quality account 2009 - 2010 · quality account artwork mc steve_layout 1 02/07/2010 16:08 page 2. 3...

Quality Account2009 - 2010

Quality Account artwork MC steve_Layout 1 02/07/2010 16:08

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Contents

Part 1Introduction 3

The Trust’s Clinical Services 4

Part 2Priority 1 – Improving the Car Pathway 6

Priority 2 – Improving the Patient Environment 8

Priority 3 – Improving Stakeholder Engagement 10

Statement of Assurance from the Board 12

Audit in the Trust 19

Research Activity 19

Commissioning for Quality and Innovation (CQUIN) 19

Care Quality Commission: Registration and Inspection 19

Data Quality 19

Part 3Review of Quality Performance 20

Consultation Process 22

External Perspective on Quality of Services 22

Appendix 1 23


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The combination of improving quality andincreasing value is the essence of strategicobjectives at Mersey Care. We aim to improvethe value given to the taxpayer and improvequality for those who receive our services.

In this, the Trust’s first Quality Account I amdelighted to provide information on how thequality of acute care has improved in the Trustduring 2009 - 2010 and the areas where furtherimprovement is required.

None of the improvements could have beendelivered without the commitment of our staff andthe involvement of service users and carers in thework that we do. Through collaboration, sharingknowledge and experience and learning fromfailure we have achieved real improvements in theway we deliver care. What those who receive ourcare think is most important to us, so theimprovements evidenced in the results from theNational Patient Survey are a real encouragement.

Our improvement is also recognised by thevarious regulators responsible for assessing theTrust’s performance against a range of qualitymeasures. In 2009 - 2010 Mersey Care was ratedas the ‘most improved’ mental health trust andachieved full compliance in relation to the carestandards contained within the Standards forBetter Health framework. The annual health checkrating for 2009 - 2010 scored ‘good’ for quality ofservices and the Trust was registered ‘withoutconditions’ by the Care Quality Commission forsafety, effectiveness and quality of thearrangements in place to reduce healthcareassociated infection and to safeguard children.

At the start of 2009 - 2010 we launched our CareManifesto which outlined a clear commitment toimproving the quality of the patient experience.Since its launch the Board and the Trust’sservices have adopted the principles contained inthe Manifesto and we are starting to see thepositive impact of this reflected in our governancearrangements and in the feedback we receivefrom service users and carers.

We know there is more to do and we will continueour campaign to further improve the care andservices we provide. To assist us in determiningour priorities for quality improvement during 2010 - 2011 a range of engagement events wereheld with staff and service users. The eventsidentified 3 main priorities for improving quality:

• Improving the care pathway

• Improving the patient environment

• Improving stakeholder engagement

Addressing these priorities will involve significanteffort over the next 12 months particularly in lightof the current economic conditions. Over the last12 months we have enjoyed good workingrelationships with our commissioners and we willcontinue to work with them to deliver the qualityimprovements specified within the contract theyhave with us. We will be open and transparentabout what we can and will do to improve qualityand by involving other stakeholders we will findways to work better and more productively.

As we move towards becoming the equivalent ofa Foundation Trust we look forward to having aMembers Council and the contribution to bemade by all who have a stake in helping usimprove our quality. I extend a personal invitationto come and join us as a member of the Trust andbe part of our campaign to deliver better mentalhealth. Please go tohttp://www.merseycare.nhs.uk/foundation_trust/membership_form.asp for an application form.

I hope that you find our Quality Accountinformative and of help in assessing our progressagainst the priorities we have identified for thecoming year. The information supporting thecontent of the Quality Report is to my knowledgeaccurate and was published by the Board on 30thJune 2010.

Part 1 - Introduction

Alan Yates, Chief Executive


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Mersey Care Addictions Clinical Business Unit

Addictions CBU provides drug and alcoholservices for the population of Liverpool, Seftonand Kirkby and alcohol services only forKnowsley, from Windsor Clinic and the KevinWhite Unit. Community services are alsoprovided.

The services provide care and treatment forpeople suffering from alcohol or drug dependencyand offer a range of care pathways andindividually tailored therapeutic programmeswithin both residential and community settings.These are delivered by a consultant-led multi-disciplinary staff group.

Service Director: Bob Dale

Clinical Directors: Jayne Bridge and Dr Mohammed Faizal

Mersey Care High Secure ServicesClinical Business Unit

High Secure and associated services areprovided from Ashworth Hospital. Ashworth isone of three high secure hospitals and serves theNorth West of England, West Midlands andWales. It provides in-patient care and treatmentfor men who are deemed to be a grave danger toothers, under the Mental Health Act 1983, inconditions of maximum security.

Service Directors: Astrid Henderson and Paul Weare

Clinical Director: Dr Caroline Mulligan

Mersey Care Liverpool Clinical Business Unit

Liverpool CBU provides mental health servicesand care to adults in Liverpool. Services includeacute in-patient care, accident and emergencyliaison, crisis, community mental health teams,assertive outreach, early intervention inpsychosis, homeless outreach and psychology. Agateway system ensures that people are referredto the most appropriate service for their needs.

Service Director: Carol Bernard

Clinical Director: Dr Simon Tavernor

Mersey Care Positive Care Partnerships CBU

Positive Care Partnerships CBU covers Sefton,Kirkby and North Liverpool for adults and olderpeople. Services include acute care, accident andemergency liaison, crisis, and gateway services,community mental health teams, assertiveoutreach and early intervention in psychosis andpsychology. Assessment and/or treatment isprovided for people experiencing mental healthdifficulties. The aim is to deliver care that respectsindividuals, values diversity, preserves dignity andpromotes recovery and inclusion.

Service Director: Karen Lawrenson

Clinical Director: Dr Sudip Sikdar

The Trust’s Clinical Services


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Mersey Care Rebuild CBU

This CBU provides services for clients withlearning disabilities in Mossley Hill Hospital andOlive Mount Mansion, including communityresidential services, community teams, in-patientservices, respite services, on call service and theAsperger’s service.

The Brain Injuries Rehabilitation service providesin-patient and outpatient care. They specialise inassessment and rehabilitation for people whohave an acquired brain injury. The aim of the inter-disciplinary team is to maximise the service user'srehabilitation potential and quality of life.

The Rehabilitation Unit is currently involved in aprocess of review. The aim of this is refocusingthe team's approach to rehabilitation to one thatencompasses recovery, minimises hospital stayand facilitates early return to appropriate settings.Rehabilitation services are provided fromRathbone Hospital.

Network Employment's experienced team ofemployment advisors assist with job searches,on-the-job training and employment support inthe workplace. They offer advice in relation toequal opportunities and the DisabilityDiscrimination Act.

The supported housing scheme enables serviceusers to maintain their own tenancies within thecommunity, helping to develop skills andindependence and promote social integration aswell as providing a positive alternative to in-patient care.

Service Director: Irene Byrne-Watts

Clinical Director: Dr Tim Matthews

Mersey Care SaFE Partnerships CBU

SaFE (Safe and Forensic Environments)Partnerships CBU provides medium secure andlow secure services, criminal justice liaison andprison health liaison services.

The in-patient medium secure services at ScottClinic provide forensic mental health assessmentand rehabilitation to mentally disorderedoffenders or others displaying similar behaviours.Services include pre-admission assessment, in-patient treatment and aftercare and are offeredto residents of Merseyside, Greater Manchester,Lancashire and Cheshire. The services compriseof an outpatient department based in Liverpoolcity centre and provide support to communityservice users via the forensic integrated resourceteam. Also based at Scott Clinic are the Forensicpersonality disorder assessment and liaison teamand substance misuse service for Cheshire andMerseyside.

Low secure service users have severe andenduring mental health problems, and arepreparing to return to life in the community. Thisinvolves finding the most effective treatment andtherapy, finding ways to support independentliving, and locating residences which provideappropriate support for people when they leaveRathbone Low Secure Unit.

The criminal justice liaison team is a court basedmental health liaison service addressing theneeds of mentally disorded offenders at points ofthe criminal justice system. The prison healthliaison team forms part of a national developmentaimed at improving mental health care withinprisons. The team provides secondary mentalhealth services into HMP Liverpool in Walton, andthe prison based primary care psychologicalservice provides a range of psychologicalinterventions to offenders.

Service Director: Paul Ikin

Clinical Director: Hilary Lomas


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Regular and ongoing consultation with serviceusers provided the Trust with qualitativeinformation on the range of improvementsrequired. This information was used inconjunction with performance data to give anoutline of areas for consideration as key priorities.

These were discussed at both the SeniorLeadership Team meeting and the ClinicalBusiness Unit Leaders Forum, where there isrepresentation from senior service managers,service directors and service users. Mersey Carehas chosen three specific areas for improvement,designed to be entirely inclusive of all the Trust’sservices.

Priority 1 - Improving the Care Pathway

Rationale

The Trust is committed to improving quality andenhancing value in relation to every aspect of anindividual’s care.

Aims

There will be an increased emphasis on how theTrust can help to improve the physical health andoverall well being of service users during 2010 - 2011. We will develop a set of measuresthat will enable us to record improvement in thisarea. In addition we will also develop measuresthat help us to assess progress in relation to othercomponents of recovery such as:

• employment status (experience)

• the effective use of the Care ProgrammeApproach (CPA) (effectiveness)

• guaranteeing a full review of needs every twelvemonths (safety).

In 2010 - 2011 the Trust will develop its QualityStrategy by establishing a more robust frameworkfor quality and service improvement. A new andupdated Suicide Prevention Policy and DualDiagnosis Strategy will be produced with clearlydefined outcomes associated withimplementation.

Current Status

A number of national priorities have directed thequality improvement agenda in the Trust during2009 - 2010 and these have been routinelyreported to the Trust Board. The Trust hasperformed well against the existing set of qualityindicators in some areas but there are still areasfor improvement where the expected standardsneed to be embedded into all agreed carepathways.

At a local level, Mersey Care has been part of aninitiative to provide individual personalisedbudgets and is keen to see this valuable leadingedge work further developed.

The Trust has also worked closely with otherpartners and service users, carers and youngcarers to promote and develop a number ofschemes designed to support families and youngpeople having to deal with the effects of mentalill-health, for example Keeping the Family in Mindproject.

Part 2


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The table below provides an indication of Trust performance against a number of national targets.

Quality Indicator Performance Performance Trust Target for2008 - 2009 2009 - 2010 2009 - 2010

Delayed Discharges 13.91% 10.04% Less than 7.5%

Average length of stay 43 days 46 days (excluding high secure services) (to Feb 2010)

Establish specialist teams and reach agreed activity in relation to:

i) Assertive Outreach teams caseload 429 438 414(as at end of

Feb)

ii) Access to crisis resolution Calculated using 71.2% 90%and home treatment different method (provisional)

from current usage.

iii) Early Intervention in 383 460 468Psychosis caseload (to end Feb)

‘Did not attend’ rates (DNA) 13.52% 13.72% excluding Addictions (to end Feb)

CPA 7 day follow-up 94.99% 97.35% 95.00%(to end Feb)

Identified Areas for Improvement

The Trust is committed to achieving continuousimprovement in all aspects of the care pathway.Three areas are in need of improvement on thecurrent performance:

• Access to Crisis Resolution Home Treatment

• Delayed discharges

• CPA 7 day follow-up.

Measuring and Reporting Outcomes

It is recognised that further work is required todetermine appropriate indicators and metricsassociated with measuring and reportingoutcomes. The Trust is working with other mentalhealth trusts from the North West as part of theAdvancing Quality initiative to develop a commonset of metrics and outcome measures that willenable Mersey Care to benchmark itsperformance against best practice standardsrelating to first episode psychosis and dementiacare. The Trust will also roll out theimplementation of HoNOS (Health of the NationOutcome Score), a scale used to measure thehealth and social functioning of people withsevere mental illness.


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Priority 2 - Improving the Patient Environment

Rationale

Service users expect to be treated with respectand dignity at all times during their contact withthe Trust.

Aims

We aim to always meet the needs of service usersand carers as far as can be reasonably expected,so it is important that arrangements are in placewhich enable and encourage a strong serviceuser voice to be heard, listened to and respondedto appropriately. We will develop a set ofmeasures that will enable us to recordimprovement that helps us to assess progress inrelation to the patient environment such as:

• Regularly asking service users if they weretreated with dignity and respect and were caredfor in gender appropriate environments(experience)

• Routinely monitoring if service users wereinvolved in and were satisfied with theirindividual care plans and had access toappropriate activities and therapies(effectiveness)

• Regularly asking service users whether they feltsafe whilst an in-patient (safety).

Current Status

During 2009 - 2010 the Trust gave greaterconsideration to the service user experiencewithin the acute/in-patient environment.Significant attempts were made to capture theviews of and provide a response to ‘hard to reach’groups and also service users being cared for inour secure care settings.

We routinely asked service users about theirexperience of acute care and in particular whetherthey felt safe and if their privacy and dignity hadbeen respected. The results of these surveys areavailable for further review alongside details of the

Trust’s programme of work to address dignity andprivacy standards across the organisation during2009 - 2010. The gender group successfullyconducted a programme of work that hasenabled the Trust to declare itself compliantagainst the Delivering Single Sex Accommodation(DSSA) standards.

The Trust continues to meet national patientenvironment (PEAT) targets and has reviewed itscleaning standards as part of its commitment toenhancing the patient environment. The infectioncontrol team works routinely with ward teams insupport of the ward based infection control linknurses as well as providing high quality clinicalleadership with regard to inspection anddelivering assurance requirements in relation tocompliance with the Hygiene Code.

A number of wards have sought accreditationfrom the AIMS programme (Acute In-patientMental Health Service) - an initiative run by theRoyal College of Psychiatrists - which identifiesand acknowledges services that have highstandards of organisation and patient care andformally recognises enhanced practice standards.All wards are engaged in the user-led ‘Star Wards’initiative which gives practical ideas to wardbased teams for improving the daily experiencesand treatment outcomes for those in receipt ofacute care. Significant work has been undertakenin the Trust to improve the quality of the patientenvironment through the use of cultural activitiessuch as dance, health and wellbeing schemes,musician in residence and use of reading groups.All of these programmes continue to have apositive impact on individuals’ lives. In-patientareas have been involved in utilising some of theservice improvement tools available e.g. LEANmethodologies and the Productive Ward series toassist them in raising quality and standards.Please note LEAN is a widely used term thatmeans a systematic approach to ensuring betteroutcomes by eliminating waste and adoptingmore efficient processes and methods. Thefollowing table provides evidence of improvementacross a range of quality indicators relating to in-patient areas.

Part 2


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Quality Indicator Current Performance Trust Target (where applicable)

Maintenance of NHSLA compliance Compliant Compliant

Compliance with prison security standards

Physical security to the standard of securityexpected by the Home Office in category Bprisons

The Standards for Medium Secure Units (MSUs)include all the Department of Health standards(Health Offender Partnerships, 2004) and extrastandards identified by members of the QualityNetwork for MSUs

96% 90%

96% 90%

Delivering structured activity for service users.All service users offered at least 25 hoursstructured activity per week (High secure dataonly for 2009 - 2010)

35 hours 25 hours

PEAT is an annual external assessment of in-patient healthcare sites in England. It is abenchmarking tool to ensure improvements aremade in the non-clinical aspects of patient care.

Environment – GoodFood - ExcellentPrivacy and Dignity - Excellent

Benchmarkedperformance againstprevious years results

Action plans created within the appropriatetimescale after publication for all relevant NICETechnological Appraisals and Clinical Guidelinesguidance

2 non-compliant All comply

Number of hospital acquired infections reportedby the Trust (MRSA and C Difficile)

0 0

% of service users with known or suspected CDifficile infection to be isolated within 4 hours

100% 100%

% of planned admissions assessed for MRSA 100% 100%


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Identified Areas for Improvement

The Trust recognises that there is significant roomfor improvement in the standard and quality of itscurrent buildings and estate. The currentenvironments in many cases cannot deliver thestandards service users should routinely expectwhen admitted as an in-patient. The TIME project(Time to Improve Mental Health Environments) willeventually see the creation of a number of newpurpose built units across the Trust’sgeographical footprint. In the interim, a priority isto make the safest and most effective use ofexisting buildings to best support individualprivacy and dignity. These priorities are alreadyreflected in the Trust’s estates strategy andcapital plans.


The annual patient survey provides an indicationof where the Trust can improve standards againstestablished internal benchmarks and those ofother similar organisations which are reflective ofthe care they receive from clinicians andprofessionals.

During 2010 - 2011 the Trust will develop amatron-led clinical performance framework whichwill report routinely on key areas of the in-patientcare patient experience. In addition we willdevelop our arrangements for obtaining ‘real time’feedback from service users through theintroduction of electronic survey methods whichwill allow us to benchmark the quality of careprovided between each of the wards on our in-patient units.

Priority 3 - Improving Stakeholder Involvement

Rationale

To become a better organisation by building onour involvement with stakeholders andstrengthening our governance

The development of a large, diverse,representative membership is a naturalprogression for the organisation in building andmaintaining effective links with the communitieswe serve and the staff we employ. It strengthensthe direct involvement of stakeholders in theorganisation’s corporate governance anddecision making processes.

Aim

To improve involvement with all our stakeholders.We will develop a set of measures that will help usto assess progress in relation to stakeholderinvolvement such as:

• Routine use of service user satisfaction surveysand the creation of more specific opportunitiesfor carers to comment on the quality of services(experience)

• Publication of actions or changes to practicestemming from complaints (effectiveness)

• Supporting and facilitating enhanced input andscrutiny of our service environments throughthe greater use of the SURE (Service UserResearch and Evaluation Group) and LINksvisits to our facilities (safety).

Part 2


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The development of the Members Council is workin progress and builds upon the Trust’s existingand well established stakeholder involvementarrangements. Listening and responding to theviews and expectations of service users andcarers is at the heart of how Mersey Care doesbusiness. Over 200 service users and carers areactively involved in the work of the Trust andhave, for example, been involved in theappointment of over 2,500 staff. The Trust alsorecognises that to ensure good outcomes forservice users and carers it must make sure itsstaff are well supported, effectively trained andare empowered to work innovatively andeffectively. An action plan in response to the mostrecent staff survey has been developed with theaim of promoting an enhanced workingenvironment for all our staff to achieve thesegoals. The work of the Members Council willfurther strengthen the governance of theorganisation by operating as a strategic advisorycommittee to the Board as defined in theproposed terms of reference.

The Council will be responsible for representingand presenting to the Board, the interests of themembers and partner organisations in the localhealth economy and for providing regularfeedback and information about the Trust, toconstituencies and stakeholder organisations.

This includes consultation with the followinggroups

• Commissioners

• Public/community

• Partner organisations

• Service users/ carers and families

• Staff.

When established, the Members Council willprovide a new forum where all of the above will berepresented collectively. The membershipnumbers as at 31st March 2010 and targets forfuture membership are detailed below.

Constituency Actual Minimum Required Target Target Target (31/03/10) for Election (31/03/10) (31/03/11) (31/03/12)

Public Liverpool 572 179 597 1194 1810

Public Sefton 138 115 384 768 1165

Public Knowsley 129 59 198 396 601

Public Wider 468 49 49 98 149

Public Total 1307 402 1128 2456 3725

Service User 232 145 484 968 1468

Carer 70 97 322 644 977

Service User/Carer 5 0 0 0 0Unknown class

Staff 4368 4244 4244 4244 4244

Total 5982 4888 6278 8312 10414

Current Status


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Areas for Improvement

During 2010 - 2011 we will improve the strategicapproach to working with identified partners in avariety of ways. In particular we will review andclarify our arrangements for patient and publicinvolvement and increase our activities in relationto the development of social enterprise. The Trustrecognises that it is essential to work in partnershipwith voluntary and charitable partners to providethe best possible services to the communities weserve and will seek out new ways to strengthen thiscommitment further as part of our plans.

We will also develop a more systematic approachto engagement with service users and carers bylistening to their feedback, acting promptly torespond to the issues they raise and improving ouroverall approach to customer care.


The following measures will help us to identifyprogress in relation to improving stakeholderinvolvement

• Enhanced use of service user and carersatisfaction surveys

• Analysis of complaints and compliments

• Number of PALS contacts per 1000 service userson case load

• The effectiveness of the Members Council will beevaluated annually based upon definedoutcomes determined by the Council at the startof the year. This evaluation will specificallyinclude:

• The breadth of issues considered by theCouncil

• Effectiveness of communication andconsultation with membership constituencies

• Effective application of Human Rightsprinciples

• Impact on organisational decision making

• Membership recruitment

• Response to members’ concerns

• Council members’ experiences – individualand collective.

It is anticipated that the evaluation will be objectiveand enhanced through the commissioning of theSURE group.

Statement of Assurance from the Board

During 2009 - 2010 Mersey Care NHS Trustprovided and/or sub-contracted 74 NHS services.It has reviewed all the data available on the qualityof care in all of these services. The incomegenerated by the NHS services reviewed in 2009 - 2010 represents 100 per cent of the totalincome generated from the provision of NHSservices by the Mersey Care NHS Trust for 2009 - 2010.

Audit in the Trust

During 2009 - 2010, there was one national clinicalaudit and nil national confidential enquiries thatcovered NHS services provided by the Trust.During this period the Trust participated in 100% ofnational clinical audits it was eligible to participatein, and for which data collection was completedduring 2009 - 2010.

National Audit of the Organisation of Services for Bone Health of Older People

• At the time of the audit in November 2008,Mersey Care did not have a falls prevention /reduction policy; however one has beendeveloped since

• At the time of the audit, the Trust did notcalculate in-patient falls; nor has the Trustcalculated its injurious in-patient falls, however,since this audit the Trust now calculates falls rateand injuries against occupied bed days

• At the time of the audit, the Trust had notundertaken any local audits to assess aspects offalls and bone health services; however the Trustnow undertakes quarterly audits.

Part 2


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The Prescribing Observatory for Mental Health(POMH-UK) runs national audit-based qualityimprovement programmes open to all mentalhealth trusts in the United Kingdom

The national clinical audits (POMH-UK) thatMersey Care NHS Trust was eligible to participatein during 2009 - 2010 are as follows:

i) The prescribing of high dose and combinationanti-psychotics on adult mental health acuteand intensive care wards: time-seriesbenchmarking POMH-UK

ii) POMH-UK baseline audit, ‘MedicinesReconciliation’

iii) POMH-UK audit 'Use of anti-psychotics inpeople with learning disabilities'.

Additionally the following audits were available

Screening for metabolic side effects of anti-psychotic drugs in patients treated by assertiveoutreach teams and assessment of the sideeffects of depot anti-psychotics. The Trust did nottake part in these topics.

The national clinical audits that Mersey Careparticipated in, and for which data collection wascompleted during 2009 - 2010, are listed belowalongside the number of cases submitted to eachaudit or enquiry as a percentage of the number ofregistered cases required by the terms of thataudit or enquiry.

POMH-UK audit 'Use of anti-psychotics inpeople with learning disabilities'

Thirty nine mental health trusts within the UnitedKingdom participated in the baseline audit of aquality improvement programme to address theuse of anti-psychotic medication in people with alearning disability. Nationally data was submittedfor 2,319 service users from 145 clinical teams.Mersey Care submitted 12 patient records from 2clinical teams.

POMH-UK baseline audit, ‘Medicines Reconciliation’

Nationally, 42 trusts submitted data for 1,790service users from 375 clinical teams. MerseyCare submitted 51 patient records from 11 clinicalteams. This was a baseline audit for a qualityimprovement programme addressing medicinesreconciliation. A re-audit is due to be conductedin September 2010.

The prescribing of high dose and combinationanti-psychotics on adult mental health acuteand intensive care wards: time-seriesbenchmarking POMH-UK

POMH-UK is due to publish the annual report inMay 2010 for the data entry period April 2009-March 2010. As of December 2009 the Trust hadsubmitted 126 entries relating to patient records.


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The reports of 10 local clinical audits were also reviewedby Mersey Care in 2009 - 2010 and actions taken in

response to the audit findings.

A summary of the audit findings is outlined below anddetails of the improvements achieved in these areas arerecorded within the minutes of each local governanceforum.

1. CONSENT TO TREATMENT - FINDINGS

• All Forms 38 must be reviewed annually

• All Forms 39 which are invalid must be reviewedimmediately

• Mental Health Act Commission (MHAC) 1 forms mustbe completed and stored as per the requirements ofthe MHA and as detailed within the Trust policy

• All discussions held with the patient must bedocumented in the clinical notes

• All qualified nursing staff and medics to ensure that theconsent to treatment form corresponds to medicationcurrently prescribed

• Consent to treatment forms must be attached to theprescription sheet.

Actions taken: This audit was presented to theClinical Governance Committee in April 2009. Sincethe audit the Checklist document has been revised tocapture more specific information required for theaudit and to include Mental Capacity Act information. A re-audit was scheduled and undertaken inNovember 2009. The audit results will be shared inJune 2010.

Part 2


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2. HANDLING MEDICINE (MEDICINEMANAGEMENT) – FINDINGS

• Ward staff and pharmacy staff to ensure thatinspections by pharmacy are recorded formonitoring purposes

• Management to decide whether it is sufficientfor any qualified staff to hold the keys or thatthe designated key holder must be the nurse incharge at all times and the policy to be revisedaccordingly

• Myrtle Ward to purchase a medicine cupboardor medicine trolley

• Wards to be reminded of the importance tosecure the medicine trolley when not in use

• Wards to be reminded of the importance tosegregate internal and external preparations.

Actions taken: This audit was presented to theClinical Governance Committee in March 2009.Since the audit, specific areas of the Trusthave agreed that all qualified staff are suitableto hold the keys to medicine cupboards andtrolleys. A re-audit was scheduled andundertaken in June 2010 and the report of thataudit is to be shared with the Trust in October2010.

3. AUDIT ON HEALTH RECORD KEEPING - FINDINGS

• Management to discuss the practice of MerseyForensic Psychiatry Services with regard tohand written documents being removed andreplaced by typed versions

• Consideration to be given to either merge TrustPolicies IT09, and IT06, or to revise Trust policyIT06 to include requirements of the MentalHealth Guidance: requirement 403, andpaperwork to be revised accordingly:

o All documents in the health record to includethe service user’s name

o All documents in the health record to includethe service user’s ID

o All documents in the health record to be filedchronologically.

Actions taken: This audit was presented to theClinical Governance Committee in April 2009.Since the audit staff have been briefedregarding proposed revision to Trust policyand improvement will be monitored throughre-audit. A re-audit is scheduled to be includedin the 2011 - 2012 clinical audit programme.

4. HANDLING OF SUSPECTED ILLICITSUBSTANCES – FINDINGS

• Management to agree whether it will assistmonitoring if a record is made to indicate that aDOOP container is not deemed appropriate

• Management to decide whether it is sufficientthat the DOOP container is denatured bypharmacy staff rather than a registered nurseand the policy to be revised accordingly

• The policy to be revised to ensure the sameterminology is used throughout when referringto the controlled drug register.

Action taken: This audit was presented to theClinical Governance Committee in June 2009.Since the audit discussions took placeregarding expanding the audit in future toinclude information stored on the patientelectronic systems. A re-audit was scheduledand undertaken in December 2009 and thereport of that audit is to be shared with theTrust in July 2010.


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5. SUPERVISION OF CLINICAL PRACTICE - FINDINGS

• Appendix 2 to the policy, Clinical SupervisionAgreement, to be amended to include a sectionto record the agreed frequency of sessions,allowing for this frequency to be reviewed whennecessary

• All staff who participate in supervision of clinicalpractice must complete a Clinical SupervisionAgreement document with their supervisor

• A Supervision Recording Form must becompleted during each supervision of clinicalpractice session

• Supervisors and supervisees must arrangesupervision of clinical practice sessions to takeplace during the supervisee’s normal workingweek, as specified within the policy

• The next audit of Trust policy SD33 to includethe following issues:

o Staff to explain reasons supervision of clinicalpractice sessions are held outside of theirnormal working week

o Staff to provide information regarding theirlack of preparation prior to entering asupervision of clinical practice session.

Actions taken: This audit was presented to theClinical Governance Committee in June 2009.Policy is being reviewed and a re-audit isscheduled to be undertaken in March 2011 andimprovements in practice will be monitored.

6. SERVICE USER MISSING FROM AN IN-PATIENT AREA – FINDINGS

• The audit results to be considered when thepolicy is revised

• Where the policy specifies ‘where further actionis needed’, staff must make it clear indocumentation that further action wasconsidered and deemed unnecessary to ensurethat a lack of further action is not misinterpretedduring future monitoring.

Actions taken: This audit was presented to theClinical Governance Committee in March 2010.Since the audit specific areas of the Trustmonitor staff compliance with the policyduring reflective practice reviews. Policy isunder review with a target completion date ofJuly 2010. A re-audit is scheduled to beincluded in the 2011 - 2012 clinical auditprogramme.

Part 2


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7. RESUSCITATION POLICY REQUIREMENTS - FINDINGS

• Emergency contact numbers to be put on alltelephones in in-patient areas

• Notices to be placed in in-patient servicesidentifying the nearest location of defibrillatorsand resuscitation bags

• The policy to be explicit regarding identifyingdesignated staff to undertake Basic LifeSupport (BLS)

• If the decision is made to withdraw firstresponder services from the Maghull site(outside high secure services) by HSS, thenconsideration is to be given to train other staffas first responders to cover the Maghull siteand this must be reflected in the policy.

Actions taken: This audit was presented to theClinical Governance Committee in August2009. Since the audit emergency contactnumbers and the location of equipment havebeen displayed in all in-patient areas. Thedecision to withdraw first responder servicesoutside HSS on the Maghull site has beentaken and the transition successfullyimplemented. A re-audit is scheduled to beincluded in the 2011 - 12 clinical auditprogramme.

8. COPYING CLINICAL CORRESPONDENCE - FINDINGS

• When a service user completes a consent formto indicate whether they do or do not wish toreceive copies of clinical correspondence, theform must be filed appropriately and the policyto specify where the form should be filed

• The address of a service user must be checkedat the time a letter is to be written and thepolicy to suggest the forum in which this checkshould be undertaken. (HSS to determinewhether a service user wishes correspondenceto be posted to their ward address or anexternal, postal address)

• When a service users expresses a wish toreceive copies of clinical correspondence everyattempt must be made to accommodate this,unless it is deemed inappropriate to do so, inwhich case a reason will always bedocumented

• The policy to specify that when it is deemedinappropriate to copy letters to service users,the reasons must be documented in the clinicalnotes

• Consideration to be given to the practice ofensuring service users are asked if they wouldlike to receive, and do receive, copies of clinicalcorrespondence to be included in the CPAprocess.

Action taken: This audit was presented to theClinical Governance Committee in January2010. Since the audit service users are nowasked whether they wish to receivecorrespondence at their annual CPA meeting.Specific areas of the Trust plan to develop alocal procedure which will better meet theneeds of their patient group. A re-audit isscheduled to be included in the 2011 - 2012clinical audit programme.


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9. SEARCHING SERVICE USERS AND PROPERTY - FINDINGS

• The audit results to be considered when thepolicy is revised

• Information leaflets to be obtained by wardmanagers and made available to service users

• Ward managers to ensure that service usersand visitors are made aware that searches maybe undertaken in accordance with the policy

• Staff to be reminded of the procedures to followwhen there is cause to necessitate a search:

o Justification for the search must always bedocumented in the clinical notes

o Reasons for the search must always beshared with the service user

o A clear rationale for the search must alwaysbe documented in the clinical notes

o The outcome of the search must always bedocumented in the clinical notes

o The service user’s feelings regarding thesearch must always be recorded in theclinical notes

• A designated Mersey Care Services SearchRegister document must be used in allinstances.

Action taken: This audit was presented to theClinical Governance Committee in March 2010.Since the audit specific areas of the Trustmonitor staff compliance with the policyduring reflective practice reviews. A re-audit isscheduled to be included in the 2011 – 12clinical audit programme.

10. PHYSICAL HEALTH CARE - FINDINGS

• A set of clinical standards for physical healthcare are to be devised

• The physical health screening tool to be revisedand an electronic version to be available onEPEX which will be integral to the CPA process

• Staff to be made aware of the importance tocomplete the assessment and store it in theservice user’s health record

• Staff to be made aware of the importance tocomplete all relevant sections of theassessment and to identify if / when a section isnot applicable to the service user.

Action taken: This audit was presented to theClinical Governance Committee in August2009. Since the audit the Physical HealthScreening Tool has been revised for useacross the Trust and incorporates clinicalstandards for physical health care. A re-auditis scheduled to be undertaken in November /December 2010 and the report of that audit willbe shared with the Trust in early 2011.

Part 2


19

Research Activity

The number of patients recruited during 2009 - 2010 to participate in research approvedby a research ethics committee was 424. Duringthe period April 2009 to March 2010, 41 studiesrecruited service user and carer participants. Ofthese studies the breakdown of participants was413 service user and 11 carers.

Commissioning for Quality and Innovation(CQUIN)

A proportion of Mersey Care income in 2009 - 2010 was conditional on achieving qualityimprovement and innovation goals agreedbetween the Trust and any person or body theyentered into a contract, agreement orarrangement with for the provision of NHSservices, through the Commissioning for Qualityand Innovation (CQUIN) payment framework.

The performance management report producedfor the Board each month details the achievementagainst CQUIN targets.

Care Quality Commission: Registration and Inspection

Following introduction of the new regulatorystandards for quality and safety the Trust isrequired to register with the Care QualityCommission and its current registration status is‘Registered without Conditions’. The Care QualityCommission has not taken enforcement actionagainst Mersey Care NHS Trust during 2009 - 2010.

The Trust has participated in special reviews orinvestigations by the Care Quality Commissionrelating to the following area during 2009 - 2010:

• Inspection report on the prevention and controlof infections on 21st and 22nd October 2009.

At an un-announced follow-up inspection, fullassurance was provided on the three areas forimprovement raised by the Care QualityCommission.

Data Quality

The Trust submitted records during 2009 - 2010to the Secondary Uses Service for inclusion in theHospital Episode Statistics which are included inthe latest published data. The percentage ofrecords in the published data:

• which included the patient’s valid NHS number was:

74.5% for admitted patient care;

81.3% for outpatient care.

• which included the patient’s valid GeneralMedical Practice Code was:

100% for admitted patient care;

99.9% for outpatient care.

Mersey Care’s provisional score for 2009 - 2010for Information Quality and Records Managementassessed using the Information GovernanceToolkit was 86%.

Mersey Care NHS Trust was not subject to thePayment by Results clinical coding auditduring 2009 - 2010 by the Audit Commission.


20

Review of Quality Performance

In addition to the measures outlined in the three priority areas, the Trust routinely tracksperformance against the following measures:

Accommodation status

Admissions and occupiedbed days for patientsunder 18

Delayed transfers of care

Quality-Clinical Effectiveness

Quality-Patient Experience

% of service users on currentcaseload who have had theiraccommodation status recorded

Number of occupied bed daysfor patients aged under 18 on anadult ward

< previous year green; >previous year red

>=80% green; 60%-80%amber; <60% red 16.63%

208

Number of admissions ofpatients aged 17 or under toacute psychiatric wards

From Jan 10 =0 admissionsgreen; >0 red unless authorisedby commissoners

1

% of occupied bed daysaccounted for by delayedtransfers of care (including leave)

<=7.5% green 7.5%-15%amber; >15% red 10.04%

Employment status

Readmissions

% of service users on currentcaseload who have had theiremployment status recorded

>=80% green; 60%-80%amber; <60% red 17.78%

Cancellations by provider % of booked outpatientappointments cancelled by provider

<10.18% green; >=10.18%-<=14.45% amber; >14.45% red

% of booked outpatientappointments cancelled by provider

<8.49% green; >=8.49%-<=10.66% amber; >10.66% red

11.40%

Cancellations by service user 12.17%

% of patients on CPA who havebeen recorded as having beenoffered a copy of their care plan

>95% green; 85%-95% amber;<85% redPatients on CPA offered a copy

of their care plan80.65%

% of service users on currentcaseload who have had theirethnicity recorded or do not wish tostate ethnicity

>=95% green; 90%-95% amber;<90% red

Service user ethnicity94.12%

Number of service users not seenwithin 6 weeks of referral by GP

0 breaches green; >0 redWaiting times-Outpatients 56

Number of service users waitingmore than 6 weeks for theirappointment as at month end.(Excludes Low and Medium SecureServices.)

0 waiting over 6 weeks green;>0 red

Waiting times-PsychologicalServices 30

Readmissions within 28 days ofdischarge as % of totaladmissions. Excludes Addictionsand Learning Disabilities servicesand admissions from other NHSproviders

<=5% of admissions green;5%-6% amber; >6% red

4.36%

Readmissions within 90 days ofdischarge as % of totaladmissions. Excludes Addictionsand Learning Disabilities servicesand admissions from other NHSproviders

<=7% of admissions green;7%-10% amber; >10% red

8.22%

Indicator Description ThresholdsPerformance

2009 - 10

Part 3


21

Bed occupancy-LocalServices

Quality-Patient Safety

Occupied bed days excludingleave as a % of available beddays

>80% - <=90% green; >75%- <=80% or >90% - <=95%amber; <75% or >95% red

83.01%

Bed occupancy-Low andMedium Secure Services

Occupied bed days includingleave as a % of available beddays

>=85% - <=95% green;>95% or <85% red 91.77%

Bed occupancy-High SecureServices

Incidents

Occupied bed days excludingleave as a % of available beddays

>=91%-<=95% green;>=89%-<91% or >95%-<=97% amber; <89% or>97% red

91.18%

Workforce-Sickness absence % of available time lost due tostaff sickness

<=5.65% green; 5.65%-6.65% amber; >6.65% red 6.17%

Workforce-PersonalDevelopment Plan

% of staff recorded as havinghad a PDP review within the last12 months as at quarter end

>= 90% green; 80%-90%amber; <80% red 61.00%

Workforce-Knowledge andSkills Framework

% of posts recorded as having aKSF outline as at quarter end

>= 90% green; 80%-90%amber; <80% red 96.00%

Number of 'Never Events' asdefined by the National PatientSafety Agency

0 green; >0 red 0

Number of escapes-High Secure 0 green; >0 red 0

Number of escapes-MediumSecure

0 green; >0 red 0

Number of absconds from leaveof absence-High Secure

0 green; >0 red 0

Number of absconds fromescorted leave-Medium Secure

0 green; >0 red 3

Absconds from unescorted leaveas a % of total unescorted leave-Medium Secure

0%-5% green; 5%-10%amber; >10% red 0.01%

Indicator Description ThresholdsPerformance

2009 - 10


22

Consultation Process

Mersey Care NHS Trust is committed to involvingall stakeholders and has a structured consultationprocess in place to gather opinion and feedbackfrom service users and members of the publicincluding the use of NHS Choices and the PatientOpinion website and has utilised this involvementto inform the content of our Quality Report.During the consultation a number of constructiveand pragmatic suggestions were made as to howwe could enhance this process and ensuregreater and more regular contributions to theconstruction of a meaningful Quality Report.

These proposals and enhancements will beadopted as part of the programme of work for2010 - 2011 which will see much greaterengagement with all our stakeholders includingour local LINks networks.

As part of the Trust’s commitment to equality anddiversity in line with current legislation, thisdocument has also been impact assessed by theequality and diversity team.

We have involved service users and carers withthe purpose of securing their input into thisdocument regarding its content and helping us toidentify those areas which should be considered apriority for quality improvement. As part of thework to establish systems which will embedsystematic improvement and learning in the Trust,service users and carers have identified a numberof explicit areas of the ‘patient experience’ whichthey want the Trust to take greater account of,and to monitor progress against during 2010 - 2011. The future development of theTrust’s Quality Account will therefore ensure anactive level of engagement with members of theservice user and carer forum and otherstakeholders to capture the patient experience ona more sustained and responsive basis.

External Perspective on Quality of Services

We have also consulted with our commissionersin Liverpool, Sefton and Knowsley to ensureagreement on the key priorities and have soughtthe views of local LINks and the Overview andScrutiny Committee both to obtain a directperspective of Mersey Care’s Quality Accountfor 2009 - 2010 and to determine a collaborativeand ongoing approach to supporting quality and improvement.

The Trust has received feed-back from localLINks. These responses acknowledged the needto build more substantive relationships with theTrust to ensure the issues contained with theQuality Account are addressed in a sustainableway that will ensure openness and appropriatechallenge. Specific comments about the contentand style of the report have to some extent beenincorporated into it. The distinctions anddifferentiations between services and specialitiesrequested by Sefton LINks have beenincorporated into the public report and a glossaryof terms will be produced to accompany thepublication of the report in future. The full writtennarrative from our lead commissioner and SeftonLINks are attached in Appendix 1.

The Quality Account was finalised andconfirmed at the June Trust Board meetingand published on the Trust’s website on 30th June 2010.


23

Commissioning PCT Statement

On behalf of Liverpool Primary Care Trust, thelead commissioner for Mersey Care NHS Trust Iwould like to acknowledge the progress made inthe drive to deliver high quality care for all thoseusing their services.

As Director for Service Improvement andExecutive Nurse in Liverpool PCT I can confirmthat to the best of my knowledge this QualityReport is a true and accurate reflection of the2009 - 2010 progress Mersey Care NHS Trust hasmade against the identified quality standards. TheTrust has complied with all contractual obligationsand has made good progress over the last yearwith evidence of significant improvements in keyquality measures.

Liverpool PCT is supportive of the processMersey Care NHS Trust has taken to engage withpatients, staff and stakeholders in developing aset of quality priorities and measures for 2010 - 2011 and applaud their continuedcommitment to improvement.

We find the submitted Quality Report to representan appropriate level of effort and areas of focusfor service improvement and we look forward toMersey Care NHS Trust continued improvementof quality standards in 2010 - 2011.

Trish Bennett

Director for Service Improvement & Executive Nurse

Liverpool Primary Care Trust

Sefton Local Involvement Network (LINk)response to Mersey Care NHS Trust QualityReport 2009 - 2010

It appears that the Trust is presenting generalinformation as opposed to detailed and conciseaccounts of the individual areas. We felt anintroduction to Mersey Care and its serviceswould have been helpful. In addition to thisintroduction, further details of the sites andservices provided across Merseyside would havealso been helpful.

We were pleased to see the addition of audits anddetails of services, medicines, wards and facilitieswere included, but for the reasons stated above,we were unable to put these in the geographicalcontext of the areas covered by Mersey Care.

We could find no reference to hospital dischargewithin the Report.

There is no clear definition between mental healthservices and learning disability services. This is inreference to patients and service users of MerseyCare. Sefton LINk feels strongly that there shouldbe a clear distinction between these conditions.

We felt a glossary or some explanation of termswould be a helpful addition to the report,especially if it were intended to be viewed by thegeneral public.

We would like to commend the Trust on theirpatient involvement strategy and we feel this is apositive area that has been well presented in theReport. While Sefton LINk welcomes the fact thatthe Mersey Care report are brief, we feel thatmore details and substance should have beenincluded.

Ann Bisbrown-Lee

Chair, Sefton LINk Steering Group

Appendix 1


Mersey Care NHS Trust

Communications Department

Trust Offices

Parkbourn

Maghull

L31 1HW

0151 473 2885

www.merseycare.nhs.uk


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