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Quarterly Quality Improvement Report
Quarter 3 – 2011/12
Edition 2 – January 2012
Executive Summary
Helen Dabbs, Deputy Chief Executive/Director of Nursing and Partnerships
Sally Wheatley, Deputy Director Clinical Governance
THE 16 CORE ESSENTIAL STANDARDS OF QUALITY AND SAFETY
Although the Care Quality Commission (CQC) do not specifically describe what a system
of clinical governance should look like as clinical governance has several purposes
beyond simply establishing the essential standards of quality and safety, the Essential
Standards as a whole support the development of an effective clinical governance system,
and the outcomes and prompts for the following outcomes are of particular importance:
Outcome 1: Respecting and involving people who use services
Outcome 2: Consent to care and treatment
Outcome 4: Care and welfare of people who use services
Outcome 5: Meeting nutritional needs
Outcome 6: Cooperating with other providers
Outcome 7: Safeguarding people who use services from abuse
Outcome 8: Cleanliness and infection control
Outcome 9: Management of medicines
Outcome 10: Safety and suitability of premises
Outcome 11: Safety, availability and suitability of equipment
Outcome 12: Requirements relating to workers
Outcome 13: Staffing
Outcome 14: Supporting workers
Outcome 16: Assessing and monitoring the quality of service provision
Outcome 17: Complaints
Outcome 21: Records
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EXECUTIVE SUMMARY AND OVERALL CONCLUSIONS
1. Background
The purpose and context of the quarterly Quality Improvement Report was set out in detail in
Edition 1 of the Quality Improvement Report, October 2011.
2. Report Format
The report is principally a thematic report which draws together a number of interrelated sources of
intelligence in the domains of patient experience, patient safety and clinical effectiveness. It
contains the following sections:
Executive Summary and Overall Conclusions
Section 1 - Introduction and background
Section 2 - Inspection of Trust Services during 2011/12
Section 3 - Patient Experience
Section 4 - Patient Safety
Section 5 - Clinical Effectiveness
Section 6 - Business Divisions Self Assessment of CQC Compliance
Section 7 - Future Reporting Arrangements
Appendices containing:
- Action Plans developed following inspections by the Care Quality Commission (CQC)
- Business Divisions Self Assessment of Compliance against the CQC Essential
Standards of quality and safety
The report has continued to be developed during Quarter 3 and this edition includes the following
additional information:
Outcomes of CQC Mental Health Act Inspections during 2011
Quality ratings assigned to Business Divisions by the Senior Leadership Team (SLT) at
their quarterly Performance Reviews
The Equality Delivery System and its links to the Essential Standards of quality and safety
The Productive Series (NHS Institute for Innovation and Improvement) which is used within
the Trust to underpin a number of quality improvement activities
Initial themes arising from the survey undertaken for the 2011/12 patient and carer
experience
Commissioning for Quality and Innovation (CQUIN) scheme
The additional information has been assessed alongside other external and internal sources of
information to provide an increasingly robust assessment of quality improvement priorities.
The report will continue to be refined during the remainder of 2011/12, to provide a consistent
quarterly Quality Improvement Report for the Board of Directors (BoD) from April 2012 and
appropriate formats for Business Divisions.
3. Strategic development
The BoD Development Day on 26 October 2011 included a session to progress the ‘Quality
Improvement Approach’ agreed in September 2011 and the following arrangements were
approved by the BoD in November 2011:
o The creation of a Clinical Governance Group – a fourth formal policy and planning group
reporting to the BoD to provide a forum for the discussion, debate and action on the three
domains of quality
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o The refocusing of the Performance and Assurance Group terms of reference, to focus on
performance, risk and corporate assurance priorities
o The Trust Quality Council (TQC) meeting quarterly to provide a clinical reference group, to
discuss and debate good practice and new clinical developments
o The streamlining of sub-groups with revised executive director membership
o The Deputy Chief Executive / Director of Nursing and Partnerships to adopt the lead
director role in respect of CQC and for compliance with the Essential standards of quality
and safety, supported by the Director of Business Assurance
o The Director of Business Assurance to adopt the lead director role in respect of Monitor
and for compliance with the Trust’s terms of authorisation, supported by the Director of
Finance
4. Communications on Quality
To support the revised approach to quality improvement, a strategy for the dissemination of key
quality information and messages throughout the Trust is being developed, which will be supported
by a unique brand and logo.
This will include an Intranet page dedicated to quality with access to a range of information,
resources and contacts. Existing communication vehicles including the ‘Leading the Way with
Quality’ Workshops facilitated by the Chief Executive, Team Talk, Trust Matters and Weekly
Bulletin will also be used for engaging staff and for disseminating quality information, as will a
range of Trust groups. Dissemination of the findings of the quarterly Quality Improvement Report
for the BoD will provide a key initial focus.
The strategy will aim to promote the widest possible engagement in both operational and corporate
services with our quality work to ensure that all Trust staff are aware of, and focused on the
identified priorities, with the ultimate aim of continuous improvement in the quality of services for
patients.
5. External Regulatory Assessment and Impact
A number of areas for improvement have been identified through:
the inspections conducted by the Care Quality Commission (CQC) during 2011/12
the findings of the investigation following the publication of the ‘Who Cares’ report
the Trust’s Mental Health Community Survey results
our own quality work
Outcomes of CQC Inspections of Trust Services during 2011/12
o 6 inspections of services during 2011. The main themes of the CQC inspections have
highlighted the 3 main themes of:
Personalised Care Planning
Record Keeping
Clinical Roles and Responsibilities
Outcomes of CQC Mental Health Act Inspections
o 8 CQC Mental Health Act Inspections during 2011
o In the main, issues are associated with Outcome 10: Safety and suitability of
premises; Outcome 21: Records; and, Outcome 1: Respecting and involving people
who use services
The ‘Action Plan in response to the CQC Inspection visit on 15th September 2011 (incorporating
the actions previously identified from the 8th June 2011 CQC inspection), Phase Two – September
2011 to March 2012’ was developed in Quarter 2 to address the areas for improvement on an
urgent and sustainable basis, and to provide a framework for monitoring implementation.
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Although the second CQC inspection on 15 September 2011 found that there had been some
improvements, there remained issues with the recording of care planning in relation to Outcome
21: Records and Outcome 9: Management of medicines.
Subsequent CQC inspections which have taken place during Quarter 3 on 11 October, 1-2
November and 28 December 2011 identified issues to do with personalised care planning
(Outcome 4: Care and welfare of people who use services); records (Outcome 21: Records); and,
quality monitoring systems (Outcome 16: Assessing and monitoring the quality of service
provision).
The Action Plan represented Phase Two of a three phase approach with updates provided to the
BoD through the ‘Report by the Deputy Chief Executive / Director of Nursing and Partnerships and
Minutes from the Trust Quality Council’ – November 2011 BoD Paper F and December 2011 BoD
Paper F, which include Quality Improvement as a standing section.
The Phase Two actions have been completed and signed off in December 2011.
The ‘Report by the Deputy Chief Executive / Director of Nursing and Partnerships and Minutes
from the Trust Quality Council’ – December 2011 BoD Paper F proposes Phase Three of the
Action Plan for 2012/13, which will evolve into a Trust-wide approach to embed learning, improve
practice and patient experience.
The recent CQC inspections and the unannounced visits carried out by the Quality Improvement
Team within the Nursing and Partnerships Directorate during Quarter 3 have identified the need for
two interrelated work streams in each Business Division:
o In-patient services
The Inpatient services quality improvement approach will use ‘Productive’ to focus on:
personalised care planning
record keeping
leadership roles and responsibilities (including the delivery of The Productive Leader
programme to Modern Matrons).
o Community services
The quality improvement challenge for the services provided in the community by all
Business Divisions will be larger and more complex. In December 2011, the BoD was
asked to consider how the approach can be delivered: Structures suggested were:
Centralised resource
Centralised resource working out into the Business Divisions
Business Division accommodated resource.
The result of the BoD discussions has been worked up by SLT and will be progressed in Quarter 4.
6. Internal Corporate and Business Division Self Assessment of Compliance
The evidence included within the report and summarised in this section has identified the following
themes and, where necessary, areas to be included within the ‘Action Plan in response to the CQC
Inspection visit on 15th September 2011 (incorporating the actions previously identified from the 8th
June 2011 CQC inspection), Phase Two – September 2011 to March 2012’’ (Appendix A), and
within Phase Three as set out above.
Quality Ratings from the Quarter 2 Performance Reviews of the 8 Business Division show:
o 2 are green (Forensic/CAMHS)
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o 3 are amber/green (Psychological Therapies, Substance Misuse and DCIS)
o 3 are amber/red (Learning Disabilities, Older People and Adults)
The shift between Quarter 1 and Quarter 2 has seen 2 Business Divisions move to amber/red
and 1 maintain amber/red.
Unannounced Visit Findings
o 30 visits were completed between September and December 2011 to all inpatient
services and a small number of community teams
o The finding are consistent with the 3 top three risks to quality:
o Personalised care planning
o Record keeping
o Leadership roles and responsibilities
6.1 Patient Experience Corporate Assessment
The evidence included within the report and summarised in this section has identified the following
themes:
Eliminating Mixed Sex Accommodation compliant with standards.
The results of the Quarter 2 - 2011/12 patient and carer experience CQUIN show all
areas scored high on the privacy and dignity domain, but responses to other sections
were mixed across Business Divisions and geographical areas. Analysis of Quarter 3
responses is underway.
Themes identified within the Care Programme Approach (CPA) audit in the Adult
Business Division are consistent with two of the top three identified risks to quality,
namely personalised care planning and record keeping. Issues regarding the recording
of Care CPA status on records and arrangements for 7-day follow up have also been
identified by the Business Intelligence Group (BIG). Re-audit is scheduled for Quarter 4
when new records will have been introduced and training provided.
In relation to the Trust Community Survey Results 2011, Business Divisions have
reported improvements in clinical practice and monitoring systems resulting from their
action plans in relation to care planning, assessment of needs regarding use of alcohol
and non prescription drugs and medication monitoring. The process for the 2012
Community Mental Health Survey commences in January 2012 and the initial results
are likely to be available in June 2012.
The process for setting and reporting on Business Division Patient Experience Quality
Markers is being reviewed following presentations to TQC in October 2011, with a view
to increasing our ability to measure impact.
The Patient, Carer and Public Engagement (PPE) Strategy is being reviewed to provide
a refreshed approach including new name and brand for the strategy by March 2012.
19 formal complaints received, 6 completed responses. 3 of these relate to CQC
Outcome 4: Care and welfare of people who use services, as does the positive
feedback (81%) from Your Opinion Counts (YOC) forms and compliments.
Patient Safety Corporate Assessment
The evidence included within the report and summarised in this section has identified the following
themes:
It is clear that care planning (Outcome 4: Care and welfare of people who use services)
and records (Outcome 21: Records) remain the most frequently recurring themes
identified through Serious Incident investigations. The majority of Serious Incidents
occur within the Adult Business Division. Feedback from NHS Doncaster Incident
Management Forum (IMF) indicates the need for improvements in practice regarding
records.
Issues identified through the analysis of serious incidents are linked to the CQC
outcomes and Quality Markers in order to inform the Business Divisions CQC Provider
Compliance Self Assessment and to identify improvement priorities.
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Audit of care plans in relation to safeguarding children has highlighted difficulties in
identifying information.
There is a drop-off in the return rate of Looked after Children CQUIN questionnaires,
potentially due to methodology.
The Trust is involved in 9 Local Authority Designated Officer (LADO) investigations in
relation to staff employed by the Trust.
The potential future publication of Trust safeguarding reviews may lead to adverse
publicity.
There is an increase in numbers of staff attending/completing Mandatory and Statutory
Safeguarding Children Training.
Safeguarding Adult Training figures continue to show some gaps in information and low
figures. This will be a continued focus of work during Quarter 4.
Infection Prevention and Control (IPC) training figures show a poor uptake. Business
Divisions are required to provide action plans to achieve 100% compliance by March
2012.
Consistently low rates of infections, 0 cases of C Diff and 0 cases of MRSA support the
quality of the Infection Prevention and Control (IPC) work being carried out.
The Trust has no outstanding patient safety alerts.
6.3 Clinical Effectiveness Corporate Assessment
The evidence included within the report and summarised in this section has identified the following
themes:
A Clinical Effectiveness Committee has been established reporting to the Clinical
Governance Group, incorporating work previously undertaken by the Eliminating Mixed
Sex Accommodation Group, Essence of Care Group, Health and Well-Being Steering
Group and NICE Guidance Group.
Good progress has been made with Doncaster Community Integrated Services (DCIS)
‘Productive’ project plan, with 100% take up rate by the 66 identified teams. Work is on
target to complete the foundation modules by March 2012.
No issues have been identified with implementation of NICE Guidance. A Trust wide
approach to NICE Quality Standards is being developed, co-ordinated through the
Clinical Effectiveness Committee.
Three year clinical audit programme approved covering period January 2010 to
December 2012
o 45 clinical audit domains identified over the 3 year time frame
o Agreed clinical audits specified by commissioners have been initiated
o The data collection phase of 3 National Audits has been completed and the data
submitted to the relevant national lead body (supports CQC Outcome 4: Care and
welfare of people who use services and Outcome 9: Medicines Management).
o 1 further audit has been completed on record keeping, which identified variable
performance against standards. Action plan implemented and monitored by the
Clinical Effectiveness Committee.
o A Qualitative clinical records audit tool has been successfully piloted within 7 teams
(this work supports one of the top three identified risks to quality, namely
personalised care planning).Trust approach to be established in Quarter 4.
o A performance management process has been implemented for clinical audit action
plans, monitored by Clinical Effectiveness Committee.
o The process for monitoring Prescribing Observatory for Mental Health UK (POMH
UK) audit action plans will be integrated within the monitoring approach undertaken
by the Clinical Effectiveness Committee, reporting to the Clinical Governance Group
with effect from January 2012.
o A number of clinical policies are exceeding their review date and are being
managed by the Clinical Effectiveness Committee.
Medicines Management
o Outcomes from CQC inspections to be finally signed off i.e. Patient Identification
Policy and approach to self administration of medicines.
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o Medicines Management Committee will report to the Clinical Governance Group
from January 2012, strengthening the Medicines Management governance
arrangements.
Non Medical Prescribing
o Post of Non Medical Prescribing Lead ready to be advertised
o Revised Non Medical Prescribing Policy ratified and will be launched in January
2012.
o Mapping exercise of non medical prescribing supervision completed. Analysis of
findings and actions required is being undertaken to ensure each Non Medical
Prescriber has appropriate supervision.
Making Every Contact Count (MECC)/Physical Health and Well-Being – good progress
made in refocusing the role of identified champions to enable them to take a lead on
delivery of staff training associated with the Health and Well-being CQUIN.
Implementation plan around training, assessment and care planning agreed with each
Business Division for completion by February 2012, in line with the CQUIN timescales.
Significant level of training delivered.
6.4 Business Divisions Self Assessment of Compliance
Inclusion of Quality Ratings from Quarter 2 Business Division Performance Reviews
has highlighted discrepancies between the corporate assessment of quality undertaken
by SLT at the Business Divisions Quarter 2 Performance Review and the Business
Divisions self assessments. This has necessitated discussions with the relevant
Business Divisions and some changes to their self assessment to reflect a more
accurate position.
The Trust’s self assessed compliance with the Essential Standards of quality and safety
is providing an increasingly robust analysis of compliance and identify the priorities for
quality improvement.
The Nursing and Partnerships Directorate and the Business Assurance Directorate are
working jointly with the Business Divisions to ensure the approach is embedded.
The evidence included within this section has identified the following themes:
4 Red ratings (not met, action is required quickly) have been assessed as follows:
o Adult Mental Health Services: Outcome 6 – Cooperating with other providers
and Outcome 21 – Records
o Learning Disabilities: Outcome 10 – Safety and suitability of premises and
Outcome 21 -Records
This is an increase in one Red rating from Quarter 2, relating to the Major Concern regarding
Outcome 21: Records identified at the CQC Inspection of Oak Close, Rotherham on 11 October
2011.
The Red rated outcomes are priorities which are already identified within the ‘Action Plan in
response to the CQC Inspection visit on 15th September 2011 (incorporating the actions previously
identified from the 8th June 2011 CQC inspection), Phase Two – September 2011 to March 2012’
(Appendix A).
39 Amber ratings (Mostly met, action required is moderate) have been assessed as
follows:
o Adult Mental Health Services: 7 outcomes (1 more than Q2)
o CAMHS: 2 outcomes (same as Q2)
o Forensic: 3 outcomes (1 more than Q2)
o Psychological Therapies: 5 outcomes (1 more than Q2)
o Learning Disabilities: 5 outcomes (3 more than Q2)
o Substance Misuse: 6 outcomes (same as Q2)
o Doncaster Community Integrated Services: 11 outcomes (3 more than Q2)
o Older People’s Mental Health Services - 0 outcomes (same as Q2)
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The Business Divisions self assessment of Amber ratings has increased in Quarter 3 by 9 from the
30 reported in Quarter 2. This is a reflection of the more robust assessment process which has
been developed through the Essential Standards Champions Group with increased checks and
challenges put into the system through the Nursing and Partnerships and Business Assurance
Directorates.
The Outcomes rated most frequently by the Business Divisions in Quarter 3 as Amber
are:
o Outcome 1: Respecting and involving people who use services (5 Divisions)
o Outcome 4: Care and welfare of people who use services (5 Divisions)
o Outcome 6: Cooperating with other providers (3 Divisions)
o Outcome 7: Safeguarding people who use services from abuse (3 Divisions)
o Outcome 9: Management of Medicines (4 Divisions)
o Outcome 10: Safety and suitability of equipment (4 Divisions)
o Outcome 14: Supporting workers (5 Divisions)
This is in comparison with Quarter 2, where only Outcomes 4, 10 and 14 were identified. Once
again this is a reflection of the more robust assessment process. In addition, the introduction of the
Equality Delivery System – with the first Trust report due at the end of January 2012, has required
more in depth assessment particularly in relation to all outcomes and particularly Outcome 1.
Business Division self assessments will continue to be used to inform the focus of the
unannounced visits by the Nursing and Partnerships Directorate and to inform the choice and more
precise definition of Quality Markers.
7. Conclusion
The identified risks to quality are the reason the Trust’s current Monitor Governance Risk Rating is
Amber/Red, and why the decision was taken by the BoD on 28 July 2011 and 27 October 2011 to
submit Declaration 2 to Monitor for its Quarter1 and Quarter 2 Quality Governance Declarations
2011/12.
This is also the recommendation to the BoD for the Quarter 3 Quality Governance Declaration.
The corporate assessment of the evidence contained within the patient experience, patient safety
and clinical effectiveness sections of the report, and also the Business Divisions self assessment
support the overall conclusions from the external regulatory assessment, which identify the same
top three risks to quality as were identified in Quarter 2:
Personalised care planning
Record keeping
Leadership roles and responsibilities
These risks are being managed through:
The ‘Action Plan in response to the CQC Inspection visit on 15th September 2011
(incorporating the actions previously identified from the 8th June 2011 CQC inspection), Phase
Two – September 2011 to March 2012’.’
The development of Phase Three of the Action Plan for 2012/13 as described above. This will
evolve into a Trust-wide approach to embed learning, improve practice and patient experience,
comprising two interrelated work streams in each Business Division for In-patient and
community services the detail of which has been worked up by SLT and will be progressed
during Quarter 4.
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