quality account...annual report 2009/2010 1 quality account 1st april 2009 – 31st march 2010...

1ANNUAL REPORT 2009/2010

Quality Account 1st April 2009 – 31st March 2010

Specialist Mental Health Service for Bury, Rochdale, Oldham, Stockport, Tameside and Glossop

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2 PENNINE CARE NHS FOUNDATION TRUST 3ANNUAL REPORT 2009/20102ANNUAL REPORT 2009/2010

Part 1: Statement on Quality from the Chief Executive ..............................................4

Part 2: Priorities for Improvement and Statements of assurance from the Board ......5Performance in 2009/10 against Quality Indicators identifi ed in the 2008/9 Quality Report ...... 5Delayed discharges7 - day follow upGatekeeping

Our priorities for Quality Improvement in 2010/11 ..................................................................... 7A reduction in patients going absent without leave (AWOL) and abscondingA reduction in slips, trips & fallsA reduction in medication errorsEffective gatekeepingAn effective response to complaints

Statements of assurance from the Board .................................................................................. 17Information on participation in clinical audits and national confi dential enquiries ..................... 18Information on the use of the CQUIN Framework ....................................................................... 24Information on registration with the Care Quality Commission ................................................... 24Information on the quality of data ............................................................................................. 26

Contents

Part 3: Other Information ......................................................................................27Review of Quality Performance in 2009/10

Review of Patient Safety Indicators 2009/10 ........................................................................... 29Absent without leave, absconding, missingSelf-harmSlips, trips and fallsMedication errorsPhysical assaults against staff

Review of Clinical Quality Indicators 2009/10 .......................................................................... 42Delayed discharges7 - day follow upGatekeeping

Review of Patient Experience Indicators 2009/10 .................................................................... 46 Healthcare Acquired InfectionsEffective handling of complaintsDelivering single sex accommodation

Performance against key national priorities and national core standards .................................. 52Other additional content relevant to the quality of NHS services ................................................ 54

Annex ...................................................................................................................56Statement on Quality Account from Lead Commissioning PCT

4 PENNINE CARE NHS FOUNDATION TRUST 5ANNUAL REPORT 2009/2010

Part 1: Statement on Quality from the Chief Executive of the NHS Foundation TrustThis year has been another successful year for Pennine Care. As outlined in our Annual Report last year, we have in place a Quality Improvement Strategy, known as ‘Quality Matters’ which sets out our quality improvement goals for 2009-2014. At the heart of this is our commitment to continue to provide outstanding care to our patients, whilst remaining fi nancially sound.

High quality and ever improving care has always been central to what Pennine Care has strived to achieve and we are proud that for the second year running we have been rated “Excellent” by the Care Quality Commission for our services. In our Quality Strategy, as well as focussing on a number of key indicators this year for improvement, we have also looked forward fi ve years to embed the quality improvement work in our business planning for the long term. This will include a fundamental shift in the way the organisation is managed, implementing service line reporting and service line management to enable us to deliver the improvements that we want to make.

The priorities for quality improvement set out in this Quality Account have been chosen to refl ect our goals to improve patient safety, clinical effectiveness and the patient experience. They have been chosen by the Board, and refl ect the themes common in our ongoing and varied consultations with patients and carers, the Council of Members, the wider Foundation Trust membership, and staff.

This year has seen great improvements in services and important clinical engagement and

debate in what the Quality Strategy must achieve. We will work closely with all our staff to continue to place quality at the heart of what we do and keep this as a priority for us in the coming year.

To the best of my knowledge, the information in this document is accurate.

Signed:

John ArcherChief Executive8th June 2010

Quality Account

Part 2: Priorities for Improvement and Statements of assurance from the BoardPerformance in 2009/10 against Quality Indicators identifi ed in the 2008/9 Quality Report

The Trust identifi ed three quality priorities in 2008/9 which were reported in last year’s Quality Report.

Priority 1:A reduction in delayed discharges to meet the Monitor target of no more than 7.5% delayed discharges.

Priority 2:95% of patients discharged from an inpatient ward must receive a follow up in the community within seven days.

Priority 3:All patients that have an inpatient stay in Pennine Care would have been assessed through a gatekeeping function within the Crisis Resolution and Home Treatment Team.

The Trust achieved the following level of performance against each of these indicators in 2009/10:

8%7%6%5%4%3%2%1%0%

Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 2009/10

% of delayed discharges

% of occupied bed days with delays<7.5% target

Priority 1: Achieved in all twelve months. Achievement is ongoing, and monitoring is in place.


100%99%98%97%96%95%94%93%92%


% of patients discharged on CPA followed up within seven days

followed up on CPA95% target

Priority 2: Achieved in eleven of the twelve months. Achievement is ongoing, with monitoring in place.

Priority 3: Achieved in all twelve months. Achievement is ongoing, and monitoring is in place.

100%

95%

90%

85%Apr May Jun Jul Aug Sept Oct Nov Dec Jan Feb Mar 2009/10

% of admissions assessed through a gatekeeping process

% admission gatekept by CRHT90% target

Our priorities for Quality Improvement for 2010/11The Trust has undertaken a wide ranging consultation exercise to determine its quality priorities for the year. This has included discussions with the Board, Council of Members, service users and carers, and our staff. Bearing in mind their input, the quality indicators used in previous years, and the priority areas indicated by Monitor and the Care Quality Commission, the Trust has identifi ed the following quality priorities for the year 2010/11, spanning the three quality themes of Patient Safety, Clinical Quality and Patient Experience. These indicators also form part of the indicator-set used in Part 3 of this Quality Account to report on Quality in 2009/10.

Priority 1: A 3% reduction in AWOL/Absconds/Missing as a percentage of all admissions.

Priority 2: A 3% reduction in slips/trips and falls.

Priority 3: A 10% reduction in medication error incidents related to omitted medicines, medicines recording incidents and the wrong frequency of administration.

Priority 4: Ensuring that all patients who have an inpatient stay in Pennine Care are assessed through a gatekeeping function within the Crisis Resolution and Home Treatment Team.

Priority 5: Ensuring an effective response to complaints.

These priorities have been assessed in terms of their impact and feasibility, as well as their ability to address areas of importance identifi ed by all of our stakeholders. The Council of Members (the elected body holding the Board to account, elected from the wider membership) has been consulted on the Quality Report during its construction, including on the priorities for Quality Improvement.

The priorities form an integral part of the Trust’s Quality Strategy, and have been agreed and signed off by the Trust’s Chief Executive, John Archer, and our Chairman John Schofi eld. Like our priorities, the Quality Strategy and other quality improvement work undertaken by the Trust has involved a wide variety of stakeholders including clinical and support staff from across all services, and the Council of Members.

Performance against our identifi ed priorities is described below:

Priority 1: A 3% reduction in patients going absent without leave (AWOL), absconding and going missing, as a percentage of all admissions.

Current performance:The Trust has seen a 28% decrease in the number of incidents of patients going AWOL, absconding or going missing in 2009/10 compared to 2008/9 (Table 1). However, this fi gure is not an exact like for like comparison due to a change in the way that data was recorded which was made this year. As a result, the target for improvement this year is signifi cantly less, refl ecting a challenging yet realistic target.


How will we track improvement?

The Trust will continue to strengthen its own internal monitoring of absconding and AWOL events and will set its own benchmarking standards as opposed to relying on national average fi gures. We will aim to reduce AWOL and absconding incidences by a further 3% in 2010/2011.

The Trust will also analyse the reported data which will be used to ensure action plans and recommendations to reduce these incidents are performance managed within services.

Areas for improvement:

The Trust has identifi ed a number of patient types who are considered more likely to abscond:

• Absconded during a previous admission – nine times more likely to abscond

• Refusal of medication in previous 48 hours – three times more likely to abscond

• 35 years or under – three times more likely to abscond

• Male – two times more likely to abscond• Diagnosis of schizophrenia – two times more

likely to abscond.The Trust has targeted efforts to reduce AWOLs etc. in these target groups. These types of patients will form the key areas for our improvement efforts in 2010/11.

Actions planned to improve performance:

The Trust has a number of initiatives to work on in the future in order to improve quality in this area. We will continue to implement the research within the Anti-Absconding Workbook (City University, 2003) across all wards. We will also report the data differently to allow us to more effectively monitor incidences across the Trust. These measures include:

• Reporting the total number of events as opposed to displaying them as the percentage of inpatient admissions as this will prevent the possible misinterpretation of the total

Missing 54 32(community patients)

AWOL 462 256(detained patients)

AWOL – not returned from leave 115 159(detained patients)

Absconded 201 95(non-detained patients)

Absconded – not returned from leave 21 70(non-detained patients)

Total 853 612

2008/2009 2009/2010Table 1:

fi gures. For example, under the previous reporting system the monthly data may have been infl uenced by an unusually low or high admission rate for the month, or by long-term patients who may go AWOL or abscond multiple times during a single admission.

• Reporting on the number of events by ward, in order to ascertain any trends.

• Presenting data detailing the absolute number of events linked to single individuals. This will help to both identify patients at increased risk of going AWOL or absconding and will also provide extra information based around the total number of AWOL or absconded patients, not just the individual incidents themselves.

We will continue to use the metrics identifi ed as measures of quality in this area, to report in a way which is consistent in future years.

How will we report this priority?

The Trust will continue to report this priority internally to the Board, and externally in the Quality Account for 2010/11.

Priority 2: A 3% reduction in slips, trips and falls Current performance:

Following guidance from the National Patient Safety Agency (2007), the Trust developed a Falls Prevention Strategy, which aimed to reduce the number of falls across the organisation each year by 3%. Outstanding results were obtained in 2007/2008 with an 18% decrease in falls observed compared with 2006/2007. We further improved on this in 2008/09 when we reported a 21% decrease in falls compared with 2007/08. This meant the Trust had achieved an overall decrease in falls of 35% against the baseline fi gure in the two years since our strategy was initiated, and far exceeded the target identifi ed.

In the 2009/10 reporting period we have reported a small increase of 3% from last year. This is disappointing, and the Trust hopes to ensure a decrease in future as we implement new strategies and continue to highlight this key issue.

The Trust identifi ed the reduction of slips, trips and falls as part of the Patient Safety First Campaign and Tameside Older People’s Service has shown signifi cant success in reducing falls within their inpatient units.

Within the South Division, the Falls Prevention Strategy Group continues to monitor and work towards maintaining the safety of patients in relation to falls.


120

100

80

60

40

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0

Incidents of slips, trips and falls by month 2009/2010

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il 0

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Jul 0

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Jul 0

9

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Service user falls can have signifi cant implications in terms of both human and fi nancial costs. For individual patients, the consequences can range from distress and loss of confi dence, to injuries that cause pain and suffering, loss of independence and occasionally death. These incidents can also bring about feelings of anxiety and guilt for the patients’ relatives and hospital staff.

Financial implications can include incurred costs such as those relating to treatment, increased lengths of inpatients stay, complaints and, in some cases, litigation.

The Trust will work to track improvement using the measures currently in place, reporting as detailed below.


The Trust has identifi ed the following two goals:

• To increase staff awareness in relation to falls prevention

• To reduce the number of slips, trips and falls by 3% per annum.

A signifi cant proportion of falls occur within the Older People’s population and as a Trust a clear priority is to reduce this fi gure in the coming year. In addition, we would like to gain a more comprehensive understanding of staff slips, trips and falls and would like to reduce the number of occurrences by 3%.

Figure 1: Number of slips, trips and falls by month


We will be reporting data for slips, trips and falls in a new way so that we can more effectively monitor incidences in higher risk areas. The new reporting measures include:

• Reporting the total number of incidents instead of displaying them as a percentage of inpatients. The results presented to the Board will also be broken down according to whether they occurred in Adult or Older People’s Services or if they were actually staff falls (Figure 2). This will also prevent the possible misinterpretation of the fi gures that could be skewed by multiple incidents being accountable to a single patient.

• In addition we will also identify any patients or staff involved in multiple incidents, in order to determine if there is particular cause for concern.

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65 and overUnder 65Staff

Figure 2: New reporting mechanism for slips, trips and falls.


The Trust is working towards providing additional training on falls prevention throughout the Trust. This patient safety priority will be monitored through the Integrated Risk and Clinical Governance Group and the recently convened Divisional Governance Groups where information is provided through a monthly dashboard.

In addition, the data indicates that the majority of falls are linked to the Older People’s Services. A thematic analysis was undertaken in Tameside to identify factors linked to increased falls in older people. Following the successful pilot in Tameside, this thematic analysis will be conducted across the Trust to gain a comprehensive data set. The aim of this project is to provide robust information in relation to those at highest risk to develop a bespoke risk assessment tool for use in Older People’s Services.

We will also develop an information leafl et for relatives and carers through the Falls Prevention Strategy Group to help raise awareness and supportive preventative action.


This priority will be reported through the Trust’s Integrated Governance Group as well as at Board level where appropriate, and through service line, divisional, borough and team reports as needed.

Priority 3: A 10% reduction in medication error incidents related to omitted medicines, medicines recording incidents and the wrong frequency of administration. Current performance:

Medicines are a central component in the delivery of high quality healthcare and their effective use contributes signifi cantly to achieving successful outcomes for patients.

A total of 303 medication error incidents were recorded by the Trust in 2009-2010. This was a fall from 510 in 2008-9. Three particularly high categories in which medication errors occurred were as follows:

• 46 (15.2%) related to Omitted medicines (78)• 54 (17.8%) related to Medicines Recording

Incidents (161)• 42 (13.9%) related to Wrong frequency of

administration (158)


Medication error incident statistics will be reviewed on a quarterly basis by the Managing Prescribing Risk Sub-group of the Drugs and Therapeutics Committee. This multi-disciplinary group looks at individual incidents and analyses incident trends in order to make recommendations about risk management or training issues following each quarterly meeting. In 2010-11, particular emphasis will be placed on omitted medicines, medicines recording incidents and wrong frequency.

A ‘Learning from medication error incidents’ bulletin will continue to be produced on a quarterly basis and circulated throughout the Trust in order to disseminate fi nding and share learning.


The medication error incidents specifi ed have been selected as areas for improvement for the following reasons:

• Omitted medicines (78) In February 2010 the National Patient Safety

Agency (NPSA) issued a rapid response report entitled ‘Reducing harm from omitted and delayed medicines in hospital’. The Trust is therefore required to work on reducing the risks associated with omitted or delayed medicines.

• Medicines recording incidents (161) and wrong frequency of administration (158)

In 2009-2011 these two categories of incidents accounted for the largest percentage of medication error incidents and hence are considered a priority.


An assessment of prescribing competence for all junior medical staff will be formalised and introduced in 2010 and will form part of the Trust Medicines Management Induction Process.

Updated medicines management training will be introduced in early 2010 and this will include training on the reporting of medication error incidents and Adverse Drug Reactions.

There will be a review of the uptake and use of the Registered Nurse Competency Appraisal Framework for the Safe Administration of Medicines.


The Managing Prescribing Risk Group will report on all medication error incidents, but particularly those in the specifi ed categories, to the Drugs and Therapeutics Committee and the Risk and Clinical Governance Committee.

The Learning from Medication Error Incidents bulletin will focus on the fi ndings and learning from the specifi ed categories.

An end of year update will be written for the Quality Account report next year.

A reduction in these categories will form the basis of our efforts to reduce errors in the future.

350

300

250

200

150

100

50158 - Wrong

Frequency (inc.giving twice)

78 - Omitted Medicine/ Ingredient

Other 15 Categories

Apr 09 - Mar 10Apr 08 - Mar 09

161 - Meds Recording Incident


Priority 4: All patients that have an inpatient stay in Pennine Care would have been assessed through a gatekeeping function within the Crisis Resolution and Home Treatment Team. The Trust’s target is to ensure that 90% of all admissions are gatekept by Crisis Resolution and Home Treatment teams. Current performance over the last year can be seen from the graph below:


This year the Trust has continued the weekly monitoring of gatekeeping, in order to gain a fuller understanding of any issues in the quickest possible time. This has resulted in an increase in performance this year. The Trust intends to continue to track improvements in this way.

Identifi ed areas for improvement

The Trust will continue to strive to improve arrangements for those patients admitted to Pennine Care wards who reside out of the Trust’s footprint.

Administrative procedures have been strengthened within teams to ensure that the

correct protocols are followed and that all activity is appropriately recorded. The Trust will also ensure greater effi ciency in inpatient beds to improve the patient experience by offering more care at home.

Actions planned to improve performance

The further development of the Trust’s Access and Liaison function will create new challenges for those seeking to ensure gatekeeping for all patients. It is hoped that work towards a common single point of entry for the Trust will enhance the

100%

95%

90%




gatekeeping function and improve performance still further. Increased training will be provided to staff and managers within teams responsible for gatekeeping patients to ensure that the procedures are followed appropriately and that patients receive the best care.


The Trust will continue to report this priority through existing Trust structures to ensure that operational and strategic staff and managers are aware of issues and can take remedial action where necessary. This includes Work Programme Groups, the Trust’s Service Development Group, borough and team based meetings as appropriate.

Priority 5: Ensuring an effective response to complaints to the Trust Current performance

In 2009/10 the Trust received 147 complaints.

The table below details the percentage of complaints responded to within timescales agreed with the complainant during 2009/10:

Whilst 91% of the complaints responded to during 2009/10 have been responded to within timescales agreed with the complainant, in some of these cases the Trust has had to agree extensions to the original timescale due to delays in the investigation of the complaint. In all cases though, response times are tracked.

The Complaints Department reports on numbers, trends and the location to which complaints relate, including to Board level. These reports are largely based on the single most prominent issue raised in a specifi c complaint and the Borough in which the service complained of was delivered.

In 2009/10, the complaints response times were as follows:

Complaints responded to within timescales agreed with complainants:

Quarter 1 93%

Quarter 2 91%

Quarter 3 89%

Quarter 4 89%

Percentageof complaints 15% 38% 47% responded to

Within 10working days

Within between 11 and 25 working days

In over 25 working days



The Trust will be tracking improvement through monthly, quarterly and annual reporting into the integrated governance structure, reporting on the numbers of complaints received, the main issues raised in those complaints, themes identifi ed and the types of recommendations made.

This will be complemented by training offered Trust wide to staff on how to effectively investigate complaints and feedback provided to Divisional Governance Managers on current complaints status. This will enable a two-way process of handling complaints, learning from them and tracking improvements.

Areas for improvement

The Trust has identifi ed two main areas for improvement in this area:

1) To ensure that all concerns raised by complainants are dealt with in accordance with an agreed action plan with the complainant (which includes timescales and the form of response) and national legislation.

2) To ensure that the Trust maximises the opportunity for service improvement offered by complaints, by investigating and identifying areas for improvement and making recommendations to deliver change, and the effective reporting into the integrated governance structure.

Specifi cally, the Trust will strive to meet the following aims to enable it to meet those areas for improvement:

• Quicker response times to complaints, delivered primarily through the timely investigation of complaints received;

• More effective information reporting, including more specifi c information about the issues raised in complaints, the areas of the Trust that they relate to and the complaints

investigation performance of the different Divisions; and

• Maximising the learning taken from complaints through the making of recommendations and the monitoring of their implementation.

Actions planned to improve performanceNext year, the Trust plans a number of specifi cactions to meet the stated aim in relation to complaints include:

• Training to be revised to emphasise the need for the timely investigation of complaints and the making of effective recommendations.

• From April 2010, more precise recording and reporting of the issues raised in complaints, including all of the concerns raised in each complaint, not just the main concern.

• From April 2010 detailed reporting on Divisional performance in relation to investigation times. This will include the reasons for any delays in responding within the requested timescale, thereby allowing for the identifi cation of problems and improvement of response times.

• A review of the Trust’s Complaints Policy to be undertaken in 2010 to ensure that it refl ects best practice and offers support to Trust staff in meeting the stated aim in relation to complaints.


The Trust will continue to report numbers, reasons and types of complaints to Board level to allow a strategic view on quantity. Qualitative responses will be formulated and reported corporately through the Trust’s Integrated Governance Group, and service line groups across the Trust, down to borough and team level as appropriate.

Statements of Assurance from the BoardDuring 2009/10 Pennine Care NHS Foundation Trust provided one NHS service.

Pennine Care NHS Foundation Trust has reviewed all the data available to us on the quality of care in one of these NHS services.

The income generated by the NHS services reviewed in 2009/10 represents 100% of the total income generated from the provision of NHS services by the Pennine Care NHS Foundation Trust for 2009/10.


Number Title of Audit Led by Numbers of cases Notes (Nationally) submitted as a percentage of cases required

448 National Health Funded by DOH N/A Audit did Promotion in and supported by not commence Hospitals (NHPH) Royal College of Nursing

Privacy and Part of Essence N/A Audited as part Dignity of Care of Essence of Care programme

2009 015 POMH Topic 1 Royal College 100% 82 cases Prescribing high of Psychiatrists required, dose and combined 82 submitted antipsychotics (82 data sets)

2009 POMH-UK Royal College 100% Topic 8 Medicines of Psychiatrists reconciliation

2009 016 POMH Topic 2 Royal College N/A Report not yet Assertive outreach - of Psychiatrists received by Trust screening for side effects of antipsychotics

2009 021 National Audit of Royal College N/A Report not yet Continence Care (NACC) of Physicians received by Trust

Information on participation in clinical audits and national confi dential enquiries During 2009/10 fi ve national clinical audits and no national confi dential enquiry covered NHS services that Pennine Care NHS Foundation Trust provides.

During that period, Pennine Care NHS Foundation Trust participated in 100% of national clinical audits and 100% of national confi dential

enquiries of the national clinical audits and national confi dential enquiries which it was eligible to participate in.

The national clinical audits and national confi dential enquires that Pennine Care NHS Foundation Trust participated in, and for which data collection was completed during 2009/10, are listed below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

2009/2010

The reports of two national clinical audits were reviewed by the provider in 2009/10 and Pennine Care NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

Audit Name: POMH-UK Topic 8 Medicines

The Trust has made ‘Medicines Reconciliation’ a topic at the recent Quality Matters event that was held to highlight quality initiatives and priorities. A workshop was held which informed a variety of practitioners from across the Trust about improvements necessary to practice to implement the necessary changes.

Progress against this audit is being monitored through the Trust’s Drugs and Therapeutics Committee.

Audit Name: POMH Topic 2 Assertive outreach - screening for side effects antipsychotics

The report for this audit is to be written externally, and is not yet due. Once the report is received

from the Royal College of Psychiatrists, an action plan will be developed.

The reports of 25 local clinical audits were reviewed by the provider in 2009/10 and Pennine Care NHS Foundation Trust intends to take actions to improve the quality of healthcare provided as detailed in the reports, available on request from Planning and Modernisation, Trust Headquarters, 225 Old Street, Ashton-under-Lyne, OL6 7SR.

A selection of actions are detailed below, full reports are available on request from the above address.

Action Co-ordinator Timescale

Feedback results to EIT at team meeting CPN Care Co-ordinator June 2009 to raise awareness of NICE guideline standards

Prioritise, assess and offer those clients CBT Therapist September 2009identifi ed for CBT and FI

Develop data front cover for client case notes Asst. Psychologist September 2009

Develop audit pro-forma based on updated Asst. Psychologist April 2010NICE guidelines for schizophrenia (2009)

Re-audit based on new criteria CPN Care Co-ordinator May 2010

Audit Name: Adherence to the NICE Guidelines for Schizophrenia in relation to CBT and Family Intervention Audit Number: 405


Audit Name: Clinical Audit of Section 136 of the Mental Health ActAudit Number: 421

Audit Name: Clinical Audit of Suicide Prevention: April 2009 to September 2009


Audit results to be taken to Mental Health Law Mental Health June 09 Scrutiny Group and Mental Health Law Forums Law Manager

Police Liaison offi cers to highlight importance Mental Health June – July 09 of recording time of leaving on Part A of the Law Forums form to provide data for length of time they have spent on site

New Section 136 Policy to be distributed with Mental Health August 2009 audit results Law Manager

Trust to consider using the Royal College of Mental Health November 2009 Psychiatrists Report on Standards of the Use Law Manager of Section 136 (CR149) to carry out a pilot in one borough

Re-Audit Mental Health August 2010 Law Manager


For a detailed action plan regarding the standards, see the Suicide Prevention and Self-Harm Working Group Action Plan

Continue to audit six-monthly Clinical Audit Department Ongoing

Changes made to the SPA audit tool after Clinical Audit Department Ongoing discussion at the Working Group to update and simplify the tool to make completion easier – continue to review and monitor

Audit Name: Mental Capacity Act Audit Number: 446

Audit Name: Tribunal Service: Mental HealthAudit Number: 447


To review the Trust’s Mental Capacity Act Mental Health December 2009 guidance to ensure that staff are appropriately Law Manager recording the application of the Mental Capacity Act.

Re-audit Mental Health 2010 Law Manager


Introduce a system for MHL Offi ces to fl ag any Deputy Mental Health September 2009 tribunals extending beyond an eight week turn- Law Manager around to the Deputy Mental Health Law Manager

Review the process and deadlines for processing Deputy Mental Health November 2009 hearings, include the request to Responsible Law Manager Clinicians for dates, offering dates to solicitors and forwarding these to the Tribunal Offi ce

Review the inputting of hearings on to the Deputy Mental Health October 2009 Registers to ensure standardisation across Law Manager the Trust

Results to be considered by: Mental Health Law Manager/ October 2009 Mental Health Law Scrutiny Group Governance Managers/ Mental Health Law Forums Deputy Mental Health Consultant Groups Law Manager Mental Health Law Administrators Meeting

Re-Audit Mental Health Law Manager August 2010

The Trust undertakes a programme of local audit on clinical performance which is reported to the Board of Directors.


Information on participation in clinical research The number of patients receiving NHS services provided or sub-contracted by Pennine Care NHS Foundation Trust in 2009/10 that were recruited during that period to participate in research approved by a research ethics committee is approximately 123.

This fi gure includes a degree of uncertainty due to the nature of the research that the Trust undertakes. Whilst we do keep a record of locally approved research in accordance with the Research Governance Framework, we do not have up-to-date recruitment fi gures for all of these projects.

This cause of uncertainty is primarily in the case of student or other externally managed research, which constitutes the majority of Pennine Care’s work. We have been able to provide recruitment data for approximately 62% of the research projects recruiting in the 2009/10 period. We feel this is a fairly proportionate refl ection of our total recruitment for that period.

Pennine Care is, however, currently re-evaluating its existing research systems and processes and introducing new, robust ones in order to be better equipped to provide this and other quantitative data in the future. This shift in working practices will also enable us to exceed legislation and governance requirements and move towards achieving best practice.

Our new research strategy is to help the Trust develop as a leader in high-quality mental health research by engaging with existing and potential researchers, and promoting research that benefi ts our service users. We plan to achieve this by actively developing relationships with our own staff who have a research interest, thus enabling them to fi rst participate in research and ultimately

develop their own projects. We hope that this locally initiated research could be a direct driver for service improvement and patient care, both in Pennine Care and in the wider mental health arena.

The Trust is committed to continuous improvement, and embraces a model of clinical leadership which uses clinical audit to benchmark practice and inform change.

Clinical audit has an important role within the Trust. It is embedded within the clinical governance structure and is important in ensuring the quality of services and patient safety across the Trust. The Trust encourages all healthcare professionals, including clinicians, nurses, social workers, psychologists and occupational therapists, to participate in clinical audits and provides training to ensure that individuals are equipped with the skills required to conduct audits. As part of the clinical audit strategy, the Trust aims to signifi cantly increase the number of audits conducted annually by 2010.

Clinical audit is monitored and supported centrally by the Clinical Audit Department, The Clinical Audit Department works closely with all departments within Integrated Governance, including Pharmacy, Risk and Mental Health Law and oversees the development of all audits initiated by the various departments. In addition, the Trust has nominated Medical Clinical Audit Leads, supported by the Clinical Audit Department, within each borough. The Audit Department also has representation at Divisional Integrated Governance Meetings held within each Division and at the Work Programme Group Meetings at which clinical audit is a standard agenda item.

Clinical audit quality is of the utmost importance. All clinical audits conducted within the Trust

must fi rst receive approval from the Clinical Audit Department. All audits are reviewed in terms of the applicability to the Trust, robustness of the proforma, involvement of service users and adherence to Information Governance procedures. The Clinical Audit Department has developed standard templates which must be used when applying for audit approval and when writing the subsequent audit report. Written approval is only given when the Department is satisfi ed with all aspects of the proposed audit. All audits conducted must be written-up as a formal report using the template provided by the Clinical Audit Department. An action plan must be included in the report if areas for improvement are identifi ed, and audit leads are required to feedback audit results locally. In addition, all reports produced in a given year are published in the Annual Clinical Audit Report which is widely disseminated and made available on the Trust intranet.

The clinical audit cycle is not complete until a re-audit has been conducted as this is used to determine if improvements in services have been achieved. The Audit Department ensures that re-audits are conducted within the timescale detailed in the audit report action plan.

The Clinical Audit Department also has responsibility for conducting audits against National Standards and Guidelines including NICE Guidelines. Within the Trust, there is a dedicated NICE and Clinical Effectiveness Panel that reviews all published guidelines and determines the audit programme for national guidelines accordingly. The NICE and Clinical Effectiveness Panel is chaired by the Medical Director and is facilitated by the Clinical Effectiveness Manager to ensure continuity in the conduct of clinical audit.

The Trust strongly promotes locally led audits initiated by various healthcare professionals, but

in addition, the Trust also develops and publishes an Annual Clinical Audit Programme, which is managed by the Clinical Audit Department. The yearly Clinical Audit Programme specifi cally addresses national and Trust priorities and is developed in conjunction with all relevant departmental managers, Work Programme Groups and Executive Directors and the Chief Executive. A number of service user-led audits are also included within the Annual Programme. Audit topics are selected at the Service User and Career Forum Meetings, which are held frequently at the Trust. The development of the selected audits is supported by the Clinical Audit Department.

The Trust also participates in and subscribes to other national initiatives, such as the quality improvement programmes run by the Prescribing Observatory for Mental Health (POMH-UK). The programmes that the Trust participates in comprise a cycle of clinical audit against evidence-based standards and bespoke change interventions, including prompt feedback of benchmarked data that allow our Trust to compare their prescribing practice with other participating Trusts. As a Trust, we are also taking part in the National Continence Care Audit, led by the Royal College of Physicians, and the National Audit of Psychological Therapies for Anxiety and Depression, led by The Royal College of Psychiatrists.


Information on the use of the CQUIN FrameworkCommissioner Quality scheduleA proportion of Pennine Care NHS Foundation Trust’s income in 2009/10 was conditional on achieving quality improvement and innovation goals agreed between Pennine Care NHS Foundation Trust and any person or body they entered into a contract, agreement or arrangement with for the provision of NHS services, through the Commissioning for Quality and Innovation payment framework.

Further details of the agreed goals for 2009/10 and for the following 12 month period are available on request from the Trust at: Pennine Care NHS Foundation Trust, 225 Old Street, Ashton-under-Lyne, OL6 7SR.

In 2009/10, £966,122 was contingent on performance against the range of indicators below. The Trust received £966,122 as a result of its performance. Further information on the fi nancial performance of the Trust is available within the Annual Accounts.

These standards have been based on quality indicators outlined in the mental health model contract and some locally driven indicators. The areas of focus are outlined below:

• Care Planning – allocated care coordinator, recorded employment and accommodation status

• CAMHS service improvements• Privacy and Dignity and the elimination of

mixed sex accommodation• Physical Health and Well-being of patients• Improvements to services for people with

Learning Disabilities• Improvements to Older People’s Services

• Increasing Access to Psychological Therapies• Implementing the Productive Ward

Programme• Improvement to A&E waiting time performance• Reduction in voluntary inpatient admissions• Collaborative service improvements in

conjunction with PCTs• Improving the service user experience• Ensuring that wider contractual and

performance improvement measures are achieved.

Information on registration with the Care Quality CommissionPennine Care NHS Foundation Trust is required to register with the Care Quality Commission and its current registration status is “Registered”. Pennine Care NHS Foundation Trust has no conditions on registration.

The Care Quality Commission has not taken enforcement action against Pennine Care NHS Foundation Trust during 2009/10.

Pennine Care NHS Foundation Trust is subject to periodic reviews by the Care Quality Commission and the last review was on 31st March 2009. The CQC’s assessment of Pennine Care NHS Foundation Trust following that review in the Annual healthcheck resulted in the Trust achieving “Excellent” in Quality of Services and “Excellent” in Use of Resources.

Pennine Care NHS Foundation Trust intends to take the following action to address the points made in the CQC’s assessment:

• Improvements to performance against CAMHS performance indicators

• Improvements to performance indicators in the Green Light Toolkit for Learning Disabilities.

Pennine Care NHS Foundation Trust has made the following progress by 31st March 2010 in taking such action:

• Improvements to performance against CAMHS performance indicators including enhanced reporting links from CAMHS to Board level within the Trust, and a greater focus on highlighted improvement areas.

• Improved scores against the Green Light toolkit for Learning Disabilities. This has been achieved through the establishment of a Trust Learning Disabilities working group, and through the enhancement of links to local PCTs for the better provision of LD services.

Pennine Care NHS Foundation Trust has not participated in any special reviews or investigations by the CQC during the reporting period.

Response to regulatorsPennine Care NHS Foundation Trust’s recent declaration to the Care Quality Commission indicated our compliance with all of the core standards in the Annual Health Check and the regulations required by the registration process. The latest Healthcare Commission ratings placed the Trust amongst the top performers for mental health services in the country, scoring “Excellent” for quality of services and “Excellent” for Use of Resources.

Use of the Care Quality Commission’s Registration and Quality and Risk profi leThis year for the fi rst time, the Trust has to register its services with the Care Quality Commission, indicating how it meets 16 regulations from the Health and Social Care Act.

We have had to register all our services against the following regulations and assess our own compliance with the outcomes underpinning each of these.

Section 1: Involvement and information• Respecting and involving people who use services• Consent to care and treatment• Fees etc.

Section 2: Personalised care, treatment and support• Care and welfare of people who use services• Meeting nutritional needs • Cooperating with other providers.

Section 3: Safeguarding and safety• Safeguarding people who use services from abuse• Management of medicines• Safety and suitability of premises• Safety, availability and suitability of equipment.

Section 4: Suitability of staffi ng• Requirements relating to workers• Staffi ng• Supporting staff.

Section 5: Quality and management• Statement of purpose• Assessing and monitoring the quality of service provision• Complaints• Notifi cation of death of service user• Notifi cation of death or unauthorised absence of a service user who is detained or liable to be detained under the Mental Health Act 1983• Notifi cation of other incidents• Records.


Section 6: Suitability of management• Requirements where the service provider is an individual or partnership• Requirements where the service provider is a body other than a partnership• Requirements relating to registered managers• Registered person: training• Financial position• Notifi cations - notice of absence• Notifi cations - notice of changes.

In addition to these and to support our own process, the CQC have published a Quality and Risk profi le for the Trust. This indicates where we are achieving better, average or worse than other similar organisations against a range of targets, the patient survey and the staff survey.

The new regulations within the Health and Social Care Act 2008 have changed the process in which the Care Quality Commission is assessing compliance within Pennine Care. Through internal assessment we believe there are two areas for improvement in light of the new regulations.

Supporting staffThe Care Quality Commission’s assessment has highlighted that the Staff Survey places Pennine Care slightly below the national average in a small number of areas. It is believed that Pennine Care does support its staff but recognises there is more work to do in communicating with Staff and providing training plans and monitoring managers against these plans. Plans are in place to achieve this, and are detailed within the Trust’s Annual Report.

Healthcare acquired infectionFollowing an inspection from the Care Quality Commission the Trust has implemented a full review of its processes to inspect the quality

of our ward environments. Pennine Care has made signifi cant progress on hygiene and cleanliness and has undertaken a programme of work to ensure that every member of staff is aware of their responsibilities in this area. The Care Quality Commission have re-inspected our wards and agreed that they are now adhere to the code of conduct. Pennine Care, as part of its registration declaration, submitted an action plan of improvement, this is now in place to ensure our wards are meeting and continue to meet the code of practice.

Information on the quality of dataPennine Care NHS Foundation Trust submitted records during 2009/10 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data. The percentage of records in the published data:

• which included the patient’s valid NHS number was:

- 100% for admitted patient care;- 99.9% for outpatient care; and- N/A for accident and emergency care.

• which included the patient’s valid General Medical Practice Code was: - 100% for admitted patient care; - 98% for outpatient care; and - N/A for accident and emergency care.

Pennine Care’s score for 2009/10 for Information Quality and Records Management, assessed using the Information Governance Toolkit, was 83%.

Pennine Care NHS Foundation Trust was not subject to the Payment by Results clinical coding audit during 2009/10 by the Audit Commission.

Part 3: Other InformationReview of Quality Performance in 2009/10

Current view of the Trust’s position and status for qualityDuring 2009/10, the Trust has made a large amount of progress with regard to quality. This has focussed on two key pieces of work, namely the Integrated Governance Quality Indicators and the development and agreement of ‘Quality Matters’ – a quality improvement strategy 2009-14.

Integrated Governance Quality IndicatorsAt the beginning of 2009/10, a range of indicators were agreed by the Board of Directors as our fi rst ‘quality account’ measures. These indicators were debated at both clinical and board level with a range of improvement work streams attached to them. It was agreed that these would be monitored on a monthly basis by the Board of Directors. These indicators are:

Patient Safety• Patients going absent without leave,

absconding, or going missing• Self harm incidents• Slips, trips and falls• Medication errors• Physical assaults reported against staff

(PARS).

Clinical quality• Delayed transfers of care• CPA seven day follow up• Crisis Resolution Home Treatment

gatekeeping for all referrals• Privacy and Dignity Improvement Plan

• Grade 4 and 5 incidents• Mental Health Act Admissions• Items on the Trust Risk Register

Patient experience • Complaints• Compliments• Infection Control• Investigations• Coroners investigations• LitigationFor some of these we have generated internal improvement targets and for others it has been about improving the data or monitoring trends, with the expectation that these will inform targets in the future.

For the purposes of this Quality Account, the information below indicates the Trust’s performance against some of these indicators, covering the themes of Patient Safety, Clinical Quality and Patient Experience. The indicators reported this year have changed from last year. This refl ects the Trust’s work to widen the scope of its quality improvements, refl ecting the consultations that we have had with our partners, members and other stakeholders. The range of indicators reported this year is wider than last year, and is more extensive.

Quality MattersThe second key work stream has been the development and agreement of our quality strategy, ‘Quality Matters’. We took a decision to use this as an opportunity to build on our clinical engagement work. The development of the strategy involved a wider range of consultant, nursing and practitioner staff. A wide range of service users and carers were also involved in thinking about and defi ning which quality indicators would make a real difference to the care they received.


The priorities for 2009 – 2011 in the strategy are:

• Staff Learning and Organisational Development

• The Productive Ward Programme• Physical Health and Health Promotion• Medicines Management• Standardised Clinical Risk Assessment

The strategy also establishes how future quality improvement priorities will be developed and link into the business planning cycle.

In addition to the strategies outlined above, we have also made signifi cant progress on the following:

• We have continued to make good progress in improving single-sex wards and gender separation. The Trust has already invested signifi cantly in this area and complies with both single gender and privacy and dignity standards. The Trust recognises the ongoing work required to ensure that our patients receive services in line with this. In order to support this work, we have also developed a monthly patient survey on the wards around patients feeling safe and how gender separation is being managed.

• Increasing awareness and compliance with hygiene and hand-washing improvements have continued across the Trust, supported by our Infection Control Nurses and Modern Matrons. Work has also commenced across all wards to continue to improve cleanliness and hygiene following a visit by the Care Quality Commission, which found some areas in need of improvement. The numbers of infections continue to remain low, the Board of Directors receives monthly update on compliance with the Hygiene Code.

• Improving Health and Safety on wards continues to be a top priority for our wards and capital programme. A signifi cant replacement programme of windows across our estate has been completed to ensure security, minimal ligature risk and also bring more natural light into our wards areas.

• The Trust has once again met all of its Core Standards, and has been scored “Excellent” for the quality of its services by the Care Quality Commission.

Launch of the Making Connections Not Assumptions Project, set up to address service diffi culties in meeting the needs of older South Asian women with mental health problems.

Review of Patient Safety Indicators 2009/10Priority 1: Patients going absent without leave (AWOL), absconding, and going missing Description of issue and rationale for prioritising:

Improvements to the levels of AWOLs has been identifi ed as a key quality measure for the Trust.

The current measurement of this target includes a range of people, some of whom genuinely abscond, but others of whom are late returning from leave. Work this year has concentrated on introducing the AWOL toolkits to all wards and improving the quality of the data.

At Pennine Care the following defi nitions are used to describe incidents of unauthorised absence:

• The term ‘AWOL’ or ‘absent without leave’ refers to any inpatient detained under the Mental Health Act, who either leaves the ward without permission or who fails to return to the ward after a period of leave.

• The term ‘absconding’ refers to any other inpatient (i.e. not detained under the Mental Health Act) who either leaves a ward without permission or who fails to return to a ward after a period of leave.

• The term ‘missing’ is used to describe those patients who go missing whilst in the community.

AWOL and absconding incidences from acute inpatient psychiatric wards are a signifi cant clinical problem that can place patients and others at risk, as well as being burdensome and anxiety provoking for staff. The negative consequences of going AWOL or absconding are numerous and can include violence, aggression, self neglect, prolonged treatment

time and hospital stays and substantial fi nancial implications. In addition, research informs us that about a quarter of inpatients who commit suicide do so after going AWOL or absconding and on very rare occasions there have been homicides by patients in this group (Bowers, 1999). Police resources must also be considered, as about half of all these cases are reported to the police, who then have to invest time and personnel in trying to return patients to hospital (Bowers, 1999).

Aim/goal

To reduce the level of patients going Absent Without Leave (AWOL), missing or absconding during the year.

Current status

AWOL and absconding incidences represent a key safety and patient experience improvement area across the Trust. We are committed to understanding and implementing preventive initiatives to reduce the rates of such incidents. We rigorously measure all AWOL and abscondment events on a monthly basis (Figure 1) across the Trust to ensure that we are able to detect any increases or abnormalities which we need to act upon. Currently, we use a national average abscondment rate derived from The Healthcare Commission report ‘The Pathway to Recovery’ to measure our performance at a national level.


*Data correct as at January 2010

In comparison to 2008/09, in 2009/10 we have observed at 27% decrease in the number of incidents of patients going AWOL, absconding or going missing (below).

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

AWOL/absconded/missing

% of admissionsNational average (27%)

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Missing 54 32(community patients)

AWOL 462 256(detained patients)

AWOL – not returned from leave 115 159(detained patients)

Absconded 201 95(non-detained patients)

Absconded – not returned from leave 21 70(non-detained patients)

Total 853 612

2008/2009Table 1 2009/2010

Figure 1:Identifi ed areas for improvement

The Trust will continue to strengthen its own internal monitoring of absconding and AWOL events and will set its own benchmarking standards as opposed to relying on national average fi gures. We will aim to reduce AWOL and absconding incidences by 3% in 2010/2011.

The Trust will also analyse the reported data which will be used to ensure action plans and recommendations to reduce these incidents are performance managed within services.

Current initiatives

The Trust has monitored the impact of the implementation of the toolkit and continues to manage performance improvement.

Pilot sites have been implementing the Anti-Absconding Workbook (City University, 2003). The focus has been on awareness of certain high-risk patient groups:

• Absconded during a previous admission – nine times more likely to abscond

• Refusal of medication in previous 48 hours – three times more likely to abscond

• 35 years or under – three times more likely to abscond

• Male – two times more likely to abscond• Diagnosis of schizophrenia – two times more

likely to abscondThe outcomes of these initiatives are being monitored by the Divisional Integrated Governance Groups and the Integrated Governance Group.

New initiatives

The Trust has a number of initiatives which it will work towards in the future in order to improve quality in this area. We will continue to implement the research within the Anti-Absconding Workbook (City University, 2003) across all wards. We will

also report the data differently to allow us to more effectively monitor incidences across the Trust. These measures include:

• Reporting the total number of events as opposed to displaying them as the percentage of inpatient admissions as this will prevent the possible misinterpretation of the total fi gures (Figure 2). For example, under the previous reporting system the monthly data may have been infl uenced by an unusually low or high admission rate for the month, or by long-term patients who may go AWOL or abscond multiple times during a single admission.

• Reporting on the number of events by ward, in order to ascertain any trends.

• Presenting data detailing the absolute number of events linked to single individuals. This will help to both identify patients at increased risk of going AWOL or absconding and will also provide extra information based around the total number of AWOL or absconded patients, not just the individual incidents themselves.

We will continue to use the metrics identifi ed as measures of quality in this area, to report in a way which is consistent in future years.


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AWOL (detained pt)Missing (community pt)Trust target

Incidents of AWOL,abscondment and missing

Figure 2: New method of presenting data relating to AWOL, abscondment and missing patient incidences.

Priority 2:A reduction in self-harm incidentsDescription of issue and rationale for prioritising

Self harm is a very common reason for hospital presentation; the Registrar General’s fi gures for England and Wales for 2003 indicate 170,000 people presented to general hospitals after self- harming. People who have self-harmed represent 4–5% of all A&E attendances, and self harm is one of the top fi ve causes of acute medical and surgical admissions in the UK. It is suggested however that the majority of episodes of self harm never reach the health service. In addition, self harm is often linked to mental health conditions and, as such, is a common occurrence within secondary mental health services, especially in adolescent services.

There is often controversy about the terminology used to describe an act of self harm as defi ned above; disagreements generally revolve around the degree and kind of intent required. Descriptive labels found in literature include deliberate self-harm (DSH), parasuicide, parasuicidal behaviour, non-fatal self-harm, and more pejorative labels like suicide gestures and manipulative suicide

Figure 1: The number of self harm incidents in 2008/09 vs. 2009/10 across the Trust

attempts are present. Use of pejorative labels has been argued to create blame and dislike toward the service user. For the purpose of this report the term self-harm will be used.

Pennine Care recognises that it cannot realistically expect or achieve risk elimination. However, the Trust expects that all efforts will be made to achieve risk minimisation and a reduction in self-harm incidences is a key Trust priority.

Aim/goal

• To increase staff awareness in relation to self-harm and increase reporting

• To reduce the number of self-harm incidences Pennine Care NHS Foundation Trust collates the self-harm fi gures by including all incidents coded as a suspected self-harm attempt, attempted self-harm (no injury), self-harm using medication, self-harm excluding medication and attempted suicide. The data is collected and reported on a monthly basis. The number of self-harm incidences which occurred between April 2008 and March 2009 vs. April 2009 and March 2010 is depicted in Figure 1.

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Trust self harm incidents 2008 - 2010


Factors infl uencing the number of self-harm incidences

The number of incidences which have occurred since July 2008 is infl uenced by the opening of the Hope Unit. The Hope Unit is a 12-bedded ward providing acute, short-term intensive, inpatient assessment and treatment for young people with severe acute mental illness or psychiatric disorder, for whom enhanced community treatment is no longer viable or safe. The target age group for service users is predominantly 16–17 years old and the service is managed through the CAMHS Directorate. Due to the nature of the client population served by this Unit, it is to be expected that there will be an impact on the self-harm fi gures for the Trust. So far there have been 250 self-harm incidents reported from the Hope Unit this year, i.e. since March 2009.


We have made signifi cant progress in relation to raising awareness of self-harm and increasing our reporting of incidences. This has been achieved through internal training and awareness campaigns. However, a priority moving forward is to reduce the number of inpatient self-harm incidences by 5% and community incidences by 3%.

Current initiatives

In order to reduce the incidents of self-harm, annual ligature assessments are conducted in inpatient wards across the Trust. This assesses environmental suicide risks and remedial and preventative action taken where possible. The Trust has installed collapsible curtain/shower rails to reduce ligature points on inpatient units.

All service users who present with threat of, or incidents of self-harm, receive a full risk and psychosocial assessment; the fi ndings of risk assessment of self-harm are documented and an annual audit will be conducted to ensure 100% compliance.

Risk assessment is integral to deciding on the most appropriate level of risk management and intervention with a service user, where the assessor aims to make every effort to achieve harm minimisation. The Trust has introduced STORM training, which is specifi c to self harm to ensure that all relevant staff are competent in identifying individuals at most risk.

New initiatives

A variety of new initiatives are planned for the coming year. These include:

• STORM training, which will be continued to be rolled-out across the Trust.

• The Trust is intending to use information from a thematic evaluation which was conducted within CAMHS to identify common themes in relation to self-harm incidences, e.g. time of event, place of event etc. to implement a number of initiatives to try and reduce self-harm incidences. This includes measures such as introducing various activities for inpatients at time points that are strongly correlated to incidence times.

• Guidelines for the Assessment and Management of self-harm have been developed and will be ratifi ed in April/May 2010. The purpose of the guidelines is to ensure that the Trust adopts a systematic and shared approach to risk assessment and management of self-harm at individual practitioner, team and organisational levels. The new guidelines will be implemented via the Divisional Integrated Governance Groups and the governance structure within the CAMHS Directorate.

Priority 3: A 3% reduction in slips, trips and falls Description of issue and rationale for prioritising

Service user falls can have signifi cant implications in terms of both human and fi nancial costs. For individual patients, the consequences can range from distress and loss of confi dence, to injuries that cause pain and suffering, loss of independence and occasionally death. These incidents can also bring about feelings of anxiety and guilt for the patients’ relatives and hospital staff.

Financial implications can include incurred costs such as those relating to treatment, increased lengths of inpatients stay, complaints and, in some cases, litigation.

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Aim/goal

• To improve the patient experience for older people by preventing falls where possible

• To increase staff awareness in relation to falls prevention

• To reduce the number of slips, trips and falls by 3% per annum.

Current status

Following guidance from the National Patient Safety Agency (2007), the Trust developed a Falls Prevention Strategy, which aimed to reduce the number of falls across the organisation each year by 3%. Outstanding results were obtained in 2007/2008 with an 18% decrease in falls observed compared with 2006/2007. We further improved on this in 2008/09 when we reported a 21% decrease in falls compared with 2007/08.


This meant the Trust had achieved an overall decrease in falls of 35% against the baseline fi gure in the two years since our strategy was initiated, and far exceeded the target identifi ed.

In the 2009/10 reporting period we have projected a small increase of 3% from last year, based on projected fi gures for the 11 months of data available. Whilst it is disappointing not to have a decrease, the Trust predicts falls will continue to decrease in future as we implement new strategies and continue to highlight this key issue.

The Trust identifi ed the reduction of slips, trips and falls as part of the Patient Safety First Campaign and Tameside Older People’s Service has shown signifi cant success in reducing falls within their inpatient units.

Within the South Division, the Falls Prevention Strategy Group continues to monitor and work towards maintaining the safety of patients in relation to falls.


A signifi cant proportion of falls occur within the Older People’s population and as a Trust, a clear priority is to reduce this fi gure in the coming year. In addition, we would like to gain a more comprehensive understanding of staff slips, trips and falls and would like to reduce the number of occurrences by 3%.

Current initiatives

A thematic analysis was undertaken in the Tameside Older People’s Unit to identify factors linked to increased falls in older people. The information obtained was used to develop a comprehensive falls prevention training package, which has been rolled out in many areas of the Trust.

New initiatives

We will be reporting data for slips, trips and falls in a new way so that we can more effectively monitor incidences in higher risk areas. The new reporting measures include:

• Reporting the total number of incidents instead of displaying them as a percentage of inpatients. The results presented to the Board will also be broken down according to whether they occurred in Adult or Older People’s Services or if they were actually staff falls (Figure 2). This will also prevent the possible misinterpretation of the fi gures that could be skewed by multiple incidents being accountable to a single patient.

• In addition we will also identify any patients or staff involved in multiple incidents, in order to determine if there is particular cause for concern.

The Trust is working towards providing additional training on falls prevention throughout the Trust. This patient safety and experience priority will be monitored through the Risk and Clinical Governance Group and the recently convened Divisional Integrated Governance Groups where information is provided through a monthly dashboard.

A thematic analysis was undertaken in Tameside to identify factors linked to increased falls in older people. Following the successful pilot in Tameside, this thematic analysis will be conducted across the Trust to gain a comprehensive data set. The aim of this project is to provide robust information in relation to those at highest risk to develop a

bespoke risk assessment tool for use in Older People’s Services.

We will also develop an information leafl et for relatives and carers through the Falls Prevention Strategy Group to help raise awareness and supportive preventative action.

Figure 2: New reporting mechanism for slips, trips and falls

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Priority 4: A reduction in medication errors Description of issue and rationale for prioritising

Medicines are a central component in the delivery of high-quality healthcare and their effective use contributes signifi cantly to achieving successful outcomes for patients. The effective use of medicines is usually the mainstay of treatment in patients with severe mental health illness, and is known to signifi cantly reduce the risk of relapse and to improve quality of life when used appropriately.

The Trust needs to be able to demonstrate that the systems associated with medicines are of the highest quality and that the staff involved in medicines processes are trained to a high standard.

It is important that all clinical staff have a working knowledge of medicines management and that this knowledge is used to listen to service users and carers about the things that concern them.

In-keeping with the above, the Trust has developed a Competency Appraisal Framework for Registered Nurses around the safe administration of medicines. Following implementation this will be used to improve standards of practice and quality.

Medication errors are patient safety incidents involving medicines in which there has been an error in the process of prescribing, dispensing, preparing, administering, monitoring, or providing medicine advice, regardless of whether any harm occurred.

This is a broad defi nition and the majority of medication errors do not result in harm. However, some do have the potential to cause harm and are often termed ‘near misses’.

Reducing medication errors improves the patient experience and reduces the risk of a patient being harmed and it is acknowledged that the complexity of care pathways in mental health services increased the potential for medication errors.

An agreed 10% reduction target has been set for the number of medication error incidents in specifi ed categories across the Trust and there will be an on-going programme to reduce incidents and improve the quality of reporting.

Aim/goal

• To optimise the use of medicines by promoting effective and evidence-based clinical practice and effective risk management

• To enable patients to make the best possible use of medicines

• To meet the needs of individual patients, to increase accessibility and to ensure the highest possible standards in all aspects of medicine use.

The Trust’s Medicines Management Strategy 2009-2011 identifi es key actions that the Trust will take to ensure that the goals are met and that the systems associated with medicines are of a high quality.

Current status

The three identifi ed categories of medication error for the year were:

• Category 78 – Omitted Medicines

• Category 152 – Patient Identifi cation

• Category 158 – Wrong frequency or time of administration of medicines

At 31st March 2010 the Trust had recorded 103 medication errors against the three codes concerned. This compared to 169 errors in the year to 31st March 2009.

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• Successful implementation and roll out of the Registered Nurses Competency Assessment Framework and improved and enhanced medicines management systems.

• A 10% reduction in medication related errors within a year of implementation of our quality improvement strategy in the following categories:

- Patient identifi cation (code 152) - Wrong frequency or time of

administration (code 158) - Omitted medicine (code 78).

Current initiatives

The medication error incident statistics are reviewed on a quarterly basis by a Sub-group of the Drugs and Therapeutics Committee. This multi-disciplinary group looks at individual incidents and analyses incident trends in order to make recommendations about risk management or training issues following each quarterly meeting.

A ‘Learning from Medication Errors’ bulletin is produced and circulated in order to disseminate fi ndings and share learning.

Particular emphasis has been placed on patient identifi cation, wrong frequency or time and omitted medicine incidents in 2009.

In 2009, electronic web based incident reporting was introduced. The system allows coding of errors by both cause and type ensuring increased accuracy in coding and hence learning (NRLS).

In 2009, the Trust became a member of the National Prescribing Observatory for Mental Health (POMH-UK) whose aim is to help specialist mental health Trusts to improve their prescribing practice.

The Trust will continue to subscribe to the POMH-UK national clinical audit programme, which provides valuable information on our performance and allows us to bench-mark ourselves against other mental health Trusts.

In early 2010 quick access to the electronic British National Formulary (e-BNF) was made available on all PCs belonging to the Trust enabling healthcare professionals to use the BNF more easily.

New initiatives

An assessment of prescribing competence for all junior medical staff will be fi nalised in 2010 and this will form part of Trust Medicines Management induction.

A review of all medicines management training will be undertaken which will include training on reporting medication error incidents and Adverse Drug Reaction reporting.

A further three categories of medication error incidents will be selected for a reduction of 10% during 2010-2011.

Priority 5: A reduction in physical assaults against staff (via Physical Assaults Reporting System)Description of issue and rationale for prioritising

Physical assaults against NHS staff are a key priority for every Trust, as all employers have a statutory duty to protect their staff from work-related violence and aggression under European legislation. Whilst there is little data around the physical and emotional impact on staff, or the fi nancial impact on Trusts that violent incidents create, it is clear that is an important issue and that identifying and reducing the risks of physical assaults is vital to improving the working lives of our staff.

For Pennine Care as a specialist mental health Trust this issue is particularly important. National fi gures for 2008/09 show that staff in Mental Health Trusts are around eight times more likely to be assaulted than staff in other types of Trust. Within the 75 Trusts identifi ed as incorporating mental health, Pennine Care sits in the top quartile in terms of incidents, although this is largely due to the reporting mechanisms in place within the Trust which lead to a higher number of disclosures.

As such Pennine Care has developed strategies and initiatives as detailed below.

Aim/goal

• To reduce the incidence of physical attacks against staff

• To improve the working lives of staff by promoting safer therapeutic practice and environments.

Current statusPennine Care recorded 804 incidents in 2008/09, an increase of approximately 5% from

PARS (assaults on staff)

100

80

60

40

20

0Apr 09 May 09 Jun 09 Jul 09 Aug 09 Sept 09 Oct 09 Nov 09 Dec 09 Jan 10 Feb 10 Mar 10

2007/08. This increase refl ects the opening of additional inpatient facilities and also refl ects the Trust’s continuing work to promote the reporting of all incidents, even those where there has been no signifi cant injury. In the period 2009/10 we recorded 790 incidents, which results in a 2% decrease from 2008/09. The Trust hopes to continue and improve upon this downward trend in the future.


The Trust has identifi ed training and improving the safety of lone working as key areas where improvement initiatives should be focused.

Current initiatives

The Trust is strongly committed to learning from incidents and carries out an ongoing programme of training for staff that includes many important initiatives.

There is a focus on the provision of training in the national course Promoting Safer and Therapeutic Services. This is a bespoke mental health course enabling staff to work collaboratively with service users and cares in determining the causes of


violence in the widest sense (service design, delivery etc).

A primary focus is on safety across all our services and service delivery environments. There have been wider issues explored this year in our primary prevention strategy of the ‘Think’ (safer place to work) Campaign looking at Diversity Issues and Lone Working Safety.

A Lone Working Information Strategy has been produced to support the national roll out and our local pilot of the lone working assistive devices. A dedicated training course has now also been developed for community and lone working personal safety issues.

The organisation is working in a targeted way to sensitively develop bespoke training interventions for areas of higher clinical activity (reporting low risk but high frequency assaults).

Active working links have been created, and representation has been given by the Trust on the CFSMS Expert Reference Group for Non-Physical Interventions.

New initiativesThe Trust continues to support an ongoing programme of safety and security improvements.

A major programme of works has been undertaken across the Trust to provide state-of-the-art nurse call and staff attack alarm systems.

Funding is allocated each year to maintain and improve our security systems, including CCTV, fencing and improvements to lighting. The Trust funds security guard services as required. The Trust encourages a proactive security culture, and we invest in an ongoing programme of Management of Violence and Aggression (MVA) training. We offer de-escalation training to prevent incidents happening in the fi rst place, and meet

national guidelines on the training of staff in confl ict resolution. The Trust provides staff with personal attack alarms on request and at no cost. The ‘Think’ campaign is still actively promoted and there is a multi-agency protocol in place with Greater Manchester Police, Crown Prosecution Services and Greater Manager Trust Chairmen, which supports legal action being taken against perpetrators of assaults.

The Trust ensures that staff who are the subject of physical assault receive immediate assistance, and support. The impact of an assault can cause physical and emotional distress for all concerned, and the Trust aims to provide the right support to respond to these incidents through its staff support service and one-to-one counselling where needed.

Review of Clinical Quality Indictors for 2009/10 The Trust identifi ed a number of Clinical Quality indicators for 2009/10, based on Monitor’s key performance indicators in this area. The indicators also refl ect those reported on in the Trust’s Quality Report 2008/9.

Priority 1: A reduction in delayed discharges to meet the Monitor target of no more than 7.5% delayed dischargesDescription of issue and rationale for prioritising

Improvements to the levels of delayed discharges has been identifi ed as a key quality measure for mental health Trusts.

The Trust has worked hard to build on improvements to discharge arrangements this year so as to minimise delays for patients, and ensure that all service users are treated in a setting appropriate to their needs. Delays in

discharging patients not suited to their present treatment setting can have a negative effect on both the patient concerned and the wider ward environment. As a result, the Trust has worked hard to develop partnerships with fellow providers and to tighten discharge arrangements.

Aim/goal

To maintain a level of delayed discharges at or below 7.5%, and to see an improvement in the delayed discharge fi gures year-on-year.

Current status

The target has been achieved throughout the year, and continues to be achieved.

8%7%6%5%4%3%2%1%0%


% of delayed discharges

% of occupied bed days with delays<7.5% target


The Trust will continue to strengthen its own internal monitoring of delayed discharges, to refi ne processes and further improve. We have implemented signifi cant changes to discharge planning recently, and will continue to work to improve these arrangements.

Partnership working is crucial in reducing delays to discharging patients into the care of partners. The Trust will continue to work to maintain and strengthen partnerships with Secure Commissioners, Local Authorities and others involved in the continuing care of patients.

Current initiatives

The Trust has further refi ned its Trust-wide discharge protocol, and has widened communications throughout the Trust to ensure that discharge information is communicated more effectively. We have also continued to work more effectively with partners to facilitate improved discharge arrangements.

The implementation of the discharge protocol has resulted in a much clearer understanding across all departments of the discharge arrangements necessary to prevent delays, and how to escalate problems to ensure their resolution.

New initiatives

In the year ahead, the Trust will work to further relations with external partners such as Specialist Commissioners to ensure that discharges from Pennine Care to other providers can take place without unnecessary delay.

In addition, new service structures and the re-design of some clinical practices will facilitate smoother discharge planning. Once again the emphasis will be on minimising admissions in the fi rst place, and on reducing delays to discharges by planning for discharges from the point of admission.


100%99%98%97%96%95%94%93%92%


% of inpatients discharged on CPA followed up within seven days

% followed up on CPA95% target

Priority 2: 95% of patients discharged from an inpatient ward must receive a follow up in the community within seven days

Description of issue and rationale for prioritising

Ensuring that patients receive follow-up care after discharge from an acute ward is crucial to aid recovery and prevent relapse or harm.

The Trust has prioritised this area again this year to continue to ensure that effective follow-up care is provided, thus improving the quality of care for patients by trying to ensure a seamless transition from one service to another. Although the patient pathway traverses several of the Trust’s service lines, we are aware that patients make no such distinction, and as a result are striving to perfect joined up working and ensure that quality of care remains high at all stages on the pathway.

Aim/goal

To ensure that 95% of all patients discharged from acute wards receive a follow-up visit within seven days.

Current status

The target has been achieved in all but one month of the year. It was missed by a small amount in

April 2009. Progress was made immediately, and has been maintained since, with the target being exceeded in every month since this date.


Effective recording and monitoring of data and activity will ensure continual improvement in this measure. The Trust will work closely with community teams and their managers to ensure that effective processes are in place to continue to meet and exceed this target.

Current initiatives

No new initiatives have been implemented in 2009 – 10. The Trust has continued to fulfi l its statutory obligations to record and report seven-day follow up visits. Response to trends in performance will continue, targeting increased support and resources as appropriate.

New initiatives

The Trust will work to improve its performance, and also to respond to the increasing drive to ensure a follow-up appointment within a shorter time-frame than seven days. This will involve the appropriate training and targeting of resources to enhance the patient experience.

Priority 3: All patients that have an inpatient stay in Pennine Care would have been assessed through a gatekeeping function within the Crisis Resolution and Home Treatment Team

Description of issue and rationale for prioritising

Crisis Resolution and Home Treatment teams provide intensive care for patients suffering acute episodes of mental illness, in their own home. This reduces the frequency of inpatient admissions, which is benefi cial to the patient who can remain within the community and in a familiar setting. It is also benefi cial to the Trust and wider services because acute inpatient beds are reserved for the most acutely ill, and transfers between community services and inpatient services are lowered.

Aim/goal

To ensure that 90% of all admissions are gatekept by Crisis Resolution and Home Treatment teams.

Current status

This target has been met in every month of the year.

Identifi ed areas for improvementThe Trust will continue to strive to improve arrangements for those patients admitted to Pennine Care wards who reside out of the Trust’s footprint.

100%

95%

90%




Current initiatives

This year the Trust has continued the weekly monitoring of gatekeeping, in order to gain a fuller understanding of any issues in the quickest possible time. This has resulted in an increase in performance this year.

Administrative procedures have been strengthened within teams to ensure that the correct protocols are followed and that all activity is appropriately recorded. This has meant that only the correct issues have been identifi ed, and that responses to them are appropriate

New initiatives

The further development of the Trust’s Access and Liaison function will create new challenges for those seeking to ensure gatekeeping for all patients. It is hoped that work towards a common single point of entry for the Trust will enhance the gatekeeping function and improve performance still further.

Increased training will be provided to staff and managers within teams responsible for gatekeeping patients to ensure that the procedures are followed appropriately and that patients receive the best care.


Review of Patient Experience Indicators for 2009/10 The Trust identifi ed a number of Patient Experience indicators for 2009/10. The indicators reported here arose after the involvement of all stakeholders including staff, FT Members, the Council of Members, and the priorities of our regulators and partners.

Priority 1: A reduction in Healthcare Associated Infections Description of issue and rationale for prioritising

The Trust prioritised the reduction of Healthcare Associated Infections (HCAI) and incidents in relation to Infection Prevention and Control. This was to ensure that we were compliant with Health and Social Care Act 2008: Code of Practice for NHS on Prevention and Control of HCAI.

This issue is considered most important to all stakeholder groups, and is vital to the ongoing improvements to quality that the Trust wants to make. Confi dence in the cleanliness of the hospital environment is a vital part of the patient experience.

Aim/goal

• To continue to reduce the risk of Health Care Associated Infections.

• To ensure compliance with national standards such as the HCAI Code of Practice and Trust Infection Prevention and Control Policies.

• To increase Infection Prevention awareness amongst staff through training programmes and so reduce the number of infection control incidents.

Infections 2008/09 2009/10

MRSA 5 (skin) 3 (skin)

C. diff 2 2

ESBL 1 1

D&V 6 8 (3 Norovirus confi rmed)

There has been a 40% reduction in cases of MRSA reported, no change in C. diff cases and an increase of 25% of reported D&V cases.

Current statusPerformance in 2009/10 and 2008/09 are as follows:

There were 91 Infection Control incidents in 2008/09 and 60 in 2009/10, which is a reduction of 34%.

Needlestick injuries have also reduced by 15% from last year.


A number of areas have been identifi ed that require improvement:

• Structured audit programme, which includes cleanliness of equipment and appropriate use of storage areas

• Cleaning schedules for all equipment• Monitoring of ward environment on a weekly

basis by ward manager• Replacement of old equipment• Audit of hospital mattresses• Further Infection Prevention and Control

training for staff• A further reduction in needlestick injuries

Although there has been a signifi cant improvement in these areas in recent years, there is still some improvement to be made in practice across the Trust, particularly in embedding some of the procedural improvements that have been made.

Current initiatives

The Trust will continue to improve its monitoring systems of Infection Prevention and Control by measuring compliance against The Health and Social Care Act 2008: Code of Practice for NHS on prevention and control of HCAI standards and the Strategic Health Authority Assurance Framework.

Compliance with Pennine Care NHS Foundation Trust Infection Prevention and Control Policies will be monitored by internal audits and unannounced spot-checks of the environment, and matron walkabouts.

Incidents

Cause Code 2008/09 2009/10

148 – Infection Control Incident 20 7

35 – Contact with Bodily Fluids 3 7

36 – Contact with Harmful Substance – Breakage 1 0

37 – Contact with Harmful Substance – Cleaning 2 5

38 – Contact with Harmful Substance – Other 8 3

80 – Needlestick Injury 26 22

92 – Sharps – Disposal 10 5

94 – Sharps – Misc 21 10

99 – Spillages 0 1

91 60


New initiatives

The Trust has a structured plan in place to improve the Infection Prevention and Control Standards and ensure that the environment is clean, safe and well-maintained. In the coming year, the following new initiatives will be taking place:

• Six-monthly audits of inpatient areas (due July 2010)

• One-yearly audits of community units (as from April 2010 – due October 2010)

• Ward managers will inspect the environment and equipment in their wards weekly using a standardised tool

• Matrons will undertake monthly environment inspections with Estates and Domestic Services

• Deputy Director of Nursing & Integrated Governance will undertake a rolling programme of unannounced spot checks of wards

• Infection Control nurses will meet with matrons, estates and domestics monthly to ensure action plans are implemented

• Wards will have nominated Infection Prevention and Control champions

• A Cleaning Schedule has been implemented for all equipment in inpatient areas, this will be monitored via the audit programme

• Commode cleaning guidelines have been introduced

• Training has been implemented for matrons, champions and mandatory training for qualifi ed inpatient staff

• Implement needle safety devices across the Trust.

Priority 2: Effective handling of complaints to the TrustDescription of issue and rationale for prioritising

The effective handling of complaints offers the Trust an opportunity to obtain service user and carer feedback on services and to identify areas for improvement within the services provided and to deliver positive change.

In order for the Trust to take full advantage of the opportunities that complaints offer, it is essential that complaints are dealt with in an effective and timely manner in accordance with the relevant national legislation. Whilst managing complaints in this manner, it is also essential that accurate and detailed information is extracted from the complaints received to enable productive reporting into the integrated governance structure.

The Trust has prioritised this quality indicator as it gives a clear opportunity to assess areas of weakness and improve the experiences of patients. We welcome patient feedback in all its forms, and encourage complaints if patients, carers or others feel that care has not met our high standards. Handling complaints remains a top priority for the Trust.

Aim/Goal

The aim in relation to the Trust’s handling of complaints is two-fold:

1) To ensure that concerns raised by complainants are dealt with in accordance with an agreed action plan with the complainant (which includes timescales and the form of response) and national legislation; and

2) To ensure that the Trust maximises the opportunity for service improvement offered by complaints, by investigating and identifying areas for improvement and making

recommendations to deliver change, and the effective reporting into the integrated governance structure.

Current status

In 2009/10 the Trust received 147 complaints.

The table below details the percentage of complaints responded to within timescales agreed with the complainant during 2009/10:

Whilst 91% of the complaints responded to during 2009/10 have been responded to within timescales agreed with the complainant, in some of these cases the Trust has had to agree extensions to the original timescale due to delays in the investigation of the complaint.

The Complaints Department reports on numbers, trends and the location to which complaints relate, including to Board level. These reports are largely based on the single most prominent issue raised in a specifi c complaint and the Borough in which the service complained of was delivered.

In 2009/10, the complaints response times were as follows:

Quarter 1 93%

Quarter 2 91%

Quarter 3 89%

Quarter 4 89%

Complaints responded to within timescales agreed with complainants:

Percentageof complaints 15% 38% 47% responded to

Within 10working days

Within between 11 and 25 working days

In over 25 working days


Identifi ed areas for improvements

The following areas for improvements have been identifi ed:

• Quicker response times to complaints, delivered primarily through the timely investigation of complaints received;

• More effective information reporting, including more specifi c information about the issues raised in complaints, the areas of the Trust that they relate to and the complaints investigation performance of the different Divisions; and

• Maximising the learning taken from complaints through the making of recommendations and the monitoring of their implementation.

Current initiativesCurrent initiatives to meet the above stated aim include:

• Monthly, quarterly and annual reporting into the integrated governance structure, reporting on the numbers of complaints received, the main issues raised in those complaints, themes identifi ed and the types of recommendations made;

• Training offered Trust wide to staff on how to effectively investigate complaints; and

• Feedback provided to Divisional Governance Managers on current complaints status.

New initiativesNew initiatives to meet the stated aim in relation to complaints include:

• Training to be revised to emphasise the need for the timely investigation of complaints and the making of effective recommendations.

• From April 2010, more precise recording and reporting of the issues raised in complaints,

including all of the concerns raised in each complaint, not just the main concern.

• From April 2010 detailed reporting on Divisional performance in relation to investigation times, including the reasons for any delays in responding within the requested timescale, thereby allowing for the identifi cation of problems and improvement of response times.

• A review of the Trust’s Complaints Policy to be undertaken in 2010 to ensure that it refl ects best practice and offers support to Trust staff in meeting the stated aim in relation to complaints.

Priority 3: Delivering single sex accommodation Description of issue and rationale for prioritising

The Department of Health have clearly articulated their desire to have all organisations delivering the highest standards of privacy and dignity within all areas of a hospital. One element of this agenda was to deliver same-sex accommodation. Pennine Care believe this issue to be of the utmost importance for our inpatient units and therefore prioritised this in 2009/10, after consultation with patients groups, staff and Members.

Aim/goal

Patients at Pennine Care NHS Foundation Trust deserve privacy and they deserve to be treated with dignity. By making these considerations our priority, we are on our way to making patients hospital experience as comfortable as possible, through delivering the Same-Sex Accommodation project.

Our goal is to ensure we meet compliance with Same-Sex standards and develop above and beyond our statutory requirement.

Current status

All of our wards are compliant with Delivering Same-Sex Accommodation and we ensure that patients will sleep in the following:

• In a same-sex ward, where the whole ward is occupied by either men or women only

• In a single room, or • In a mixed ward, where men and women are

in separate bays or rooms.


Plans are currently being developed to achieve our desire to have 100% single bedroom accommodation. 80% of our beds are currently single bedrooms the majority of these have en- suite bathroom facilities.

By the autumn of 2011 we hope to have 90% of our accommodation as single bedrooms.

Current initiatives

In March 2010 we completed the £100,000 Strategic Health Authority project to ensure we had single-sex accommodation throughout our wards and to train and communicate out to our staff. We are pleased that these projects have been completed and we are now analysing the impact on service user perception.

New initiatives

Taking this agenda forward, we will develop our Estates Strategy to incorporate our ward changes and ensure that we comply with privacy and dignity agenda and continue to enhance the patient experience.

Not all of the indicators above are the same as those indicated in 2008/09. The change is due to the signifi cant amount of work with stakeholders and the Board to identify a more complete and relevant set of indicators giving a better picture of the true state of quality and improvements across the Trust.

However, information on performance in 2009/10 against those priorities which were identifi ed in 2008/09 is contained in the Quality Narrative in Section 1 of this report.

Above: David Heyes MP opens the new Etherow Unit, Tameside


Performance against key national priorities and national core standardsWe have chosen to measure our performance against the following metrics, in line with last year:

* % of patients that answered “yes defi nitely” or “yes to some extent”.

** % of patients that answered “Excellent” or “Very Good”.

Performance 2009/10 2008/09 2007/08 Target National Peer GroupMeasures Average Average

Patient Safety

Number of serious and 706 734 598 N/A N/A N/Auntoward incidents

Patients with MRSA 2 0 0 0 N/A N/Ainfection/10,000 bed days

PARS reporting 793 864 803 N/A N/A N/A

Clinical Outcome Measures

7 day follow-up 98% 98% 97% 95% N/A 97.4%

Delayed transfer of care 3.1% 5.7% 12.2% 7.5% 8.2% 12.0%

Gatekeeping 96.9% 99.6% N/A 90% N/A N/A

Performance 2008/09 2007/08 2006/07 Target National Peer GroupMeasures (Continued) Average Average Patient Experience Measures

Patient treated with 97% 99% 98% 98% 98% N/Arespect and dignity*

Support for carers/ 70% 65% 72% 67% 67% N/Afamily*

Quality of care** 60% 58% 58% 58% 58% N/A

Please note: The Trust currently does not benchmark SUI and PARS because of the complexity of the measures. There are 5 grades of SUI and the focus of the Trust’s efforts is on reducing the most serious incidents. Analysis of the increase of SUIs in 2008/09 has found that a major cause has been an increase in out of area patients and those requiring seclusion. For PARS reporting the increase can be attributed to higher reporting rates as a result of a highly publicised staff safety campaign to encourage reporting. It is not believed that there has been a reduction in quality this year.

National averages and peer group averages provided for seven day follow-up and delayed transfers of care were calculated using the original guidance provided by Monitor so are based on occupied bed days excluding home leave.

Gatekeeping monitoring was introduced in April 2008, so data for 2007/08 is not available.

The Trust has its own target of not having any MRSA bacteraemia. There is no national targets for mental health Trusts, the acute Trusts have the targets. Peer wise mental health Trusts would

expect to have very small numbers.

There is no national target for mental health Trusts for incidents of Clostridium diffi cule.

Data source: National average for delayed discharges taken from the Audit Commission Trust Provider Mental Health Benchmarking Club for 2007/08.

Peer group average for delayed transfers of care taken from the North West SHA Mental Health Providers Benchmarking Report for Q3 2007/08.

Peer group average for seven day follow-up taken from the North West SHA Mental Health Providers Benchmarking Report for Q3 2007/08.

National average for patient experience measures is taken from the 2008/09 Patient Experience survey, and target based on the National Average.

The Trust has met and exceeded all Monitor Compliance Framework targets this year, in relation to Delayed Discharges, seven day follow-up, gatekeeping and Crisis Resolution Home Treatment.

The Trust declared compliance with 42 of the 42 Core Standards.

National targets and regulatory requirements

Target 2009/10 2008/09 2007/08 Target National Peer Group Average Average

The Trust has fully met Fully met Fully met Fully met Fully met Fully met Fully met the HCC Core Standards and National Targets

Clostridium diffi cile 2 1 0 N/A N/A N/A year-on-year reduction

MRSA - Maintaining the 0 0 0 N/A N/A N/A annual number of MRSA bloodstream infections at less than half the 2003/04 level

Maintain the level of 9 9 9 9 N/A N/A crisis resolution teams set in the 03/06 planning round


Other additional content relevant to the quality of NHS servicesReview of servicesThe Trust provides services in a range of specialties/areas. The Board has reviewed the available data on the quality of care in these specialties/areas. The board has used the results of this review to develop a plan for improving the quality of the Trust’s services, which has formed the basis for our quality indicators and strategy as described above.

The Trust has continued with a range of ongoing initiatives which are designed to increase the quality of people’s experience of our services across the Trust.

Our commitment to increasing quality through innovation has been evidenced through our re-investment of £1.5m of our surplus into new projects aimed at increasing service quality. This use of opportunities afforded to Foundation Trusts has allowed for over two dozen quality improvement projects to acquire funds for a year of work. These projects included:

• Investing in an electronic records management system

• Improvements to the estate including refurbished bedrooms

• More clinical pharmacists to provide medicines management support to services

• Research into services for adult patients with Asperger’s Syndrome

• Work to better manage the fl ow of patients into and out of inpatient beds

• Additional support for early-onset dementia• A conference for staff with the aim of boosting

the emotional intelligence of the workforce.

Some other examples of our other work to improve the quality of services include:

• The New Ways of Working project, which has been successfully implemented in Oldham and Bury, and which is now being considered for implementation in Rochdale. The practice of consultants either being based on inpatient wards or working within community teams has seen great benefi ts for both service users and staff. Wards have been quieter and better managed with multi-disciplinary team meetings each morning to agree discharge plans.

• Therapeutic programmes have been introduced across the Trust which have supported our service users to get involved in a range educational and leisure activities and really improved the quality of the stay on wards to support recovery.

• Community teams have also seen the benefi t of having medical support, advice and teaching made available through consultants being within the teams. Work has continued on integrating our community services with local authority and third sector opportunities, where these exist.

• Re-investment in our Community teams has seen the commencement of a ‘Transforming Communities’ project aimed at developing enhanced clinical pathways and improved interface between services.

• Access to our services has been simplifi ed and improved with the introduction of a pilot Mental Health Referral Management System in Bury. This pilot scheme involved signifi cant liaison with partners and GPs, will now be rolled out across the Trust to give a single point of entry in each borough for all secondary care mental health services for adults and older people.

• Service users in Middleton will now have

access to seamless care when required, as the Trust has addressed a long-standing service inequality by agreeing with the local commissioner to provide inpatient services to that local community. This will in turn allow for revised community services arrangements for the whole of Heywood, Middleton and Rochdale, benefi tting patients across the borough as a whole.

• There have also been improvements to the quality of specialist service provision this year, with increased business support to enable front-line service delivery staff to concentrate on delivering higher quality services. In addition, the Trust has been working closely with colleagues from the North West Specialist Commissioning Team, and the local PCTs, to identify those patients currently treated out of area (OATs). These patients can in many cases be treated by Pennine Care, closer to home, resulting in a signifi cant increase in the quality of care as well as a fi nancial saving.

Throughout our quality reviews of services we have borne in mind the need to ensure high levels of patient safety, clinical effectiveness and patient experience. Our corporate goals and our mission statement to improve the patient experience refl ect this. Where the amount of data for review has not enabled quality improvements to take place at the rate we would like, improvements to systems and processes have taken place.

Research and innovationThe Trust has an excellent reputation in terms of the delivery of clinical services and is committed to achieving the same reputation in relation to research. The Trust has established a robust research governance structure to ensure that all research undertaken is conducted in accordance with legislation and the Department of Health’s Research Governance Framework.

The Trust actively participates in Mental Health Research Network (MHRN) adopted studies and currently employs two Clinical Study Offi cers who are funded by the MHRN. In addition, during 2008/2009 the Trust has been focusing on developing internal research that has a clear benefi t for patients and has been actively supporting individuals wishing to pursue a career in research. For example, the Trust participates in the Clinical Scholarship Scheme funded by NHS North West, which is designed to provide individuals with the skills required to conduct research. In addition, the Trust has supported NIHR MRes and PhD Scholarship applications.

The Trust is host to NIHR Research for Patient Benefi t grants and is the lead Trust for certain streams of an NIHR Programme Grant linked to the Personal Social Service Research Unit (PSSRU).

The Trust is constantly striving towards innovation and has conducted a number of service evaluations either to evaluate the effectiveness of current services or to gain the evidence-base in relation to the benefi t of innovative services. For example, we are currently evaluating our service dedicated to supporting people with dementia, their families and staff in care homes through a dedicated Community Mental Health Team (CMHT). Due to the innovative nature of this CMHT, we are submitting our fi ndings to the National Care Home Congress and hope to develop a research bid to explore the effectiveness of this service further.

As mentioned above, the Trust is working with its partner commissioners on the CQUIN framework, and has agreed a set of indicators prior to the introduction of CQUIN upon which a proportion of our income is dependent.


AnnexStatement from Commissioning Primary Care Trust

Statement from NHS Heywood, Middleton & Rochdale regarding the Pennine Care NHS Foundation Trust Quality Account 2009/10.

NHS Heywood, Middleton and Rochdale is the lead commissioning body for Pennine Care NHS Foundation Trust and as such has led this review of the Pennine Care Quality Account 2009/10. The review has compared the accuracy of the qualitative information and data contained in the Quality Account with the qualitative information and data provided by Pennine Care, as part of its contractual requirements during the year. The presentation and scrutiny of this information and data in year has been facilitated through the Pennine Care/PCT Sector Quality Group which reports to the Pennine Care Lead Commissioner Group. The Sector Quality Group brings together Pennine Care with its fi ve main commissioners (NHS Bury, NHS Oldham, NHS Heywood, Middleton and Rochdale, NHS Tameside & Glossop and NHS Stockport). Pennine Care has engaged consistently and effectively with the Sector Quality Group thus enabling constructive debate to address gaps and risks and to agree mitigation plans. For example, inaccuracies in data reporting were recently reported to the Sector Quality group by a number of the commissioning organisation members. The details were debated with Pennine Care and improvements were agreed and promptly implemented.

Pennine Care has also worked with the commissioners to devise and implement a bespoke quality schedule in advance of the introduction of the new National Mental Health contract. This has proved invaluable in progressing the quality agenda and has helped to embed a culture of ongoing quality monitoring in readiness for the introduction of the new formal system in 2010/11. The commissioners look forward to developing more comprehensive measures of quality and safety with Pennine Care in 2010/11.

NHS Heywood, Middleton and Rochdale is not required to check data included in the Quality Account that is not part of existing contractual/performance monitoring discussions.

Having considered the contents of this Quality Account, NHS Heywood, Middleton and Rochdale confi rms that it considers that this Quality Account contains accurate information in relation to the services provided to it by Pennine Care during 2009/10.

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quality account...annual report 2009/2010 1 quality account 1st april 2009 – 31st march 2010...

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