PUBLIC – NOT TO BE REMOVED UNTIL END OF BOARD MEETING

Report to the Meeting of the Oxford Health NHS Foundation Trust

Board of Directors

29th March 2018

Quality and Safety Report:

Quarterly Clinical Effectiveness Report

For: Information

1.0 Executive SummaryThis report provides a summary of the Trust’s position, primarily in Quarter 3-4 (October-January 2017-18) in relation to the Key Lines of Enquiry (KLOE) which are considered by the Trust’s Quality Sub-Committee - Effectiveness (QSCE).Governance Route/Approval ProcessThis report is a quarterly report providing a summary of escalation reports from the subcommittee’s subgroups shared at the Clinical effectiveness subcommittee held on the 11th January 2018. RecommendationThe Board is asked to note the report. Author and Title: Rebecca Kelly: Trust Professional Lead Occupational Therapist

and deputychair of the QSCEDr Mark Hancock: Lead Executive Director: Medical Director and chair of the QSCE

1. A risk assessment has been undertaken around the legal issues that this report presents and [there are no issues that need to be referred to the Trust Solicitors

BOD 36/2018(Agenda item: 8)

2. Strategic Objectives – this report relates to or provides assurance and evidence against the following Strategic Objective(s) of the Trust

1) Driving Quality Improvement(Goals: patients will be safe from harm; patients will achieve the clinical outcomes they want; and patients and carers will have an excellent experience)

2) Delivering Operational Excellence(Goals: our services will be effective and efficient; information will be translated into knowledge; and our planned surplus will be delivered)

3) Delivering Innovation, Learning and Teaching(Goals: the impact of the AHSN, AHSC and CLAHRC will be maximised; we will collaborate in research and innovation; and we will deliver high quality teaching)

1.0 Executive Summary

This report summarises the work of the subgroups that feed into the quality subcommittee effectiveness (QSCE) and highlights areas where we can demonstrate areas of innovation, good practice and assurance about prcatice and areas where we know we have ongoing work to improve our effectiveness.The key areas addressed in the report include:1.1 Clinical Audit1.2 Drugs and Therapeutics1.3 Learning and Development1.4 Mental health Act and Capacity1.5 Physical health (including for those with mental health

conditions)1.6 Psychological, Occupational and Social Therapies1.7 Public health1.8 Research1.9 Status of clinical policies and procedures

1.1 Clinical Audit Report (including NICE update)There was no formal report submitted to the QSCE on the 11 th January as the Clinical Audit Group (CAG) took place after this on the 29th

January 2018 however the following summarised a number of audits which were undertaken in 2017/18 and reported to the CAG in January 2018:

Do not attempt cardio pulmonary resuscitation (DNACPR) 2017/18. The overall audit rating has been calculated on the compulsory sections of the Trust’s lilac DNACPR form and the standards relating to the information documented in the health record relating to the DNACPR decision

The chance of survival following Cardiopulmonary Resuscitation (CPR) in adults is between 5-20% depending on the circumstances. Although CPR can be attempted on any person, there comes a time for some people when it is not in their best interests to do this. It may then be appropriate to consider making a Do Not Attempt CPR (DNACPR) decision to enable the person to die with dignity.

Under the Mental Capacity Act (2005), health and social care staff are expected to understand how the Act works in practice and the implications for each patient for whom a DNACPR decision has been made.

2015/16 (n=45)

2017/18

(n=91)Standard of recording on the lilac DNACPR form (n=91)Has the following patient information been recorded on the lilac form?Name 93%

(42/45)100%

(91/91)Address 93%

(42/45)99%

(90/91)Date of birth 100%

(45/45)99%

(90/91)NHS or hospital number 96%

(43/45)93%

(85/91)Date of the DNACPR decision been recorded 91%

(41/45)96%

(87/91)Institution name recorded (this is only applicable when version 5 & 6 of the DNACPR form has been used)

50% (21/42)

79% (60/76)

Following the audit a discussion was held at the Mortality and Morbidity meeting. Medical staff agreed that the need to review the DNA CPR forms for patients who are admitted to ensure that there is one in place which is correct and completed in full and that an entry is made in the patient’s record regarding the discussions with either the patient or family. This served as a reminder that medics are responsible for the quality of the DNA CPR forms of patients that are under their care and this reminder will be disseminated.

Essential Standards (December 2017) This audit evaluates the care provided in the adult inpatient mental health units against 41 standards of care 16 of which related to patient experience of care and 25 to the clinical care provided by staff. This a regular bi-monthly audit that has been taking place in the inpatient wards for over four years. Where issues are highlighted actions are taken at the time.

The results of the audit received an overall rating of ‘good’, when rated using the trust audit result rating matrix. A small number of standards were rated as requiring improvement. These included:

the clarity of documentation rating to how decisions about the patient’s capacity were made-although there has been some good improvement over the last three months.

Whether it has been documented that the patient’s capacity to be involved in care and decision making has been assessed/reviewed either at or since the last ward round.

The evidence of Family/Carer/Next of Kin involvement in care as appropriate

Whether the patient’s current medication regime is clearly documented in the progress note although there has been improvement in the last three months.

Whether a Nutritional needs assessment was completed (this excludes the Eating Disorder Unit) although there has been improvement in the last three months.

Whether the care plan identifies appropriate therapeutic activities related to patient need.

There were a number of areas of excellent practice (over 80%) including:

Care plans which address the needs of children Section 17 forms are being crossed through and uploaded onto

Carenotes Patients are being given a copy of their section 17 leave form The current level of risk is being highlighted for staff through the

patient status at a glance/safety board (PSAG). Up to date T2 or T3 (legal forms) filed with the medication cards Patients are being orientated to the ward and are aware of ward

routine including their rights and restrictions. Paper copies of the current Section 17 leave form (FS17 form)

are being kept in nursing office for ease of access. Where appropriate, there is a record that the patient’s rights

have been read in accordance with section 132 and understood. Patients are being screened for (Venous Thromboembolism) VTE

within 24 hours of admission. Patients are receiving a physical health assessment within 24

hours of admission.

Patients on older adult mental health wards have a "knowing me” form completed as part of the assessment process.

Staff always knock on patients’ bedroom doors prior to entering. Patients report that staff are courteous towards them. Patients report that they are involved in their discharge planning Wards are contacting the care coordinator for discharge planning Patients are being seen by the dietician on assessment (to

develop meal plan) (Eating Disorder Units only). Patients report being given a choice of food that meets their

specific needs. Date and level of general observations are being clearly

documented. There is evidence that the observation records are fully

completed by staff for the previous 24 hours. Patients on close observations are able to explain why these are

in place. There are some good examples of observation and engagement improvement work in adult inpatient wards in particular on Sapphire ward, Sapphire ward has not had any level 3 or 4 observations since February 2018. The improvement work has changed the way in which observations are viewed on the ward. Observations are now viewed by all as opportunities for engagement with the patient rather than being a task focused activity. Ruby ward data collecting is ready to go as the second ward to undertake this work. Ashurst PICU are also considering what issues there are on the ward with observations. They have set up fortnightly meetings and will be completing a process map, aim and driver diagram.

CPA report for all Directorate Q2 2017/18 The Care Programme Approach (CPA) audit is a quarterly audit undertaken by the three Directorates (Adults, Older Adults and Children and Young People) across the Trust.For the current audit the tool was significantly changed for the Children and Young People Directorate and so there are only four areas that could be compared with previous audits. These include:

Up-to-date risk assessment Elements of care planning Medication monitoring requirements Consent / Sharing of care plans

The overall combined results were Requires improvement and are given below:CPAMapped Audit Standards for Quarter 2 Q2

17/18

Risk Assessment

Has a risk assessment been completed within the last 6 months? 76% (256/336)

Have all the elements of risk been assessed at the last CPA review?

86% (220/257)

Does the risk summary address all of the risks identified? 92% (227/247)

Care PlanningIs there evidence that the care plan was reviewed at the last CPA review (last 6 months)?

79% (266/336)

Did the last CPA review include a review of the current mental health needs?

98% (262/266)

Did the last CPA review include a review of current medication? 94% (218/233)

Did the last CPA review include a review of the side effects of medication?

69% (134/193)

Is there evidence that the Social care needs (including finance and benefits) have been assessed?

85% (200/234)

Did the last CPA review include a review of physical health needs?

80% (196/244)

Does the care plan contain personalised goals which reflect the patient’s assessed needs?

96% (252/262)

Is there evidence the carer/family invited to the CPA review? 85% (194/229)

Is there evidence the care plan demonstrate the involvement of the carer/family where appropriate?

89% (211/237)

Is there evidence that the service user has been offered/given a copy of the care plan? (this may have been shared in a letter to the GP)

79% (199/251)

Is there evidence that the care plan has been shared with the GP? (this may have been shared in a letter to the GP)

76% (204/268)

Are the triggers and signs of relapse personalised to the service user?

89% (237/266)

Is the contingency plan/crisis plan personalised to the service user?

90% (222/246)

Medication monitoring requirementsIs the service user prescribed psychotropic medication 224 PatientsIf yes, does the care plan detail the medication prescribed? 95%

(212/224)

If yes does the care plan include the side effect monitoring needs relating to psychotropic medication?

69% (153/222

Consent / Sharing of care plansIf yes, has it been recorded if the service user has given consent to share information?

62% (156/251)

Overall audit ratingRequires

Improvement

The breakdown of the overall audit by directorate is given below:

Although it is clear further work needs to be done to ensure that CPA is being delivered to either a good or excellent standard there are no areas in which the Trust is being rated as unacceptable. Service and Clinical directors have developed action plans which will, be monitored through the Trust quarterly performance reporting mechanism..

National Confidential Inquiry into Suicide and Homicide was published in November 2017 and has a number of key messages for services including the need for:

a renewed emphasis on suicide prevention on in-patient wards, with the aim of re-establishing the previous rate of decrease in in-patient suicide.

building on the recent fall in suicide following discharge from in-patient care

awareness of the potential suicide risk in patients with a diagnosis of an eating disorder, ASD or dementia

Clinicians and pharmacists should be aware of the potential risks of opiate and opiate-containing analgesics.

Overall audit rating per quarter

Q3 16/17 Q4 16/17 Q1 17/18 Q2 17/18

Trust Wide Good GoodRequires

improvement

Requires improveme

nt Adult

Directorate GoodRequires

improvement

Requires improveme

nt

Requires improveme

ntOAMH CMHTs Good Good Good Good

CYP Directorate

Requires improveme

ntGood

Requires improveme

nt

Requires improveme

nt

Reaffirmation that much of the risk to others from mental health patients is related to co-existing drug or alcohol misuse rather than mental illness itself. This is an important message in combating stigma.

A greater focus on alcohol and drug misuse as a key component of risk management in mental health care, with specialist substance misuse and mental health services working closely together as reflected in published guidance.

The suicide prevention nurse consultant will feed these national findings into directorates and ensure actions are taken and the suicide prevention strategy update. The risk team and learning from incidents lead will ensure that findings from homicides are shared.

News (older adult) December 2017 (also see section 1.5) The NEWS audit replaces the Track and Trigger early warning system audit which was introduced into clinical areas back in 2010. The audit focuses on front line clinicians documenting the completed clinical observations (Blood Pressure, Heart Rate, Respirations etc.), and the documentation of any escalations and actions necessary in promoting safe care for patients that showed signs of deterioration within the patient’s notes. Each Community Hospital ward audits ten randomly selected patient notes on a monthly basis. The audit tool automatically calculates the compliance enabling wards to take immediate action. Actions are taken at the time of the audit and recorded on the data collection tool. Compliance with the standards relating to the appropriate escalation is also now being monitored monthly through the Community Hospitals Safety Metrics Dashboard.The overall rating was good for Dec 2017. Ratings have been either good or excellent over last 6 months

Physical Health Audit January 2018 – Older Adult Mental Health Wards. Ten patients’ records are audited monthly on older adult mental health wards. Data collection is undertaken monthly using a self-populating audit tool which identifies areas requiring improvement at the time of the audit. This allows immediate action to be undertaken to rectify areas requiring improvementSome notable practice includes: Amber Ward:

Excellent completion of clinical observations and documenting appropriate action taken with the modified early warning system (MEWS).

Falls risk assessment review after 28 days of admission has improved from unacceptable to good.

Care planning for patients at risk of falls is excellent

Cherwell Ward Compliance with completion and escalation of MEWS rated as

excellent consistently over the last 6 months Excellent completion of falls risk assessment within 24 hours and

re-assessment after 28 days of patient being on the ward Care plan relating to patients at risk of pressure damage / falls /

nutrition and continence are rated as either good or excellent consistently over the last 3 months

Sandford Ward Compliance with completion of MEWS rated as excellent Completion of Braden within 24 hours and appropriate care

planning rated as excellent

CQUIN goal 9 preventing ill health by risky behaviours – alcohol and tobacco The rationale for this CQUIN is to ensure patients smoking status and alcohol consumption are documented and advice is given in relation to stopping smoking and referral to specialist alcohol services are offered where appropriate.

The CQUIN Scheme was established to encourage all NHS Commissioned organisations to improve quality of services and promote innovation. The key aim of the CQUIN framework for 2017/18 seeks to help deliver the objectives set out in the five year forward view, particularly around the need for a radical upgrade in prevention and to incentivising and supporting healthier behaviour. In July 2017 data was collected for Q1 with the trust overall result rating as “Requires Improvement”. In October data was collected for Q2 with the trust overall result rating as “Good”. In December 2017 data was collected for Q3 with the trust overall result rating as “Good”.

The results of the audit demonstrate that the patient’s smoking status is now being routinely recorded in the patient’s health record. The overall trust rating of ‘Good’, has been sustained since Q2 and improved from the Baseline rating of ‘Requires Improvement’ in Q1. There has been significant improvement with the Mental Health Wards now regularly recording both smoking and alcohol information in the Physical Health Review Form. In total 27 physical health review forms had been completed in Q3 compared to 7 in Q1.

The recording of screening for both smoking and alcohol was rated as ‘Excellent’ across Mental Health Wards and was rated as ‘Good’ for Community Hospitals, Community hospitals are now routinely using the updated Baseline Assessment Pack.Areas for improvement

For all Community Hospital Wards to routinely record smoking status.

For all Community Hospitals Wards to routinely record alcohol consumption.

For all Mental Health Wards to use the updated Physical Health Review Form.

Some wards are not regularly recording in the smoking and alcohol status sections within the baseline assessment packs.

Monthly Medicines Safety Audit in Older Adults This audit is undertaken on a monthly basis with a sample of ten patients record in community hospitals with Older adult mental health wards starting from December 2017.

All wards were rated as either good or excellent Two of the community hospitals were 100% compliant against

each standard every month and one of the wards improved their overall rating from requires improvement in October to excellent in November and December

No actions were required following the audit.

One of the challenges for the Corporate audit team has been an ongoing issue with staff turnover and recruitment meaning that an established clinical audit team was not in place at the start of this year. This has also meant that some of the processes and assurance that had been in place had slipped and attendance at the quarterly CAG meeting had fallen.

The Clinical Audit arrangements in the Trust have been subject to an internal assurance review by TIAA to review the arrangements in place with regard to clinical audits. The findings from this review reflected what was already known and an action plan has been developed.

Plans to make a number of changes to the CAG were discussed including the introduction of Dr. Robbie Dedi (deputy medical director) as the new Chair, a review of the terms of reference, and how audits will be agreed and reviewed with learning shared between directorates. Additionally, there has been some successful recruitment into the corporate audit team.

A verbal update on progress with the Clinical audit plan was given. It is expected that the audit plan will be on track by the end of this financial year and a one off meeting to discuss and agree the audit plan for 2019/19 has taken place. Work is being undertaken to ensure that areas representing high risk are prioritized for the plan while some audits may be better incorporated as part of quality improvement projects. A full report will be tabled at the next CAG meeting in April 2018.

The CAG also received a Nice Implementation report highlighting progress against NICE guidelines and standards. This process has also been subject to a TIAA assurance review which gave reasonable assurance. Work continues in directorates to review guidance identify gaps and most importantly develop action plans to address any high risk areas. It is recognised that this is a very large piece of work given the breadth and spread of services and the number of guidance relevant to services across the Trust and progress is slow because of this.

1.2 Drugs and Therapeutics Group (DTG) –

All inpatient units (plus Urgent Care and Emergency Medical Assessment Units) have been audited for the safe and secure handling of medicines standards.  Overall the compliance with standards is good and there are no major risks or concerns.  Local issues are addressed through an improvement plan for each unit, co-ordinated by the Medicines Safety Team.  The most common local issue is regarding temperature monitoring in clinic rooms and medicines fridges; most units use digital data loggers which are more accurate than manual thermometers, but are not automated so still rely on.  A business case is being developed to see whether a fully networked temperature monitoring system may be beneficial to the trust.

All community-based teams are being audited this quarter.  The most significant concern is the recording systems for FP10 prescriptions in bases, but work is already underway to address this.

All units have had a quarterly controlled drugs audit and the improvement in results seen over the previous quarters has been sustained.  The trust has attended all relevant Controlled Drugs (CD) Local Intelligence Network (LIN) meetings and provided quarterly returns to NHSE. A new national reporting system for CD incidents and concerns is being implemented.

The trust continues to take part in the POMH quality improvement projects and we have successfully used the Clinical Record Interactive Search (CRIS) for these.   Although some of the project results have been disappointing, it has been recognised that there are some key factors affecting our results, specifically the lack of electronic prescribing (which would provide clinical decision support to prescribers) and inconsistencies in how medicines information is recorded in Carenotes, which makes data collection for audit challenging.

The Trust’s Drugs and Therapeutics Group has overseen the review and ratification of the shared care prescribing agreements with primary care.  The main concern to escalate is the decision by Oxfordshire CCG to agree a shared care arrangement with the OUH for melatonin (used to help sleep, particularly in children) but have refused to agree shared care for our CAMHS.  It has been highlighted that this could be perceived as discriminatory and does not demonstrate parity. Otherwise all shared care agreements are working effectively and we are continuing to develop new protocols which align more closely with patient pathways and support a recovery model more effectively

1.3 Learning Advisory Group (LAG) The last LAG was held on 15th November 2017.

The terms and conditions of the Learning and Advisory Group have been amended and were approved by LAG and Clinical Effectiveness Group.

Nursing associate trainees continue to progress on their programme with 24 of the original 26 still on programme. A further 100 nursing associate trainees are to be recruited this calendar year. The original cohort were all healthcare support workers employed by the Trust but we will be advertising externally for trainees going forward. Alongside this work is being undertaken to review skill mix to try and ensure that clinical areas will be clear how the nurse associate fits into their teams once they are qualified.

Twenty-three healthcare support workers have begun their Level 3 apprenticeship programme and there are eighteen employees doing either their Leadership and Management Level 3 or the Business and Administration Level 3 apprenticeship. Besides delivering the apprenticeships, Learning and Development is providing functional skills support so that the apprentices can achieve the required level in literacy and numeracy. Further cohorts of apprentices will start in September 2018.

Ensuring that all employees complete their mandatory training is an ongoing challenge. Information governance is required to be at 95% compliance by the end of March 2018 in order to ensure that the requirements of the Information Governance Toolkit are met. Currently, the rate is 92% but work is being undertaken to ensure those that have not done the training do complete it. Work to do this has raised issues about sessional workers who have not undertaken sessions recently. Currently, they are not cleansed from the system

unless they have not worked for six months. This then presents challenges in relation to compliance with mandatory training.

A full-time member of the resuscitation team has resigned and the team’s establishment was not permanently increased to take account of additional training in Immediate Life Support (This is a level of life support required to be undertaken by qualified mental health nurses working in inpatient areas). The Executive Management Team agreed an increase in the establishment of the resuscitation team and the recruitment process has commenced. However, even when the additional establishment is in post there will be a period of training required before staff are competent to lead the delivery of the Immediate Life Support (ILS). A risk based approach was taken to ensure that those wards where rapid tranquilisation commonly occurred had their staff trained in ILS and it is recognized by the Resuscitation team that other staff need to be trained in ILS as a priority.

An audit of personal development reviews (PDRs) was undertaken by TIAA in 2017. They reported limited assurance with the process. All the actions within the action plan have been achieved. An area that was not addressed by TIAA was the level of compliance in the Trust. Non-medical staff PDR was as low as 60%. This may have reflected a failure to record the PDR rather than failure to undertake it. Currently, this rate has increased to 76% overall with Children and Young People Directorate achieving 83%. The average is brought down by rates in the Adult Directorate and Corporate Directorate both of which are at 71%. However, all directorates have significantly improved their PDR rates. Medical appraisal remains fairly constant at 68%. The PDR policy is in need of review and a process is in place to do this. Discussion is taking place whether the PDR policy and the supervision policy should be combined.

1.4 Mental Health Act/ Capacity Legislation Group – The last meeting was held on 4 January 2018.

Numbers of patients subject to the Mental Health Act remain high, there are currently 360 detained patients and 98 patients under a community treatment order.

The CQC Mental Health Act visits continue to make recommendations relating to care planning and patient involvement, section 17 leave,

and section 132 rights re-presentation. Risks continue to remain due to inconsistent compliance. Areas of concern continue to be in relation to the recording of leave, rights, consent to treatment, and patient involvement and empowerment with respect to care planning. The CQC do, however, give positive comments and feedback with regard to the care patients receive. Associate Medical Directors continue to actively take the issues raised to their respective Directorates and we are still seeing evidence that this is resulting in improved compliance by staff. Where the same issues continually arise Directorates are raising staff awareness and monitoring is provided with action taken by ward managers, modern matrons and responsible clinicians.

Action has been taken to ensure continued improvement with regards to Section 132 rights1 compliance. A new S132 Rights form has been introduced which is now available on Carenotes making the process much more efficient for staff.

Compliance in recording of section 17 leave2/CTO3 consideration and consent to treatment has improved. Directorates treat the CQC visit reports as working documents and monitor their areas on a regular basis against these to ensure that actions are completed. A new Section 17 leave form has been implemented and an improvement in recording CTO consideration is evident.

A more effective and streamlined system to record Responsible Clinician4 (RC) to RC transfers and ensuring handover between professionals has been introduced and is working well.

There continues to be an ongoing issue with patients who are deprived of their liberty who may not always be subject to a standard authorization (Deprivation of Liberty Safeguards-DoLS) because of resource issues in adult social care which is outside of the control of the Trust. In these circumstances active care planning, regular review 1 Section 132 of the Mental Health Act 1983 applies to all patients who are detained or subject to a Community Treatment Order (CTO). It places a duty on the hospital managers to provide certain information to patients and their Nearest Relative (NR), regarding which section of the MHA they are subject to and the effects of that section.2 Patients detained under the Mental Health Act 1983 can only leave the hospital when granted leave of absence under s17, by the patient’s Responsible Clinician (usually their consultant psychiatrist).3 CTOs or community treatment orders (Part 17A of The Act) were introduced in 2008 under the 2007 Mental Health Act amendments. They replaced Supervised Discharge and allow for patients on unrestricted orders to be treated within the community rather than under detention in hospital, under certain conditions. 4 The Responsible Clinician has overall responsibility under the MHS 1983 for the care and treatment of service users being assessed and treated under the Mental Health Act.

and risk assessment are put in place. Nationally there has been a huge increase in the number of applications for DoLS, and councils are routinely breaching statutory timescales for completing DoLS assessments and deciding whether to authorise a deprivation of liberty in care homes or hospitals. In 2015-16, 42% of applications made had not been signed off by the end of the financial year. Changes to address this are being considered by the law society as there is a recognition that the system is in crisis. Legal advice regarding processing DoLS applications has been fed back to CQC by the Trust.

Section 1355 and 1366 legislative changes are now implemented within the Trust and have been effective from 11 December 2017. The most significant change impacting on practice is the timeframe in which a person may be detained in a place of safety which has been reduced from 72 hours to 24 hours (with the allowance of a 12-hour extension on clinical grounds). Regulations supporting the legislative change have also been published. The impact on the Trust will be that there will be significant pressure placed on both health and social care to undertake assessments in a timelier manner but then to find an inpatient bed in cases where someone needs admitting either informally or under a section of the Mental Health Act. Directorates and relevant wards with Places of Safety attached will be closely monitoring processes in order to ensure these changes to section 135 and 136 are applied.

1.5 Physical Health Group The last Physical Health group was held on 8 January 2018

The Improving Physical Health for People with Severe Mental Illness Conference was held on the 26th January. At the last QSCE meeting it was reported that the planning of the conference was progressing well, speakers were confirmed and places oversubscribed. In addition, the Physical Health strategy is nearing completion. Some changes were required to reduce the scope of the draft document and to present it in summary form. It was anticipated that this would be considered and ratified by the Well Led Committee on the 24th January.

5 s135(1) provides for a magistrate to issue a warrant allowing a police officer to enter premises to remove a mentally disordered person to a place of safety.6 “If a person appears to a constable to be suffering from mental disorder and to be in immediate need of care or control, the constable may, if he thinks it necessary to do so in the interests of that person or for the protection of other persons remove that person to a place of safety….. or, if already in a place of safety to keep them there or to take them to another place of safety.”

There are some good examples of improving physical health for people with severe mental illness in the adult directorate:

A new physical health lead for in-patient services has been appointed and this has led to significant improvements in patients’ access to the wellbeing clinics on the ward; development of skills for healthcare assistants and improvements in the use of MEWs and physical health monitoring for our mental health in-patients. In the adult community mental health teams (AMHTs), work to improve access to physical health care is going well. The physical health clinics are providing advice on diet, exercise, smoking, health and fitness.

The Nutrition Action Group has now been incorporated into the work programme for the Physical Health Group. Following feedback from the Adult Directorate changes will be made to the Nutrition and Hydration Policy in relation to the user of the MUST Tool in Adult Services.

Work has been undertaken to ensure that the requirements to have emergency drugs immediately available in all areas in line with UK Resuscitation Council guidelines are met. Changes have been made to the location of drugs and equipment across the Trust to ensure that we are compliant with CQC standards and estates work is ongoing around this.

A new End of Life Care Plan has been developed based on national priorities and NICE guidelines; the new care plan addresses the findings from a baseline clinical audit of end of life care completed in Q1 2017/18. Patients’ and carers’ views have directly informed the content style and layout of the plan and its development. The People in Partnership Group and the National Council for Palliative Care (NCPC) took part in the process. A number of actions are underway to implement this: The care plan roll out timescales have been revised to ensure

appropriate engagement from all stakeholders, matrons and link nurses.

A monthly audit tool has been devised to examine compliance with the five key national priorities.

The pilot of the new care plan is underway; the pilot teams were asked to participate in an audit to evaluate improvement prior to full roll out.

Training has been delivered to clinical development nurses in community hospitals to support the roll out.

Extensive work is underway in relation to recognising the acutely ill and deteriorating patient including:

The Older adult directorate has continued to pilot and roll out a new early warning sign (NEWS) tool, training and an assessment

of the effectiveness of its use across community hospitals and mental health wards. This work includes the identification and management of sepsis. Simulation training on Human Factors and Recognising the Acutely Ill and Deteriorating Patient has been undertaken by over 100 staff in community hospitals. This was a bespoke training programme designed in conjunction with OXStar. This programme combined with the introduction of a modified NEWS T&T score across all sites and a ‘care and comfort’ rounding bundle has had a significant effect for the CH patients in that there have been no issues of harms resulting from ‘failure to rescue’ in the hospitals since the introduction of these initiatives.

The monthly audit (reported in section 1.1) of the use of the NEWS T&T tool in community hospitals demonstrated an improvement in the escalation of abnormal observations over Q2

Work has been undertaken in the Urgent Care environment to develop a process to enable proactive review of patients with suspicion of sepsis when there are no overt features requiring immediate referral.

The service has ‘targeted information leaflets’ for patients and families regarding sepsis risks and specific areas of concern.

The EMU have reviewed referral paperwork to ensure that a ‘pre-screening for sepsis’ is undertaken. A process of audit of compliance against the key standards within the NICE guidance as applicable to this clinical setting has been developed

Scoping the inclusion of Sepsis awareness for all staff within the Trusts induction programme is underway.

Plans for the creation of a faculty within the Community hospitals to continue delivery of the training initiated by the OXStars work

Standardisation of the Witney EMU sepsis processes into the Rapid Access Care Unit (RACU) in Henley and Abingdon EMU sites

Undertaking to deliver sepsis recognition and awareness sessions across a variety of trust sites to coincide with ‘world sepsis day’

Development of a bespoke package or training and processes to support the recognition of, and escalation of concerns in relation to sepsis for district nursing and care home support service teams.

Identification of local sepsis champions across the older adult and mental health wards with links and resources to raise awareness of sepsis and necessity to escalate concern and take action to support patients in the event that this happens.

Six staff will be sent to the train the trainer course in March 2018 delivered by OxStars and funded by the Thames Valley Safety Network

A sepsis training package has been developed and implemented; a surveillance trigger tool has been rolled out across community hospitals.

As part of the work in the reduction of avoidable and acquired pressure damage, the directorate is working to improve the reporting and review of low grade harms to help minimise the number of significant harms with lapses in care.

By end of Q3, notable improvement over time was noted in the number of acquired significant pressure ulcers with a notable decline in the number of acquired category 4 pressure ulcers and sustained lower numbers of category 3 acquired pressure ulcers.

Whilst the Trust remains an outlier (due to a higher number of category 2 pressure damage) based on Q3 2017/18 Safety Thermometer Returns- it must be noted that that a higher rate of reporting lower grade harms must not be regarded as an adverse indicator. An increase in the number of acquired harms with lapses in care should be noted as an adverse indicator- but the national tool does not reflect this. Notable data quality issues and discrepancies in the definitions of ‘new’ and ‘old’ harms compared to peers were also identified. This reinforces the fact that Safety Thermometer data must not be used in isolation.

Fig. 1 Category 1 acquired pressure damage

Fig. 2 Category 2 acquired pressure damage

Fig 3. Category 3 acquired pressure damage

Fig 4. Category 4 acquired pressure damage

Dec-16

Jan-17

Feb-17

Mar-17

Apr-17

May-17

Jun-17Jul-1

7

Aug-17Sep

-17Oct-

17

Nov-17Dec-

1702468

101214161820

Category 4 PUMean*LCLUCL

Number of CAT 4 Ac-quired PU

Month

CAT 4 Acquired Pressure Ulcers

Fig 5. Acquired pressure damage category 2 and above with lapses in care

Progress relating to key initiatives included in the Pressure Ulcers Reduction Project is using the Quick Time Learning (QTL) approach which has been rolled out across all district nursing teams with modifications to the process to allow wider adoption and is as follows:

Improve reporting all pressure damage including low grade harms- including category 1 pressure damage.

The handover process has been updated to include a requirement to discuss all identified pressure damage promptly at team meetings and ensure as a team appropriate interventions and support have been provided.

A handover poster and flow chart outlining the requirements have been developed for use by all teams.

Initial Review (short pressure damage analysis form) has been activated for all acquired grade 2 pressure damage – the clinical leads will be required to complete the questionnaires to identify any lapses in care. There are technical challenges linked to the adoption of Initial Review’s to analyse category 2 harms which the quality and risk teams are trying to resolve.

Learning from incidents with lapses in care is shared by clinical development leads at team meetings.

The Older People Directorate quality team will collate the learning at a county-wide level and ensure the learning is shared via the ‘Learning from Incidents Poster’ or presentations of safety metrics data at the county-wide meetings.

By end of Q3, an improved Initial Review completion rate was noted for category 2 acquired pressure ulcer to enable the service to identify cases with lapses in case and develop improvement plans.

The React to Red initiative encourages the use of the initial SSKIN7 bundle assessment on the first district nursing visit to allow early care planning; education with patients and their carers; and promote better communications between nursing teams and care agencies. The initiative was piloted in Didcot in April 2017, but was delayed due to recruitment challenges in the team. The react to red project recommenced in December 2017. A second React to Red project commenced jointly with OUH, relating to the Home Assessment Reablement Team (HART) service commenced in November 2017

1.6 Psychological, Occupational and Social Therapies Group (POSTG) –

The last meeting was held on 20th December 2017

Following discussion at the Nice Implementation group a new process for reviewing NICE guidelines was agreed. For guidance that has a psychological, Occupational or Social therapies related focus, POSTG have led on producing a summary of the guidance to assist with the gap analysis undertaken. However, this has resulted in some delays in the information being available. In future requests for the summaries 7 five steps approach to managing and preventing pressure ulcer damage

Surface: make sure your patients have the right support Skin inspection: early inspection means early detection - show patients and carers what to look

for Keep your patients moving Incontinence/moisture: your patients need to be clean and dry Nutrition/hydration: help patients have the right diet and plenty of fluids

will come to POSTG directly from the NICE implementation group rather than be initiated from POSTG.

A Competencies Framework for Psychological therapies practice across all grades of staff has been produced which is now available on NHS England website. This will now be used as part of the Adult and Older People psychological framework and shared with other services for consideration as part of their skills development and the team developing the online competencies process.

Following the Psychological therapies restructure, Gaps in services have emerged due to the transition in the Neurodevelopmental Pathway in Bucks. This has highlighted concerns over the lack of commissioning to cover the demand. A proposal being put together to manage this.

There are some good examples of clinical interventions to support patients to self-manage their conditions. The N&W AMHT developed a self-help workbook with patients that provide some tools and resources to support recovery. These have been well received by the wider patient group and are due to be rolled out across the directorate. The North AMHT are now looking at developing further self-help workbooks with service users for Psychosis and other mental health issues.

The Early Intervention in psychosis team (EI) have now embedded an Individual Placement and Support (IPS) worker in Bucks EI services and one has just started in Oxford EI service. These workers have a very specific evidence based remit to actively support people to gain paid employment. The Trust has submitted a bid with Berkshire Health care to NHS England to extend this highly successful intervention across all AMHTs in the Trust.

Peer Support worker are now being recruited to have people with lived experience working within our services to support patients’ recovery. Key elements of Peer Support in mental health are that it is built on shared personal experience and empathy, it focuses on an individual's strengths not weaknesses, and works towards the individual's wellbeing and recovery.

Talking space (IAPT) are developing improved accessibility to services using digital platforms. They are trialling new software and preliminary findings are showing good results and feedback received has been positive.

A Motivational Interviewing Pilot was started with a district nursing team in the North of Oxfordshire. Psychology support will be provided

via Talking Space Plus (IAPT) to build up clinician’s skills in managing patients with long-term conditions, anxiety or depression. Evidence from a pilot in Long-term Conditions demonstrated that patients who received psychological support had better outcomes in managing their long-term conditions. Motivational interviewing helps nursing staff improve patient concordance with care plans including pressure damage prevention care plans.

Talking Space Plus has been delivering teaching and supervision to the district nursing team for a period of 3-6 months. This work commenced in October and involved 17 staff in total. Sessions provide teaching on understanding anxiety and depression, motivational interviewing and how to refer to other services. Primary measures for this project are days between acquired pressure damage in pilot cluster, confidence and competence of staff to lead conversations relating to anxiety and depressions and motivational interviewing, and number of patients referred to Talking Space Plus

1.7 Public Health Group – Kate RiddleThe main public health focus is in relation to health promotion. Making Every Contact Count8 online training has had some positive

feedback and agreement has now been reached to make this part of the staff training curriculum via a task and finish group linked to the wellbeing group.

Flu immunisation uptake has remained lower than hoped despite a very active campaign to encourage staff to have their immunisations.

Smoke free initiatives– An eBurn project is underway with a pilot being undertaken in forensic services. The policy will be reviewed as part of this work.

1.8 Research Management Group- Emma StratfulThe Research management group continues to meet and review Dashboard reports of activity from the various components of research that the Trust and its partners are engaged in. - Biomedical Research Centre (BRC), Clinical Research facility (CRF), Collaborations for Leadership in Applied Health Research and Care (CLAHRC), Diagnostic Evidence Cooperative (DEC), Clinical Research Network Thames Valley and South Midlands (TV&SM CRN), Case Records Interactive Search (CRIS),

8 Making Every Contact Count (MECC) MECC is an approach to behaviour change that uses the millions of day-to-day interactions that organisations and individuals have with other people to support them in making positive changes to their physical and mental health and wellbeing. MECC supports the opportunistic delivery of consistent and concise healthy lifestyle information and enables individuals to engage in conversations about their health at scale across organisations and populations

Research Feasibility, Set-Up, Delivery and Management (including quality assurance).

The new process (Pipeline) for assessing all studies for feasibility and public engagement is going well. This was implemented to ensure the best use of resources was made following cuts to funding. OHFT continues to meet targets for the National Institute for Health Research (NIHR) metrics in Performance and Delivering studies although numbers of patients being recruited to studies has fallen slightly.

Funding for CRN has been reduced this year and the research and development (R&D) senior management team are looking closely at requirements for R&D going forward.

1.9 PoliciesA number of policies and procedures due for renewal were considered and extension approvals given for: CP16 – Clinical Risk Assessment and Management(CRAM) requires

some rewording: 3-month extension agreed. CP102 – Venus Thromboembolism –The Head of Nursing for Older

people is undertaking a review of roles and responsibilities. 3-month extension agreed.

CP22 - Physical Assessment and Examination of Service Users. This policy has been reviewed by the Head of Nursing for Older people and it requires no substantive changes with minor amendments. 3-month extension agreed.

CP48 – Advance Statements – The Head of Information Governance advised that there had been no changes in legislation since the last policy review - 3-month extension was granted.

It was agreed that following policies should be extended for a period of six months to allow for a full review. They are all currently fit for purpose and out for consultation: MM08 – Independent Non-Medical Prescribing Policy CP85 – Medical Gas Systems Safety

A further policy was considered (P19 – Consent to examination or treatment). This had been reviewed by the Head of Information Governance who reported that no changes were needed. The report was circulated for virtual approval.

The following policies are now approved, signed and on the intranet: MM06 – Covert Administration Policy (review due Q2 2018)MM02 – Medicines Reconciliation Policy (review due Q2 2018)