Humber NHS Foundation Trust Humber Mental Health Teaching NHS Trust Humber NHS Foundation Trust (Foundation Trust status awarded 1st February 2010) QUALITY REPORT 2009-10
Contents Quality Statement 4 Our Trust Values 5 Q.1 Trust Quality Assessment 6 Q.1.1 Historic and current view of the Trust s position for delivering high quality care 6 Q.1.2 Overview of governance arrangements 7 Q.1.3 How we have prioritised our quality improvement initiatives 7 Q.1.4 Our 2009/10 selected priorities and proposed initiatives updates 8 Priority 1: Same Sex Accommodation 9 Priority 2: PEAT (cleaning, food and infection control) 10 Priority 3: 7 Day Follow-up 11 Priority 4: Delayed Discharges 12 Priority 5: Gatekeeping/Single Point of Access 13 Q.1.5 How did we review our services 14 Comments from our Commissioners and other key stakeholders 19 Example Quotes from patients and carers 22 Q.1.6 Looking forward 2010/11 23 Glossary 28
Quality Statement During 2009/10 Humber NHS Foundation Trust provided mental health, learning disability and addiction services for children, adults and older people across the City of Hull and the East Riding of Yorkshire. We also provided forensic services to patients from the wider Yorkshire and Humber area. Our income in 2009/10 was 83.9 million and as at 31 March 2010 we had 1611.94 whole time equivalent staff in post. During 2009/10 monthly reports on the Trusts performance against national and local quality indicators were reported to the Trust Board, these public reports provided the Trust Board with up to date and accurate information on the quality of care delivery across our services. These Board level reports are part of a three tier performance management system which runs from Ward to Board and ensures that high quality care is at the heart of all we do. We also recognise that, in order to offer assurance to patients that we provide high-quality care, we must be able to demonstrate, through quality reporting, that we have high levels of reported patient satisfaction, services that are as safe as possible, and clinical outcomes that are higher than the national average. In 2008/09 the Trust published its first quality accounts and set five priorities for quality improvement for 2009/10 and has been reporting progress monthly to the Trust Board. These quality accounts represent our achievements for 2009/10 and following consultation with stakeholders, set our priorities for 2010/11. The Trust was successful in gaining Foundation Trust status on the 1st February 2010 and therefore this document represents our final quality account as a NHS Trust and our first Quality Report as a Foundation Trust. The document outlines: Increased accountability to the public for quality, explaining the quality of the care we offer and how we are seeking to improve and engage the Trust Board in leading the quality agenda. That we are proud that feedback from patients tells us that they are largely satisfied with our services. That we rank highly in national league tables, for example patient and staff experience. That over the past year, we have made some significant quality improvements: successfully improving privacy and dignity for our patients. That we have also made great progress in the prevention and control of healthcare-associated infections. Along with improving the quality of care for our patients, we also want to be an organisation where staff feel recognised and rewarded. We want staff to work within an environment where they are able to provide the highest quality of care possible. We recognise that there will always be challenges to meet and will continue to strive for the highest quality in all care provided, putting our patients at the heart of everything we do. The information contained in this document has been subject to robust internal review and, where applicable external verification. Therefore, to the best of my knowledge these accounts are a true and accurate reflection of the quality of care we deliver to the communities we serve. David Snowdon Chief Executive June 2010 4 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Our Trust Values Underpinning all of our work with patients and carers is the commitment to uphold the values and principles of the NHS. These are: VALUE Compassion Respect and Dignity Commitment to the quality of care Improving lives Working together for patients Everyone counts IMPACT We will make sure we take the time to listen and understand We will ensure people are treated as individuals, in environments where their dignity is maintained By getting the basics right we will maintain and improve the quality of care We will strive to deliver continuous quality improvement, improving peoples' health and wellbeing. We will promote activities that make a positive impact on the 'work life balance' of our staff We will work with partners across organisational boundaries to improve user and carer experience We will maintain clear focus on people as well as services All of the above support delivery of our vision to improve the health and wellbeing of the communities we serve. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 5
Q.1 Trust Quality Assessment Q.1.1 Historic and current view of Trust s position for delivering high quality care The Care Quality Commission (CQC), formerly the Healthcare Commission, undertakes an annual health check. This quality account has reviewed the CQC assessment 2008/09 results and has compared with previous years and with other mental health trusts in the Yorkshire and the Humber Strategic Health Authority. Our Trust was rated excellent for quality of services and good for the use of resources for the second year running based on performance in 2008/09. These results place our Trust alongside the best performers locally, regionally and nationally. As part of the East Coast Audit Consortium s 2009/10 annual plan for the Humber NHS Foundation Trust, a review has been performed to ensure that the Trust has a robust system for demonstrating compliance with the Standards for Better Health, and that there are effective reporting mechanisms in place to fully evidence the midyear declaration for 2009/10. The East Coast Audit Consortium have offered significant assurance that the Trust has developed and implemented a robust system for demonstrating compliance with the Standards for Better Health, and has a clearly auditable and linked process. The East Coast Audit Consortium sample testing of seven standards indicated that within the Trust there is a sufficient body of documentary evidence to support the Trust s fully met annual declaration for 2009/10. 6 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Q.1 Trust Quality Assessment Q.1.2 Overview of governance arrangements The keys to effective governance within the Trust are robust integrated committee structures and management processes, which give the Board of Directors confidence that all risks are being effectively controlled and managed and that attention is focused on the core business of the organisation to care for and treat patients. The Board committee structure is evaluated for effectiveness on an ongoing basis by the Board of Directors and committee members. Q.1.3 How we have prioritised our quality improvement initiatives To determine these priorities, we reviewed our clinical performance against Key Performance Indicators for the year. Through a series of reviews we assessed each initiative in terms of: impact on improving quality through considering the likely improvement in safety, clinical outcomes and experience feasibility, in terms of the ease of implementation, resources required and likely time to completion or delivery Clinical Governance Strategy We have an established Clinical Governance strategy supporting high quality care, which is underpinned by compliance with the Health Care Standards. This strategy provides a vision for the strategic development of Clinical Governance throughout the Trust and helps demonstrate its direction in the next three years towards the delivery of excellent mental health and learning disability services for both our patients and carers. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 7
Q.1 Trust Quality Assessment Q.1.4 Our 2009/10 selected priorities and proposed initiatives updates Our Trust uses a Traffic Light system to report on performance and on the quality of services, e.g. Green = Good, Amber = Fair and Red = Weak. This is translated to reflect the organisation s performance on the selected priorities and initiatives. To achieve quality performance our traffic light system has allowed our Trust to: monitor critical clinical processes and activities using metrics of clinical and corporate performance that trigger alerts when potential problems arise analyse the root cause of problems by exploring relevant and timely information from multiple perspectives and at various levels of detail manage people and processes to improve decisions, optimise performance, and steer the organisation in the right direction. The following were the priorities and updates for 2009/10 Priority 1: Single Sex Accommodation Priority 2: PEAT (cleaning, food and infection control) Priority 3: 7 day follow-ups to patients following discharge from an inpatient stay Priority 4: To prevent delays in discharge from inpatient stays Priority 5: Gatekeeping/Single Point of Access to ensure a multi-disciplinary Approach to admission to an inpatient ward 8 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Priority 1: Single Sex Accommodation Description of issue and rationale for prioritising: All Trusts must be compliant with the same sex accommodation requirements by 2010 including the Department of Health minimum standards of: no shared sleeping accommodation no shared toilets patients do not have to pass through opposite sex facilities to access their own Aim/Goal: To ensure that our Trust is compliant by 2010. Position as at 31/03/2010 All our inpatient units are fully compliant. However, the Trust not only wants to meet the target, but to exceed it, therefore it acknowledges that further work is required at Townend Court to enhance the facilities provided to our learning disability inpatients. Further information on our work to deliver same sex accommodation Every patient has the right to receive high quality care that is safe, effective and respects their privacy and dignity. The Humber NHS Foundation Trust is committed to providing every service user who is receiving services within our inpatient units with same sex accommodation, because it helps to safeguard their privacy and dignity when they are often at their most vulnerable. The majority of our inpatient services are provided within single bedded rooms. Where patients have to share a room this will be with members of the same sex, and same sex toilets and bathrooms will be close to their bed area. Lounges for women only use are available on all of our inpatient units on request. Looking back to 2009/10, how have we measured success? By seeking the views of people who have used Humber NHS Foundation Trust inpatient services. The Trust carried out regular patient surveys to ensure that the standards have been maintained. We have regularly updated the Trust Board on how our inpatient services are viewed by patients in terms of privacy and dignity issues. These reports have been published on our website. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 9
Priority 2: PEAT (cleaning, food and infection control) Description of issue and rationale for prioritising: The Clean Hospitals Programme has been implemented and monitored by the Patient Environment Action Team (PEAT) and involves patients and carers. For this year the programme has been adapted to reflect the changing expectations of patients, the way the NHS is organised and to ensure that the results of the programme provide an accurate picture of the standards that should be achieved. Aim/Goal: To maintain and improve on previous PEAT scores. Position as at 31/03/2010 Our focus in 2009/10 was on cleanliness. Although this was not a mandatory requirement, the Trust completed 90% of deep cleans, excluding the forensic units. Within the forensic units, a limited deep clean has taken place due to building works. We have undertaken a full analysis of all PEAT assessments. The data gathered guides the Trust in producing 2009/10 s Clean Hospital Programme. To support this programme, the total capital allocation awarded to address Privacy and Dignity standards, including same sex accommodation, was 253,500. At December 2009, the Trust was reporting two units which were attaining unacceptable overall scores. Following proactive activity, we can now confirm that one of these units is reported as very good with a PEAT score of 95% and the other unit reported as acceptable with a PEAT score of 90% ensuring that the Trust is fully compliant with the Clean Hospital Programme. Looking back to 2009/10, how have we measured success? By seeking the views of people who use Humber NHS Foundation Trust inpatient services. The Trust has regularly surveyed the patients of inpatient units to ensure that the standards of food and cleanliness are maintained or improved. 10 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Priority 3: 7 Day Follow-up Description of issue and rationale for prioritising: Supported by the evidence set out in the National Suicide Prevention Strategy for England (Professor Louis Appleby 2002), it is recognised that anybody being discharged from inpatient care should be contacted by a mental health professional, either face to face or by telephone, within seven days of that discharge. Aim/Goal: To ensure that everyone who is discharged from our inpatient care is followed up within the required criteria. Exceptions to this are: people who die within seven days of discharge where legal precedence has forced the removal of a patient from the country patients discharged or transferred to other NHS hospital for psychiatric treatment Position as at 31/03/2010 For Quarter 4 the 7 day follow up rate Trustwide was 100%. The graph below shows that the Trust has achieved a 100% follow up rate for seven months of the last financial year (09/10) and has consistently achieved or been above the national target of 95% for the other five months. Looking back to 2009/10, how have we measured success? In July 2009 the Performance Team implemented a more robust pro-active process for the tracking of discharges and 7 day follow-ups. This, along with the standard that all patients should be seen face to face within seven days of discharge and that telephone contact should only be used as last resort, has had a positive impact by increasing the Trustwide average 7 day follow-up rate from 95.02% (April 08 to March 09), 0.02% above the national target, to 98.73% (April 2009 to March 2010) which is 3.73% above the national target. 102% 100% 98% 96% 94% 92% 90% 88% Trustwide Figures for 7 Day Follow-up 2008/09-2009/10 86% 84% 82% Apr-09 May-09 Jun-09 July-09 Aug-09 Sept-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Target 2008/09 2009/10 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 98% 89% 94% 95% 93% 96% 96% 96% 97% 96% 96% 95% 100% 95% 96% 97% 100% 98% 100% 100% 98% 100% 100% 100% Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 11
Priority 4: Delayed Discharges Description of issue and rationale for prioritising: In the last quarter of 2008/9 our Trust was 2% above the national measure of 7.5%. Our traffic light rating for this period was weak and there was an expectation that delays in discharges would be kept to a minimum. Aim/Goal: To reduce the number of delayed discharges in the Trust below the national key performance indicator set of 7.5%. Position as at 31/03/2010 In Quarter 4 of 2009-10 our Trust had an overall delayed discharge rate of 6.16%, this being a favourable 1.34% below the national target of 7.5%. As Care Quality Commission only examines delayed discharges where NHS provision is the delaying factor, this reduced the figure significantly to show the Trust as being a favourable 3.98% below the national measure of 7.5%. Looking back to 2009/10, how have we measured success? As part of a transition programme, over 2009/10 Humber NHS Foundation Trust has worked in collaboration with a local private provider who offers long term care for older people and for patients no longer requiring treatment within an NHS hospital. Four patients in our older people s services who were classified as "Delayed Discharges have now been successfully transferred to more suitable accommodation. As a Trust we are still working collaboratively with the private sector to maintain high quality of care. 12% Delayed Discharge Figures 2009/10 10% 8% 6% 4% 2% Target 0% Apr-09 May-09 Jun-09 July-09 Aug-09 Sept-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 12 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Priority 5: Gatekeeping/Single Point of Access Description of issue and rationale for prioritising: To comply with Mental Health Policy implementation guidance Crisis Resolution Home Treatment (CRHT) must ensure that all admissions to an inpatient unit have a Gatekeeping assessment (an admission has been gate kept when a multidisciplinary decision includes CRHT staff agreeing that home treatment is not a suitable alternative). Aim/Goal: 90% Position as at 31/03/2010 100% Single Point of Access This service is accessed by patients at the start of their mental health journey (ease of access) and quickly refers callers to the most appropriate NHS resource. In such circumstances appropriate means the service best able to clinically meet patient needs in a timely manner. Gatekeeping Assessments This is the role CRHT teams play in deciding who needs to be treated in hospital and who can be treated at home. In the initial assessment by the team, additional information is sought, with patient permission, from family and friends to gain a full picture of how mentally ill the person is and the risk they present to themselves and/or others. Following assessment, the community services then review where best that patient s needs can be met. Looking back to 2009/10, how have we measured success? We have looked at performance data from the existing Single Point of Access Service in Hull with a view to implementing this model in the East Riding Business Unit. 102% Gatekeeping Figures 2009/10 100% 98% 96% 94% 92% 90% 88% Apr-09 May-09 Jun-09 July-09 Aug-09 Sept-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 13
Q.1 Trust Quality Assessment Q.1.5 How did we review our services The Trust provides services for Mental Health, Learning Disability and Addictions specialties/areas. For 2009/10 the Trust has undertaken 29 service reviews. The data from these audits has been presented and discussed at relevant committees, clinical networks and clinical teams who have reviewed the available data on the quality of care in their sections of these specialties/areas. The Trust has undertaken specific reviews in the following areas; Working Age Adult 8 Older People 2 Addictions 5 Children s 5 Learning Disability 2 All Service Areas 7 TOTAL 29 The relevant committees and clinical networks have used the results of these reviews to develop plans for improving the quality of the Trust s services. The Trust has robust governance arrangements in place to manage any adverse incidents. For this reporting period we have undertaken 30 serious untoward incident (SUIs) investigations and 14 management reviews. Outcomes found during these investigations have been shared with all relevant parties and any lessons learnt are acted upon. Information on participation in clinical audits The Trust was eligible to participate in three national clinical audits and related clinical quality data collection programmes, such as national confidential enquiries, covering services it provides. The full list of potential audits and those the Trust participated in can be provided on request. In relation to the Trust s participation: The Trust participated in two out of three of the national clinical audits for which it was eligible. The Trust undertakes a programme of local audit on clinical performance which is reported to the Trust Board. 14 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Q.1 Trust Quality Assessment Information on participation in clinical research The number of patients recruited in the previous year to clinical research (that is, research approved by a Research Ethics Committee) was 501. 66 were recruited to National Institute for Health Research (NIHR) Projects. 435 were recruited to studies conducted by Psychology Students employed by the Trust. The Trust has an ongoing programme of care review activity for 2010/11, and the Trust has commissioned a programme of themed reviews covering all speciality areas, which will be reported on in our next Quality Accounts. Information on what others say about our Trust The following is an overview of the quality and resources provided by our Trust based on performance in 2008/9 against the Care Quality Commission indicators (CQC). Historic & Current view of Trust s position for delivering high quality care Financial HCC HCC Year Quality Resources 2005/06 Fair Fair 2006/07 Fair Good 2007/08 Excellent Good 2008/09 Excellent Good 2009/10 Pending Pending (October 2010) (October 2010) Humber NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is fully compliant. The Care Quality Commission has not taken enforcement action against Humber NHS Foundation Trust during 2009/10. The most recent periodic review carried out by the CQC made the following conclusions for the second year running our Trust was rated excellent for quality of services and good for the use of resources. Humber NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period. These results place our Trust alongside the best performers locally, regionally and nationally. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 15
Q.1 Trust Quality Assessment Information on the National Patient Survey The National Patient Survey enables Trusts to benchmark themselves against other mental health trusts. The data in the following table, as published in our Integrated Business Plan for Foundation Trust status, was constructed from the National Patient Survey question regarding rating of the care received within the national parameters which are Excellent, Very Good, Good, Fair, Poor and Very poor. The table shows our Trust as being the best performing mental health trust in the Yorkshire and Humber Strategic Health Authority in 2008. The results for 2009 will be made available to the Trust in July/August 2010. SHA Comparators 2005/6 2006/7 2007/8 2008/9 rating rating rating rating Information on the quality of data In 2009/10 the Trust submitted 1380 records to the Secondary Uses System (SUS) service for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records which included the patient s valid NHS Number was 99.8%. The Trust s rate for clinical coding (for diagnosis) was 76.8% and the percentage of records which included the patient s valid General Practitioner Registration Code was 100%. Work is being undertaken in the coming year to develop a more robust process for the managing of corporate records with the implementation of a Trust Information Management and Lifecycle Policy. Humber Mental Health Bradford Care Trust Rotherham, Doncaster, S Humber FT Leeds Partnership FT Sheffield Health and Social Care FT 75 70 77 75 71 71 66 70 74 71 71 74 69 72 72 73 67 65 72 68 16 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Q.1 Trust Quality Assessment The Information Governance Toolkit Achievement Against Requirements There is a mandatory requirement for the Trust to submit an annual central return measuring its performance in the following areas of information governance: Information Governance Management Confidentiality and Data Protection Assurance Information Security Assurance Clinical Information Assurance Secondary Use Assurance Corporate Information Assurance There are a total of sixty requirements across the six areas of information governance (plus two that have been deemed not relevant to this Trust) and each requirement is rated from zero for no compliance, to three for full compliance. Performance is traffic lighted according to the percentage achieved in each initiative as follows: 0 to 39% RED 40% to 69% AMBER 70%+ GREEN The requirements in each initiative are assigned to a lead officer. They have assessed the level of attainment against their requirements, giving any supporting evidence for these scores and describing improvement plans to move to the next higher level. The following table shows the Trust s performance against the requirements: Initiative Results 2009/2010 Information Governance Management Confidentiality and Data Protection Assurance Information Security Assurance Clinical Information Assurance Secondary Use Assurance Corporate Information Assurance TOTAL 86% (Green) 85% (Green) 95% (Green) 75% (Amber) 53% (Amber) 66% (Green) 80% (Green) Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 17
Q.1 Trust Quality Assessment Commissioning for Quality and Innovation (CQUIN) CQUIN are measures which determine whether we achieve quality goals or an element of the quality goal. These achievements are on the basis of which CQUIN payments are made. 2009/10 was the first year in which CQUIN was implemented for mental health trusts, in this first year the Trust was required to demonstrate its ability to report on quality improvement and innovation goals which were agreed between the Provider and its Commissioners through the CQUIN payment framework. The Trust achieved this and was awarded a maximum quality payment of 314,749, this is broken down as follows:- Commissioner Final CQUIN payments 2009/10 Commissioner Final CQUIN payments 2009/10 NHS Hull 149,987 NHS East Riding of Yorkshire 117,772 Commissioner Final CQUIN payments 2009/10 NHS Barnsley 47,000 18 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Comments from our Commissioners and other key stakeholders NHS Hull I welcome the opportunity to review and comment on the Draft Quality Report 2009-10 for Humber NHS Foundation Trust. I can confirm that, to the best of my knowledge the report is a true and accurate reflection of the quality of care delivered by Humber NHS Foundation Trust and that the data and information contained in the report is accurate. Our joint commitment to continuous quality improvement and learning lessons has led us to restructure our formal contracting process so there is a specific focus on quality. This allows us to scrutinise issues of quality and outcomes with the same rigour that contracting has previously afforded to finance and performance. The development of local scrutiny of serious and untoward incidents allows us to monitor action plans locally, collect evidence of lessons learnt and revise specifications and services if necessary. During the period covered by this report Humber NHS Foundation Trust, NHS Hull and NHS East Riding of Yorkshire accepted the findings of a joint Independent Inquiry (SUI Reference 2005/95 and SUI Reference 2003/1578) commissioned by Yorkshire and the Humber Strategic Health Authority. An action plan was produced which addressed the recommendations from the Independent Inquiry reports, and has been thoroughly implemented. As commissioners and provider we have had significant input into the shaping of both regional and local CQUIN schemes mentioned in the report and will continue to set challenging targets in order to provide incentives to improve services and service user experience. Chris Long Chief Executive NHS Hull Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 19
Comments from our Commissioners and other key stakeholders NHS East Riding of Yorkshire We would like to see a continuation of the positive working between Humber NHS Foundation Trust and NHS East Riding of Yorkshire to deliver improved quality of patient care and the patient experience. It is encouraging to see local quality standards (CQUINS) reflecting commissioner priorities within the Quality Account. We would welcome further developments in capturing the patient experience to inform service delivery and how some of the targets identified translate into improved outcomes for patients. Ivan Ellul Chief Executive NHS East Riding of Yorkshire 20 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Comments from our Commissioners and other key stakeholders Hull Local Involvement Network (LINk) Hull LINk welcomes the opportunity to comment on the Trust s Quality Accounts. Since the LINk was set up a very constructive relationship has been built up with the Trust, enabling us to engage with the service to deliver our key aim of improved services for patients. In our view the document is representative and provides comprehensive coverage of the Trust s services. It is encouraging that the Trust is meeting the same sex accommodation requirements for inpatients and also the seven day follow up for discharged patients. We also welcome the progress made in reducing delayed discharges. The introduction of the Single Point of Access has been a key development in the past year and we are encouraged that the system is helping patients reach the most appropriate NHS resource. A major item on our work plan this year was our enquiry into mental health services for young people. This involved gathering information and feedback from groups supporting young people and a survey of people with experience of services. Over 100 people and groups had their say on this issue. Our resulting report included recommendations around: improving transition between children s and adult s services; involving young people in how services are designed; and improving publicity and awareness of services. In response the Trust committed to formalise protocols regarding transition between services, including the single point of access services, interagency link team and the child and adolescent mental health service. The Trust was able to highlight a lot of activity to engage young people and made us aware of a forthcoming overall service evaluation. Jonathan Appleton LINk Team Leader Hull Local Involvement Network (LINk) Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 21
Our patients and carers say... Thank you for all your support. I ve reached the light at the end of the tunnel; you played a part in that too. A special thank you for the support and reassurance you have given to us. Thank you so much for all the care and support you have given to R over the last five years. We have appreciated your hard work and commitment as his key worker and particularly thank you for your efforts in planning his transition. Thanks for all your help and support. My future is a lot brighter now thanks to you. Many, many thanks for all of your help and support whilst I was going through a very difficult time. I just wanted to write and thank you for all of your help when I came to see you earlier last year. Before speaking to you I had no idea what was going on inside of my head and no clear image of who I was. Through talking to you I found myself and started to love myself in a way that I don t feel many people every get the luxury of. 22 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Q.1 Trust Quality Assessment Q.1.6 Looking forward 2010/11 Agreed quality performance 2010/11, including: An overview of the quality of care provided by our Trust will be based on our performance in 2010/11 against the following indicators agreed by the Trust Board following consultation with key stakeholders. Our indicator set includes: Patient safety Infection control To ensure that all patients who are undergoing any treatment or intervention in an inpatient or outpatient setting are protected from the potential and actual acquisition of healthcare associated infections (HCAI). Same sex accommodation All Trusts must be compliant with same sex accommodation requirements set out by the Department of Health 2010 minimum standards. 7 day follow-up This is supported by evidence set out in the National Suicide Prevention Strategy and it is recognised that anyone being discharged from inpatient care will be contacted within seven days. Clinical effectiveness Physical Health and Wellbeing To ensure that we as a Trust have clinical performance procedures in place to ensure we meet the physical health needs of those with mental health needs and learning disabilities. Access To ensure all patients and carers have a clear pathway in to services in the right time to meet the right person to assess and treat identified need. Delayed discharges Any identified patient who no longer requires inpatient treatment with no alternative accommodation will be registered or reported as a delayed discharge. Each of these patients will have an action plan to signpost them to suitable accommodation as quickly as practicable. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 23
Q.1 Trust Quality Assessment Patient experience Assessment of food and cleanliness This is an element of the Department of Health s Clean Hospitals programme and is monitored by the Patient Environment Action Team (PEAT). Carer Experience To co-ordinate and capture the experience of carers who have access to and work within our services. Key national priorities Meeting Early Intervention in Psychosis new cases target Meeting Vital Signs targets Meeting Crisis resolution targets Admissions to adult in patient units for people aged 16 or 17 Pathways for Learning Disability To improve care pathways for Learning Disabled patients ensuring that safe and effective care is given. 24 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Q.1 Trust Quality Assessment Commissioning for Quality and Innovation (CQUIN) 2010/11 Yorkshire and the Humber have worked to develop the regional indicators below for the 2010/11 CQUIN scheme. Regional 1 Improving the proportion of patients who receive rapid face to face response EXPECTED OUTCOME To improve the proportion of patients in crisis who receive rapid face to face response will improve patient experience and reduce inappropriate bed use. 2 Improvement of the number of referrals being seen and treatment commencing within eight weeks EXPECTED OUTCOME To allow progress towards a no waits culture in mental health services. 3 Improving the experience of black and minority ethnic (BME) patients by ensuring that safe and effective care is given EXPECTED OUTCOME To improve BME patients experience by ensuring that safe and effective care is given. 4 Improving the focus on the care of patients in line with the essence of care EXPECTED OUTCOME To ensure the physical wellbeing of inpatients on older people s mental health wards. 5 Improving in pressure ulcer prevention and management in line with the Essence of care EXPECTED OUTCOME To improve pressure ulcer prevention and management. 6 Development and implementation of care pathways for all patients with learning disability requiring mental health services EXPECTED OUTCOME To improve the experience of mental health services for patients who have a learning disability by ensuring that safe and effective care is given. This is also aligned to the Green light toolkit. 7 Development and implementation of an integrated Dementia pathway across mental health and Learning Disability services EXPECTED OUTCOME To improve the experience of patients with dementia by ensuring that safe and effective care is given, communication channels are clear, and cross boundary working is achieved across mental health, community and acute sectors. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 25
Q.1 Trust Quality Assessment Local CQUIN indicators have been produced with the three primary care trusts for which we provide services and have been included within the national CQUIN template before being submitted to the SHA for assurance. Local 1 Improving access for people experiencing problems that require an urgent response EXPECTED OUTCOME To improve the proportion of patients in crisis who receive rapid face to face response will improve patient experience and reduce inappropriate bed use. 2 Patient satisfaction EXPECTED OUTCOME Patient views of whether they have been treated with dignity and respect is the biggest indicator of their broader experience of care. The Care Quality Commission annual inpatient survey 2009 demonstrated that our Trust s performance needed to be improved in this area. 5 Patient transfers EXPECTED OUTCOME To have collaborative working with local PCTs for agreement for repatriation of our patients currently in out of area treatment. 6 Co-morbid condition EXPECTED OUTCOME For every practitioner to have skills and knowledge on how to improve the assessment and management of patients with a mental health problem and other identified co-morbid conditions. 3 Violence and aggression EXPECTED OUTCOME To reduce adverse incidents when dealing with disturbed or violent behaviour by any individual in an in-patient setting, who poses a serious risk. 4 Improving care experience EXPECTED OUTCOME To increase in the number of carers reporting satisfaction. 26 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Q.1 Trust Quality Assessment Local CQUIN Values It was agreed following discussion at the PCT Chief Executives meeting in January 2010 that the allocation of CQUIN money will be broken down for Mental Health and Community into 0.5% Regional determination and 1.0% for Local determination. Below, subject to confirmation, are the values of our scheme. Payments will be made according to the following schedule: 50% of financial value of scheme paid in advance, in monthly instalments Reconciliation against performance in months 3, 6 and 9 Commissioner Financial value of Scheme NHS Hull 311,126 Year end reconciliation against performance and gateway within six weeks of 2010-2011 year end. Commissioner Financial value of Scheme NHS East Riding of Yorkshire 240,000* *subject to confirmation Commissioner Financial value of Scheme NHS Barnsley 143,296 Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 27
Glossary BME Black and Minority Ethnic people The National Service Framework emphasises the need to improve mental health services for black and minority ethnic people. The Department of Health has published Delivering Race Equality in Mental Health Care, a five-year action plan for tackling discrimination and achieving equality in services for black and minority ethnic patients and communities. CQC Care Quality Commission The independent regulator of health and social care in England, aiming to make sure better care is provided for everyone in hospitals, care homes and people s own homes. CQUIN Commissioning for Quality and Innovation Measures which determine whether we achieve quality goals or an element of the quality goal. These achievements are on the basis of which CQUIN payments are made. Co-morbid Co-morbid condition The presence of one or more disorders in addition to a primary disorder, for example, dementia and diabetes. CRHT Crisis Resolution Home Treatment teams Provide intensive support for people in mental health crises in their own home: they stay involved until the problem is resolved. Designed to provide prompt and effective home treatment, including medication, in order to prevent hospital admissions and give support to informal carers. HES Hospital Episode Statistics The national statistical data warehouse for England of the care provided by the NHS. It is the data source for a wide range of healthcare analysis for the NHS, government and many other organisations and individuals. LINk Local Involvement Network A network of local people and community groups who want to improve social care and healthcare in their local area. NIHR National Institute for Health Research Commissions and funds research 28 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Glossary PCT Primary Care Trust Primary care is the care provided by people you normally see when you first have a health problem. It might be a visit to a doctor or a dentist, an optician for an eye test or a trip to a pharmacist to buy cough mixture. NHS walk-in centres and the NHS Direct telephone service are also part of primary care. All of these services are managed the local primary care trust (PCT). PEAT Patient Environment Action Teams An annual assessment of inpatient healthcare sites in England that have more than 10 beds. It is a benchmarking tool to ensure improvements are made in the non-clinical aspects of patient care, such as cleanliness, food and infection control. SUS Secondary Uses System A single source of comprehensive data to enable a range of reporting and analysis. SUI Serious Untoward Incident An out of the ordinary or unexpected event (not exclusively clinical issues) that occurs on NHS premises or in the provision of an NHS or a commissioned service, with the potential to cause serious harm. SHA Strategic Health Authority Manages the NHS locally and provides an important link between the Department of Health and the NHS. Humber Mental Health Teaching Trust Humber NHS Foundation Trust QUALITY REPORT 2009 to 2010 29
and finally... We look forward to working with our patients, carers, staff and other key stakeholders to continue to strive to improve the health and wellbeing of the communities we serve. David Snowdon Chief Executive June 2010 30 QUALITY REPORT 2009 to 2010 Humber Mental Health Teaching Trust Humber NHS Foundation Trust
Humber NHS Foundation Trust For further copies of this report or more information please contact: Julie Wilson Corporate Assurance Trust Headquarters Humber NHS Foundation Trust Willerby Hill Beverley Road Willerby HU10 6ED 01482 389135 Jules.Wilson@humber.nhs.uk www.humber.nhs.uk Printed onto eco-friendly recycled paper