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Quality Account 2015/16DRAFT

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Quality Account 2015/16 DRAFT v1.15

ContentsPart 1: Statement on Quality................................................................................................................3Statement from the Chief Executive....................................................................................................3Our Services......................................................................................................................................... 4What is a Quality Account?.................................................................................................................. 5Our strategy for quality......................................................................................................................... 6Our vision, values and goals................................................................................................................8Part 2: Quality Improvement Priorities and Statements of Assurance...............................................9How we decided our Quality Improvement Priorities for 2016/17......................................................9Priority 1: Safety – Reduce avoidable harm......................................................................................10Priority 2: Experience – Improve Service User Satisfaction.............................................................11Priority 3: Effectiveness – Improve our outcomes............................................................................12How we will make improvements.......................................................................................................13Statements of assurance from the Board..........................................................................................15Part 3: Review of Quality Performance in 2015/16...........................................................................27Progress against our Quality Improvement Priorities 2015/16.........................................................28Core Quality Indicators...................................................................................................................... 38Our Performance Indicators...............................................................................................................42Assuring the Quality of our Services.................................................................................................65Supporting our Staff........................................................................................................................... 67Awards 2015/16.................................................................................................................................. 71Quality Case Studies..........................................................................................................................71Statements from our Partners............................................................................................................74Statement of Directors’ Responsibilities in respect of the Quality Account.....................................76Glossary.............................................................................................................................................. 77

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Part 1: Statement on Quality Statement from the Chief Executive Welcome to the 2015/16 Quality Account for Staffordshire and Stoke on Trent Partnership NHS Trust.

Our Quality Account for 2015/2016 provides examples from across our services which reflect the quality of care that is being delivered and describes how we prioritise safety, effectiveness and service user and carer experience.

This report also indicates areas where improvements have been made and how we will continue to work to ensure that quality is improved within the organisation.

Our focus is on listening to our service users, their families and carers and acting on their feedback to learn lessons, improve and sustain change.

We continually monitor and improve the quality of our services through a wide range of programmes. This Quality Account will detail this work and how we have performed against our Quality Improvement Priorities for 2015/16.

The Partnership Trust is located within the geographical boundaries of Staffordshire County Council and Stoke-on-Trent City Council. We serve a diverse population of 1.1 million people, covering a wide geographical area stretching from the Staffordshire Moorlands, which borders the Peak District in the North to the conurbation of the Black Country in the South.

We deliver services to a diverse population in a variety of settings including two community hospitals and 92 venues as well as in people’s homes.

A key aim for the NHS is to wide avoidable hospital admissions. Also, when a stay in hospital is required, the aim is to make it as short as possible without compromising safety. Our community care role is central to help our health economies with both these aims.

We are proud of the work of our community health and adult social care services and the work they have done to support people to avoid hospital admissions and return home after a hospital stay.

There have been a number of challenges during 2015/16 such as the delivery of our Cost Improvement Programme, significant pressure in the health system for domiciliary care and an increasing demand for social care services as well as issues surrounding our workforce such as capacity and recruitment and retention. Despite this, I am impressed with the dedication and work our teams provide.

In November 2015, the CQC also undertook their first full inspection of the Trust. The inspection team highlighted a number of specific examples where they were impressed with our services and the caring approach of our staff. We also received feedback relating to a number of areas for improvement which have now been resolved or are being addressed. We are awaiting our final rating which will be published in Q1.

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Understanding the care needs of all communities we serve is key to getting decisions right as we move forward and develop as an organisation. We have now built strong relationships with our stakeholders and have had good engagement in developing our Quality Improvement Priorities for 2016/17. Stakeholder input is essential for us to continue to provide high quality care for our service users.

We hope you find this Quality Account interesting and informative. If you would like to comment on any part of it, details of how you can do that are included at the back of the document. We would be delighted to hear from you.

On behalf of the Board I am pleased to present this account to you. I hereby state that to the best of my knowledge that the information contained in the following Quality Account is accurate.

[SIGNATURE will be inserted in final version]Stuart PoynorChief Executive

Our ServicesThe services that we provided during 2015/16 are:

Adults community services Childrens community services Community Hospitals Specialist Inpatients Acute Care in the Community Sexual Health services Therapy services Offender Health services Dental services Adult Social Care services

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What is quality?High quality care is where:

service users are in control, have effective access to

treatment or care, are safe, where illnesses are not just

treated but prevented, and where service users have a

positive experience of care.

What is a Quality Account?

A Quality Account is an annual report detailing the quality of services that have been provided by an NHS

healthcare provider. The report is made available to the public.

A Quality Account allows us to report on the quality of our services and show our key partners (service users,

their families and carers, our working partners, commissioners, our staff and the public) how our

services have improved.

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Our strategy for qualityOur aimThe Quality Framework aim is that all service users receive the highest quality of care - by ensuring that front line teams are empowered by the organisation to provide this.

Our model of qualityOur model of quality puts service users and carers at the heart of what we do. The framework influences all layers in our trust to improve quality.

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Our vision, values and goals

Our Vision

We will deliver personalised care of the highest quality, with the best possible outcomes for users and carers, empowering them to remain independent.

Strategic Goals

We will deliver high quality and safe services which

provide an excellent

experience and best possible

outcomes

We will work with partners, people

and carers to deliver integrated services, simply and effectively

Our organisation will develop and deliver

sustainable, innovative services

that support independence

We will have the right people and time, well trained and motivated, able to deliver

the right level of individual care

We will make excellent use of our resources and improve levels of efficiency across our

services

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Part 2: Quality Improvement Priorities and Statements of AssuranceHow we decided our Quality Improvement Priorities for 2016/17Our three priority areas are based on:

Our existing priorities from 2015/16 that need to be maintained National guidance and best practice Views from our service users, staff, commissioners and partner agencies. Our vision, strategic goals and objectives

We ran a consultation from 1 to 29 February 2016 to get views on our priorities, and our Quality Governance Committee reviewed our priorities in April 2016.

Our three priority areas are:

1. Safety – Reduce Avoidable Harm2. Experience – Improve Service User Satisfaction3. Effectiveness – Improve Our Outcomes

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Priority 1: Safety – Reduce avoidable harmOur aim: Improve our safety culture and workforce, eliminating avoidable harm of all typesMeasures for 2016/17 Why this is important 2016/17 target

Number of avoidable and attributable grade 3 and 4 pressure ulcers developed in our care

In line with Sign Up To Safety, we want to reduce avoidable harm by 50%, by 2018

Zero grade 3 and 4 avoidable and attributable pressure ulcers developed in our care in community hospitals

Minimum 10% reduction in the incidence of avoidable and attributable grade 3 and 4 pressure ulcers developed in our care within our community services (i.e. a tolerance of 21 cases maximum)

Number of serious incident falls reported whilst in our care

In line with Sign Up To Safety, we want to reduce avoidable harm by 50%, by 2018

Reduce serious incident falls in all our care settings, by a minimum of 10% for 2016/17 (with a tolerance of 11 cases)

Total number of adverse incidents reported (all incidents)

(Aligned to indicator 5.6 in the 2015/16 NHS mandate)

Services that report more incidents, with a low proportion of harm, have a better safety culture

Increase the number of incidents reported by 10%, for all reporting services1 compared to those reported by the same services in 2015/16

Percentage of reported serious incidents applicable to the Trust

(Aligned to indicator 5.6 in the 2015/16 NHS mandate)

Services that report more incidents, with a low proportion of harm, have a better safety culture

Reduce the number of serious incidents as a proportion of all incidents reported

Number of reported safe staffing incidents, in line with our Safe Nurse Staffing Escalation Policy

Our staffing escalation policy traffic light system includes the requirement to report red staffing levels

Baseline to be developed (local and national)

1 Tolerance targets will be subject to rebasing due to the changing nature and profile of our services

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Priority 2: Experience – Improve Service User SatisfactionOur aim: Sustain our overall Service User experienceMeasures for 2016/17 Why this is important 2016/17 target

Friends and Family Test

Implementation of the Friends and Family Test in our Trust gives our service users and carers the opportunity to provide feedback and identify areas where improvements can be made to the services that they receive.

We want our Staff to actively listen and value the feedback from our service users and carers to constantly improve.

90% would recommend our services to their friends and family if they needed similar treatment and less than 5% would not recommend us.

Feedback from service users and carers on the quality of care that they have received from our services

Focussing on service user and carer feedback on the quality of care enables us to target service improvement against key themes.

90% of our service users and carers are extremely satisfied with the quality of our services.

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Priority 3: Effectiveness – Improve our outcomesOur aim: Improve the outcomes and personalisation of our services Measures for 2016/17 Why this is important 2016/17 Target

Number of teams utilising outcome measures.

Focussing on outcomes allows us to test the effectiveness of the care we deliver.

Key services collect and analyse outcome data, and have plans for improving the outcomes of their service, in line with our rollout of our electronic care records system (RiO).

Qualitative Goals:

Continue to collect and monitor outcomes where we now have a baseline

Improve data collection where existing recording is in place, including use of electronic systems

Care plan audits: proportion of people receiving a copy of their care plan or equivalent care plan information

The ADASS national survey highlighted good practice around copying care plans to service users, compared with our 2014/15 baseline audit.

We want to apply this good practice in an integrated way across all services.

Care plan audits (whole trust measure):

Social care: continued trajectory increase (stretch target) to 75%

Health (new): Baseline to be developed with intention to combine into single Health & Social Care target in 2017/18

Feedback from service users and carers that they feel involved in decisions regarding their individualised plans of care.

Focussing on service user and carer feedback on the quality of care enables us to target service improvement against key themes.

90% of our service users and carers agree that they feel involved in decisions regarding their individualised plans of care.

Mortality – Review all unexpected deaths in our community services where we are the lead provider, and all deaths in community hospitals

Monitoring and investigating unexpected deaths occurring within our services enables us to learn and apply lessons

Review to be completed of all deaths in our community hospitals

Review to be completed for all unexpected deaths within the care of Trust services.

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How we will make improvementsMonitoring our progressEach frontline team is responsible for the quality of the care they provide.

If a team has an issue around quality they cannot resolve they will escalate this to their team or service manager, who can either help resolve the issue, or raise it at the relevant neighbourhood or area meeting.

Neighbourhood and areas managers are required to offer assurance of quality or escalate issues to the Divisional Business Meeting, which is chaired by the Chief Operating Officer for the division. Each Division reports its assurance or escalations to the Quality Governance Committee, the principal committee by which our Trust Board assures itself of the quality of our services.

Quality Governance

Divisional Business Meeting

Local Manager

Frontline Team

Trust Board

Esca

latei

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High

light

goo

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Methods we will use to improve quality in 2016/17Our strategies for quality2 are the main way we will address our quality improvement priorities. We have revised our safety, effectiveness, and experience strategies ensuring that:

Key measures for each strategy directly support our quality priorities for 2016/17 Each strategy is offered as a ‘strategy on a page’ Each strategy is focussed on guiding quality improvement at the frontline

In addition to our strategies for quality, we will:

Act on the recommendations of our regulators, following their inspection of our services. Ensure our services are Safe, Caring, Responsive, Effective, and Well-led through our

Trust quality assurance visit programme. Work to create a more open and honest culture in the NHS, including supporting our staff

to speak out to raise concerns3. Support frontline staff to deliver quality improvements. Provide tailored leadership development and support for team leaders, in line with our

team development governance framework. Help each of our divisions to develop their service priorities, including reviewing the

impact of service developments on quality. Develop our service line reporting, allowing our frontline teams to see integrated finance,

performance and quality information. Provide leadership, support and advice to frontline staff, helping them to promote best

practice and excellent customer service. Manage and promote our research portfolio, helping our staff to contribute to the evidence

base for health and social care.

2 See our Safety, Effectiveness, and Experience strategies on our website here:

http://www.staffordshireandstokeontrent.nhs.uk/About-Us/quality-framework.htm

3 See our information on raising concerns, on our website here: http://www.staffordshireandstokeontrent.nhs.uk/About-Us/raisingconcerns

http://www.staffordshireandstokeontrent.nhs.uk/About-Us/raisingconcerns

http://www.staffordshireandstokeontrent.nhs.uk/About-Us/quality-framework.htm

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Statements of assurance from the BoardReview of servicesDuring 2015/16 Staffordshire and Stoke on Trent Partnership NHS Trust provided and / or sub-contracted 39 NHS services.

The Staffordshire and Stoke on Trent Partnership Trust has reviewed the data available to them on the quality of care in 39 NHS services.

The income generated by the NHS services reviewed in 2015/16 represents 100% of the total income generated from the provision of NHS services by the Staffordshire and Stoke-on-Trent Partnership NHS Trust for 2015/16.

Participation in clinical audits and national confidential enquiriesPlease note as an integrated health and social care Trust the term “clinical audit” does not apply to all of the services we provide. Therefore we use the term “practice audit” to include clinical and social care audit activities.

During 2015/16, seven national clinical audits and one national confidential enquiry covered NHS services that Staffordshire and Stoke on Trent Partnership NHS Trust provides.

During this period Staffordshire and Stoke on Trent Partnership NHS Trust participated in 100% (7) of national clinical audits and 100% (1) of national confidential enquiries which it was eligible to participate in.

The national clinical audits and National Confidential Enquiries that Staffordshire and Stoke on Trent Partnership NHS Trust participated in during 2015/16 are as follows:

National Audit of Intermediate Care Sentinel Stroke National Audit Programme Falls and Fragility Fractures Audit Programme National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme Rheumatoid and Early Inflammatory Arthritis UK Parkinson’s Audit (previously known as National Parkinson's Audit) Diabetes (Adult) Foot care NCEPOD - sepsis

The national clinical audits and national confidential enquiries that Staffordshire and Stoke on Trent Partnership NHS Trust participated in, and for which data collection was completed during 2015/16, are listed in the table below alongside the number of cases submitted to each audit or enquiry as a percentage of the number of registered cases required by the terms of that audit or enquiry.

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Table: National Clinical Audits and national confidential enquiries

Audit Participation Cases Submitted by teams as a percentage of cases required

National Audit of Intermediate Care Yes N/A – data provided was not service user specific

Sentinel Stroke National Audit Programme Yes 100% (725/725)

Falls and Fragility Fractures Audit Programme (FFFAP)

Yes 100% (44/44)

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme - Pulmonary rehabilitation work stream

Yes 100% (264/264)

Rheumatoid and Early Inflammatory Arthritis Yes 93% (30/32)

UK Parkinson’s Audit (previously known as National Parkinson's Audit)

Yes 100% (40/40)

Diabetes (Adult) Foot care Yes 84% (38/45)

National Confidential Enquiry into Perioperative Death – Sepsis

Yes 100% (0 cases returned, and 5 organisational questionnaires returned)

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The reports of two national clinical audit reports were reviewed by the provider in 2015/16 and Staffordshire and Stoke on Trent Partnership NHS Trust intends to take the following actions to improve the quality of healthcare provided:

National Clinical Audit

Actions identified

National Audit for Intermediate Care

Improve the recognition of cognitive impairment Improve our pathway for intermediate care services Increase the use of assistive technology Improve handover and coordination of care between our

intermediate care services

National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme - Pulmonary rehabilitation work stream

Improve our prescribing of aerobic and resistance training and use of strength measurement

Review and enhance referral pathways for Pulmonary Rehabilitation

Update our Standardised Operating Procedures in line with NICE Quality Standards

Local Clinical AuditThe reports of 29 local clinical audits were reviewed by the provider in 2015/16 and Staffordshire and Stoke on Trent Partnership NHS Trust intends to take the following actions to improve the quality of care provided in health and social care delivery.

Table: Changes to practice from practice audit (not exhaustive)

Title of Audit Actions to improve quality of care

Dental Quality of Radiographs

This was a re-audit conducted in Dental Services to provide assurance of the quality of Radiographs being performed by Salaried Dentists. A comparison was made to the previous year’s audit, the service has maintained their compliance for the Number of Grade one radiographs at 81%, which is above the required 70%. Improvements were made to standards in relation to “Bitewing” x-rays with 90% correct anatomical coverage and an adequate number of films being used in 99% of instances.

Dental Services will continue to encourage further participation within the audit, and where staff are not taking radiographs regularly they will also be encouraged to actively identify opportunities to take radiographs.

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Title of Audit Actions to improve quality of care

Audit to Improve the Management, Safety and Outcomes of older adults with Hospital Acquired Pneumonia

The audit identified high compliance with patients receiving treatment within an agreed timeframe. To further improve the response rate to patients receiving the appropriate treatment the following actions were put into place:

Health Care Assistants and Nursing staff to receive further acute training to support the early identification of an unwell patient

Regular pharmacy updates for all staff to access changes in 1st and 2nd line antibiotics available for out of hours

Clear care plan to be identified, including the duration of the treatment plan.

Sexual Health Chaperone Use

The audit aimed to ensure that current guidelines relating to the use of chaperones for intimate examinations are being met. Results showed that chaperones were available in 100% of cases where required, which was an increase from the previous audit.

Improved documentation was noted during the audit with a 22% increase in the offer of a chaperone being recorded.

Recommendations from the audit reinforce the good practice already in place in the service. The results were distributed to all staff within sexual health services to highlight improvements and support continued improvement with documentation.

Speech and Language Referrals

The patient referral process was reviewed by the speech and language therapy service to identify numbers of inappropriate referrals and the reasons for them not being accepted in order to provide information and training to referrers to reduce the number and ensure patients are receiving effective treatment.

9.7% of referrals were identified as not appropriate, 45% of the referrals were submitted by another health professional team largely due to concerns around speech sounds in children. 43% of the referrals were made too early.

The speech and language team have worked with the health professionals and provided bespoke training around the Staged Referral Pathway to ensure patients are referred appropriately.

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Participation in Clinical Research We are a research active trust providing patients with the opportunity to participate in national research studies, submitting successful research grants to fund innovative research and working closely with academic partners to provide an environment that encourages research activity.

The number of patients receiving NHS services provided or sub-contracted by Staffordshire and Stoke on Trent Partnership Trust in 2015/16 that were recruited during that period to participate in research approved by a research ethics committee was 757. This has been a successful year for research growth with our research activity increasing from 617 patients entering into research studies last year to 757 in 2015/16. We had 51 portfolio studies during the year.

The West Midlands Clinical Research Network sets five high level objectives to measure improvement including: timeliness of trial permissions, time to first patient recruited and total number of patients participating in research and the total number of commercial studies performed. This year we successfully achieved all five of these high level objectives, performing especially well in increasing the number of participants recruited into West Midlands Clinical Research Network portfolio studies and increasing the number of commercial contract studies delivered.

Research into practice

We were short-listed for the Health Service Journal award for ‘Making it easier to do the right thing - getting clinical research into practice’ reflecting our collaboration with Keele University in implementing research findings on back pain treatment into clinical practice. Our musculoskeletal/rheumatology team have also been honoured with the prestigious ‘Best Practice Award 2016’ from the British Society of Rheumatology for its work with Clinically Appraised Topic (CAT) groups improving research findings being incorporated into clinical practice.

We were chosen to be one of three sites recruiting to a nationally funded study evaluating the risk of inflammatory arthritis in GP patients with psoriasis. A collaborative PhD fellowship with Warwick University has started in 2015, following a successful grant from the National Society for Ankylosing Spondylitis (AS) to assess fatigue in AS.

In addition to our portfolio research, some of our staff are participating in student research projects:

Spasticity and Contractures at the ankle after head injury (Physiotherapy) Managing minor illness in children under 5: The role of the health visitor; a practitioner’s

perspective Self-Management support for people affected by Multiple Sclerosis (Physiotherapy) ACT for chronic pain An evaluation of the impact emotionally intelligent leadership has on staff members of

integrated adult health and social care teams in Staffordshire and Stoke on Trent NHS Partnership Trust

To improve the acute and sub-acute care of patients with dementia, when they become unwell

Discharge prescription evaluation (Pharmacy) A Service Development to Explore the Perspective of Parents as Commissioners of

Speech and Language Therapy

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Examples of outcomes of our research activity

We have broadened our spread of research studies in the community, with new studies in prisons, community occupational therapy and dementia. There has been funding for successful placements for research facilitators in occupational therapy, podiatry, prisons and social care. We received a formal accolade from the West Midlands Clinical Research Network for increasing dementia study activity, and championed the ‘enrich’ programme in care homes.

Examples of the success of this partnership are the MARQUE 2 – Agitation and quality of life in care homes; and the Alzheimer Disease Genetics studies. Research continues to grow within the musculoskeletal and rheumatology services, with the Rheumatoid Arthritis Annual Review Clinic and Hip Injection Studies starting to recruit patients; and the STarTBack Absorptive Capacity Study began looking specifically at how the evidence from the STarTBack research trial is being translated into clinical practice.

Use of the Commissioning for Quality and Innovation (CQUIN) payment framework In 2015/16 a proportion of our income – 2.5% of healthcare services commissioned through the standard NHS contract – was conditional on achieving quality improvement and innovation goals agreed between ourselves and our NHS commissioners through the Commissioning for Quality and Innovation (CQUIN) payment framework.

Table: Summary of CQUINS achievement for 2015/16

Area 2015/16 Commissioning for Quality and Innovation (CQUIN) schemes

North Urgent Emergency Care – nursing home pilot

To ensure that patients with emergency care needs are treated in the right place, with the right facilities and expertise, at the right time.

Achievement of Q1, 2, and 3. On track to achieve Q4

This information on CQUIN payments will be populated after formal confirmation of Q4 outturn with commissioners, anticipated during May 2016

The Trust achieved XX.X% (by value) of all its CQUIN initiatives. We partially achieved the XXXX CQUIN initiative(s):

Target: [XX% and description] Our achievement: XX.X%

Further details of the agreed goals for 2015/16 will be available electronically at:

http://www.staffordshireandstokeontrent.nhs.uk/About-Us/quality-and-innovation.htm

The agreed goals for 2016/17 are subject to formal contractual sign off and will be published when this is complete.

http://www.staffordshireandstokeontrent.nhs.uk/About-Us/quality-and-innovation.htm

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North & South Dementia & Delirium - to improve care for patients with dementia or delirium during episodes of emergency unplanned care.

North: On track to achieve year-end target

South: year-end target anticipate not achieved

North Learning from Respiratory Patients (April – September 2015) - Identify causative factors and service improvements for the admissions of patients with respiratory conditions.

Achieved

North Working Collaboratively in improving assessment and prevention of Pressure Ulcer through delivery of an educational programme to enable identification and maintenance in the use of correct Pressure Ulcer equipment in Nursing Homes in North Staffordshire


North Community Hospitals Sepsis – early identification and treatment of sepsis through a community hospitals sepsis bundle within all community hospitals directly commissioned from the Trust by CCGs


North Medication Safety Thermometer – reducing high risk medication errors and harms to patients from medication errors in all community hospitals directly commissioned from the Trust by CCGs


South Star111 - to improve the patient experience and optimise the outcome of care for individuals where it is clinically safe and appropriate to do so thereby avoiding unnecessary attendance at A&E departments.

Achievement of Q1, 2, and 3.

Q4: This Scheme was negotiated as a “proof of concept”. It was mutually agreed that benefits had not been realised and therefore the scheme was discontinued in-year.

Specialised Length of Stay - Neurological Rehabilitation - To reduce the average length of stay for patients within specialised rehabilitation


Specialised Enhancing Services for Prisoners with identified Learning Disabilities


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Specialised Health Visiting – Mapping the Maternal Mental Health Pathway for perinatal women by Health Visiting Service.


Specialised Health Visiting - Health Visitor Support for Breastfeeding, Early Attachment and Positive Parenting


Information on the Care Quality Commission (CQC) registration and periodic/special reviewsStaffordshire and Stoke on Trent Partnership NHS Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Partnership Trust has no conditions on registration.

The Care Quality Commission has not taken enforcement action against the Trust during 2015/16.

The registration details are available on the Care Quality Commission website: www.cqc.org.uk

CQC inspections and ratings (Position at 29 April 2016; this section will be updated as new information becomes available)

The Care Quality Commission inspected Staffordshire and Stoke on Trent Partnership NHS Trust between 2 and 6 of November 2015.

On 29 March, the CQC issued its draft inspection report; this is currently subject to the factual accuracy review and revision. The final version is expected to be published by the CQC in May 2016.

CQC rating

Safe Effective Caring

Responsive

Well-led Overall

Partnership Trust

TBC TBC TBC TBC TBC TBC

The CQC provided their initial feedback in writing to the Trust on 13 November 2015. The Trust responded on the 20 December with its initial action plan.

On 15 December 2015, the Care Quality Commission issued a warning notice under Section 29A of the Health and Social Care Act 2008.

The Trust has developed a comprehensive Quality Improvement Plan identifying the key improvement actions associated with the CQC feedback in all its forms and specifically with respect to delivering the improvements identified within the warning notice.

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

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The Trust has written to the CQC identifying the actions that it had taken with respect to the areas identified within the warning notice on the 30 December 2015 and again on the 26 February 2016.

These actions include:

1. Mental Capacity Act - a review of the Training Needs Analysis and additional 2,065 staff trained since December 2015.

2. Do Not Attempt Cardio-Pulmonary Resuscitation – A revised DNACPR document was issued based on the national template.Audit of DNACPR and Capacity demonstrates sustained improvement over three audit cycles (Jan-March).Quarterly Audit of DNACPR and Capacity forms part of 2016/17 audit programme

3. Safer Staffing Escalation Policy - Strengthened reporting requirements, development of local escalation plan with weekly registered nurse fill rate for out of hours nursing service.

4. Competencies - Issue of clarification to all community nursing teams identifying the interventions appropriate to role.

5. Staffing Capacity and Demand - Upgrade to Community Nursing electronic planning system

6. Recruitment - Significant regional, national and international recruitment programme.7. Handover in Community Nursing Services - Review of handover systems in use,

development of Standard Operating Procedure guiding good handover, closing of the gaps between day and out of hours service (East Staffs)

8. End of Life Care – Develop the End of Life steering group chaired by our Director of Nursing developing; working draft strategy.Revised End of Life medication authorisation charts issued (review commenced prior to inspection) along with the development of an End of Life care pathway based on NICE guidance issued in December 2015.Our nurse consultants offered strengthened supervision both professional and clinical.

9. Duty of Candour – Training through a mixture of face to face and e-learning offering a significant increase in training compliance. Awareness material included Trust Newsletter, payslip memos, and screensaver reminders. Monitoring – Automatic notification via our risk team monitoring all Duty of Candour incidents and supporting teams to develop notification letters confirming issues to patients/families. We developed a central process for the development and sign-off of Duty of Candour outcome letters.

Additional Inspections

At the same time as the main CQC inspection the Trust also received inspection of three of its services registered under social care provision. Outcome reports have now been issued for all three services, two were rated as Good (Living Independently Staffordshire Moorlands and Living Independently Staffordshire Lichfield & Tamworth) and one as Requires Improvement (Brighton House).

The three reports that have already been issued are on the CQC website and links are included on our website as per the CQC guidance:

http://www.staffordshireandstokeontrent.nhs.uk/Services/LIS.htm

http://www.staffordshireandstokeontrent.nhs.uk/Services/LIS.htm

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Living Independently Staffordshire – Lichfield & Tamworth Inspection and rating

The Care Quality Commission inspected this service on 9 November 2015. This was an announced inspection.

CQC rating


Responsive

Well-led Overall

LIS Lichfield & Tamworth

Good Good Good Good Good Good

Living Independently Staffordshire – Moorlands inspection and rating

The Care Quality Commission inspected this service on 17 November 2015. This was an announced inspection.

CQC rating


Responsive

Well-led Overall

LIS Moorlands


Brighton house inspection and rating

The Care Quality Commission inspected this service on 9 November 2015. This was an unannounced inspection.

CQC rating


Responsive

Well-led Overall

Brighton House

Good Good Good Requires Improvement

Requires Improvement

Requires Improvement

We have developed an action plan to address the two areas that require improvement, which has been monitored by the service’s registered manager. All actions on the plan are due for completion by the end of April 2016.

Living Independently Staffordshire – Cannock inspection

The Care Quality Commission inspected this service on the week commencing 29 February 2016. This was an announced inspection.

CQC rating Safe Effective Caring

Responsive

Well-led Overall

Living Independently Staffordshire – Cannock


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Data QualityStaffordshire and Stoke on Trent Partnership NHS Trust is taking the following actions to improve data quality:

Continue to deliver the data quality strategy, and approved data quality work plan for 2016/17.

Replace the multiple client information systems currently in use with a more modern IT solution.

Implement Trust-wide support and training where required around the consistent use of systems and coding.

Improve access to data quality reports for front-line staff. Empower individual staff to take on a data quality role within their team with training and

support. Assess and score the data quality of key performance indicators. Produce and deliver data quality improvement plans. Include data quality as standing agenda item in divisional business meetings and

quarterly performance reviews. Staff communication tools to raise the profile of data quality and highlight requirements.

NHS NumberStaffordshire and Stoke on Trent Partnership NHS Trust submitted records during 2015/16 to the Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest published data.

The percentage of patients in the published SUS data which included the patient’s valid NHS number was:

100% for admitted patient care 100% for outpatient care

The percentage of patients in the published SUS data which included the patient’s valid General Medical Practice Code was:

100% for admitted patient care 100% for outpatient care

The percentages above are based on Provisional April 2015 to January 2016 SUS Data at the Month 10 Inclusion Date.

Information GovernanceStaffordshire and Stoke on Trent Partnership NHS Trust’s Information Governance Assessment Report score overall for 2015/16 was 77% and was graded Satisfactory with improvement plan.

We achieved the minimum level attainments in 38 out of the 39 toolkit requirements with an improvement plan to address the one remaining outstanding requirement relating to Information Governance awareness and training. During 2015/16 we did the following in relation to Information Security and Information Governance, overseen by our Information Governance Steering Group

Hosted a Trust wide event ‘working smarter’, promoting secure mobile working, good records management and efficient working

Issued a wide range of communications and guidance materials, including an information governance bulletin for staff

Reviewed the Information Governance Policies,

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Delivered a wide range of training to staff on all aspects of information governance, Continued to strengthen the security of our systems, and action alerts relating to cyber

security,

On average the compliance rate for IG Training in 2015-16 was 75%, this is 9% higher than the previous year. Furthermore, training compliance has remained above 80% for the second half of the year. The Trust remains confident we can continue to improve compliance towards the 95% target in the Information Governance toolkit.

The national Digital Maturity Assessment provides a framework for assessing the extent to which we are supported by the effective use of digital technology. For our 2015/16 assessment we were rated as:

Very good progress for readiness (80%), Good progress with Capabilities (47%), and N/A for Infrastructure (data not available)

Details on the information governance toolkit are available from www.igt.hscic.gov.uk and data on Digital Maturity is available from https://www.nhs.uk/Service-Search/Performance/Search

In April 2016 Our Executive Risk Management Committee reviewed of information governance risks escalated in relation to cyber security, and will look at these areas further during 2016/17.

Clinical coding error rate Clinical coding translates the medical terminology written by clinicians to describe a patient’s diagnosis and treatment into standard, recognised codes. Staffordshire and Stoke on Trent Partnership Trust was not subject to the Payment by Results clinical coding audit during 2015/16 by the Audit Commission.

https://www.nhs.uk/Service-Search/Performance/Search

http://www.igt.hscic.gov.uk/

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Part 3: Review of Quality Performance in 2015/16

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Progress against our Quality Improvement Priorities 2015/16 Priority 1: Safety – Reduce avoidable harm Our aim: Reduce avoidable and attributable grade 3 and 4 pressure ulcers and reduce serious incident falls developed in our care

Our Progress

Safety – incident reporting (priority 5)

Organisations that report more incidents usually have a better and more effective safety culture. You can't learn and improve if you don't know what the problems are.

Our ambition was to increase the number of incidents reported by 10% compared to all incidents reported during 2014/15. We were able to raise this by 27% from 10,357 in 2014/15 to 13,155 in 2015/16.

We planned to reduce the proportion of serious incidents as a percentage of all reported incidents applicable to the Trust. We succeeded in reducing our proportion of serious incidents from an average of 3.47% in 2014-15 to 2.21% in 2015-16.

We aimed to increase the number of “near misses” reported by 25% in 2015-6 compared to our 2014-15 baseline. The number of near misses reported was actually increased from a baseline of 73 to a total of 1,115.

We wanted to improve our patient safety incident reporting rate to be within the median range of other community trusts with bed based services, based on the total number of patient safety incidents, as reported to the National Reporting and Learning System (NRLS). The latest available comparative reporting data shows a continually improving picture compared with the last data set. We have improved our reporting rate from 77.53 incidents (October 2014 - March 2015) to 98.1 incidents (April - September 2015) per 1,000 bed days, which is now within the median range of community Trusts.

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Safety – reducing avoidable harm (priority 1)

We wished to avoid the development of any avoidable grade 3 or 4 pressure ulcers attributed to the care received in our community hospitals. Unfortunately we were unable to meet this target, as two avoidable and attributable pressure ulcers were developed in our care in community hospitals.

We set ourselves the target of reducing the incidence of grade 3 and 4 avoidable and attributable pressure ulcers developed in the care of our community services, by a minimum of 10% for 2015/16 (with a tolerance of 23). We were able to meet this target with a prevalence of 23 cases.

We were unable to reduce our serious incident falls in all our care settings by 10% for 2015/16. Twenty one cases were reported by the Trust against our maximum tolerance of 12. All these cases have been reviewed by our falls review group to identify any learning to reduce the likelihood of further cases, the group deemed that all the cases reviewed were unavoidable. We are working with our partners in our health economy to identify system issues and improvements to further reduce the risk of falls, such as wearable technology, and the timing of patient transfers between hospitals.

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Priority 2: Experience – Improve Customer Satisfaction Our aim: Sustain and maintain our overall customer experience, as measured by the “Friends and family test”

Our Progress

Experience – friends and family test feedback (priority 2)

We wanted to collect feedback from over 1300 service users and 200 carers each month. We received an overall 35,750 survey returns from service users (an average of 2979 responses each month) and 7,327 returns from carers (an average of 610 responses each month).

We were required to ensure that our Friends and Family test score demonstrated that more than 90% would recommend our services to their friends and family if they needed similar treatment and less than 5% would not recommend us. We are pleased to report that over 96% of service users would recommend us and less than one per cent (0.67%) would not recommend us.

Additionally over 98% of carers would recommend us with just 0.28% who would not.

Our aim was to increase the number of compliments we receive compared to that of 2014-15 (2,022). We received 1,581 compliments; an additional 16,810 positive comments were received from our service user and carer experience surveys.

Experience – using and acting on feedback (priority 2)

We succeeded in our plan to report thematic patient feedback in the form of word clouds. All monthly divisional business meeting reports relating to service user experience have included word cloud analysis. This analysis is used by our local teams to develop actions of improvement.

We also succeeded in publishing 16 patient stories, associated learning, and improvement actions, in relation to the North Staffordshire respiratory pathway for 2015/16. These stories were submitted to our commissioners in September 2015.

We set a target for our Independent Complaints Review Panel to review at least 20 complaints in 2015/16, split across the divisions, including multi-agency complaint responses. The Panel has been able to review 25 complaints overall.

We also set out to produce an annual report on our actions taken in response to recommendations by our Independent Complaints Review Panel, implementing and demonstrating learning from all recommendations of the panel. The Panel report for the review of complaints in 2014-15 was received by the Trust Board in August 2015.

We set out to publish all complaints and outcomes of investigations and findings of the Independent Complaints Review Panel on the Trust website. We have been unable to achieve this by Q3, though we have consent for five cases to be published, and these are awaiting publication on our website.

[Insert wordclouds and example of Children & Young People Friends and Family Test comment card as below]

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Experience – personalisation / care plan audits (priority 2)

We set ourselves a target of ensuring that by the end of 2015/16, 95% of our service users receive a copy of their care plan, in relation to social care support planning.

For 2015/16, Our overall record keeping audit results showed that there was documented evidence of a support plan to determine care delivery 99% of the time, and there was documented evidence that a copy of the support plan and risk profile has been given to Service User 63% of the time.

Although we did not achieve our target across the whole of the trust, our Living Independently Staffordshire service audit showed that a copy of the support plan and risk profile was given to our service users 99% of the time.

We will continue with this audit and associated improvement work during 2016/17.

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Experience – targeted feedback from service users (priority 2)

We wanted to improve our experience in 4 key areas, based on our consultation with service users and carers in 2014/15.

We achieved our aims – at least 90% extremely satisfied – against three of the four areas:

85% were extremely satisfied with the quality of care that they have received from our services.

92% were extremely satisfied with our providing accurate health and social care information to support their recovery through an episode of ill health or injury.

96% felt extremely satisfied that they were involved in decisions regarding their individualized plans of care.

97% Feedback from service users and carers that they feel they have care and support that was directed by them and responsive to their individual needs.4

We put actions in place in response to all feedback that identified improvement areas. We will continue monitoring and improving this area as part of our quality priorities during 2016/17.

Priority 3: Effectiveness – improving outcomesOur aim: Improve the outcomes of our care for our service users

Our progress

Effectiveness – outcomes (priority 3)

Following the delivery of a CQUIN scheme in 2014/15 we pledged to collect and analyse outcomes data from a range of services such as allied health professionals, children’s clinical teams and our community intervention services.

Whilst services continue to collect outcomes data at a local level our ability to collect and analyse this centrally has been delayed by the introduction of our new electronic patient record system. The recording of outcomes data is an integral part of this roll out during 2016-17.

4 Revised wording, in line with national guidance, compared to the 2014/15 published quality account.

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Priority 4: Effectiveness - Supporting independence by personalised careOur aim: Ensure our service users have choice and control over the shape of health and social care support we provide

Our progress

Effectiveness – personalised care (priority 4)

We set out to work with Staffordshire County Council to increase the use of the electronic market place for social care offering advice and information regarding social care services. We have achieved this by delivering a series of events for our frontline social care staff raising awareness and offering information on the use of Staffordshire Cares, assistive technology and the electronic market place in general.

We aimed to ensure that our staff working in our Integrated Local Care Teams, Community Intervention Services and Living Independently Staffordshire Teams continued to receive person centred care training. We have trained an additional 140 staff in personalisation this year. In addition to this Staffordshire County Council delivered six ‘Person Centred Planning-Policy into Practice’ workshops between January and March 2016.

We wanted to maintain the proportion of people who feel that they were supported to make their own decisions about their social care and/or services above 85%. Of the 3,228 people who responded to our survey almost 95% felt that they were supported to make their own decisions.

We wanted the result of the 2015/16 National Annual Survey question ‘the proportion of people using social care that have control over their daily life’ to exceed 78%. We expect to see the results of this in May 2016.

We achieved our plan to increase the proportion of people who receive self-directed support to over 87% against our target of 84%. We were not able to achieve our target for increasing the proportion of people receiving direct payments seeing a 1% decrease compared to last year from 24.6% to 23.6% (our target was 27.5%). We now plan to simplify the administration process to service users to enable the improved uptake of direct payments.

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Priority 5: Safety – workforceOur Aim: Ensure that our workforce can provide safe levels of care

Our progress

Safety – providing safe levels of care (priority 5)

We pledged to monitor the safety of our staffing levels within our community hospitals in relation to shift by shift service need, taking into account the demand on the service. Each month the Community Hospitals Safe Staffing Report and Dashboard are presented to the Trust Board and published on the organisations web site:

http://www.staffordshireandstokeontrent.nhs.uk/Services/safe-staffing.htm

We were also required to publish two acuity staffing establishment reviews, which look at safe staffing levels in community hospitals, during 2015/16. This has been achieved through:

A review of staffing establishments against patient acuity was undertaken in the summer of 2015. The findings identified a change in skill mix was required for some wards although no changes to overall staffing numbers were recommended.

The publishing of our winter acuity review has been delayed due to the extension of our staffing review into April 2016. This is due to changes in our community hospitals; (5 of our wards transferred to UHNM management) and a change in the way we receive patients into the remaining wards (predominately admitted from community services). This report has yet to be presented to our Trust Board and it is anticipated that this will take place in May 2016.

We aimed to use our workforce planning toolkit to review Community Staffing levels:

In June 2015, NICE was asked to suspend further work on the safe staffing programme as the work would be taken forward by NHS Improvement, in conjunction with NHS England. This work stream would include guidance on community nursing staffing levels; to date there has been no further publication to provide national guidance on this topic.

Within the Partnership Trust the safe community nursing levels have been set using the workforce planning toolkit and monitored through the community nursing dashboard, which is reported to our Executive Management Team and commissioners.

Although safe services have been maintained throughout the year there have been a number of challenges to meet the community nurse staffing numbers and skill mix as a result of vacancy and the national shortfall in nursing resources.

Operational Team plans and workforce planning toolkit implementation dashboards are being completed on a monthly basis to ensure teams are staffed appropriately. This is supported by the operational safe staffing dashboards.

Deviation templates are being completed to convey any changes to staffing model recommended by our Workforce Planning Toolkit. Sign off is required by respective Chief Operating Officers, Professional Leads, and our Workforce Information & Planning Group.

Competency frameworks have been designed for core Adult AHP and Adult Nursing. Adult Speech and Language Therapy will be the early implementer site.

During 2016/17 as part of our Quality Priorities we will monitor and report the number of safe staffing escalations through our incident reporting system into our governance processes.

https://web.nhs.net/OWA/redir.aspx?SURL=iU1NPnivQmetLHy1WTBTNwHF9c4i_W_L5ICCY1fRahyi4vMbBWXTCGgAdAB0AHAAOgAvAC8AdwB3AHcALgBzAHQAYQBmAGYAbwByAGQAcwBoAGkAcgBlAGEAbgBkAHMAdABvAGsAZQBvAG4AdAByAGUAbgB0AC4AbgBoAHMALgB1AGsALwBTAGUAcgB2AGkAYwBlAHMALwBzAGEAZgBlAC0AcwB0AGEAZgBmAGkAbgBnAC4AaAB0AG0A&URL=http%3A%2F%2Fwww.staffordshireandstokeontrent.nhs.uk%2FServices%2Fsafe-staffing.htm

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Safety - mortality

We set out to develop a robust reporting mechanism for mortality across the trust, ensuring that we reviewed all unexpected deaths in community hospitals, by July 2015.

We reviewed 93% (331 of 356) of unexpected deaths in community hospitals during 2015/16. Whilst we were unable to achieve the review of 100% of unexpected deaths in community hospitals by July 2015 we did achieve this by year end.

There has been a change in the review process in April 2015, in order to provide greater assurance that we have reviewed the care given by our community hospitals immediately prior to death and also to identify if any aspect of our care was poor quality and has in any way contributed to the patient’s death.

The process now uses a trigger tool applied within 72 hours of the death. The outcome of the trigger tool will inform whether a full root cause analysis investigation is required. All Root Cause Analysis investigations are considered at the Trusts Mortality Review Group where any organisational learning and improvement actions are identified.

Safety - training

We set ourselves the target that 90% of our directly employed staff would have had an appraisal in the last 12 months. At the end of March 2016 63% of staff had received an appraisal within the previous 12 months.

A new appraisal timeline has been produced for 2016/17 and this will align appraisal to the Strategic goals. We have introduced a new approach to appraisal delivery and have mandated that all staff appraisals will be delivered between April and July 2016. This will continue to be subject to monthly monitoring and reported to our Workforce Matters Committee.

Our Target for the delivery of statutory and mandatory training within Trust timescales is 90% for all of our directly employed staff. We achieved a compliance rate of 85% in March 2016. We have improved our compliance rate across all training types through the strengthened use of electronic learning approaches where appropriate, allowing our staff to access training more flexibly.

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Safety – raising concerns

We pledged to publish in our 2015/16 quality account quantitative and qualitative data describing the number of formally reported concerns in addition to incident reports, the action taken in respect of them and feedback on the outcome. In its first annual ‘Learning from Mistakes League’ in March 2016, NHS Improvement rated our reporting culture as having “good levels of openness and transparency”, ranked 96 out of 230 Trusts.5

Concerns raised during 2015/16:

Type of concern Number received

Individual employment concerns 32

Staffing And Capacity Issues 21

Handling Of Commissioning / Tendering 16

Safety / Quality Risks 5

Poor Leadership 4

Grand Total 78

Work done to improve our services:

The Ambassador for Cultural Change is an innovative role which we developed and established. It forms the model for the Freedom to Speak Up Guardian. There are 29 Cultural Change champions who have been trained and supported by the Ambassador for Cultural Change.

Our Human Resources team have supported staff with individual employment concerns to ensure the correct resolution is received.

Teams involved in tender processes were given the opportunity to discuss concerns and given the necessary support and reassurances. Lessons were learned from the experience staff had regarding tender processes to ensure organisational improvements in this area.

New national guidelines have been published in April 2016. We will review our existing procedures in line with these guidelines and make any necessary amendments to ensure that we continue to offer best practice.

Staff raising concerns will receive a report of findings, and learning actions arising from their concern

We will re-launch our raising concerns process under the new name Freedom to Speak Up.

We identified an executive and non-executive director as our trust board leads for Freedom to Speak Up, our executive lead is our Director of Workforce Development.

5 See https://www.gov.uk/government/publications/learning-from-mistakes-league

https://www.gov.uk/government/publications/learning-from-mistakes-league

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Core Quality IndicatorsThe core set of indicators relevant to the Trust, as required by NHS England is set out in this section.

ReadmissionsTable 1: Mandatory quality indicator for readmissions

Quality Indicator Age 2009/10 2010/11 2011/12 Comparator 2011/12

The data made available to the National Health Service Trust or NHS Foundation Trust by the Health and Social Care Information Centre with regard to the percentage of patients aged— (i) 0 to 14; and (ii) 15 or over, readmitted to a hospital which forms part of the trust within 28 days of being discharged from a hospital which forms part of the Trust during the reporting period. 6

0-15 0.00 0.00 0.00 West Midlands region 10.65 (95% confidence: 10.45 to 10.85)

16+ 0.00 0.00 12.16 (95% confidence: 10.71 to 13.75)

England 11.45 (95% confidence: 11.42 to 11.48)

Staffordshire and Stoke on Trent Partnership Trust considers that this data is as described for the following reasons:

As of 16 April 2015, latest data available on the Health and Social Care Information Centre (HSIC) pertains to 2011/12.

The partnership Trust readmission rate is not significantly higher than the England average, after taking the 95% confidence interval into account.

Staffordshire and Stoke on Trent Partnership Trust intends to take the following actions to improve this percentage, and so the quality of its services, by:

Reviewing latest data once available from the Health and Social Care Information Centre

Analysis of data and national comparisons and developing improvements via the Safety and Effectiveness Operational Groups responsible for quality in community hospital inpatient services.

Staff who would recommend the TrustMandatory quality indicator for staff who would recommend the Trust

Quality Indicator 2012/13 2013/14 2014/15 2015/16 National

6 2010/11 and 2011/12 data: Numbers of patients too small for meaningful comparisons

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2015/16

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

64% 64% 64% 71% All organisations: 68%

Best 93%Worst 18%

Community trusts: 74%

Best 82%Worst 67%


The survey was administered by an external agency, allowing consistent comparisons of the experiences of staff across the NHS.

Staffordshire and Stoke on Trent Partnership Trust has taken the following actions to improve this score, and so the quality of its services, by the following:

Staffordshire and Stoke on Trent NHS Partnership Trust has demonstrated a significant increase in this score since 2014/15. A number of actions were identified within the Organisational Development and Organisational Health strategies to help achieve this and examples are:

Embedding Trust Values across systems and processes e.g. Values-based recruitment, Corporate Welcome designed around the Trust Values & values reviewed at Appraisal

Staff engagement, e.g. information and listening events, Team Away Days, Talent Management opportunities, Celebrating Excellence awards.

Compassionate and Appreciative approach to leadership at all levels, e.g. Team leader development programme with Master classes such as ‘Courageous conversations’ training, Coaching and Buddying.

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Patient safety incidentsTable 1: Mandatory quality indicator for patient safety

Quality Indicator 1 Oct 2013 to 31 Mar 2014

1 April 2014 to 30 Sept 2014

1 Oct 2014 to 31 Mar 2015

1 April 2015 to 30 Sept 2015

National 1 April 2015 to 30 Sept 2015

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

Number of patient safety incidents

1609 1635 3,857 5,344 33,796 (all Community Trusts)Range: 542 to 5,344

Rate of patient safety incidents per 1,000 bed days

28.2 32.44 77.53 98.1 Median: 146.03

Range7 38.22 to 267.74

Number of safety incidents that resulted in severe harm or death

14 15 10 20 Average 16.4 incidents per Community TrustRange 0 to 67(312 incidents across 19 Trusts)

Percentage of Patient safety incidents that resulted in severe harm or death

0.9% 0.9% 0.3% 0.4% 0.9% (all NHS Community organisations)


Latest available data from the Health and Social Care Information Centre is for the period 1 April 2015 to 30 September 2015.

Our Trust reporting rate has increased from 77.53 to 98.1, an increase of 26.5% and we are now in the middle 50% of reporters when compared with other NHS community organisations.

We have reported 5,344 incidents during April 2015 – September 2015 in comparison to the 3857 incidents reported October 2014 – March 2015.

Staffordshire and Stoke on Trent Partnership Trust intends to take the following actions to improve this percentage, and so the quality of its services, by:

7 Excluding trusts where no rate was published

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Continuing to improve our incident reporting process by promoting web-based electronic incident reporting for our staff, making it easier for them to report incidents

Engage leaders and frontline colleagues to focus on improving their safety culture Ensure that lessons learned are fed back appropriately to patients and staff


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Our Performance IndicatorsHow we measure performance We use a comprehensive set of indicators to monitor performance and manage service improvement. These indicators include national, contractual, and internal metrics and targets, which cover the core service dimensions of operations, quality, finance, and workforce.

Performance is reported and discussed at Team, Area, Division, Committee, and Trust Board level. This generates a constant flow of business intelligence that enables the early detection and correction of emerging performance concerns. Performance improvement plans are produced for indicators reported below target, and where business intelligence provides an early warning that performance may deteriorate.

The Trust currently is in the process of implementing two major IT projects that will facilitate immediate access to performance information updates across the organisation, improve data quality, and automate early warning systems.


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Performance IndicatorsThe figures identified in the table below are draft, awaiting final validation through national data submission cycles. The final figures will be available on 18 May 2016, and will be published in the final version of this account.

Commentary against each area of underperformance will be included in the final version once the full year end performance is available.

Indicator Target DRAFT Outturn 2015/16

Mixed Sex Accommodation: Single Sex Number of Breaches 0 0

Number of Never Events 0 0

Methicillin-Resistant Staphylococcus Aurous (MRSA) Screening on Admission (% screened on elective admission) 95% 99.5%

Methicillin-Sensitive Staphylococcus Aureus (MSSA) (No of cases hospital associated) - 2 -

Compliance with Vulnerable Adults Quality Standards 80% 88%

Cases Where the Risk of Harm has been Reduced (Social Care) 94% 93.9% ×

Actions: TBC

Delayed Transfers of Care Community Hospitals within the Trust (percentage of occupied bed days) - Overall Trust Percentage - 6.1% -

Average Length of Stay (ALOS) (Community Hospitals Median) 23 17

Admitted Patients Meeting the 18 Week Consultant Led Referral to Treatment Target 90% 98.7%

Non-Admitted Patients Meeting the 18 Week Consultant Led Referral to Treatment Target 95% 99.6%

Patients on Incomplete Consultant-Led Pathways Waiting Less Than 18 Weeks 92% 99.1%

Therapies - Percentage of Patients Treated Within 18 Weeks from Referral to Treatment 95% 99.7%


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Physiotherapy - First Appointment Within Local Waiting Targets 90% 92.7%

Patients Receiving a Diagnostic Scan Within 6 Weeks of Referral 99% 100%

Waiting time from assessment start to assessment completion: percentage completed within 4 weeks 75% 76.9%

Proportion of carers assessed or reviewed in the year out of the totalnumber of carers 'on the books

70% 61.0% ×

Actions: We believe that this reported performance is an understatement due to data recording issues, and this is being addressed through systems upgrades and staff training.

Long stay residential care permanent admissions: Older people aged 65+ 525 492

People receiving reablement in the year, where the immediate outcome was no support or low level support 72% 62.4% ×

Actions: TBC

Older People still at home 91 days after discharge from hospital into reablement 85% 85.6%

Older people still at home and needing no on-going Social Care services 91days following receipt of reablement services 55% 50.9% ×

Actions: TBC

Clients receiving long-term support at any point in the reporting period who have had one or more reviews 70% 73.5%

New-borns that Receive a Face to Face New Birth Visits within 10-14 Days by a Health Visitor 95-98%

93.76% based on February 2016 data

×

Actions: TBC


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Children who Received a 12 month review within 15 months 95-98%


Children who Received a 2 - 2.5 Year Review 95-98%


×

Actions: TBC


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Sign up to safetyReporting when things go wrong is essential in healthcare, but it is only part of the process of improving patient safety. It is equally important that the Trust looks at the underlying causes of patient safety incidents and learn how to prevent them from happening again. Incidents may occur because of any one of multiple reasons and it is essential that the Trust identifies these reasons and ensure that lessons are learnt and implemented to prevent reoccurrence.

Sign up to Safety aims to deliver harm free care for every patient, every time, everywhere. It champions openness and honesty and supports everyone to improve the safety of patients. Launched in 2014/15, Sign up to Safety’s three year objective is to reduce avoidable harm by 50% and save 6,000 lives across the NHS.

The aims of our Sign up to Safety plan are mirrored in our 2016/17 Quality Priority for Safety.

Our Safety Improvement Plan continues to build on our existing quality improvement work specifically around:

Patient Safety Strategy Zero Tolerance Pressure Ulcer Action Plan Raising Concerns Campaign Safety Culture Programme Fighting Falls Campaign

The Risk and Safety team convey lessons learnt throughout the Trust by web based incident feedback to reporters, divisional / area team reporting and regular articles across the Trust a and to Committees.

To support the cascade of lessons learnt the Risk and Safety Team have issued quarterly newsletters ‘Quality Matters’ during 2015/16. The aim of the newsletter was to update staff on Patient Safety and Risk matters. The newsletter also cascaded the sharing of lessons learned which may be relevant to other teams and services and to share good practice.

Reducing Harm from Avoidable Pressure ulcersWe have been successful in reducing the number of avoidable and attributable pressure ulcers that have developed in the community. We noted in 2015/16 a 32% reduction in Avoidable pressure ulcers in the community in comparison to the previous year 2014/15.

Training programmes in pressure ulcer management have been delivered across the Trust. The introduction of non-registered staff training in regards to pressure ulcer prevention, and the REACT to RED programme has been rolled out, therefore involving all staff.

Acting on Lessons Learned – Pressure Ulcers

Grading Pressure Ulcers

The education programme from tissue viability for community nurses to verify pressure ulcers is on-going. In addition, photographs of all the various grades of pressure ulcer have been added to the Safeguard incident reporting system so reporters can view pictures of the grade of ulcer they are reporting, with associated descriptions.


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Reducing FallsThe multidisciplinary Falls Review Group has improved how it reviews and identifies areas for learning in each of the incidents. Improved incident reporting has helped us to understand when, where and how patients/service users fall. In 2015/16 we have:

Developed tools so that we can quickly identify when service users are at risk of falls, and plan care in a personalised way. For example, we use hi-lo beds (height-adjustable) where we find a patient is at risk of falling out of bed.

Reviewed our incident reports, and evidence-based practice guidance, which showed us that inpatients with dementia have an increased risk of falls. We then revised our ward environment to be friendlier to service users with dementia.

Used text messaging telehealth in one of our community-based falls management services. This helps to reduce the risk of service users falling. We recognised the team that implemented this innovation with our 6 Cs award, because of the way they work together to provide a patient-focussed service.

Reducing falls remains a key priority in 2016/17. We will continue to learn from incidents and improve our services to reduce falls.

We will deliver briefing sessions for our staff for multifactorial falls prevention and management

We will continue our Sign up to Safety programme, including a Falls Awareness day in June 2016

We will explore innovative ways of working, such as the use of Assistive Technology to support our service users who are at risk of falls

Acting on Lessons Learned – Reducing Falls

•Evidence with regard to mobility status over time has been clearly recorded in the plan. A meet and greet with family to ascertain baseline regarding cognition issues and behaviours that pose a risk to falling undertaken, to ensure appropriate location and type of bed was used.

•Importance of access to full case history when patients are transferred across settings including behaviours that pose a risk to falling. This is especially important in relation to out-of-hours transfers.

Safety Culture Programme As part of the Safety Culture Programme, a number of senior nursing staff attended a masterclass to develop new initiatives for delivering high quality, safe care.

The staff devised two new tools for improved safety. The first was the “Safety ACE Initiative” card, which aims to assist patients on community hospitals wards with understanding their role in safety during their stay.

“ACE” stands for Authoritative, Considered and Enthusiastic – the approach which staff are required to take when caring for their patients. To assist with record-keeping, the initiative has a range of bright, easy to identify stickers, which can be used to mark patient files, signifying that they have been informed on safety.


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In addition to simplifying the information for patients, the cards help to save teams money by reducing the number of leaflets being printed and distributed – instead, a single, laminated card is used on admission to explain safety on the ward to the patient.

The team also developed a universal emergency evacuation tool, allowing straightforward identification for all staff of patients and their needs in such a situation. Wards have also adapted this tool to identify safety concerns ‘at-a glance’ such as falls and pressure sores.

Incident reportingIncident reporting is an integral tool in managing patient safety. The information collected through reporting allows us to analyse what, how and where safety issues may be occurring.

Chart: Number of Incidents reported (applicable to Trust care) set against the proportion of serious incidents each month

We encourage our staff to report any incident that gives them cause for concern. We are committed to an open and transparent culture of raising safety concerns to ensure the safety of people who use our services.

Serious incidentsEach Serious Incident affects service users and staff. Making sure these are reported effectively and in a timely manner will help the Trust to learn the most from such incidents to improve safety. The Trust has a robust process for making sure that we act on Serious Incidents promptly and that we follow up resulting actions. All Serious incident reports are presented to the relevant Trust Committees or review panels to identify actions and learning themes.

“…the cards make the world of difference. It’s easy to read and very simple, which is made better by all of the staff being so friendly and helpful!” Community

Hospital Service User


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Pressure ulcers, ward closures and slip trips and falls were the most reported serious incident. These serious incident reports go through tissue viability / falls and infection control review panels which identify specific learning and actions that are applicable for the Trust.

Duty of CandourThe Duty of Candour applies to patient safety incidents that occur during care provided that result in moderate harm, severe harm or death. The Duty of Candour also applies to suspected incidents which have yet to be confirmed, where the suspected result is moderate harm, severe harm or death.

To support staff in understanding the requirements of Duty of Candour organisational training has been delivered across the Trust through formal teaching sessions and online training. The training has been made mandatory for identified staff and compliance is reported to the Operational divisions through the Training Department.

The Trust formally monitors compliance with all Duty of Candour incidents that have been reported. They are presented weekly as a standardised agenda item and monitored at the Executive Management Team Meeting.

All Trusts are required to deliver the following process in order to meet the requirements of Duty of Candour:

All service users or their identified relevant person, who experience a patient safety incident whilst in our care will receive a verbal apology and a copy of the Duty of Candour notification letter within 10 working days.

Inform the service user/relevant person that an investigation will be completed. Following the patient safety investigation, the service user or relevant person will receive

a further written or verbal correspondence dependent on personal choice on the outcome of the investigation. The Duty of Candour outcome letter will provide the detailed findings from the investigation and identified learning actions for the Trust.

NHS Safety ThermometerOverall, for 2015/16 we reported a Harm Free Care prevalence of 90.73%, compared to a national target of 95%. This can be associated to an increase in people being admitted to the Partnership Trust’s services with existing pressure damage (old harm). This is when a person developed the pressure ulcer in another organisation, and then received further care from the Trust who has a duty to report the harm and treat the individual and their existing harm.

The prevalence of new harms (harm occurring during Partnership Trust care) for 2015/16 is reported at 3.17% which means that 96.83% of patients receiving care by the Partnership Trust did so without experiencing harm.

The data collected from the NHS Safety Thermometer is circulated to teams and operational managers; with each team (ILCT) receiving data for each of the 4 harms. We provide data to our teams allowing them to compare themselves against their peers, so that good practice can be shared and areas of concern highlighted and acted on.

Central Alerting SystemWe use the national Central Alerting System for issuing safety based alerts to our services and teams. The Central Alerting System issues patient safety alerts, important public health messages and other safety critical information and guidance. We receive alerts by email direct from the Central Alerting System. We send relevant alerts to teams who take necessary actions and confirm this with our risk team.


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During 2015/16 we received 119 alerts, of which 97 required acknowledgement and addressing within the required time frame. 94 alerts have been acknowledged and closed within the time frame. A further 3 alerts open at the end of the year were acknowledged, and are being addressed within the required time frame. There were 22 alerts which did not require our response.

Recommendations from Her Majesty’s CoronerHM Coroner may require organisations to make improvements as a result of an inquest, known as a “regulation 28” report. We did not receive any of these reports during 2015/16.

Adult SafeguardingAs an integrated health and social care organisation we have an important role in undertaking many aspects of adult safeguarding including undertaking adult safeguarding Section 42 enquiries8 in conjunction with the Local Authorities. We continue to work closely with Staffordshire and Stoke-on-Trent Adult Safeguarding Partnership Board to ensure a multiagency approach to safeguarding adults at risk to the population we serve and continually raising awareness.

Our staff receive specialist training and support relating to the implementation of the Care Act 2014, Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards and additional training for staff undertaking adult safeguarding enquiries*. Adult safeguarding training is updated and renewed in response to learning identified in practice, following safeguarding adult reviews, incident reporting and in accordance with national guidance and legislation.

We have developed and provided a MCA policy, implemented a competency framework and undertaken a pilot audit to measure compliance with legislation and to ensure continual improvements. Future audits are planned as part of the on-going Trust programme. We also have a Deprivation of Liberty Safeguards policy and training programme, support staff to make requests for authorisations to the relevant Local Authority, report via our governance processes and follow up to meet timescales. This approach ensures the provision of safe care to the most vulnerable individuals within our services.

Our Director of Nursing and Quality is the Executive lead for adult safeguarding and our governance arrangements include exception reports from our Safeguarding Adults Committee to our Quality Governance Committee and ultimately to our Trust Board. Adult Safeguarding Champions provide additional support to our staff and are a valuable resource to promote and sustain improvements in practice.

Safeguarding ChildrenWe are committed to ensure the wellbeing of all children using our services.

During 2015/16 we worked closely with Staffordshire and Stoke on Trent Safeguarding Children Boards to keep children safe by sharing information and fully engaging in the safeguarding processes.

The Trust has nominated leads at board level, who are committed to promoting the protection of Children. These are our Medical Director (Named Doctor), The Director of Nursing and Quality,

8 Adult Safeguarding enquiries are undertaken in accordance with Care Act 2014 legislation. Local Authorities receive adult safeguarding referrals from a number of sources. Each case is assessed and then it is determined if an enquiry is undertaken. If an individual is at risk of immediate harm, swift action is taken to ensure their safety.


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and a Non-Executive Director lead. We have a dedicated Safeguarding Children Team that provides training, supervision advice and support to all our services.

During 2015/16 we saw a rise in the demand for service with more children becoming subject to child protection plans (1085 in February 2016), Looked After Children (1667 in February 2016) for both Stoke and Staffordshire. The numbers of Domestic Abuse referrals have continued to rise significantly into Quarter 4, placing considerable pressure on all partner agencies.

Following a number of inspections by OFSTED (2), CQC (1), HMIC (3), the overall outcome for the health economy approach to Safeguarding Children through its Multi Agency Safeguarding Hub model is rated as “Good”.

All our staff are trained so they know how and when to report safeguarding concerns. This year a new e-learning package for level 1 has been developed which has been peer assessed by both Staffordshire and Stoke-On-Trent Local Safeguarding Training Committees.

We are developing a new training package for Level 2 Safeguarding Children, and we will be assessing knowledge and skills of our staff before and after they take the course to ensure the quality of the training. There is a focus on the training for sexual health workers to ensure their knowledge and skills framework equips them to identify and support the most vulnerable of our children, those trapped in Child Sexual Exploitation, Missing and the Looked after system.

Child protection supervision is key to supporting the front line staff. All types of supervision are used - 1:1 / Group / Restorative and action learning. We continue to support the Serious Case Review (SCR) process and are implementing the key findings of SCR Learning Reviews both national and locally.

Infection ControlInfection Prevention and Control is taken very seriously within the Trust, and is an agenda item on all directorate business meetings. We have an Infection Prevention and Control Committee that provides assurance to the Quality Governance Committee that the Trust is compliant with the 10 criteria within the Hygiene code which was updated 2015.

Clostridium difficileDuring 2015/16 we identified 22 cases of Clostridium difficile (bacteria that can cause symptoms such as diarrhoea) in our community hospital wards. 19 cases were identified as unavoidable; no lapses in care were identified for these cases.

There were three cases that we identified as avoidable:

We changed the frequency of cleaning in high usage areas, to enable the cleanliness standards to be met throughout the whole day.

We changed training of medical staff on induction to ensure that new Trust documentation was implemented correctly and staff members were aware of how to complete it appropriately.

Methicillin Resistant Staphylococcus Aureus (MRSA)All Trusts in England have a zero tolerance for Methicillin Resistant Staphylococcus Aureus (MRSA) bacteraemia. No MRSA bacteraemia have been isolated in our Community hospitals in 2015/16.


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Infection control training3027 staff members attended Infection control training sessions which equated to 86% of Trust staff. This year the session content was reviewed to include Antimicrobial Stewardship and the importance of using safe sharp devices to reduce inoculation injuries. The Infection Control Team also supported education programmes outside of the Trust in the local Universities, Primary care settings and with 124 local Care homes.

Friends and Family TestThe Friends and Family Test (FFT) is a simple, question that has been rolled out across all our health and adult social care community teams. Our service users and carers can identify if they would recommend our health and social care services to a family or friends who needed similar services. The national goal for all NHS providers is to achieve a Family and Friend score of 90%.

We have received feedback from 39,327 service users and carers. This is a 33% (13,436) increase in feedback compared to 2014/2015 (25,891). Each of our operation teams and divisions has a FFT score which is monitored monthly and practical actions implemented from our feedback.

As a Trust, we are extremely proud that 96% of our service users in 2015/2016 said that they would recommend our services and less than 1.8% would not recommend us.

Where we had suggestions of improvement from our experience surveys, we acted upon these at team level as well as identifying themes by each division.


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Division Top three themes from service user and carer feedback

South Community Teams “ Improve the communication with your service users”

“Improve length of waiting times”

“Review your flexibility and availability within Appointment”

North Community Teams “Review your appointment times”

“Ensure that the individualised care needs of service users are met”

Improve communication between departments and with your service users and carers”

Specialised Services Appointment availability for Sexual Health Services

“Improve communication between departments and with your service users”

“Waiting times at appointments”

Children and Young Peoples Services

Improve communication between departments and with your service users and carers”

Improve signage, facilities and equipment

Access to Services

Community Hospitals “Food choice at the Haywood Hospital”

“Staffing levels at Haywood and Leek Moorlands Hospital”

“Jackfield and Chatterley Wards delays in response to nurse call bells”


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[Scatter the “you said we did” examples in the table below as speech bubbles through the document, ensure each team is mentioned in each bubble]

Service You Said We Did

South Community Teams

More flexibility in Tamworth Physiotherapy appointments after 3pm.

Flexible appointments are available until 6:00pm according to clinic opening times.

North Community Teams

More information regarding the charging for Adult Social Care.

The Trust has worked with external partners across the Local Health Economy. A comprehensive suite of information for Service Users and Carers is now available on the website. http://www.staffordshireandstokeontrent.nhs.uk/Services/carers_2.htm


It would be beneficial if Seisdon LIS carers would telephone if they have been delayed on a previous call.

All team members have been issued with mobile phones and reminded to contact service user if they have any delays.

Specialised Services

A clearer appointment system for Biddulph sexual health centre is needed and the 0300 number requires adding to the website.

Our Communications Team has updated Biddulph Health Centre information on the services page of our Trust website.

Appointments are being reviewed to ensure patient choice to either attend a walk in centre or book an appointment are available.

Children and Young People

More information is needed for Dyspraxia in children.

A leaflet has been developed by the Physiotherapy Team.


Our Service Users have said that it is extremely difficult to speak to staff on the phone at the Appointment Booking Centre for South Podiatry appointments.

The team manager has responded that staff have completed customer service training in August and that there are monthly team meetings to resolve any learning issues which arise.


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Specialised

Services

Long waiting times for North Staffordshire sexual health service.

A triage system is now in place which advices patients on approximate waiting times. The Triage Nurse provides a detailed explanation of the clinic process.

Community

Hospitals

Better quality and variety of menu requested by service users.

The sites and facilities manager has responded that the food supplier for Cheadle, Bradwell, and Leek Moorlands Hospitals has been changed.


There has been a change in room for the Madeley Health Visitor baby clinic and the new room at the GP surgery is not suitable, more room is required.

The Madeley Team are now using Loggerhead fire station once a month for the baby clinic.


More room and a bigger space at The Galaxy youth group who provide a social and education group for Lesbian, Gay, Bisexual and Transgender

Due to the increased membership of the group, extra staff have been recruited. Available space within the building has been reviewed. The team now breaks off into smaller groups.

Community Hospitals

Staff photo info board out of date

All staff have up to date name badges. A review has been undertaken of the staff information boards and irrelevant information has now been removed.


The baby clinic in Seisdon is very busy and overcrowded; a suggestion was made for an advance booking system.

Geographical working is being introduced which will contribute to improving staffing levels and reducing caseloads.

Specialised

Services

Better estimation of waiting times in sexual health - Cobridge.

A triage system is now in place which advises patients on approximate waiting times and explanations of clinic process.


District Nursing seems very rushed in Leek & Moorlands Integrated Local Care teams.

We have an ongoing recruitment process in place and are currently increasing staffing numbers to ensure the best delivery of care.


Continuity of care could be improved at Rugeley Integrated Local care teams

Nurses are attached to set GP practices to achieve continuity wherever possible. A separate night service is currently being set up in Cannock to assist in continuity of care for day and night services.


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South Community Team

Tamworth and Lichfield falls: Difficult to contact team, calls not answered at switchboard

Messages will now go directly through to the team email addresses. The Burton Telecare Manager has transferred one of their call centre operators to the community hospital’s in order to ensure calls are answered more promptly.


You would like specific time of calls from West and South west ILCT’s District Nursing.

Our District Nurses do prioritise insulin, deltaparin visits. We do inform our service users if they are having morning/afternoon visits.

Community Hospitals

More staff needed at the walk in centre.

Agency staff are being used to ensure that enough staff are on shift at the Walk in centre. A new band 6 and 7 Nurse has been successfully recruited.


Centres where Health Visiting services are delivered need a private room or corner to breastfeed and positive promotion and signs to ensure a breastfeeding friendly environment.

Onsite facilities are being reviewed for breastfeeding and signage on trust sites.


IPOPS in Seisdon should have longer opening times to include earlier or later appointments

Appointments are offered to new service users from 9am. Follow up appointments start from 7:50am and the latest appointment is 4:40pm.


Telephone system problems – Stafford CIS

The service is currently working with IT to reconfigure the telephone systems to allow service users and carers greater access to the team.


On the internet opening hours are incorrect – Sexual Health Clinic

Correct opening times for all sexual health clinics are available on our Trust website

Community Hospitals

When walking into the department I am unsure what to do as there is a reception area but no reception staff – Leek Minor Injuries Unit

We are in the process of recruiting meet and greet volunteers who will assist MIU patients to follow the correct booking in procedure.


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Complaints and PALSThe Trust works in partnership with Staffordshire County Council as part of a legal contractual agreement to manage the statutory complaints process for Adult Social Care services. Our Operational Teams review learning and develop actions of improvement for every complaint we receive.

In 2015/16, we have received 343 complaints for our health and adult social care teams. All complaints were acknowledged within three working days in line with the Health and Social Care Complaint regulations. We also received 1535 PALS contacts through its service, 905 of which were related to our services.

Division Complaints Top 3 Complaint Themes PALS contacts

Top 3 PALS Themes


151 Access to services

Appointments

Patient Care

219 Clinical Treatment

Patient Care

Appointments



Appointments

Communications


Values & Behaviour

Patient Care


40 Values/Behaviour

Clinical Treatment

Appointments


Appointments

Clinical Treatment

Children and Young Peoples Services

14 Values/Behaviour

Communication

Clinical Treatment

30 Communication

Access to services

Appointments

Community Hospitals

65 Appointments

Communication

Admission/Discharge


Patient Care

Admission/Discharge

Actions and lessons learnt from complaints and PALs in 2015/16: Change in process within operational teams. The actions have included; full

implementation of a new system within a department, fragmented change within a current process, introduction of template letters for service users to ensure all appropriate


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information is provided to patients, the review and development of new pathways, guidance for staff and introduction of a message book within a department

Communication. The actions have included: improved communication, appropriate sharing of information between departments and other organisations, ensuring clear communication with patients and their relatives/carers

Correct policy and procedure. The actions have included: improving links between internal and external departments relating to the handover of patient care, staff being reminded of the importance of completing incident reports in line with Trust policy, cross checking patient information from one database to another to check for any inaccuracies

Staff to attend appropriate training. Training needs were identified for staff in relation to record keeping, competencies, Customer Service Excellence, communication and information governance.

Record keeping. This is to include documenting unsuccessful communications as well as successful and recording ward rounds, appointment cancellations or changes and future care plans.

Parliamentary and Health Service Ombudsman (PHSO) and Local Government Ombudsman (LGO) reviewsIn 2015/16 4 complaints were referred to the PHSO and 8 to the LGO for review.

During the year we received the final outcome of 13 referrals that are now closed, which include complaints referred in previous years. Of these,

8 were upheld (4 Health and 4 Adult Social Care) 5 were not upheld (3 Health and 2 Adult Social Care).

Of the complaints which were not upheld by either the PHSO or LGO it was identified that we had either acted in line with appropriate guidance, had offered apologies within the complaint response and identified appropriate actions for improvement from the initial investigation.

The eight cases upheld by the Ombudsman identified:-

Insufficient information or support provided Assessments not completed as recommended No clarity on finance arrangements Poor communication Staff did not follow appropriate procedures

Learning and improvements are incorporated within team, area and divisional action plans and monitored monthly.

ComplimentsDuring 2015/2016, the Trust received 1,581 compliments for our health and Adult Social Care Teams. An additional 16,810 positive comments were received from our service user and carer experience surveys.


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Service compliments from experience surveys:

[Scatter the list below through the document using speech bubbles, colour coded]

Stoke Family Nurse Partnership is a wonderful service- Keep it up! Children’s Specialised Services Stoke provides an excellent service and it has greatly

improved our family life. All staff are extremely kind, caring and considerate at all times. They go above and beyond on many occasions

Children’s Specialised Services Lichfield staff are professional and caring. I cannot praise and thank the staff enough for the support they have provided

Moorlands Physiotherapist made me feel very relaxed and comfortable; I didn’t feel under pressure to complete exercises. Very pleasant physio.

I am very happy with the support and service I am getting from Moorlands LIS. Staff have listened to my needs and been very supportive

The District Nurses from Rural ILCT are all very polite and helpful and they will go out of their way to do all they can for me.

Whenever I have contacted Newcastle Community Rehab they have always dealt with my problem promptly.

The team at Milehouse and Lyme Valley ILCT are great. They support me and are always there when we need them, professional, caring, responsive!

The physiotherapist from Newcastle was very thorough and listened to me; they also recommended exercises which I am doing at home.

The Stoke Cancer and Supportive Therapies are the best team in the world. Please don’t ever take this service away!

District Nurses from ILCT Stafford provide a very caring personal service and no matter how much care and support we need, they are there day and night. We cannot speak highly enough, Thank You.

The LIS team from Stafford listened to me. All the girls were very friendly and nothing was too much trouble. I would recommend this service to anyone.

A really good service from the LIS team in Seisdon with lovely staff. I thank you for helping me to regain my independence

We go home from visiting very happy and comfortable knowing our loved one is being well cared for and looked after by all the nursing staff on ward 2 at Cheadle. Thank you

I would like to thank the Dementia carers at Leek for making me very welcome on every visit, with their smiles, reassurances and never making me feel "In the way". Whatever I asked for was seen to immediately. I felt that my contribution and opinion mattered.

Staff on the Scotia Ward at the Haywood Hospital are lovely and provided excellent care and attention. I couldn't be more satisfied, won’t want to go home after being looked after so well. Nothing was too much trouble.

The Dental Team from North Tunstall were fantastic from the moment I walked in to the time I left. Keeping me informed throughout.

The specialist nurse (and then doctor) who saw me at Sexual Health in Leicester- Loughborough were absolutely brilliant and gave me amazing service. I can't thank them enough.

St Peters Sexual health Team are lovely, helpful, caring and considerate. They provide a great service.


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Patient Led Assessments of the Care Environment (PLACE)

The PLACE assessment programme focusses on the areas that patients say matter. These assessments help us to improve our services in partnership with patients.

Our overall 2015 assessment results were higher than the national average in all areas. Our assessment for “food” has decreased across our hospital sites compared to our 2014 assessment of 92.53%. As a result, we have developed a Nutrition Policy and reviewed the number of food options available at mealtime.

Hospital Site Cleanliness Food Privacy, Dignity and Wellbeing

Condition, Appearance and

MaintenanceDementia

Organisational Pecentage 99.53% 88.89% 91.90% 95.71% 80.97%

National Average Percentage 97.57% 88.49% 86.03% 90.11% 74.51%

Bradwell Hospital 100% 83.64% 87.30% 98.36% 78.02%

Cheadle Hospital 100% 87.63% 98.55% 96.69% 80.29%

Haywood Hospital 98.99% 92.85% 90.08% 92.86% 80.97%

Leek Moorlands Hospital

99.66% 85.91% 92.84% 97.90% 87.23%

Longton Cottage Hospital

100% 88.03% 96.92% 98.36% 80.76%

Patient Led Assessments of the Care Environment Results 2015.

PLACE: a patient summary statement

"An old building, of which parts have recently been refurbished, has a high standard of cleanliness and provides greater privacy than some of the modern buildings. The staff appear to have high morale and this reflects in the care given to the patients."


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National Institute for Health & Care Excellence (NICE) and National GuidanceWe are committed to implementing all relevant NICE Guidance to ensure we provide evidence based health and social care, improving outcomes for people using our services.

We aim to review all newly published guidance for relevance to our services within one month, and a full compliance assessment within six months (within three months for Technology Appraisal Guidance). We reviewed all guidance issued by NICE during 2015/16 for relevance to services provided by the organisation. We identified 59 pieces of guidance as relevant to the organisation.

We reviewed our NICE Guidance Implementation policy, and developed our electronic reporting system for monitoring compliance against NICE guidance.

Below are examples of how NICE guidance has improved practice:

NG9 Bronchiolitis in Children: We developed written information to give to parents/carers following contact with our Children’s services. Written and verbal key safety information on warning signs to look for in the child’s condition is provided to parents/carers to support them when caring for children at home.

NG31 Care of dying adults in last days of life: The Last Days of Life care plan was reviewed against the recommendations and immediate improvements made. The care plan will ensure the person’s physiological, psychological, social and spiritual needs are met by the continual assessment and review any changes of their condition.

NG15 Antimicrobial Stewardship: We completed a baseline assessment to ensure appropriate practice is in place in all relevant services. We implemented an antimicrobial steering group and updated our Medicines Management Policy to ensure safe and appropriate use of antimicrobials.

Medicines Management Prescribing of medicines is the most common therapeutic intervention in the NHS. Our Medicines Management team works to ensure that patients receive the medicines they need to effectively manage their condition and that medicines are procured, stored, used and disposed of safely across the Trust.

A Trust Medicines Management Group, with representation from all relevant professions and service areas, reviews guidelines, governance processes and policies to ensure our service users gain optimal benefit from medicines. We collaborate with other Health Providers and Commissioners across the local health economy through Area prescribing Committees, Formulary Groups and other local networks to ensure our service users access medicines in line with national and local strategies

We have a strategy to improve Medicines Optimisation for patients. The Medicines Management team, led by the Clinical Director of Pharmacy Services, are leading on the delivery of the four key principles of medicines optimisation, as outlined in our Medicines Optimisation Strategy:

Understanding the patient experience of medicines Evidence based choice of medicines Making medicines optimisation part of routine practice Ensuring medicines are used as safely as possible


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Pharmacy services in community hospital are prioritising the development of the clinical role of our pharmacist and Medicines Management Technicians. Across the Trust we also support non-medical prescribers ensuring The Nursing and Midwifery Council, NMC Standards and Health and Care Professions Council, HCPC Standards of prescribing are maintained.

We improved our scoring against the Trust Development Authority Medicines Optimisation and Pharmaceutical Services Framework significantly over the last year. A Medicines Safety Officer has been appointed and over the last year the Trust has collated and submitted data to National Medicines Safety Thermometer, taking note of associated learning.

In 2016/17 our work will include bringing Medicines Safety Issues to the fore and further developing the above and new initiatives to optimise the use of medicines.

Mortality ReviewsWe have made improvements to our mortality review process in 2015/16. Our Mortality review group reviews the care that our services have provided in the time immediately preceding a patient’s death. At each meeting the group reviews deaths to assess whether we can improve the quality of our care. Our Mortality Review Group (MRG) meets monthly and is currently chaired by the Medical Director. We also report information from our mortality reviews to our commissioners.

We changed our categorisation from 1 February 2016, in harmony with the one of the robust classification bandings recommended by NHS England – the Confidential Enquiry into Stillbirths in Infancy – as this aligned well with our processes for reviewing mortality.

During 2015/16 we had 4,154 discharges from our community hospitals, and 355 of these were deaths. The three biggest causes of death in our Trust are cancer, pneumonia, and end-stage heart failure. 86% (305 out of 355) of deaths in our community hospitals were for patients receiving palliative care.

Our Mortality Review Group reviewed 93% (329/355) of the deaths in our community hospitals, along with any reported unexpected deaths in our community services.


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Table: Classification (Grading) of community hospitals deaths reviewed by the Mortality Review Group April 2015 – March 2016

Classification of death (April 2015 – January 2016) Number of Cases

C1 = LIKELY with appropriate management undertaken 232

C2 = Likely appropriate management was NOT undertaken 0

C3 = UNLIKELY with appropriate management 30

C4 = UNLIKELY appropriate management was NOT undertaken 2

Death unclassified at point of review 7

Review not yet completed 26

Classification of death (February and March 2016) Number of Cases

G0 = Unavoidable Death, No Suboptimal Care 58

G1 = Unavoidable Death, Suboptimal care, but different management would not have made a difference to the outcome

0

G2 = Suboptimal care, but different care MIGHT have affected the outcome (possibly avoidable death)

0

G3 = Suboptimal care, different care WOULD RESONABLY BE EXPECTED to have affected the outcome (probable avoidable death)

0

Good practice noted as part of mortality reviews included:

Family said 'the care provided to patient and support to family as extraordinary and everybody been excellent' family further mentioned that they noticed excellent team work & communication among the team.

In one case where patient passed away within 6 hours of transfer to our services, our meet and greet provided an effective communication with family from the start. The family highly appreciated the communication and giving them a true picture of patient’s condition.

One case involved a patient with palliative/end of life care needs. There had been several meetings with the family during admission, and family highly appreciated the care and support provided.

Effective use of step up bed. Complex arrangements to ensure patient could be admitted safely and to ensure appropriate medical governance was in place


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In two cases we found that mortality was unlikely, and appropriate management was not undertaken we investigated further and made improvements, including changing the way Out of Hours services responded. We referred both these cases to HM Coroner, and are awaiting his response. Other shared learning as part of mortality reviews included:

Ensuring that documentation is more comprehensive. Enhancement of communication with community teams Teaching sessions and training in relation to palliative & end-of-life care Ensuring that Venous Thromboembolism risk assessments are reviewed during

admission

We have also developed a nurse-led “deteriorating patient protocol, which identifies patients in need of a senior review, as part of our implementation of the Academy of Medical Royal Colleges for daily senior review.

During 2016/17 we will continue to review mortality, reviewing our mortality data themes and trends in addition to individual deaths.

Acting on Lessons Learned – Mortality Review

Ensure it is established whether a service user has a DNACPR in place and, if they do, that all staff are aware of this how to access it.

Paramedics should not be contacted via 999 if a service user is found dead and a DNACPR is in place. Death should be certified by the GP.

If Paramedics are contacted for a service user who appears to have died (where NO DNACPR is in place), basic life support/resuscitation should be commenced immediately whilst awaiting the arrival of Emergency Services

If a service user appears unwell but is refusing contact with a GP, it is suggested that replace with: community services seek advice from their direct manager, Clinical colleagues (via the HUB or DN service) immediately. It may be necessary to inform the GP of their concerns, ensuring that the GP is aware that they are being contacted without the consent of the service user but this decision will be made based on assessment of capacity to make that decision.

The completion of an MRG trigger tool should take place alongside the death certificate, and should utilise access to all relevant information including the clinical record.


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Assuring the Quality of our ServicesQuality Visits Our Quality Visit programme across all of our health and social care teams is used to assess the consistency and safety of our services against local, operational and regulatory standards.

The aim of the Visits is to continuously improve quality by sharing good practice and identifying areas of improvement.

The visit teams use, organisational performance data, staff interviews, observation in areas and patient conversations. Visit teams include clinicians and/or professional experts as part of a peer review which facilitates shared best practice and personal development.

In 2015/16 we conducted 27 Quality Visits.

Good practice and learning identifiedIn every Quality Visit, aspects of good practice and learning are shared across the Trust. Examples include:

Positive and professional attitude of staff throughout the organisation Commitment to learning and making improvements High levels of incident reporting and 'being open' Good awareness of Safeguarding requirements Improvements in some community facilities and premises Patient safety seen as a priority in all areas Evidence of good infection control practice

Development areasThemes that have been identified and addressed include:

Patient records – ensuring proper storage and protection of confidential data. Staffing numbers and the recruitment of new staff. Clinical Stores – improving monitoring and stock control. The development of business continuity plans and contingency planning The detailing of mental capacity and cognitive understanding on assessment records

All teams that receive a Quality Visit agreed an action plan to address the issues found in their area.

The resulting action plan to address the issues found within each area is shared and monitored within neighbourhood and area teams. These are then reviewed and overseen by the Divisional Business Meetings.


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Quality Impact Assessment of Cost Improvement ProgrammeWe assess the impact on service quality of our plans to deliver cost improvements. We call this a Quality Impact Assessment. Our Director of Nursing and Quality and Medical Director lead these assessments, and report the outcomes to our Trust Board.

Our 2015/16 Cost Improvement Programme target was originally £13.700m, however a subsequent review led to an agreement with the Trust Development Authority that the target should be revised to £9.900m.

Whilst 60 ideas were originally considered, with a value of £6.820m, some were not appropriate to proceed, and some delivered at lower values than their original suggestion. Throughout the year 170 schemes were considered, with 121 delivering financial savings totalling £9.142m.

Of the 170 schemes, 84 were approved by the QIA Panel and 3 were rejected. The QIA Panel only fully review schemes which potentially impact on quality, whilst financial schemes with no quality impact (e.g. price reductions) are reported to the panel but not routinely assessed. There were 65 schemes which did not require a full QIA review. The remaining 27 did not proceed and hence were not assessed on the grounds of quality.


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Supporting our Staff Staff SurveyTable: Staff Survey Response Rates

2014 2015

The Trust

National Average

The Trust

National Average

Improvement/ Deterioration

Response Rate

35% 42% 42.5% National Average: 41%

Community Trusts Picker average 47.3%

7.5% improvement

Each year NHS organisations invite staff to complete an annual staff survey. We used this to identify key areas for improvement based on the 2014 results

The organisation achieved a 7.5% increase in the 2015 response rate from the previous year.

Our 2015 response rate compares at 1.5% above the national average and 4.8% below the Picker average for Community Trusts.

Key Areas for improvement

What have we done?

Staff Involvement & Engagement

The Chief Executive regularly sends Thank you cards and personal letters to staff who have been nominated by others for truly ‘Living the Values’

The development of methods of celebrating success within teams such as ‘Moments of Brilliance’ boards with recognition through The Word, Twitter & Yammer

Ensuring Effective Communications

Use of screensavers to share key corporate messages

“1 Vision” is a quarterly event held in the North and the South where the Chief Executive and Executive Directors attend and are able to listen to staff, answer questions and share current news. This now includes presentations and success stories from front line staff as a way of recognising and sharing excellent practice

Reducing Work Related Stress

Extra Stress and Resilience training for all managers

We continued our Leadership Development Programme that focuses on Compassionate and Appreciative leadership. Over 800 staff have attended the


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Key Areas for improvement

What have we done?

‘Leadership Gateway’ which has been extremely well evaluated

Developing the Role of Team Leader

We supported our ILCT Team Leaders with a bespoke development programme

Team leaders are able to access an innovative Buddy Scheme for support with team development plans

Coaching and mentoring has been made available to support team leaders

Leadership Master classes are designed to help the Team Leaders and other leaders in their roles

These activities have been overseen by a new Organisational Health Group that has members from different directorates and teams i.e. Organisational Development, Workforce, Communications, Service Improvement, Professional Leadership, Operations, Service User & Carer experience.

The 2015 National Staff Survey was launched in September 2015 and staff were provided with half an hour of work time to complete the survey. The results have demonstrated that we have performed:

Significantly better on 20 questions Significantly worse on 3 questions The scores show no significant difference on 37 questions

Top Scores Improved 2014 2015 + -

No appraisal/ KSF review in the last 12 months 22% 11% 11%

Not enough staff in organisation to do my job properly 53% 46% 7%

Do not receive regular updates on patient/service user feedback in my directorate/department

22% 15% 7%

Never/rarely look forward to going to work 16% 10% 6%

Dissatisfied with my level of pay 34% 28% 6%

Last experience of physical violence not reported 25% 20% 5%


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Top scores declined 2014 2015 + -

Last experience of harassment/bullying/abuse not reported 42% 52% 10%

Appraisal/performance review: training, learning or development needs not identified

27% 33% 6%

Felt pressure from manager to come to work despite not feeling well enough.

20% 23% 3%

Staff Engagement scoresThese are calculated using 9 questions form the National Staff Survey .This has shown an increase from 2014 which is a positive reflection on the actions to improve staff involvement and engagement. The highest possible score is 5.0.

Staff Survey 2014 Staff Survey 2015

3.70 3.79

What are we doing for 2016-17?It is recognised that there are area for improvement across the whole organisation as well as specific needs relevant to only some teams.

The overall Staff survey results were initially shared with the Executive Management Team.

Divisional and local reports were then created and discussed with the relevant managers ‘Clinics’ are being held in each division so that managers can scrutinise the results

specific to their teams and develop action plans A strategic Task Group has been set up with senior representatives from each division

and corporate directorates as well as staff side representatives. The strategic group will report to Workforce Matters Sub-Committee and also discuss

actions with other relevant groups i.e. Organisational Health and Staff Health and Well-Being

The Trust-wide Action Plan will therefore be populated after the first meeting of this task group in May 2916. However actions have already commenced such as ensuring all staff are able to complete and gain approval for their Personal Development Plan within their Appraisal. This will be completed between April and the end of June 2016.

Developing our Social Care workforceOur Occupational therapists are promoting a ‘single handed care’ approach. This means that we work with service users to see if equipment can increase their independence and reduce the need for multiple carers. By safely reducing the number of carers we promote health and wellbeing, and preserve the dignity of our service users.

We are developing practice guidance and an Adult Social Care Practice Quality Assurance Framework.


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In order to ensure that Social Work and Social Care Staff are kept informed about best practice and as part of developing a research culture we are continuing to provide access to Social Work journals via the Trusts library service and an online resource Care Knowledge

With are furthering and embedding our links with local Higher Education Institutions being part of a national Social Work Teaching Partnership pilot with Keele University

Professional LeadsThe Professional Leadership Team are all registered practitioners (nurses, allied health professionals or social workers) and they ensure professional leadership is in place for all frontline staff and other parts of our Partnership Trust. Professional Leads promote, influence and support:

Provision of expert clinical and professional advice to staff, colleagues and executives. Developing policy and maintenance of professional standards, such as record keeping Developing competency frameworks to support the delivery of safe, effective care Supporting managers, staff and teams in the development of new services and quality

improvements.

Some of the key achievements of the Professional Leadership team during 2015/16 are: 6C’s Challenge Award: We award teams when they demonstrate how their care aligns

to the 6C’s and our values. For example, we commended the Broadfield Ward at Haywood Hospital for their compassionate tailored approach to rehabilitation. One patient who was cared for on the ward said “The doctors who treated me initially saved my life, but the team on Broadfield Ward gave me the chance to live it.” During 2015/16 we gave the 6C’s award to 18 teams.

On the Record Campaign: The Professional Leadership team have led the ‘On the Record Campaign’ to raise record keeping practice through leadership, collaborative working, governance, training and rapid cycle audit. Improvements in practice have been made. We clarified our guidance to ensure that carbon-copies of care records are legible following an incident and a quality visit. In 2016/17 we will focus on ensuring our records reflect a personalised approach to care planning, in line with our quality improvement priorities. We will also continue with our regular record keeping audit programme.

Supporting staff to maintain their Professional Registration: We have provided Nursing and Midwifery Council (NMC) Revalidation Awareness raising workshops and regular updates to our nursing and midwifery staff so as to support preparation for the changes in standards. We also ensured that our staff have guidance on standards of conduct, performance and ethics that the public expect from health professionals.


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Awards 2015/16Some examples of our award successes this year include:

Our multidisciplinary Rheumatology team were recognised by the British Society of Rheumatology in their 2016 Best Practice Awards in Rheumatology and Musculoskeletal Health. The team were awarded an ‘Outstanding Best Practice’ award for their evidence based care project work with partners. Their work aims to ensure the highest quality clinical care for patients with musculoskeletal problems.

We won international recognition from UNICEF Baby Friendly Award in April 2015. The Trust was recognised for its promotion and support of breastfeeding, joining forces with UNICEF UK’s Baby Friendly Initiative to increase breastfeeding rates and improve care for all mothers within Staffordshire and Stoke-on-Trent.

Speech and language therapist, Janet Cooper won a prestigious national ‘Giving Voice’ award by the Royal College of Speech and Language for her outstanding work and commitment to the speech and language therapy profession. Janet was recognised for her work with local stakeholders on the Stoke Speaks Out initiative, designed for children in Stoke-on-Trent who have communications difficulties.

Staffordshire buddies charity awarded South Staffordshire Sexual Health Service and HMYOI Swinfen Hall health care team with gold awards for their commitment to outstanding quality of health care to gay, lesbian and bisexual people who use the services either in the community or in the prison setting.

Community nurse, Hannah Beech was awarded Mentor of the Year at the 2015 Keele University School of Nursing and Midwifery awards for her role in mentoring student nurses through their placements with the Partnership Trust.

In recognition of their joined up working with Staffordshire Fire and Rescue Service, Partnership Trust visual impairment rehabilitation officers were awarded the NHS Collaboration Award at the 2015 Health Business Awards. The collaborative working involves the rehabilitation team providing practical and interactive training to firefighters in Staffordshire to help raise awareness of the difficulties people living with visual impairments experience on a daily basis.

Quality Case Studies[To be interspersed through the document]

Celebrating sexual health servicesWorld Aids Day is marked every December and last month saw Leicester sexual health team up with Leicester City Council, local MPs and local voluntary sector organisations LASS and Trade to sign the ‘Halve It pledge’ – a national pledge committing Leicester, Leicestershire and Rutland to halve late HIV diagnoses by 2020.

The month before was national HIV testing week and the Trust’s sexual health teams offered free and confidential HIV testing in a variety of locations to residents of Stoke-on-Trent and North


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Staffordshire. An art exhibition titled ‘HIV Unfolded’ was held at AirSpace Gallery in Hanley, with artists and local people sharing a snapshot of HIV from their perspective.

Profiling pressure ulcersStaff form the tissue viability team helped spread key prevention messages to patients and members of the public at Haywood Hospital as part of World Pressure Ulcer Day on 19 November. We have since launched our pressure ulcer campaign, ‘React to Red’. The Trust’s tissue viability team offered advice and information about how to prevent pressure ulcers in their early stages at a series of drop-in sessions at Haywood Hospital on Thursday 17 December. Tissue viability specialists also went e on to wards to discuss with staff, patients and their carers and families, the signs and actions to be taken if you ‘React to Red’.

Investing in our nursesWe have always valued specialist practice and in recent years have encouraged community nursing staff to take the Specialist Practitioner Qualification (SPQ) course to enhance their skills. A recent study by the Queen’s Nursing Institute highlights the value of the SPQ. The work, funded by the Department of Health, identifies key themes including direct benefits to patient care, personal and professional development, the benefit to employing organisations, and cost savings. We have supported 14 community nurses to completing the course so far and all are now in District Nursing Sister positions. These practitioners hold the NMC recordable qualification of a ‘specialist practitioner’ which supports them in exercising higher levels of judgement, specialist knowledge and decision making in clinical practice.

Their training could not have been achieved without the support and dedication of their Community Practice Educators and Community Practice Teachers who facilitate the learning in practice throughout the 12 month programme.

First Trust in Staffordshire to sign Deaf CharterOn 12th February, we signed up to a Deaf Charter; derived from the British Deaf Association’s British Sign Language Charter it sets out five pledges to improve the access and rights of local deaf, hard of hearing and deaf blind people. The pledges highlight the Trust’s commitment to personal, fair and diverse services when providing health and social care services and employment.

The five pledges are:

ensure access for Deaf and Hard of Hearing people to information and services promote learning and high quality teaching of British Sign Language and other methods of

communication used by Deaf and Hard of Hearing people support Deaf and Hard of Hearing children and families ensure staff working with Deaf and Hard of Hearing people can communicate effectively

in British Sign Language and other methods of communication Consult with our local Deaf and Hard of Hearing communities on a regular basis.

Supporting people with DementiaStaff from the Partnership Trust, along with members of the public, have knitted over 120 ‘twiddle mitts’ for patients with Dementia at the Haywood Hospital.

The mitts are knitted cuffs with added accessories and textures which people with Dementia can hold and ‘twiddle’ to provide stimulation and help combat any restlessness and agitation they may experience during a visit to hospital.


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Nutrition and Hydration WeekAs part of Nutrition and Hydration Week 2016 the Partnership Trust held many events to raise awareness of the Trust’s nutrition policy and the importance of eating and drinking well. Staff from across the Trust held tea parties, presented nutrition and hydration stands in our community hospitals, hosted quizzes and webinars, and encouraged service users to learn more about good nutrition and hydration.

Experience surveys updated based on feedbackIt is important that all those who access the services provided by the Trust have the opportunity to provide feedback on their experience and tell us what is working well and what can be improved.

Ahead of the new reporting year, the service user and carer experience team have reviewed the Trust’s experience surveys, taking into account comments and feedback from staff and service users.


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Statements from our PartnersFormal comment and consultationDuring May 2016 we circulated a draft of this quality account for formal comment to:

Healthwatch Stoke-on-Trent Healthwatch Staffordshire Stoke Overview and Scrutiny Committee Staffordshire Health Scrutiny Committee North Staffordshire Clinical Commissioning Group Stafford and Surrounds Clinical Commissioning Group East Staffordshire Clinical Commissioning Group South East Staffordshire and Seisdon Peninsular Clinical Commissioning Group Stoke-on-Trent Clinical Commissioning Group Cannock Chase Clinical Commissioning Group Leicester Clinical Commissioning Groups Telford and Shropshire Clinical Commissioning Groups NHS England (Shropshire and Staffordshire Area Team; Leicestershire and Lincolnshire

Area Team)

In addition, we placed a copy of the draft Quality Account on our Internet site, and asked our staff, service user groups, and other partner organisations to comment on the draft.

As directed by regulation and national guidance, this section contains the formal responses we received from our local Healthwatch, Overview and Scrutiny Committees, and Clinical Commissioning Groups.

We also thank the staff, service users and partner agencies who responded to our consultation.


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Healthwatch Stoke-on-Trent

Healthwatch Quality Account Statement SSOTP 2015/16

Healthwatch Staffordshire

Staffordshire Health Scrutiny

Stoke City Councils Adult and Neighbourhoods Overview and Scrutiny Committee

North Staffordshire CCG and Stoke on Trent CCG

Stafford and Surrounds CCG, Cannock Chase CCG, East Staffordshire CCG and South East Staffs and Seisdon CCG


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Statement of Directors’ Responsibilities in respect of the Quality AccountThe Directors are required under the Health Act 2009, National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year.

The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements).

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

the Quality Account presents a balanced picture of the Trust’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, conform to specified data quality standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Account has been prepared in accordance with Department of Health guidance.

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

By order of the Board

[SIGNATURES of Board members will be inserted in final version]


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Glossary6C’s The 6C’s focus on putting the person being cared for at the heart of the care they are given the 6C’s are Care, Compassion, Competence, Communication, Courage and Commitment.

Board The role of the Board is to take corporate responsibility for the organisation’s strategies and actions. The chair and non-executive directors are lay people drawn from the local community and are accountable to the Secretary of State. The Chief Executive is responsible for ensuring that the board is empowered to govern the organisation and to deliver its objectives.

Care Quality Commission The CQC is the independent regulator of Health and Social Care in England. It regulates health and adult Social Care services, whether provided by the NHS, local authorities, private companies or voluntary organisations to make sure that the care that people receive meets essential standards of quality and safety. www.cqc.org.uk

Commissioners / Clinical Commissioning GroupsCommissioners are responsible for ensuring adequate services are available for their local population by assessing needs and purchasing services. They commission services (including acute care, primary care and mental healthcare) for the whole of their population, with a view to improving their population’s health.

Clinical commissioning groups (CCGs) are NHS organisations set up by the Health and Social Care Act 2012 to organise the delivery of NHS services in England.

Commissioning for Quality and Innovation (CQUIN) A proportion of the Partnership Trust’s income is conditional on quality and innovation, through the Commissioning for Quality and Innovation (CQUIN) payment framework. This proportion is normally 2.5% of healthcare services commissioned through the standard NHS contract. The goals are agreed between the Trust its NHS commissioners through the Commissioning for Quality and Innovation (CQUIN) payment framework.

Direct PaymentsThe Direct Payments scheme is a UK Government initiative in the field of Social Services that gives users money directly to pay for their own care, rather than the traditional route of a Local Government Authority providing care for them.

“Discharge to assess” processThis is a new discharge process, where patients leave hospital as soon as they are medically fit. Their support needs are then assessed at home, rather than in hospital.

http://en.wikipedia.org/wiki/National_Health_Service_(England)

http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012

http://en.wikipedia.org/wiki/Health_and_Social_Care_Act_2012

http://en.wikipedia.org/wiki/Local_Government

http://en.wikipedia.org/wiki/Local_Government

http://en.wikipedia.org/wiki/Social_Services

http://en.wikipedia.org/wiki/Her_Majesty's_Government

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


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A home-based assessment can be more insightful than ward-based assessments, provide a better experience of care, and help to avoid costly extended hospital stays.

EQ-5DThe EQ-5D™ is an international standardised evidence-based instrument for use as a measure of health outcome.

Applicable to a wide range of health conditions and treatments, the EQ-5D health questionnaire provides a simple descriptive profile and a single index value for health status

See www.euroqol.org for further information.

Healthcare Healthcare includes all forms of healthcare provided for individuals, whether relating to physical or mental health, and includes procedures that are similar to forms of medical or surgical care but are not provided in connection with a medical condition, for example cosmetic surgery.

Information GovernanceInformation Governance provides a framework which determines how we process and handle information and particularly how we protect our service user’s personal and sensitive information.

The national Information Governance Toolkit aims to improve data security across the NHS and demonstrates that organisational have systems and polices in place for information governance.

Integrated Local Care Teams (ILCTs)Health and social care teams merged and working together to improve outcomes for people using services

Local Health Economy (LHE)This describes all local health and social care providers across a specific geography and looks at the geography of people using the services and variations in health outcomes.

MRSAMethicillin-Resistant Staphylococcus aureus, a bacterium with antibiotic resistance.

A bacteraemia is identified from a blood sample. The sample identifies that a bacteria is present in the blood in this case the sample was MRSA bacteria

MSSAMethicillin-Sensitive Staphylococcus aureus, a bacterium which is sensitive to Methicillin.

Staphylococcus aureus is a bacterium that commonly colonises human skin and mucosa (e.g. inside the nose) without causing any problems. It can also cause disease, particularly if there is an opportunity for the bacteria to enter the body, for example through broken skin or a medical procedure.

http://www.euroqol.org/


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National Institute for Health and Care Excellence (NICE)The National Institute for Health and Care Excellence (NICE) recommends best practice guidelines to healthcare providers in the NHS. The guidelines make recommendations on medical treatments, including drug treatments, in order to reduce the variation in the availability and quality of treatment. www.nice.org.uk

National Safety Campaign – “sign up to safety”The national safety campaign - ‘Sign up to Safety’, was launched in March 2014. Every hospital Trust that chooses to join will commit to a new ambition: to reduce avoidable harm by a half, reduce the costs of harm by one half, and in doing so contribute to saving up to 6,000 lives nationally over the next three years.

Never EventA “Never Event” is a serious occurrence that should never happen and can be prevented. They are considered unacceptable and eminently preventable. Examples include:

A surgical procedure carried out on the wrong site (e.g. wrong knee, wrong eye, wrong patient, wrong limb, wrong organ)

Death or severe harm as a result of maladministration of insulin by a health professional. Death or severe harm as a result of a patient falling from an unrestricted window.

A list of Never Events for 2015/16 can be found on the Department of Health website:

https://www.england.nhs.uk/wp-content/uploads/2015/03/never-evnts-list-15-16.pdf

Overview and Scrutiny Committees Since January 2003, every local authority with responsibilities for adult Social Care (150 in all) has had the power to scrutinise local health services. Overview and scrutiny committees take on the role of scrutiny of the NHS – not just major changes but the on-going operation and planning of services. They bring democratic accountability into healthcare decisions and make the NHS more publicly accountable and responsive to local communities.

Patient Advice and Liaison Services (PALS)Patient Advice and Liaison Services have been introduced in England from 2002 to ensure that the NHS listens to patients, their relatives, carers and friends, and answers their questions and resolves their concerns as quickly as possible.

Patient Safety IncidentA patient safety incident is an event, or something which happens which has an effect on a patient’s safety. This happening may or may not be linked to other events. Staffordshire and Stoke on Trent Partnership NHS monitor such incidents to learn from them and prevent them happening again.

PersonalisationPersonalisation is a Social Care approach described by the Department of Health as meaning that “every person who receives support, whether provided by statutory services or funded by themselves, will have choice and control over the shape of that support in all care settings".

http://www.nice.org.uk/


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Practice AuditPractice audit (Clinical & Social Care Audit) is a quality improvement cycle that involves the measurement of the effectiveness of care against agreed and proven standards for quality, and then taking action to bring practice in line with standards so as to improve the quality of outcomes.

Pressure Ulcers / Pressure damagePressure Ulcers are also known as pressure sores or bed sores. They occur when the skin and underlying tissue become damaged. In very serious cases, the underlying muscle and bone can be damaged. www.nhs.uk/conditions/pressure-ulcers

Quality IndicatorsA quality indicator is an agreed-upon process or outcome measure that is used to determine the level of quality achieved.

Research Clinical research and clinical trials are an everyday part of the NHS. The people who do research are mostly the same doctors and other health professionals who treat people. A clinical trial is a particular type of research that tests one treatment against another. It may involve either patients or people in good health, or both.

Risk Management SystemsThese enable staff across the organisation to identify and report risks to the quality of care. The organisation is then better able to manage these risks, focusing on addressing those issues that are more likely to have a greater adverse impact on patient experience, safety and effectiveness. An example of a system would be the Ulysses incident reporting software that the organisation uses to monitor risks and incidents.

Root Cause AnalysisRoot Cause Analysis is a class of problem solving methods aimed at identifying the root causes of problems or events. It is a structured approach that aims to identify the factors that resulted in a harmful event, so that future behaviours, actions, inactions or conditions can be changed to prevent its re-occurrence.

Self-directed paymentsIf you are eligible for care and/or support from the local authority then you should be closely involved in constructing your care or support plan, based on what you think will best meet your eligible care needs.

Serious IncidentA “serious incident” requiring investigation is an incident that occurred in relation to services provided and care resulting in either, unexpected or avoidable death, serious or permanent physical or psychological harm, a scenario that prevents or threatens the organisations ability to provide healthcare services, allegations of abuse, adverse media coverage or public concern about the organisation, or, any of the Never Events on the national list. See www.npsa.org.uk

http://www.npsa.org.uk/

http://www.nhs.uk/conditions/pressure-ulcers


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Safety ThermometerThe NHS Safety Thermometer is a local improvement tool for measuring, monitoring and analysing patient harms and ‘harm free’ care. From July 2012 data collected using the NHS Safety Thermometer is part of the Commissioning for Quality and Innovation (CQUIN) payment programme. For more information on this national initiative see: http://www.ic.nhs.uk/services/nhs-safety-thermometer

SSKIN bundleThe SKIN bundle is an assessment and communication tool for pressure ulcer prevention covering the following: Surface, Skin inspection, Keep moving, Incontinence and Nutrition. See www.patientsafetyfirst.nhs.uk/

Tissue ViabilityTissue Viability is a specialist area of healthcare dealing with the treatment and the healing of almost any type of wound, focusing on wounds which are difficult to heal. Tissue Viability covers every aspect of wound care including advice on pain, diet, mobility, continence, life style choices, and the specialist equipment which may need to be used.

Venous thromboembolism (VTE)Venous thromboembolism (VTE) is a condition in which a blood clot (thrombus) forms in a vein. Blood flow through the affected vein can be limited by the clot, and may cause swelling and pain.

http://www.patientsafetyfirst.nhs.uk/

http://www.ic.nhs.uk/services/nhs-safety-thermometer


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