south staffordshire and shropshire healthcare nhs foundation trust

South Staffordshire and Shropshire Healthcare NHS Foundation Trust

Combined Complaints, PALS, Incident, Serious Incidents and Claims

Report Quarter 1 2011-12

01 April-30 June 2011

ITEM 8

1

1. Executive Summary

1.1 The NHSLA Risk Management Standards for Mental Health and Learning Disability

Trusts Standard 5 “Learning From Experience” requires Trusts to have in place approved documentation which ensures a systematic approach to the aggregation of incidents, complaints and claims on an ongoing basis. This is to ensure that there is an overarching regular report that links to the continual improvement of patient safety through a combined process for learning lessons.

1.2 South Staffordshire & Shropshire Healthcare NHS Foundation Trust promotes an open

risk reporting culture that fosters both a proactive and reactive approach to managing risk. Those approaches include a systematic process for assessing, reporting and managing risk; monitoring compliance against Care Quality Commission Core Standards and NHS Litigation Authority Risk Management Standards; implementing a range of internal and external audits and the development and maintenance of risk registers and risk treatment plans.

1.3 The Trusts risk management system, known as Safeguard, records data for complaints,

PALS, incidents and claims and is currently being further developed to support systematic reporting and aggregation of risk management data.

Web Based incident reporting is currently being rolled out across the Trust with many

areas now able to report electronically. During quarter one 17.2% of incidents were reported via web based reporting. Connection problems in Shropshire has delayed the roll out, but this is now working and training on in-patient areas has commenced.

This report presented to the Quality, Effectiveness and Risk Committee represents the combined quarterly risk management report on activity for complaints, PALS concerns, compliments, incidents, serious incidents and claims for the period 1 April 2011 to 30 June 2011. This report provides factual data on activity reported during the quarter and highlights any significant clusters and trends that required further investigation and action.

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2. Summary 2.1. Overall Summary of Reported Data by Quarter & Month Figure 1

Summary of Complaints PALS and Serious Incidents

0

10

20

30

40

50

60

70

Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

Total Complaints Total Concerns Total Compliments SIs

Summary of Incidents and SIs

0

100

200

300

400

500

600

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900

Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11

Q2 2010/11 Q3 2010/11 Q4 2010/11 Q1 2011/12

Figure 1 above provides a summary of complaints, PALS concerns, compliments, SIs and Incidents over the last four quarters (1st July 2010 – 30th June 2011).

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• The number of PALS concerns reported during the first 2 quarters has been sporadic, although there was a significant increase in PALS concerns received during quarter 4, there was a slight decrease in quarter 1. There do not appear to be any significant patterns or trends associated with the PALS concerns reported, other than those specifically reported on in Section 4.1. Section 2.2 of this report provides a further comparison of this quarterly data by directorate.

• The number of compliments received during quarters 2 and 3 has also been sporadic, although quarter 4 saw a significant increase; there was a slight decrease during quarter 1. Section 2.2 of this report further details compliments received by directorate for the past 4 quarters and section 4.3 provides a breakdown by directorate for quarter 1.

• The number of complaints received during the last 4 quarters of the year has remained fairly consistent. Section 2.2 provides a breakdown of complaints over the past 4 quarters by directorate and further detail regarding the receipt and outcome of complaints during quarter 4 is provided in section 3

• The number of SIs reported during the last for quarters has remained fairly consistent. There has been a slight increase this last quarter (1) compared with the previous quarter but there is no statistical significance to this rise. Section 2.2 provides a breakdown of SIs by directorate over the past 4 quarters and section 7 provides detail of SIs reported during quarter 1.

• The number of incidents reported during the past 4 quarters has gradually reduced from a peak approaching nearly 800 in July 2010 to around 500 in June 2011. Two directorates account for most of the reduction – Mental Health Shropshire, especially due to the closure of Lime Ward in Autumn 2010 and DNLD particularly due to changes of clientele on Stonefield House and the transfer out of the Trust of services at New Burton House in early Autumn 2010.

Section 2.2. provides further detail of incidents by directorate. Section 5 of this report provides further detail of the top 10 incident categories reported during this quarter with a further breakdown by team for the top 5 reported categories.

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2.2. Summary of Data by Directorate Figure 2

Incidents

2947 49 34

141116 100 99

459

385

283

125

1024

838

728

637

466490

471

551

111138

108 94

0

200

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1000

1200

2010-11 (2) 2010-11 (3) 2010-11 (4) 2011-12 (1)

Corporate Childrens Forensic Learning Disabilities Mental Health Shropshire Mental Health Staffordshire Specialist Services Figure 3

Serious Incidents

1

1314

211

2

6

4

21

16

12

15

2120

27

8

22

1213

67

0

5

10

15

20

25

30

2010-11 (2) 2010-11 (3) 2010-11 (4) 2011-12 (1)

Corporate Childrens Forensic Learning Disabilities Mental Health Shropshire Mental Health Staffordshire Specialist Services

Figure 2 provides a breakdown of incidents over the past 4 quarters by directorate. The level of incident reporting is generally comparable with the size of the directorates, however Children’s Directorate has a fairly low level of incident reporting and Mental Health Shropshire has the highest incident reporting level. As expected there are higher reporting rates for inpatient services and the top categories of incidents reported remain fairly consistent across the 4 quarters. The top reported incident categories are also comparable with national statistics (NPSA) and are detailed further in section 5 of this report. Figure 3 provides a breakdown of SIs reported over the past 4 quarters by directorate. The two Mental Health Directorates are the largest directorates and therefore their SI rates are higher but comparable with the size and nature of services provided within the directorates. Section 7 of this report provides further detail of the SIs reported during quarter 1. Please note that the SI totals are also included within the incident totals and are uploaded to the NPSA as part of the overall incident statistics.

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Figure 4

Complaints

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12 2

12 2

1 1

8

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22

26

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Qtr 2 2010/11 Qtr 3 2010/11 Qtr 4 2010/11 Qtr 1 2011/12

Corporate Children's Forensic Learning Disabilities Mental Health Shropshire Mental Health Staffordshire Specialist Services

Figure 5

Compliments

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3

87

10

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8

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4 4

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31

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35

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Q2 2010-11 Q3 2010-11 Q4 2010-11 Q1 2011-12


Figure 6

PALS Concerns

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14

36

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46

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8

23 23

8

44

13 3

17

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39

28

4846

55

73

7 65

3

0

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70

80

Q2 2010-11 Q3 2010-11 Q4 2010-11 Q1 2011-12


Figure 4 provides a breakdown of complaints received by quarter and directorate. There has been a slight increase in the number of complaints received for Mental Health Staffordshire and Shropshire, compared with the previous quarter. A further breakdown is provided in section 3.1of this report. Figure 5 provides a breakdown of compliments by quarter and directorate. Following an increase in the number of compliments received between quarters 2 to 4, there has been a decrease in the number of compliments received during quarter 1. The compliments received during quarter 1 are detailed further by department in section 4.3 of this report. Figure 6 provides a breakdown of PALS concerns by quarter and directorate. There was a decrease in the total number of PALS concerns received by directorate per quarter between quarter 1 and quarter 3, although, there was an increase in quarter 4, which was a result of the increase in concerns received for Business Development & Facilities and for Mental Health Shropshire, quarter 1 saw a slight reduction in the number of concerns received. A further breakdown of PALS concerns for quarter 1 is provided in 4.1 of this report.

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3. Quarter 1 Complaints

3.1. Complaints Received

Figure 7

Quarter 1: Complaints Received by Category

0

1

2

3

4

5

6

7

8

9

Appointment (OP) Delay

Attitude Of Staff

Clinical Treatment

Communication/Info to Patients

Confidentiality

Diagnosis Problems

Discharge Arrangements

PCT Commissioning including waiting lists

Medication

Mental Health Act

Appointment Cancellation

Change of Consultant

Patient Choice

Figure 8

Communication/Information to

Patients

Attitude of Staff

Clinical Treatment


Change of Consultant

Request

Appointment Delay

Confidentiality

Diagnosis Problems


PCT Commissioning,

including waiting lists

Medication

Mental Health Act

Patient Choice

Children's 1 1 2

Developmental Neurosciences and LD 1

Forensic 1

MH Shropshire 2 2 1 1 2 1

MH Staffordshire 4 3 2 1 1 1 1 1 1

Specialist Services 1

Total 8 4 4 1 1 2 1 2 4 1 1 1 1

There has been a total of 31 complaints received during Quarter 1. Within the Mental Health South Staffordshire Directorate, there have been higher rates of reporting, with CMHT Stafford receiving 5 complaints, which covered different main categories.

Having looked at the data in more detail, there appears to be four themes which required further investigation, as follows:

• Communication/Information

• Clinical Treatment

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• Attitude of Staff

• Discharge Arrangements Directorate/Division Site Department Main Category (KO41a)

Children’s Cross Street Clinic

CAMHS Communication/Information

MH Shropshire Oakengates CMHT Central Wrekin

Communication/Information

MH Shropshire Telford CMHT North Wrekin


MH South Staffordshire Park House CMHT Cannock Communication/Information

MH South Staffordshire St George’s Hospital

CMHT Stafford Communication/Information

MH South Staffordshire Cherry Orchard House

Early Intervention Team


MH South Staffordshire QUEST Day Opportunities


Specialist Services Liverpool Inclusion - IAPT Communication/Information

MH Shropshire Shelton Hospital Chestnut Ward Clinical Treatment

MH Shropshire Shelton Hospital Chestnut Ward Clinical Treatment


CMHT Stafford Clinical Treatment

Specialist Services Birmingham Inclusion – Drug Services

Clinical Treatment

Children’s Stafford CAMHS Attitude of Staff


Crisis Attitude of Staff


Norbury House Attitude of Staff


Norbury House Attitude of Staff

Children’s Cannock CAMHS Discharge Arrangements

Children’s Lichfield CAMHS Discharge Arrangements

MH Shropshire Castle Lodge Castle Lodge Discharge Arrangements

MH Shropshire Shelton Hospital Stokesay Ward Discharge Arrangements

On further scrutiny, it is apparent that there have been two complaints made in relation to Norbury House (attitude of staff). On analysing these further, there was no correlation in relation to staff, service user or issue raised. Two complaints were received in relation to Chestnut Ward (clinical treatment). At the time of writing, only one had been investigated and a comprehensive action plan invoked. However, the Consultant Nurse/Associate Clinical Director will be undertaking some additional work in relation to the similarity of themes raised through VA, SIs and complaints. As with all complaints that require action, improvement plans are prepared by the Investigating Officer for monitoring by the Service Relations Department.

The PCT Commissioning (including waiting lists) complaint related to the Primary Care Mental Health Service in Shropshire.

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3.2. Complaints Concluded Figure 8

Quarter 1: Complaints Resolved by Category

0

1

2

3

4

5

6


Appointment Delay

Attitude Of Staff

Clinical Treatment

Confidentiality

Communication/Info to Patients


Mental Health Act

Patient's Privacy & Dignity

Figure 9

Quarter 1: Complaints Resolved by Outcome

0

1

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9

10

Not Upheld Partially Upheld Upheld Withdrawn

The Service Relations Department concluded 20 complaint cases during Quarter 1. Figure 8 provides a breakdown of concluded cases by category and Figure 9 provides a summary of the outcome of the cases. Section 10 of this report provides a summary of lessons learnt from those completed cases that were upheld and partially upheld.

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3.3. Complaint Acknowledgement & Response Times Figure 10

Complaint Acknowledgement Times 95% of the complaints received in Quarter 1 were acknowledged within the required statutory timescale (1 complaint exceeded the timescale by one day)

Response Times for Completed Complaints

Less than 10 Working Days

11-25 Working Days

26+ Working Days

Response timescale as Agreed with Complainant 6 13

Of the above responses number achieved within agreed timescale

6 12

Withdrawn/third party consent not received 1

Figure 10 above shows that all but one of the complaints received were acknowledged within the required statutory timescale. It also shows response timescales agreed with the complainant and the achievement rate. In line with new Regulations, there is no longer a set timescale within which health and social care organisations must investigate complaints. Instead complainants and organisations will be required to agree upon an individual timescale, taking into account the complexity, the complainant’s personal situation and approach to resolving complaints on a case by case basis. Although it is acknowledged that complaints should be investigated in a timely manner, the emphasis must be on outcome, being customer focused and above all “getting it right first time”. 3.3. Parliamentary and Health Service Ombudsman (PHSO)

The PHSO requested two casework files for consideration. Following an initial assessment, the PHSO considered that no further action was required. 4. Quarter 1 PALS

4.1. PALS Concerns Received Figure11

PALS Q1 Concerns by Category

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1

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7

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11

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6

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8

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8

10

12

01 Bed Management

01 Discharge

01Transfer

02 Aids And Appliances

02 Premises Access To

03 Delays

05 Staffin

g Levels

06 Rude

06 Unhappy With Care

06 Unhelpful

07 Care Plan

07 Consultants

07 CPN

07 Diagnosis Problems

07 Extra Support N

eeded

07 Medication

07 Unhappy With Service

08 Avail O

f Supp Grps

08 Oral Communication

08 Patients Rights

08 Writte

n

09 Rights Not Explained

11 Dignity

11 Patients Choice

11 Privacy/security

12 Damage To Property

12 Missing Property

12 Patients Finance

13 Health & Safety

13 Premises General

15 Failure To Follow Procedure

17 Transport G

eneral

19 Food

19 Other

24 Other

25 PCT Commmissioning Incl W

ai

Categories

10

Concerns Received by Category and Directorate Figure 12

Category Chief

Operating Officer

Business Development & Facilities &

Estates

Childrens Forensic Learning Disabilities

Mental Health

Staffordshire

Mental Health

Shropshire

Specialist Services

HIS

01 Bed Management 3 4

01 Discharge 1

01Transfer 4

02 Aids And Appliances 3 2 1

02 Premises Access To 1

03 Delays 1 4 1

05 Staffing Levels 4 1

06 Rude 1 1

06 Unhappy With Care 1 6

06 Unhelpful 1 1

07 Care Plan 1 2

07 Consultants 1 7 1

07 CPN 2

07 Diagnosis Problems 1 1

07 Extra Support Needed 2 5 4

07 Medication 1 6 1 1

07 Unhappy With Service 1 1 1 2 2

08 Avail Of Supp Grps 3

08 Oral Communication 2 1 1

08 Patients Rights 2 3

08 Written 2 1 1

09 Rights Not Explained 1 1

11 Dignity 1

11 Patients Choice 1 1

11 Privacy/security 1 1

12 Damage to Property 1

12 Missing Property 1

12 Patient Finance 1 1

13 Health & Safety 1

13 Premises General 9 2

15 Failure To Follow Procedure 1 1

17 Transport General 1

19 Food 4 1 1

19 Other 1

24 Other 1

25 PCT Commissioning 8

Total 5 17 8 4 3 73 28 3 1

There was a total of 142 PALS concerns received during quarter 1. As previously noted, there was an increase in the total number of PALS concerns received by directorate per quarter between quarter 2 and quarter 4, however, there was a slight decrease in concerns received during quarter 1. The highest number of reported concerns during quarter 1, totalling 11, related to requests for extra support by service users. These were spread across teams and no trend was identified. An equal number of concerns regarding the premises in general were received. Chebsey House had the highest number with 5 concerns and a trend was identified. These concerns were in relation to the removal of a number of items from the ward following a ligature and environmental risk assessment. These were to be replaced with anti-ligature ones. There were also 9 concerns received regarding consultants, 5 of these were for the CMHT Stafford team and were related to requests for a change of consultant. Although the concerns were clustered in one team, the requests did not relate to any one particular consultant. The PALS team also received 8 concerns, which were clustered in CMHT Cannock older people team; a trend was identified as these all related to the cessation of the dementia services.

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There were 9 concerns regarding medication, however, there were no identified trends as the issues were specific and not clustered to any particular team. 4.2. PALS Concern Outcomes Figure 13

Q1 PALS Concerns by Outcome

107

1 1

6

18

89

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100

Formal Complaint Managers Taking

Action

Resource And

Risk Identified

Resource Issue Risk Identified Sat With Res But

Not Outcome

Satisfied Transferred

Outcomes

The PALS Department completed 142 PALS concern cases during quarter 1. Figure 13 provides a summary of the outcomes of the concerns completed during the quarter. A high number of concerns resulted in a satisfied outcome. 4.3. Compliments Received Figure14

Q1 Compliments Received

2

1

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8

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3 3

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4-2-11's Group

Baswich Ward

Brockington

Brocton House

CAMHS - Argyle Street

CAMHS - Cannock

Castle Lodge Dawley

Chebsey House

Chestnut Ward

CMHT - Central Wrekin

CMHT - Stafford

CMHT - Stafford Older Adult

Community - LD Nursing

East Wing

Elm Ward

Maple Ward

MSC OAP

Mytton Oak, RSH

Newhouse

Norbury House

Occupational Therapy Shrops

Occupational Therapy Staffs

Old Age Psychiatry

Patient Services

Prison Inreach

Psychology Staffs

Rowans Ward

Stokesay Ward

Stonefield House

Whittington Ward

Department

The Trust received a total of 83 compliments during quarter 1, Figure 14 shows the number of compliments received by each department. Of the total compliments received, 6 were in relation to food, 1 was in relation to activities on the ward, 3 were in relation to the ward environment and 73 were compliments about members of staff.

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5. Q1 Incidents

5.1. Top Ten Incidents Reported by Category Figure 15

53

227

102

39

80

6660

51

85

36

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50

100

150

200

250

Assault-Non-

Physical-Other

Assault-Non-

Physical-

Patient To St

Assault-

Physical-Injury

Pt To St

Assault-

Physical-No

Inj Pt To Pt

Assault-

Physical-No

Inj Pt To St

Found On

Floor

Other Type Of

Incident -

Clinical

Self Harm Any

Lig Round

Neck/Bag

Over Head

Slip, Trip, Fall

On Same

Level

Child

Protection

During quarter 1 there were a total of 1559 incidents reported which is a decrease from last quarter of 186 incidents. The spread of incidents across the directorates is comparable quarter on quarter and there is no significant rise from the previous quarter of any one incident category. All patient safety incidents are reported to the NPSA and uploaded on a weekly basis. The NPSA have set a wide range and number of incident categories to report against and therefore figure 15 above provides a breakdown of the Trusts top ten reported incident categories which relates to 51.3% of total reported incidents for quarter 1. The top ten categories reported for quarter 1 mirror those of the previous quarter other than “Child Protection.” – this may well be due to increased reporting linked to improved recognition of the issues and the appointment of the Safeguarding Lead. There has been a decrease in the total number of incidents reported across the top ten categories.

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5.2. Top Five Incident Categories Reported by Team Figure 16

Assault – Non-Physical – Patient to Staff

5

1

3

1 1

7 7

45

10

1 1 1 1 1

7

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32

1 1 1

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1 1

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45

Ashley House

Assertive Outreach Telford

Baswich Ward

Beech Ward

Brockington

Brocton House

Bromley Ward

Castle Lodge Dawley

Chebsey House

Chestnut Ward

CMHT - North East Shropshire

Community - LD Nursing

Community Substance Misuse

Crisis - Shrewsbury

Early Intervention

East Wing

Ellesmere House

Elm Ward

Hatherton Centre

Headquarters Building

Inclusion - IAPT Sefton

Kingsley Day Services

Maple Ward

MSC - Adult Acute

Newhouse

Newport House

Norbury House

Norton House

Radford House

Rowans Ward

Stokesay Ward

Stonefield House

Substance Misuse

West Wing

Whittington Ward

Wroxeter Ward

Figure 16 provides a breakdown of Non-physical Assault Patient to Staff incidents reported during quarter 1. There were a total of 227 incidents reported this quarter compared with 244 last quarter which represents a decrease of 6.9%. The 4 highest reporting wards during Q1 were Whittington (41incidents), Ellesmere (29 incidents), Norbury (23 incidents) and Maple (21 incidents). The remaining 113 incidents were spread relatively evenly amongst a further 28 wards or areas of the Trust. There was an increase of 105% of reported incidents for Whittington Ward during Q1 compared to Q4, there was an increase of 52.6% for Ellsmere House for Q1 compared to Q4, there was an increase of 43.7% for Norbury House for Q1 compared to Q4 and there was a significant increase in incidents reported on Maple Ward during Q1 compared to Q4. There were however significant decreases on 2 wards – Stonefield House (81.1%) & Stokesay House (66.7%) – for reported incidents in Q1 compared to Q4.

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Figure 17

Assault – Physical – with Injury - Patient to Staff

1

20

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3

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4

5

2

1 1

2

1

3

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1

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15

4

5

9

0

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15

20

25

Ashley House

Baswich Ward

Beech Ward

Brocton House

Chebsey House

Chestnut Ward

East Wing

Ellesmere House

Elm Ward

MSC - Adult Acute

MSC OAP

Mytton Oak, RSH

Newport House

Norbury House

Oak House, RSH

Rowans Ward

Stokesay Ward

Stonefield House

West Wing

Whittington Ward

Figure 17 provides a breakdown of physical assault with injury from patient to staff reported during quarter 1. There were a total of 102 incidents reported this quarter compared with 94 last quarter which represents a slight increase of 8.5%. The three highest reporting wards for the period were Baswich House (20 incidents), Norbury House (17 incidents) and Stokesay Ward (15 incidents). Incidents reported on these wards accounted for 49% of the overall total. The remaining 51% of reported incidents were spread relatively evenly across a further 17 Wards or areas. There was an increase of 42.8% of reported incidents for Baswich House during Q1 compared to Q4, there was an increase of 142.8% for Norbury House for Q1 compared to Q4 and there was an increase of 150% for Stokesay Ward for Q1 compared to Q4. There were however significant decreases on 2 wards – Stonefield House (78.9%) & Rowans Ward (61.5%) – for reported incidents in Q1 compared to Q4.

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Figure 18

Assault Physical – No Injury – Patient to Staff

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11

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20

Baswich Ward

Brocton House

Bromley Ward

Chestnut Ward

Community Specialist Nursing T

Day Centre

East Wing

Ellesmere House

Kinver Ward

Liaison Service, RSH

Maple Ward

MSC - Adult Acute

Newport House

Norbury House

Radford House

Rowans Ward

Stokesay Ward

Stonefield House

West Wing

Whittington Ward

Figure 18 provides a breakdown of Assault Physical No Injury Patient to Staff incidents during quarter 1. The total number of reported incident this quarter was 80 which mirrors Q4 where 80 incidents were also reported. The highest reporting wards for Q1 the period were Norbury House, Baswich House and Stokesay Ward. Incidents reported on these wards accounted for 56.3% of the overall total. The remaining 43.7% of reported incidents were spread relatively evenly across 17 Wards or areas. There was a significant increase of reported incidents for Norbury House where 18 incidents were reported during Q1 compared to none during Q4, There was a significant increase of reported incidents for Baswich House where 16 incidents were reported during Q1 compared to none during Q4 and there was an increase of 175% for Stokesay Ward for Q1 compared to Q4. There were however significant decreases on 2 wards – Stonefield House (91.7%) & Brocton House (80%) – for reported incidents in Q1 compared to Q4.

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Figure 19

Slip, Trip or Fall On Same Level

1 1

9

1 1

7

1

3

15

1 1

2

11

2

4

1

3

1

4

1

2

9

2 2

0

2

4

6

8

10

12

14

16

Ashley House

Assertive Outreach

Baswich Ward

Beech Ward

Brocton House

Bromley Ward

Castle Lodge Dawley

Chebsey House

Chestnut Ward

CMHT - Lichfield

CMHT - Stafford

Day Centre

East Wing

Ellesmere House

Elm Ward

Facilities & Estates

Maple Ward

MSC - Adult Acute

Newhouse

Quest Day Opportunities

Radford House

Rowans Ward

Stokesay Ward

Whittington Ward

Figure 19 provides a breakdown of slips, trips and falls on same level incidents during quarter 1. The total number of slips, trips and falls on same level incidents this quarter is 85, with previous quarters having been ;- (2010/11) Q1 = 122, Q2 = 94, Q3 = 90, Q4 = 85. 24 wards and departments are shown above, 10 of which recorded only one incident in the quarter. Of the remaining 14 wards where more than one incident was recorded during the quarter ;- all the Old Age Psychiatry wards listed above i.e. Baswich, Bromley, Chestnut, East Wing, Maple and Rowans continue to be subject of the ongoing Falls Thematic Review process (along with three other OAP wards not listed above – i.e. Beech, Elm & MSC OAP, though Beech has now closed) Along with the thematic review The Falls Working Group is considering a wide range of other issues especially those around multiple fallers. The roll out of web based reporting also includes a falls questionnaire to more accurately record the circumstances around slips trips and falls.

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Figure 20

Found On Floor

43

1

3

5

24

6

3

1

7

21

23

1

0

5

10

15

20

25

30

Baswich Ward

Beech Ward

Brocton House

Bromley Ward

Chebsey House

Chestnut Ward

East Wing

Elm Ward

Elms House

Maple Ward

MSC - Adult Acute

MSC OAP

Newhouse

Rowans Ward

Whittington Ward

Figure 20 provides a breakdown of Found on Floor incidents during quarter 1. The total number of reported Found on Floor incidents this quarter is 66 which represents a 13% increase compared to Q4 where 58 incidents were reported. Some of these incidents might well have been falls but there is no reliable evidence to confirm this. The wards with the highest level is an OAP in-patient service area. 5.3. Action Taken Assault: It should be recognised that that in real terms there has been a decrease (circa 15%) in physical and non-physical assaults (patient to staff & patient to patient) during Q1 compared to Q4 and such incidents predominately continue to occur in a small area of services provided. The Security Management Specialist, Violence & Aggression Advisor and Risk Management Team continue to work closely with the Wards that contributed to the highest reported numbers of assaults to ensure that trends and impact factors are recognised at a local level and that individual teams are taking responsibility to implement appropriate control measures to mitigate against the risk of violent and/or aggressive behaviours. As a result of such scrutiny there are currently clinical reviews being undertaken on Whittington Ward, Stokesay Ward and Baswich House. The terms of reference for these reviews have been agreed with the appropriate clinical leads and Security Management Specialist and aim to highlight the following areas which may have had an impact on identified increases in violent and/or aggressive activity:

• Incident reporting mechanisms

• Care planning and risk management procedures

• Staffing arrangements

• Staff support

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• Training

• Service user experience

• Engagement with other department and partner agencies

• Environmental issues On completion of the clinical reviews reports highlighting areas of concern, areas of good practice and recommendations/action plans shall be submitted to QERC in September 2011. Slips, Trips & Falls & Found on Floor: Found on Floor and Multiple Fallers data form part of the 2nd Falls Thematic Review Action Plan. This will be reviewed at the Falls Group meeting in August. Now using statistical process control run sheets to more easily identify statistical changes. Incidents are reported to Modern Matrons daily to enable them to review local areas. The 2nd Thematic Review was presented to Shropshire, Telford & Wrekin PCT who raised questions for further discussion on 30 September 2011. 5.4. Trends Identified Assault and slips trips and falls are areas identified both nationally and locally as high reporting and high risk areas for mental health and learning disability trusts. The Trust incident reporting rates are in line with the national benchmark (NPSA) and in response to this Quality Effectiveness & Risk Committee (QERC) has established a thematic review schedule to monitor closely these areas. In addition to this monthly trend reports are being generated to support clinical areas with early detection and management of individual service users who are considered high risk.

6. Q1 Reporting of Incidents, Diseases & Dangerous Occurrences Regulations

The total number and type of RIDDOR reports made to the Health and Safety Executive from 1st April 2011 to 30th June 2011 is as follows:- Incident Date Injury Extent Injury Type Body Part Department

05/05/2011 Patient/Public Maj Inj/Condition Fracture Shoulder (L) Chestnut Ward

10/05/2011 Staff Minor Inj & Over 3dayAbs Pain Knee (R) Chestnut Ward

10/05/2011 Staff Minor Inj & Over 3dayAbs Bruise Face Stokesay Ward

13/05/2011 Patient/Public Maj Inj/Condition Fracture Wrist (L) East Wing

16/05/2011 Staff Minor Inj & Over 3dayAbs Sore Neck West Wing

16/05/2011 Staff Minor Inj & Over 3dayAbs Strain/sprain Neck West Wing

21/05/2011 Staff Minor Inj & Over 3dayAbs Pain Back Baswich Ward

01/06/2011 Patient/Public Maj Inj/Condition Fracture Arm (R) Chestnut Ward

05/06/2011 Patient/Public Min Inj/Condition Cut Hand (R) Ellesmere House

23/06/2011 Staff Minor Inj & Over 3dayAbs Bruise Rib(s) Radford House

26/06/2011 Staff Minor Inj & Over 3dayAbs Scald Arm (R) Newhouse

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7. Q1 Serious Incidents 7.1. Serious Incidents Reported by Category & Directorate Figure 21

11 1 11 11

1 1 1 12 2

1 12

5

1

2

1 3 11

1 1

12

1 1

5

0

5

10

15

20

25

Absconded/Late From Leave/Home

Assault-Non-Physical(NO Contact)-Other

Assault-Physical(Made Contact)Injury Other

Assault-Physical(Made Contact)Injury Pt To St

Assault-Physical(Made Contact)InjuryVis/Rel T

Child Protection

Communication Problem -Non Clinical

Contraband Breach

Fall From Bed/Chair/Other Furniture Etc

Fire - Any Incl.Arson But Not Smoking Related

Found On Floor

Found With Injury (Cause Unknown)

Monitoring Of Patient Absent/Inappropriate

Self Harm Any Lig Round Neck/Bag Over Head

Slip, Trip, Fall On Same Level

Under 18 Admission

Unexpected Death - Non-Patient

Unexpected Death Community Or Out Pt

Unexpected Death In-Patient

Childrens Forensic Learning Disabilities Mental Health Shropshire Mental Health Staffordshire Specialist Services

Figure 21 provides a breakdown by directorate and category of the SIs reported during the quarter. As previously mentioned these cases are also included within the total reported incident figures, some of which will have featured in the top five incident reporting categories detailed in section 5.2 of this report. There has been a reduction in the numbers of serious incidents in all categories which correlates to the overall reduction in incidents. This correlation maps to the Q1 period for 2010/11. 7.2. Serious Incidents Completed Figure 22

Cause 1 Childrens Forensic Learning Disabilities

Mental Health

Shropshire

Mental Health

Staffordshire

Specialist Services

Assault Physical Patient to Staff 1 1

Child Protection 5 1

Medical Emergency 1

Patient Arrested 1 1

Self Harm 2 1

Under 18 Admission 1

Unexpected Death of In-Patient 1 1

Unexpected Death of In-Patient on Leave 1

Unexpected Death Community/Out Patient 4 6 8

Unlawful Detention 1

Vulnerable Adult 1 1 2

Total 5 2 2 11 13 8

Figure 22 provides a breakdown by directorate and category of Serious Incidents completed during quarter 1. There were a total of 41 SIs completed during this quarter. Section 10 of this report provides a summary of lessons learnt from those completed cases. Monthly performance reports to the Trust Board now include outcomes and specific learning points from individual SIs. The Quality Effectiveness & Risk Committee also receives an Executive Summary Report of each individual completed SI investigation.

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7.3 Unexpected deaths In order to take a more proactive approach in identifying trends and clusters, the Risk Management Team are using statistical process control to monitor unexpected deaths reported across the organisation. Figure 23 below shows there are no clusters or trends although there remains a wide variation of between 1 and 12 deaths within the control limits. The Risk Management Team will continue to monitor the charts and report through the quarterly risk reports. Figure 23

Unexpected Deaths SSSFT (SPC)

0

2

4

6

8

10

12

14

Apr-09

Jun-09

Aug-09

Oct-09

Dec-09

Feb-10

Apr-10

Jun-10

Aug-10

Oct-10

Dec-10

Feb-11

Apr-11

Jun-11

Month

No. of Unexpected deaths

Total number

Unexpected

deathsMMR

LCL

UCL

7.4 Suicides Members of the Quality and Risk teams met recently with the South Staffordshire Coroner to review current reporting processes and to also discuss a recent report by South Staffordshire PCT which indicated an increase of suicides in the locality. The coroner agreed to setting up a meeting between himself and the 2 Trust’s in order to compare data from both the PCT and the Trusts suicide reports, ensuring a joined up approach to addressing any issues. Following this meeting the Trust Suicide Action Plan will be updated.

8. Q1 Liability Claims 8.1. Total Liability Claims on File

The total number of liability claims on file at the end of Quarter 1 are as follows:-

Liability Type

Clinical Negligence 4

Employers Liability 22

Public Liability 2

Total 28

8.2. New Liability Claims Received Q1 There is one new liability claim this Quarter as follows:-

Liability Type

Employers Liability 1

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8.3. Liability Claim Outcomes Q1 There was one liability claim closed this quarter as follows;-

Liability Type Outcome Month Closed

Employers Liability Claim Upheld & Settled June 2011

Total 1

9. Q1 Lessons Learnt

The risk management reporting systems are being developed to capture appropriate theme areas for analysing and reporting lessons learnt. Added to this the Risk Management Department have produced a learning lessons bulletin which has been cascaded across the Trust both by email and by being published on the Trust website. The Trust continues to monitor and take action in respect of themes that emerge from lessons learnt. Current emerging themes identified through the process of learning lessons are: 9.1 Record keeping Lessons learnt relating to record keeping has featured as an ongoing theme in serious incident investigations and complaints, although there is no specific theme relating to any one area of record keeping. The Trust has a number of actions currently in progress to address issues relating to the consistency and accuracy of record keeping and these include;

• Dissemination of guidance to all appropriate staff in relation to file structure • Ensuring there are robust processes in place for recording the transfer of files

between departments • Ensuring that in all areas of the Trust file structures are consistent with requirements

set out within the Trust policy and procedures • Ensuring that robust processes are in place for making sure that data held in paper

files and electronic files is up to date and aligned. 4.2 Engagement of Carers The need to actively engage carers in care planning processes for service users has featured in lessons learnt from completed serious incident investigations and complaints. This issue is also been agreed as a development Commissioning for Quality and Innovation Framework indicator for this year. By the end of March 2012 it is envisaged that the Trust will have undertaken a review of the current processes for engaging carers and developed an implementation plan for improving carer engagement and communication. A working group has been established to facilitate this work and the group includes carer representative, carer groups, clinical staff, corporate support from the Quality and Clinical Development Directorate, regional Care Programme Approach lead and commissioner representation from the governance team. 4.3 Risk Assessment In response to a number of recommendations from serious incidents relating to effective risk assessment and management the Trust’s clinical risk management policy has been recently revised. In addition the Trust has reviewed its risk management training programmes and a new clinical risk management training programme has been implemented. The new training programme commenced in December 2010 and to date 51% of relevant staff have attended the training. This training has a number of generic themes but has also incorporated bespoke content to take account of the differing clinical directorates needs. A thematic review of care planning has been undertaken and as part of this review, a set of assessment and care planning standards have been developed. These will be agreed at Quality Effectiveness & Risk Committee in August and subsequently implemented across clinical directorates

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10. Q1 Essential Standards Summary Report 10.1 Overview of key themes and findings in Quarter 1 The following areas were visited

31st March 2011 Beech Ward (BW)

31st March 2011 Chebsey Ward (CW) May 2011 Bromley Ward (BRW) May 2011 Chestnut Ward (CHW) June 2011 Stonefield House (SH) June 2011 Radford House (RH)

Consistently good performance was found in the following dimensions;

• involvement and information

• personalised care, treatment and support

• suitability of staffing A good range of information for service users/ carers was available across all areas and case notes were found to include appropriate risk assessment documentation. Staff were found to be knowledgeable and professional in delivering care. Some further work is required to ensure that training compliance continues to improve. Inconsistent performance was found in the following dimensions;

• safeguarding and safety

• quality and management Some areas visited were not as clean as they could have been. The need to improve the quality of documentation was identified across all areas visited, including care plans, care records and checks to clinical equipment. 10.2 Summary of findings of visits to date in Quarter 1 First impressions

• Staff were friendly, at ease and welcoming and staff were interacting with patients in the communal area (BW)

• The first impression of the ward was that it was a calm and welcoming environment. The ward was bright and clean, there was evidence of planned activities getting under way. A mixture of staff interacting with service users in the general area and others in the office (CW)

• The environment was clean and tidy and although the ward was busy, the atmosphere was calm (BRW)

• Staff were generally friendly and welcoming; some were obviously busy attending to patients. The main entrance and corridor was light and airy and appeared clean, tidy and uncluttered (CHW)

• Despite the ward being busy and staff all engaged with service users or other duties we were made to feel very welcome (SH)

• The ward was light and pleasant, generally clean with a relaxed atmosphere (RH)

Involvement and Information

Findings and good practice Areas for improving quality

• Each patient is allocated a key nurse and social worker who co-ordinate their care needs (BW)

• There is a clients and visitors information point on the ward providing information about help

• Information on some notice boards in the main ward area was out of date and requires updating (CW)

• Remove out of date information from

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lines, PALS, IMHA and advocacy (CW)

• There were a number of patient information leaflets neatly presented in the foyer and a large number of thank you cards. This created a positive first impression of the ward (BRW)

• Information on the ward’s activity programme was displayed clearly in the main corridor (CHW)

• There were good examples of service user involvement e.g. in care planning (SH)

• Relationships between service users and staff were observed to be good (RH)

notice boards. Review information for service users/ carers to ensure it is in clear straightforward language (BRW)

• Care plans should be signed by a service user or, if discussed with family carer, signed by them to indicate their involvement (CHW)

Personalised care, treatment and support


• Patients undergo a nutritional screening assessment when they are admitted. The ward has access to the services of a dietician (BW)

• A clear process was described for monitoring patients’ weight on a weekly basis. The nurse was clear what intervention to take if a patient was losing weight. The doctor confirmed that issues were brought to their attention (CW)

• The atmosphere of the ward appeared greatly improved following the introduction of the occupational therapist and a structured activity programme. Risk assessments were completed and updated (CHW)

• Risk management processes were found to be robust with good evidence of clinical risk management and environmental risk management (SH)

• Care plans and risk assessments were evident in notes reviewed. Attention to safety and security by staff appears to be robust (RH)

• Patient notes were incomplete and need improving (BW)

• Improve communication between ward and community staff (CW)

• Review the content and process of ward handovers to ensure effectiveness (BRW)

• Timescales for care plan evaluation need to be agreed and monitored (SH)

Safeguarding and safety


• Daily checks to the fridges were recorded, and all equipment was seen to have a PAT test (CW)

• The unit is a somewhat depressing building however staff have worked very hard to brighten the areas. All areas appeared clean and tidy with floors and carpeting being in good order (SH)

• Attention to security and safety of patients was evident (RH)

• Disposable wash bowls should be used. The plastic wash bowls should be disposed of (BW)

• The temperature in room 136 (used for assessment) was unbearably hot and we were told that it is difficult to control the temperature in this room (CW)

• The Ward Manager should maintain a record that staff have received relevant training on the use of specific ward based equipment (CHW)

• Areas of the ward require cleaning and routine monitoring is required to ensure that this is done (RH)

• Consider improving the starkness of the bedrooms and communal areas

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by introducing some bright, uplifting art work and uplifting colour schemes (BW)

Suitability of staffing


• The ward manager told us that the staff are pro-active and work well together as a team (BW)

• A student nurse described how she was fully supported during her placement on the ward (CW)

• All staff have been on the 5 day MAPA training and are up to date with their 2 day training. New starters are given a structured induction which is tailored to their needs (CHW)

• Staff were professional in their manner and had a good knowledge of systems and processes (RH)

• The staff team were excellent and knowledgeable. There were some relatively newly qualified staff who were able to answer questions asked with ease (BRW)

• One member of staff had not received 5 day MAPA training. The ward should continue to ensure that all staff are up to date with relevant statutory and mandatory training (CW)

• The team should maintain records of the peer group supervision. This would serve to demonstrate the commitment to supervision of practice and staff support (CHW)

• Ensure that staff are up to date with fire training and improve processes to ensure that regular updates occur (SH)

Quality and management


• Evidence reviewed showed that fire risk assessments are done annually (CW)

• A directorate meetings template was in use on the ward and this identifies and reinforces the divisional governance structure (RH)

• Ensure that patient files are stored in a lockable filing cabinet which is kept locked when not in use. The office door should also be locked shut when unoccupied (BW)

• The team should consider how it can capture the quality initiatives taking place at ward level so that these can be shared more widely and recognised (CHW)

• Improve access to computers for ward staff (BRW)

• Documentation and filing within patient records needs to be improved (RH)

• Ensure that there are records available to show that clinical equipment is routinely checked (RH)

Areas identified as in need of urgent improvement

• The ligature point identified at Radford House was removed within 1 day of notifying Facilities and Estates.

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10.3 Action taken following the Essential Standards Visits Wards are asked to provide an update of progress against issues raised within one month of receiving the report. This update is requested on a standard action plan template which is sent to the wards. Performance development managers oversee this process, in order to ensure that issues are addressed and that any action taken is recorded. To date, the Performance Development Team has had confirmation that immediate actions relating to Beech Ward have been addressed. (The ward is due to close so longer term issues will not be resolved.) Chebsey House has addressed all actions and an action plan has been received from Bromley Ward with evidence of progress/ improvements made. The following tables provide an update on actions identified following visits during the last two quarters of 2010/11. Table 1: Quarter 3 2010/11

Location Date Completed/Outstanding

Baswich 14th October 2010 Actions completed

Stonefield House 14th October 2010 Actions completed

Elm Ward 25th November 2010 Actions completed

Buildwas Ward 25th November 2010 Actions addressed (ward was subsequently closed)

West Bank 25th November 2010 Actions completed

Whittington Ward 25th November 2010 Actions completed

Table 2: Quarter 4 2010/11

Location Date Completed/Outstanding

George Bryan – East 6th January 2011 Actions completed

George Bryan – West 6th January 2011 Actions completed

Ellesmere House February 2011 Actions completed

Ashley Ward February 2011 Actions completed

south staffordshire and shropshire healthcare nhs foundation trust

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