starfish health and wellbeing
TRANSCRIPT
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Quality Account
2018/19
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Title Page Number Part 1
Statement and Introduction from the Chief Executive 3
Services Provided by Starfish Health and Wellbeing 5
Part 2 6
Priorities for Improvement 6
Patient safety 7
Patient Experience 8
Clinical Effectiveness 9
Part 3 10
Looking Back Over the Past 12 Months 10
Staff Wellbeing 10
Increase referrals 10
Working with Long Term Health Condition 10
Feedback from LTC-IAPT Service in Cannock and Stafford 11
Service Review 27th Feb 2018 12
Complaints 13
Patient Experience Questionnaires (PEQ) 13
A Sample of Patients Feedback 14
KPI Target For 17/18 15
Information Governance Toolkit attainment levels 15
Information Governance 15
External Quality Reviews 16
Stafford and Surrounds Clinical Commissioning Group (CCG) and
Cannock Chase Clinical Commissioning Group comment
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Part 1
Statement and Introduction from the Chief
Executive
I am very pleased to introduce this Quality Account for Starfish Health and Wellbeing
(CIC).
Starfish Health and Wellbeing believes that when we come together with a shared
vision of the future, a shared understanding of the way to achieve it and a shared
commitment to values of contextual understanding, co-operation, compassion and
resilience, we can achieve our goals.
The future we see:
• Embraces psychological difficulties as lesser or more extreme experiences on
a continuum;
• Recognises the pivotal role of the individual and the vital importance of the
contextual elements of their life in recovery;
• Sees the therapist as an invaluable guide and supporter on the road to
recovery;
• Sees all other staff, support, volunteers, peer mentors and associates as being
critical factors in our continued success;
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• Values the essential role of transition support through social engagement to
facilitate community integration and recovery;
• Understands the value that can be added using technology to support, extend
and enhance psychological services.
This year we have worked to refine and embed our values with our staff and the people
we serve.
This year’s Quality Account has been produced openly and honestly in order to
describe the progress we have been making, where there are areas for improvement
are and state our priorities or next year.
We always want to listen to people from the communities we serve and commissioners
in order to improve the services we deliver. We would like to thank our staff, clients
and stakeholders for their ongoing hard work and support, as well as the help we’ve
received in identifying our strengths and priorities.
To the best of my knowledge all the information in this document is accurate.
Iain Caldwell Chief Executive Officer
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Services Provided by Starfish Health and Wellbeing
IAPT Services Starfish Health and Wellbeing are commissioned by Cannock Chase CCG
Hartlepool and Stockton CCG, South Tees CCG, and Stafford and Surrounds CCG
to provide:
Primary Care therapy service Improving Access to Psychological Therapies (IAPT).
These services are part of the national drive to increase access to evidence based
psychological therapy services for common mental health problems.
Primary Care Service
Starfish Health and Wellbeing are commissioned by GP First to improve low level
support for patients within Primary Care. The focus of this service is to create capacity
within the current Primary Care teams; reduce dependency on GP’s, reduce the
prescribing of SSRI’s; navigate and signpost patients to the most suitable services
within the shortest time period to ensure the pathway for the patient is as seamless as
possible.
Social Hubs Starfish Health and Wellbeing are commissioned by Wolverhampton City Council
to provide community based, preventative Social Hubs.
The purpose of the service is to improve and maintain the mental wellbeing of adults
which helps to prevent them from (re-)entering higher level/statutory services
wherever possible by promoting: independence; empowerment (choice and control)
and personal resilience skills for those who have/have had or who are at risk of mental
ill-health.
Youth Employment Initiative
Starfish Health and Wellbeing are commissioned through the European Union Social
fund to offer targeted support to 16-29-year olds, not in paid employment or full-time
education/training/self-employment to move closer to the job market.
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Part 2
Priorities for Improvement for 18/19
Starfish Health and Wellbeing have considered our priorities in line with our vision,
strategic goals and objectives, our Quality Governance Strategy and both NHS
Outcomes Framework and the CQC frameworks.
Starfish Health and Wellbeing will support the increase in referrals which is set out in
the NHS Five Year Forward Plan which states that “By 2020/21 there will be increased
access to psychological therapies, so that at least 25% of people (or 1.5 million) with
common mental health conditions access services each year”.
Our Quality Priorities form part of our overall activity for the monitoring and
improvement of quality delivered. These have been made up of a mixture of the
continuation of existing priorities and a response to emerging priority areas during
2017-18.
Our three priority areas are:
1. Patient safety
2. Patient Experience
3. Clinical Effectiveness
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1 Patient safety
Priority area Approach Rationale
Improve documentation of Risk Assessment (patient safety)
Move documenting of risk assessment audits from the 6-monthly clinical Audit schedule to the monthly clinical Audit schedule. Highlight any areas of none compliance. Put remedial measures in place e.g. review training for staff.
Increased Audits improve compliance. Targeting risk assessment will improve patient safety.
Learning Lessons to Reduce Harm
Ensuring that lessons learnt from all reviews are shared across our services to maximise learning and reduce harm
Ensure all services receive and act on learning from all reviews to minimise the likelihood of repeating error across other services.
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2 Patient Experience
Priority area Approach Rationale
Improve Performance against service access target
Undergo a Service redesign to expand the offer to patients. Train staff to use online digital platforms.
Over the next year more patients will access services and we want to ensure we make best use our resources whiles giving the highest quality of service.
Improve the completion of Patient Evaluation
questionnaire (PEQ)
Develop a process of sending PEQ’s via email, through the secure data management system.
In order to improve the services, we deliver, it is critical that we get constructive feedback from Patients. Improvement for 18/19: 50% completion at end of treatment. 75% completion at assessment.
17/18 completion rates
Stafford and Cannock 62% at assessment 14% at end of treatment Teesside 59% at assessment 14% at end of treatment
Improve Patient Information
Review patient information leaflets, to ensure that it includes all service offer.
At a service review, patients stated that they were not aware of the full-service offer for their problems e.g. groups, self-help of telephone sessions. A question on 18/19 service review will be added around service offer.
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3 Clinical Effectiveness
Priority area Approach Rationale
Improve Service performance against
National Recovery Target
Develop new work plans that track each target, and give clarity of direction. Update case review process.
By having an improved
system with more detailed
checks, starfish will
deliver continuous
improvement and
outcomes for patients.
Moving to 55% of people
recovering in 18/19.
17/18 Recovery Rates Cannock Chase 53%
Hartlepool and Stockton
51.4 % Stafford and Surrounds
53% South Tees 51.5
Improve the use of specific clinical measure for patients with Long Term Health Condition (LTC)
Train more staff to use specific clinical measure for patients with LTC Provide physical health training package for staff
Starfish have been involved in the successful implementation of wave 2 IAPT-LTC in Cannock and Stafford and want to develop this further and also start role IAPT-LTC in Teesside Improvement of 10% for 18/19 17/18 Rates 730 clients have entered treatment from 'go live' date of 1st August 2017, 1100 clients with a long-term condition have entered treatment from 1st April 2017 - 31st March 2018, including those seen within Core prior to go live.
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Part 3
Looking Back Over the Past 12 Months
Our priorities for the past 12 months were:
Staff Wellbeing:
• We Improved communication by, setting up a monthly briefing document
from management and governance meetings and disseminate through team
meeting and emails with questions to feed back to meetings.
• We Improved the working environment by, completing a deep clean, hire
a new cleaners and refurbished staff kitchens.
• We set up a new worker benefits scheme, as few staff have used the old
scheme
• We organised monthly shared lunches so staff can meet each other and
speak to staff they would not normally meet, because rota’s.
Increased referrals: Starfish Health and Wellbeing supported the increase in referrals which was set out in
the NHS Five Year Forward Plan which states that “By 2020/21 there will be increased
access to psychological therapies, so that at least 25% of people (or 1.5 million) with
common mental health conditions access services each year”.
Working with people with long-term conditions: Long-term conditions (LTC) are now a central task of the NHS. Addressing these
needs requires a partnership with patients over the long term rather than providing
single, unconnected ‘episodes’ of care.
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• As a result, our services have integrated our teams in Cannock and Stafford to
primary care settings and staff have undergone training in LTC. New pathways
have been designed with physical health teams to offer an integrated approach.
This as ensured more convenient and tailored treatment for patients.
• In Teesside, a number of staff have been trained and the data management
system is in the process of being reconfigured to enable the team to collect and
upload data.
Feedback from LTC-IAPT Service in Cannock and Stafford
The Respiratory team report that the service is making a difference to our patients
regarding their level of anxiety due to their breathlessness. They add that the staff are
great and fitting in to our service very well.
A patient diagnosed with chronic pain and fibromyalgia is now able to walk without
their sticks and reduced their intake of pain medication due to their engagement with
our service. They said, “last year I wanted to end my life, I dread to think where I would
be without this service” they also said “I have grown in confidence at each session, I
can’t thank you enough”.
2, A patient diagnosed with COPD and Asthma has now completed therapy, they said
that our service has enabled them to think differently about their diagnosis and can
now identify when they are anxious and has coping strategies to deal with the physical
sensations of anxiety rather than think its related to their illness.
3, A patient diagnosed with COPD says, “you have been fantastic, you have helped
me cope with this illness and helped me change my thinking when feeling helpless”.
Even though still very poorly the Core IAPT Community Wellbeing Worker was able to
organise the installation of a Lifeline alarm which has made a huge difference to this
patient and they state, “I feel much safer and more secure, Thank you”.
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Service Review 27th Feb 2018
Attendance: 16 people mixed age and gender
Feedback themes:
Positives Feedback:
• Many people felt the service was valued” and helped a lot. They reported of
“missing this if it wasn’t available”
• People found the Wellbeing group excellent: “both funny and informative”
presentation skills excellent”
• A number of staff where mentioned for praise “allowing me a little extra time to
talk” which made them feel “important and cared for”
• People commented on having lots of time in treatment and that the option of
CWW to help with other areas of life was “very helpful”
Constructive feedback:
• People stated that they were not aware of the full-service offer for their
problems e.g. groups, self-help of telephone sessions.
• 2 people reported that the therapy “ended too soon” and that they were getting
better but was told they had to be ended based on the scores.
• There was a discussion about preferences for older or younger staff: 3 People
feedback that they felt the staff were “too young” and that they wouldn’t know
what “life experience was”. 2 older people of the group disagreed and reported
of having a good working relationship regardless of the age difference (one of
these people were 82 yrs old and reported of having “an excellent worker over
half her age”
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Complaints
Starfish Health and Wellbeing records all incidents and complaints that present to each
service. All complaints are taken to the Area Clinical Governance Group for review
and analysed for common themes. Action plans are instigated where needed to enable
the service to develop and learn from any mistakes.
Out of the 9256 entering treatment there was a total of 19 complaints received. Complaints could be broken down into 2 themes
• Issues with communication e.g. Letter not being sent out and telephone
messages not followed up.
• waiting times for reallocation following staff leaving or going on long term sick
Patient Experience Questionnaires (PEQ)
We ask people to complete post-therapy satisfaction questionnaires for all our IAPT
services.
End of Service PEQ
Satisfaction Rating Completely
Satisfied
Satisfied Neither or
dis-
Satisfied
Not
Satisfied
Not at all
Satisfied
Did staff listen to you and treat your concerns seriously?
98%
1.6% 0% 0.4% 0%
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A Sample of Patients Feedback
Fantastic. Speaking to and listening to the therapist was so helpful. Wonderful to
deal with someone who understands my situation.
I have always felt very comfortable and safe here and think they always give good
advice and point you in the right direction
First time I have ever felt listened to by a mental health professional
Good understanding of my situation but also what I want to do for the long term and
relevant to me. Clear explanation of the support to be given.
I feel this has been a life line for me and I now feel more able to cope with anything
in the future therapist has been amazing and I would recommend this service to
family + friends
Very understanding and helpful. Gave very good advice and help, very supportive.
Already has a great understanding of my issues and I feel comfortable I can and will
have the opportunity to tackle them all
I am happy with all aspects of my session
The service provided was fantastic and a massive help. I was shown coping
techniques that will help me in the long term as well as short term.
I cannot recommend the service enough. I have gone from a person not been able
to motivate myself to get out of bed and function normally - to someone who is going
back to college and changing to a new career with a new zest for life. I will never be
able to thank the therapist enough for her brilliant work
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KPI Target For 17/18
Target Expected achievement Actual achievement
Clients moved to recovery 50% 52.2%
Completion of ethnicity coding
90% 97.3%
Percentage of clients seen within 6 weeks of referral
75% 95.9%
Percentage of clients seen within 18 weeks of referral
95% 100%
Information Governance Toolkit attainment levels
The Starfish and Wellbeing Information Governance Assessment Report score overall
score for 2016/17 was 67% and was graded Satisfactory at level 2.
An audit of the last years toolkit and have completed an action plan to improve next
year’s score.
Information Governance
Information is a vital asset of the organisation and is fundamental to all areas of the
business. It needs to be accurate and up to date, accessible, relevant and rich with
evidence. Improvements can be made in how the organisation views information
governance and how it applies to the information required to run the organisation,
make decisions and inform future developments. With the introduction of General
Data Protection Regulations (GDPR), all policies and procedures will be reviewed to
ensure compliance with this new legislation. In the coming year we aim to increase
knowledge and understanding of IG and encourage individual ownership of
compliance.
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External Quality Reviews
Over the next 12 months Starfish Health and Wellbeing will undertake 2 quality reviews:
1. Accreditation Programme for Phycological Therapy Service (APPTS).
The APPTS is a new accreditation programme that works with psychological therapies
services in the UK whose primary function is to provide psychological therapies to
improve the psychological wellbeing of adults in the community Peer Review 22 May
2018.
This programme includes a two-month self-assessment, an independent service user
survey, an independent staff survey and an external peer review. All information will
be then assessed by the programme board.
2. ISO 9001:2015, the international standard specifying requirements for quality
management systems.
The ISO is a quality management system (QMS) is a formalised system that
documents processes, procedures, and responsibilities for achieving quality policies
and objectives. A QMS helps coordinate and direct Starfish Health and Wellbeing’s
activities to meet client and regulatory requirements and improve its effectiveness and
efficiency on a continuous basis.
Quality management systems serve many purposes, including:
• Improving processes
• Reducing waste and inefficiency
• Lowering costs
• Facilitating and identifying training opportunities
• Engaging staff
• Setting an organisation wide direction
Starfish Health and Wellbeing will receive an external audit from the ISO assessors to
take place in Cannock 10 July and in Teesside 11 July: These audits will assess if
Starfish Health and Wellbeing will continue to meet the standards necessary to hold
the ISO Quality Mark.
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Stafford and Surrounds Clinical Commissioning Group (CCG) and
Cannock Chase Clinical Commissioning Group Comment on this
Quality Account for 2017/2018.
Stafford and Surrounds Clinical Commissioning Group (CCG) and Cannock Chase
Clinical Commissioning Group are pleased to comment on this Quality Account for
2018/2019.
Local CCGs are committed to working closely with Starfish Health and Wellbeing to
improve standards of quality and safety for the services they commission within
Stafford and Cannock. Formal monitoring of the quality and safety is undertaken
through the Clinical Quality Review Meetings (CQRM) which meets once a quarter
with representation from Starfish Health and Wellbeing and the CCG. Staff from both
organisations work closely together to address any quality concerns as they arise.
Review of 2017/2018
The CCG believes that this is a positive account of the key quality improvements that
have taken place over the past 12 months. Of particular note are the following:
• The organisation works with patients who have a long-term condition (LTC) to
offer an integrated approach to pathways.
• Formal complaints are low – organisation-wide there were 19 complaints with
9256 patients entering treatments. Themes and trends have been identified
with actions to address in place.
• Patient satisfaction levels are high at 98% for the patient experience
questionnaires.
The CCG looks forward to continuing to work with Starfish Health and Wellbeing in
2018/2019 to continue the positive work with the organisation and to maximise the
opportunities for the quality and safety of local patients. Commissioners will be
working with the provider to review and redesign pathways for patients within Stafford
and Cannock and to share learning across the organisation to embed best practice.