the foundations for continued success · workbridge therapy clinics st andrew’s northampton...

The Foundations for Continued SuccessQuality Account 2015/16

St Andrew’s Healthcare www.standrewshealthcare.co.uk

Workbridge www.workbridge.org.uk

Therapy clinics www.standrewstherapy.co.uk

St Andrew’s Northampton Cliftonville Northampton NN1 5DG

t: 01604 616 000

St Andrew’s Birmingham 70 Dogpool Lane Stirchley, Birmingham West Midlands, B30 2XR

t: 0121 432 2100

St Andrew’s Nottingham Sherwood Avenue Sherwood Oaks Business Park Mansfield, NG18 4GW

t: 01623 665 280

St Andrew’s Essex Pound Lane North Benfleet Wickford, SS12 9JP

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ContentsPart 1Progress and plansTransforming lives together: Gil Baldwin 4An ambitious vision for our patients: Dr Alice Parshall 6Directors’ responsibilities 9

Part 2Quality of PrioritiesOur quality priorities 11Statements of assurance 13Participation in Clinical Audits 13What others say about St Andrew’s 18Involvement and feedback 22

Part 3Review of Quality PerformancePatient involvement 25Meeting standards 26Care pathways and physical healthcare 29Handling risks and incidents 30

St Andrew’s showcase

Occupational Therapy 32Workbridge 34Collaborative ward reviews 35

3St Andrew’s Healthcare | Quality Account 2015/16St Andrew’s Healthcare | Quality Account 2015/162 3St Andrew’s Healthcare | Quality Account 2015/16

Transforming Lives TogetherGil Baldwin Chief Executive Officer

While 2014/15 was a year of renewal and change, this year was very much about outlining the path we will take to become a world-class provider of specialist mental healthcare. We started it by sharing our five year strategy which has, at its core, our vision: transforming lives by building world-class mental healthcare services.

We are privileged to have the opportunity to transform the lives of our patients. Our success will also have a huge impact on the lives of their families, carers and everyone in the St Andrew’s community. To achieve our vision we need to deliver world-class holistic care, develop and adapt innovative therapies and put people first, prioritising safety and recovery.

Embedding our new strategy

An initial step in providing world-class care saw us reorganise the Charity around six ‘care pathways’, each with its own clinical vision and leadership team to meet the specific needs of our patients. We also rolled out our Positive & Safe programme, aligned to the Department of Health initiative, to reduce restrictive practices across the Charity by de-escalating situations, where possible, at an early stage.

Putting people first is clearly about our patients, but it also means providing support to our employees and showing that their contribution is valued. So this year we introduced a new engagement survey for our people to tell us what’s good about working at St Andrew’s and where we can improve.

I was pleased that colleagues felt we go the extra mile in looking after patients and that we do a good job at recognising their efforts. Of course, there are always areas we can improve and we are now looking at rewarding performance more fairly and reducing paperwork across the Charity.

Delivering this in a way that doesn’t compromise safety means our people can spend even more time with patients. Technology is the key here and we are investing in a number of systems to help us drive both efficiency and insight, using data to help predict patients’ likely behaviour. This will be fundamental in improving and personalising the care that we provide.

We are already seeing the first fruits of these changes. The quality of our care in our Birmingham and Nottinghamshire sites was endorsed by the Care Quality Commission, who rated both sites as ‘good’ following inspections last year, and we reached record occupancy levels of 93 per cent. Most importantly, we helped 300 patients return to the community or move to lower levels of security.

Looking ahead

The year can be characterised, then, as laying the foundations for our continued success. Greater efforts must be made to innovate. We will improve our care for patients by modelling our clinical methodologies – so that we have the right people, consistently delivering the right care at the right time. This is easier said than done, but it’s a critical step in providing truly world-class care for all our patients.

We will assess our progress against two measures: the degree of personalisation in our care, so that we truly treat the person and not their condition; and our patients’ health – mental, physical and spiritual.

Alice Parshall, our new Chief Medical Officer, expands on our ambitions in this area in her statement on page 6.

A pathway to the community

It’s also important for us to maintain our relevance in a world where the general direction, led by the NHS, is towards treatment being conducted in the community and nearer to home.

We will achieve this by continuing to extend our pathways beyond the hospital environment. It means we are able to provide world class treatment in three distinct, connected stages.

A patient may begin in a personalised ‘home in hospital’, which then leads to ‘home near hospital’ – allowing gradual reintegration into the community – followed by ‘home at home’, where they are empowered to live as independently as possible. Our aim is not to bring an individual to an impersonal institution, but to wrap the most supportive environment around them in a setting where they can recover best.

Providing a ‘home at hospital’ could be as simple as painting the walls of a patient’s room in their favourite colour, or creating a familiar pub environment for residents with dementia – both of which we already do. It’s about knowing what works best for each individual.

We also provide placements in a ‘home near hospital’ model as part of our Adolescent, Women’s and Neuropsychiatric Pathways.

Berkeley Close and Berkeley Lodge in Northampton act as a stepping stone back into the community for 35 patients with neurological conditions. We have also acquired a new six-bed unit to support the Autistic Spectrum Disorder and Learning Disability Pathways near our Nottinghamshire site.

The final ‘stage’ in the pathway will see us develop teams that support the transition from ‘home near hospital’ to ‘home at home’, to replicate the patient’s personalised care in the setting of their choice. This journey from institutionalised care to the community is, for some patients, complex and challenging, but one that we must embrace if we are to truly transform lives.

Clarity of purpose will be the key to our ongoing success, and I hope from this you gain a sense of the momentum within St Andrew’s today. None of this would be possible without the commitment and dedication of our people. We have been through a considerable amount of change in the last 18 months and I am enormously proud of our colleagues’ professionalism in rising to the challenge. I would like to thank them all for embracing this change while continuing to deliver outstanding care for our patients.

Gil Baldwin CEO

1.

5St Andrew’s Healthcare | Quality Account 2015/16St Andrew’s Healthcare | Quality Account 2015/164

An ambitious vision for our patientsDr Alice Parshall Chief Medical Officer

The Care Quality Commission (CQC) pilot inspection programme in September 2014 was a milestone for us. It provided clarity on where our provision of care was strong and what we could do to improve. Since then, we have delivered significant transformation, not least the restructure of the Charity into six care pathways: Adolescents; Autistic Spectrum Disorder; Learning Disability; Neuropsychiatry; Men’s Mental Health and Women’s Mental Health. Launched in June 2015, the new pathway approach means that we can deliver greater consistency in how we care for our patients, while tailoring care plans specifically to the individual.

We’ve also reviewed each of the CQC’s five domains – Safe, Effective, Caring, Well-led and Responsive – and driven transformations ranging from the introduction of a new ‘ward to board’ governance structure, to launching support groups for carers and ensuring we have a greater patient voice in everything that we do. An example of this is the role played by our patients in the design of our new FitzRoy building – due to be Europe’s largest adolescent-specialist residential facility when it opens later this year.

It was very pleasing to see the CQC endorse our improvements at their follow up inspections of our Birmingham and Nottinghamshire sites last year, where both were rated ‘good’. We are looking forward to welcoming the CQC back to our Northampton site in June 2016, so that we can demonstrate the innovations we’ve delivered in patient care at this site.

Looking ahead, our focus is now on improving care even further. In the UK as a whole, people with mental health conditions are at high risk of earlier death from physical illness. St Andrew’s is determined to address this issue. We are working with leaders in healthcare to complement the NHS Five Year Forward View and take strides to place equal focus on physical, mental and spiritual wellbeing.

This journey has begun with an ambitious clinical modelling programme that has three main streams. The first sees us move to outcome-driven care, where each individual is given an appropriate level of choice and control over their health plans. An essential part of this is to reduce restrictive practices.

The second stream concentrates on front line delivery of care, to ensure we provide the best possible service to our patients. Initiatives include collaborative ward reviews (see page 35), where processes and care approaches in each ward are discussed by a cross-section of colleagues from across the pathway.

The third area of focus is on our effectiveness. This forms an essential part of our shift to value-based care. We are comprehensively reviewing our processes to ensure we are delivering the best possible balance of support for our patients. The review ranges from seeking ways to deliver more integrated multi-disciplinary care, to assessing ward staffing and training requirements to ensure that we safely and efficiently meet patients’ needs.

A final Charity-wide initiative is set to deliver major benefits to patients through knowledge management. We are redesigning our clinical IT systems, including how we record patient health information.

Our new healthcare data will deliver value in three core areas; by empowering patients and carers to take control of their recovery, through collating evidence about the effectiveness of certain treatments for each patient’s condition, and by using practice-based evidence to make decisions about individual care plans in real time.

As a Charity we have high ambitions for our patients and our staff. Transparency and candour will be the foundations of our success; with scrupulous review and acting on our learning as the building blocks.

Alice Parshall, Chief Medical Officer

1.


1.2 Statement of directors’ responsibilities in respect of the Quality Account The Department of Health has issued guidance on the form and content of the Annual Quality Account. In preparing the Quality Account, Directors should take steps to satisfy themselves that:

• The Quality Account presents a balanced picture of the Charity’s performance over the period covered

• The performance information reported in the Quality Account is reliable and accurate

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

• The data underpinning the measures of performance reported in the Quality Account is:

- Robust and reliable

- Conforms to specified data quality standards and prescribed definitions

- Subject to appropriate scrutiny and review

- Has been prepared in accordance with Department of Health guidance.

The Directors confirm to the best of their knowledge and belief that they have complied with the above requirements in preparing the Quality Account for 2015/16.

1.

Peter Winslow, Chairman

Date: 24 June 2016

Gil Baldwin, Chief Executive Officer

Date: 24 June 2016


Quality Priorities 2016/172.

2.1 – Our quality priorities for the coming year The table below details our chosen quality priorities for the coming year (2016/17). Progress with the implementation of these priorities will be monitored through the Quality and Risk Board (QRB) throughout the year. Specific targets and trajectories for improvement will be developed where appropriate.

2.

continued overleaf

2016/17 Priority Why we have chosen this priority

How we will monitor and measure this priority

Develop the Quality Improvement Strategy and Implementation Plan, aligned to the Quality Improvement Strategic Direction approved by the Board

To ensure that high quality care is embraced by every member of staff, in collaboration with patients and carers as a customary way of working. This will enable us to demonstrate progress towards personalisation and health (both physical and mental).

We will do this through testing, introducing ‘outcomes’ to staff to build understanding and delivering programmes for change.

We are developing a preliminary outcome suite, a timeline for business and IT change to 2020 to take the quality improvement programme forward, and establishing a repository for QI projects. All QI projects will be based around activity and/or safety. Progress is monitored through the Quality and Risk Board.

Improve health outcomes for our patients through implementing a robust outcome management; capability with established processes for directing improvement efforts

To establish the Charity as a Learning Health System through the identification of desired health outcomes, measuring them, evaluating their value and developing a strong clinical evidence base.

We will do this through developing a clear hierarchy of outcomes for patients and advancing our strategy for automating data collection; routinely collect high quality data, process it efficiently and maximise its usefulness; align this work with the wider health landscape and external benchmarking and develop a systematic approach to cultivating behavioural changes.

Delivery of year two of the Restrictive Interventions Reduction Programme

In support of positive and proactive approaches, we are continuing to develop our culture within which physical interventions are only ever used as a last resort.

Progress with this programme is monitored through the Restrictive Interventions Oversight Group. The project plan is currently being revisited to ensure that actions remain pertinent and support our outcome based approach to health and personalisation.


2016/17 Priority Why we have chosen this priority How we will monitor and measure this priority

Ensure safe staffing and re-configured clinical teams underpin effective safe care and treatment at ward level

To further embed the work already started through our people strategy to support recruitment, retention, employee engagement and training.

The Assurance Board oversees progress with the Safe Staffing agenda through monitoring that staffing numbers and skills are maintained at the appropriate levels. This Board will also ensure that any breaches are addressed in order to provide upwards assurance to the Board of Directors.

Prioritise, identify and promote patient safety as an outcome; supported by measureable KPI’s delivered through strengthened and fit for purpose Serious Incident and Safeguarding (Adults and Young People) processes

To build further on the work undertaken to embed an open and learning culture across the Charity and to further improve upon our safety of care.

We are taking steps to improve reporting, investigations and learning lessons and to ensure that the processes that underpin these are robust and efficient. We are working closely with external organisations to further improve information sharing. Progress is monitored through the Quality and Risk Board. The Patient Safety Group has also been re-established to further embed these principles and share best practice.

Full implementation of the Physical Healthcare strategy, including smoking cessation, weight management, effective antibiotic management and healthcare screening

The Charity is committed to the implementation of a preventative/outcome driven clinical strategy. This priority will incorporate existing work with regards to these areas.

As part of the preventative clinical outcomes work we will be redefining KPIs. We will move away from, for example, capturing the number of patients who develop obesity or type 2 diabetes related to their medication regime and inactivity, to a more positive measure of effective prevention, leading to a better health outcome for our patients.

Develop an effective Morbidity Mortality Review arrangement, aligned with the NHSE Avoidable Mortality requirements

By reviewing each death we will be able to identify any clear learning points and ensure implementation of actions through the learning lessons framework.

We have an established Mortality Group that will monitor that each death is reviewed using a standardised framework.

We are reviewing and updating our End of Life Policy to reflect an emphasis on staff and carer experience and include the managed clinical network and learning from mortality review.

Advance the Charity’s Patient Engagement strategy on multiple levels to ensure the patient’s voice is heard and acted upon

To support the Charity’s commitment to quality and therefore improved services for our patients.

The patient engagement strategy will be co-produced to support personalisation outcomes and patient voice. This is monitored through the Quality and Risk Board and includes complaints data, Friends and Family Test and other patient survey data.

Audit Title Cases Submitted % of the number of registered cases required

Prescribing for Attention Deficit Hyperactivity Disorder (ADHD) in children, adolescents and adults

39 100%

Prescribing Valproate in Bipolar Disorder 24 100%

2.

Statements of assurance from the board

2.2 – Review of services

From 1 April 2015 to 31 March 2016 St Andrew’s provided services in the field of mental health, learning disability and brain injury to 1,232 patients, commissioned by 186 different bodies, of which 96.3% were NHS services or organisations. The remaining 3.7% of patients are funded by non-UK organisations, private funders or individuals.

St Andrew’s has reviewed all the data available on the quality of care in respect of the services for which it provides clinical NHS care. The services reviewed in the Quality Account for 2015/16 represent 100% of St Andrew’s income that was generated from the provision of NHS services during the period 2015/16.

2.3 – Never Events

‘Never Events’ are described as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented’ (National Patient Safety Agency (NPSA) 2009).

We are pleased to confirm that there were no ‘never events’ at St Andrew’s during the reporting period.

2.4 – Clinical audit

Participation in national Clinical Audits

The national clinical audits relevant to St Andrew’s are those co-ordinated by the Royal College of Psychiatrists Prescribing Observatory for Mental Health UK (POMHUK). The topics for 2015/16 were:

The reports of these national audits have been reviewed by the Medicines Management Group and the Quality and Risk Board. St Andrew’s intends to improve the quality of healthcare provided by including links and guidance regarding prescribing, monitoring of effectiveness and side effects.

Mandatory review dates and indications will be included in Electronic Prescription and Medication Administration (EPMA) templates currently under development as part of our EPMA project.


Ligature Audit

Care Planning

HoNOS and CGAS

Long Term Segregation

Offenders given an MHTR as part of Community Order

Physiotherapeutic treatment and clinical management

Comparison of HCR20 factors between patients with high functioning ASD and other ASD

Evaluation of yellow placemat usage in NPS

Prevalence in the patient population to morbidity of mental illness and sexual dysfunction

The use of sensory strategies through the Adolescent Pathway

12 month study of admissions to Sherwood and Frinton PICU’s

Length of stay within forensic settings

PICU admissions and discharges

48 hour admissions

Psychotropic prescribing in ASD

Progress notes – peer audit

Mealtime observation

Discharge summary

Dental infection control

PPE and spillage of bodily fluids

Infection control environment

Annual health check

Food storage in ward serveries

Quality of progress notes

Collaborative Risk Assessment

HCR 20

Service Evaluation and Treatment Outcomes – Neuropsychiatry

Improving compliance with relational security

Deaf patients understanding of care plans

Contact with staff on wards

Customer satisfaction survey – Consultancy Service

Neurobehavioural feedback in and ABI setting: Evaluating the role of core skills in a neurobehavioural service

CPA patient review

Patient Admission and Assessment Forms

Proportion of RiO entries per week recording positive behaviour as ‘green behaviour’

Compliance with verification of death against the recommended guidelines set out by the ARMC

Routinely collected clinical information on physical health, mental health in NPS

Recognising positives: creating opportunities for and promoting adaptive behaviours within a sample of adults with progressive neurological conditions

TR training feedback

Nutritional screening

OT monthly audit of tools, cupboards and containers

Safe handling and disposal of sharps

Management of patient equipment (specialist)

Nursing standards

Seclusion

Ward metrics

Section 17

Seclusion Room Environment

NHS Wales quality audit

The use of PRN medication in a secure hospital

Evaluation of psycho-education intervention for female inpatients with a PD diagnosis

Implementation of actions following safeguarding interventions

Evaluation of Ownfone devices on Berkeley Close

Use of ‘my hospital passport’ for ASD patients

The effect of exercise on mood of patients with PD

Quality of medical appraisals

Medication equipment and medications for seizures in the Neuropsychiatry Pathway

PICU admissions and discharges

Support from Secondary support required, received and outcomes from secondary and tertiary health care providers in the management of physical health conditions in the Neuropsychiatry Pathway

Baseline of personalisation through the Spiritual Needs Assessment Tool

Dysphagia policy

Staff understanding of dental care for psychiatric inpatients

Care plans BMI

Hand hygiene

Management of patient equipment (general)

Commode audit

Mental Capacity Act

Safety level system

2.

Participation in local Clinical Audits

During 2015/16 68 local clinical audits were registered internally with the central Quality Assurance Team. These audits included:

Learning from Clinical Audits

The clinical audit strategy was revised this year to ensure clarity in the use of auditing and to embed clinical quality at all levels of the Charity. This will create a culture that is committed to learning and continuous organisation development. It will also deliver demonstrable improvements in patient care through the development and measurement of evidence based practice.

Three audits undertaken this year have been detailed below as examples of our learning:

1. The Care Planning audit was undertaken to provide a semi-quantitative baseline of the care planning process end-to-end, including assessments as currently required; the identification of individualised needs against which to plan care, the Care Plan itself and the operation of links and triangulation between these. It also allowed for the evaluation of clinician involvement and the engagement of patients and carers.

Findings include the need to carry out a stock check of the necessity and value of all assessments that are being undertaken to identify which can can be stopped. It is also important to identify which are the ‘core’ assessments that must be carried out for every patient and then those that are pathway specific. We must recognise the high fidelity (90%) between recognised need and planning care, but equally recognise the variety of elements of the assessment data that are seen as redundant.

The full audit report was presented to the Clinical Senate in November 2015.

Clinical Senate agreed to the development of a comprehensive programme management approach to address the issues identified within the audit. A project plan has been worked up in conjunction with the Chief Medical Officer, the Director of Nursing and Quality and the Deputy Director of Quality and Compliance. This has been signed off and is to be monitored by the Clinical Senate.

2. An audit of the Perception of Organisation Barriers to Pain Treatment Planning was undertaken to establish a baseline of the collective readiness of our neuropsychiatry service to develop excellent pain management within a neuro-palliative context treatment.

The findings included the need to undertake a training needs analysis to design and implement key learning as part of pain management; to establish clearer clinical assessment processes, relevant tools and documentation which are embedded by the enhanced physiotherapy provision and to establish clearer prescribing protocols.

The results of this audit were disseminated through the Neuropsychiatry Quality and Risk Group and a re-audit will be undertaken in 18 months time.

3. The audit of Comparison of Individual HCR-20 Factors between Forensic Patients with high functioning ASD and other ASD was carried out to observe if there were differences in the risk profile of these two groups of patients.

The findings were not statistically significant between hfASD and other ASD groups, although further inspection of mean rank differences did highlight certain factors where differences were found.

Recommendations included:

• That the description of ‘violence’ was limited in the HCR-20 documents and that ‘behaviour’ needed to be understood in the context of whether it is anti-social or whether it is a lack of understanding of ASD

• The understanding and need for relationships based on the ASD diagnosis needs to be clarified, as does defining relationship problems for a person with ASD (this needs further research and elaboration)

• Employment problems or aversion to employment need to be considered in the context of social and communication difficulties

• Co-morbid personality disorder requires the specification of historical presentation and risk of violence; traumatic experiences can easily be missed if specific details of the contextual effect of trauma are not elaborated

• Violent attitudes may be situation or person specific and may be entirely absent; attendance and meaningful engagement with supervision and treatment needs to be differentiated and a lack of statistical significance is possibly due to the HCR-20 not being ASD specific.


Articles/Book Chapters

Published Articles Accepted for publication Book Chapters

29 4 5

Conference Attendance

Oral Presentation

Poster Presentation

Symposium Workshop E Poster

27 11 2 3 3

Patient Participation in Research Studies (by pathway)

MMH WMH NPS ALS ASD LD

2 - 1 5 18 2

2.

2.5 – Participation in clinical research

Participation in research allows us to understand the needs of our patients, what interventions and treatments work to improve outcomes and develop, adapt and adopt more effective therapies and treatments. We actively look for gaps in knowledge and potential therapies and treatments, design research proposals, identify collaborators, obtain resources, recruit participants, collect and analyse data, report results and apply findings. This allows St Andrew’s to deliver improved quality of care.

The number of patients receiving NHS services provided by St Andrew’s in the 2015/16 reporting period that were recruited to take part in research approved by the research ethics committee was 26.

Affiliations:

• Institute of Psychiatry, Psychology and Neuroscience (IoPPN)

• University of Northampton

• University of Birmingham

• University of Buckingham

• University of Cambridge

2.6 – Goals agreed with the Commissioners

The Commissioning for Quality and Innovation (CQUIN) programme provides a national framework for improving quality and innovation within NHS funded care to realise better patient outcomes. First launched in 2009/10, the scheme sets annual quality improvement goals. Despite increasingly challenging requirements, St Andrew’s has

maintained 100% achievement since their inception. 2.5% of the Charity’s income during 2015/16 was conditional on achieving these goals. The majority of goals are mandated nationally through our contracts with NHS England, though CQUIN forms are part of contractual agreements with all NHS commissioners. The CQUINs relevant to the

specialist care provided by the Charity in 2015/16 are summarised below, along with our success in achieving them. Further details on the agreed goals for the reporting period and the following 12 month period are available electronically by emailing our contracting team on [email protected].

Academic data for the Quality Account 1 April 2015 – 31 March 2016

Secure Service Users Active Engagement Programme 100% 100% 100% 100%

Improving Physical Healthcare 100% 100% 100% 100%

Supporting Service Users In Secure Settings To Stop Smoking 100% 100% 100% TBC

Mental Health Carer Involvement Strategies 100% 100% 100% 100%

CAMHS- Improving Pathways 100% 100% 100% 100%

CAMHS- Improving Patient, Family and Carers Admission Experience 100% 100% 100% 100%

CQUIN Q1 Q2 Q3 Q4


2.

The Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. All providers of regulated activities must be registered with the CQC under the Health and Social Care Act 2008. As from 1 April 2015 all providers are expected to meet the fundamental standards as laid down by the CQC.

St Andrew’s is required to register with the Care Quality Commission. We are registered to carry out the following regulated activities:

• Assessment or medical treatment for persons detained under the Mental Health Act 1983

• Treatment of disease, disorder or injury.

St Andrew’s has the following condition of registration:

• The Adolescent Service must not provide services for people under the age of 13 years.

The CQC has not taken any enforcement action against St Andrew’s during the 2015/16 reporting period.

St Andrew’s has not participated in any special reviews or investigations by the CQC during the reporting period.

The CQC carried out two inspections with regard to the Fundamental Standards. The first of these was to St Andrew’s Nottinghamshire in June 2015. The results are detailed below:

The results of these two visits demonstrate that both of our Nottinghamshire and Birmingham sites are fully compliant with the Fundamental Standards. A further visit to the Northampton took place in June 2016 which will be followed by a visit to St Andrew’s Essex in September 2016.

The CQC undertook 22 unannounced inspections under the Mental Health Act across the Charity during this year. Our overall position on these inspections has improved with closure of previously identified actions being noted in all reports.

The second of these was to St Andrew’s Birmingham in October 2015. The results are detailed below:

Overall Rating Requires Improvement Good

Safe Requires Improvement Good

Effective Requires Improvement Good

Caring Requires Improvement Good

Responsive Good Good

Well-led Requires Improvement Good

Overall Rating Good Good

Safe Requires Improvement Good

Effective Good Good

Caring Good Good

Responsive Good Good

Well-led Good Good

Domain Sept. 2014 Rating June 2015 Rating

Domain Sept. 2014 Rating Jan.2016 Rating

2.7 – What others say about St Andrew’s

Some of the comments that were made in these reports are as follows:

Inspection of Bayley ward in the Adolescent Pathway, April 2015

Care plans were individualised and showed consideration of the least restrictive options. Risk assessments had been completed and there was evidence that risk assessments and care plans had been reviewed and updated. Patients knew who their care co-ordinators were and were aware of the contents of their care plans, including longer-term goals and discharge plans.

Inspection of Northfield ward in the Men’s Mental Health Pathway, June 2015

All treatment was given under an appropriate legal authority. We saw good evidence of the patient’s capacity/consent at the most recent authorisation.

All the patients we spoke to were aware of their medication. Patients told us their responsible clinician had spoken to them about their specific medication. One patient told us the ‘responsible clinician had done so well for me’. The patient told us his medication was right for him and was keeping him well.

Inspection of Thornton ward in the Women’s Mental Health Pathway, October 2015

Detention papers were all present and in good order. Approved Mental Health Professional (AMHP) reports were available. We saw timely renewal of detentions and Second Opinion Appointed Doctor (SOAD) applications had been made where appropriate. Annual statutory reports were made to the Ministry of Justice (MoJ) where appropriate.

Inspection of Berkeley Close in the Neuropsychiatry Pathway, December 2015

There was clear evidence of individual patients’ capacity to understand their rights which were provided regularly and where appropriate information was provided in an accessible format. All of the patients we spoke to were well informed of their rights under the Mental Health Act.

Inspection of Church ward in the Adolescent Pathway, January 2016

We saw that comprehensive risk assessments had been completed. These included historical information, current formulation and a risk management plan. Positive behaviour support plans were completed together with patients and there was an emphasis on supporting positive behaviour through shared goal-setting, positive reward systems and manipulating the environment to maximise routine, predictability and safety and to minimise the risk of over stimulation.

Other external agencies

A quality visit was carried out by NHS Wales to the Northampton site in November. A three ‘Q’ status was maintained for the adult services, a ‘Q’ was deducted for the CAMHS service in relation to the ‘tired’ appearance of the environment on Richmond Watson ward. This has now been redecorated and the ‘Q’ has been reinstated.

NHS Wales also carried out a quality visit to St Andrew’s Birmingham in January. The visit was extremely positive and the 3 ‘Q’ status will be maintained.

The Royal College of Psychiatrists carried out a Quality Network review in St Andrew’s Birmingham. It awarded an overall compliance rate of 94% for low secure standards and 95% for medium secure. The peer review team commended several aspects of services within St Andrew’s Birmingham such as; physical security, procedural security, relational security, safeguarding, family and friends, physical healthcare, workforce and governance, meeting 100% of standards in these areas.

A Quality Network visit has also been undertaken in the CAMHS pathway. The draft report has been received and is very positive. The report highlighted areas of good practice including individualised care for patients and a cohesive, enthusiastic and motivated team.


2.

2.8 – Data Quality

St Andrew’s will be taking the following actions to improve data quality:

• Strive to harness the power of our data to drive decision making across all our pathways, from the point of care to all supporting services

• Enable a culture of information sharing, gathering and assimilation, ensuring our people have the information they need when they need it

• Adopt an approach to managing data, deriving insight and driving action.

We have agreed upon five strategic goals for data and committed to develop our data management capabilities with investments across people, process and technology to enable a data-driven culture based on timely, relevant and accurate information. The development of a data quality strategy is a key deliverable for 2016/17 which will outline improvements to be made in our data quality landscape and agree tactics to drive deeper understanding and shared responsibility for data quality throughout the Charity.

2.9 – NHS Number and General Medical Practice Code Validity

As a non-NHS provider St Andrew’s was not required to submit records during 2015/16 to the Secondary Uses Service for inclusion in the Hospital Episode Statistics which are included in the latest published data.

2.10 – Information Governance Toolkit

St Andrew’s Information Governance Assessment Report overall score for 2015/16 was 100% and was graded ‘green’.

Significant improvements were made in the area of Information Governance (IG) in 2014/15 and this good practice has continued in 2015/16. The IG team is based within the Charity’s Quality and Governance Directorate and forms part of its compliance function. A new Information Governance Manager was appointed in June 2015 and a comprehensive review of the information governance function began.

In July 2015 the Charity was audited by the Information Commissioner’s Office. The audit focused on the security of personal data, subject access requests and data sharing. The audit concluded that there was reasonable assurance that there are processes and procedures in place to deliver data protection compliance. The audit identified some scope for improvement in existing arrangements to reduce non-compliance with the Data Protection Act. An action plan has been agreed and the Charity is on target to complete all the actions within the agreed deadline.

There were also areas of good practice identified and the auditors were particularly impressed with the Charity’s network of Information Governance Champions.

This initiative has continued to develop and there are 25 representatives appointed covering a mix of clinical and non-clinical areas.

The focus of the IG team during the past year has been on continuously improving staff awareness of IG matters and this has been achieved through face-to-face training and the increased availability of training and guidance materials. Toolkit compliance levels (including level 3 requirements) have increased during the year to 95%, with all evidence being uploaded to the toolkit website for the first time. Compliance with requirements at level two is at 100%. This has been achieved by the IG team working with action owners to gather the required evidence and the management of these relationships by the IG team. In addition, a robust process for the approval of toolkit evidence has been put in place, providing increased assurance of the quality of toolkit evidence submitted.

2.11 – Clinical coding error rate

St Andrew’s was not subject to the Payment by Results clinical coding audit undertaken by the Audit Commission during the reporting period.

2.12 – National Core Indicators of Quality

St Andrew’s Healthcare Commentary

2013/14 2014/15 2015/16 St Andrew’s Healthcare considers that this data is as described for the following reasons

Emergency re-admission to St Andrew’s within 28 days of discharge

0% 0.24%(1 patient)

0.64% (3 patients)

Staff recommendation of St Andrew’s as a place to work

70% 61% 46% Note: The Charity has undergone a restructuring and considerable change during this financial year. Uncertainty amongst staff is reflected within the score. However, this result gives us a good baseline and through implementing our detailed action plans we will be able to improve upon this result.

St Andrew’s does not take part in the NHS staff survey, therefore data is not directly comparable.

Staff recommendation of St Andrew’s to family/friends

n/a n/a 52%

Domain 5 – Treating and caring for people in a safe environment and protecting them from avoidable harm

Number of patient safety incidents and percentage resulting in severe harm or death

16,715 (1.35%)

19,297 (1.19%)

18,637 (1%)

Of the recorded incidents 229 resulted in ‘serious harm’. During the reporting period there were 12 deaths within the age range 51 to 94. All are identified as being from natural causes, two are awaiting coroner’s inquests.


In producing this document we have listened to a range of partners who have an interest in our work. The people formally consulted on these accounts were:

• Our Lead Commissioner (NHSE)

• Clinical Commissioning Groups

• Northamptonshire Health and Social Care Scrutiny Committee

• Local Healthwatch

• POhWER

• Colleagues

• Patients

2.13 - Involvement and feedback

NHSEOur feedback is that there isn’t anything significant that would need changing and we note that it reflects the implementation of a strategic change and StAH have recognised the impact of this within the QA e.g. lower staff satisfaction levels etc.

Healthwatch

During 2015/16 Healthwatch Northamptonshire (HWN) has welcomed the opportunity to work more closely with St Andrew’s. In June and August 2015 HWN visited St Andrew’s to conduct some patient experience focus groups and interviews and the St Andrew’s patient experience team were particularly helpful and cooperative in facilitating this work. We have also seen progress made by St Andrew’s regarding their openness and transparency and willingness to work in partnership. We look forward to working more closely with St Andrew’s over the coming year to support, challenge and assist them in ensuring high quality, innovative and patient-centred care.

We believe St Andrew’s has chosen appropriate quality priorities for 2016/17 and that they demonstrate that patient experience is an increasingly important component of quality at St Andrew’s. We appreciate that the 2016/17 quality priorities are specific and measurable and would be interested to see more details about the projects and actions planned.

We are pleased to see further prioritisation of reducing restrictive practices (restraint and physical interventions). This is something we have had concerns about and believe it will contribute to improved patient safety. The relative of one patient also told us their concerns about restraint. We also support the prioritisation of safe staffing, including staff engagement and training. We have not heard much feedback from patients and the public about St Andrew’s but the negative feedback we have heard relates to staff conduct (three incidents).

We agree that physical health, including prevention, is a priority. One member of the public who responded to our 2015/16 ‘Make Your Voice Count’ campaign told us about the misdiagnosis of a physical complaint and did not feel they got the help they needed. We also support the updating of the End of Life policy and would like to highlight the importance of sensitive and good communication with relatives and carers of patients at the end of their lives.

We are especially pleased to see the inclusion of advancing patient engagement as a quality priority and support St Andrew’s desire to ensure the patient voice is heard and acted upon.

We commend St Andrew’s for the progress they have made towards improving patient experience and involvement over the past year and are pleased to see the use of patient stories and the impact these have had on staff. We welcome the additional details about how patients have been involved and are keen to know of any further ways patients will be engaged and heard over the coming year.

We thank St Andrew’s for working to produce a clear and readable Quality Account document but recommend the inclusion of an Easy Read summary.

It is our opinion that this Quality Account demonstrates St Andrew’s aims to be an open and transparent organisation and we are pleased to see evidence of learning from incidents and the sharing of good practice.

Nene and Corby Clinical Commissioning Groups

St Andrew’s annual quality account for 2015/16 has been reviewed by NHS Nene Clinical Commissioning Group (Nene CCG) and NHS Corby Clinical Commissioning Group (Corby CCG). It is acknowledged that the account reflects the activity of the whole Charity and not just the Northampton site. The statement of director’s responsibilities is an overview of the quality of the service provided by the Charity to NHS.

The account describes three priorities for quality improvement based on patient experience; clinical effectiveness and patient safety. Included in the description are the benefits to service users and how these will be measured.

Neither NHSE nor CCG CQUIN plans for 2016/17 have been included in the account; these have not been agreed locally with commissioners. However, information on achievement for the NHSE Specialist commissioning 2015/16 CQUINs has been included.

The Charity has participated in two national audits; the outcome of one is included in the report. Other national audits such as Schizophrenia and Dementia were not undertaken as these were only applicable to community based care.

Local and internal audits undertaken have been listed; examples of the findings of some of the audits have been detailed.

The quality account does demonstrate that service users are involved in research but the Charity has not referenced the research or innovative activity and learning.

The quality account has included statements on data quality, information governance (IG) and clinical coding.

A list of external agency contributors to the account is included.

Whilst there are statements of endorsement from service users there is no inclusion of any complaint information or feedback. This would be helpful to provide a more balanced perspective and to demonstrate learning.

The quality account references registration with CQC and there is a summary of the CQC MHA visits to the Charity during 2015/16.

Statements from patient engagement groups and commissioners have not yet been included. Commissioners believe the account to be factually accurate.

Northampton County Council Health Adult Care and Wellbeing Scrutiny Committee

The NCC Health Adult Care & Wellbeing Scrutiny Committee formed a working group of its members to consider a response to your Quality Accounts 2015/16. Membership of the working group was as follows:

• Councillor Sally Beardsworth

• Councillor Eileen Hales

• Councillor Sylvia Hughes

• Mr Andrew Bailey (Northamptonshire Carers Representative)

The formal response from the Health, Adult Care & Wellbeing Scrutiny Committee based on the working group’s comments is as follows:

• It was noted that St Andrew’s had been very proactive in contributing to improving local mental health services, something the working group considered to be very commendable.

• It was disappointing to note a low response to the audit of nursing standards.

• There was a lack of data in the document.

• How were the length of stays monitored?

• There was no feeling of how many residents from Northamptonshire received a service from St Andrew’s and the working group would have liked to have seen Northamptonshire specific figures.

• It was felt it would have been helpful to include a breakdown of the hospitals St Andrew’s operated with details of the services delivered at those sites and the numbers of people taking part in those services.

• It was also felt helpful if specific differences in quality of performance were shown.

• Although wards were referred to in the document, information on where those wards were located was not.

• They were congratulated on providing re-admission figures.

• The working group was pleased to note St Andrew’s were re-establishing links with carers and support groups.

POhwER

As we have only just started working with you, it is difficult for us to comment on activities that took place last year. However we can provide you with some comments and suggestions regarding how our involvement with you for next year can support some of your objectives. I hope these prove helpful/useful to this exercise.

Priority 1 “Develop the Quality Improvement Strategy…”

POhWER will routinely provide information on the individual outcomes achieved by service users as a result of advocacy support and engagement.

Priority 5 “Prioritise, identify… Serious Incident and Safeguarding…”

POhWER have robust process and policies around safeguarding and will continue working with St Andrew’s to further develop close working practices to ensure the prompt reporting of all serious incidents and safeguarding issues.

Priority 8 “Advance the Charity’s Patient Engagement…”

POhWER will support this objective by having in place a robust engagement strategy for their work with St Andrew’s. Their reporting processes will allow St Andrew’s to monitor patient engagement across the organisation.

Below are the consultation responses we have received..

2.


Review of Quality Performance3.

3.1 – Actively involving patients in their care plans

This section reflects on how the Quality Improvement Priorities for the last year have progressed.

3.2 – Increasing patient involvement in how the Charity is run

Involving patients in their care plan development is an essential part of their recovery. Engagement in the process commences with the patient’s views and opinions being sought on assessment. During the first three months of admission the clinical team will work with the patient to form the basis of the patient view in care plans.

In our most recent Annual Patient Survey (October 2015) 67% (n=100) of our patients felt that they were involved as much as they wanted to be in decisions about their care and treatment.

During the year we have debated the use of the CPA survey with our patients as they were unclear about the way it was worded. This has been reworked and the five question survey incorporated within this working in collaboration with the patients. This has been trialled during January and was rolled out in February.

The Patient Experience Team works with patients, their families, staff and other people connected with the Charity to make sure patients are involved in every aspect of St Andrew’s work, with a particular focus on the way services support recovery. The team is receiving an increasing number of requests for patient involvement in a wide range of activities.

We actively champion inclusion and collaboration to improve the Charity’s services and help develop patient-centred strategies that embrace and promote a culture in which patient experience, co-working and involvement are paramount.

The team works with individual services across the Charity to ensure that they comply with standards relating to patient experience. Patients have been invited to share their stories at several events and meetings across all areas of the Charity throughout the last year, to promote a culture of patient involvement. 100% of staff who were surveyed about the impact of hearing these patient stories said that they were very good/quite good and they learnt something from the stories.

Priority How this will be monitored, measured and reported

Benefits to patients, families and carers

Actively involving patients in their care plans.

Quarterly reviews of 20 Care Programme Approach (CPA) Standards and ‘five question’ surveys. Reported to quality assurance and management boards.

Quality of care will be improved by identifying and addressing each patient’s needs. Communication with patients and their families and carers will also improve.



Increasing patient involvement in how the Charity is run.

Following patient involvement, staff surveys take place to understand the impact of patient input. Results will be reported through the quality compliance team and management board. Lessons learned and improvements are addressed by the Patient Experience Team.

Patients’ experiences will improve.


3.

Currently patients and/or carers are able to participate in the running of the Charity through the following activities:

• 33 patient volunteers regularly working with the patient experience team

• Patients and carers continue to share their experiences with the board and at key forums

• Patients share insights at staff inductions, with medical students, pre-admission work stream, positive and safe work stream, patient information development group, patient forums, the cashless payment project, communications workshop and interviewing new staff

• Peer support workers commenced employment with learning and development in January

• Development of the information programme for carers is underway

• Carers’ self-support group

• Carers developing DVDs to educate staff about carers needs

• Carer contribution to ward information templates for carers

• Patient safety patients reference group under development

• Involvement in advocacy tenders

• Involvement in the end of life care project

• Involvement in diversity learning sessions.

During the year we have maintained a focus on increasing staffing levels through on-going campaigns to increase the number of both registered and non-registered nursing staff on our wards. As a result of this we have achieved the following:

Total number of Band 5 nurses hired 145

Total number of health care assistants HCAs hired 245

Number of Band 5 nurses in pipeline 105

Number of HCAs in pipeline 159

Total number of employees hired during the year 1,002 (Mar 2015-Feb 2016)

3.3a – Meeting CQC Fundamental Standards including the Duty of Candour

3.3c – A major campaign to focus on the retention of staff and recruitment of qualified staff in each of our hospitals

3.3b – Delivering skilled nursing care through St Andrew’s nursing practice standards

St Andrew’s has had a project team in place all year to ensure that the requirements of the Duty of Candour (DoC) are cascaded to all staff, that staff understand their responsibility with the duty and that the right mechanisms are in place to enable us to fulfil this regulatory requirement.

Prior to the DoC legislation, we had an “Open and Honest Care Policy” which advocated the same responses when things go wrong. This policy has been updated to reflect the requirements of the DoC and to set out the process of implementation across the Charity.

We have carried out audits of safeguarding, complaints and incidents in order to ascertain whether incidents had occurred for which DoC had not been initiated, any such cases were followed up with the relevant Service Director.

The internal incident reporting system has been reconfigured to enable incidents notifiable under DoC to be flagged and all associated correspondence uploaded to the system. This gives a clear picture of what has been notified under DoC and allows us to ensure that the process has been fully implemented, giving us full evidence of compliance.

The DoC oversight group has been established to oversee all incidents that are notified under DoC and to act as an internal resource offering advice and guidance to staff.

An audit of the standards was completed during November 2015. Overall compliance with the six nursing standards has been measured between 91-100% in those who responded. The results, however, are not statistically significant due to the low number of respondents.

The Modern Matrons, Nurse Managers and Clinical Nurse Leaders continue to support the development and adherence to the nursing standards. They will be further supported by the Advanced Nurse Practitioners, Practice Development Nurses and Nurse Consultants when these are in place.



Meeting CQC Fundamental Standards including the Duty of Candour (effective from April 2015).

Regular internal reviews on compliance and progress of our consolidated action plan will be reported to the quality assurance team and management board.

Patients and carers will have greater confidence that the care and treatment received is of high quality.



A major campaign to focus on the retention of staff and recruitment of qualified staff in each of our hospitals.

Fortnightly monitoring by the HR team will confirm that we are recruiting to the required numbers of staff outlined in our recruitment plans.

Patients will benefit from the consistency of care afforded through greater permanent staff numbers.



Delivering skilled nursing care through St Andrew’s nursing practice standards.

Annual monitoring against the Royal College of Nursing ‘Six Cs’ (care, compassion, competence, communication, courage, and commitment) will be reported to services, quality compliance groups and management board.

Quality of care will be improved by changing the culture of how we work together to achieve the best results. A greater focus on patients’ needs will improve outcomes.


3.

The employment markets across all our locations, particularly for qualified nurses and specialist healthcare professionals, became ever more challenging and more competitive during 2015 and this has remained the case into 2016.

We have recently increased our recruitment activity to include the hiring of RGNs, thus widening our access to potential nurses and bringing more physical healthcare nursing experience into our wards. We are also about to start a tender process with potential framework suppliers for international nurse recruitment to assess if it is a viable option to meet our demands for mental health, learning disability and general nursing. We appreciate that the supply of specialist mental health and learning disability nurses will always be limited and have raised the numbers of nurse bursaries available to our own staff to 20 per year. This guarantees a stronger future pipeline of our own trained nurses and offers excellent career development and support opportunities to our non-registered staff.

We have revised our recruitment strategy to better enable us to plan for and meet the challenges within our different markets and are currently honing our strategy and plans for each individual pathway. We have also finalised the development of our employer value proposition and are in the process of implementing our employer brand and associated materials. This will enable us to differentiate St Andrew’s and position the Charity as an employer of choice within these competitive candidate markets.

In order to retain experienced staff in the Charity, we have implemented retention and engagement plans in each of our care pathways. Initiatives include our CARE awards recognition scheme, staff suggestions boxes, wellbeing events, new nurse clinics, a programme of work to improve visibility of our career pathways for registered and non-registered staff, reviews of induction processes and regular continuing professional development events.

Our voluntary staff turnover figure rose from 8% in April 2013 to 12% in March 2015. Since then we have been able to stabilise this turnover figure at 12%, which is a considerable achievement given the high levels of demand for healthcare staff in the current employment market.

In November we launched our “Your Voice” employee engagement survey which gave the Charity an engagement score of 59%. Our target is to have 75% employee engagement by 2020. We are currently implementing cross-charity action plans based on staff feedback from the survey with the aim of making significant progress towards our engagement target during 2016.

3.3d – Ensure staff are engaged and supported by rolling out A Leader’s Journey

3.3f – Enhancing physical healthcare

There is a repeat of the internal audit looking into the delivery of physical healthcare within the Charity. Last year’s physical healthcare CQUIN has been rolled over into 2015/16; a random sample of 100 patients have had their submissions reviewed by the Head of Physical Healthcare and Healthcare Director prior to submission to the Royal College of Psychiatrists for the CQUIN award.

We continue to reduce DNA rates by delivering more of the physical healthcare on the wards, with the patients, rather than central clinics at all four sites.

We have been able to secure GP time at the Nottinghamshire site, which will significantly improve services for our patients there.

3.3e – Implement care pathways with treatment directories of evidence based interventions

The three-day ‘A Leader’s Journey’ programme has been attended by 400 leaders and now forms part of the induction for new manager- and director-level employees. We have also designed a one day programme which is available to all staff to help sustain our positive culture.

Care pathways were implemented on 1 July 2015. Care pathway management teams were re-organised to enable delivery of the care pathway framework. Each pathway has submitted its “Care Directory”, which have all been reviewed, formatted and returned along with a missing information map. The missing information has been requested and a second review will be undertaken.

This work has identified the need to carry out a more significant review of nursing interventions through the Modern Matrons.

Nursing intervention listings are not up to date and this is being reviewed within each pathway. This work was undertaken during February 2016.

Priority How these will be monitored, measured and reported


Ensure that staff are engaged and supported by rolling out the ‘A Leader’s Journey’ programme which covers taking responsibility and building relationships.

The Charity’s Management Board will review the results.

The continuity of patient care will be improved, delivered by high quality members of staff.



Enhancing physical healthcare. Charity-wide monthly reviews of access to routine physical health checks, on-site and external clinics (in and out of hours) will be reported to the Quality Compliance Team and Management Board.

Patients’ overall physical health will be improved and unsettling off-site treatment will be minimised.



Implement care pathways with treatment directories of evidence-based interventions.

To be reviewed at each stage of patients’ care pathways and reported dependent on the pathway and service commissioner.

Care will be consistently delivered in line with best practice and each patient’s needs resulting in better outcomes.


3.

3.3g – Becoming an explicit ‘Centre of Excellence’ by implementing ‘Positive and Safe’ across the Charity

Positive and Safe is a key Charity programme of works and the implementation of interventions to support this agenda are monitored via our steering group, chaired by the Executive Director of Nursing and Quality. Some of our progress to date is as follows:

• A review of our risk management tools has been undertaken

• Risk assessment process is being streamlined

• Positive Behaviour Support (PBS) is being rolled out across the Charity

• Redesigned our annual mandatory refresher training in conflict resolution to include assessment of competence

• Our care co-ordinator training has been re-designed to include PBS care plans to support the roll out of the new design

• A patient-carer reference group has been established to work with staff on the review and development of appropriate practices to improve patient and carer experiences

• The process for post-incident debriefings, with a particular focus on incidents involving episodes of restraint, seclusion, rapid tranquilisation and serious incidents, has been reviewed and updated

We are now closely monitoring the impact of the training on the use of restrictive interventions.

The new Management of Actual and/or Potential Aggression (MAPA) training programme commenced at the beginning of January 2016. We have trained 1,014 staff in on the MAPA five day training and a further 1,046 staff on the one day foundation course. There has been positive feedback from attendees with an overall rating of 9 out of 10 for the programme. Some of the comments received from those who have been on the training so far are:

- After 35 years if I can learn something new and come out feeling positive so can others

- I completed my MAPA 2 weeks ago and I enjoyed the course very much, it will work as long as all staff do the same thing

- I’m finding that I am ‘opting out’ when safe to do so, ending the episode of restraint and using more skills to de-escalate

- I’ve used lots of the verbal skills and have found that the low level interventions have been really helpful in preventing a full restraint

- My team and I faced a difficult situation; we used MAPA and found it really effective!

- Throughout the week the tutor has always been approachable, encouraging questioning and been open and non-defensive in her replies

- It’s given us new ways of thinking and ways of working as a team which highlights the needs of the individual rather than the policy

- It’s much easier to remember!



Becoming an explicit ‘Centre of Excellence’ by implementing ‘Positive and Safe’ across the Charity

Progress with our action plan will be monitored each month. Reporting will be made to the relevant boards and committees according to the action.

Patient recovery will be enhanced by ensuring patient and staff safety, dignity and respect.

3.3h – Improving risk management across the Charity

3.3i – Learning lessons from incidents

A new Corporate Risk Manager has been appointed who is currently reviewing the corporate risk management arrangements. The following areas have been identified as a priority:

• Improve ‘ownership’ and ‘risk acceptability’ in the risk assessment methodology

• Address ‘risk materiality’ of risks in the operation of the risk register process

• Review the Datix risk register template and revise as appropriate

• Develop a plan for organisational roll-out of the revised Datix risk register to support improved risk assessment

• Present an updated risk management plan for Executive Committee approval in February 2016.



Improving risk management across the Charity

Reports on progress, mitigation, new risks, and the results of controls and assurance testing will be made to the relevant boards and the Audit and Risk Committee.

Incidents of harm to patients will be reduced as we manage and minimise risks.



Learning lessons from incidents Weekly reviews of serious incidents, safeguarding, complaints and CQC notifications will be reported Charity-wide. They will be included in the Charity’s quality dashboard and quality and compliance report.

Patients will be safer in our care as a result of the steps we take to reduce the possibility of recurrence of serious incidents.

Weekly reviews of incidents are undertaken and information provided to the Executive Team. A Learning Lessons Group has been established, to date it has looked at:

• The disconnect between policies being written, launched and embedded at ward level. Work is underway to improve this through exploring better ways of communicating changes to policy and new policy. A policy alert is cascaded to all staff and further ideas such as policy awareness sessions are being explored.

• Following an incident in which confidential information had been left in a filing cabinet which was put into storage, a process has been implemented for all cabinets to be checked prior to removal and the production of an audit trail to ensure that filing cabinets are easily located.

It has also been recognised that the group requires greater input directly from care pathway staff to significantly improve learning. Membership of the group has been adjusted to reflect this.


This section highlights some of the important successes for patients and for the Charity during the year.

St Andrew’s Showcase

Occupational Therapy: Garden design features in BBC showcase Outstanding team work by patients at St Andrew’s has helped the Charity to achieve an unprecedented honour in the gardening world – our very own design space at this year’s BBC Gardeners’ World Live expo.

Based on the BBC TV series, the popular annual event attracts celebrity hosts such as Alan Titchmarsh and Monty Don, and is attended by more than 90,000 visitors. The honour comes thanks to an entry in the BBC Gardeners’ World Live Beautiful Borders competition, which invited budding garden designers to submit literature themed designs for this year’s show.

Service manager Chloe Dowell, who co-ordinated the entry, took inspiration from a storyboard poster submitted by a patient with the input of the wider Neuropsychiatry Pathway.

“Horticulture is such a central part of St Andrew’s – it’s evident in our grounds, our therapies and in the success of the Workbridge nursery.

I thought the competition would be a great way for patients to put their thoughts on this on paper and I have to say the entries did not disappoint,” Chloe said.

“The winning entry was bright and vibrant, and showed real insight when it came to the theme of literature. Each plant had been carefully chosen to relate to the theme and quotes were woven along the pathway, which is something we wanted to carry through in the final entry.”

Occupational Therapist Sarah Hayes facilitated the design sessions which inspired the final border. “This was such a great activity that brought the entire ward community together, so to top it off with this amazing outcome is just wonderful,” Sarah said. “Weeks of hard work and careful thought went into this – in fact our lead designer even bought his first gardening book just for the occasion! He was very excited by the news and hopes to be able to get involved with the preparations for the final border.”

Chloe said the border is centred on the life and works of the poet John Clare, who spent 23 years as a patient at St Andrew’s.

“The border represents the difficulties faced by him and others who have mental health problems, as they search for a sense of peace and wellbeing. The garden features a winding mosaic path bordered by plants that have strong associations with wellbeing – such as sunflowers for pride and lavender for loyalty and love. Dotted throughout the garden will be lines from Clare’s poems, showing a shift in mind frame from the dark and unhappy start, to peace which can be found at a tree of wellbeing,” Chloe said.

St Andrew’s Healthcare received a silver merit award for the completed border which was judged at Birmingham National Exhibition Centre in June 2016. One of nine finalists, it was the only entry to use self-grown plants.


Workbridge: New lease of life for a historic vocational scheme For more than 30 years Workbridge, which is based in the grounds of St Andrew’s Northampton site, has been a place where magic happens. It’s a space where patients and service users have the opportunity to not only test and stretch their talents, but to build work ready skills and qualifications to aid them in their journey through life.

The centre has undergone a £650,000 redevelopment to prepare more people for the world of work.

Walking through the bright corridors, it is the sound of excited chatter which outshines the centre’s sparkling new veneer. A group of patients and staff are gathered in the reception area, laughing amongst themselves. In the hallway, a service user stops one of the service managers: “It’s so big now!”, he says, before rushing off to the bespoke woodwork studio - one of the four key services united under a single, crisply painted ceiling.

“At the heart of the new Workbridge is a refreshed pathway structure,” explains Sarah Cotton, Senior Service Manager. “With the additional space and equipment we now have, every patient and service user will be able to take small steps up through each of our services – office skills, design and print, catering, and woodwork. Our new training kitchen is a key example of this. We’d previously use the coffee shop kitchen which could be quite a daunting place to start. Our new training kitchen is kitted out with the same industrial appliances, but is a less pressurised environment away from the gaze of customers. Patients and service users can use this space to learn from the basics up – starting with cleaning and cutting, to blending, cooking and baking. Their dishes are shared with the coffee shop as well as their colleagues, who now have their own canteen to take breaks, eat and play pool. It is all overseen by a senior instructor, who is certified to deliver accredited training such as food hygiene.”

As part of the redevelopment, the office skills service was split from design and print – creating new opportunities to expand the range and capacity of the products it creates. While canvas printing makes up the mass of current orders, Sarah hints that they would now be able to investigate the viability of printing on fabrics and even laser engraving. The woodwork studio has enjoyed a similar rejuvenation – with new skills-based work zones, extraction system and a state-of-the-art router completing what is now an industrial grade woodwork and joinery studio.

As for the future, Sarah is optimistic: “These training areas have already been earmarked for use in the coming years. There’s no shortage of ideas of what we could do here, how many more people we could pull into this community. But that’s a story for another day.”

Collaborative Ward Reviews: Developing and sharing a collective model of good practice There has always been a need to improve practice - this is widely acknowledged across the Charity and was front of mind when Men’s Mental Health Pathway Clinical Director, Dr Tim Exworthy, established the concept of collaborative ward reviews. The fundamental point of the review is to empower the wards to proactively reflect on their practices, instilling a culture of enquiry.

“The collaborative ward reviews came from the desire to develop a form of self-inspection,” Tim said. “But rather than do things to the team, we wished to work with the team and get them asking questions of their own practice. The aim is that constant questioning and reflection will lead to continued improvement. At its heart, it’s a way for the wards to reflect on and identify good practice which can be acknowledged and shared across the pathway, as well as to identify areas they want to work on and improve.”

Since starting in November 2015 the ward reviews have been conducted on two thirds of the men’s pathway and other pathways have adopted the approach.

Each review is facilitated by three members of the Senior Management Team (SMT), who spend two hours meeting with staff and patients. Ahead of each visit a pack of quality data and information about the ward is scrutinised for possible trends in any of the Care Quality Commission’s five domains, featured on the ward’s quality dashboard.

At the review the ward team gives a short presentation of what they see as their strengths and also the areas to develop or improve. A patient representative is also invited to give his views on the same areas and, as Tim said, it is heartening to hear so many of them speak about staff support in their recovery and how safe they feel on the ward. There is also a broader discussion around issues arising from the presentations or review of the data. The meeting concludes with three broad action points which the ward team will address during the next three months.

“Teams need to feel empowered to constantly review how they work and their performance.

“We wish to instil in the team a constant search to improve the way they work,” Tim said. “One aspect of this is the intelligent use of data from the dashboard to identify adverse trends and ensure issues are addressed before they get worse. It is the difference between periodically checking the oil level in the car and topping up as necessary or waiting until it runs out of oil altogether and things go critical in the engine itself.

“The reviews are intended to be constructive and collaborative. We want to identify areas of good practice that can then be shared with other wards. In this way we are learning lessons from each other,” Tim said. “We will have visited all our wards in Northampton by June and the whole pathway later in the summer. We can then start the second cycle of reviews, but by then we will expect the teams to be more self-reflecting and more proactive in addressing issues before we visit them. The more we do, the more we’ll improve.”


the foundations for continued success · workbridge therapy clinics st andrew’s northampton...

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