AIMS

Psychiatric Intensive Care Unit

Maintaining the AIMS standards

Continuing Self Review within Core Group:

5 staff to lead the following -

• Environment

• Health records

• Policies

• Timely admissions

• Activities

Signed up to AIMS one year ago

The initial AIMS review process allowed us to identifyareas where we could implement improvement/change.

Current Projects:• Extra care area• Review of seclusion policy• Introduction of Band 4’s to the team• Productive Ward• Starwards• New models of supervision• Meridian

How have we maintained/improved standards?

• Health and Social Care Diplomas for HCA’s Band 3

• Rotational Charge Nurse Post – opportunity for trained staff to develop managerial and leadership skills.

• Individual interest/leading new initiatives.

Weekly in-house training: Opportunity for both teaching and learning.

Staff Development

Month 1 April 2011

Target Description Patient Safety Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar YTD Actuals YTD Target

Distance from Target YTD

11/12 TargetFull Yr 11/12 Out

TurnR/A/G

Patient Safety Incidents 4%

To reduce the number of service users who experience a slip, trip or fall (not to exceed 450 recorded falls in year)

0% 0% 0% 0%

Violence & Aggression with TMAV 2% 1%

Violence & Aggression without TMAV 1% 1%

Infection Outbreaks 0% 0% 0% 0%

Medication Incidents/Near Misses - Prescribers 1% 0% 0% 0%

Medication Incidents/Near Misses - Administrators 1% 0 0% 0%

Seclusion 4% 7 34

Absent Without Leave 0% 0% 1% 0%

Deaths 0% 0% 0%

Serious Incidents 0% 0% 1% 0%

Quality MetricsAIMS 125/128 125/128 125/128

Meridian 19/25% 90% 19/25 80%

QUINCES 9/9% 9

PEATS 13/16% Jan-00

Inpatient Survey 18/25 90.00% 90.00%

Suicide Audit 18/25 100% 100%

Star Wards Nil Nil Commence Aug Enrolled

PerformancePhysical AssessmentsCare Plans offered 100% 100% 100% 100%

To ensure that service users who smoke are aware of the services available to help stop them smoking

100% 100% 100% 100%

Breach of Follow Up Within 7 days 1 0 0

Minimising Delayed Transfers of Care 8% 8% 0%

Admission Times - Time of DayReadmission TimeLength of StayLine of Sight - Hours Out of County 1046 hrs 910 hrs

Breach of out of county paitents - 24 Hour Discharge Letter 1 2

Admissions to inpatients services had access to crisis resolution home treatment teams

To provide 95% of adult patients with a HoNOS baseline and 95% of older adults with the HoNOS 65 baseline with a planned review date.

GoverancePolicy protocol checksMHA AdherenceNMC Registration 1 100% 100%

Rio Adherence24 Hour Checks 100% 100% 100%

Safeguarding Adults 0% 1% 1%

Meetings 17 9%

Activities on Ward 230hrs 210 hrs 230hrs

Section 17 Leave - Facilitated 100% 100% 96.00%

Section 17 Leave - Non Facilitated Nil 0% 4.00%

Human Resources3 in 3 o% 1.0% 1.0% 3.0%

10 in 6 Nil

Cost of sicknessNumber of people CRB checked 2% 2.0% 100.0% 100.0%

Absence Rate % 8% 8.0%

Grievance - New in Month Nil 0.0%

Referrals to Occupational Health One 3.0%

Bradford score of 300 One 3.0%

Disciplinarys new in month Nil Nil

Return to Work Interviews One 3.0%

Maternity Leave One 4.0%

Investigation Nil Nil Nil 2.0%

Supervision 50% 6wk period 50.0% 60.0% 50.0%

Appraisals Ongoing Ongoing 90.0% 95.0%

Capabilities Nil Nil Nil Nil

Return to Work Interviews 1% 1.0% One

Suspensions nil Nil Nil Nil

Vacancies 4% 4.0% None

Referrals to Occupational Health 1% 1.0% One 2.0%

Cost of Sickness 343%

FinancePay - Under / Over spend Under

Non Pay - Under / Over spend nil

Bank Staff CostsAgency Staff Costs Nil Nil Nil Nil

TrainingCompulsory Training 72% 80.0% 80.0% 80.0%

Fire Safety Face-To-Face 72% 80.0% 80.0%

Information Goverance 28% 30.0%

Personal Safety Awareness 100% 100.0% 85.0%

CPD 40% 40.0% 40.0% 40.0%

Safeguarding Adults Level 1 100% 100.0% 100.0% 100.0%

Safeguarding Children Level 1 100% 100.0% 100.0%

Trust Induction 100% 100% 100% 100%

Harvest Ward

• Clients and Families• Good Record Keeping• Ensuring Effective MDT / RiO• Service Level Agreements and

Out of County Admissions• Budgets• Busy Unit

The Challenges

Essence Of Care / Productive Ward

We have been working towards benchmarking within essence of care for some years, this process along with productive ward allowed us a brilliant starting point to move forward with the AIMS accreditation which continues to support our ongoing vision for the future of our unit.

• Protected Therapy Time• Enhancing the Healing Environment• New Furniture• New Signage• Showers• Windows• Carpets• External Donations• Staff Uniform

Ward Environment