Account DRAFT Quality - Sefton · 2017-05-02 · DRAFT Quality Account 2016/17 ... 2.7 Sign Up to...

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DRAFT Quality Account

2016/17

This Quality Account can be made available in a range of languages and formats on request.

An executive summary is available via the Mersey Care NHS Foundation Trust website.

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Contents

1.0 PART ONE: Introduction and Statement on Quality by Chief Executive ...41.1 Introduction and Statement on Quality by Chief Executive...............................4

1.2 Our Strategic Direction: Transforming our Trust ...............................................5

1.3 Improving Quality (STEEEP) ............................................................................6

1.4 Pursuing Perfect Care.......................................................................................6

2.0 PART TWO: Priorities for Improvement 2017/18 and Statement of Assurance from Board ...................................................................................8

2.1 Priorities for Improvement 2017/18...................................................................8

2.2 Review of Quality Performance 2016/17 ........................................................10

2.3 Statements of Assurance from the Board: Review of Services ......................17

2.4 Participation in National and Local Clinical Audits and National Confidential Enquiries .........................................................................................................18

2.5 NHS Staff Survey Results 2016......................................................................202.6 Research and Development ...........................................................................212.7 Sign Up to Safety Campaign...........................................................................252.8 Commissioning for Quality and Innovation (CQUIN) ......................................282.9 Care Quality Commission ...............................................................................332.10 Duty of Candour..............................................................................................372.11 Data Quality Improvement Plans ....................................................................382.12 Information Governance .................................................................................39

3.0 PART THREE: QUALITY INDICATORS........................................................40

3.1 Quality Indicators ............................................................................................403.2 Re-admissions ................................................................................................463.3 Performance against NHS Improvement's Single Oversight Framework

Indicators.........................................................................................................463.4 Stakeholder Metrics ........................................................................................47

ANNEX 1: STATEMENT FROM COMMISSIONERS, LOCAL HEALTHWATCH ORGANISATIONS AND OVERVIEW AND SCRUTINY COMMITTEES ...................50

ANNEX 2: STATEMENT OF DIRECTORS’ RESPONSIBILITIES FOR THE QUALITY REPORT....................................................................................................................................51

ANNEX 3: TRUST CLINIC AUDIT REPORT 2016/17 .................................................................53

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1.0 PART ONE: Introduction and Statement on Quality by Chief Executive

1.1 Introduction and Statement on Quality by Chief Executive

We are delighted to present on behalf of the Trust Board, the Mersey Care NHS Foundation Trust Quality Account for 2016/17. This provides details of how we have improved the quality of care we provide, particularly in the priority areas we set out in our previous Quality Account (2015/16). The purpose of our Quality Account is to:

enhance our accountability to our service users, carers, the public and other stakeholders of our quality improvement agenda

enable us to demonstrate what improvement we have made and what we plan to make

provide information about the quality of our services show how we involve and respond to feedback from our service users,

carers and others ensure we review our services, decide and demonstrate where we are

doing well but also where improvement is required.

We continue to make quality the defining principle of the Trust and demonstrate quality improvements in the care and services we provide. To assist us in determining our priorities for quality improvement for 2016/17 a range of engagement events were held with key stakeholders.

Mersey Care is striving to provide perfect care for the people we serve. At its core, this means we are an organisation that does not accept compromises in the quality of care or minimum targets set by others, but supports learning and improvement in our services so that we strive to get the basics of care right every time, for every service user. This is a bold ambition in difficult times, but with engaged and motivated staff and supportive commissioner and partner organisations, we firmly believe it is possible.

We hope that you find our Quality Account helpful and informative. The information supporting the content of the Quality Accounts is to our knowledge accurate and will be published by the Board on 31 May 2017.

_______ Date Chief Executive

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1.2 Our Strategic Direction: Transforming our Trust

The Trust is striving to provide perfect care for the people we serve and make a positive difference to the lives of service users and carers. In order to pursue perfect care, we believe that change must happen across four domains of our services, our people, our resources and our future. Three years ago, we recognised the scale of the challenge for us in continuing to improve services and their quality in the context of a more competitive, financially constrained environment. As a result, we embarked on a co-ordinated programme of strategic change to our service and workforce models in order to continue to meet people’s increasingly complex needs within the resources available to us. Our strategy is set within a long term financial framework which entails savings of £6.2 million in 2017/18 and £5.4 million in 2018/19 from service and workforce model redesign in local and secure services, to invest in our major estate schemes (Southport, Liverpool 2 and Medium Secure Unit in Maghull) of £109.7m over coming years.

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Our services – we will improve the quality of our services, and strive to provide safe, timely, effective, equitable and person-centred care every time, for every service user. As we strive for continuous improvements in quality, we will also strive for find ways to save time and money.

Our people – we will have a productive and high performing workforce that work in great teams, and we will work side by side with service users and carers.

Our resources – we will make full use of our resources, ensuring our buildings work for us, and using technology to help improve our care.

Our future – we will create opportunities for improvement and grow in the future, by working more closely with primary care and other organisations, delivering the benefits of research, development and innovation, and by growing our services.

1.3 Improving Quality (STEEEP)

Providing high quality services in safe environments is our core purpose. As such, we start from a strong underlying position on quality. This is reflected in our CQC ‘Good’ rating in 2015. We await the report from a further inspection of our services in March 2017.

We plan to improve quality through Perfect Care in 2017-19 by developing a standard operating platform; continuing with our perfect care programme and implementing transformation plans in our clinical and corporate services.

1.4 Pursuing Perfect Care

Perfect Care means getting the basics of care right every time, whilst setting our own stretching goals for improvement and relentlessly pursuing safer care through a learning culture. In practice this means that we try to make every episode of care safe, timely, effective, equitable and positively experienced (STEEEP).

We have set ambitious goals in pursuit of perfect care:

Adopt a 'No Force First' approach (avoid physical restraint, including medication-led restraint)

Zero suicide for those in our care Physical health for service users A just and learning culture – promoting accountability within a blame-free

environment

Priorities for safe care will be the roll out of suicide prevention training across all Divisions and fully embedding No Force First on all wards with individual ward action plans that are clinically specific. We will adopt the new National Safe Sustainable Staffing improvement resource and review all inpatient and community teams at regular intervals and continue to report staffing levels on a monthly basis. We will also continue to implement the Partnership for Patient Protection programme (P4P2) via the violence reduction project in the Specialist Learning Disability Division and the self-harm project across Local and Secure Divisions.

Timely care priorities will be to address access issues for our Talk Liverpool IAPT service and improve access to tier 3 and 4 psychological therapies and

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psychotherapy. We will also focus on meeting new targets for access to treatment for first episode psychosis and access to CBT and psychology in our secure services. As a partner in the local health economy, will work to deliver 24 hour mental health crisis care, including the new liaison response times of 1 hour in A&E and 24 hours on acute wards. Delivery of these new access and waiting time standards is dependent upon funding from our commissioners.

Priorities for the delivery of effective care will be to improve the ‘flow’ of service users in local services through developing alternatives to inpatient admission, reducing length of stay through bed management, and supporting discharge through developing step down services and addressing delays in discharge caused by social factors. We will implement a new structure for community mental health teams and ensure a greater focus on people with complex needs on care programme Approach (CPA) in order to reduce their caseload. In secure services we will focus on discharge from low secure services and the community forensic team. We will also target our improvements efforts on physical health, to ensure that metabolic screening is undertaken comprehensively using the Lester tool and that physical health risk factors are addressed.

Equitable care priorities will be the development of a sensitive and comprehensive understanding of the needs of service users at service level and to address the priorities identified.

To deliver person-centred care we will work closely with the clinical teams that have seen an increase in complaints to address any root causes. As we implement other aspects of our transformation plan in local services (e.g. a new crisis pathway, a new structure for community mental health teams) we expect patient experience scores to improve. We will also focus on achieving 90% compliance with the Triangle of Care and establish peer-run carer support groups throughout the Trust.

Our pursuit of perfect care in our services depends on a ‘just and learning organisational culture’. People make errors, and errors cause accidents. In healthcare, errors and accidents result in morbidity and adverse outcomes, and sometimes mortality. The trust has been progressing plans to develop a just and learning culture at Mersey Care. This has been informed by the significant input from the wide range of engagement events throughout the trust over recent months. The engagement has enabled the Trust to draft a high level goal aimed at addressing the issues that inhibit reporting and learning and ultimately stop us from delivering Perfect Care. We are planning incremental yet significant changes to fundamental aspects of organisational and procedural management to create a just and learning culture for all.

To achieve our perfect care goals we will us the same improvement methodology across the organisation. This will be the Institute for Health Improvement’s ‘Model for Improvement’ supplemented, where appropriate, by teams of experts using Design Thinking methodology. This will ensure an empathic approach to problem solving and improving quality which is standardised and easily utilised by clinicians in the clinical divisions.

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2.0 PART TWO: Priorities for Improvement 2017/18 and Statement of Assurance from Board

2.1 Priorities for Improvement 2017/18

In preparation for our Quality Account the Trust has undertaken a process of involvement and engagement with key stakeholders to establish their views on what our key priorities for 2017/18 should be.

Representatives from the following groups have been engaged and invited to provide feedback;

Healthwatch for Liverpool, Sefton and Knowsley Local Overview and Scrutiny Committees NHS England (Cheshire and Merseyside) Liverpool Clinical Commissioning Group South Sefton Clinical Commissioning Group Southport and Formby Clinical Commissioning Group East Lancashire CCG Knowsley Clinical Commissioning Group Council of Governors Local service user groups

In addition to the above, the perfect care steering group has considered suggestions for 2017/18 quality improvement priorities. These are consistent with the six key elements in the Trust Model of Quality: STEEEP:

Safety of Patients Timely care Effectiveness Efficient care Equitable care Positive patient experience

After consultation and discussion with key stakeholders and with the Trust Board the areas of quality improvement for 2017/18 will be:

Priority 1: No Force First

1) By September 2017 all wards will implement a debriefing protocol after incidents for both service-users and staff to ensure individual and organisational learning takes place following incidents.

2) By March 2018 the core strategies from the Reducing Restrictive Practice Guide will be implemented on all wards. The wards will produce evidence of these strategies and the impact on the ward. This will be reported into the Reducing Restrictive Practice Monitoring Group.

3) By March 2018 planned prone restraint (face down floor based restraint) will be reduced by 20% as part of our longer term strategy to eliminate completely.

4) By March 2018 a Research Evaluation of the programme will be completed by Liverpool University.

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Priority 2: Towards Zero Suicide

1) By September 2017 a Suicide prevention dashboard will be in place to track and monitor progress on the 10 key parameters for safer mental health services. By March 2018 a report will be produced on the effectiveness of the dashboard as a performance improvement tool, to support clinical decisions.

2) By March 2018, the safety planning intervention will be integrated to the Level 2 Suicide Prevention training and will be made available at high risk points and there will be a core staff group able to implement the plan.

3) By March 2018 in-patient wards will be implementing a design based solution to reduce self-harm, with an evaluation completed.

4) By March 2018 a proof of concept study on the zero suicide app in conjunction with Stanford University will have been completed.

5) The Safe from Suicide team will continue to monitor and measure suicide and near-fatal self-harm data and respond with enhanced support and interventions, including training, supervision, psychologically informed risk formulations and safety planning. Specific team based interventions will result from the suicide data, where problems are identified.

Priority 3: Improvements in Physical Health Pathways

1) By September 2017, the physical health pathway for community service users on care programme approach will be fully implemented.

2) By March 2018 65% of community service users on CPA will have a completed physical health pathway.

3) By March 2018, there will be a 90% uptake of the Annual Health Check (AHC) for all long stay inpatients across all clinical divisions.

4) By March 2018, 100% of inpatients screened as smokers will have prescribed nicotine replacement therapy on admission.

Priority 4: A Just and Learning Culture

1) Within one week of an incident, a copy of its 72 hour review will be shared with all members of the relevant teams (July 2017).

2) Good practice stories will be published every month in order that we can extract the maximum possible learning from things that go well and from things that did not go as expected (September 2017).

3) We will publish quarterly data on our web site to transparently demonstrate whether our staff have felt supported when things in our care haven't gone as expected (September 2017).

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Monitoring and Reporting Arrangements

A nominated lead will be identified for each priority and will chair a work stream forum which will coordinate progress and monitor activity.

The delivery of the Quality Account will be monitored by the Centre for Perfect Care Committee and reported to the Quality Assurance Committee and the Executive Committee, both of which are committees of the Board.

The above priorities are all aligned to the Trust’s Strategic Framework and ensure quality remains at the forefront of our agenda.

2.2 Review of Quality Performance 2016/17

In June 2016, the Trust published its Quality Account reporting on the quality of services against six areas of priority. Following engagement with key stakeholders the following priorities would be the key areas of quality improvement:

Priority 1: No Force FirstPriority 2: Towards Zero SuicidePriority 3: Improvements in Physical Health Pathways

The following table summarises the elements of achievements in relation to these priority areas.

Table 1: Quality Account Progress 2016/17Priority Description Delivery

1 No Force First1) By July 2016, individualised performance outcomes

and targets will be developed for each inpatient area.

2) By July 2016, a guide of strategies for implementing No Force First will be developed and roll-out commenced.

3) By July 2016, a research project will commence to evaluate the impact of on ward safety, staff and service user satisfaction and workforce metrics.

4) By September 2016 a policy on reducing restrictive practice will be developed.

5) By March 2017 there will be a further 20% reduction in restraint from the baseline, across all wards.

Achieved

Achieved

Achieved

Achieved

Achieved

2 Towards Zero Suicide1) By March 2017, safety planning intervention to be

embedded at the following high risk points in local services:a. Safe inpatient discharge plan pathwayb. Stepped Up care pathway.

Partially Achieved

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Priority Description Delivery

2) By March 2017, all staff in primary service user contact roles will have undertaken level 2 team based clinical risk management and intervention training.

3) By December 2016, the Safe from Suicide team will monitor and measure suicide and near-fatal self-harm data and respond with enhanced support and interventions, including training, supervision, psychologically informed risk formulations and safety planning.

4) By December 2016, four pilot wards will have implemented a design based solution to reduce self-harm. This will be rolled out across all inpatient wards by March 2017.

5) By December 2016, a ‘zero suicide app’ will be developed for implementation across the Trust (in conjunction with Stanford University).

Partially Achieved

Achieved

Partially Achieved

Achieved3 Improvements in Physical Health Pathways

1) By October 2016, the community physical health pathway will be reviewed and implementation of revised standard will commence in January 2017.

2) By March 2017, 100% of community service users on Care Programme Approach will have a completed physical health pathway.

3) By December 2016, 100% of inpatients will have metabolic screening completed in line with the National Audit of Schizophrenia standards.

4) By March 2017, all inpatients screened as smokers will have prescribed nicotine replacement therapy on admission.

Partially Achieved

Not Achieved

Partially Achieved

Partially Achieved

Detailed Progress on Quality Account Objectives 2016/17

Priority 1 Progress: No Force First

No Force First (NFF) is Mersey Care’s Restrictive Practice Reduction Programme and is a central priority for the organisation. The impact of No Force First on wards, when implemented well, reduces conflict and restraint and associated work related sickness with significant benefits for service users and staff.

The programme has progressed well this year and built upon the successful roll out to all areas across the Trust achieved in March last year. The focus of this years work

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has been to achieve more comprehensive and sustainable structures to monitor, deliver and integrate the approach in clinical practice.

Objectives 2016/17;

a) By July 2016, individualised performance outcomes and targets will be developed for each inpatient area. Data is provided to all ward managers relating to incidents and restraints. This provides highly detailed information on a weekly basis so that staff can identify trends e.g. time of day, level of restraint, staff involved etc. to enable ward staff to identify specific areas they wish to target.

b) By July 2016, a guide of strategies for implementing No Force First will be developed and roll-out commenced. The guide was delayed for a number of reasons : 1) consultation with divisions and co-production with service –users took a lot longer than expected 2) When SpLDD was acquired consultation and incorporation of their Safewards approach was necessary so staff continued the progress they had made with Safewards but also adopted the philosophy of No Force First 3) There were a number of evidence based tools which were outwith of NFF that were being used to reduce restrictive interventions, conflict and incidents e.g. the DASA ( Dynamic Appraisal of Situational Aggression ) it was considered helpful to include these tools in the guide so that wards could also include these interventions in their tool box of strategies to reduce restraint. The guide is now complete and we are in the process of developing a strategy for roll out across all in-patient wards.

c) By July 2016, a research project will commence to evaluate the impact of NFF on ward safety, staff and service user satisfaction and workforce metrics. A research project by an MSc student was carried out of a thematic analysis of NFF interviews from 10 staff across the service and two focus groups in May- August 2016. A driver diagram has been generated consisting of action-orientated solutions to address the key areas identified to improve the sustainability of the strategy in the future.

d) The research in collaboration with Professor Richard Whittington and Dr Alina Haines at Liverpool University took some time to establish due to releasing research staff, HR processes and contracts. It is currently ongoing and represents an analysis of the qualitative experience of NFF for service –users and staff. Phase one of the project relates to the are starting initially to evaluation of the secure division pilot wards, Phase two will be a wider analysis of the approach. Locktons still provides ongoing actuarial analysis of the data trends.

e) By September 2016 a policy on reducing restrictive practice will be developed. A Reducing Restrictive Practice Policy has been developed to outline the Trusts key strategic commitment to reduce conflict, restriction and harm to service users and sets out the organisations commitment to least restrictive principles. This has been approved and is in the current policy set. In addition this work has been further expanded to include a prohibited items protocol and a number of governance groups have been established both divisionally and Trust wide to ensure appropriate monitoring and governance of the principles set out in this policy.

f) By March 2017 there will be a further 20% reduction in restraint from the baseline, across all wards. As a Trust there was an overall reduction in

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restraint of 22% from the April 2015 baseline to March 2016. Over this period assaults on staff also reduced by 13.9 %.

Table 1 - Trust Restraint Data

Table 2 - Trust Assault Data

Table 3 - Trust Assaults Resulting in Harm Data

Wards across the Trust vary in performance and base rates of restraint. One of the trends identified in the data from Secure division and some areas in SPLDD is that the length of time in restraint has reduced and also the level of restraint applied has been lowered e.g. using supportive arm holds (secondary physical intervention) rather than an emergency on the floor restraint (tertiary physical intervention).Both these developments are likely to improve the experience for service-users in this area and reduce work related sickness as a consequence. One of the main challenges going forward is to review the way we give intermuscular medication as this could potentially reduce a significant number of restraints, especially in the prone position. This has been an objective set for next year.

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Priority 2 Progress: Zero Suicide

Dr Rebeca Martinez, Consultant Psychiatrist/Associate Medical Director for Suicide Prevention, is the identified lead for this priority area and chairs the Safe from Suicide team established to oversee the implementation of the Zero Suicide Strategy and Policy.

Objectives 2016/17

a) By March 2017, safety planning intervention to be embedded at the following high risk points in local services: Safe inpatient discharge plan pathway Stepped Up care pathway.

The co-designed Safety Planning intervention has been implemented on Brunswick Ward, Baird House Stepped Up Care, Park Unit and Southport Stepped Up Care teams. An evaluation report has been produced with recommendations for future implementation, e-learning support, sustainability and implications for safety and feasibility.

The intervention has not been embedded at all high risk points as planned, due to the time intensity of the intervention, and the high volume service settings targeted. A PDSA cycle is underway examining the feasibility of implementing an alternative simplified version of the safety planning modelbased on the the Columbia Safety Plan. This has been rolled out at Clock view, the conclusion of the evaluation report is expected by June 2017 at which point the Safe from Suicide Team will make a decision about the way forward for an organisation wide intervention.

b) By March 2017, all staff in primary service user contact roles will have undertaken level 2 team based clinical risk management and intervention training

The Level 2 suicide prevention training package has been co produced and piloted in different iterations with Park Lodge, Southport and Clock View- the pilot process with Clock view and Southport is continuing. Additional facilitator training/resource pack will be completed by May 2017. An evaluation report of the training pilot will be completed by September 2017.The SfS team do not have the resources to deliver the training across the organisation as originally envisaged. Following the pilot the team will make recommendation regarding the delivery model for the level 2 training.

The objectives for this priority are partially completed, the major obstacle has been the resource for implementation across the organisation. An alternative model of team based implementation will be tested in 2017/18, which will allow the Divisions to take ownership of the training implementation, this will be part of a phased implementation approach.

The Level 1 suicide prevention training has now been undertaken by over 80% of staff, with an initial positive evaluation of the training. A refresher module will be available from May 2016. A generic module will be completed by June 2017 and will be made available to outside organisations and evaluated.

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c) By December 2016, the Safe from Suicide team will monitor and measure suicide and near-fatal self-harm data and respond with enhanced support and interventions, including training, supervision, psychologically informed risk formulations and safety planning.

The Safe from Suicide Team is now working in partnership with the clinical divisions to review all deaths and serious self-harm to ensure there is adequate follow-up, support and, where appropriate, the necessary interventions. This has included 2 Oxford model events, support for the GP referral and triage process in local division and supporting the Southport Action Plan.

We have identified and priuoritised for action areas identified with higher than expected suicides, and engaged clinicians with support and training.The safe from Suicide team additionally has a quarterly review to identify any themes arising from the deaths, to ensure a data driven approach to our interventions.We have been collaborating with Manchester University who will carry out an external evaluation of the interventions implemented as part of the Zero Suicide Program.

d) By December 2016, four pilot wards will have implemented a design based solution to reduce self-harm. This will be rolled out across all inpatient wards by March 2017.

Four wards are engaged with the Centre for Perfect Care and using a Design Thinking methodology have been engaged in the process of finding solutions which are locally appropriate for the reduction of self-harm in in-patient settings.Poplar and Dee Ward are already working on the implementation of solutions whilst Harrington and Arnold have developed models for implementation.

e) By December 2016, a ‘zero suicide app’ will be developed for implementation across the Trust (in conjunction with Stanford University).

Approval to move to the next stage of development for the ‘zero suicide app’ was granted in November 2016. An ethics application has been submitted to do a “proof of concept study” on three in-patient settings within Mersey Care. This project is collaboration with Stanford University, both parties maintain fortnightly contact to work through the issues surrounding the app and ensure there is continuous development and movement towards the end product.

The application has been developed and is currently been optimised for the initial phase of the research study. Ethics approval has been granted for the study.

Priority 3: Progress Improvements in Physical Health

Dr Simon Tavernor, Consultant Psychiatrist is the nominated lead for this priority area. A Trust wide physical strategy group supports and oversees this priority area.

a) By October 2016 the community physical health pathway will be reviewed and implementation of revised standard will commence in January 2017.

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Due to a delay with in the Local Division for agreement of the community pathway work did not commence on developing this until February 2017. The pathway has now been developed alongside clinicians and the performance team and is in line with the standards for cardiometabolic screening and intervention set out in the Lester Tool (2014) and will be launched in epex at the end of April 2017.

b) By March 2017 100% of community Service Users subject to CPA will have a completed physical health pathway

There has been a change in the parameters of what has been measured for this indicator in 2016/17.

2015/16 indicator reported on ‘Service Users on CPA who had ever had an Annual Health Check’ however the indicator for 2016/17 has reported on ‘Service Users who receive an Annual Health Check once a year’.

The number of community patients who have had an annual health check is detailed in Table 1. The Trusts current position is 54.53%, there has been a gradual improvement on performance (December 2016 - 50.26%, March 2017 – 51.26%). Delays in the implementation of EMIS has impacted on this performance, this has been due to the upgrading of computers required across the Local Division to be EMIS compatible. This upgrade is expected to be completed in June 2017 which will allow training to be commenced which will be target ted at the Community Hubs in the first instance.

Table 1 – AHC Community Physical Health Assessment (20/4/2017)Division Service Line Numerator Denominator %

Adult Mental Health Services

1264 2315 54.60 %

Assessment Services

7 11 63.64 %

Complex Care Services

22 48 45.83 %

Specialist Services

99 162 61.11 %

Local Division

Local Division Total

1319 2429 54.30 %

Forensic - Low Secure

2 2 100.00 %

Forensic - Medium Secure

28 36 77.78 %Secure Division

Secure Division Total

29 37 78.38 %

Trust Total 1341 2459 54.53 %

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c) By December 2016 100% of inpatients will have metabolic screening completed in line with the National Audit of Schizophrenia standards.

d) By March 2017 100% of all inpatients identified at risk, following cardio metabolic screening, will have a record of interventions offered.

The Trust has taken part in the CQUIN 2016/17 which as a mental health indicator has submitted a sample of 100% of eligible cases, to date the trust has not revived the results, these are expected May 2017.

e) By March 2017 all inpatients screened as smokers will have prescribed nicotine replacement therapy on admission.

As part of Mersey Care’s commitment to improve the physical health of people using mental health services the trust is committed to:

Supporting Service Users to Stop Smoking Improving the smoke free status of the service. Adhering to NICE guidance on interventions. Providing continued support during leave and discharge.

The Trust introduced the key performance indicator “By March 2017, all inpatients screened as smokers will have prescribed nicotine replacement therapy on admission”; this was to coincide with Local Division becoming ‘Smoke Free’ and aligning with Secure Division who have already delivered on this NHS priority.

The Local Division introduced ‘Smoke Free’ in August 2016 but faced with a number of challenges the programme was suspended in September 2016. Since this date the Trust has been in the planning stages to reintroduce the initiative. An audit was completed of all smokers on all inpatient wards in March 2017 to establish a baseline position of nicotine replacement therapy prescribing practice upon admission, as this was considered fundamental to the successful reintroduction of ‘Smoke Free’.

The audit results highlighted that at present it is not practice to routinely prescribe nicotine replacement therapy; the focus is upon those people who express a wish to give up smoking. However, there is the recognition that routine prescribing for all smokers will be in place when the policy is fully implemented for inpatients in September 2017.

Improvement Plans for Physical Health

The Trust has commissioned a Service Evaluation of the Provision of Physical Health. This is a joint piece of work in conjunction with Edge Hill University. The evaluation commenced in February 2017 and will be undertaken in 2 phases with a final report and recommendations to be tabled at the Quality Assurance Committee in July 2017. A lead modern matron for physical health has been appointed for the local division to focus on developing physical health strategies and interventions. This position will support progress for 2017/18.

Phase 1 – will review the current strategy and policies against national standards and guidance, review the governance arrangements including all meeting, ward to board reporting and review of the delivery of the physical

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health standards of care for inpatients and community to ensure they are meeting the requirements for the National CQUIN.

Phase 2 – will review roles and responsibilities for the provision of physical health care across the workforce including identifying training and development needs, identify areas of best practice across the Trust and identify opportunities and challenges to deliver physical health care work within the workforce.

2.3 Statements of Assurance from the Board: Review of Services

During 2016/17 Mersey Care NHS Foundation Trust provided 42 NHS services to NHS Commissioners, including public health (local authorities).

Druing 2016/17, the Trust contracted with:

1) NHS Liverpool CCG (with Liverpool City Council) and NHS Sefton CCG (and associates), for local mental health, learning disability and addiction services across the Liverpool, Sefton, Knowsley, Halton, St Helens and West Lancashire areas.

2) Liverpool, Sefton, Knowsley, Halton, St Helens, Wirral and Lancashire Local Authorities for addiction services.

3) NHS England (through its regional and various sub-regional teams) for:

a) low, medium and high secure services and colleagues from NHS Wales in respect of high secure services

b) low & medium and high secure Services for specialist learning disabilities services

c) personality disorder services at HMP Garth.

4) Aintree University Hospitals NHS Foundation Trust for the Liverpool Community Alcohol Service and psychological support for Weight Management and Bariatric Services.

5) Walton Centre NHS Foundation Trust for Neuropsychology and Neuropsychiatry services.

6) Manchester Mental Health and Social Care Trust for psychiatry services to HMP Manchester.

7) National Probation Service for community personality disorder services, Resettle and Psychologically Informed Planned Environment (PIPE) services.

8) East Lancashire CCG for Enhanced Support Services.

9) Lancashire Care NHS Foundation Trust for Dental services for low and medium secure services.

10) Lancashire Care NHS Foundation Trust for Speech and Language Services.

The Trust also provides staff support services to a number of local NHS and non-NHS organisations, and hosts Informatics Merseyside.

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Mersey Care has reviewed all of the data available on the quality of care in all of these services.

The income generated by the NHS services reviewed in 2016/17 represents 100% of the total income generated from the provision of NHS services by Mersey Care NHS Foundation Trust for 2016/17.

2.4 Participation in National and Local Clinical Audits and National Confidential Enquiries

National Clinical Audit Reports 2016/17

During 2016-2017 six national clinical audits and one national confidential enquiry covered relevant health services that Mersey Care NHS Foundation Trust provides.

During that period Mersey Care NHS Foundation Trust participated in 100% of national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries which it was eligible to participate in.

The national clinical audits and national confidential enquiries that Mersey Care NHS Foundation Trust was eligible to participate in during 2016/2017 are as follows:

National Confidential Enquiry into Suicide and Homicide by people with Mental Illness

National Physical Health CQUIN of Cardio Metabolic Assessment for patients with Schizophrenia

POMH: Prescribing Valproate for Bipolar Disorder POMH: Prescribing Antipsychotic Medication for People with Dementia POMH: Monitoring of Patients Prescribed Lithium POMH: Rapid Tranquillisation POMH: Prescribing High Dose and Combined Antipsychotics

The national clinical audits and national confidential enquiries that Mersey Care NHS Foundation Trust participated in during 2016/2017 are as follows:


National Physical Health CQUIN of Cardio Metabolic Assessment for patients with Schizophrenia

POMH: Prescribing Valproate for Bipolar Disorder POMH: Prescribing Antipsychotic Medication for People with Dementia POMH: Monitoring of Patients Prescribed Lithium POMH: Rapid Tranquillisation POMH: Prescribing High Dose and Combined Antipsychotics

The national clinical audits and national confidential enquiries that Mersey Care NHS Foundation Trust participated in, and for which data collection was completed during 2016/2017, 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.


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National Physical Health CQUIN of Cardio Metabolic Assessment for patients with Schizophrenia – 100% for community patients and 100% for inpatients (awaiting final report)

POMH: Prescribing Valproate for Bipolar Disorder 100% (awaiting final report)

POMH: Prescribing Antipsychotic Medication for People with Dementia 100%

POMH: Monitoring of Patients Prescribed Lithium 100% POMH: Rapid Tranquillisation 100% (awaiting final report) POMH: Prescribing High Dose and Combined Antipsychotics 100%

(awaiting final report)

The reports of 3 national clinical audits were reviewed by the provider in 2016/2017 and Mersey Care NHS Foundation Trust intends to take the following actions to improve the quality of healthcare provided:

Recommended actions from the POMH: Prescribing Antipsychotic Medication for People with Dementia audit are:-

1) Due to the small sample size it is recommended to run an internal audit looking at the same standards but over a more extensive time period. Re-audit to take place March-May 2017 and report to July DTC.

2) Recording of data on to was a concern across the wards audited – LK full name to feedback concerns to CIS/Digital Board. QPA to be circulated within the local division.

3) Recommended actions from the POMH: Prescribing for substance misuse: alcohol detoxification. Audits (2015/2016)are: -

4) Recording of blood tests, and physical health tests require improvement. LK to report to the Physical Health Care group and AMD for Physical health Care.

5) Thiamine although prescribed for a significant number of service users was prescribed orally not parenterally. LK to raise issue with the specialist trust team at Windsor Clinic. Report back to DTC in January 2017.

Recommended actions from the POMH: Monitoring of Patients Prescribed Lithium. Audit have just been received and the results are being analysed.

Participation in Trust Wide Clinical Audits

The reports of 38 clinical audits were reviewed by the Trust in 2016/2017 and it intends to take action to improve the quality of healthcare provided (see appendix 1 for list of clinical audit topics and brief synopsis).

All of the Trust’s clinical audits are presented to and reviewed by the Quality Assurance Committee and Audit Committee and provide the assurance that quality issues are being addressed at Board level. The Trust encourages all services to be quality focused and as such encourages all clinical areas and disciplines to participate in the review of services through clinical audit. Audit findings have been shared at divisional governance forums.

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Please see Annex 3 for Local Clinical Audit Report 2016-17.

2.5 NHS Staff Survey Results 2016

Indicators KF19 (percentage of staff experiencing harassment, bullying or abuse from staff in the last 12 months).

Any comparison to 2015 scores is as a guide only and is not statistically valid due to the significant changes in the organisation over the past 12 months.

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Key Finding 2016 National Average ( MH/LD)

Threshold for average score

2015 Comment

KF26 - %age of staff experiencing harassment, bullying or abuse from staff in last 12 months (lower the better)

20% 22% 21% - 25% 19% Deteriorated by 1% since 2015 but still above national average

KF 21 percentage of staff believing that the organisation provides equal opportunities for career progression or promotion (higher the better)

82% 87% 83% - 88% 81% Improved since 2015 but still 1% below the national average

2.6 Research and Development

The Trust has continued to give priority to supporting NIHR (National Institute for Health Research) adopted studies along with a large variety of student, staff and internally generated research studies. The Trust has 99 open studies, of which 34 are adopted NIHR studies and the remaining 52 are student, 2 CLAHRC and 11 Trust specific studies. Performance metrics for NIHR adopted studies are based on approval times and delivery of participants to time and target and the Trust has consistently achieved these over the past year.

The number of service users recruited during this period to participate in research, approved by a research ethics committee was 747. In addition, 162 staff and 130 carers participated in research studies along with 11 participants from case file/other research projects – a grand total of 1,039 this year (compared to 794 last year – a 31% increase)). Of these, 426 service users, 63 carers and 31 staff (a total of 520) recruits were from NIHR adopted portfolio studies and 519 from non-adopted studies

The acquisition of Calderstones NHS Partnership Trust has resulted in the research team at Mersey Care expanding by two posts with a more diverse and welcome range of skills and studies.

The range of studies being supported continues to be varied including learning disability, mental health, forensic, genetics, dementia, perinatal mental health, liaison and diversion services and offender personality disorder pathway. Studies have expanded to include several technology focused studies supporting service users and carers living in the community.

Recruitment, consent and retention into mental health and dementia studies continues to be complex and often time-consuming due to the nature of our service users’ ill health. Despite this, one of the highest recruiting studies this year was to a dementia study gathering health information from people with memory problems where 99 service users and carers took part.

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The R&D team also invested resources in additional studies which were withdrawn, not approved or did not progress to full application: eg. study review, expressions of interest not relevant, studies deemed audit/innovation/evaluation.

The Specialist LD (SpLD) Division staff supported and undertook several evaluations and internal Trust generated projects which lead to 9 articles and research papers published in peer reviewed specialist journals. Staff and students attached to the SpLD Division have been active in attending and presenting sessions at a number of conferences over the past 12 months to share evidence based and innovative practice. Ten clinicians from SpLD Division attended 15th International Conference on the Care and Treatment of Offenders with a Learning and/or Developmental Disability to present research findings and feedback on innovative practice within the Trust. Topics presented included reducing the use of restraint in secure services, a preliminary evaluation of seclusion room contactless monitoring technology, a creative arts project to explore autism, the role of Occupational Therapy in supporting people with behaviour which challenges services, working with NOMS to improve support for people with learning disabilities in probation and feedback from a study into working with carers/families of people in secure services. The R&D team based in SpLD Division has continued to hold regular CPD sessions to update on key research topics and methodologies: these have included thematic analysis based; critiquing published literature using the CASP (Critical Appraisal Skills Programme), Research and Innovation priorities and writing for publication. The R&D team extend these sessions to other research interested personnel in the Trust.

The Secure Division has been successful in developing a programme of PhD studentships focussing on their specialist areas of need along with relevant publications.

The Trust continues to support several studies within the National Confidential Inquiry into Suicide and Homicide by People with Mental Illness (NCISH) programme.

The Trust successfully hosted the final phase of a two year NIHR funded study led by a psychologist in the Trust, working in collaboration with the Universities of Liverpool and Bangor. This project investigated the application of a human rights based approach to healthcare and if this lead to significant improvements in the care and wellbeing of people with dementia in hospital inpatient and care home settings. The results are currently in the process of being written up for submission to peer reviewed journals.

Recruitment is underway to a successful joint research funding (NIHR Research for Patient Benefit programme) bid between the Trust, UCLAN, University of Manchester, Lancashire Care NHS Trust and MAHS-CTU for project entitled: A feasibility trial of glycopyrrolate in comparison to hyoscine hydrobromide and placebo in the treatment of clozapine-induced hypersalivation. This is building our capacity and knowledge in delivering trials. Delivery has been supported through funding from the NW Coast Comprehensive Research Network for 2 days per week of a clinical trials pharmacist on a fixed term basis until the end of March 2017 to build Trust capacity to deliver clinical trials in order to allow our service users access to new and innovative drug therapies.

Recruitment is underway to a randomised controlled trial (RCT) to investigate whether MBT (Mentalisation Based Therapy) is an effective treatment for high-risk men in the community with antisocial personality disorder as part of the Offender Personality Disorder Pathway. The Trust is one of only 11 sites in the UK and the study is being jointly delivered by the National Probation Service and partner Health

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Service Providers as an integrated part of the Offender Personality Disorder Pathways Strategy.

We continue to seek opportunities to increase research capability through training of staff as Principal and Chief Investigators and working with the CLAHRC and academia to develop opportunities for clinical staff to apply for PhD studentships.

Working with colleagues in Communications and IT a new Centre for Perfect Care website has been developed (www.centreforperfectcare.com/) which will raise the profile and knowledge of research externally.

The Research team is part of the Centre for Perfect Care and therefore closely linked with the three main priorities of No Force First, Zero Suicide and Physical Health. Discussions are underway on how the new priority of Delivering a Just and Learning Culture can be supported through aligned research projects. Through an established collaboration with the University of Liverpool entitled the Perfect Care Research Collaboration and the employment of a Research Associate and Research Assistants, several research and evaluation projects have been delivered to support the Perfect Care priorities and develop programmes of research to support Perfect Care. These have included safety planning; No Force First; DASA; HOPE (Hospital Outpatient Psychotherapy Engagement Service) evaluation (a service providing rapid access to psychological therapy, specifically tailored for those presenting at Accident & Emergency Departments in Liverpool City Centre following an episode of self-harm). The HOPE evaluation lead to a successful bid to Liverpool CCG for funding to investigate the potential for making a shift to delivering this self-harm intervention in the community. We continue to build links with University of Liverpool and The Reader organisation and more recently specifically around reading as a catalyst for prevention of self harm.

We have established and continue to build strong links and networks with other research active organisations including the Northwest Coast Academic Health Science Network (AHSN - now renamed to the Innovation Agency) Liverpool Health Partners (LHP), Northwest Coast Genomics Health Care Alliance and the Collaboration for Leadership in Applied Health Research and Care (CLAHRC). We have co-sponsored and supported the Household Survey with CLAHRC which has gathered information to support the discovery of local level and socio-economic factors that affect inequalities in physical and mental health. The full project is scheduled to be completed in 2018. We remain involved in the analysis of the data with other partners. The NWC AHSN, the NWC CLAHRC and LHP have provided opportunities for the Trust to build further research partnerships and opportunities for a wide variety of innovation initiatives. The R&D team is actively pursuing opportunities to secure commercial studies through the Joint Research Office at LHP and the CRN and also in setting up a memorandum of understanding with the clinical trials unit to set up phase 1 clinical trials. These developments have built upon the Trust’s established partnerships with academia, the CCG, service users and carers, city councils and third sector organisations.

We are members of the UK Pharmacogenetics and Stratified Medicine Network with positive and collaborations with pharmacogenetics at the Wolfson Centre for Personalised Medicine at the University of Liverpool continuing to be developed in the area of mental health.

The acquisition of the former Calderstones site has opened up opportunities to work more closely with the Lancaster University Health Hub which is a research collaboration between the Universities of Lancaster and Cumbria and seven NHS

http://www.centreforperfectcare.com/

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Trusts. The Lancaster Health Hub was set up in 2010 to support NHS Trusts with the academic and network links to enable them to develop high quality, externally funded research projects some of which may be eligible for the National Institute for Health Research (NIHR) Portfolio database. We have a number of collaborative studies being both planned and undertaken.

We continue to maintain links with the NW Coast Clinical Research Network, Liverpool University, Liverpool John Moores University, Edge Hill University, University of Central Lancashire, Chester University and Manchester University. High Secure Services have maintained and built upon their longstanding collaboration with UCLAN.

A review conducted in June 2016 of known academic research collaborations identified 56 active collaborations across the Trust. As a result we have been involved in a number of international, national and local research projects and external funding bids.

The trust is supporting several projects through international collaboration. These include Stanford University in California with a research project driving the development of a suicide prevention app along with colleagues from the University of Liverpool. International research links have included joint bids, honorary contracts, memorandums of understanding and joint working with colleagues in Norway, Netherlands, Switzerland, Sweden, Australia, Maastricht and the USA.

The Trust is a delivery partner in a national genomics project (100,000 Genomes Project) which aims to sequence 100,000 whole genomes from NHS patients to accelerate the development of new diagnostics and treatments. The project focuses on patients with rare disease and their families and the Trust is supporting the recruitment of participants with severe learning disabilities with associated congenital malformation and autistic tendencies. It enables Mersey Care to be formally involved in the emerging medical field of genomics. This project is not classed as research but a transformative programme to build infrastructure and knowledge in participating trusts

Engaging service users and carers is crucial to ensure the research leads to useful improvements and change for healthcare which is core to providing patient-centred care. Therefore, it is important to ensure that the research the Trust undertakes is representative, robust, unbiased and based on evidence. It is also important that the research team works with as wide a section of the population as possible. To facilitate this various means of communication are used to ensure that people know about what research is being planned and ways in which individuals can be involved. The ability to demonstrate meaningful participation within research from PPI groups promotes opportunities for external funding. Research funders such the National Institute of Health Research now require patient and public involvement as a condition of receiving research funding.

PPI involvement is a means of supporting and contributing to the research process as an advisor or co-researcher on areas such as the design or management of the study, and this is separate from participating in the research itself. The research team may require insight into a specific topic or health condition, and therefore require input from service users, carers or the public to allow them to ensure their research is most relevant to the needs of service users or carers. These views and opinions provide a different perspective to the view of NHS staff or the internal research team.

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To increase opportunities for service user and carer involvement in research and innovation we have launched our Consent to Contact process. This will allow interested people to register their interest in being contacted about potential research and innovation opportunities – as participants, members of research teams or receive information. This will be further promoted through the newly developed Centre for Perfect Care website with plans to investigate the development of a secure login in the coming year to supplement paper systems.

A bespoke training package for service users and carers has been developed in collaboration with University of Liverpool. This group is conducting their own piece of research on staff perceptions on the level of diagnosis of borderline personality disorder.

The R&D team based in the SpLD Division has undertaken significant discussions with service users, carers and staff to help inform and develop a research project being planned to look into physical health and wellbeing.

The Service User Magazine (News and Views) produced on a monthly basis is an effective communication method used by the SpLD to keep service users and staff informed of current issues within the Division. The R&D team regularly publishes articles within this magazine to ensure service users are up to date with R&D activity, how they can be involved and how they can contribute towards both research ideas and processes. The R&D team also liaise with the Media Crew (a group of service users that meets weekly to discuss and plan work that allows information to be accessible for service users) to request their expertise concerning research related information to ensure it is accessible and using appropriate language for the SpLD site population.

The R&D team are working with the central Communications Team to develop opportunities to promote research participation through the Centre for Perfect Care website, social media and the Mersey Cares Magazine.

A Research Facilitation Forum (RFF) has been established to act in an advisory capacity to influence the development of research ideas, conducting of research and to support and facilitate research in the field of mental and physical health. It performs a supportive role for the Centre of Perfect Care to support its objectives on research and development and innovation. The forum meets monthly and has multidisciplinary representation from across the trust.

The Trust has joined the UK-CRIS (Clinical Record Interactive Search) programme which is lead by the University of Oxford. This system will be deployed at several MH trusts with Mersey Care being the only partner in the NW region. UK-CRIS unlocks and transforms clinical data held in Trust systems to provide a rich and pseudonymised resource allowing researchers to investigate hypotheses and identify patient cohorts. CRIS will also provide an invaluable tool for service evaluation and audit. It will link to the new clinical notes system (RiO). The R&D team is working closely with Informatics and Information Governance to ensure a successful implementation in line with RiO.

2.7 Sign Up to Safety Campaign

Sign Up to Safety is a national initiative to help NHS organisations and their staff achieve their patient safety aspirations and care for their patients in the safest way possible.

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Mersey Care is committed to Sign Up to Safety and support the philosophy of locally led, self-directed safety improvement.

The original sign up to safety pledges were developed with the clinical divisions and signed off by the executive team. They were developed to ensure they mirror the objectives contained within the Quality Account and align with our perfect care goals.

We will continue as part of Duty of Candour to appoint family liaison officers who will support family members and carers when incidents occur and ensure they are guided and supported through the entire post incident review process.

The Sign Up to Safety agenda in the Trust will be reviewed and amended in April 2017 following a stock take of progress made so far. The Just Culture campaign and appointment of the Freedom to Speak up (FTSU) Guardian are aimed at reducing the concerns that many staff have had when an incident has occurred. Previously staff have felt that they would be blamed for the incident and potentially suspended. The FTSU guardian role Provides staff with a vehicle to raise their concerns about risks and safety in a way that is controlled, supportive and remains internal to the trust. This means that the organisation can deal with issues more contemporaneously and implement remedial actions to enhance the safety and quality of service provision. Safety.

The Trust is working with Stanford University to undertake improvement work to reduce the number of self harm incidents in the Trust. It is using Design Methodology to do this. The work is currently in the implementation phase and all wards involved across the organisation have undertaken changes to their practice including:

Using safety huddles to share information with staff on current plans to manage ward/ incident risk.

Providing specific training on the prevention and management of self harm to staff.

The outcomes of this work will be evaluated through the work of the Project lead with support and guidance from Stanford University.

The Trust is currently reviewing the number and type of assaults that are inflicted on staff with the aim of identifying ways that the number and level of harm caused by of assaultive behaviors can be reduced. This work is being lead by the Head of Workforce.

The Trust has agreed to fund the development of a mortality review process that will meet national guidelines and enhance the quality and timeliness of the reviews that are undertaken following the death of person who is being treated by the organisation. The Trust is using Mazars and Locktons two external agencies to provide guidance regarding best practice in this area. The Trust has started to undertake a series of thematic mortality reviews to identify learning following the deaths of patients in certain diagnostic groups, these will be shared with the Quality Assurance Committee and any remedial actions required implemented by the clinical divisions. . These include:

Patient who have a mental illness and a problem related to alcohol misuse. Alcohol

Patients who have died whilst being cared for an inpatient in the Trust.

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The Trust is currently reviewing all deaths that have occurred with in the Trust and identifying if care provided was of an acceptable standard. In accordance with national guidance it will develop an avoidability assessment tool that can be used to add to the rigor of this process, The Trust is working closely with local acute Trusts’ to develop systems to share information so that reviews are representative of a holistic approach. Mazars recognised that Mersey Care NHS Trust was the first organisation in their expereinc3 to do this.

The outcomes of the reviews that occur are shared on a monthly basis with the Mortality Review Group, which is chaired by the Trust Medical lead for this programme. This process allows themes to be identified and the quality of the processes used to be monitored. The Executive Director of Nursing provides executive oversight and guidance to the process

The Five Sign Up to Safety Pledges

1) Putting Safety FirstWe are committed to reducing avoidable harm in our organisation. We will do this by focusing on our zero suicide, no force first and self harm projects. Safety is at the centre of our perfect care work and one of our six quality domains.

2) Continually LearnWe will make our organisation more resilient to risks by acting on feedback from patients and by constantly measuring and monitoring how safe our services are. Post incident reviews, particularly related to serious self harm and suicides will be a significant part of this process. The mortality review process will also continue to be updated to reflect the recommendations of the MAZARS review.

3) HonestyWe will be transparent with people about our progress to tackle patient safety issues and support staff to be candid with patients and their families if something goes wrong. We will continue to develop our internal systems for raising concerns and appoint a ‘speak out safely’ guardian. We will continue to implement the national Duty of Candour guidance in full and measure the use of this process across the organisation. Encouraging and guiding our staff to raise concerns using a variety of methodologies will remain a key priority.

4) CollaborateWe will take a leading role in supporting collaborative learning to ensure improvements are made across all of the services that patients use. We are part of a UK collaborative with six other hospitals and The Risk Authority at Stanford in the United States working on a ‘partnership for patient protection’ project which aims to raise patient safety to a new level using technology never used in healthcare, to make our services the safest in the world.

Working closely with our commissioners we will review our root cause analysis to ensure it meets national guidance and develop internal outcome measures.

5) SupportWe will help people understand why things go wrong and how to put them right. We will give staff the time and support needed to improve and celebrate progress. Staff involved in incidents and complaints will be supported when

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things go wrong and also enable them to learn from these events. We will continue to develop our internal mechanisms for supporting staff including the use of counselling and post incident debriefs.

2.8 Commissioning for Quality and Innovation (CQUIN)

2016/17 CQUIN Goals (Q4 reporting submitted to commissioners. Performance will be confirmed in May 2017)

In 2016/17 2.5% of Mersey Care income was conditional on achieving quality improvement goals agreed between the Trust and its commissioners, through the Commissioning for Quality and Innovation (CQUIN) payment framework. The Trust was also assigned four sets of CQUIN indicators, relating to local services, low, medium and high secure services, and Specialist Learning Disabilities Services (SLDD). As at the end of March 2017, the Trust has under achieved the National Physical Health CQUIN. The Trust did, however, achieve all commissioner indicators for high, medium and low secure services and the SLDD. Local services requirements were overall under achieved. Table 2 provides a summary of local, high, medium and low secure services and SLDD CQUIN performance for 2016/17.

2016/17 CQUIN Update

The Trust reported that all milestones were achieved, with the following exceptions:

National Physical Health CQUIN Part 1 (Cardio Metabolic Assessment for Patients with Schizophrenia)

National Physical Health CQUIN Part 2 (Communication with GPs) indicator, failed to achieve the set target for the audit carried out in quarter two. It has been confirmed that £0.03 million has been returned to commissioners

Table 2: CQUIN Update (Awaiting confirmation of results from Royal College re physical Health. Due May 2017)

RAG Status Liverpool CCG CQUINs

A

National Physical Health Part 1 Cardio Metabolic Assessment and Treatment for Patients with Psychoses in the following areas:

a) Inpatient Wardsb) Early Intervention Psychosis Servicesc) Community Mental Health Services (Patients on CPA)

RNational Physical Health Part 2 Communication with General Practitioners90% of patients to have either an updated CPA i.e. a care programme approach plan or a comprehensive discharge summary shared with the GP.

G

National Staff Health and Wellbeing Part 1Introduction of health and wellbeing initiatives:

a) Introducing a range of physical activity schemes for staffb) Improving access to physiotherapy services for staffc) Introducing a range of mental health initiatives for staff

G

National Staff Health and Wellbeing Part 2Healthy food for NHS staff, visitors and patientsTo achieve a step-change in the health of food offered on Trust premises:

a) The banning of price promotions on sugary drinks and foods high in fat, sugar and salt

b) The banning of advertisement on Trust premises of sugary drinks and

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RAG Status Liverpool CCG CQUINs

foods high in fat, sugar and saltc) The banning of sugary drinks and foods high in fat, sugar and salt from

checkoutsd) Ensuring that healthy options are available at any point including for those

staff working night shifts

GNational Staff Health and Wellbeing Part 3Improving the uptake of flu vaccinations for frontline clinical staffThe target to be achieved is an uptake of 75% of frontline clinical staff by 31st December 2016

GCollaborative WorkingThe introduction of a system for To continue collaborative working which helps primary and secondary care work more effectively together to anticipate and manage complex physical and mental health care needs.

G

Physical Health TrainingThis is a Physical Health Training and Education Package for diabetes, wound care and catheter care. It is imperative that staff are highly skilled to recognise, respond and support patients with their physical health in addition to their mental health.

G Digital Maturity - Digital Maturity AssessmentDigital Maturity Assessment.

G Digital Maturity - Information Sharing NetworkDigital Maturity

G Digital Maturity - Shared Records, Guidance and PrinciplesDigital Maturity

G Digital Maturity – Neighbourhood Readiness Assessment for Community Care Team & rollout for EMIS Web

G

Accreditation Programme for Psychological Therapies Services - IAPTTo gain accreditation with the national Accreditation Programme for Psychological Therapies Services (APPTS), organised by the Centre for Quality Improvement (CCQI). This will be achieved by the Talk Liverpool service being measured against a set of quality standards through self review, involving therapists and service users, and a peer review visit.

G

Improving access to psychological therapies by older people experiencing depression and anxietyTo increase the percentage of older people (aged 65 years onwards) who experience depression and/or specific anxiety condition and enter psychological treatment, to 8% of the total population accessing primary care based psychological therapies in Liverpool.

RAG Status Addictions Service

GImproving Physical HealthThe annual health check ensures service users have a comprehensive physical and mental health assessment supporting care pathways at discharge and reducing the negative impact of untreated physical morbidity on recovery.

G

Dual DiagnosisDual diagnosis - facilitates the closer working relationships between mental health, addiction services and primary care, which improve patient safety, patient experience and quality of life through reconciliation of treatments and clear pathways.

GLearning From Service Users ExperiencePatient Experience and Performance Outcomes - service users who are fully engaged in the care they receive have the capacity to achieve the best outcomes, facilitating a reduction in relapse and a reduction in avoidable representations.

G Performance and OutcomesPatient Experience and Performance Outcomes - service users who are fully

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engaged in the care they receive have the capacity to achieve the best outcomes, facilitating a reduction in relapse and avoidable representations.

RAGStatus

South Sefton CCG and Associates CQUINs.

A

National Physical Health Part 1 Cardio Metabolic Assessment and Treatment for Patients with Psychoses

a) Inpatient Wardsb) Early Intervention Psychosis Services

Community Mental Health Services (Patients on CPA)

RNational Physical Health Part 2 Communication with General Practitioners90% of patients to have either an updated CPA ie a care programme approach plan or a comprehensive discharge summary shared with the GP

G

National Staff Health and Wellbeing Part 1Introduction of Health and Wellbeing initiatives


G

National Staff Health and Wellbeing Part 2Healthy food for NHS staff, visitors and patientsTo achieve a step-change in the health of the food ordered on Trust premises:


b) The banning of advertisement on Trust premises of sugary drinks and foods high in fat, sugar and salt

c) The banning of sugary drinks and foods high in fat, sugar and saltd) Ensuring that healthy options are available at any point for those staff

working night shifts

GNational Staff Health and Wellbeing Part 3Improving the uptake of flu vaccinations for frontline clinical staffThe target to be achieved is an uptake of 75% of frontline clinical staff by 31st December 2016

G

Transition from Child and Adolescent Mental Health to Adult Mental Health and Learning Disabilities To continue to improve transitions from Improving young peoples and families’ experience of transition from CAMHS to adult mental health, eating disorders, neuro-development and Learning Disability Services and the transfer from 18 inpatients to community living

GCollaborative WorkingThe introduction of a system for To continue collaborative working which helps primary and secondary care work more effectively together to anticipate and manage complex physical and mental health care needs.

RAGStatus High Secure Division CQUINs

G

National Physical Health Part 1 Cardio Metabolic Assessment and Treatment for Patients with Psychoses

a) Inpatient Wardsb) Early Intervention Psychosis Servicesc) Community Mental Health Services (Patients on CPA)

GNational Physical Health Part 2 Communication with General Practitioners90% of patients to have either an updated CPA i.e. a care programme approach plan or a comprehensive discharge summary shared with the GP

GNational Staff Health &Wellbeing Part 1Introduction of health and wellbeing initiatives

a) Introducing a range of physical activity schemes for staff.

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b) Improving access to physiotherapy services for staff.Introducing a range of mental health initiatives for staff

G

National Staff Health & Wellbeing Part 2Healthy food for NHS staff, visitors and patientsTo achieve a step-change in the health of the food offered on Trust premises:



c) The banning of sugary drinks and foods high in fat, sugar and salt from checkouts

d) Ensuring that healthy options are available at any point including for those staff working night shifts

G

Healthy Lifestyles National Staff Health & Wellbeing Part 3Improving the uptake of flu vaccinations for frontline clinical staffThe target to be achieved is an uptake of 75% of frontline clinical staff by 31st December 2016

G

Carer Involvement Implementing “Sense of Community” in High Secure WardsSense of Community (SoC). Better ways of involving and engaging carers to

promote the recovery of patients.

G

Reducing Restrictive Practices within Adult Secure ServicesThe overall aim is to develop an ethos in which people with mental health problems are able fully to participate in formulating plans for their well-being, risk management and care in a collaborative manner. As a consequence more positive and collaborative service cultures develop reducing the need for restrictive interventions

RAGStatus Medium and Low Secure Division CQUINs

G

National Physical Health CQUIN Cardio Metabolic Assessment and Treatment for Patients with PsychosesImproving physical healthcare:

a) To reduce premature mortality in people with severe mental illness b) Of all mental health and learning disability services users across Mersey

Care NHS Foundation Trust.

G

Collaborative Risk Assessment National Staff Health and Wellbeing Part 1Introduction of health and wellbeing initiatives


G

National Staff Health and Wellbeing Part 2Healthy food for NHS staff, visitors and patientsTo achieve a step-change in the health of the food offered on Trust premises:



c) The banning of sugary drinks and foods high in fat, sugar and saltd) Ensuring that healthy options are available at any point including for those


G

National Staff Health and Wellbeing Part 3Improving the uptake of flu vaccinations for frontline clinical staffThe target to be achieved is an uptake of 75% of frontline staff by 31st December 2016

GRecovery colleges for Medium and Low Secure PatientsThe establishment of co-developed and co-delivered programmes of education and training to complement other treatment approaches in adult secure services.

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G

Reducing Restrictive practice within Adult Secure ServicesThe overall aim is to develop an ethos in which people with mental health problems are able fully to participate in formulating plans for their wellbeing, risk management and care in a collaborative manner. As a consequence more positive and collaborative service cultures develop reducing the need for restrictive interventions.

RAGStatus Specialist Learning Disabilities Division CQUINs

G

National Physical Health CQUIN Cardio Metabolic Assessment and Treatment for Patients with PsychosesImproving physical healthcare:

a) To reduce premature mortality in people with severe mental illness b) Of all mental health and learning disability services users across Mersey

Care NHS Foundation Trust

G

Staff Health and Wellbeing Part 1Introduction of health and wellbeing initiatives


G

National Staff Health and Wellbeing Part 2Healthy food for NHS staff, visitors and patientsTo achieve a step-change in the health of the food offered on Trust premises:



c) The banning of sugary drinks and foods high in fat, sugar and saltd) Ensuring that healthy options are available at any point including for those


G

National Staff Health and Wellbeing Part 3Improving the uptake of flu vaccinations for frontline clinical staffThe target to be achieved is an uptake of 75% of frontline staff by 31st December 2016

G

Reducing Restrictive practice within Adult Secure ServicesThe overall aim is to develop an ethos in which people with mental health problems are able fully to participate in formulating plans for their wellbeing, risk management and care in a collaborative manner. As a consequence more positive and collaborative service cultures develop reducing the need for restrictive interventions.

GExit / Transition Strategy for Service Users moving to Community SettingsTo ensure the timely planned transition of service users leaving inpatient services and moving to community homes

2017/18 CQUIN GOALS

The 2017/19 CQUIN targets for the trust have been agreed with commissioners, and the trust is currently working towards quarter one 2017/18 targets.

Local Division 2017/19 CQUIN Schemes

1) National Staff Health & Wellbeing2) National Physical Health3) Improving A&E Attendance4) Child and Young Person MH Transition5) Preventing ill Health by risky behaviours – Alcohol and Tobacco6) Primary Care Liaison Service7) IAPT – Training and Information for Community based nurses

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Secure Division 2017-19 CQUIN Schemes

1) National Staff Health & Wellbeing2) National Physical Health3) Implementing Sense of Community in High Secure Wards4) Preventing ill Health by risky behaviours – Alcohol and Tobacco5) Recovery College for Medium and low secure patients6) Reducing Restrictive Practices within Adult Secure Services7) Discharge and resettlement

Specialist Learning Disabilities Division CQUIN Schemes 2017-19

1) National Staff Health and Wellbeing2) Improving physical healthcare to reduce premature mortality in people with

severe mental illness3) Preventing ill Health by risky behaviours – Alcohol and Tobacco4) Recovery College for Medium and Low secure patients5) Reducing Restrictive Practices within Adult Low and Medium Secure Services6) Discharge and Resettlement7) Exit / Transition Strategy service users Moving to Community Settings

2.9 Care Quality Commission

Mersey Care is required to register with the Care Quality Commission and its current registration status is: ‘Registered without any improvement conditions’. The Care Quality Commission has not taken enforcement action against the Trust during 2016/17 and the Trust has not participated in any special reviews or investigations by the Care Quality Commission during the reporting period.

The registration system of the Care Quality Commission ensures that people can expect services to meet the fundamental standards based on the key areas of:

Person-centred care Dignity and respect Need for consent Safe care and treatment Safeguarding service users from abuse and improper treatment Meeting nutritional and hydration needs Premises and equipment Receiving and acting on complaints Good governance Staffing Fit and proper persons Duty of candour.

All mental health trusts are subject to the CQC intelligent monitoring system. The CQC published the third intelligent monitoring report for mental health trusts in February 2016. There has been no further report published since this date.

In summary, the Trust was identified as having six risks and two elevated risks. The risks and elevated risks are:

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Safe Proportion of mortality among people in contact with community mental health

teams aged 0 to 74 (elevated risk ) Composite indicator showing Trusts flagging for risk in relation to the number of

deaths of patients under the Mental Health Act.

Effective Monitoring of alcohol intake in the past 12 months Has family intervention ever been offered to the service user?

Responsive Composite indicator to assess bed occupancy Proportion of care spells where patients are discharged without a recorded

crisis plan (elevated risk) PLACE (patient-led assessments of the care environment) score for facilities.

Well-led Proportion of days sick in the last 12 months for nursing and midwifery staff.

The organisation has been sited on these areas of risk during 2016/17 and quality and performance improvement plans have been put into place.

There has been a particular focus on mortality reviews within the Trust, developing thematic reviews and undertaking detailed post death reviews following the guidance from the Mazars review report published in December 2015,

In July 2016, Calderstones Partnership NHSFT was acquired by Mersey Care NHS Trust and this organisation also has a current registration status of: ‘Registered without any improvement conditions’. There are no intelligence monitoring reports available for the Calderstones services, which are now known as the Specialist Learning Disability Division.

As a combined service, Mersey Care and Calderstones were subject to 38 unannounced Care Quality Commission/Mental Health Act inspections in 2016/17 of wards within local, secure and specialist learning disability services as part of their programme of inspections. These inspections consider the domains:

Purpose, respect, participation and least restriction Admission to the ward Tribunals and hearings Leave of absence General healthcare Other areas such as environment, standard of food etc.

The CQC reports have all been responded to within agreed timescales and have shown in the vast majority of cases that previous issues raised have been actioned appropriately. The inspections have highlighted the following areas during recent reviews:

Use of Section 132 and 17 of the Mental Health Act (1983) Care plans not being shared with service users.

These areas highlighted were also noted in the previous year’s annual report however although there are still some deficits there has been a noticeable

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improvement in the use of the Mental Health Act over the past year particularly in relation to the use of section 58.

There has been focussed training delivered to both clinicians and hospital managers to raise awareness and ensure consistency in the application of appropriate sections of the MHA 1983.

Further information about the Care Quality Commission registration status of Mersey Care can be found at: http://www.cqc.org.uk/directory/rw4The last formal inspections by CQC of the local and secure divisions were on 1 June 2015.

The last formal inspection of the specialist learning disability services was on 12th October 2015.The outcomes and feedback from both of these inspections were reported in the annual reports for each organisation for 2015/16.

The CQC provided the Trust with their feedback and identified a series of areas that require improvement, There were 8 regulatory breaches (MUST DO’s) identified for the Local Division as follows

In community learning disability services, systems and processes did not effectively assess, monitor and improve the quality and safety of the services provided. We found concerns with accuracy of recording and quality of data to monitor compliance with waiting and response times. There was no effective system to monitor referrals, waiting lists and unmet needs. There was a clear system in place to report incidents, however, we were concerned about the lack of a comprehensive investigation into a serious incident affecting a member of staff last year. This is a breach of Regulation 17(2)(a)

In rehabilitation services, Rathbone Rehabilitation Unit had a comprehensive ligature risk assessment with points identified and actions to minimise risk of service users tying ligatures. However, this risk assessment did not assess the risk posed in the garden area which had gym equipment, smoking shelter and benches. This is a breach of regulation 12 (2)(a)

In rehabilitation services, individual supervision rates across the service were not in line with Trust policy of four to six weeklyIn the three months prior to our visit there were a total of 188 shifts that required extra cover, of these shifts, 159 were filled leaving around 15% of shifts below numbers clinically required. This is a breach of regulation 18 (2)(a)

In older people’s inpatient services, the Trust had not ensured that patients were treated with dignity and respect. This was because Irwell ward did not comply with the guidance on same sex accommodation. Patients of Irwell ward did not have their privacy promoted. Patients of Irwell ward were not provided with food and drinks in a manner that promoted their independence and dignity. This was in breach of Regulation 10

The Trust had not ensured that care and treatment was provided in a safe way for patients in terms of the risks presented by the environment. This was because Irwell ward did not have action plans to mitigate against the risk of suicide that the environment may present. Identified risks were not appropriately addressed in care plans on Irwell ward. The Trust had not ensured that staff, particularly health care assistants of Irwell ward, were appropriately skilled and supervised or supported in their role. This was because the staff did not receive sufficient support and training to meet the needs of patients with dementia. This is a breach of regulation 10

http://www.cqc.org.uk/directory/rw4

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In inpatient learning disability services, the care and treatment must only be provided with the consent of the relevant person. The registered person must act in accordance with the Mental Capacity Act 2005. Staff at Wavertree Bungalow had limited knowledge of the MCA 2005. All staff were not trained in MCA 2005. Mental capacity assessments to consent to treatment and admission were not carried out and no best interests meeting were held. At STAR Unit, where best interests meetings were needed, this was not done in a proper manner. This is a breach of regulation 11(1)(3)

In adult inpatient/PICU services, rapid tranquilisation was not carried out in accordance with NICE guidance as patients did not always have physical healthcare checks carried out afterwards, which may put them at risk. This was in breach of regulation 12 (a)(b)(c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

At a Trustwide level, there was evidence that individuals were not receiving timely access to psychological therapies. The Trust should review waiting times and ensure that action plans are in place so that people receive timely access to psychological intervention. This was in breach of regulation 18(a)(b)(c) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

There was one regulatory breach (MUST DO’s) identified for the Specialist Learning Disability division (Calderstones) as follows:

The provider must ensure that staff attend the life support training to the trusts required level of 80%.

The Secure Services Division did not have any areas of improvement requirements that were regulatory breaches identified.

All divisions received recommendations related to ‘should do’s’ and local action required.

A process of implementing detailed action plans was put in place immediately and the actions have now been completed or embedded in ‘business as usual’ activity. The Trust has continued to meet with the CQC on a quarterly basis to share progress on actions previously agreed and this now includes representation from the Specialist Learning Disability Services. The Trust has an inspection scheduled with the CQC for March/April 2017 and is confident that progress with the comprehensive action plan, already shared with CQC will be evidenced during the inspection. The areas that have already been inspected in March 2017 or due to be inspected in April 2017 are : High Secure Services Wards for People with a Learning Disability Forensic Learning Disability wards Medium and Low Secure Services Wards for Older Adults Addictions Services

Mechanisms have remained in place in Mersey Care to enable services to monitor compliance with the CQC regulations on a regular basis including the introduction of surveillance mechanisms to the Specialist Learning Disability division in addition to the Secure, Local , corporate and executive level. The Trust continues to implement internal Trust Quality Review Visits which somewhat mirror that of the CQC, and again these have been implemented and completed across the whole of the Specialist Learning Disability division. These visits are both announced and an

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unannounced and include out of hours visits across inpatient and community services. This process provides verification of compliance to self-assessments and allows triangulation of assurances.

Table 1 below outlines the aggregation tool for the five domains.

Table 1: Summary of CQC Inspection Findings 2015

Both organisations (Mersey Care NHS Trust and Calderstones Partnership MHSFT) are currently rated as ‘Good’ and will remain rated separately until the next formal CQC inspection has been completed (in March /April 2017).

Following publication of this 2017 inspection report, the Trust will have one overall rating for the organisation.

2.10 Duty of Candour

Candour is defined in Robert Francis’ report as: ‘The volunteering of all relevant information to persons who have or may have been harmed by the provision of services, whether or not the information has been requested and whether or not a complaint or a report about that provision has been made.

Duty of Candour guidance is formally considered for each incident of moderate, severe harm or death. In addition, other incidents that result in lower levels of harm may be considered depending on the seriousness of the incident.

The Trust has changed the system it uses to implement Duty of Candour due to the identification of delays in achieving all targets set and limited data being available to support the actions that had been carried out. The implementation of Duty of Candour is now managed and implemented centrally though close liaison with the Clinical Teams is maintained.

The Patient Experience and Pals Lead undertakes this work liaising closely with all clinical divisions to ensure that all appropriate incidents are identified as requiring the Duty of Candour process. This is undertaken though each clinical division’s surveillance meeting.

The central management of this process ensures that investigators who are primarily clinical staff are supported to share the findings of reviews in a timely and professional manner. This change of process has ensured that all national targets are now being met. The capacity to do this work will be increased as the appointment of Mortality and Incident Practitioners takes place in the fist quarter of 2017/18 following funding becoming available as outlined above to increase the number of mortality

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reviews undertaken. These practitioners will have a role in delivering Duty of Candour and will be trained and supported by the current lead.

The Quality Assurance Committee receives updates at every meeting regarding adherence to each of the steps within the Duty of Candour national guidance, this includes information on:

Informing service users/ carers verbally that an incident has occurred. Providing a follow up letter which includes details of any review process that

will occur. Sharing the outcomes of the review process with service users/ carers.

All actions are recorded on the Trust’s Risk Management data base (Datix) as are copies of letters and incident reports.

2.11 Data Quality Improvement Plans

Good quality information (that is information which is accurate, valid, reliable, timely, relevant and complete) is vital to enable individual staff and the organisation to evidence that they are delivering high quality/perfect care that supports people on their recovery journey, and to reach their goals and aspirations whilst keeping themselves and others safe.

Good quality information also enables the efficient management of services, service planning, performance management, business planning, commissioning and partnership working.

The Trust has a Corporate Data Quality Policy in place and a trust Data Quality Strategy which includes an agreed set of Data Quality Standards. The trust Data Quality Steering Group meets bi-monthly and oversees an annual Action Plan which also feeds into the Information Governance Toolkit requirements for Data Quality including the Annual Audit of Nationally Submitted Data Sets e.g. CDS, MHSDS.

The trusts corporate Data Quality Team run regular validation routines on the trusts electronic health record systems and on the National Data Set submissions. Local and National Data Quality reports are used to validate and update data with key themes highlighted to Clinical Divisions for action.

The importance of Data Quality is also highlighted in Clinical Information Systems training along with the importance of Good Record Keeping.

Mersey Care NHS Foundation Trust submitted records during 2016/17 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:100.0% for admitted patient care;100.0% for outpatient care.

which included the patient’s valid General Medical Practice Code was:99.6% for admitted patient care;99.6% for outpatient care."

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Latest data (SUS DQ dashboard) available from NHS Digital on 11 April 2017 relates to M11 2016/17 (April 2016 to February 2017).

2.12 Information Governance

The Trust Information Governance compliance score 2016/17 was 87% (Green – satisfactory) with the Trust attaining a minimum level two in all standards. The Trust was also awarded “significant assurance” status following audit of the Information Governance Toolkit.

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3.0 PART THREE: QUALITY INDICATORS

Insert narrative

3.1 Quality Indicators

Mandated Indicator Data period Data Source

Mersey Care NHS

Foundation Trust

National average

Highest national position

Lowest national position

Statement

Q4 2015/16 100.0% 97.2% 100.0% 80.0%

Q1 2016/17 99.0% 96.2% 100.0% 28.6%

Q2 2016/17 97.2% 96.8% 100.0% 76.9%

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of patients on Care Programme Approach who were followed up within 7 days after discharge from psychiatric in-patient care during the reporting period.

Q3 2016/17

http://www.england.nhs.uk/statistics/statist

ical-work-areas/mental-health-community-teams-

activity/

95.7% 96.7% 100.0% 73.3%

The Mersey Care NHS Foundation Trust considers that this data is as described for the following reasons: it has been submitted in accordance with detailed reporting local guidance informed by national reporting rules and advice taken from regulators over the years. The Mersey Care NHS Foundation Trust has taken the following actions to improve this percentage, and so the quality of its services, by establishing performance reports within its business intelligence system available to operational staff that enables ready identification of those due to be followed up and also enables scrutiny of any "breaches" to enable lessons to be learnt and practice changed if required to avoid similar situations occurring in future.

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of

Q4 2015/16

http://www.england.nhs.uk/statistics/statist

ical-work-areas/mental-health-community-teams-

activity/

100.0% 98.2% 100.0% 84.3%

The Mersey Care NHS Foundation Trust considers that this data is as described for the following reasons: it has been submitted in accordance with detailed reporting local guidance informed by national reporting rules and

http://www.england.nhs.uk/statistics/statistical-work-areas/mental-health-community-teams-activity/












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Mersey Care NHS

Foundation Trust

National average



Statement

Q1 2016/17 99.6% 98.1% 100.0% 78.9%

Q2 2016/17 100.0% 98.4% 100.0% 76.0%

admissions to acute wards for which the Crisis Resolution Home Treatment Team acted as a gatekeeper during the reporting period.

Q3 2016/17 97.2% 98.7% 100.0% 88.3%

advice taken from regulators over the years. The Mersey Care NHS Foundation Trust has taken the following actions to improve this percentage, and so the quality of its services, by establishing performance reports within its business intelligence system available to operational staff that enables scrutiny of any "breaches" to enable lessons to be learnt and practice changed if required to avoid similar situations occurring in future.

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the percentage of staff employed by, or under contract to, the trust during the reporting period who would recommend the trust as a provider of care to their family or friends.

2015

Dataset: 21. Staff who would

recommend the trust to their family or friends (Q21d)

http://www.nhsstaffsurveys.com/Page/101

9/Latest-Results/Staff-Survey-

2016-Detailed-Spreadsheets/

61% 58% 82% 37%

The Mersey Care NHS Foundation Trust considers that this data is as described for the following reasons: it has been obtained via the annual national NHS staff survey which is subject to ROCR approval. The Mersey Care NHS Foundation Trust has taken the following actions to improve this score, and so the experience of staff, by having established internal governance processes in all divisions to ensure appropriate review and response to results. This is supported by a programme of activities led by our workforce and organisational effectiveness teams and is monitored through the annual staff survey and quarterly Friends and Family Test results. .

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Mersey Care NHS

Foundation Trust

National average



Statement

2016 60% 61% 82% 45%

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the trust’s “Patient experience of community mental health services” indicator score with regard to a patient’s experience of contact with a health or social care worker during the reporting period.

2012

Indicator: 4.7 Patient experience of community mental health services (https://indicators.ic.nhs.uk/webview/)

88.1 86.5 91.8 82.6

The Mersey Care NHS Foundation Trust considers that this data is as described for the following reasons; it has been obtained via the annual national community mental health service user survey which is subject to ROCR approval. The Mersey Care NHS Foundation Trust has taken the following actions to improve this score, and so the quality of its services, by the development of an internal patient experience survey across both inpatient and community services. The two clinical divisions have established internal governance process to ensure appropriate review and response to results. This is supported by review by a trust wide quality surveillance

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Mersey Care NHS

Foundation Trust

National average



Statement

2013 89.3 85.8 91.8 80.9

meeting on a monthly basis and review on a quarterly basis by the trust's quality assurance committee where specific areas of focus are identified.

The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death

April 2015 to September 2015

Dataset: 5.6 Patient safety incidents reported https://indicators.ic.nhs.uk/webview/

2,854 incidents;

27.6 per bed day

2,587 incidents

per organisati

on; 42 incidents per 1000 bed days

83.7 incidents per 1000 bed days

6.5 per 1000

bed days

The Mersey Care NHS Foundation Trust considers that this data is as described for the following reasons: It has been reported in accordance with the guidance laid down by the NRLS for recording patient safety incidents. The Mersey Care NHS Foundation Trust has taken the following actions to improve this rate, and so the quality of its services, by developing local action plans to increase reporting levels as well as deploying technology driven reporting platforms to encourage reporting in community settings. Following the implementation of the trust’s mortality committee, the trust is to commence incident reporting on all deaths for service users who have had contact with the trust. This will enable a review of all deaths to identify if they should be reported as patient safety

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Mersey Care NHS

Foundation Trust

National average



Statement

October 2015 to March 2016

2,896 incidents; 27.9 per 1000 bed

days

2,613 incidents

per organisati

on; 42 incidents per 1000 bed days

85.1 incidents per 1000 bed days

14 per 1000

bed days

incidents and be subject to further investigation. Historically, the requirement has been to report “unexpected deaths” only. Quality surveillance dashboards have been developed to provide live whole trust incident monitoring and alerts.

April 2015 to September 2015

Dataset: 5.6 Safety incidents involving

severe harm or death https://indicators.ic.n

hs.uk/webview/

42 incidents resulting in

severe harm or death

(0.41 incidents per

1000 bed days)

27 incidents resulting in severe harm or

death per organisation; 0.44 incidents per 1000 bed days

1.40 incidents resulting in severe harm or death

per 1000 bed days


per 1000 bed days

The Mersey Care NHS Foundation Trust considers that this data is as described for the following reasons: It has been reported in accordance with the guidance laid down by the NRLS for recording patient safety incidents. Following the implementation of the trust’s mortality committee, the trust is to commence incident reporting on all deaths for service users who have had contact with the trust. This will enable a review of all deaths to identify if they should be reported as patient safety incidents and be subject to further investigation. Historically, the requirement has been to report “unexpected deaths” only. The Mersey Care NHS Foundation Trust is taking the following actions to improve this

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Mersey Care NHS

Foundation Trust

National average



Statement

October 2015 to March 2016

45 incidents resulting in

severe harm or death

(0.43 incidents per

1000 bed days)

30 incidents resulting in severe harm or

death per organisation; 0.53 incidents per 1000 bed days


per 1000 bed days


per 1000 bed days

rate by using all data available to develop preventative strategies i.e. falls reduction strategy, "No Force First" and suicide reduction strategy. The trust has implemented a series of perfect care projects in relation to suicide prevention, physical health care and restraint.

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3.2 Re-admissions

The Quality Account reporting arrangements for 2016/17 includes an indicator on readmissions for all trusts. Review of the NHS Digital indicator portal for the quality account highlighted the following methodology for reporting (this was initially confirmed for the completion of the 2014/15 account, no change in methodology has subsequently been notified to the trust).

"To find the percentage of patients aged 0-15 readmitted to hospital within 28 days of being discharged, download ""Emergency readmissions to hospital within 28 days of discharge: indirectly standardised percentage, <16 years, annual trend, P"" (Indicator P00913) from the HSCIC Portal and select from the “Indirectly age, sex, method of admission, diagnosis, procedure standardised percentage” column.

To find the percentage of patients aged 16 or over readmitted to hospital within 28 days of being discharged, download ""Emergency readmissions to hospital within 28 days of discharge : indirectly standardised percentage, 16+ years, annual trend, P"" (Indicator P00904) and select from the “Indirectly age, sex, method of admission, diagnosis, procedure standardised percentage” column. "

The latest version of both readmission reports were uploaded in December 2013 and the "Next version due" field states "TBC"

As Mersey Care NHS Foundation Trust does not provide inpatients services for under 16 year olds, data for this indicator for the 0 to 15 year old patient group is not included.No data relating to Mersey Care NHS Foundation Trust is included in the "Emergency readmissions to hospital within 28 days of discharge : indirectly standardised percentage, 16+ years, annual trend, P" (Indicator P00904) report downloaded from HSCIC indicator portal. Data for mental health trusts is incomplete with only a small number of trusts allocated to the mental health cluster reporting any data. Therefore it is deemed inappropriate to include any data for this indicator in the trust's 2016/17 quality account.

Dataset: 3.16 (P01863) Unplanned readmissions to mental health services within 30 days of a mental health inpatient discharge in people aged 17 and over provides readmissions information at CCG level but not provider level. Data comes from MHLDS (previously MHMDS). The latest version was published March 2016 with the next version due June 2017.

3.3 Performance against NHS Improvement's Single Oversight Framework Indicators

"In preparing the Quality Report for 2016/17, NHS Foundation Trusts are required to report on indicators that appeared in both NHS Improvement's Risk Assessment Framework and the Single Oversight Framework.

Performance has been reported for the ""Admissions to inpatient services had access to crisis resolution/home treatment teams"" indicator in Section 2.3 (the core mandated indicators) so is not repeated here in line with the guidance.

Please note that the indicators for mental health trusts are reported on a quarterly basis so this is how the data is presented here and the full year position (based on the arithmetic mean) is calculated on that basis."

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Indicator Performance threshold

Q1 2016/17

Q2 2016/17

Q3 2016/17

Q4 2016/17

Full year position

Early intervention in psychosis (EIP): people experiencing a first episode of psychosis treated with a NICE-approved care package within two weeks of referral *

>=50% 45.7% 61.9% 70.5% 65.0% 60.8%

Improving access to psychological therapies (IAPT): people with common mental health conditions referred to the IAPT programme will be treated within 6 weeks of referral

>=75% 93.3% 91.1% 80.6% 83.0% 87.0%

Improving access to psychological therapies (IAPT): people with common mental health conditions referred to the IAPT programme will be treated within 18 weeks of referral

>=95% 99.6% 99.9% 98.9% 98.2% 99.1%

* Data for Q4 2016/17 relates to period 1 January to 28 February 2017 as this what was available as at 18 April 2017.

3.4 Stakeholder Metrics

The following indicators have been selected in consultation with stakeholders and agreed by the Quality Assurance Committee, which is a committee of the Board, the indicators selected are presented for each of the following quality domains.

1) Patient Safety2) Clinical Effectiveness3) Patient Experience

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Theme Indicator Performance threshold Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Oct-16 Nov-16 Dec-16 Jan-17 Feb-17 Mar-17Incidents of Harm - proportion of incidents that result in harm (classified as low, moderate, severe or death)

Trust Target is 14.45% based on Q3 2015/16 baseline

13.67% 13.10% 12.64% 14.99% 9.84% 11.80% 10.47% 9.27% 8.42% 8.98% 10.99% 11.98%

Duty of Candour - Duty of candour incidents (moderate harm or above) 0 = green; >0 red 1 3 5 4 3 5 4 8 5 1 5 1

Safe Staffing - % of shifts filled by nurses against planned establishment (NHS England Fill rate measure) / CHPPD

% of shifts filled by nurses against planned establishment (NHS England Fill rate measure)

104.70% 106.21% 104.63% 108.24% 107.75% 109.47% 112.09% 113.44% 108.52% 109.84% 108.39% 107.70%

30 Day Readmission Rate <10.58% green; >=10.58% red 0.90% 2.46% 1.87% 0.00% 1.34% 0.50% 0.54% 2.54% 2.29% 0.46% 0.52% 1.42%

Number of Out of Area Treatment (OATs) 0 = green; >0 red 18 13 7 10 4 19 12 17 23 14 6 13

(OATs) - No of Occupied Bed Days 0 = green; >0 red 204 99 35 96 52 237 230 139 329 247 36 210Bed Occupancy - Number of Occupied Bed Days (Including Leave)

85% to 90% = green; <85% or >90% amber; <80% or >95% red

22633 23015 22146 22373 22013 21654 22566 21656 22222 22075 19934 22047

Overall Patient Experience Score Trust Target is 95% 91.70% 91.30% 89.50% 87.60% 92.50% 90.60% 94.20% 91.40% 92.80% 91.30% 92.50% 93.40%Access to Services - Can you access services when you need them?

Trust Target is 95% 92.55% 90.28% 89.93% 85.86% 93.70% 91.87% 92.70% 91.67% 91.07% 93.68% 91.85% 93.10%

Involved in care - Have you been involved in the development of your care plan?

Trust Target is 95% 83.35% 90.22% 93.61% 93.57% 94.05% 94.11% 93.07% 95.35% 97.11% 91.21% 95.16% 97.00%

Patient Safety

Clinical Effectivness

Patient Experience

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ANNEX 1: STATEMENT FROM COMMISSIONERS, LOCAL HEALTHWATCH ORGANISATIONS AND OVERVIEW AND SCRUTINY COMMITTEES

AWAITING FEEDBACK

Presentation to the CCGs/Healthwatch

5 and 12th May

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ANNEX 2: STATEMENT OF DIRECTORS’ RESPONSIBILITIES FOR THE QUALITY REPORT

In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

the content of the Quality Report meets the requirements set out in the NHS foundation trust annual reporting manual 2016/17 and supporting guidance

the content of the Quality Report is not inconsistent with internal and external sources of information including: board minutes and papers for the period April 2016 to the [date of signing this

statement] papers relating to the Quality reported to the Board over the period April 2016

to the [date of signing this statement] feedback from commissioners dated XX/XX/20XX feedback from governors dated XX/XX/20XX feedback from local Healthwatch organisations dated XX/XX/20XX feedback from Overview and Scrutiny Committee dated XX/XX/20XX the trust’s complaints report published under regulation 18 of the Local

Authority Social Services and NHS Complaints Regulations 2009, dated XX/XX/20XX

the [latest] national patient survey XX/XX/20XX the [latest] national staff survey XX/XX/20XX the Head of Internal Audit’s annual opinion over the trust’s control environment

dated XX/XX/20XX CQC inspection report dated XX/XX/20XX

the Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered

the performance information reported in the Quality Report is reliable and accurate

there are proper internal controls over the collection and reporting of the measures of performance included in the Quality Report, and these controls are subject to review to confirm that they are working effectively in practice

[this point is only required where the foundation trust is not reporting performance against an indicator that otherwise would have been subject to assurance] as the trust is currently not reporting performance against the indicator [xxx] due to [xxx], the directors have a plan in place to remedy this and return to full reporting by [xxx].

the data underpinning the measures of performance reported in the Quality report is robust and reliable, conforms to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review and

the Quality Report has been prepared in accordance with NHS Improvement’s annual reporting guidance (which incorporates the Quality Accounts regulations) as well as the standards to support data quality for the preparation of the Quality Report.

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The directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Report.

By order of the board:

……………. Date …………………………. Chairman

…………… Date ………………………… Chief Executive

(NB signed and date in any colour ink except black)

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ANNEX 3: TRUST CLINIC AUDIT REPORT 2016/17

Name of Audit Outcomes Actions/Improvements

1. MUST Audit

Various MUST audits have been carried out on a quarterly basis throughout 2015/16 to measure the rate of screenings for malnutrition on admission, the use of the MUST tool, use of care plans and referral rates.

Over a twelve month period an increase of 5.3% from 91.08% to 96.38% was seen for adult inpatients screened for malnutrition on admission, using the MUST tool.

100% of patients had an appropriate care plan in place; however a decrease in compliance at 96.8% was reported in quarter 2, this reached 100% at quarter 4.

High risk patient referrals to the Dietetics Team increased from 45% to 47.62% from quarter 2 to quarter 4.

Compliance of national and Trust policy regarding MUST nutritional screening and planning is discussed as a recurring agenda item at the Trust Physical Health Forum and Hospital Food Standards Steering Group – audit results discussed.

Dieticians have been working with the BiT Performance Team to design a MUST audit report to enable access to all nutrition and referral information in a timely manner to identify gaps and improve referral rates and access to intervention.

2. Records Audit

This audit considered the requirements specified within Corporate Health Records Policy and Procedure (IT06) and the Information Governance Toolkit Standard 404. The aim of the audit was to monitor the standard of record keeping of clinical health records by all specialties.

Equality and diversity details show an overall increase in compliance from 76% to 83%.

There is a significant improvement in the entry being keyed in on shift from 68% to 97% of cases.

The entry is written in plain English including the correct use of grammar and spelling, however shows a decrease in compliance from 75% to 67%.

Next steps/plan of care being visible showed a significant decrease in compliance from 66% to 53%.

The Trusts Health Records Sub Committee will increase awareness of good record keeping standards across both divisions by promoting “A Guide to Good Record Keeping” booklet available electronically and in manual format.

An audit tool will be developed that will encompass a more detailed view of health records. This will be done in conjunction with members of the Data Quality Steering Group/Data Quality Manager.

The process for the Trustwide Record Keeping Audit will be reviewed.

3. Falls Audit

Using a sample of patients from the older adult wards we monitored the assessment and actions carried out for service users who have either suffered a fall or are at high risk of falling within the Local

82% of service users were assessed using the Falls Risk Assessment Tool (FRAT) within 24 hours of admission or as soon as is reasonably practical.

100% of service users who were identified as high risk of falling had a multifactorial falls

Re-issue falls symbols and order instructions to clinical areas.

Matrons to reiterate the need to complete post fall huddles, completion will be monitored at frailty reviews.

Amend general observations form

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Division at Mersey Care compared to the practice recommended by NICE within the Clinical Guidelines; CG161, Falls Assessment and Prevention of Falls in Older Adults.

assessment and management plan in place. 41% of service users did not have a falls symbol displayed on information board or medicines chart.

100% of all service users on older adult wards were reviewed at weekly frailty awareness meetings and the information was recorded in the Frailty Review Documentation on ePEX.

94% of service users were referred when necessary to allied health professionals as required.

32% of service users were not promptly examined by a doctor following a fall.

to include environmental checks.

Will be raised at the Trustwide Falls Group.

4. MEWS (Modified Early Warning Score) Audit

The aim was to audit the compliance of MEWS across 12 eligible inpatient wards across the Local Division.

A random sample of two patients per ward was selected; one long stay (over two weeks) and one short stay (less than seven days).

New Admissions

33% of service users had all observations completed at the prescribed frequency.

66% of service users had their overall MEWS score calculated correctly.

Escalation to medical review occurred in 67% of cases indicated.

Long Stay Admissions

75% of service users had all observations completed at the prescribed frequency.

58% of service users had their overall MEWS score calculated correctly.

Escalation to medical review occurred in 33% of cases indicated.

Nursing staff to be made aware of their accountability in reviewing MEWS scores on each shift to ensure that they are calculated correctly and concerns have been escalated appropriately.

Inpatient wards to request further training as and when required.

MEWS audit to become integral to the Ward Assurance Framework which all wards will complete on a monthly basis to evidence compliance.

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5. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

To audit the use of DNACPR orders in (Local and Secure Divisions) according to standards set out in Unified DNACPR Adult Policy, North West Policy.

There were incomplete DNR forms in care records.

The information in the forms was too brief and uninformative.

It was unclear who the DNR decision had been communicated with within the forms.

All clinical staff to be aware of the Unified DNACPR Adult Policy and the Trust’s directives regarding DNACPR.

Medical staff to be made aware of their accountability in ensuring that the order is valid and provide robust documentation of the required assessments and evidence.

Ensure a full set of the Trust’s directives regarding governance of the DNACPR orders are available and signposted in the relevant policies.

Ensure that no inappropriate treatment takes place on a patient in the event of an incomplete, editable and unlocked form.

6. Care Programme Approach (CPA), Risk Assessment and Care Plan

The aim of the audit was to monitor standards of risk assessment and care planning within Mersey Care’s Policy and Procedure for the Care Programme Approach. The audit focused on all community teams within the Local Division.

Overall team performance across all four individual standards varied.

96% of service users audited were assessed as having had a completed risk assessment.

Whilst 83% of service users audited had an appropriate care plan to reflect assessed risk, the variance across teams ranged from 62.5% to 100%.

There was a contingency/crisis plan in place in 67% of cases where risk was identified.

75% of service users risk assessment had been reviewed within a twelve month period.

To explore whether it is possible to incorporate an alert for updating/completing CPA documentation within the new electronic clinical information system.

Findings to be shared with teams to enable targeted improvement as required.

This audit to be added to the junior doctors audit programme 2016/17 and to be repeated in April 2017.

7. DNA Audit – Community Outpatient Appointment and New Primary Care Referrals to Mental Health

New Primary Care Referrals

All new GP referrals were entered on to the clinical information system within one

Development of a single point of access service specification to include review of the referral process.

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Services

The aim of the Did Not Attend (DNA) audit was to identify trends to DNA patterns and identify solutions to reduce the overall rate and to ensure outpatient appointment clinics are efficiently run, responsive and improve the service user experience.

working day of receipt.

The demographics of the service user were adequate on the referral letter; however, some contact numbers were not recorded on the referral forms or not up to date which made it difficult for assessment staff to arrange appointments with individuals or follow up on DNAs.

The quality of information provided by the GP/referrers varied across the Local Division and 90% of referrals had no documented evidence that the individual had consented to a referral to mental health services.

Discussions with assessment staff highlighted that some individuals were surprised that they have been referred to mental health services when contacted by the team to discuss the pending appointment.

All referrals had a presenting problem recorded; however, this varied in the quality of detail provided by the GP/referrer across the Local Division.

Risk information – 60% of referrals had no risks identified and 48% of referrals did not have the risk assessment completed; therefore, it would be difficult to prioritise appointments based on limited risk information.

64% of the referral letters did not provide evidence of any previous primary care interventions as per NICE

Review of the current model and development of new standards in managing/reducing DNA.

Review of the Trust DNA Policy SD08 and align this with the Community Re-design Group.

Re-audit to be added to the trainee doctors audit programme 2016/17.

Development of a single point of access service specification to include review of the referral process.

Review of the current OPA model and development of new standards in managing/reducing DNA.

Review of the Trust DNA Policy SD08 and align this with the Community Re-design Group.

Re-audit to be added to the trainee doctors audit programme 2016/17.

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guidelines indicate, prior to referral to tier 4 services which may contribute to the high DNA rate.

The quality of information recorded in the clinical records following the triage discussion varied across the Local Division and the triage rationale was not clear regarding presentation or allocation for appointments (urgent or routine).

There was only 10% of service users contacted by the assessment team to remind them of the appointment.

83% of service users were notified of an appointment by letter; however, the time scales of these being sent out varied across all teams with some letters only being sent out a week before the appointment.

There were only 52.5% of service users contacted by the assessment services on the day of the DNA to ascertain reason of non attendance or update on mental state.

Although, 74% of the DNA was discussed in the next triage meeting, the quality of information recorded varied across the three sites and no clear rationale to outcome of the DNA clinical discussion was recorded to support further OPA or discharge planning.

79% of referrers were notified of non attendance by letter; however, there is no evidence

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that the service user was written to following DNA.

Community DNA OPAs

Only 50% of service users were sent a reminder letter one week before their appointment was due; however, some service users were written to months in advance; therefore, this may not support OPA attendance due to timescales.

79% of service users were contacted by telephone one to two days before their appointment.

51% of service users who DNA was clustered

1-5.

82% of service users were on non CPA (medic only).

100% of CPA service users who DNA their appointment were followed up within one week and the outcome was recorded in the clinical record.

70% of non CPA DNA had some form of review by the clinician assigned to the OPA; however, the quality of the review/decision was difficult to ascertain as the recording varied across the three sites.

62% of DNA had a contact recording the outcome of DNA or follow up plan.

25% of GPs were notified by letter within the five working days deadline (SD08 policy) following the service user’s DNA.

50% of service users who

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DNA their last appointment had a previous DNA within the last two years; furthermore, 46% have DNA on one to six occasions over this time period.

19% of GPs were notified by letter within the five working days deadline (SD08 policy).

8. Triangle of Care Audit

The aim of the audit was to identify the key elements from the Triangle of Care Assessment Tool that can act as the benchmark against which to measure compliance.

This will enable the Local Division to evaluate practice and to ensure safe working practices that involve the carer in the service user journey.

The audit sample covered all community teams and inpatient wards in the Local Services Division.

81% of carers were identified with the service user during the assessment process.

55% of carers were regularly updated and involved in the service users’ care plans and treatment plans and were compliant with the standard.

40% of carers were encouraged to share information regarding the service user to inform assessment and treatment.

0% of carers were offered an early formal appointment to hear story, history and address any carer concerns.

22% of carers were involved in the discharge planning process.

5% of carers had treatment and strategies for medication explained to them.

Consent was sought from 11% of service users when sharing consent with carers.

Agreement was reached with 3% of service users about the level of information that can be shared with their carer.

Although overall there has been a low level of compliance with the standards, this could be due

Explore the possibility of having a dedicated area on the clinical information system for staff to record carer contact and involvement.

The Division, at the end of February 2016, had achieved 57.9% compliance with Carer Awareness training. The Division needs to achieve full compliance.

Ensure all teams complete quarterly Triangle of Care assessment and involve carers in this process.

Re-audit standards in 12 months time.

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to poor recording. The current clinical information system does not have a dedicated area where carer contact can be recorded.

9. Discharged Service User Experience in Adult Mental Health in Relation to NICE Clinical Guidance Audit

To examine the preparation of service users by multi disciplinary teams for discharge back to the community.

To identify delays, blocks and highlight what helps in ensuring a service user progresses through their inpatient journey and what impedes discharges.

98% of cases indicated that any changes to a service users care, particularly discharge, was discussed and planned carefully beforehand with the service user and was structured and phased.

67% of the service users care plans supported effective collaboration with social care and other care providers during endings and transitions, and included details of how to access services in time of crisis.

30% of cases evidenced both arrangements with involved family or carers was discussed before discharge or transfer of care and they also discussed service user's financial and home situation; including housing, before they were discharged from inpatient care. 40% of cases partially met this standard.

80% of service users were given clear information about all possible support options available to them post discharge or transfer of care.

100% of service users were given at least 48 hours notice of the date of their discharge from a ward when plans for discharge are initiated by the service.

MDT reviews to include service user’s readiness for discharge in planning meetings.

Named inpatient nurse should ensure that if the patient has no family or carers identified then this is clearly documented in the clinical record and an alternate source of support should be offered.

Review discharge planning process to ensure that the service users are fully prepared for discharge and have access to the correct contact numbers for the team or out of hours.

Ensure staff are continually adhering to Trust Discharge Policy by carrying out six monthly re-audits and establishing any areas of concern or training needs.

10. Cardiovascular Disease; Management of Stable Angina, Chronic Obstructive Pulmonary

Management of Stable Angina

100% of service users with

Overall compliance was excellent for the management of stable angina and COPD sections of this audit showing 100% for each

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Disease, and Hypertension Audit

To monitor the physical health interventions offered and provided to patients within the Secure Division at Mersey Care compared to the practice recommended by NICE within the Clinical Guidelines; CG126, Management of Stable Angina, CG101, Chronic Obstructive Pulmonary Disease and CG127, Hypertension.

stable angina were offered a short acting nitrate for preventing and treating episodes of angina.

100% of service users with stable angina were considered for the prescription of Aspirin 75mg daily by healthcare professionals.

100% of service users with stable angina and Diabetes were prescribed an Angiotensin-Converting Enzyme (ACE) Inhibitor.

Chronic Obstructive Pulmonary Disease

100% of service users who have a diagnosis of COPD had an FEV1 recorded; their smoking status reviewed and were offered a flu vaccine and/or Pneumovax.

100% of service users with a diagnosis of COPD were prescribed oral or inhaled steroids.

Hypertension

94% of service users, who had a clinic blood pressure of 140/90Hg or higher, had regular hypertension reviews, were offered lifestyle interventions and were commenced on anti-hypertensive therapy.

100% of service users who had a diagnosis of diabetes or chronic kidney disease and their clinic blood pressure was 130/80Hg or higher, had regular hypertension reviews, were offered lifestyle interventions and commenced

standard.

All aspects of these audits will continue to be measured in the new Wellman’s Monthly Checks audit that will be completed throughout 2016/17 to ensure the high standard of care continues.

Patients will continue to be encouraged to comply with any interventions offered to them. Patient refusals will be reported throughout 2016/17 so improvements can be measured.

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anti-hypertensive therapy.

11. Diabetes

To monitor the physical health interventions offered and provided to patients within Mersey Care Secure Division compared to the practice recommended by NICE within the listed Clinical Guidance CG66, Diabetes Type II.

100% of service users with type II diabetes had their HbA1c levels measured at the correct monthly intervals to control their blood glucose.

100% of service users with a diagnosis of type II diabetes who were not previously diagnosed with hypertension or renal disease had their blood pressure measured at least annually.

100% of service users whose blood pressure reached and consistently remained at the target were monitored every four to six months and checked for possible adverse effects of anti-hypertensive therapy.

100% of service users had a full lipid profile, including high density lipoprotein (HDL) cholesterol and triglyceride estimations when they were assessed for cardiovascular risk after diagnosis, annually and before starting lipid modifying therapy.

No patients audited were offered structured education around the time of their diagnosis of type II diabetes as education is offered on an individual basis when required.

We have contacted Xpert and Desmond but our patient numbers are too small to be accredited.

We will continue with the individualised packages and look at the National Diabetes Prevention Programme.

All aspects of the audit will continue to be measured in the new Wellman’s Monthly Checks audit that will be completed throughout 2016/17 to ensure the high standard of care continues.

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12. Nutrition Support in Adults and the Management of Obesity

The Nutrition Support in Adults Audit will focus identification of nutritional screening on admission, care plan, review of intervention, documentation, and enteral feeding.

The Management of Obesity Audit will focus identification of nutritional screening on admission, care plan, review of intervention, pharmacological treatments, bariatric surgery and documentation.

Nutrition Support in Adults

100% of newly admitted service users were nutritionally screened using Mersey Care’s adapted MUST Screening Tool within 72 hours of admission.

100% of service users with a MUST score of medium risk 1 or high risk 2+ had an individualised MUST nutritional care plan produced and documented in their patient records and were referred to a dietician.

100% non compliance was seen where service users with a MUST score of medium risk 1 and high risk 2+ should have their MUST score reviewed on a weekly basis.

Management of Obesity

50% of newly admitted service users were not nutritionally screened using Mersey Care’s adapted MUST Screening Tool within 72 hours of admission.

71% of service users with a MUST score of high risk obesity 0 had an individualised MUST nutritional care plan produced and documented in their patient records and the patient referred to a dietician.

78% of service users who met the criteria for Orlistat did not have the use of the drug recorded in the patient weight management care plan and if the drug was deemed inappropriate. Justification for non prescription was not

72 hour admission MUST added to the admission checklist.

Reasons for breach of the 72 hour admission nutrition screening to be documented in clinical notes.

To review MUST screening process for long standing stable nutrition, support patients and amend the screening tool accordingly.

Secure matrons to ensure that all clinical staff attend the Trust MUST training sessions.

Screening tools and referral process to be displayed in all ward clinic rooms and health centre.

Consider holding a regular physical health MDT to discuss other treatment options (pharmacological, bariatric and gym) in line with NICE Guidance.

Wards to email dieticians with the MUST details and reasons for breach etc. This will then be documented in patient’s clinical notes by the dieticians.

Matrons to ensure that the clinical staff are booked onto the Trust MUST training.

Dieticians to add the referral guidelines to MUST training package.

Include direction in the Weight Management Pathway to follow the guidance in the BNF for the prescription of Orlistat.

Review of Mersey Care HSS Guidelines for prescription of Orlistat.

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documented in the patient records.

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SECURE DIVISION AUDIT REPORT 2016/17

Topic Outcomes Actions/Improvements1. Policy and Procedure for the Use

of Clinical Risk Assessment ToolsThe aim of the audit was to examine the extent to which clinical risk assessment instruments are being used within HSS and the timeliness of these. A further aim was to examine the quality of HCR-20 risk assessments that are being completed.

Comparison over previous years, shows improvement in the completion of the following clinical risk assessments:

- High Risk Register (HRRTilt); with 2016 results showing 96% compliance, with full levels of compliance on admission .

- Identification of Individuals who Present a Risk to Children (IIPRC) was audited was audited there was a slight improvement on the previous audit, 82% to 87% compliance for completion at initial CPA.

Use of the Short Term Assessment of Risk and Treatability (START) assessment has decreased in comparison to the previous audit 85% to 70% , although is high during the admission process

The availability of up to date Level Three risk assessments, including the HCR-20, has further decreased since the time of the previous audit 90% to 77%

The overall quality of Level three risk assessments has remained high, with the majority of these using HCR-20 Version 3 to develop risk formulations and recommendations for treatment and management

1. Maintaining the Level Three database2. Review of the clinical risk assessment policy

and procedure with clearly defined timescales for review of risk assessment tools

3. Training updates for the use of START

2. Termination of Seclusion and Long Term Segregation A review of “termination of seclusion” practice of secure

Of the 31 patients included in the audit, Seclusion was terminated immediately after it was deemed no longer warranted for 24 patients (77%).

Reminders sent to all teams that;

- Seclusion should be terminated as soon as it is deemed no longer necessary

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Topic Outcomes Actions/Improvementspsychiatric services (high, medium and low) compared to the standards as set out in the policy for termination of seclusion

It was not terminated immediately for 7 patients (23%).

For the 7 patients whose seclusion was not terminated immediately after it was deemed no longer warranted, 5 were terminated within 1 day (71%) and 2 were terminated within 2 days (29%)

All had a care plan in place referring to the safe management and support of the patient on the ending of seclusion (100%).

All of those were informed by a risk assessment (100%) and all provided details of the support that will be offered when the seclusion comes to and end (100%).

Of the 31 patients, 30 had a post incident review / debrief following the episode of seclusion (97%).1 was unknown (3%).

For the one patient who did not have a post incident review / debrief, no reason was given as to why.

- Post incident debriefing should be undertaken with patient on termination of seclusion

3. Zero Suicide PolicyThe audit was against the standards outlined in the Trust’s zero suicide policy.

By identifying key points, such as appropriate risk assessment, management and formulation, and

Standard 1: Medication Safety- All 28 Service Users (100%) were prescribed

medications for a mental disorder.- For all 28 (100%), medication and dosage was

clearly documented in their health records.- 21 of the 28 were compliant with medications

(75%). No reason was given for the 7 that were not.

Results have been shared with clinical teams and the standards within the Trust strategy reinforced, with particular emphasis on:

1. Patients identified as Risk of Suicide should have a suicide risk formulation documented in their note

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Topic Outcomes Actions/Improvementsseveral other areas relevant with suicide prevention, within the zero suicide policy, it is hopeful to identify service users at risk of suicide at an early stage, and prevent death.

Standard 2: Suicide Prevention Pathway- 27 of the 28 Service Users had and initial

assessment on admission (96%).- Of those, 22 had a full psychosocial assessment

(81%), 23 had a suicide risk formulation (85%) and 24 had an assessment of mental state (89%).

- 25 of the 28 had assessments clearly documented in their clinical records (93%).

Standard 3: Restricted Access to means of Suicide- Of the 28 Service Users, 6 were reviewed

monthly regarding removing potential ligature points (21%).

- How often the remainder were reviewed varied between 2 monthly and 6 monthly.

- 27 of the 28 Service Users had appropriate risks identified and assessed (96%), 21 had mitigation plans in place (75%) and 7 did not have this information documented (25%).

Standard 4: Risk Formulation- 25 of the 28 Service Users had a risk

formulation in place (89%).- Of those, all contained a description of the risk /

problem (100%).- 19 of the 25 had predisposing factors identified

(76%), 19 had precipitating/trigger factors identified (76%), 20 had perpetuating factors identified (80%) and 19 had protective factors

2. The suicide risk formulation should identify the factors that predispose, precipitate, perpetuate and protect against risk of suicide

3. Where risk of suicide is identified, this should be reviewed regularly and discussed by the patients MDT/Care team

4. Every patient identified as risk of suicide should have a care plan to address the issues that place the person at risk.

5. The patient identified as risk of suicide should be receiving targeted intervention as set out in their care plan

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Topic Outcomes Actions/Improvementsidentified (76%).

Standard 5: Management of Suicidal Thinking and Behaviours- 27 of the 28 Service Users were identified as

High Risk Suicide (96%).- Of those 27, 12 had access to means removed

(44%). This information was not documented for the remaining 7 (56%).

- Of the 27 identified as high risk suicide, 26 had continued and regular assessment of risks (96%).

- 5 were on an increased level of observations (19%), 22 were not (81%).

- 20 of 27 Service Users were receiving target-specific interventions (74%).

4. Well MansA Clinical Audit using survey data to determine that all wards across the Secure Division are participating in the agreed Monthly Wellman Checks to ensure the Highest Standard of Care. To offer Assurance that all wards are carrying out the necessary Physical Health Checks within an agreed timeframe.

Over the two reporting periods in 2016/17 the response rate was consistent. The survey reported that around 80% of patients self reported they were engaging in the Well Man’s health checks.

This is monitored via the secure services Physical Health Monitoring group with emphasis as ward level of improving engagement.

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LOCAL DIVISION AUDIT REPORT 2016/17

Topic Outcomes Actions/Improvements5. Use of Restrictive Interventions with

service users with protected characteristics in the Local Division

This was service evaluation as opposed to Clinical Audit, as there was no specific standards to measure against.

The aim was to audit the ethnicity of service users within Local Division who experience restrictive interventions.

For the purposes of this report the ethnicity data has been aggregated into white; non-white and not known/recorded, however, the Trust reports and monitors against the sixteen ethnicity categories used by the NHS.

Based upon an ethnic profile of 89% of services users report being ‘white’; 7% ‘non-white’ and 4% unknown the use of restraint, rapid tranquilisation and seclusion on multiple occasions was aligned to the ethnicity profile service users.

Therefore there was no evidence of disproportionate use of restricted practices with people of non white ethnicity.

For studies to be undertaken as part of equality monitoring reviewing other protected characteristics..

6. IAPT Impact of Waiting Times on Self harm and Zero Suicide InitiativesThe purpose of this study was to assess the impact of wait times on self-harm and Trust’s zero suicide initiatives in Talk Liverpool Improving Access to

The study found that Talk Liverpool compliant with national waiting time standards for beginning treatment, but had lengthy waits between 16 to 24 weeks for follow-on individual therapy at Step 2 and stepping up between Step 2 and Step 3.

Continue to monitor the Trust’s improvement plan to address waiting times and waiting lists for the Talk Liverpool (IAPT) service.

Ensure the Talk Liverpool service maintains

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Topic Outcomes Actions/ImprovementsPsychological Therapies (IAPT) services for people with common mental health conditions.

During 2015/16, there was a total of 123 patient related incidents reported at various stages of the care pathway.

The study found no evidence that longer waits routinely directly correlated with an increase in patient related incidents, or a worsening of a person’s condition. This was supported by the patient’s outcome scores.

It appears that recovery rates for Talk Liverpool have been below the national target regardless of how long patients have waited for second follow-up therapy appointments.

However, increased waits are demonstrably associated with poor patient experience and decreased patient satisfaction with the service, though not with treatment when patients receive it.

systems for robust assessment and management of risk when people enter the service andthroughout treatment and discharge, that are consistent with the Trust’sclinical risk management and zero-suicide policies.

Ensure Talk Liverpool proactively manages the information given to patients on existing waiting lists and maintained contact with them.

Review of impact of waits on self-harm and zero suicideinitiatives

7. CPA Planning for CPA Service users and Person Centred Care Plans for Non-CPA Service UsersThe audit aims to review the most recent CPA 07 Care Plan or Statement of Care for the service users selected in the sample to monitor the standard of documentation and to measure whether Care Planning is

The main principles applicable to all service users on CPA or Non-CPA are that they must have the appropriate care plan in place to support follow up. This must include:

- Service users have a CPA 07 care plan or statement of care in place 94%

1. Person Centred Care Plans:- Service users to collaborate with the

lead clinicians - The care plan will have mutually agreed

goals and interventions. Where appropriate and in agreement with service users, carers and family support to be included in the care plan.

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Topic Outcomes Actions/Improvementsprovided within accordance of local agreed standards

compliance- Care plan to be reviewed annually 88%

compliance- Service user has been offered a copy of

the care plan 71% compliance

93% of service users had a crisis plan. The main principles of a crisis plan are to ensure service users utilise their coping strategies and support networks in times of crisis. This should include:

- Self-help techniques 64% compliance- Contact details for professional help

93% compliance- Out of hours support 93% compliance

- A detailed crisis plan with supportive interventions/actions will be evidenced within the care plan.

- Service user to receive a copy of their care plan and this should be evidenced within the clinical notes.

2. Follow up reviews:- All future follow up reviews will be led by

the service users care plan - All clinical review outcomes will be

recorded within the clinical notes that reflect the service user’s primary problems and goals.

3. All care plans will have a DNA contingency plan highlighting what actions will be taken by both the service user and clinical team following a DNA.

8. Dual Diagnosis The audit reviewed the treatment and management of people with co-morbid substance misuse and mental health issues.

26 of the 29 patients had an Agreed Care Plan for the Treatment and Management of Substance Misuse in place.

None of the 26 included advice regarding the risk of overdose in relation to lowered tolerance levels and the mixing of substances including alcohol.

12 of the 26 included information regarding the care and provision provided by specialist drug and or alcohol services.

1. Identify a Dual Diagnosis Clinical lead on each inpatient ward that will be responsible for the on-going monitoring of policy adherence and the identification of training needs for the inpatient staff group.

2. Identify specific training needs for potential Dual Diagnosis leads.

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Topic Outcomes Actions/Improvements

6 of the 26 had an action to refer the Service User to Drug/Alcohol Support Specialist Services as part of the Discharge Plan although of the 20 that did not, 9 were current inpatients.

9. Audit on new patient assessments as per MSNAP 5th edition standardsTo audit the assessment of new patients referred to memory service based on MSNAP standards

Overall the key areas are being addressed in the initial assessment of new patients referred for memory problems.

Dementia screening bloods – 55%Past medical history – 95%Current medication – 100%Sleep – 60%Diet – 80%Smoking – 40%Drug and alcohol – 85%MSE – 100%Cognitive examination – 90%Carer interview – 85%Vision –10%Hearing – 5%Mobility – 80%Risk assessment – 100%Mental health assessment – 100%Social history and living situation – 100%Diagnosis – 95%Driving – 85%Document is signed and dated – 100%Social support available to patient – 65%26 of the 29 had an Agreed Care Plan for

Some areas achieved 100% compliance but in other areas there was scope for improvement.

There needs to be improved compliance with documenting vision, hearing, social support available, smoking, sleep and dementia screening bloods.

Results have been shared with Core Trainee and Clinical Lead and re-audit is planned for 2017/2018.

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Topic Outcomes Actions/Improvementsthe Treatment and Management of Substance Misuse in place.

None of the 26 included advice regarding the risk of overdose in relation to lowered tolerance levels and the mixing of substances including alcohol.

12 of the 26 included information regarding the care and provision provided by specialist drug and or alcohol services.

6 of the 26 had an action to refer the Service User to Drug/Alcohol Support Specialist Services as part of the Discharge Plan although of the 20 that did not, 9 were current inpatients

SPECIALIST LEARNING DISABILITY DIVISION (SLDD) AUDIT REPORT 2016/17

Topic Outcomes Actions/Improvements10. Collaborative Risk Assessments

To ensure that all service users are involved in a process of collaborative risk assessment and management

To ensure that adequate staff members have been trained enabling them to complete the collaborative risk

This audit was undertaken as part of the CQUIN measures set out by NHS England with regards to secure service users active engagement programmed (collaborative risk).

- 100% of service users had a normal risk profile.

Following the audit a brief was sent out though the local team meeting (LTM) reminding staff to update the user friendly risk profile when changes are made to the normal risk profile. IT also sent out guidance to all staff on completing the user friendly version.

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Topic Outcomes Actions/Improvementsassessments with service users

- 99% of service users had a user friendly risk profile in place.

- 93% of service users had a clinical note confirming that the risk profile had been completed collaboratively.

- Overall 100% of service users had either of a user-friendly risk profile or a clinical note evidencing that their risk profile had been completed collaboratively.

- Only 45% of the user friendly risk profile scores matched that of the normal risk profile.

- 73% of the trusts qualified staff had received training on collaborative risk

Discussions are ongoing with IT regarding the possibility of adding the user friendly risk profile version onto Carenotes Assist to act as a prompt.

As a result of the low number of the user friendly risk profiles matching that of the normal risk profiles IT will create and run a report which will clearly identify where there are differences.

11. Hand Washing This audit was undertaken as the Health and Social Care Act (2008) Code of practice on the prevention and control of infections and regulated guidance, states that there should be an on-going programme of audit, revision and update in relation to hand hygiene.

The audit was completed as a survey sent out to staff.

Emollient hand cream should be available in all areas and staff should start using it to prevent skin from the drying effects of regular hand hygiene.

Checks should be made to ensure non-touch taps are fitted to all hand basins.

Clinical nurse managers are to ensure that all areas are complaint with the hand hygiene procedure.

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There were a few areas of the survey in need of improvement due to low compliance. The levels of compliance varied from ward to ward.Emollient hand cream was not always available.Only 43% of staff reported that they believed that the taps were non-touch.Although 82% of staff adhere to good hand hygiene techniques, there are 17% of staff who only sometimes adhere to this technique. Improvement should be made as hand hygiene is crucial in reducing avoidable infection.No staff gave answers that would indicate full compliance across all questions.Apart from the area where there were no hand washing posters in place all staff washed their hands following all the steps identified on the poster.

Seven staff failed to follow the procedure 9.2 – Dress code for trust staff.

There was also confusion around the term; ‘bare below the elbow’ some staff thought this meant they were not allowed to wear tops with long sleeves.

Hand hygiene will continue to be audited in the future.

12. Integrated Care PlansTo ensure that all Service users have an

This was a re-audit of that completed in May 2015.

MDT’s need to revisit each ICP and ensure it is completed in full and that the

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Topic Outcomes Actions/Improvementsintegrated care plan within care notes that is completed in full. From the 58 service users sampled, all had

an integrated care plan uploaded within their care notes.

Of the 58 ICP’s audited 53 of these had some information missing from one or more sections of the ICP

Only 5 ICP’s had all section completed, however overall significant improvements were seen within each sections.

information is accurate.

A mini re-audit of ICP’s is scheduled to take place in August 2016 just concentrating on the areas of concern from the audit.

13. ChokingTo ensure that all service users who have had a choking incident have been screened to assess the risk of choking in accordance with Trust Procedure 4.15: Dysphagia dated 1st December 2013.

This was a re-audit of that completed in July 2015.

An improvement can be found regarding the choking screen being reviewed post incident although the majority are still not being completed within 2 days of the incident occurring.

A slight increase can be seen regarding the risk of choking being discussed with the service user post incident although the level of compliance remains low at only 38%.

There has been a decrease in the number of people present when the choking incident occurred that have been trained in both eating and drinking and the choking screen.

Eating and Drinking training and risk of choking screen - Dysphagia have been booked to take place throughout the year with the LO&D department.

Staff have been briefed to ensure that a choking screen is completed within 2 days of the incident occurring and that all choking incidents must be reviewed as part of the ward round.

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Topic Outcomes Actions/Improvements14. Positive Behaviour Support Plans

The aim of the audit was to check the quality of the organisational individual positive behaviour support plans.

Since the last audit the PBSP has been included into the integrated care plan rather than being a stand-alone document.

All PBSP had a functional assessment / primary preventative strategies / secondary preventative strategies / tertiary strategies and post crisis support plans, however No PBSP contained all the required information identified in the audit tool. There is marked improvement on the results from the baseline audit completed in February 2015.Although the audit may show deficits in the information required for the PBSP the plan It is worthy of note that the CQC were ‘very impressed’ with the PBSP’s they viewed, saying they were some of the best they have seen

The trust is currently providing training on what information should be in the PBSP and how these should be completed, which should improve the content of the PBSP’s.

The results of the audit are to be taken and discussed at the positive and safe board.

15. Part IV Mental Health Act T2 CompletionTo check compliance of T2 forms against prescribed medications

The great majority of T2 forms were fully compliant with requirements.

The auditor did have some difficulty locating some of the T2 forms as this were not kept in any specific place.

A discussion took place following the audit and it was agreed that every service user must have their own individual file containing all information regarding medication, i.e. med card, T2/T3 etc

16. EpilepsyTo ensure wards are fully compliant with regards to NICE guidance for epilepsy and the Trust’s procedure 24.5 Management of epilepsy and status epilepticus and the recommendations from the Southern Inquiry.

This audit was undertaken as a result of the Southern Inquiry.

This was the final of a series of audits over a period of 3 months July-September 2016.

None of the epilepsy treatment and care

Following the audit results the auditor sat down with relevant ward managers on an individual basis to ensure they understood the requirements . As a result all relevant documentation is now present.

There are no plans for a further re-audit.

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Topic Outcomes Actions/Improvementsplans were 100% compliant with NICE guidance.

The treatment and care plan, epilepsy risk assessments and the buccal midazolam treatment and care plans for servicer service users are still not included in their epilepsy treatment and care plans within the ICP and there are still information voids within the treatment and care plan.

The reason for the information voids may well be due to the service users not having a seizure since admission or for several years therefore it would be difficult to answer some of the questions, however, where this is the case it is not always reflected in the treatment and care plans.

The person centred epilepsy care plan was introduced following the July 2016 audit, however as the results show nearly half of the service user with a diagnosis of epilepsy do not have these completed.

Epilepsy is to be included in the Quality Review Visit process for the division to gain assurance.

17. Smoking CessationTo ensure that all service users within the trust who smoke are offered the relevant information and support with regards to smoking cessation.

This audit was undertaken as part of CQUIN measures set out by NHS England with regards to smoking cessation in mental health services.

There is little evidence to suggest that when service users are admitted to the trust they

As a result of the audit the following actions are currently in progress. This was slightly delayed due to the acquisition by Mersey Care but should now be back on track.

Band 4 and ward based "smoking cessation champions" to be trained up to provide

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Topic Outcomes Actions/Improvementsare given any information regarding smoking cessation and the support that the trust can provide should they wish to give up smoking either following admission or at some point in the future.The service users did not appear to have received any information on the trusts policy re smoking or the benefits of stopping smoking. It would appear from the information available that if the service user said ‘don’t want to give up/ not ready to give up smoking’ no further information was given to them.The trust’s admission health physical form is completed and has to parts, A and B. Part A is completed within the 1st hour of admission and does not contain any smoking related questions. Part B which does have smoking related questions can be completed up to 7 days after admission.

information on benefits of smoking cessation as part of the programme and once in post implement NICE guidelines around pre-admission smoking cessation checklist.

Part A admission physical Health document to include questions relating to smoking habit of new admissions

Person centred smoking cessation plan to be integrated into individualised smoking cessation plan of current smokers.

Service users will be supported to comply with recommended pharmacotherapies in their smoking cessation plan/abstinence.

18. Type 2 DiabetesTo ensure that the trust is discharging their responsibility with regards to NICE guidance for type 2 diabetes

This audit was undertaken to establish the trusts level of compliance with the NICE guidance for type 2 diabetes.

Overall impressions for the management of type 2 diabetes at Calderstones NICE guidelines were followed.

But there are areas, we could improve as follows:

As a result of the audit Dr responsible for physical health is giving consideration for a protocol to be completed with regards to the unlicensed use of metformin. This is still ongoing.

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Topic Outcomes Actions/ImprovementsAdherence to healthy life styles including weight management and smoking cessations.

Monitoring lipid profile annually.

Lipid lowering medication should be prescribed for all type 2 diabetes.

Albumin Creatinine ratio measurement check- up annually

19. Standard of Completion of H5 Form (section 20 renewal of authority for detention)

This audit was requested to be completed by a consultant. It had come to light that there was a big variation in the completion of the H5 form.

The audit found the following:

No mention of patient’s exact diagnosis of mental disorder- Learning disability of Mild, Moderate or severe in nature.

Variation in description of Nature and degree of illness.

It appears that there is no uniformity of information given on completion of H5 form and no standard was set by the trust.

Following the audit it was agreed that the following should be standard items when completing H5:

Patient’s admission date and Diagnosis if available.

Reason for admission briefly. Nature and degree of illness especially

degree. Current risk at the time of completion of

H5 should indicate patients health, safety and protection of others.

Brief reason why informal admission is not appropriate.

20. Communication PlansTo ensure that all service users have a

This is a re-audit of those conducted in April and November 2015..

As a result of the audit all Clinical Nurse Managers and Ward managers have been

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Topic Outcomes Actions/ImprovementsCommunication Plan within their integrated treatment and care plan which is completed in full and provides the information recommended by the Speech and Language therapists.

From the service users sampled all (100%) had a communication plan in place in the ICP. These communications plans ranged from being fully completed documents to partially completed ones. The quality of the plans also varied; some plans provided detailed information regarding a service user’s communication skill, whilst others provided limited information about an individual’s ability to communicate.

In many areas of the plan there has been an improvement compared to the previous two audits conducted in July and November 2015 though there was a slight decrease in the completion of ‘Expression of Language’. However, the number of communication plans fully completed has risen by 24% compared to the audit conducted in November 2015.

Overall 63% of communication plans contained all the relevant information.

sent a briefing outlining the exact requirements of the communication plan.

21. Chronic Kidney DiseaseTo ensure that the Whalley Specialist LD Division adheres to the NICE guidance.

This audit was requested by the NICE committee to assess compliance against the NICE guidance.

It is a routine practice for in-patients within the Whalley Division to undertake annual eGFR, Urea and Creatinine checks or

As a result of the audit the Health Centre Staff were briefed that eGFR is to be re-tested in 2 weeks if the result is less than 60 or more than 90.

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Topic Outcomes Actions/Improvementsearlier if clinically indicated.

ACR, eGFR, serum Urea and Creatinine are used as primary screening tools in ‘at risk’ cases though ACR is used mainly as a diagnostic tool at the Whalley Division.

Very good practice is demonstrated but there is room for improvement especially in the re-testing of cases when eGFR is abnormal.

22. Clinical SupervisionTo assess whether clinical supervisions were taking place in accordance with the Trust’s Supervisions Procedure

Clinical staff were asked to complete a survey regarding their views and experiences around clinical supervision.

The results of the survey indicate that not everyone receives regular supervision. Only 56% of staff reported that they had received clinical supervision.

The issues identified within the audit are to be flagged up to Operations and Clinical Nurse Managers.

There are no current plans for a future re-audit. Supervision will be monitored via surveillance and any areas of concern will be raised and an action plan to rectify will be devised and tracked.

23. Staff MeetingsTo establish Trust compliance re staff meetings and if they follow a set agenda. Trust Procedure SD33

The data shows compliance to meet the criteria in some areas, however in other areas the compliance was as low as 11%.

Staff issues are the greatest problem in preventing meetings from taking place, especially those wards that have a number of vacancies and long term sickness. Additionally meetings tend to be held before or after shifts which is problematic for staff.

The issues identified within the audit are to be flagged up to Operations and Clinical Nurse Managers.

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Topic Outcomes Actions/ImprovementsUntil these issues are addressed it may be unlikely that meetings will be held consistently.

There was a compliance of only 42% when comparing CPA invites to the service users contact details, quality assurance should take place to check all contacts on the list are accurate, make additions where necessary and delete those no longer in use

CORPORATE DIVISION AUDIT REPORT 2016/17

Topic Outcomes Actions/Improvements24. Falls Audit

Using a sample of patients from the Older Adult Wards we monitored the Assessment and Actions carried out for service users who have either suffered a Fall or are at High Risk of Falling within the Local Division at Mersey Care compared to the practice recommended by NICE within the Clinical Guidelines; CG161, Falls Assessment and Prevention of Falls in Older Adults

32% of Service Users were not promptly examined by a doctor following a fall.

All patients admitted to Complex care services were assessed using the Falls Risk Assessment Tool (FRAT). The Trust standard is within 24 hours of which the audit demonstrated 61% compliance. This is a drop from the 82% compliance from the previous audit.

All the patients assessed as ’high risk’ of falls went on to receive a Multifactorial Falls Assessment and had a management plan completed, which is consistent with the


Inpatient Wards to request further training as and when required.

MEWS Audit to become integral to the Ward Assurance Framework which all wards will complete on a monthly basis to evidence compliance.

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Topic Outcomes Actions/Improvementsprevious year’s audit results.. These patients were readily identifiable on service user information boards but not on medicine cards.

Frailty reviews and follow up referrals were completed for all the relevant patients.

Of the patients that experienced a fall as an inpatient all but one had a medical examination following the fall, which is an improvement on last year’s audit which was 32% compliant.

25. MUST AuditMUST Audits have been carried out on a quarterly basis throughout 2016/17 to Measure the Rate of Screenings for Malnutrition on Admission (MUST Tool), Use of Care Plans and Referral Rates

The audit measures 12 standards across there three reporting periods the overall compliance score for the audits have been: Q1 = 61% Q2 = 69% Q3 = 61%

Since Q1 audit, there has been an improvement in the accuracy of BMI information recorded but there were issues with the accuracy of the MUST score.

There has been improvement in completed referrals to a dietician. But improvement work is needed to make CPA plans more personalised.

Given the audit results from Q3 there has been a case study audit undertaken to examine the records in greater detail to try and understand what is contributing to the drop in compliance.

Each ward area has an individualised action plan addressing the issues of concern highlighted in the audit results.

This audit topic and quarterly schedule will continue for 2017/2018 to continue to drive compliance and improvement work.

26. Records AuditThis audit considered the requirements

There has been a decrease in relation to completing clinical records during the shift

The Trusts Health Records sub-Committee will increase awareness of good record

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Topic Outcomes Actions/Improvementsspecified within Corporate Health Records Policy & Procedure (IT06) and the Information Governance Toolkit Standard 404. The aim of the audit was to monitor the standard of record keeping of clinical health records by all specialties

that contact takes place from 97% to 81% compliance.

There were small decreases in relation to recording purpose of contact and visible plans of care.

There has been a significant improvement in correct use of grammar and punctuation from 67% to 91%; and the use of known abbreviations from 90% to 97%.

keeping standards across both Divisions by promoting “A Guide to Good Record Keeping” booklet available electronically and in manual format.

An audit tool will be developed that will encompass a more detailed view of health records. This will be done in conjunction with members of the Data Quality Steering Group/Data Quality Manager.

The process for the Trust Wide Record Keeping Audit will be reviewed.

The results have been shared with the divisions to produce a divisional action plan in relation to the areas identified for improvement.

27. Safeguarding Audit: Domestic Abuse (Sefton Local Children Safeguarding Board-Sefton LSCB)A multiagency audit led by Sefton LSCB to evaluate their involvement with the child and the parents or carers and also their collaboration with the partnership with respect to the known Domestic Abuse in each case and the impact of the partnership working upon the outcomes for the child.

MCFT highlighted as undertaking an audit which was “thorough, well evidenced, framed in knowledge of research and practice guidelines in relation to Domestic Abuse and clearly articulated the impact or the intended impact of the action or help provided on the child, young person”

Conclusions for MCFT:

Ensure where appropriate that Mental Health practitioners contribute to

There is a MCFT representative from the Safeguarding Team attending the Multi Agency Risk Assessment Conference (MARAC) meeting. The trust representative acts as a liaison in identifying new cases and updates on existing inquiries.

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Topic Outcomes Actions/Improvementsmultiagency assessments and plans by sharing relevant information and attending relevant meetings and reviews

28. MEWS (Modified Early Warning Score) AuditThe aim was to Audit the compliance of MEWS (Modified Early Warning Scores) across 12 eligible Inpatient wards across the Local Division.

New Admissions:33% of Service Users had all observations completed at the prescribed frequency.

66% of Service Users had their overall MEWS Score calculated correctly.

Escalation to Medical Review occurred in 67% of cases indicated.

Long Stay Admissions:75% of Service Users had all observations completed at the prescribed frequency.

58% of Service Users had their overall MEWS Score calculated correctly.

Escalation to Medical Review occurred in 33% of cases indicated.


Inpatient Wards to request further training as and when required.

MEWS Audit to become integral to the Ward Assurance Framework which all wards will complete on a monthly basis to evidence compliance.

PHARMACY /MEDICINE MANAGEMENT AUDIT REPORT 2016/17


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Topic Outcomes Actions/Improvements29. Controlled Drugs The storage, use of registers and

appropriate stock levels of Controlled Drugs are audited on a quarterly basis by trust clinical pharmacists.

There is a requirement for 100% compliance against all of the audit standards.

A development in quarter 3 2016 was to introduce a new summary reporting format using the trust template for medicines management audits.

Any concerns identified during the audit processes are reported to the Local Intelligence Network via the CDAO.

There have been some minor issues of discrepancies being crossed through in the register rather than bracketed.

The CDAO and Chief Pharmacist have produced an annual report with regard to CDs for the Drugs and Therapeutics Committee

30. Recorded Drugs The revised ‘Duthie’ guidelines for storage of medicines in hospital settings require trusts to assess whether extra measures of control need to be put in place for ‘medicines liable for diversion’. Mersey Care operates a recorded drugs policy and has identified the following drugs for these tighter controls:-

Quarterly audits have taken place in the

To continue as part of schedule of Medicine Management Audits

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Topic Outcomes Actions/Improvementsclinical divisions; there have been no significant issues to report. Occasional discrepancies have been dealt with via DATIX or Ulysses reports and reviews.

31. Storage Audits Quarterly audits take place to give assurance that medicines are being stored in compliance with legislation and trust policies as described in SD12 The Handling of Medicines Policy. Standards audited are as follows:-

Actions are addressed directly with each ward/clinic manager and all reports are sent to the divisional clinical nursing leads.An example of the reporting matrix is shown below; copies of the full reports are available on request from Pharmacy Services.

A significant action from the Q3 audits was the introduction of air-conditioning units in to the new clinic rooms at the Scott Clinic (addressing the issues highlighted in the example return shown below)

32. Antimicrobial Ward pharmacists undertake quarterly audits of antimicrobial prescribing the results are presented to the trust’s Infection Prevention and Control Committee (IPCC) and on quality reports to local commissioners. The results of the audits throughout 2016 have been consistently good an annual report has been presented to the IPCC.

The issue of stop and review dates on prescriptions remains the area that requires most improvement; as electronic prescribing rolls out across the trust it is hoped that this issue is addressed.

33. High Dose and Combination Antipsychotics (local)

In November 2016 a trust-wide audit of prescription took place against the following standards:-

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Topic Outcomes Actions/Improvements- Combination therapies – How many

service user’s are prescribed more than one Antipsychotic

- The volume of antipsychotics prescribing across the trust

- The amount of when required (prn) antipsychotic prescribing and administration

- How many service users are prescribed doses greater than 100% of the BNF maximum adult daily dosage.

An overview of the audit shows the following:-

The number of service users on prescribed two or more antipsychotics is 14.3% lower compared with the 2013 audit.

The number of service users prescribed high doses is 31% lower than 2013.

The mean daily prescribed antipsychotics doses are 4% higher compared to 2013, however the mean daily doses of PRN doses decreased by 4. 6%.

Prescribing of PRN prescriptions have remained similar to the 2013 audit.The data collected shows fewer service users are prescribed antipsychotics when

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Topic Outcomes Actions/Improvementscompared to the 2013 data.

34. Rapid Tranquillisation (SD11)(local) Use of Rapid Tranquilisation is audited against the following standards: -

Audit standard 1 Documented evidence of violent or aggressive behaviour requiring IM medication preceding use.

Audit Standard 2 Documented evidence of non-restrictive interventions being offered prior to RT being considered, where possible.

Audit Standard 3 Documented evidence that appropriate p.r.n. medication had been offered prior to RT being considered.

Audit Standard 4 When RT has been necessary, the medication used has been within the Trust Formulary in SD11.

Audit Standard 5 Clopixol Accuphase is not prescribed for RT.

Audit Standard 6 The use/consideration of antimuscarinic medication when haloperidol is used as the drug of choice during RT.

Audit Standard 7 Combination doses of antipsychotic medication have not exceeded 100% BNF maximum doses.

Audit Standard 8 Post- RT Monitoring has been carried out in line with the standards available at the current time and is documented on EPEX*.

*If however, consent/co-operation with observations has proven difficult this has been documented on EPEX and observations have been carried out at the next available opportunity and fully documented.

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Actions have including introducing further scrutiny of the use of Clopixol Accuphase following the July audit and the December audit indicated issues with compliance with the standards specifically on one particular ward – a local action plan has been introduced.

Re-audit is planned for March 2017 and the audit schedule will continue on a quarterly basis.

35. Medicines Reconciliation Medicines reconciliation is part of the medicines safety agenda locally and nationally. The below chart shows the results of the May 2016 audit focusing on Medicines Reconciliation.

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Topic Outcomes Actions/ImprovementsLooking at the trust figures in total (taking in to consideration ward transfers) the overall

results for the May 2016 audit were:-

Number of admissions reconciled within 3 working days – 78% (62%) Number of admissions reconciled in more than 3 working days - 9% (17%) Number of admissions not fully reconciled - 13% (21%)

The results were a significant improvement over the November 2015 audit figures shown in red above; the re-introduction of the ward based pharmacist role has enabled the improvement in performance.

Further work is required to look at the issues to improve the number of admissions not fully reconciled and progress will be monitored via the trust’s Drugs and Therapeutics Committee.

HarringtonAlbertBrunswickOakSTARBrain InjuriesAltIrwellScottKWUMorrisDeeRRUAllertonChildwallAcornNewtonWindsor HouseBoothroydRowbothamPark UnitWindsor Clinic0

10

20

30

40

50

Number of admissions

Number of transfers from wards within Mersey Care

Number reconciled within 3 working days

Number reconciled outside 3 working days

Number not reconciled at all / not found

Medicines Reconciliation May 2016

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QUALITY SCHEDULE AUDIT REPORT 2016/17

Topic36. Do Not Attempt Cardiopulmonary

Resuscitation (DNACPR)To audit the use of DNACPR orders in (Local & Secure divisions) according to standards set out in Unified DNACPR Adult Policy, North West Policy. This audit was completed twice during 2016.

On the initial audit, there were incomplete DNR forms in care records. Whilst there was an improvement on the next audit with one person out of ten sampled not having a form; there were five patients with the out the date on the completed form.

The information in the forms was too brief and there were issues with the readability of information where documents had been scanned.

It was unclear who the DNR decision had been communicated with within the forms.

All clinical staff to be made aware of the Unified DNACPR Adult Policy and the trust’s directives regarding DNACPR.

Ensure a full set of the trust’s directives regarding governance of the DNACPR orders are available and signposted in the relevant policies.

Clinicians need to ensure robust documentation and completion of orders, capacity assessments, discussions and communications with staff and NOK.

Clarify the rules governing an indefinite order and review to ensure the best interests and practice for the patient.

37. Learning Disability Reasonable Adjustments AuditThe audit will aim to improve the care provided and outcomes for those with learning disabilities and to prevent avoidable deaths as per the Access to Healthcare Pathway.

Of the 98 Service Users who did meet the LD Referral Criteria. 18 had an intake assessment completed (18%).

Of the 18 who had an intake assessment completed, 4 had basic health issues identified (22%).

15 of the 18 had been allocated to a profession

That all individuals referred to Learning disability services are registered with a GP - to identify this at intake.

Named health worker ensures that GP details are entered in the electronic record

Given that there is no agreement across CCG that the Cardiff tool is the accepted bench mark agreement to be reached with

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Topic

GP summary sheets were requested for 30 (31%). No information was received for 5 (17%), Satisfactory information was received for 24 (80%) and 1 was unknown (3%).

29 were signposted to GP for their Learning Disability Annual Health Check (30%).

None of the 98 Service Users had had the Cardiff Tool completed.

Of the 29 Service Users signposted to GP for LD annual health check, none had dates for when this was completed.

Of the 69 Service Users who had not been signposted to GP for LD annual health check, none have a confirmed date for this to take place.

Of the 69, 10 have had a physical health screen completed on ePEX (14%)

Of the 98 Service Users, 15 required further assessments (15%), of which 1 had a nursing referral completed for a Health Needs Assessment (7%); the results of this were not communicated with the GP.

CCG as to the most appropriate battery of measurement’s (LDSAF 2016)

That the Physical Health facilitators working with practices to identify who has a low uptake of LD health checks.

For those service users who are reluctant to take part in an annual health check will have a reasonable and proportionate plan in place to assist health surveillance

To ensure compliance with health needs assessment and complete electronic patient record physical health screen.

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TopicOf the 98 Service Users, 38 were given ‘Every contact counts / health promotion’ advice or information (39%), but not in an accessible format.

4 of the 98 Service Users have a Health Action Plan (4%).

2 of the 98 Service Users have a Hospital Passport (2%).

None of the 98 Service Users had a Health and Wellbeing intervention undertaken.

38. Learning Disability Risk Assessment AuditMersey Care is required to ensure that all patients with a learning disability have had a risk assessment completed within 48 hours of admission or 2 weeks prior to admission to an in-patient ward across the trust using a recognised risk assessment tool.

Over the two quarter periods reported the results have been fairly consistent. Within the respite care facility for people with multiple and profound learning disabilities the compliance was around 95%, although this group of people have frequent admissions.

For the Assessment and Treatment Unit it was consistently 100% for both quarters

To maintain compliance with risk assessment standard

Q3 data collection delayed by 2 weeks due to CQUIN data collection although remains compliant with contract requirement

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