adult social care in Plymouth into our organisation, which is enabling us to develop and deliver services in new ways, and the expansion of our community health services to cover South Hams and West Devon. In January this year, our organisation rebranded from Plymouth Community Healthcare to Livewell Southwest to reflect the growing diversity and geographical spread of our social enterprise. Our philosophy remains rooted in delivering the very best in care and support to the people in our communities to help people be safe, well and at home. Our staff are our greatest asset. As a major employer in the region, we are committed to developing the workforce of the future with the right skills and abilities to deliver services in new ways. Service innovation and workforce development are crucial to ensuring health and social care services can meet the needs of changing demographics as we shape what we do to serve an aging population with increasingly complex needs. As we move forward into the next phase of our organisation s development, we are focused on continually improving our services to deliver truly coordinated person-centred care and to develop our workforce to meet the current and future needs of our communities. I would like to formally thank all my colleagues at Livewell Southwest for the contribution they make to the delivery of quality services. I would also like to express my grateful thanks to our partner organisations in the statutory, community and voluntary sectors, and to the people who use our services who continue to give us such valuable feedback on their experiences in using our services. To the best of my knowledge, the information contained within this report is accurate. Sustainable, successful & admired Providing seamless system leadership Based around local people & communities Where experience 3 2 exceeds expectations 3 4

4 Our vision, values & aims Services we provide Our vision at Livewell Southwest is to help the local population to be physically and mentally well, to get better when they are ill and to remain as independent as they can to the end of their lives. In essence, our vision is to support people to be safe, well and at home. To help us achieve this, Livewell Southwest has developed a set of five aims against which we measure our achievements. 1 2 A Recognised Employee-Led Organisation Our staff are our greatest asset and everyone plays a significant part in developing our organisation Based around Local People & Communities We work in locality teams that reflect the uniqueness of the communities we serve 3 4 Sustainable, Successful & Admired We are large enough to be sustainable and small enough to be effective Providing Seamless System Leadership We are responsive to change and continually developing new ways of working Our organisation is at the forefront of integrating health and social care. What this means is that we are starting to deliver care for people in new ways that are more efficient, with professionals who would previously have worked in individual teams now working together. This new way of working helps us to deliver the right care for people, in the right place, at the right time. 5 Experience Exceeding Expectation We deliver excellent quality care shaped and 5 informed by our staff and communities 6

5 During 2015/16 Livewell Southwest provided over 75 healthcare services through NHS commissioning as well as public health and adult social care services commissioned by local authorities. In producing this Quality Accounts, Livewell Southwest has reviewed all the data available to us on the quality of care in all of our NHS and public health services. The income generated by the NHS services reviewed in 2015/16 represents 87% of the total income generated from the provision of services by Livewell Southwest for 2015/16. Livewell Southwest provides a broad range of community health and adult social care services for approximately 330,000 people across Plymouth, and community health services in South Hams and West Devon. We also provide some specialist services across this patch and into other areas of Devon and Cornwall. Our social enterprise status means we can continually innovate to deliver care in new ways. As a Community Interest Company, Livewell Southwest can focus on what is right for the communities we serve rather than following national policies, and we can move faster in delivery. We work very closely with partners across public services and the voluntary sector to provide care for people in the most effective ways. Our locations and reach of our services... Plymouth Mount Gould, Windsor House, Plym Bridge House, Thornberry Centre, Glenbourne, Syrena House, Cumberland Centre, Acute GP, Westbourne, Centre Court, Plympton Clinic, Southway Clinic, Lee Mill. South Hams South Hams Hospital The Hayloft West Devon Tavistock Hospital Abbey Rise Mental Health Learning Disabilities Complex Care Children & Family Services Wellbeing Frailty Adult Social Care 7 Extending reach into other parts of Devon and Cornwall for some specialist services 8

6 2 Our priorities for quality improvement 2016/17 Statement from Geoff Baines, Director of Professional Practice, Safety & Quality 9 Looking forward to 2016/17 our key focus is to continue to develop our services around our locality working model, to finalise the work that we have started in co-locating our health and social care staff into multi-disciplinary teams. We continue to develop our workforce so we are fit for the future to deliver the right care for people, at the right time and in the right place. We maintain our focus on a number of development and quality improvement priorities that we believe to be important in supporting people to be safe, well and at home. Our priorities are shaped around input from staff and people who use our services, our commissioners and partners, local and national initiatives. Supporting people to be safe, well and at home is the clear vision for Livewell Southwest. As part of this we believe our five aims support us to ensure that continual improvement is part of our ethos. In this section we have mapped each of our priorities against our five aims to show how this works in practice. 10

7 Health and social care is changing. Our priorities for quality improvement will be influenced by both local and national strategies. This inclues the NHS Five Year Forward View, the Adult Social Care Outcomes Framework, the local strategy including the Health & Wellbeing Boards, the Transformation & Sustainability Plan and the NEW Devon CCG/Plymouth City Council Integrated Commissioning Strategy. Key areas for development for us will be Learning Launching Developing from and acting on the outputs from our staff survey 2015/16 and from feedback from people who use our services, partners and commissioners our staff wellbeing programme It s All About You and working towards the Workplace Wellbeing Charter our services and workforce around integrated teams delivering to the unique needs of our communities 11 We will also develop... A responsive and collaborative approach to working with developing GP Federations and other groups of Primary Care Professionals A wider arrangement of working across communities with the Community and Voluntary organisations that exist within our area 12

8 KEY AREAS FOR DEVELOPMENT AIM PRIORITY HOW WILL WE DO THIS? HOW WILL WE MEASURE IT? A recognised employee-led organisation Use input from staff across the organisation in helping to shape the future of our organisation and the services we deliver. Identify and provide Executive Team support for developing project proposals put forward by staff undertaking the Social Enterprise Leadership course. Develop the role and position of Our Voice, our staff engagement council. Monitor progress at Executive Team level Staff survey results Providing seamless system leadership Proactively avoid preventable hospital admissions from the local community. Promote and support the continued and full utilisation of our Urgent Care services. Inform and influence future health and social care delivery models. Monitor usage of Urgent Care services. Attendance and input to Sustainability & Transformation Plan. Based around local people and communities Continue to develop our organisation around the communities we serve. Listen to staff and people in communities about their health and social care service needs. Continue to co-locate our health and social care staff into locality teams. Procure services locally where possible. Staff survey and patient feedback. Monitor progress at Executive Team level. Monitor supplier usage via finance team. Where experience exceeds expectations To reduce the need for people with complex needs to tell their story more than once. Continuing to develop integrated teams that are co-located and share information effectively via SystmOne. Respond, learn from and act on incidents, complaints, service user and staff feedback in a timely manner. Monitor progress at Executive Team level. Staff survey and patient feedback. Numbers of compliments, complaints and incidents. Sustainable, successful and admired To develop our organisation in innovative ways so we are fit for the future delivery of health and social care services Continue to develop our paid-work placements and apprenticeships schemes. Support our staff in effectively using their three days a year of protected Continuing Professional Development time. Monitor uptake and feedback on our paid-work placement and apprenticeship schemes. 13 Staff survey. 14

9 Participation in audits By being involved in clinical audits nationally, regionally and locally we can discover where the organisation is providing excellence and where we can improve. In the year 2015/16, Livewell Southwest participated in three national clinical audits and one national clinical outcomes enquiry. The reports of 14 local clinical audits were reviewed by Livewell Southwest in 2015/16. For every local clinical audit undertaken, where appropriate, an action plan is created for the teams involved. Each audit has an identified lead and the action plans are monitored within operational and governance meetings. AUDIT/ENQUIRY DATA COLLECTION COMPLETED NUMBER OF CASES SUBMITTED ACTIONS IDENTIFIED Sentinel Stroke National Audit Programme Continuing data collection starting Jan 2013, ending 2016/17. Mount Gould Hospital stroke rehab completed 112 cases to discharge and the Early Supported Discharge team completed 198 cases to discharge. Action planning is in progress. National Confidential Inquiry into Suicide and Homicide by People with Mental Illness Quarterly returns made. Two questionnaires sent to clinicians re suicides. Zero homicides. Quarterly returns to review data and identify individuals who have had contact with our mental health services in the 12 months prior to the event. Consultants/clinicians complete questionnaires which are submitted to the Enquiry. Audit of Early Intervention in Psychosis Data submitted 1 Dec early Jan cases submitted. Action planning is in progress. Parkinson s Disease National Audit Data submitted October care of the elderly Action planning is in progress. 10 physiotherapy 12 occupational therapy speech and language therapy 16

10 CQUIN DESCRIPTION Dementia Physical health in serious mental health To support the identification of patients with dementia and delirium, alone and in combination alongside other medical conditions. It aims to prompt appropriate referral, follow up and effective communication between providers and general practice, through the introduction of a care plan on discharge; after the patient is discharged from hospital or community services following an episode of emergency unplanned care. To ensure that service users with serious mental illness have comprehensive metabolic risk assessments, the necessary treatments and the results recorded and shared appropriately with the patient and the treating clinical teams. People affected by this CQUIN are all patients with psychoses, including schizophrenia, in all types of inpatient units commissioned from all sectors, and the community early intervention psychosis services. Urgent & emergency care To ensure that patients with ambulatory care and similar conditions that do not normally require admission to a hospital bed receive highly responsive urgent care services outside of hospital. Improving diagnosis in A&E This indicator has been developed to incentivise better data recording and encourage improved and timely communication and intervention between acute trusts and mental health providers to improve outcomes for those with mental health conditions seeking urgent and emergency care. CAMHS to AMHS transition This CQUIN focuses on improving the transition from CAMHS to adult mental health services either within Livewell Southwest or the voluntary sector. Enhanced Recovery To lead the development and roll out of enhanced recovery for medicine within our own organisation and to contribute to the whole system work programme. The principles of enhanced recovery in medicine are that people recover sooner if they are mobilised early, have privacy and dignity, are well hydrated, have easy access to energy drinks and have a clear plan to get home. Psychological Therapies To seek to achieve improvements in the provision of safe, timely and effective psychological therapies, reducing standard referral to assessment time and subsequent assessment to treatment time, thus optimising patient experience and outcomes

11 Livewell Southwest is registered with and regulated by the CQC and is subject to periodic inspections. Livewell Southwest has participated in routine inspections by the CQC in connection with compliance with the Mental Health Act during this reporting period. The most recent published inspection of our services by CQC is from March 2015 after a follow up inspection of Syrena House, a specialist mental health unit in Plymstock for adult males. The inspection focused on medicines and concluded that appropriate arrangements were in place for the management of patient medication. Data Quality Full reports of CQC inspections are available to view on the CQC website at Good quality information underpins the effective delivery of patient care and is essential if improvements in quality of care are to be made. We understand the importance of ensuring that information held within the organisation is of the highest quality possible. This enables us to make informed, accurate and timely decisions about people who use our services and our community involvement. We have recently completed migrating our services away from multiple patient administration platforms on to a single organisation wide unified platform (TPP s SystmOne), which brought many benefits, not only patient safety & care, but in data quality. This system is linked directly to the NHS Spine Authentication portal, which holds all NHS Number registrations and the most up-to-date GP details for patients which will automatically update our records. The NHS number is the only national unique patient identifier used to help healthcare staff and service providers match people to their health records. Whilst the whole of the NHS and independent sector have made significant improvements in the NHS number allocation, at Livewell Southwest we continue to strive for 100% compliance across all of our record systems. 19 The plan for 2016 is to look in more depth at the data quality of each individual team, providing assurance of our clinical record keeping processes. 20

12 Secondary Usage Service Livewell Southwest submitted 1,204 inpatient and 1,189 outpatient records between 1 April 2015 and 29 February 2016 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 patients NHS number, was: 99.5% for admitted patient care (national average 99.2%) 99.8% for outpatient care (national average 99.4%) General Medical Practice Code The General Medical Practice (GMP) Code is an organisation code and Livewell Southwest has its own unique code. Accurate recording of the GMP code is essential to enable the transfer of clinical information about the patient from the patient s GP. The percentage of records in the published data which included the patients valid GMP code was % for admitted patient care (national average was 99.9%) 100% for outpatient care (national average was 99.8%) Information governance Livewell Southwest s score for 1 April 2015 to 31 March 2016 for the Information Quality and Records Management was assessed using the Information Governance Toolkit (IGT). We scored 68% and were graded as green (satisfactory). There is an information governance plan for 2016 with particular emphasis on Information Security and Data Sharing

13 3Review of our qualty priorities for 2015/16 Whether people who use our services feel cared for, safe and confident in their treatment. AIM1 a recognised employee-led organisation We set out to support and strengthen the role of employees leading the organisation through our staff engagement council Our Voice. What have we achieved this year? This year, Our Voice has been involved in several major projects across the organisation. In 2015, our organisation grew substantially to include adult social care services in Plymouth, and community health services in South Hams and West Devon. As a result we needed to change our name from Plymouth Community Healthcare to a name that reflected the new scope of our organisation. Marketing & Communications Team and the Board to shape the new branding and image for the organisation and to decide on the final name and logo choice. Our Voice also coordinated the People Awards 2015, recognising staff across the organisation for the contribution they make to delivering high quality care for people. This year more than 200 nominations were received from staff that highlighted the outstanding work that is being done across the organisation. Our Voice itself has grown this year, with 26 staff from across our localities and teams making up the staff engagement council. 23 Our Voice was involved in this process, from launching a competition for staff to come up with ideas for a new name, to helping the 24

14 Recognising the hard work of our amazing staff is really important to us all so often we think we are just doing our job. The high quality of services we deliver and the care taken to improve people s lives is truly life changing and this should be celebrated in any way we can. AIM2 based around local people & communities We set out to increase opportunities to integrate health and social care services to ensure people receive the right care, at the right time and in the right place. What have we achieved this year? In Plymouth, our organisation is at the forefront of integrating adult health and social care. In April 2015, adult social care staff transferred to Livewell Southwest from Plymouth City Council and since that date we have been working to reshape our teams and services to work in co-located multi-disciplinary community based teams. What this means is that health and social care professionals are working in teams together, for the first time. This has a number of benefits, including: More effective management at times when the health and social care system is under increased pressure, e.g. winter Minimising the duplication of roles and assessments to create more joined up delivery of services Co-located, integrated locality teams Staff engagement events were held throughout the year to help different groups of our health and social care staff to understand each other s roles, discuss key issues and ideas and to start looking at what a Single Assessment Process might look like. To maintain a smooth transition into integrated working, robust operational policies and procedures have been developed to ensure compliance with respective regulatory and professional codes of practice. A management and reporting structure review has also been completed, including a review of management tasks, functions and roles within an integrated service. Our first co-located, integrated locality team has been established in the east of Plymouth, with team moves completed in early Work is underway to continue co-locating and integrating our teams across the rest of Plymouth. More efficient use of staff capacity and skills building the workforce for the 25 future. 26

15 New and re-shaped services We have developed a number of multidisciplinary services in the last year for providing urgent care to people in Plymouth. These services are designed to support people at home and to reduce unnecessary hospital admission, including... A Community Crisis Response Team Acute Care at Home service providing acute care services that would traditionally be provided in a hospital setting Robin Community Assessment Hub an alternative to A&E for some patients that was recognised for its success at the Nursing Times Awards 2015, being shortlisted for the Emergency & Critical Care Award Integrated Hospital Discharge Service to get people home from hospital quicker with the right support in place 27 We have also integrated some of our existing services that provide specialist care to people in Plymouth, including our Learning Disabilities team (resulting in a Nursing Times Learning Disabilities Nursing Award in November 2015), Substance Misuse and Alcohol team and Safeguarding team. What s next for integration? While the work to integrate health and social care is happening at pace, there is still work to do. Bringing health and social care services together is just the start. Livewell Southwest is working with our staff, people who use our services, and the organisations that commission health and social care services locally (NEW Devon CCG and Plymouth City Council) and the voluntary sector to share our achievements, challenges and learnings from this first year. This will help shape how we deliver services in the future. 28

16 AIM3 We have established a monthly research governance meeting to guide and develop a balanced portfolio of studies as well as provide quality and safety assurance. This includes the development of a three year research development strategy for Livewell Southwest. The expansion of research activity at Livewell Southwest is seeing us working with prestigious academic establishments across the UK, including University College London, Kings College London and the MRC Centre for Neuropsychiatric Genetics and Genomics in Cardiff. to be sustainable, successful and admired We set out to develop opportunities for our organisation to be research-active, increasing the range of clinical trials available for local people in order to help us provide better services and improve overall quality. What have we achieved this year? In the past year we have firmly established our relationships with the National Institute of Health Research (NIHR). The NIHR is supporting us to develop a local research infrastructure and helping us get involved in large multi-centre portfolio trials. With their support we have increased our Research Team this year; we now have two research practitioners (an occupational therapist and a physiotherapist) and an admin support assistant, with a research nurse joining us soon. This unique and experienced multi-disciplinary team enables us to offer complex rehabilitation and community based random controlled trials. Under the close supervision of a research trial we can offer patients the opportunity to experience innovative new therapies. The number and range of trials being delivered has expanded with nine trials running this year. Along with trials in stroke and tissue viability we are now running trials in mental health, learning disabilities, multiple sclerosis and Parkinson s disease. Livewell Southwest participated in the NIHR Clinical Research Network South West Peninsula s annual snapshot of patient experience which highlighted that 94% of 1,211 respondents thought research should be a normal part of healthcare and 91% would recommend research participation to other patients

17 4 AIM providing seamless system leadership We set out to ensure effective transition for children and young people leaving child and adolescent mental health services (CAMHS) to go to other 5AIM What have we achieved this year? where experience exceeds expectations We set out to reduce avoidable harm to patients who use our inpatient services by reducing the number of avoidable pressure ulcers, reduce the harm associated with any falls occurring in our inpatient areas and providing essential education, learning and development opportunities for our staff. 31 services or to adult services. 31 What have we achieved this year? Livewell Southwest has developed a new protocol for transition from CAMHS to adult mental health services. This was produced in consultation with clinicians and managers from CAMHS, the Transition Steering Group and Forum and a sample group of young people, users of CAMHS undergoing transition. The protocol called on national initiatives for best practice guidance including: NICE: Transition from Children s to Adult Services for young people using health or social care services CQC: From the Pond into the Sea: Children s transition to adult health services (2014) NHS England guidance Social Care Institute for Excellence: Mental Health Transitions for Young People (2011) Young Minds: Transitions in Mental Health Care & Young People s Guide to Transition (2015) Livewell Southwest has focused on the reduction of harm associated with avoidable pressure ulcers within both inpatient and community settings. To ensure that we are sighted on any incidence of pressure ulcer occurrence, staff report all pressure ulcers one to four and all incidents are overseen by the tissue viability specialist nursing team to monitor for themes and trends. We also monitor pressure ulcer occurrence through the national safety thermometer. Livewell Southwest works in partnership with other agencies, services and providers including Plymouth City Council, NEW Devon CCG and Plymouth Hospitals NHS Trust using the Joint Pressure Ulcer Strategy as our standard. Throughout Livewell Southwest has implemented a number of actions to reduce pressure ulcer occurrence including a revision of our staff training programmes and the development of new guidelines and assessment tools, plus the start of a new leadership programme for district nurses (band 5 and 6) to develop a holistic patient centred approach. As a result of these actions we have noted a significant reduction in the number of acquired pressure ulcers indicating that staff are monitoring patients closely, noting risks and implementing prevention strategies in a timely way. 32

18 Research at Livewell Southwest 2015/16 Autism Cohort Trial... My son and I found the questionnaire easy to complete with relevant and valuable questions. A researcher at the university was easy to contact and really helpful. A positive experience which will no doubt have long term benefit for future generations. Kay Woodward, Parent Carer & Advocate Highlights from this year s research projects at Livewell Southwest Big CACTUS research project: This treatment has made such a difference to me. Communicating is easier and my voice is now definitely louder and clearer. It has given me the confidence to help my daughter work in the pub and to be with people, something I couldn t do after my stroke. Susan Hutchings, Stroke survivor with aphasia SUBJECT AREA RESEARCH STUDY SCOPE AND PURPOSE Learning Disabilities Autism Cohort Study To identify the changing health and social care needs of adults (16+ years) with autism as they age. This will inform and provide an evidence based approach to meet these needs and develop services locally. Mental Health ESMI (Effectiveness of Services for Mothers with Mental Illness) To determine the effectiveness and cost-effectiveness of psychiatric mother and baby units (MBUs) compared with general psychiatric inpatient services and/or home treatment teams in the first year after having a baby. Neurology SUMS (Standing Up in Multiple Sclerosis) A home based treatment involving the use of a standing frame. NEUPART (Evaluating the Effectiveness of Neupro (Rotigotine) and L-dopa Therapy in Patients with Parkinson s disease A commercial trial to evaluate the effectiveness of Rotigotine transdermal patch and Levodopa combination therapy in patients with Parkinson s disease. 33 Big CACTUS Stroke patients with aphasia receiving the latest computer software to use in their own homes for six 34 months with regular support. These patients may be participating months or even years after their strokes.

19 Thank you so much to all the Acute Care at Homes team for the excellent care and dedication you have all shown to me during my bout of cellulitis. You were all wonderful and very encouraging, and fun! I WILL get better, no doubt due to the three of you and thank you for keeping me out of hospital. 4Patient experience Livewell Southwest welcomes and encourages feedback from anyone who has experience of our services as a patient, service user, carer, family or member of the general public. Based on feedback in 2015/16, we can be proud of the range and expanse of compliments that we receive. However, we also recognise that in the rare times when care and treatment falls short of the high standards we strive for, it is important that we hear about it so we can learn from those experiences and improve what we do. COMPLAINTS COMMENTS CONCERNS / / / / / /16 35 COMPLIMENTS 1,073 1, / /16 36

20 Our complaints procedure has been established in line with NHS best practice guidance. Our aim is to resolve all concerns and complaints we receive efficiently and comprehensively. An important part of the complaint process is to ensure that we provide an open, honest and clear response and that we apologise when we identify any errors in our practice whether these are minor or major. The duty of candour is a contractual requirement for Livewell Southwest, which means that we are required to tell people who use our services if their safety has been compromised. Being open with people who use our services about what has happened and discussing incidents quickly, fully and compassionately can help all those involved. The final stage in the process is to ensure that lessons are learned to improve patient and service user experience. What have we put in place as a result of feedback in 2015/16?... ISSUES IDENTIFIED LEARNING Patient made a call to Long Term Conditions team on a Bank Holiday and queried why they did not work when the answerphone states they operate Monday to Friday. Answerphone message has been changed to advise that the service operates Monday to Friday except on Bank Holidays. Patient unhappy with the information received following amputation. Information provided to new amputees is being reviewed to ensure that it is adequate and suitable. New guidance is due to be issued shortly after publication of this Quality Account. Verbal communication provided to new amputees is also to be reviewed. Patient advised they were unaware of their appointment which had been made verbally by telephone. Non-urgent appointment letters are now to be sent as confirmation when appointments are made by telephone. 37 Patient advised that some chairs in an outpatient waiting room were not appropriate for patients with a disability due to their being too low. New chairs were ordered and installed in the outpatient department involved. 38

21 Positive and proactive care: reducing the need for restrictive interventions In July 2014 the Department of Health published Positive and Proactive Care: Reducing the Need for Restrictive Interventions. This guidance makes clear that restrictive interventions may be required in life threatening situations to protect both people who use services and staff or as part of an agreed care plan. Incident Reporting Livewell Southwest recognises the value and importance of ensuring all lessons learned from incidents are shared across the organisation. From 1 April 2015 to 31 March 2016 a total of 6,513 incidents were reported of which 6,084 resulted in no harm or were categorised as a low graded incident. The number of near misses reported was 154, the reporting and learning from these incidents allows the organisation to address issues which can prevent or reduce incidents that could have more serious outcomes. 39 Since that time Livewell Southwest has developed a document benchmarking against the standards identified by the Department of Health and this is discussed regularly at the Restrictive Intervention Governance Group. This is a multi-professional group that has formed to look at some aspects of restrictive intervention from both an operational and training perspective. There has been an increase of 1,065 incidents reported this period from the 5,448 incidents that were reported previously. This is attributable to actively encouraging all employees to report incidents and near misses; training is provided on the use of the web based reporting system, how to report correctly and the benefit of incident reporting across the organisation to further embed the positive safety culture evident throughout Livewell Southwest. 40

22 5Quality indicators Livewell Southwest is required to report on the following quality indicators which are relevant to the services we provide and to make clear where we intend to take action to improve the performance and quality of our services

23 INDICATOR TARGET 2012 / / / / 16 ACTION TO IMPROVE PERFORMANCE Percentage of patients on Care Programme Approach who were followed up within seven days after discharge from psychiatric inpatient care during the reporting period. 95% 99% 98% 98% 99% Continue to monitor through contract performance meetings. Percentage of admissions to acute wards for which the crisis resolution home treatment team acted as a gatekeeper during the reporting period. 95% 91% 83% 95% 100% Continue to monitor through contract performance meetings. Percentage of patients readmitted to hospital within 28 days of being discharged from hospital. New indicator for 2014 / 15 3% 13% 12% Continue to monitor through contract performance meetings. The number and, where available, rate of patient safety incidents reported within the organisation. New indicators for 2014 / 15 18% 5,448 incidents 5,157 Continue to monitor through contract performance meetings. The number and percentage of such patient safety incidents that resulted in severe harm or death. 1% 39/5, 448 incidents (0.71%) 54/5, 157 incidents (1.05%) Percentage of staff during the reporting period who would recommend Livewell Southwest as a provider of care to their family and friends. 60% 68% 71% - 79% Further staff survey taking place May Patient s experience of contact with a health or social care worker in Community Mental Health services who felt that they were definitely, or to some extent, treated with respect and dignity, had confidence in the person treating them and given time to discuss their condition or treatment. n/a 95% 94% - - Questions have changed significantly so data is not comparable. 43 People using mental health services who were surveyed who felt they were always or sometimes treated with respect and dignity. People using mental health services who were surveyed who felt that they were definitely or to some extent listened to carefully. n/a n/a 85% 85% 44

24 What our partners say... We have asked our stakeholders to comment on our organisation. These statements will be included shortly. 6Statements from stakeholders 45 46

25 GLOSSARY CARE QUALITY COMMISSION The CQC is the independent regulator of health and social care in England. CLINICAL AUDIT Clinical audit measures the quality of care and services against agreed standards and suggests or makes improvements where necessary. CLINICAL CODING Translates the medical terminology written by clinicians to describe a patient s diagnosis and treatment into standard, recognised codes. COMMISSIONING FOR QUALITY & INNOVATION SCHEMES (CQUINS) A payment framework which encourages further improvements in quality and innovation. GENERAL MEDICAL PRACTICE CODE A unique organisation code which helps identify the organisation and is essential to enable the transfer of clinical information about the patient from the patient s GP. HOSPITAL EPISODE STATISTICS Hospital Episode Statistics is the national statistical data warehouse for England of the care provided by NHS hospitals and for NHS hospital patients treated elsewhere. INDICATORS FOR QUALITY IMPROVEMENT A set of indicators which could be used for local quality improvement and benchmarking. INFORMATION GOVERNANCE TOOLKIT Standards by which organisations are assessed to ensure that information is held, obtained, recorded, used and shared lawfully. NATIONAL INSTITUTE FOR HEALTH RESEARCH (NIHR) A UK government body that coordinates and funds research for the NHS. NHS NUMBER A unique number which helps healthcare staff and service providers to match people to their health record. SECONDARY USES SERVICE Designed to provide anonymous patient-based data for purposes other than direct clinical care such as healthcare planning, commissioning, public health, medical research and national policy development 47 48

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