Quality Account Reporting Period: 2012/13 Published: June 2013 · The Care Quality Commission (CQC)...

Quality Account

Reporting Period: 2012/13

Published: June 2013

South West London and St George’s Mental Health NHS Trust: Quality Accounts 2012/13 1

Contents Contents ...................................................................................................................... 1

Part 1: Chief Executive’s statement on the quality of our services ............................. 2

Part 2a: Priorities for improvement .............................................................................. 4

Looking forward – our quality priorities for 2013/14 4

Part 2b: Statements of quality assurance from the Board ........................................... 9

Information on the review of services .......................................................................... 9

Participation in clinical audits 9

Participation in clinical research 11

Goals agreed with commissioners 13

What others say about the Trust 19

Data quality 19

Part 3: Review of quality performance 2012/13 .......................................................... 22

Progress against quality priorities identified for 2012/13 22

Progress against core quality account indicators 28

Complaints 30

Compliments 34

Comparisons against national benchmarking data 34

Serious Incidents 36

An evaluation of current practice against the findings of the Francis Report............... 38

Comments from stakeholders ..................................................................................... 39

Amendments following comments from stakeholders ................................................. 47

Feedback .................................................................................................................... 47

Glossary ...................................................................................................................... 48

Annex - Statement of Directors Responsibility in Respect of the Quality Account ...... 49

Independent Auditors’ Limited Assurance Report ....................................................... 50


Part 1: Chief Executive’s statement on the quality of our services Welcome to our fourth set of Quality Accounts, which provides the Trust with the opportunity to set out our

values, achievements and goals in relation to quality. I am delighted to have joined South West London

and St George’s Mental Health NHS Trust. Since I began my new role I have made it my aim to really

focus on quality. Quality has been all over the media in the wake of the publication of the Francis Report

following on from the Mid-Staffordshire NHS Foundation Trust investigation. The findings in this landmark

document have fundamental consequences for everyone who works within the NHS and on the way that

individuals and organisations deliver care.

We need to ensure that our service users, who are some of the most vulnerable people in our community,

always come first and we not only meet, but champion the agreed fundamental standards in place to

deliver our services. This is why I have made quality our number one priority and whilst I recognised that

there is much work still to do in this area, as an organisation we are delivering noticeable improvements.

The Health Act 2009 requires all NHS organisations to publish annual Quality Accounts. Our Quality

Accounts enable readers to find easily accessible information regarding what our quality priorities are

going forward for 2013/14 (Part 2) and to retrospectively look back at where the Trust has done well, in

2012/13, and where improvements are needed (Part 3).

The Care Quality Commission (CQC) recently visited Tolworth Hospital, Springfield University Hospital

and Lavender Ward at Queen Mary’s Hospital, and have confirmed that we are now meeting all national

standards for quality and safety having addressed all 15 moderate concerns that were raised after their

initial visits in July 2012. The recent inspections found improvements in a number of areas including:

- increased staffing levels at Lavender Ward in Queen Mary’s Hospital;

- raised awareness of issues around medication and improved living areas in the wards at Tolworth

Hospital; and

- better targeted and tailored care plans for service users at Springfield University Hospital.

Two minor areas are still to be addressed at Springfield University Hospital. We will now submit an action

plan to the CQC to deal with these, and the CQC will carry out further visits to Springfield University

Hospital in the coming months to ensure that we have met this commitment.

A stronger focus on quality means embracing and implementing best practice at all times and ensuring the

assessment of quality is transparent and informed by regular service user, carer, family and staff

feedback. Key to this and to transforming service development models has been engagement and close

working with our service user reference group - SURG. On behalf of the Trust I would like to extend a

tremendous thank you to all its members who have generously donated their time and offered invaluable

input to help inform the process of creating, designing and developing new models of care.

As a Trust we have continued to involve our stakeholders in the development of the Quality Account. In

addition to holding a stakeholder engagement event in January 2013, we also published a six-month

report on our progress in October 2012, which allowed us to be transparent with our progress and allowed

our stakeholders to provide us with feedback early on in the year.

http://www.midstaffspublicinquiry.com/


The Trust’s sub-group to the Board, Quality Assurance and Safety Assurance Group has signed off these

Quality Accounts. To the best of my knowledge the information presented in this report is accurate.

Thank you to everyone involved for helping us to continue to focus on our Quality agenda.

David Bradley

Chief Executive


Part 2a: Priorities for improvement Looking forward – our quality priorities for 2013/14 This section of the Trust’s Quality Account outlines the priorities identified by the Trust and our

stakeholders to improve the quality of our services in 2013/14. The Trust has identified these priorities in

partnership with staff, service users, carers, commissioners and members of the Health, Overview and

Scrutiny Committee’s (HOSCs) and Local Healthwatch.

The Trust commenced its consultation on the quality priorities for 2013/14 in October 2012 with the

publication of a six-month report that detailed progress against the current priorities and provided

stakeholders with the opportunity to provide the Trust with feedback. This was then followed by a number

of engagement events where the Trust attended both service and carer groups in response to the six

month report. In January 2013 a Trust wide engagement event was organised which was attended by a

wide range of stakeholders, representing each of the five boroughs including Health Overview and

Scrutiny Committee Chairs, Local Involvement Networks (LINks) leads (now Healthwatch), alongside

senior clinical leads and operational management staff. David Bradley, Chief Executive, opened the main

event and Dr Ruth Allen, Director of Social Services, gave a summary of the Quality Account from

2012/13 and progress to date.

The overall feedback from stakeholders was positive with main discussion areas being around crisis

contingency planning, communication and carer input. These areas therefore informed the process for

setting the priorities for 2013/14.

Further consultation continued with staff, service users, carers and commissioners throughout the year

with attendance at various forums such as HOSCs and various other staff, service user and carer forums.

The Trust has selected priorities for safety, service user experience and clinical effectiveness. The

consultation process assisted the Trust to identify the themes for the quality priorities: safeguarding adults

and children; physical health; Health of the Nation Outcome Scales (HoNOS) and priorities identified by

service users to improve service user experience.

Patient Safety

Safeguarding children

Priority

description

To improve the percentage of all adult secondary mental health service users to

have recorded (using Safeguarding children form) whether they have

responsibility for or regular contact with children under the age of 18 years.

Target 95% of all adult service users.

Current Position 94.5% of services users on Care Programme Approach (CPA) have the

safeguarding children form completed (March 2012).

Rationale for this

priority

This is a development from the priority 2012/13. The Trust is moving from

recording this information for those service users on CPA to all service users.

Safeguarding children continues to be “the highest priority to patient safety” and

by continuing with this priority the Trust will be able to further develop multi

agency communications.


This target further develops the Trusts work on Think Family in collaboration with

a range of public sector organisations.

How progress to

achieve this

priority will be

monitored and

measured

1. Progress to achieve this priority will be monitored at the Trust’s monthly

performance meetings. Clinicians and Managers will be able to view the

completion of this information for their caseloads on individual clinical

dashboards. Improvement will be measured by extracting information from

RiO, the Trust’s electronic patient record.

2. Sample audits will be carried out where safeguarding alerts have been raised.

3. Systems will be developed and piloted during 2013 for the collection of data in

Improving Access to Psychological Therapies (IAPT) services.

Reporting Performance against this requirement will be reported regularly to the Trust

Board.

Safeguarding adults

Priority

description

1. To improve the percentage of all safeguarding adult cases that meet the

timescales for the allocation of a Safeguarding Adult Manager (SAM) and

strategy discussion/meeting as set out in local policy documents (excluding

Sutton cases as these are managed externally).

2. To improve the percentage of service users who are offered the opportunity to

feedback on their case after a strategy meeting or case conference and gather

qualitative data.

Target 1. 90% of safeguarding adult cases to meet timescales for the allocation of SAM

(within five working days) and strategy discussion/meeting (within five days)

as set out in local policy documents (excluding Sutton cases as these are

managed externally).

2. To ensure 90% of service users who have had a case conference, and 30% of

those subject to a strategy discussion/meeting are offered a feedback

interview and/or feedback form to fill in. This offer will be made dependent on

the service users’ wishes and their capacity to participate. Use this qualitative

data to improve services. Audit compliance quarterly.

Current Position 1. In April 2013 94.6% of cases Trust wide were allocated to a Safeguarding

Adult Manager within five days.

2. Not currently measured.

Rationale for this

priority

Safeguarding adults was a theme identified by Trust stakeholders in November

2011 and acknowledged, alongside safeguarding children, as “the highest priority

to patient safety” by Wandsworth Overview and Scrutiny Committee. Following

further stakeholder engagement throughout 2012/13, safeguarding adults as a

theme still continued to be of high importance.

Stakeholders fed back that as the Trust had installed a new central reporting

system, Ulysses Safeguard, to capture and monitor data, that they were now keen

to see the Trust continue to progress against the original indicators that were set.

Phase 2 of the Ulysses Safeguard development will be focusing on reporting all


Vulnerable Adult data requirements to the local authorities and integrating the

Serious Incidents and the Safeguarding information on the system so that further

links can be drawn in relation to cases, which will be completed during 2013/14.

The prompt allocation of a SAM is a key part of the safeguarding adults process.

SAMs provide the lead coordinating role and have overall responsibility for the

safeguarding adults process. SAMs ensure that actions undertaken by

organisations are coordinated and monitored, the adult at risk is involved in all

decisions that affect their daily life and those who need to know are kept informed.

Valuable information can be learned from service users who provide feedback on

their experiences of the safeguarding adults process that can be used to improve

services. This offer of feedback will be made dependent on service users’ wishes

and their capacity to participate.

How progress to

achieve this

priority will be

monitored and

measured

Progress to achieve the priorities above will be monitored by a working group and

at the Trust’s Safeguarding Adults Quality and Compliance Group. Improvement

will be monitored via the newly installed centralised system, Ulysses Safeguard,

which was developed as a result of the 2012-2013 quality account priority.

Reporting Performance against this requirement will be reported regularly to the Trust

Board.

Service user/Carer experience

Service user/Carer experience using Real Time Feedback

Priority

description

1. To provide service users and carers with the opportunity to provide feedback

using Real Time Feedback (RTF) on kiosks/tablets and via the Trust website.

2. To provide stakeholders with access to the results of feedback and action plans

e.g. What we have done as a result of feedback – ‘You said...We did’ boards

being developed and used in wards and team areas.

3. Demonstrate changes as a result of the feedback.

Target 1. To ensure that service users and carers have access to both RTF kiosks and

the Trust website facility to provide the Trust with feedback.

2. To provide quarterly reports on themed feedback and actions taken via the

Trust website. Corporate themes/actions are to be reported in an Annual Report

to the Service User Reference Group (SURG) and the Carers Friends and

Family Reference group (CFFF).

3. To review the changes as a result of feedback and set targets to reduce the

recurrent themes

Current Position 1. At year end 2012/13 the RTF kiosks had been installed in all ward areas and

service users are now able to provide feedback via the Trust’s website.

2. Not currently provided via quarterly reports.

3. Not currently provided

Rationale for this

priority

One of the main outputs from the stakeholder engagement event in January 2013

was communication. Stakeholders were keen for the Trust to develop the service


user experience priority from collecting the data from services users to include the

collection of feedback also from carers. Stakeholders commented that it would be

useful for both service users and carers to be able to give feedback from the

privacy of their own homes using the Internet. This led to the development of

access to feedback via the Trust website. Linked with the Trust website, it was also

viewed by stakeholders that it would be informative to have a summary of the

changes that have taken place as result of RTF to be summarised on a regular

basis, hence the introduction of the quarterly report. The quarterly report will

provide stakeholders with access to a summary of the ‘You said…We did’

information including actions taken to resolve any concerns raised.

How progress to

achieve this

priority will be

monitored and

measured

Progress to achieve this priority and ward scores will be monitored by the Trust’s

SURG and CFFF and the data will be provided from the Trust’s RTF group.

Reporting Performance against this requirement will be reported regularly to the Trust Board.

Clinical effectiveness

Paired Health of the Nation Outcome Scales (HoNOS)

Priority

Description

Service users discharged from services should have paired HoNOS. HoNOS is a

clinical outcome measure used by mental health services. The scales measure the

health and social functioning of people with severe mental illness. The initial aim of

HoNOS was to provide a means of recording progress towards the Health of the

Nation target ‘to improve significantly the health and social functioning of mentally ill

people’. A paired HoNOS refers to a score both on admission and discharge.

Target 95% of service users discharged from services to have paired HoNOS.

Current Position At year end 2012/13 38% of service users had a paired HoNOS completed.

Rationale for this

priority

In previous years the Trust has measured the percentage of service users who had

HoNOS completed at assessment. Wandsworth HOSC and Sutton LINks both

proposed an indicator that supported the active use of paired HoNOS.

Paired HoNOS was a theme identified by Trust stakeholders in November 2011

and was agreed as a priority for 2012/13.

At the end of 2012/13 the Trust was some way from achieving the target set at

95%, although there has been a steady improvement throughout the year. In order

to continue with this improvement this target will remain as a priority for 2013/14

and the Trust will be exploring further ways to improve the clinical value and drive

across the Trust e.g. dedicated sessions from a Consultant clinical lead.

How progress to

achieve this

priority will be

monitored and

measured

Progress to achieve this priority will be monitored at the monthly performance

meetings. Clinicians and Managers will be able to view the completion of this

information for their caseloads on personal dashboards. Improvement will be

measured by extracting information entered on RiO.



Crisis Contingency Planning

Priority

Description

To review the crisis plans of people on CPA and where a carer is stated to identify

carer involvement in the crisis plan.

Target The review of crisis plans will be measured through audit standards set in quarter

one

Current Position For 2013/14 the Trust has a Commission for Quality and Innovation payment

framework (CQUIN) to look at crisis plans for service users, as a specific

development, this priority will benefit from work that was completed during 2012/13.

Rationale for this

priority

Stakeholders from the engagement event in January 2013, highlighted that carers,

where identified, should have agreed plans in the event of a crisis. These plans

should be developed in conjunction with the service user, the carer and the team.

How progress to

achieve this

priority will be

monitored and

measured

Progress to achieve this priority will be monitored by the Trust’s Quality Account

Steering Group and at monthly performance meetings.



Part 2b: Statements of quality assurance from the Board Information on the review of services During 2012/13 South West London and St George’s Mental Health Trust provided inpatient and

community mental health services under four management teams: Kingston and Richmond, Sutton and

Merton, Wandsworth, and Specialist Services. Our service areas include:

• adults of working age mental health;

• older people’s mental health;

• child and adolescent mental health;

• mental health services for people with learning disabilities;

• drug and alcohol services; and

• prison services.

The Trust provides a number of specialist national services including obsessive-compulsive disorder

(OCD)/Body dysmorphic disorder (BDD), forensics services, eating disorder and deaf services for

children, adolescents and adults.

The Trust reviews the data available on the quality of care in all of these NHS services as part of on-going

governance processes and will continue to do so as the Trust prepares to apply for FT status. The income

generated by the NHS services reviewed in 2012/13 represents 100 % of the total income generated from

the provision of NHS services by the Trust for this period.

Participation in clinical audits During 2012/13, seven national clinical audits and a national confidential enquiry covered NHS services

that South West London and St George’s Mental Health NHS Trust provides.

During that period South West London and St George’s Mental Health NHS Trust participated in 100 % of

national clinical audits and 100 of national confidential enquiries of the national clinical audits and national

confidential enquiries, which it was eligible to participate in.

The national clinical audits and national confidential enquiries that South West London and St George’s

Mental Health NHS Trust was eligible to participate in during 2012/13 were as follows:

National Clinical Audits Coordinating Body Number of Cases Submitted

Number of Registered Cases Required

National Clinical Audits participated in and for which data collection was completed during period 2012/13:

National Audit of Psychological Therapies

Royal College of Psychiatrists 1547 -(Sutton and Merton IAPT) 1193 -(Wandsworth IAPT)

N/A

Prescribing Observatory for Mental Health (POMH-UK) Topic

Royal College of Psychiatrists 143 N/A


12a – Prescribing for people with personality disorder

POMH-UK Topic 2f – Screening for metabolic side effects of antipsychotic drugs


POMH-UK Topic 11b – Prescribing antipsychotics for people with dementia


National Clinical Audits reviewed during 2012/13:

National Audit of Schizophrenia Royal College of Psychiatrists 85 80/100

Prescribing Observatory for Mental Health (POMH-UK) Topic 1f – Prescribing high dose and combined antipsychotics on adult acute and psychiatric intensive care wards


POMH-UK Topic 3f – Prescribing high dose and combined antipsychotics on forensic wards


Prescribing Observatory for Mental Health (POMH-UK) Topic 12a – Prescribing for people with personality disorder


POMH-UK Topic 2f – Screening for metabolic side effects of antipsychotic drugs


POMH-UK Topic 11b – Prescribing antipsychotics for people with dementia


National Confidential Inquiries Coordinating Body

National Confidential Inquiry into Suicide and Homicide by People with Mental Illness

University of Manchester – The Centre for Suicide Prevention

Last available response rate received March 2013 was 92 %

The reports of six national clinical audits were reviewed by South West London and St George’s Mental

Health NHS Trust in 2012/13 and below are some of the actions the Trust has taken or intends to take to

improve the quality of healthcare provided.

The Trust subscribes to membership of POM-H (UK) which supports the implementation of NICE

guidelines to help clinical teams monitor and improve the quality of their mental health prescribing. POMH-

UK audit reports were reviewed by the Drugs and Therapeutics Audit sub-group and the findings and

recommendations circulated trust-wide. Overall the Trust performed well compared to other Trusts

nationally. However, there was a significant variation of achievement of the indicators between teams

submitting data for some of the audits. Workshops are scheduled to investigate the reasons for this

discrepancy and provide support for underperforming areas.


The national report for the National Audit of Schizophrenia (NAS) was published in November 2012. The

Trust performed in the middle range on most of the key standards and performance was in the top 10 % in

relation to:

• Prescribing clozapine

• Offering psychological therapies to treatment resistant patients

• Service users reported positively on the care they received

The national report highlighted concerns in the monitoring and management of physical health problems

nationwide. South West London and St George’s benchmarked in the mid-range with other trusts in

relation to these areas. However, the national average was below the best practice standards this Trust

aspires to and addressing these concerns has been identified as a priority for the Trust.

An action plan has been in place since the provisional findings were published in April 2012 and led by a

Physical Health Group. In addition to the Quality Account priorities for 2012/13 which included a target to

achieve 95% recording of physical health assessments within 48 hours of admission, there were a number

of CQUIN (Commissioning for Quality and Innovation) priorities related to physical health for 2012/13.

Progress against these targets was monitored by the Trust Board.

It should be noted that from the Service User survey completed as part of the national audit, 87% of

service users at South West London and St George’s Mental Health Trust reported that they had had a

physical health check with their mental health team/GP in the past 12 months (national average 65%). The

Trust also ranked above the national average in relation to service users’ overall experience of care.

These are positive outcomes which the Trust will aim to build on in the future.

The Trust will be taking part in the second round of the National Audit of Schizophrenia, commencing in

September 2013 and we hope the next report will demonstrate the improvements we have put in place for

our service users.

Participation in clinical research The Trust now has more portfolio studies open than last year, with the number of service users recruited

for the year to date* (275) already exceeding the total for the whole of 2011/12 (188). All portfolio studies

are supported by the NIHR (National Institute for Health Research) and managed locally by the London

(South) Comprehensive Local Research Network (L(S)CLRN). This aligns closely with national

performance metrics, which have seen a two-fold increase in patient recruitment over the period 2007-12.

Currently, the Trust is participating in 49 studies, of which 25 are portfolio studies and a further 24 non-

commercial studies (including educational projects). It has also upheld its reputation as an efficient

recruiting site, particularly for the Viewpoint survey led by Dr Claire Henderson (198 in total) and the

Safewards study led by Professor Len Bowers (34) - both based at the Institute of Psychiatry at King’s

College London. There are 13 clinical staff participating in portfolio research across 10 subspecialties,

including Eating Disorders, Forensic Psychiatry, Social & Community Psychiatry, Psychological Therapies,

Learning Disability, Addiction Psychiatry and Old Age Psychiatry.

The expansion of the Research and Development (R&D) staffing has also continued; last year a part-time

MHRN-funded research nurse was seconded to the R&D Office to improve Trust involvement in industry

studies in line with national priorities. Following a series of discussions with DeNDRoN, a topic-specific

research network, the local portfolio has also now expanded into dementia and neurodegeneration. To


facilitate this, we have appointed a new Trust dementia research lead, Dr Robert Lawrence, and his

engagement will enable us to gain substantial ground within the local health economy by opening up new

avenues of research income. Dr Lawrence’s mandate provides a useful link to the Age and Ageing

national specialty group, ensuring that we have a voice in influencing the focus and direction of any future

initiatives within this subspecialty.

This recent turnaround has enabled the Trust to work steadily towards the CLRN’s objective of delivering

a balanced portfolio of clinical studies from commercial and non-commercial funders across as many

mental health research areas as possible. By embedding the right mix of skills within the R&D Office, we

are confident of ensuring that the full potential of mental health research is captured and is delivered

successfully. A further advantage is that the department can now undertake long-term planning activities

by outlining agreed common research objectives and arrangements. A new South West London R&D

Cluster is proposed, of which the Trust will be part, along with three other acute Trusts in the area. By

transferring research management function to the new office for portfolio research post-approval, it is

hoped this will improve efficiency, recruitment and raise quality standards.

Further, the Trust recognises that only by identifying and meeting local information and training needs will

we be able to develop a research culture underpinned by strong interaction between stakeholders, which

is why we have started to promote greater clinician and service user involvement to enhance the

collaborative research endeavour. The Trust remains committed to promoting service user involvement at

every stage of the project lifecycle and advocates empowering them to become research ambassadors.

The new Research and Development strategy also aims to establish a new infrastructure with an identified

clinical lead in a number of research areas in mental health, known as Clinical Research Academic

Groups (CRGs) and they will link closely with the R&D Committee. It is hoped that this will facilitate

research activity and generate locally-led studies which meet Trust priorities.

Clinical services are clearly a priority; the R&D department is committed to ensuring that research both

remains an essential component of Trust activity and is widely recognised as such. However, embedding

research in NHS processes presents its own challenges. Plans are being developed to create clinical

research groups to strengthen the research and development base within the trust and to embed research

within clinical functions.

The Trust envisions an R&D function which will be characterised by transparently robust processes guided

by clear operational objectives and greater input from local and regional key stakeholders.

*The CLRN recruitment year runs from October-September.


Goals agreed with commissioners A proportion of the South West London and St George’s Mental Health Trust’s income in 2012/13 was

conditional on achieving quality improvement and innovation goals agreed between the Trust and the four

local PCTs for the provision of NHS services, through the Commissioning for Quality and Innovation

payment framework (CQUIN).

The six CQUIN areas (and measures) for 2012/13 were:

1. Safety Thermometer

2. Improving dementia prescribing

3. Recovery Goals

4. Physical Health

5. Smoking Cessation

6. Frequent Attendees

Table 1: - Overview of year end performance position against 2012/13 CQUIN requirements:

CQUIN Indicator Year-end performance

Safety Thermo-meter

1a) Pilot the mental health safety thermometer Successfully completed

Improving dementia care and prescribing

2a) POMH-UK audit Successfully completed

2b) Prescription review to take place and prescription review letter to be sent to GP every three months

Successfully completed

2c) Local, sustainable QIP to be developed and agreed with local CCGs and commissioners


2d) Discharge summaries to be sent to GP & family within one week of discharge from Trust (two weeks in contract)


Recovery Goals 3a) Audit of Care Plans for patients on CPA to show evidence of recovery focused care planning


3b) 50% of all service users on CPA to have two self-defined recovery outcomes recorded on RiO


Physical Health 4a) Sharing of CPA Register with Primary Care twice a year


4b) QOF - 95% of service users on CPA to have a full set of mental & physical health high mortality ICD10 codes by end of Q4



4c) All service users on CPAs to have had a PHA with their GP within the last 12 months


4d) Audit of care plans to demonstrate medicines reconciliation within 72 hours of admission


4e) Discharge summary to be sent to the GP and service user within seven days of inpatient discharge


4f) CPA Outcome Review Letter to be sent to GP within two weeks of CPA Review

Achieve throughout the year except for the last quarter - 92.7% at year-end compared to target of 95%

Smoking Cessation

5a) Smoking status of all service users to be recorded Successfully completed

5b) Smokers to be referred to a Smoking Cessation Advisor (SCA)


5c) Smokers referred to a Smoking Cessation Advisor to set a quit date


Reference: - CQUIN 2012/13 Achievements report, A.A. Rudkin, April 2013

“It makes it easier to talk to someone who understands my mental illness and my smoking.”

“I never knew I had the strength.”

“They said I couldn’t do it, but I did it with help, support and understanding.” "I was amazed I had

the strength."

“I feel like a new person, if I can stop smoking I can do anything.”

The Trust has built up an applauded smoking cessation service for its service users. Our Smoking Cessation Advisors are regularly invited to present at national conferences and to advise other NHS Trusts on how to set up and maintain similar support for their service users.

Since March 2011, staff have consistently referred over 17% of all identified smokers to the Smoking Cessation Advisors for support (this is above the average in other Trusts). By February 2013, this figure had risen to over 22% with over 35% of all smokers referred to a SCA setting a quit date

With the right support, mental health service users, irrespective of their diagnosis, want to and are able to stop smoking:

Comments from some of the particpants : -


Frequent Attendees

6a) Identify frequent attendees from Kingston, St George’s and St Helier Hospitals


Over the past three years the CQUIN Project Group, in conjunction with service users, clinical staff and non clinical staff, has developed a suite of tools, resources and information to support staff to achieve the CQUIN indicators and embed the process changes into everyday clinical practice. This has enabled the Trust to sustain improvements in the quality of care provided to our service users and carers (please refer to Figure 1).


Figure 1 (NB: the colours in the diagrams have no specific meaning)

Smoking Cessation

Physical Health

Improving Dementia Care and Prescribing

Recovery Goals

Frequent Attendees at A&E

Reference: - CQUIN 2012/13 Achievements report, A.A. Rudkin, April 2013

Safety Thermometer

New Smoking Cessation and NRT Policy and

referral guidance Smoking

Cessation Care Pathways for inpatient and community

services

National guidance and

NICE guidelines

Comprehensive document library

including evidence based research papers

Smoking Cessation and

Medication posters and

leaflets

Physical Health

Assessment guidance for

staff RiO

guidelines for PHA and QOF information

recording

Medicines Reconciliation

Audit Tool

Discharge Summary

editable letter to GP template

Inpatient & Community Discharge Summary process

flowcharts

Medications review process

flowchart

GP educational

visits & meetings

Promotion of Medicines Advice line and on-line

information

Medication/prescription review letter

template

Induction & training

sessions for staff on

dementia

Service user Personal

Recovery Goals info sheet

Results and learning

from Care Plan Audit

Personal Recovery Goals

template

Top tips for Recovery Oriented practice

Staff Personal Recovery Goals info

sheet

Frequent Attendees

process flowchart

Frequent Attendees guidelines for staff

Frequent Attendees

editable letter to GP template

Frequent Attendees leaflet for

service users

1:1 support for teams on the Frequent

Attendees process

MH Safety Thermometer

Data Collection tool

Harm Free Care

Definitions

Harm Free Care Definitions tool

Full nine months data

for NHS London

Safety Thermometer guidance

for staff

Local guidance on antipsychotic medicines for symptoms in

dementia

Personal Recovery Goals “Living Well

with Dementia” template

Audit results & report on Frequent

Attendees data

Improved

& flow of physical health information

to GPs

Action plans for service

improvement PDSAs

12 weeks expert smoking cessation

support package for service users


The following CQUIN goals for 2013/14 have been agreed:

CQUIN Indicator and description Intended Outcome

Feedback for improvement

Use Real Time Feedback (RTF) systems to improve overall service user and carer experience of Trust inpatient wards Intended outcome.

The use of RTF systems will be a primary vehicle / driver for the systematic improvement of quality and service user experience within the organisation.

Safety Thermometer

This indicator is to be based on the National Classic Safety Thermometer To monitor harms from falls, pressure ulcers and UTIs for those with catheters in for older people.

This CQUIN will drive behavioural change regarding the physical health of older people on inpatient wards

Crisis Plans Crisis planning was identified as an area of weakness in the 2012 community service user survey. Review crisis plans of people on CPA and implement a programme to improve the quality of crisis planning.

To really understand what service users and families value about crisis plans and to spread quality

Safe, Managed Discharges

Adequate and timely communication will ensure safe, managed discharges from inpatient services. It will support high quality care and patients’ safety in both secondary and primary care settings

To ensure that GPs are provided with timely discharge summaries which contain only the information they want and need

Smoking cessation

a) Smoking cessation service evaluation: Have people valued the Smoking Cessation service provided by the Trust? Regular feedback surveys to be completed by all people using the service b) % of people who take up the Trust’s smoking cessation service who complete the full 12 weeks support package c) Continuation of recording, referring and quit rates

To continually improve the quality of the Smoking Cessation service provided by the Trust and service users’ experience of using the service. This in turn should increase the number of people who complete the full 12 weeks support package or successfully quit smoking prior to the end of the 12 weeks

Physical Health To improve the physical health of the Trust’s inpatient service users (those for whom the physical health responsibility lies with the Trust) a) Attempt to complete a relevant Physical Health Assessment (PHA) within 48 hours of admission to an inpatient ward b) Following the initial PHA upon admission, an attempt should be made to complete a relevant PHA every six months for those service users who remain an inpatient for that period of time c) Ongoing physical health care as service user moves from inpatient to community services

For staff to be physical health aware from the moment someone enters the inpatient ward. This should result in improved physical health care for the Trust’s inpatient service users.


Further details of the agreed goals for 2012/13 and for the following 12 month period are available electronically at: http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html Information about CQUIN is available on request from Angharad A. Rudkin, CQUIN Lead, [email protected]

http://www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html

mailto:[email protected]


What others say about the Trust Statements from the Care Quality Commission South West London and St George’s Mental Health NHS Trust is required to register with the Care Quality Commission (CQC). The Trust was registered with the CQC without compliance conditions on registration. South West London and St George’s Mental Health NHS Trust has been registered to carry out the following regulated activities (activities undertaken by the Trust that require registration):

• treatment of disease, disorder or injury • assessment and medical treatment of persons detained under the Mental Health Act • diagnostic and screening procedures

Between April 2012 and March 2013, the CQC conducted unannounced inspections at the following registered Trust sites, visiting a total of nine inpatient wards: Springfield, Tolworth, and Queen Mary’s Hospitals. The CQC has not taken enforcement action against South West London and St George’s Mental Health NHS Trust during 2012/13; however, the Trust has taken actions to address a number of compliance actions identified by the CQC. The CQC judged that actions taken by South West London and St George’s to mitigate the concerns raised at Tolworth and Queen Mary’s Hospitals in relation to staffing, management of medicines and privacy and dignity of patients had led to improvement and removed the compliance actions. The Trust is now compliant with all Essential Standards of Quality and Safety at Tolworth and Queen Mary’s Hospital. Springfield Hospital was judged non-compliant with Outcome 13 (Staffing) and Outcome 14 (Supporting workers) with a minor impact on service users. The CQC noted that further work was required to make sure that all staff were up to date with their mandatory training and that accurate records are kept to reflect this. A concern was also raised around staffing levels on Avalon ward. Action plans are in place to address these concerns and progress is monitored through the Trust Quality Tracker. Further information about the Trust’s performance against the CQC Essential Standards for Quality and Safety is available at: http://www.cqc.org.uk/directory/RQY South West London and St George’s Mental Health NHS Trust has not participated in any special reviews or investigations by the CQC during the reporting period.

Data quality Statement on relevance of data quality and Trust actions to improve data quality The Trust has unified most of the data collection processes, to ensure that almost all clinical information used within the Trust is derived from the electronic clinical record (RiO). The information can therefore be easily monitored for accuracy, helping to ensure that the information is current, comparable and correct. This coherent system is the cornerstone of efforts to assure data quality and means that the information used to plan, monitor and control services is as accurate as possible. The performance measures are based on the electronic clinical record, with no need for additional data entry. Therefore the quality of information is intractably linked with the quality of the clinical record and the provision of care and support. South West London and St George’s Mental Health Trust will be taking the following actions to improve data quality:

• The Trust benchmarks strongly on inpatient data quality in comparison to many other mental health Trusts, using Secondary Uses Service (SUS) as a data source, but will continue to

http://www.cqc.org.uk/directory/RQY


ensure records are as accurate as possible. The Trust also benchmarks regularly against other providers using the Mental Health Minimum Data Set (MHMDS) reports.

• Data quality is reported by team and individual on an ongoing basis but is reviewed at the monthly performance meetings and is reported to the Board.

• Individual clinical dashboards have been developed, ‘My Dashboards’, which provide ‘live’ summaries of each individual’s caseload information including a summary of the data quality for each service user on the caseload.

• A clinical audit on data quality is completed annually to check that the information is accurate. The Trust can easily check the information contained in an individual data field, but it is more difficult to ascertain the quality of the record or whether the necessary information is contained in free text fields.

NHS number and general medical practice code validity South West London and St George’s Mental Health NHS Trust submitted records during 2012/13 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which publish information on data quality. The percentage of records in the published data:

- Which included the patient’s valid NHS number was:

99.6% for admitted service user care (compared to a national average of 99.1%);

- Which included the patient’s valid General Medical Practice Code was :

100%for admitted patient care (compared to a national average of 99.9%);

Information governance toolkit attainment levels South West London and St George’s Mental Health NHS Trust met the deadline for submission of its annual Information Governance Toolkit score for 2012/13. The Trust achieved an overall score of ‘satisfactory’ for the second year running. The Trust scored Level 2 or higher in all of the 45 requirements. Information governance personal data loss

Personal data loss risk is managed by the Trust Information Governance Group and overseen by the Senior Information Risk Officer (SIRO). The Trust is obliged to report any serious incidents (SIs) involving personal data loss in its annual report. Department of Health guidelines classify such SIs in terms of severity on a scale of 0-5, requiring SIs classified at a severity of 3-5 to be reported to the Information Commissioners Office (ICO).

In 2012/13 the Trust recorded reported seven at a severity rating of 0-2 as follows: Table 2: - Summary of personal data incidents for 2012/13

Department of Health Category

(Level or grade of incident)

Nature of Incident Total Incidents

2 Inappropriate disclosure of Patient Identifiable Information – internal

2

0 Patient Identifiable Information sent to wrong address

2

0 Patient Identifiable Information lost in transit 2

0 Patient Identifiable Information found in public place

1


Clinical coding error rate South West London and St George’s Trust was not subject to a Payment by Results clinical coding audit

during 2012/13. The Trust has continued to focus on the coverage of clinical coding of primary diagnosis

for inpatient episodes of care. During the financial period 2012/2013, the figure was 98.8%, against a

national average of 98.5%.


Part 3: Review of quality performance 2012/13 Progress against quality priorities identified for 2012/13 This section of the Trust’s Quality Account provides information on the quality of services provided in 2012/13 and reports on our progress against the 2012/13 quality account priorities. The Trust identified these priorities in partnership with staff, service users, carers, commissioners and members of OSCs and LINks.

The Trust selected priorities for safety, service user experience and clinical effectiveness.

Table 3: - Overview of Trust performance with 2012/13 Quality Account priorities

Indicator

Ap

ril 2012

sta

rtin

g

po

sit

ion

Targ

et

Ye

ar-

en

d

perf

orm

an

ce

2012-2

013

Patient Safety

Priority 1: Safeguarding Children 26% 95% 94.5%

Priority 2: Safeguarding Adults Not previously collected

95% 94.6%

Service User Experience

Priority 3: Service User Experience Not previously collected

1.33 surveys per day per ward

1.53 surveys per day per ward

Clinical Effectiveness

Priority 4: Physical health 55% 95% 84%

Priority 5: Improving the Use of the Health of the Nation Outcome Scale (HoNOS)

Not previously measurable, at the end of 2011/12 82% of service users had a HoNOS at assessment.

95% 38%

Priority 1: Safeguarding children

To improve the percentage of service users on Care Programme Approach (CPA) who have the “safeguarding children” form completed a requirement of Recommendation 12 of the Laming Report into the death of Victoria Climbie.

Target 95% of service users on CPA will have the safeguarding children form completed, identifying whether they have responsibility for or regular contact with children under the age of 18 years.

April 2012 26% of services users on CPA have the safeguarding children form completed


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ap

r-1

2

May

-12

Jun

-12

Jul-

12

Au

g-1

2

Sep

-12

Oct

-12

No

v-1

2

De

c-1

2

Jan

-13

Feb

-13

Mar

-13

Pre

cen

tage

Date

Priority 1: Safeguarding Children

Target (95% by March '13)

Trust Performance

starting position (June 2012)

Rationale for this priority

Measures for this priority were in development for much of 2011/12. This priority was proposed last year by a Safeguarding Children Designated Doctor at NHS Wandsworth and St George’s Healthcare NHS Trust. Safeguarding children was a theme identified by Trust stakeholders in November 2011 and acknowledged, alongside safeguarding adults, as “the highest priority to patient safety” by Wandsworth OSC.

The Trust has made steady progress with this priority all throughout the year from 26% to 94.5% by the end of the 2012/13. During the year the Trust introduced a process to enable the recording of information about children with whom our service users have significant impact. In addition to this new method of recording, the process of requesting this information from service users has been integrated into mandatory safeguarding children training which has been successful in increasing staff reporting. Note: - Once a child safeguarding alert has been raised the process is then overseen by the respective local authority. The Trust is provided with an overview of the process and a Trust representative should be sent to attend any related meetings.

Graph 1: Showing percentage of service on CPA with a completed “safeguarding children” form in 2012/13


Priority 2: Safeguarding Adults

1. To record and monitor the percentage of cases allocated to a Safeguarding Adult Manager (SAM) within five days of a safeguarding adult alert. 2. To record and monitor the percentage of safeguarding cases going to case conference where the service user is offered the opportunity to participate in a feedback interview or discussion

Target 1. 95% of safeguard adult cases will be allocated to a Safeguarding Adult Manager (SAM) within five days of a safeguarding adult alert 2. Service users are offered the opportunity to participate in a feedback interview or discussion in 80% of safeguarding adult cases that go to case conference.

April 2012 starting position

These priorities are not currently measurable.


Safeguarding adults was a theme identified by Trust stakeholders in November 2011 and acknowledged, alongside safeguarding children, as “the highest priority to patient safety” by Wandsworth OSC. The prompt allocation of a Safeguarding Adult Manager (SAM) is a key part of the safeguarding adults process. SAMs are senior Trust staff providing a lead coordinating role and having overall responsibility for the safeguarding adults process. SAMs ensure that actions undertaken by organisations are coordinated and monitored, the adult at risk is involved in all decisions that affect their daily life and those who need to know are kept informed. Valuable information can be learned from service users who provide feedback on their experiences of the safeguarding adults process.

The development of a centralised data system to enable these two Quality Accounts to be measured has

been a major achievement of lasting benefit to improvements in information and quality for the long

term. The centralised data system enables safer Trustwide governance of safeguarding adult cases,

enabling tracking, quality assurance and audit.

The allocation of a Safeguarding Adults Manager within five days was seen as a useful measure of

promptness and management grip of safeguarding matters. The target was missed by only the smallest of

margins, and initial investigations show that this was down to administration shortcomings, rather than any

practitioner’s failings. The Trust has been able to provide assurance that all cases meeting the relevant

threshold were subject to an appropriate level of professional scrutiny at the crucial early stage of the

process.

The target to offer 80% of service users whose cases went to case conference the opportunity to feedback

on their experience of safeguarding adults process, was met. The centralised data system was one of the

methods by which all relevant cases were tracked throughout the year.


Priority 3: Service User Experience

To record and monitor service user experience using questions/themes agreed with stakeholders: Care Planning, Shared values, information provision and overall experience.

Target To maintain a real time feedback (RTF) response rate of 1.33 surveys per day per ward during the transition from pilot to full roll-out


At year end 2011/12 Trust was meeting the target of 1.33 surveys per day per ward


A sub-group of the Trust’s Service User Reference Group (SURG), the SURG Quality and Performance Group, has developed a set of priorities for improvement based on questions asked in the inpatient and community surveys. The dashboard incorporates care planning, identified by the CQC as an area for improvement. Monitoring service user experience including care planning and treating people with dignity and respect were identified as key themes by Trust stakeholders in November 2011. Wandsworth OSC proposed care planning and Sutton LINk stated “We attach particular importance to a focus on care planning”. A real-time feedback (RTF) pilot project has been completed in March 2012 and portals are due to be activated in wards and community teams across the Trust in 2012. The pilot confirmed that the validity of data received is assured by maintaining this response rate, enabling the effectiveness of local changes implemented as a result of feedback from service users in these areas to be tracked.

The Trust agreed to record and monitor service user experience using questions that were developed by

the Trust’s service user group SURG. The Real Time Feedback (RTF) pilot commenced in March 2012

with a plan to have the RTF kiosks installed across the Trust by the end of 2012. By the end of 2012/13

the RTF kiosks/tablets had been rolled out to all the wards across the Trust and a variety of community

teams, enabling the target of 1.33 surveys per day per ward to be reached. In addition to using the RTF

kiosks/tablets service users now has the ability to submit feedback via the Trust website internet site.

Throughout the consultation stakeholders have taken a strong interest in the RTF and in summary have

asked the Trust to provide assurance around the following questions:

How often is the information reviewed and who is responsible for ensuring that the teams act on the

feedback?

The data from the RTF kiosks is reviewed regularly, by the ward/deputy manager as the data is

transferred from the kiosks automatically to relevant manager’s local computer. The data is made

available via the ‘My Dashboards’ software which makes the data readily accessible as part of the other

regular data that a manager would review, including staff information and ward performance.

The data is also accessible by the Trust’s central performance team and the Trust’s Service User

Reference Group (SURG).

How does the Trust ensure that all our service users are supported to use this technology?

As part of the ward admission orientation service users are made aware of the RTF kiosks and are offered

assistance to use the machine if required. Service users are also encouraged to use the RTF kiosk as an

additional method of communication. Wards also use this feedback information as part of weekly

community ward meetings where summary data from the machine is retrieved and discussed in a wider

group setting.


Priority 4: Physical Health

To improve the percentage of inpatients having a physical health assessment and examination undertaken within 48 hours of admission

Target 95% of inpatients will have a physical health assessment and examination undertaken within 48 hours of admission


55% of inpatients have had a physical health assessment and examination undertaken within 72 hours. The Trust does not currently measure those undertaken with 48 hours.


Sutton LINk highlighted “the need for patients to be examined on admission to identify any health needs”.

The basis of this priority was to ensure that all newly admitted inpatients have a comprehensive physical

health assessment (PHA) performed as early as practically possible to identify any physical health needs.

This priority was highlighted by Sutton Link and the Trust identified a target to improve the proportion of

service users having a physical health assessment performed and recorded in the appropriate location on

the clinical record (RiO) within 48 hours of admission. The target for achievement was set at 95% and

implementation is supported by new standards relating to the physical heath care of inpatients, along with

guidance on where to record on RIO. Ward teams were briefed on the target and standards and

supported through ward-based training as well as induction.

The data in table 4 below, demonstrates that the trust made steady improvement over the year towards

this target and by the year end had achieved 84% of assessments being completed within the first 48

hours of admission. It is acknowledged that further work is needed to understand the reasons for non-

completion, including issues relating to consent. A detailed analysis of data highlighted that in a high

proportion of cases where assessments had not been carried out it was due to ‘consent not being given’

by the patient. Often, the patient was not well enough to make the decision due to their mental state.

Clinicians have been advised to record in the notes that an attempt to assess had been made.

This standard is being carried forward in the 2013/14 CQUIN and the work will include further analysis on

the exceptions where the physical health assessment is not completed within 48 hours so that appropriate

actions can be taken to optimise the number of assessments completed and recorded.

Table 4: Showing the physical health performance 2012/13

2012/2013

Q1 Q2 Q3 Q4

PHA PHA PHA PHA

Trust 46% 62% 79% 86%

http://imapps/ReportServer?%2FPhysicalHealth%2FPHA_Admisison_Detail&BoroughFlag=2&Month=Q1&Ward=Trust&YTDFlag=0&Year=2012%2F2013&Borough=Trust&rs%3AParameterLanguage=





Priority 5: Improving the use of the Health of the Outcome Scale (HoNOS)

Service users discharged from services should have paired HoNOS. HoNOS is a clinical outcome

measure used by mental health services. The scales measure the health and social functioning of people

with severe mental illness. The initial aim of HoNOS was to provide a means of recording progress

towards the Health of the Nation target ‘to improve significantly the health and social functioning of

mentally ill people’. A paired HoNOS refers to a score both on admission and discharge.

Target 95% of service users discharged from services have paired HoNOS

Current Position This priority is not currently measurable. At year end 2011/12 82% of service users had a HoNOS completed at assessment.


In previous years the Trust has measured the percentage of service users who have HoNOS completed at assessment. Paired HoNOS was a theme identified by Trust stakeholders in November 2011. Wandsworth OSC and Sutton LINk both proposed an indicator that supported the active use of paired HoNOS.

At the end of 2012/13 the Trust was some way from achieving the paired HoNOS target set at 95% (set by

the Trust) and therefore needs to explore further ways to continue this improvement. It is important to note

however that the HoNOS at admission figures for 2012/13 on average were 73%. In addition to HoNOS

being one of the only outcome measures for mental health, not meeting the target has provided the Trust

with additional rationale to continue efforts in the area for 2013/14.

Graph 2: Showing percentage of service users with paired HoNOS 2012/13

The graph demonstrates that there has been some success in increasing the number of paired HoNOS

completed but further work is planned in 2013/14 to ensure that the improvement is sustained without

peaks and troughs associated. The Trust has also agreed to additional dedicated consultant sessions to

assist with driving up clinical value and to provide leadership to clinicians.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Jul-12 Aug-12 Sep-12 Oct-12 Nov-12 Dec-12 Jan-13 Feb-13 Mar-13

Pe

rce

nta

ge

Date

Priority 5:Improving the use of the HoNOS

Target

% Matched Pair


Progress against core quality account indicators The table below details the Trust’s performance against the core set of indicators for 2012/13. All trusts are required to report against these indicators using a standardised statement set out in the Quality Account regulations. Some of the indicators are not relevant to all trusts, and we have therefore only included indicators that are relevant to the services that the Trust provides.

Data has been sourced from both the Health and Social Centre (HSCIC) and from the Trust internal data management system, Pulse, and will be referenced accordingly.

Indicator

Targ

et

201

2/1

3

perf

orm

an

ce

Care Programme Approach (CPA) seven day follow-ups What is being monitored? The proportion of patients on CPA who were followed up within seven days after discharge from psychiatric inpatient care The SWLSTG mental health trust has taken the following actions to improve this percentage and so quality of its services, by ensuring that wards confirm and work closely with individual care coordinators prior to discharge, should a service user not be known to community services then the home treatment team will follow up the discharge to ensure that the service users’ needs are met. In addition, care coordinators are sent email reminders to remind them of upcoming discharges.

95% 98%

Source: Trust Pulse

Crisis Resolution and Home Treatment (CHRT) gatekeeping for inpatient admissions What is being monitored? The proportion of admissions to acute wards that were gate kept by the CRHT teams The SWLSTG mental health trust intends has taken the following actions to improve this percentage, and so quality of its services, by ensuring that CHRT teams are involved in both wards and liaison teams to ensure that each admission is appropriately gatekept. The Trust has also designed a bespoke gatekeeping tool to assist clinicians the recording of gatekeeping.

95% 95.8%

Source: Trust Pulse 99.2% for 9 months to December 2012 Source: NHS Information Centre Report Q1-3

28 day emergency readmissions What is being monitored? The percentage of patients readmitted to a hospital which forms part of the Trust within 28 days of being discharged The SWLSTG mental health trust intends to take the following actions to improve this percentage, and so quality of its services, by reviewing individual readmissions and reviewing the reasons for admission on an individual basis to assess to see if improvements can be made to the service user care pathway to avoid readmissions.

Less than 7.5%

8.1% Source: Trust Pulse


‘Friends and family’ test What is being measured? The proportion of staff that completed the staff survey that ‘agreed’ and ‘strongly agreed’ with the statement “If a friend or relative needed treatment, I would be happy with the

standard of care provided by the Trust.” " The SWLSTG mental health trust intends to take the following actions to improve this percentage, and so quality of its services, by engaging with staff around delivering better outcomes for our patients for improvement through the ‘Listening into Action’ initiative that is currently in operation across the Trust.

N/A 48% Source: NHS Staff Survey 2012

Patient experience of community mental health services What is being measured? The weighted average of four of 2012 survey questions from the community mental health survey (score out of 100) The SWLSTG mental health trust intends to take the following actions to improve this score, and so quality of its services, by reviewing the data from the survey and focusing our areas of weakness such as out of hours contact and crisis plans (this is a CQUIN for 13-14).

n/a 83.9%

Patient safety incidents resulting in severe harm or death What does this mean? The proportion of safety incidents resulting in severe harm or death The SWLSTG mental health trust intends has taken the following actions to improve this percentage and so quality of its services, by continuing to have a virtual risk management team (as explained on further on within the report) and continuing to review all incidents and to provide opportunities for staff to learn from these incidents.

n/a 2% Source: National Patient Safety Agency (NPSA) March 2012 to Sept 2012

Listening into Action (LiA) is a systematic approach to engaging and empowering staff within NHS organisations. As an outcome focused approach, it places staff in the centre of decision making and service development, and its evidence based methodology leads to a culture shift which embeds staff engagement and empowerment within everything that the Trust does. The LiA approach is focused on changes which lead to an improvement in the quality of care, The Trust is part of the third wave of organisations implementing LiA, and Trusts within the previous two waves have seen significant improvements in staff engagement, evidenced within staff survey results. LiA will be led by a dedicated Team within the first year of implementation, after which it is anticipated that its principles will be embedded within all aspects of the Trust’s work. For further information on the programme go to www.listeningintoaction.co.uk/LiA-info/

http://www.listeningintoaction.co.uk/LiA-info/


Complaints We take all our complaints very seriously and consider them to be a valuable feedback mechanism.

Listening carefully to the concerns, we endeavour to everything possible to resolve them and respond to

complainants. We aim to learn from what has happened and make demonstrable improvements to the

service where appropriate.

In recognition of their importance, complaints are considered at a senior level in the Trust by the Chief

Executive who responds to all complaints. They are also considered by the Head of Quality Governance

and Assistant Director of Nursing who provide direction at a weekly meeting into which the Complaints

Manager reports the complaints that have been received that week. At this meeting the rating against risk

generally, and impact of the Care Quality Commission outcomes, are considered.

In addition, significant or thematic risks are escalated to a weekly Risk Intelligence Group and a Monthly

Serious Incident Governance Group.

During the period 1st April 2012 to 31st March 2013 we received 415 complaints which is in line with the

previous year figure of 412. We continue to improve the quality of resolution and our responses to

complainants and of the 415 complaints received in the year, 24 were referred to the Ombudsman for

independent review. Four remain open for a decision and 19 were closed requiring no further

investigation.

Out of those cases referred to the Ombudsman, the Trust was only required to send one case with a

further response (after a consent issue had to be clarified with legal advice). The Trust has therefore

demonstrated a positive track record in good complaint handling even in those cases where the findings

may not have reached the expectations of the complainant.

Table 5 illustrates the themes to which complaints are allocated (and a trend analysis of the previous

year). These themes are required by the Department of Health and are a broad categorisation for use

across the NHS.

In summary the table shows a significant improvement in the number of complaints received in specific

categories. In particular, it shows:

A reduction by 100% of complaints about appointments

A reduction by 39% of complaints about attitude of staff

A reduction by 83% of complaints about premises and buildings

A reduction by 11% of complaints about clinical care

A reduction by 62% of complaints about customer care

A reduction by 55% of complaints about non clinical issues


Table 5: Overview of complaints received by theme in 2011/12 compared to 2012/13

2011-12 2012-13 Trend 2011-12 2012-2013 Trend

Complaints Total well founded (upheld or partially

upheld)

Appointments 10 0 9 0

Cancellation (OP) 1 0 1 0

Time 1 0 1 0

Delay 8 0 7 0

Attitude of staff 84 51 34 25

Medical 13 7 2 1

Nursing 39 30 16 14

Administration 3 2 2 1

Social Work 5 2 1 2

Other 24 10 13 8

Buildings Land & Plant 6 1 6 0

Premises – access to 5 0 5 0

Condition - general building 1 1 1 0

Car parking 0 1 0 1

Charges/fines 0 1 0 1

Cleanliness 0 1 0 1

Condition - ward 0 1 0 1

Premises 0 1 0 1

Unclean 0 1 0 1

Clinical 109 97 38 45

Nursing care 9 5 2 2

Diagnosis Problems 6 2 4 0

Treatment 93 90 31 41

Medication Error 1 0 1 0

Customer Care 42 16 24 8

Patients Privacy and Dignity 30 2 19 2

Admission Arrangements 2 1 1 0

Loss of personal property 6 10 3 5

Discharge Arrangements 4 3 1 1

Equipment 1 1 0 1

Aids and appliances 1 1 0 1

General Procedures 129 232 61 128

Failure to follow procedures 78 56 34 30

Communication/Info to patients 46 154 24 89

Complaints Handling 4 6 3 3

Equalities Not collected

16 Not collected

6

Non Clinical 31 14 9 6

Personal records 15 1 (4) 1

Transfer arrangements 1 1 (0) 1

Expenses Problem 1 0 (0) 0

Policy and commercial decision 13 7 (5) 3

other 1 3 (0) 1

Total 412 415 181 216


However, there was an increase in the number of complaints relating to Communication and Information

to patients, from 46 to 154 complaints. By way of learning from this theme the Trust has taken the

following actions:

Introduced a new complaints protocol (now incorporated into Policy) which focuses on early

resolution of complaints and effective communication with complainants. With an emphasis on

contacting complainants at an early stage and keeping them informed during the complaints

handling process

The Mental Health Act (MHA) Office has conducted a series of training sessions with ward staff

about the MHA including a refresher on the information that is to be provided to patients when they

are detained under the MHA.

The Trust subscribes to the (http://www.choiceandmedication.org/swlstg-tr/) website which enables

services users and their carers and families to obtain information about their medications and

conditions, and to download information leaflets that relate specifically to their treatment. The

Trust also makes information available about NICE approved medicines via a link on the Trust

website (http://www.swlstg-tr.nhs.uk/advice-support/nice-medicines-guidance/).

The development of a wide range of initiatives to improve the inclusion of carers and families in the

care process, aligned with the Carers’ Trust ‘Triangle of Care’ for which the Trust has a kitemark.

The Trust works in close collaboration with all local carers’ centres. The Trust designed, in

partnership with Carers in Mind, a unique 10-week programme for carers of people with

schizophrenia in Richmond and Kingston. This approach has been recommended by the National

Institute for Health Clinical Excellence (NICE) to help reduce relapse rates.

The Triangle of Care Initiative establishes a 3-way therapeutic alliance between service user, staff

member and carers/family members or friends (wherever this is possible) such that they are seen

as active partners in care and their knowledge and skills are valued. Most services already have

elements of best practice in place to a greater or lesser extent. However, to meet the needs of

carers, families and friends further improvements can always be made. The Triangle of Care ‘Self

Assessment’ will identify those areas of practice that are strong and will support actions for

improvement, further development and the opportunity to share good practice across services.

An audit was conducted in February 2013. Outcomes have been reviewed by the Carers family

and friend’s reference group, and good practice examples have been shared and action plans are

currently being co-produced to address areas of concern and spread good practice examples

across the Trust.

Notable Good Practice example: -

http://www.choiceandmedication.org/swlstg-tr/

http://www.swlstg-tr.nhs.uk/advice-support/nice-medicines-guidance/


Richmond Acute Carers Recovery Worker pilot - This pilot was led by Catherine Gamble,

Consultant Nurse who co-produced the project with Carers in Mind Richmond. The pilot sought to

promote and sustain family inclusion on Lavender ward and Richmond Crisis and Home Treatment

Team (CHTT).

Triangle of Care audit data, carers feedback and the narratives of those involved currently evaluate

this projects progress. Findings suggests whilst there is still progress to be made, a family work

trained Acute Carers Recovery Worker supported by an in-patient carer champion has had

considerable impact in modeling how to engage and support informal carers during and post-acute

crisis periods.

Three carer feedback quotes encapsulates this:

We are very grateful for this wonderful help. These work outcomes probably cannot be easily measured or assessed but as "service users" we can only say the Carer Recovery Worker on Lavender Ward and the Home Treatment Team has been an invaluable source of care and support to us.

When the Carers Recovery Worker came to meet me and said that she was there for me…. I just sat down and cried. I’ve been doing this for years and no one has ever been there for me before.

A service like this is invaluable and a real lifeline.

The pilot received very positive feedback after being presented at a National Triangle of Care Conference in Manchester and has generated interest from other Trusts, for example Sussex Partnership NHS Foundation Trust.

Complaints Surgery: The Complaints department launched an alternative way for patients to voice their concerns via the new complaints surgeries in various ward areas. These complaints surgeries allow service users to speak to a member of the complaints team on the ward where they have been admitted, allowing them the opportunity to talk about issues in a group or individually. Concerns can then often be dealt with immediately. Complaints surgeries are currently run fortnightly on Bluebell ward (Adult inpatient deaf ward), Addison unit (Wandsworth prison inpatient ward) and shortly will also be run on Halswell ward (Medium secure Forensic ward).

In addition to discussing concerns through theses surgeries the Trust has also received compliments about various services which have then been registered and shared with the teams and the Trust Board.


Compliments During 2012/13 the Trust has introduced a clearer process for staff to record compliments. As a result of this we have seen a rise in the number of compliments received in 2011/12 of 83 to 271 compliments received in 2012/13 which is a 226% increase. Below is an example of a compliment received from a carer whose needs were addressed as an integral part of the assessment process. The service user was diagnosed with dementia of mild to moderate degree and the carer wrote a letter to the team Outreach Occupational Therapist:

“I wanted to say a big thank you for all the time and effort you put in with not only [patient name] but myself. It is refreshing when someone sees [patient name] and not just the illness, by taking the time to get to know him you have been inspirational with organising and suggesting activities for him based around his love of art and music. As you know he now goes to art class once a week and has been accepted into the Euphonix choir, which he loves, a big thank you for that. I am grateful for all your support at a time I didn’t know where to turn, and feeling very down and isolated. You have introduced me to various groups and activities in the area, some which [patient name] and I can both attend. Some of the things we did previously being no longer suitable. It is also a great consolation to me to know that you are there if I run into difficulty in the future. Your whole work ethic is to keep [patient name] as active and stimulated as possible, thereby helping me to cope too. It is such a dreadful illness which you just have to watch get worse day by day, so thank you again for putting something back into [patient name] life.”

Comparisons against national benchmarking data A summary of data from the Quality Intelligence East (QIE) is shown on page 35, which gives an

overview of the Trust and their performance against various indicators. The data has been compiled

into a Mental Health Trust Quality Profile, which provides an assessment of quality across the 5

domains of the NHS Outcomes Framework, in comparison to a national mean:

1. Preventing people from dying prematurely

2. Enhancing quality of life for people with long-term conditions

3. Helping people to recover from episodes of ill health or following injury

4. Ensuring that people have a positive experience of care

5. Treating and caring for people in a safe environment and protect them from avoidable harm

A sixth domain has been created "Organisational Context" which contains a number of metrics

which look at organisational behaviour and measures useful in interpreting other metrics in the

profile.


Serious Incidents Overview of concerns In 2011/12 Commissioners issued a performance notice to the Trust due to the high number of overdue incidents requiring investigation. A review was undertaken by an external consultant resulting in an action plan with a number of changes and the implementation of new systems and processes. The Trust made significant changes to the systems and processes around serious incident reporting with a view to improving the timescales and quality of reporting. These changes have been reflected in improvements during 2012/13 and the Trust now has no overdue STEIS reports and has met the Key Performance Indicator (KPI) relating to the quality of reports submitted to NHS London (now replaced by Kingston Clinical Commissioning Group).

Overall in 2012/13 115 incidents were added to STEIS. Wandsworth reported the highest number of incidents which is consistent with its population size. In the South West London (SWL) sector Wandsworth has the highest population of the five boroughs in the Trust at 21.3 % (284,007 thousand). The Trust is not an outlier in the number of Serious Incidents reported in the year when compared to other mental health Trusts. The Trust however does report within the lowest 25 % of Trusts in terms of National Patient Safety Agency (NPSA) data. Only five incidents are reported per 1000 bed days, however in the data submitted March to September 2012 there was an increase to 10 incidents reported per 1000 bed days. The Trust anticipates the introduction of Electronic Incident Reporting will continue to support the improvements in reporting. In 2012/13, South West London and St George’s Mental Health Trust have sought to develop an organisational approach to sharing learning across the Trust. This included three Trustwide learning events held in 2012/13 and a project to improve risk assessment and risk management across the Trust. Monitoring of Trustwide actions from completed serious incident reports continues at the monthly Serious Incident Governance Group however, further work is required to ensure local actions are full embedded. In 2012/13 the Top five categories of reported serious incidents included Unexpected Deaths, Suspected Suicide, Allegation against Health Care (HC) professional, Attempted Suicide and Absconds. There was one reported Homicide in 2012/13 for which the investigation is ongoing and there were no reported Never Events.

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

>3months 0 0 0 1 2 0 0 0 0 0 0 0

1-3months 4 3 1 3 2 0 0 2 0 0 0 0

<1month 4 6 5 6 2 4 4 2 0 0 0 0

0

1

2

3

4

5

6

7

Overdue Serious Incidents 2012/2013


What else have we done? Introduced Electronic Incident Reporting Incidents are now entered by reporters and sent directly to managers via the system, enabling: -

Instant feedback from managers directly to reporters

Increased awareness - Training has been provided for all staff via e-learning and face to face training. Road shows have also been organised on multiple sites to increase awareness of the incidents and electronic incident reporting

Timely trend analysis - Trend analysis has enabled the Trust to provide the workforce with up to date information on incidents and provide tailor made reports

Developments - The Trust have now proposed to use the Ulysses system, which hosts Electronic Incident Reporting, to enable staff to raise Safeguarding alerts via the system as well (Phase 2)

What have we learnt?

Concerns Action

• Evidence of Trustwide learning • Monitoring of actions

• Evidence of embedding learning

• Overdue incidents requiring investigation

• Scheduled Trust wide Learning Events (Four per year)

• Aggregated analysis of incidents of suicide and self-harm

• Monitoring of Trustwide /Local Actions

• Six monthly reports on embedding

learning

• Systems to prevent overdue incident investigations

Introduction of a Virtual Risk Team

The aim of the ‘virtual’ multi-disciplinary team is to be an additional resource to all clinical areas across the trust. The role of the virtual team is to provide a framework and a reference point for clinical areas. The emphasis is on pre-emptive and envisioning work to more robustly share and manage high risk and complexity. This is achieved through inclusion, reflection and shared experience and learning rather than teaching and prescribing. This virtual team therefore provides: -

Development of a local Risk/Clinical Management Plan/Discharge planning.

Consultation and advice.

Review of the process of an incident with the whole clinical team with identified learning and actions.

Collaborative development of key learning points.

Practice development sessions-theory and practice.

Specific, short-term supervision to the clinical area.

Evaluation of progress.


An evaluation of current practice against the findings of the Francis Report

Following the publication of the Mid Staffordshire NHS Foundation Trust Public Inquiry on 6 February

2013, a summary report was discussed by the Trust Board (February 2013). This summary outlined the

background, key findings and recommendations from the report and highlighted the implications for South

West London and St George’s Mental Health Trust. The report recommended that all healthcare bodies

immediately evaluate their own organisation against the report’s findings and recommendations, and

continue to do so in the future. In response the Trust Board has commissioned an evaluation of current

practice against the findings of the Inquiry.

Expert leads have been asked to assess current practice against the recommendations and note any gaps

with explanations. Feedback from expert leads is due 1st July 2013, which will be shared with our

stakeholders in a subsequent update to the Quality Account.


Comments from stakeholders To ensure transparency and partnership involvement South West London and St George’s Mental Health NHS Trust asked key stakeholders to be involved in the development of the Quality Accounts. Stakeholders include local Healthwatch, Overview and Scrutiny Committees (OSCs) and Clinical Commissioning Groups (CCGs).

The Trust has also liaised with Trust staff to ensure the content of this Quality Accounts reflect their views

and comments.

Below are the commentaries received by the Trust:

Healthwatch Wandsworth

Healthwatch Wandsworth welcomes the continuing evidence of the Mental Health Trust’s efforts to

achieve lasting quality improvement as part of its overall strategy. The annual Quality Account provides an

important occasion for the Trust to report publicly on progress. While this year’s account contains a

wealth of detail on action taken across a range of fronts, there still in our view remains work to be done in

making the material more easily understandable to the general reader and in aligning detailed targets and

priorities more clearly with overall strategic directions.

Clearly safety and safeguarding children and vulnerable adults remains a paramount priority for the NHS

and it seems the focus is still needed here for the time being on getting basic procedures completed and

established as routine. The pursuit and maintenance of clinical excellence rightly emerges as an implicit

priority in parts of the Account although it may not lend itself to setting of annual targets. After these,

Healthwatch attaches particular importance to maintaining the impetus of the Trust’s much-needed drive

to improve its performance and standing as an organisation which really listens, responds and works with

those it serves: its service users and their families and carers. The system of Real Time Feedback has an

important part to play. It seems that 2012/13 has mainly been devoted to getting the arrangements up and

running and it is now time to start showing real evidence that the feedback is being monitored, listened to

and responded to. We accordingly welcome the commitment to publish regular reports, which we hope will

be developed in consultation with stakeholders.

We also welcome the inclusion as a new priority for 2013-4 of a review of individuals’ crisis plans. This

meets a concern that has been widely expressed, and we welcome the reference to carer involvement in

this process.

In general Healthwatch notes disappointingly few references to carers in the account of performance for

2012-3. Although we see some evidence that views expressed by carers have been taken into account in

the setting of priorities in 2013-4, the Quality Account as circulated for consultation does not mention the

Triangle of Care. This seems to us a serious omission, given the Trust’s claims elsewhere that the

Triangle approach is key to monitoring and improving quality of support to both service users and carers.

We hope that this omission will be rectified in future.

Finally, we welcome the apparent refocusing by Wandsworth CCG of their quality improvement incentives

for 2013-4 which seem to align better with the overall needs of quality improvement in mental health

services for Wandsworth.

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Wandsworth Adult Care and Health and Overview and Scrutiny Committee

It is a serious concern that the Trust achieved its targets for only one of the five priorities set out in the

2011/12 Quality Account, although it must be acknowledged that two more of the targets were only

narrowly missed. It is particularly concerning that, in the 2012 NHS Staff Survey, less than half of those

working for the trust who responded said that they would be happy with the Trust’s standards if a friend or

family member required treatment.

Also of concern is the persistent low rate of patient safety reporting to the National Patient Safety Agency.

In view of the limited achievement against the targets set in last year’s Quality Account, the decision to

continue focussing on the same priorities in 2013/14 is endorsed. In general, the targets seem reasonable

and, with the necessary measurement systems in place at the start of the year, it is to be expected that

improved outcomes will be achieved.

However, it is disappointing that the target in relation to service user experience covers only receiving and

responding to feedback; the point of the exercise should be to achieve measurably improved user

experience of care.

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Wandsworth CCG

The consensus from the CCG was that the document didn't do justice to the enormous amount / degree of

work that had gone on behind the scenes in terms of setting the quality indicators and CQUINS. Without

this backbone it didn't read through or flow well.

Examples such as the physical health indicators requiring a physical health check for patients within 48

hours of admission and a standard of 95%- read as a poor standard-with many expecting this as a given

aim for any hospital admission.

It failed to display the recognition of the importance of physical health and how Emma Whicher the

medical director highlighted the training programme for new doctors to the CQRG and demonstrated how

this was being incorporated into the culture of the work. The aim was absolutely for 100% but was set at

95 % to make some allowance for those patients too distressed for it to be done immediately.

Equally the crisis planning CQUIN- didn't refer to the recent workshop or work stream- being led by Miles

Rinaldi, involving all stakeholders.

This another positive example of acknowledging a historically underperforming area and actively engaging

all stakeholders, community and hospital staff, patients and carers to work together to establish methods

for improving standards and ensuring reporting of omissions and ongoing feedback and maintenance and

fluidity.

Real time feedback for users was felt too procedural and lacking in real outcomes. However, the

document from Glynn Dodd brought to the CQRG on the "service user experience action plan" would

have helped to show how this work is being followed through and incorporated into practice changes and

maintained as an active feed in.


The stakeholder event in January was not referred to and the carer and patient input into for example

CQUINS overall etc. just wasn't apparent, despite them having direct input into all of them-as evidenced

by the extensive discussions around the smoking cessation CQUIN and the former 2 referred to above.

Examples of improvements in SIs and duty of candour would also have been valued within the document

as well as examples of the increasing use of good national benchmarking data of quality indicators for

SWLSTG against other London trusts. The CCG were also keen to see reference to work on same sex

wards and the Francis report-and again this has been worked through e.g. on the crocus ward review so

some reference to this would help to evidence that key issues are incorporated. The work that has been

done on recruitment/retention and workforce development and uptake of mandatory training figures would

have been well received also.

************************************************************************************************************************ ******

Healthwatch Richmond upon Thames

We are pleased to see performance improvements over the past year. These improvements are

supported by signs that the Trust is moving in the right direction. Whilst the Quality Account presents

these improvements reasonably effectively, it is difficult to interpret, particularly in relation to priorities.

Additionally, in view of improvements during 2012/13, future priorities should be more ambitious.

Priorities for 2013/14 Information in this section is hard to interpret and insufficient to allow readers to understand Trust targets,

e.g. who is affected by them or how targets relate to outcomes. To illustrate this; the Safeguarding

Children priority does not clarify if the ‘child’ is a service user or associated with one; or if coordinated

safeguarding procedures similar to those for adults exist (e.g. whether a ‘safeguarding children’ manager

exists). The identification and appropriate referral of young carers is a local concern that is not addressed.

Insufficient information is provided on underlying actions that will address targets. The relevance of

several priorities are therefore unclear and additional information would be required to understand whether

achieving some targets will deliver meaningful improvement in care for Richmond’s population.

The Safeguarding Adults and Service User experience targets appear to be partially met. There is

however insufficient information presented to show the targets are ambitious. It will also be difficult to

identify what improvements result from achieving targets.

The Service user experience target will see quarterly patient and carer meetings receiving feedback

information generated through kiosks and the Trust’s website. This target is reportedly already partially

met, however no information is provided about how well systems are used, so their benefit is unclear.

Collection of patient experience is welcomed, but this target does not go far enough, nor is holding

quarterly meetings a challenging target. Patients and Carers require a greater range of verbal and written

feedback mechanisms. Furthermore, the representative groups that will receive this feedback are not

sufficiently representative. Monitoring should include Healthwatch Members and other stakeholders in all

geographical areas to provide a wider perspective. Healthwatch Richmond also does not currently have

evidence suggesting that a sufficiently broad range of Richmond’s service users and carers are involved

by the Trust. This target would not address that concern.

Performance against targets for 2012/13 Performance shows promising improvements in several areas, e.g., ‘Safeguarding Adults’ and ‘Service

User experience’. Performance in Physical Health shows significant improvement but remains well below

target. It is good that this remains a CQUIN target, but it would seem prudent to include this target in the

Quality Account.


Developments in capturing and recording of information are welcome improvements. However as targets

are achieved it will be important to demonstrate identified trends, resultant actions and outcomes. It would

be useful if the Account presented these, particularly where significant differences exist between overall

performance and performance of given services or localities. Service users and carers are particularly

interested in services on a borough-by-borough rather than a global basis.

************************************************************************************************************************ ******

Richmond CCG (LA and NHS, clinical commissioner colleagues)

A general comment is that the report gives us very little information about the quality of services that we

are in receipt of even though the paper presents a positive picture.

CQUINs – Against meeting targets of 12/13 it might be helpful to have some narrative about what was

actually done in language that is accessible rather than just ‘met’.

Physical health checks – Expectation that this is completed as basic requirement of admission, given poor

compliance previously what difference has this improvement made.

Service user experience: This is an important section and the descriptions are very procedural and there

needs to be more emphasis on what changes have arisen as a result of RTF and how these will be

incorporated into planning. Some examples of what has improved, what patients say about the RTF.

Complaints - Overall the complaints section is weak and does not address changes that have been made

as a result of complaints/themes etc.

HoNOS- process measure described but what has it meant in terms of improving patient care – how has it

been used.

Crisis contingency planning: As referred to under CQUIN, what difference has review of crisis plans

made? How many have been reviewed and what success has been achieved in managing crisis in

different ways e.g. not attending A&E.

Crisis Admissions of concern is the statement that almost 100% of admissions were gate kept by the crisis

team. This does not accord to local GP experience in Richmond. Would need clarity about whether this

purely includes CRHT or does this count liaison psych or the on-call SHO as crisis team. This can be

verified by asking patients on ward.

Physical health: Having a physical health check on admission and recording it within 2 days is not much of

an achievement. Of course mental health patients should have a physical check, like every other patient in

any specialty who is admitted to a hospital.

Local Authority targets

Given that SWLSTG is an integrated Health and Social Care service it is disappointing that there is no

mention in the report of any social care outcomes (excluding Safeguarding).

No mention of personal budgets /direct payments through self-directed support assessments

No mention of carers assessments at all

No mention of anything in relation to the approved mental health professional role; all AMHPs are

LA seconded SW (the experience of accessing an AMHP in times of crisis is a very significant

quality measure.)


Learning disabilities – As a provider of LD services will the Trust be providing an accessible version of the

document.

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Kingston Health Overview Panel, Royal Borough of Kingston upon Thames

The Health Overview Panel appreciated the Trust’s presentation on the Quality Account to the January

2013 meeting providing a 6 month update on progress and to liaise about target setting for the following

year. We are aware that the Trust has an ambitious task ahead both in terms of moving forward with

implementing its Strategic Integrated Business Plan which we considered in October 2012 together with

the work required in the lead up to applying for Foundation Trust Status. This is also set against a

change in the commissioning background and we note that the Kingston Clinical Commissioning Group

has taken on the role as lead commissioner for Mental Health for the South West London area.

We are aware of a detailed report published in June 2012 entitled “Mental Health Benchmarking and

Market Analysis – Technical Analysis” which was prepared for Clinical Commissioning Groups. This sets

out comparative data for SWLSTG alongside other Mental Health Trusts which are not identified by name.

Whilst this has informed Mental Health commissioners, we wish to draw on some areas relevant to the

targets discussed in the Trust’s Quality Account 2012/13. We would add that the Technical Analysis

clearly points the way for a number of service changes and improvements, some of which have already

been progressed and which indeed have been discussed at the Health Overview Panel e.g. changes

around the delivery of secondary Community Mental Health Services.

We are pleased to see the progress made to rectify the concerns identified by the Care Quality

Commission and hope that service standards are maintained and indeed improved into the future to

ensure no recurrence of these specific poor areas of care.

One of our main observations on the Quality Account is that whilst it is very encouraging to see the

progress made with capturing data on a whole range of indicators, plus participation in research, to inform

service provision, we would appreciate some specific examples of what this means in practice illustrating

how services and safeguarding have improved.

Progress against Quality Performance Targets 1 to 5 during 2012/13

We were pleased to see the progress on the four of the five areas. The progress on both child and adult

safeguarding are excellent achievements – under target by just 0.5%. The graph showing the month by

month progress on the safeguarding children target demonstrates very commendable early progress with

this standard. We would be interested to know whether the recording of data is delivering tangible

outcomes in supporting safeguarding e.g. whether there is a reduction in the number of safeguarding

related incidents.

Service User experience – We welcome the progress made with Real Time feedback and note that this is

now available in some community settings as well as on wards. Whilst the report discusses the number of

surveys per day we would be interested to know more about the proportion of service users covered and

whether there is a good spread of contributions across the client group i.e. feedback is not just from a

small group of service users on a regular basis. Perhaps this could be captured in a forthcoming quality

account.


We hope that future Quality Accounts will demonstrate more descriptively what has been achieved in

service provision prompted by service user experience. The Benchmarking Report referred to above

whilst reporting comparative outcomes from an earlier CQC mental health service users survey clearly

demonstrates that there have been some significant shortfalls in the past for people who use community

mental health services e.g.:

Health and social care workers not listening carefully /taking client’s views into account, issues of trust,

dignity and respect plus limited contact time.

Difficulties around contacting care coordinator and issues about care planning and crisis intervention

Support with care responsibilities

The report also details shortfalls for staff e.g.:

Issues around work life balance and intention to leave jobs

Witnessing errors, near misses of incidence plus fair and effective reporting of these

Issues around harassment, bullying and abuse and effective action from the Trust.

With regard to the comprehensive health assessments, again, we commend the Trust for the progress

made achieving the high levels of assessments on admission. We would ask whether this is followed

through and clinical findings are fully reflected in final discharge letters to GPs to ensure clients can be

well supported in Primary Care for both physical and mental health issues, recognising that not all GPs

have expertise in mental health. We hope to learn more about the interface between Secondary and

Primary care at the Health Overview Panel on 20 June 2013 and how unmet need can be picked up in

Primary Care and supported. We would welcome details of the Trust’s discharge policy and how this

operates.

Health of the Nation Outcome Scale - It would be helpful for example to explain what HoNOS is so this is

meaningful for members of the public.

Additional Targets

We welcome the reporting on the additional priority targets and particularly the progress on CPA seven

day follow-ups plus the focus on 28 day readmissions. Greater explanation of the significance of

achievement on Target 10 Patient Experience would be appreciated.

Priorities for Improvement 2013/14

We welcome the commissioning for Quality and Innovation Payment Framework (CQUIN) goals agreed

with commissioners particularly around dementia care and the process of setting recovery goals within the

Care Programme Approach. We would be interested in receiving a presentation at the Health Overview

Panel in early 2014 to hear about progress with crisis planning.

Suggestion for Future Reporting

We would like to see future reporting within the Quality Account on the area of learning from Serious

Untoward Incidents. Whilst this is a difficult area to consider in the public domain we would suggest that

this is important for the public to see that learning from incidents does take place.


We are also aware that there can be difficulties in ensuring carers are kept fully informed about relatives’

conditions and care. Carers play a very important role in supporting people with mental health problems.

It can be difficult for carers to support a person’s recovery if they are not kept informed of goals and

perhaps medication. We do, however, recognise that there can be circumstances when involvement of

relatives could be problematic particularly if family dynamics are unsatisfactory. We would welcome

discussion on carers, their involvement and support at a future meeting.

General

“Quality Accounts are annual reports to the public from providers of NHS healthcare about the quality of

services they deliver”, Source: DH Guidance. Whilst recognising the statutory requirements of the Quality

Account, we would suggest that consideration is given to changing the structure to ensure it is aimed at a

level which is more accessible and helpful to the public. A more descriptive approach would be helpful.

************************************************************************************************************************ ******

Richmond Housing and Adult Service Overview and Scrutiny Committee

Following on from the meeting held on Wednesday 29th May 2013, to discuss SWLSGMHT Quality

Account (QA), we welcome the opportunity to provide our formal response. The London Borough of

Richmond upon Thames (hereinafter ‘LBRuT’) is determined to champion the interests of its residents by

playing a full and positive role in ensuring that the people living and working in the LBRuT have access to

the best possible healthcare and enjoy the best possible health.

The Report

We appreciate that the version provided is a draft and the final version is yet to be approved. Please find

below our comments and a number of suggestions we wish to see incorporated in the final version:

We acknowledge your clear, concise, evidenced document and welcome your priorities.

We are pleased to find that crisis contingency planning, communication and carer input will inform the

process for setting the priorities for 2013/14.

We are encouraged to see the level of engagement with stakeholders, staff and users and the rationale for

the priorities chosen is set out under each priority however, it is not clear what the method / process was

to determine your priorities. We would like greater transparency in and more information about your

methodology/ process for selecting these as your key priorities over other areas and suggest a short

paragraph is added setting this out.

Under the section relating to ‘safeguarding children’, whilst we the committee are aware of the reasons

why SWLSTG would have less involvement in child-safeguarding and more in adult safeguarding this is

unlikely to be the case for members of the public and may be a cause for concern. We suggest a short

paragraph is added to the QA to clarify / explain the reasons.

In a similar vein, we suggest that a “Language and Terminology” section is included at the front of the QA

and / or a glossary. Including this takes into account the fact the public are not always aware of the

terminology used and thereby increases the QA’s accessibility.

We suggest the use of case studies to bring the work you have undertaken and their success to life thus

making it more accessible to members of the public and enabling them to identify the changes and

improvements which have taken place. From discussions on 29th May we were delighted to hear that

carer’s are being provided support via your Carer’s Support Worker on Lavender Ward. This is the type of

information that patients, carer’s and service users wish to know about as it shows your commitment to

improving quality and will in turn increase positive user experience.


We are pleased to see that you have provided detailed evidence in the QA. However, it is not clear where

this evidence is derived from. To ensure greater transparency, we strongly suggest that all sources of

information used as evidence in the QA are adequately referenced and identifiable.

Following on from the above point, in Part 2b of the QA you mention that there are a number of national

indicators which you are required to report on but do not state what they are. We would have liked to see

the indicators listed for the same reason as set out in the point above.

We were initially concerned at the 38% of HoNOS completed given that the target was 95%. Following on

from discussions as to the reasons why the percentage completed was so low, it became clear that there

are two sets of figures: one at admission and one at discharge. At present this is not reflected. We think

that this leads to an inaccurate picture of what is taking place. We would like to see a sentence /

paragraph which, explains why the figures are as they are sets out the context. We believe that this will go

a long way in reassuring service users and members of the public.

Conclusion

Our aim is to ensure that your Quality Account reflects the local priorities and concerns voiced by our

constituents as our overall concern is for the best outcomes for our residents. We hope that the

suggestions offered are taken on board. We agree with your priorities.

We wish to be kept informed of your progress throughout and thereafter.

************************************************************************************************************************ ******

Sutton CCG Under "what others have said about the trust" they only mention CQC. I would have expected, at least, some service user and carer comments. There are reviews (admittedly not many and not particularly recent) on NHS Choices and Patient Opinion which the Trust has not responded to. In addition, they have not given a numerical target for getting real-time feedback from service users: not adequate to just say they will provide access to the means to give it. And one engagement event in Kingston on this Quality Account is hardly enough: I would expect them to say they went out to other people's meetings to talk to about it. We would also like to see more about how a wider quality strategy links in to their FT application and what this will look like going forward. Particularly disappointed in the section on complaints, I don’t think the Trust has captured everything it does and how it learns from compliant as I know it does more than the text suggests. Generally lots of nice words but I would rather see ‘we will’ and ‘you will know’ because the difference ‘will be’…..type statements. I have concern that quality around safeguarding issues can be measured in how many forms are filled in. I would like to see what action is taken when an issue is raised how the forms are processed who reads them and what happens when concerns are raised. Service Users and Carers - I thought this would be a good opportunity for the Trust to provide a platform to work with Service users and carers rather than concentrate on just the RTF kiosks, perhaps a commitment for co-producitve working in service design and provision as a way to enhance quality, particularly around satisfaction with services for carers and Service users. ************************************************************************************************************************ ******


Amendments following comments from stakeholders The Trust welcomes the statements received and thanks stakeholders for their comments. The Trust will

be responding to those who provided a statement. The following changes have been made to the Quality

Account subsequent to the receipt of statements;

- A number of textual changes have been made to improve the readability and corrected some

typographical errors.

- More detailed information has been provided for the priorities for 2013/14 with additional rationale.

- Additional CQUIN achievements for 2012/13 have been included with a summary of all the tools

that has been developed to support staff to achieve the indicators.

- More detailed information has been provided for the priorities for 2012/13 with additional labeling of

graphs and tables.

- Progress against core indicators has been explained in more detail with information relating to the

source of data being added.

- The complaints section of the report has be redrafted with information included on the themes and

actions taken as a result of these themes, including work with the Triangle of Care.

- A compliments section has been added to the report with an example of one of the Trust’s

compliments received.

- A serious incidents section has been added to the report with information relating to overdue

reports and learning events.

- An evaluation of current practice against the Francis report has been added.

The Trust will ensure that the various comments, issues and recommendations made will be addressed during the year ahead and reflected into our next Quality Account.

Feedback South West London and St Georges Mental Health Trust would welcome feedback on our Quality Account

2012/13. If you would like to provide feedback or make suggestions for the content of future reports, for

example, possible priorities for 2014-15, please contact Theresa Pardey, Governance Business Manager,

[email protected] .

mailto:[email protected]


Glossary Abbreviation Definition

CCGs Clinical Commissioning Groups

CFFF Carers Friends and Family Reference Group

CLRN's Comprehensive Clinical Research Network

CPA Care Programme Approach

CQC Care Quality Commission

CQUIN Commission for Quality and Innovation

CRG's Clinical Research Academic Groups

CRHT Crisis Resolution and Home Treatment

DeNDRoN

Dementias & Neurodegenerative Diseases Research Network. A Topic specific research network

HoNOS

Health of the nation outcome scales. HoNOS is a clinical outcome measure used by mental health services

IAPT Improving access to psychological therapies

ICO Information Commissioners Office

L(S)CLRN London (South) Comprehensive Local Research Network

LINks Local Involvement Networks

MHMDS Mental Health Minimum Data Set

MHRN Mental Health Research Network

NAS National audit of Schizophrenia

NIHR National Institute for Health Research

OSCs Overview and Scrutiny committees

PCT's Primary Care Trusts

PHA Physical Health Assessment

PID Patient Identifiable Information

POM-H Prescribing Observatory for Mental-Health

QIP Quality, Innovation, Productivity and Prevention

QOF Quality and Outcomes Framework

R&D Research and Development

RiO The Trust’s electronic clinical and patient record system.

RTF Real Time Feedback

SAM Safeguarding Adult Manager

SIRO Senior Information Risk Officer

SURG Service User Reference Group

SUS Secondary Uses Service


Annex - Statement of Directors Responsibility in Respect of the Quality Account STATEMENT OF DIRECTORS’ RESPONSIBILITIES IN RESPECT OF THE QUALITY ACCOUNT The directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendments Regulation 2011 to prepare Quality Accounts for each financial year. The Department of Health has issues guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements). In preparing the Quality Account, directors are required to take steps to satisfy themselves that:

the Quality Accounts present a balanced picture of the Trust’s performance over the period covered;

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, 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 Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Account had been prepared in accordance with Department of Health guidance.

The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account. By order of the Board Date: 27/06/2013 Chairman Date: 27/06/2013 Chief Executive


Independent Auditors’ Limited Assurance Report We are required by the Audit Commission to perform an independent limited assurance engagement in respect of South West London and St George's Mental Health NHS Trust's Quality Account for the year ended 31 March 2013 ("the Quality Account") and certain performance indicators contained therein as part of our work under section 5(1)(e) of the Audit Commission Act 1998 (the Act). NHS trusts are required by section 8 of the Health Act 2009 to publish a Quality Account which must include prescribed information set out in The National Health Service (Quality Account) Regulations 2010, the National Health Service (Quality Account) Amendment Regulations 2011 and the National Health Service (Quality Account) Amendment Regulations 2012 ("the Regulations"). Scope and subject matter The indicators for the year ended 31 March 2013 subject to limited assurance consist of the following indicators:

the proportion of inpatient admissions which were 'gatekept' by a crisis resolution and home treatment team on p.28; and

percentage of patient safety incidents that resulted in severe harm or death on p.29.

We refer to these two indicators collectively as "the indicators". Respective responsibilities of Directors and auditors The Directors are required under the Health Act 2009 to prepare a Quality Account for each financial year. The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporates the legal requirements in the Health Act 2009 and the Regulations). In preparing the Quality Account, the Directors are required to take steps to satisfy themselves that:

the Quality Account presents a balanced picture of the trust's performance over the period covered;

the performance information reported in the Quality Account is reliable and accurate;

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account, 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 Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; and

the Quality Account has been prepared in accordance with Department of Health guidance.

The Directors are required to confirm compliance with these requirements in a statement of directors' responsibilities within the Quality Account. Our responsibility is to form a conclusion, based on limited assurance procedures, on whether anything has come to our attention that causes us to believe that:

the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;

the Quality Account is not consistent in all material respects with the sources specified in the NHS Quality Accounts Auditor Guidance 2012/13 issued by the Audit Commission on 25 March 2013 ("the Guidance"); and

the indicators in the Quality Account identified as having been the subject of limited assurance in the Quality Account are not reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.


We read the Quality Account and conclude whether it is consistent with the requirements of the Regulations and to consider the implications for our report if we become aware of any material omissions. We read the other information contained in the Quality Account and consider whether it is materially inconsistent with:

Board minutes for the period April 2012 to June 2013;

Papers relating to the Quality Account reporting to the Board over the period April 2012 to June 2013;

feedback from the stakeholders named on pp.39 — 46 of the Quality Account;

the Trust's complaints report dated April 2013 and published under regulation 18 of the Local Authority, Social Services and NHS Complaints (England) Regulations 2009;

reports issued by your internal auditors during the year on health and safety, controlled drugs and rapid tranquilisation;

the 2012 Care Quality Commission patient survey report;

the 2012 national NHS staff survey report;

the Head of Internal Audit's opinion over the trust's control environment dated 15 April 2013;

the Trust's annual governance statement dated 3 June 2013;

the Care Quality Commission quality and risk profile dated 31 March 2013; and

reports issued by your internal auditors during the year on health and safety, controlled drugs and rapid tranquilisation.

We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with these documents (collectively the documents"). Our responsibilities do not extend to any other information.

This report, including the conclusion, is made solely to the Board of Directors of South West London and St George's Mental Health NHS Trust in accordance with Part II of the Audit Commission Act 1998 and for no other purpose, as set out in paragraph 45 of the Statement of Responsibilities of Auditors and Audited Bodies published by the Audit Commission in March 2010. We permit the disclosure of this report to enable the Board of Directors to demonstrate that they have discharged their governance responsibilities by commissioning an independent assurance report in connection with the indicators. To the fullest extent permissible by law, we do not accept or assume responsibility to anyone other than the Board of Directors as a body and South West London and St George's Mental Health NHS Trust for our work or this report save where terms are expressly agreed and with our prior consent in writing. Assurance work performed We conducted this limited assurance engagement under the terms of the Audit Commission Act 1998 and in accordance with the Guidance. Our limited assurance procedures included:

evaluating the design and implementation of the key processes and controls for managing and reporting the indicators;

making enquiries of management;

testing key management controls;

analytical procedures;

limited testing, on a selective basis, of the data used to calculate the indicators back to supporting documentation;

comparing the content of the Quality Account to the requirements of the Regulations; and

reading the documents.


A limited assurance engagement is narrower in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient appropriate evidence are deliberately limited relative to a reasonable assurance engagement. Limitations Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used for determining such information. The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore. The nature and methods used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Account in the context of the criteria set out in the Regulations. The nature, form and content required of Quality Accounts are determined by the Department of Health. This may result in the omission of information relevant to other users, for example for the purpose of comparing the results of different NHS organisations. In addition, the scope of our assurance work has not included governance over quality or non- mandated indicators which have been determined locally by South West London and St George's Mental Health NHS Trust. Unqualified Opinion Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2013:

the Quality Account is not prepared in all material respects in line with the criteria set out in the Regulations;

the Quality Account is not consistent in all material respects with the sources specified in the Guidance; and

the indicators in the Quality Account subject to limited assurance have not been reasonably stated in all material respects in accordance with the Regulations and the six dimensions of data quality set out in the Guidance.

Paul Hughes, Senior Statutory Auditor Grant Thornton UK LLP Euston Square, London NW1 2EP 28 June 2013

Quality Account Reporting Period: 2012/13 Published: June 2013 · The Care Quality Commission (CQC)...

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