service experience desk annual report 2012/13 · service experience desk annual report 2012/13 9...

Dudley and Walsall Mental Health Partnership NHS Trust

Service Experience Desk Annual Report 2012/13 1

Service Experience Desk Annual Report

2012/13 (Incorporating Complaints, Compliments and PALs)



Contents 1 INTRODUCTION ................................................................................................................................................... 3

1.1 CHAIR’S AND CHIEF EXECUTIVE’S FOREWORD ................................................................................................................ 3

2 ABOUT THE TRUST .............................................................................................................................................. 4

2.1 OUR VISION AND VALUES .......................................................................................................................................... 4

3 SERVICE EXPERIENCE DESK ACTIVITY................................................................................................................... 6

3.1 COMPLAINTS MANAGEMENT ..................................................................................................................................... 8 3.2 LEARNING FROM FEEDBACK ..................................................................................................................................... 10

4 SERVICE EXPERIENCE - THE FULL PICTURE ..........................................................................................................12

5 KEY ACHIEVEMENTS 2012/13 .............................................................................................................................12



1 Introduction

1.1 Chair’s and Chief Executive’s Foreword

Welcome to the Service Experience Desk annual report from Dudley and Walsall Mental Health Partnership NHS Trust.

As a provider of services, we are committed to ensuring that representatives of those people who use our services and their carers are fully integrated within our decision-making and governance structures. On a day-to-day basis, we work closely with a wide range of Service User and Carer organisations across the two boroughs, seeking their views and ensuring their participation in the planning and delivery of services.

Patient knowledge and experience are essential for understanding how best to improve care. The very best user and carer involvement harnesses a passion for making things better and over the past year, we have made enormous progress with implementing and expanding our involvement strategy.

Our commitment to putting service users and carers at the heart of everything we do is demonstrated by the way that service user and carer involvement is taken into consideration at the forefront of new projects, initiatives and developments. We try to focus on the things that matter the most for patients, communities and staff and emphasise a culture of genuine engagement, involvement and transparency.

This report reviews the overall process for the management of complaints, concerns and compliments received from service users, carers or their representatives, by the Trust‘s Service Experience Desk. This also incorporates the traditional PALs function (requests for information and advice, signposting and quick resolution of concerns).

In addition, the report will review actions taken to improve services and highlights key achievements over the past twelve months.

The contents of this report specifically meet the requirements set out for Complaints Annual Reports in section 18 of the Local Authority Social Services and National Health Service Complaints (England)

Regulations 2009. The requirements state that the report should specify:

the number of complaints which the responsible body received

the number of complaints which the responsible body decided were well-founded

the number of complaints which the responsible body has been informed have been referred to—

the Health Service Commissioner to consider under the 1993 Act; or

the Local Commissioner to consider under the Local Government Act 1974

And the report should summarise:

the subject matter of complaints that the responsible body received

any matters of general importance arising out of those complaints, or the way in which the complaints were handled

any matters where action has been or is to be taken to improve services as a consequence of those complaints

Glyn Shaw – Chair Gary Graham – Chief Executive



2 About the Trust

Dudley and Walsall Mental Health Partnership NHS Trust was formed on 1st October 2008 and specialises in the treatment of both common and complex mental health conditions in children, adults and older people. It provides a comprehensive range of mental health and social care services, including:

Community mental health services for children, adults & older people

Inpatient services for adults and older people

Primary Care Mental Health services (including IAPT)

Mental Health Social Care Services (via local authority partnerships)

Psychological Therapies

Substance Misuse Services

Employment, education and training support for people with mental health problems

Specialist Deaf CAMHS (national hub)

The Trust predominantly serves the people of the Black Country boroughs of Dudley and Walsall within the West Midlands, with a combined population of around 560,000. The Trust provides services from 28 sites (including 3 hospitals) across the two boroughs.

In 2012/13, the Trust had over 327,600 contacts with services users, received around 24,055 referrals from GPs, treating just over 1,150 inpatients and holding around 22,916 outpatient consultations.

The Trust employed 1,227 health and social care staff and received an income of £71.3m.

2.1 Our Vision and Values

The Trust‘s vision is one of a recovery oriented service. The vision, encapsulating the concept of the benefits arising from a single mental health trust for the populations of Dudley and Walsall, is shown below.

The Trust‘s vision has been guided by national, regional and local intelligence and strategies where there is a growing emphasis on the well-being of the population and a focus on prevention and early detection and intervention.

The Trust is committed to upholding the principles and values of the NHS in England (NHS Constitution, 2009). There are seven key principles that guide the NHS in all it does. They are underpinned by core values which have been derived from extensive discussions with staff, patients and the public.

The core values of the Trust also reflect the NHS Constitution and are significant in that they inform attitudes and therefore behaviours of staff. The Trust‘s core values are:

Figure 1 Trust Values

Respect and dignity Commitment to quality of care

Compassion Improving lives

Working together for patients Everyone counts

„Recovery is not just about what services do to or for people. Rather, recovery is what people

experience themselves as they become empowered to manage their lives in a manner

that allows them to achieve a fulfilling, meaningful life and contributing a positive sense

of belonging in their communities‟ (NIMHE, 2005).

“Better Together - delivering flexible, high-quality, evidence-based services to enable people to achieve recovery.”



These values are realised within the Trust‘s everyday practice and are at the heart of the organisational development agenda. The Trust reviews and reflects upon the appropriateness of its vision, values and principles each year prior to defining the annual objectives.

Now well-established, the Trust is building on a position of robust performance and governance to become a high-performing mental health Foundation Trust.



3 Service Experience Desk Activity

During the period April 2012 to March 2013, we received a total of 74 formal complaints, 182 concerns and 262 compliments. SED handled 781 new cases, which involved around 7,000 contacts. 688 of cases are attributable to Service lines. The remaining 93 are attributable to corporate functions, trust generic or non-specific.

This includes complaints, concerns, compliments, suggestions and requests for information. This feedback comes from service users, carers or their representatives and from other organisations such as commissioners or MPs.

Figure 2 SED Activity by Type (Top 5)

Case type Number

Compliments 262

Informal concerns 182

Informal enquiries 134

Formal complaints 74

Potential complaints 36

SED activity is shown below broken down by the Trust‘s five service lines.

The Trust is structured into five operational service lines: Older Adults, Acute, Recovery, Community and Early Intervention. The service line portfolios are shown below. SED activity is proportionate to the size of the service and the nature of the service users in those services, for example, the Trust finds that older adults and young people are less to complain than working age adults.

Figure 3 Service Line Portfolios

Service Lines

Early Intervention Services

Community Services

Recovery Services

Older Adults Acute Services

Primary Care Mental Health

Improving Access to Psychological Therapies (Dudley)

Children & Adolescent Mental Health

Eating Disorders

Early Intervention in Psychosis

Deaf Child and Family Mental Health

Community Recovery Service Teams (CRS)

Assertive Outreach

Psychology

Transfer and Transition Team (TTT)

Criminal Justice/Offender Liaison

Day Services

Early Access service (EAS)

Rehabilitation Inpatients (Walsall)

Vocational services

Carers service

Crisis beds

Substance Misuse

Wards

Day Services

Community Mental Health Teams

Memory Service

Outpatients

Wards

Crisis Resolution Home Treatment

Psychiatric Liaison

Electro Convulsive Therapy

Medical Records

Outpatients



Figure 4 SED Feedback Received 2012/13

The number of complaints received is relatively small compared to the number of patients we see and treat each year.

The chart below shows SED activity by Type. Compliments are the largest category, with attitude of staff as the highest cause group within that. The ―other‖ category is primarily requests for information (i.e. PALs).

Figure 5



3.1 Complaints Management

Despite our focus on quality, we recognise that sometimes people‘s experience of our services is not as positive as we would hope.

In October 2007, the Health Service Ombudsman published ‗Principles for Remedy‘ as an overall good practice guide for public bodies in dealing with complaints. Our complaints policy is based around these principles which are:

1 Getting it right

2 Being customer focused

3 Being open and accountable

4 Acting fairly and proportionately

5 Putting things right

6 Seeking continuous improvement

Of the 74 cases in 2012/13, 53 were closed within the timescales stipulated in our policy (45 working days),

3.1.1 Number of Formal Complaints Received

In 2012/13, the Trust received 74 formal complaints, 72 of which were attributable to the five service lines. This is shown in the chart below along with the number of informal concerns and cases referred to the ombudsman.

Figure 6 2012/13 Complaints and Concerns Summary

Informal Concerns Formal Complaints PHSO

2012/13 Live at Apr 30th



Acute 72 7 22 8 3 2

Community 45 4 23 6 1 2

Early Intervention 21 3 11 2 0 0

Recovery 11 1 7 1 0 0

Older Adults 12 0 9 7 2 2

Total 161 15 72 24 6 6

3.1.2 Complaints referred to the Parliamentary Ombudsman

The points below summarise the six cases referred to the ombudsman:

8 complaints were live during this period with the PHSO.

6 Notifications were received from the Ombudsman during this reporting period in relation to formal complaints, 2 of which involved a serial complainant.

1 further notification was received in relation to a complaint that we had recorded as informal as dated back over 25 years.

1 further case ongoing, originally notified prior to this reporting period (07/03/11) in relation to a case that has been ongoing since July 2010.



3.1.3 Outcome of Complaints

Of the cases in 2012/13, 60% were upheld or partially upheld. The decision to uphold a case or not is made following a full investigation that involves the scrutiny of notes and records, interviews with staff and service users as appropriate. The table below summarises this.

Figure 7

Outcome of Closed Complaints

Number

Not upheld 13

Upheld 10

*Partially Upheld 33

Withdrawn 7

Closed due to no response 2

Ongoing 9

TOTAL 74

*Partially upheld outcomes are counted as upheld for KO41 reporting purposes.

3.1.4 Nature of Complaints and Concerns Received

The charts below show the nature of the complaints and concerns received by the Trust in 2012/13. Care and treatment, like within most Trusts is the highest category for formal complaints with attitude of staff the next highest.

Figure 8



Figure 9

3.2 Learning from Feedback

The Trust takes an active approach to resolving concerns before they escalate to formal complaints. We also provide feedback to staff about what changes have been made as a result of complaints and concerns.

Over the past twelve months our eight EBEs have been significantly involved in raising awareness of Trust activities and gaining valuable feedback from service users and carers. We have also gained essential and valuable feedback via informal concerns and comments from the Service Experience Desk.

Here are just a few of the selected actions that have been carried out as a result of feedback from those who use our services, their relatives and carers.

Figure 10 Comments and Actions Taken

You Said We Did

You wanted clearer signs for the Outpatients Department at Dorothy Pattison Hospital.

We provided additional signage for the Outpatients Department to clearly signpost it from the main reception area in the hospital.

You felt that awareness and access to a ‗Quiet Garden‘ at Dorothy Pattison Hospital was limited.

We put up posters informing of access to the garden which is facilitated by staff, with support from Occupational Therapy Assistants. It is also part of the ward activity schedules.

You were not sure you had seen a copy of your Care Plan.

We put posters in Outpatients to ensure that patients were aware that they had seen a copy of their care plan. We introduced ‗orange front sheets‘ to clearly indicate to patients their Care Plan.

As a result the National NHS Community Mental Health Service User Survey, have found that this year we have seen an increase in the number of people who have been given (or offered) a written or printed copy of their Care Plan.

Access to the crisis number was The out of hours CRHT telephone number had a call-waiting service installed and as a result, it was identified that the telephone does not register an



not easy. Rings out constantly. engaged tone when that telephone is in use. This may give callers the mistaken impression that it is just ringing out, when in actual fact the line is busy.

Immediate action was taken to deactivate the call waiting service on CRHT mobile phones in order to give an engaged tone so service users will be aware that the line is in use.

Availability of thyroid tests on admission.

All patients admitted to hospital are to be screened for thyroid problems without exclusions.

Understanding of personalisation was causing concern.

The personalisation process was looked into and further guidance provided to staff.

Leaflets also provided to hand to patients/carers to enable them to have a clearer understanding of the process.

The pathway from a mental health hospital to an acute hospital was unclear and distressing.

Improved communication between Trust staff and hospital staff.

3.2.1 Compliments

Over the last twelve months we are pleased to say we have also received 262 written compliments from people who have accessed our services, highlighting cases where the quality of our services has been recognised and appreciated.

Care and treatment provided by staff 243

Communication 1

Service Information (ie courses/groups) 18

The Service Experience Desk (SED) features, ―On a Happy Note‖ highlights the positive comments made by service users about their care by posting a selection of experiences from service users on the Trust Intranet every month.

Some examples of what people have said about our services are shown below.

Figure 11 Examples of compliments received by the Trust

“Thank you so much for all your help. I couldn‟t have come this far without you. I really appreciate all your patience and understanding.”

“I appreciate everything you did to help me successfully find a job which has really helped my life be happier.”

“You have been a great help to me in my time of need and you have helped me turn my life around and begin to see life in a more positive light after many, many years of negativity and increasing worries and

anxiety.”

“It's been a very difficult journey for my wife and I over the past several months - but in part to the well running of the ward and the interested and caring attitude of staff both on Clent and Wrekin I'm finally

where I want to be.”

“The world's a BETTER place because of people just like you. You are caring and giving. I want to say thanks for your time and effort helping me when I needed it. You have been there for me.”

“Thank you so much for all that you have done, we now have our „old son‟ back thanks to your services”

Overall we received 5 fewer complaints than last year, despite seeing a greater number of patients, and we received 48 more compliments about our staff and services.



4 Service Experience - the full picture

As well as gathering feedback about our services through SED, the Trust also has a Service Experience Lead who co-ordinates and reports on other forms of service experience feedback, for example:

Friends and Family test (Net Promoter)

National Surveys

Local Surveys (run by teams)

Focus groups

Ward and service visits buy our Experts by Experience, Community Development Workers and local mental health support groups (Walsall SUE and Dudley SAMh).

The findings of this work triangulates well with SED activity and feeds into our embedding lessons process described in section 3.2.

5 Key Achievements 2012/13

2012/13 was a busy year for the Trust‘s Service Experience Desk. As well as efficiently handling over 700 new cases, the team also achieved a number of improvements in how SED operates:

Introduction of the CMAP (our Complaint Management Action Plan)

SED Visibility sessions

Feedback Questionnaire (complaints process)

Redesigned SED leaflets

Enhanced reporting by Service Line

In 2013/14, the Trust will focus on further improvements to embedding lessons processes and a more effective use of the Safeguard system to capture all feedback received from service users, carers and their representatives. The Trust will also be using iPad technology to carry out local services.

service experience desk annual report 2012/13 · service experience desk annual report 2012/13 9...

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