agenda - Berkshire Healthcare NHS Foundation Trust

Transcription

COUNCIL OF GOVERNORS
The next meeting will be held on Thursday 11th December 2014 starting at 10.15am
At Easthampstead Baptist Church, South Hill Road, Bracknell
(At 9:45am prior to the start of the formal meeting, Governors will have the opportunity for a private
meeting with Angela Williams, Non-Executive Director)
AGENDA
ITEM
DESCRIPTION
PRESENTER
1.
Welcome & introductions
Chair
2
2.
Apologies for Absence
Company Secretary
1
3.
Declarations of Interest
1
1. Amendments to Register
All
2. Agenda items
All
4.
Minutes of previous meetings – 24 September
2014 (Enclosure)
Chair
5.
Matters Arising including:
•
6.
Hospital at Home Update (Verbal)
2
5
Director of Nursing & Governance
Committee/Steering Groups
1. Reports:
a. Living Life to the Full (Enclosure)
b. Membership & Public Engagement
(Enclosure)
c. Quality Assurance (Enclosure)
d. Governor Visits (Enclosure)
TIME
20
John Barrett/Verity Murricane
Philip Brooks
Gray Kueberuwa
John Tonkin
7.
Big Conversations with Patients & Carers
Elaine Williams, Listening into
Action (LiA) Lead
20
8.
Quality Account 2014/15
Medical Director
15
9.
Executive Reports from the Trust
1. Performance Report (Enclosure)
2. Patient Experience Quarter 2 Report (Enclosure)
20
Chief Executive
Director of Nursing & Governance
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10.
Audit Matters:
1. Audit Committee Annual Report (Enclosure)
2. Annual Audit Letter (Enclosure)
3. External Auditors Quality Governance Report
(Enclosure)
11.
Chair’s Remarks, including:
•
Keith Arundale, NED, Audit Chair
KPMG
KPMG
10
5
5
Chair
10
All
10
Partnership Organisations (Enclosure)
12.
Any Other Business/Governor Questions
13.
Date of Next Meeting
th
5 February 10am Joint Board/Council
th
18 February 10am Council of Governors
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Council of Governors
Meeting - Wednesday 24th September 2014
Minutes
In attendance:
John Hedger, Trust Chair
Public Governors
Ruffat Ali-Noor
Amrik Banse
John Barrett
Peter Bestley
Dolly Bhaskaran
Philip Brooks
Veronica Cairns
Mavis Henley
Gray Kueberuwa
June Leeming
Robert Lynch
Verity Murricane
Paul Myerscough
Pat Rodgers
Gary Stevens
Staff Governors
Paul Corcoran
Julia Prince
Appointed Governors
Adrian Edwards
Bob Pitts
Ali Melabie
Craig Steel
Bet Tickner
In attendance:
Julian Emms, Chief Executive Officer
Alex Gild, Director of Finance, Performance & Information
Helen Mackenzie, Director of Nursing
Chris Fisher, Non-Executive Director designate
John Tonkin, Company Secretary
Caroline Comer-Stone, Executive Assistant
Apologies:
Public Governors:
Michelle Chestnutt
Staff Governors:
Jeremy Lade
Amanda Mollett
Appointed Governors:
Sabia Hussain
Alan Kendall
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1.
Welcome & Introductions
John Hedger, Chairman, welcomed all to the meeting including Chris Fisher, new
Non-Executive Director. The Chairman noted his pleasure in seeing Gary Stevens
returning to the Council of Governors after a period of ill health.
2.
Apologies
Apologies for absence were received as noted above.
3.
Declarations of Interest
3.1
3.2
4.
Amendments to Register –
Declarations of Interest -
there were none declared
there were none declared
Minutes of the previous meeting – 21 May 2014 & 24 July
The Minutes of the previous public meetings of 21 May 2014 and 24 July were
agreed as a correct record and duly signed by the Chairman.
Robert Lynch requested further explanation about the CAMHs Tier 3 & Tier 4
services; John Hedger advised there would be an opportunity for this later in the
meeting.
5.
Matters Arising
There were no Matters Arising not otherwise covered on the agenda
6.
Committee/Steering Group Reports – John Barrett/Verity Murricane
6.1
Living Life to the Full
Governors received an update (which was taken as read) from John
Barrett/Verity Murricane on the business of the Living Life to the Full group.
Highlights were noted:
•
•
•
•
•
The appointment of a Muslim women’s visitor to Prospect Park Hospital
Community mapping concerns – to be discussed with Jayne Reynolds at
the locality meeting; further discussions to take place with MarComms.
December conference on compassion: 4 Governors attending.
Following a short helpful presentation from Elizabeth Daly, Head of
Service Engagement and Experience, Patient Experience, concerns
remain that the opinions of a sufficiently diverse selection of Mental
Health services users are not being included with the same people
responding to surveys and questions. Verity Murricane noted the
importance of achieving a representative view of service users. John
Hedger agreed that this was an important point and will no doubt be
discussed later in the Patient Engagement report.
Mindfulness: Becca Lacey, Locality Manager, Children & Families, has
joined the group and is looking to take the mindfulness programme
forward in the Trust.
The co-chairs offered their thanks to Mark Hardcastle for his invaluable
contribution over the life of the group noting that he would be moving to other
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areas of work in the Trust but that staff representation was good going
forward in the future.
6.2
Membership & Public Engagement
Philip Brooks advised that a mechanism is now in place on the Trust website
for members of the Trust and the general public to contact Governors via
email. Such emails will be coordinated by the Company Secretary John
Tonkin. There was a great deal of discussion about the use of individual
emails with the balance of opinion noting that this is a good start.
In terms of raising Governor profiles, it was suggested that photographs of
Governors be available at Trust sites and on the website.
With regard to the programme of Governor visits, Philip Brooks thanked those
Governors who had participated, noting that these visits are very much
appreciated by staff.
Paul Myerscough noted his concern about membership and public
engagement particularly highlighting the purpose of governorship as a conduit
for interface between the Trust and members/general public. He also pointed
out limited membership of 10,000 to which John Hedger replied that the Trust
policy concentrates on quality rather than quantity but that there is no
intention of limiting membership. With regard to the Terms of Reference,
Governors were asked if ‘and members of the public’ should be added to 2.2,
2.4 and 2.6. Council agreed that the amendments should be made.
Adrian Edwards voiced his disappointment to note that West Berkshire
membership was the lowest in percentage terms and requested further effort
to increase the figure. Philip Brooks commented that recruitment is difficult in
an area of dispersed population and it remains a challenge.
6.3
Quality Assurance
The report was taken as read with Gray Kueberuwa advising that the quality
visit reports are seen by the Executive Directors.
Several quality visits have been conducted since the last Council meeting
with no duplication of visits to the Governor general visit programme. With
regard to Oakwood ward no report was submitted as this was mainly an
opening day. There were confidentiality issues in respect of Winterbourne
House so an anonymised report has been submitted.
Members were pleased to note the accreditation of memory clinics particularly
with Wokingham receiving further accreditation and meeting every national
standard.
Compliments and complaints were discussed with Helen Mackenzie who
gave further explanation of points raised. John Hedger noted the importance
of Governors understanding the complaints process and how this is handled
by the Trust and in gaining further assurance.
With regard to visits, Helen Mackenzie is instrumental in drawing up the list
and this ensures a good balance between mental health and community
services. Following a request in the Terms of Reference that a staff Governor
be included, Gray Kueberuwa was approached Paul Corcoran, staff Governor
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non-clinical, who has now joined the group. This amendment was approved
by Council.
ACTION:
6.4
7.
Amend ToR to reflect staff Governor, John Tonkin
Reference Group
John Hedger noted that this was an ad-hoc group and has had no immediate
need to meet recently.
Annual Plan 2013/14 Annual Report & Accounts
Governors received and noted the 2013/14 Annual Report and Accounts.
Julian Emms noted that the Trust is operating in a very difficult environment with 14
commissioners covering a population of 1 million people. There are many pressures
on healthcare with local authorities making cuts and Monitor, the CQC and Ofsted
overseeing operations. In conclusion, the Trust had secured a good year having
delivered against plan and maintained a positive quality reputation.
The Annual Report included many references to service development and innovation.
In terms of mental health, west Berks commissioners asked the Trust to support care
homes. As a result, an in-reach team now attends care homes providing dementia
education amongst other things and, as a result, care has markedly improved for
residents. All mental health services were moved into Prospect Park Hospital with a
specific team (ASSIST) to address personality disorder. Talking Therapies is a
nationally recognised gold standard service and this has been extended to people
with physical health conditions and medically unexplained symptoms.
A single point of access now exists for CYPIT (Children and Young People Integrated
Therapy) with schools and parents with a multi-disciplinary team providing education
for ongoing therapy. There is a rapid assessment community clinic in east Berks
which is helping to prevent admissions mainly of frail elderly. The Health Hub now
enjoys simplified access with one telephone number; the next stage is TeleHealth
and deployment of additional resources.
For the second year running, the Trust was in the top 10% of Trusts for staff
engagement. Every manager has been through the Excellent Manager programme
with the Exec Team undertaking a bespoke version. Talent management and
succession planning is ongoing. The Listening into Action programme has shown
significant engagement with frontline staff in terms of making a difference to patients.
With regard to finance, the need is to ensure tax payer money is spent effectively. 5
particularly workstreams have been identified as part of the strategy refresh activity
which will be discussed next year in further detail:
•
•
•
•
•
Growing – e.g. bidding for sexual health services
Protecting existing services to ensure retention
Optimising current services and back office
Internal integration and pathway extensions
Estates strategy
Robert Lynch offered his congratulations on achieving a surplus in 2013/14 noting
that there is a wealth of business experience amongst Governors which can be
utilised. Bet Tickner enquired if the Health & Wellbeing Boards are helpful to the
Trust. Julian Emms commented that these boards are as yet in their infancy and
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would be helped by the inclusion of innovators and providers. With reference to the
Better Care fund it was reported that it has encouraged partners to work more closely
but will not address the major gaps in NHS budgets.
Governors pointed out the importance of the third sector voluntary organisations;
Verity Murricane emphasised the importance of this sector and the need to find
effective ways of working with small organisations delivering niche services e.g.
housing providers.
ACTION:
Philip Brooks to discuss with Clare Bright
Alex Gild, Director of Finance, Performance & Information highlighted the good
performance in conjunction with stabilising work on strategic plans. He noted a much
tighter financial position in year with operating costs pressures in terms of demand on
services but overall a good stable year going forward.
The 2013/14 Annual Report & Accounts were formally received.
8.
Appointment of Vice Chair of the Trust
In light of the departure of Peter Warne, NED, John Hedger sought Council approval
for the appointment of Keith Arundale, Non-Executive Director as Vice Chair of the
Trust. This was agreed unanimously.
9.
Council of Governors Annual Review
The written review of the work of the Council which had been circulated with the
agenda will be presented to the AGM later in the day by Mavis Henley and John
Hedger. Mavis Henley pointed out that at last year’s AGM, the membership was
asked to pass changes to the constitution with regard to new responsibilities under
the new Social Care Act and this reports outlines progress to date.
The review was noted and endorsed.
10.
Executive Report from the Trust
10.1
Performance Report
The Performance report was taken as read. Clarity was provided around CQC
ratings and financial results which showed release of reserves pulling the
position back to breakeven.
10.2
Patient Experience Annual Report
The Patient Experience Report was received and noted. Helen Mackenzie
noted in particular performance improvement in terms of complaints response
times.
10.3
Patient Participation Strategy – Implementation Plan
Helen Mackenzie presented the report which provided an update particularly
in respect of a series of workshops being held asking patients and the general
public how the Trust could engage more effectively. John Hedger expressed
the hope that Governors would be amongst contributors to the services
reflecting the view of constituents.
Verity Murricane applauded the initiative but questioned the means of
publicising the meetings in order to reach as many people as possible
particularly in mental health. Helen Mackenzie advised that the Trust is
5
working with a marketing company as well as drawing on the work of
commissioners who are very successful at achieving public participation.
Matthew Knight is leading on the initiative as he has extensive experience in
similar ventures across the Thames Valley and has a particular interest in
engaging people. Julian Emms pointed out that the main aim of the meetings
is to engage with the general public, the views of whom can be very different
to those of service users. The report was received and the position
welcomed.
10.4
CAMHs Update
Julian Emms (standing in for David Townsend) updated Governors with
regards to Child and Adolescent Mental Health services including a full
explanation of the Tier system of child and adolescent mental health acuity:
Tier 4
Young people detained or with serious conditions requiring inpatient
treatment. There is a national shortage of Tier 4 beds and there is currently
no such provision in Berkshire thus requiring a number of 16 year olds to be
admitted to adult wards. Tier 4 is the responsibility of NHS England specialist
commissioning who have recognised (at Thames Valley level) the situation in
Berkshire. The Trust has prepared a business case to provide Tier 4 services
at Prospect Park Hospital and a response is awaited.
Tier 3
The equivalent of community mental health teams: young individuals with
significant mental health or behavioural issues who cannot be managed in a
primary care setting but who have a formal diagnosis and treatment. Currently
teams are over-whelmed by the demand with the resulting lengthy waiting
lists. An internal review was conducted to ensure resources are available to
maximise services. National benchmarking indicates BHFT as one of the
lowest funded Trusts in the country but doing the greatest amount of work. A
business case has been submitted to local commissioners highlighting key
issues and funding requirement. Response is awaited.
Tier 2
This is the responsibility of the local authorities to provide as commissioner
and provider so it is not possible to say what services exist in Berkshire. The
primary care element is provided by GPs; specialist primary care counselling
and family support services commissioned by local authorities and schools.
Tier 1
There is no distinction between mental health and physical health. Mild
emotional issues and concerns are nipped in the bud and addressed as part
of everyday life.
Within the next 3-4 weeks issues will be raised around the provision of safe
services with the Trust currently providing in the region of £500k funding over
and above contract. This issue has been discussed at the Trust Board
meetings in detail over the last 9 months.
Bob Pitts requested that Julian Emms email the appointed Governors with the
main issues to take back to the local authorities.
ACTION:
Julian Emms
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11.
Election of Lead & Deputy Lead Governors
Governors received and noted the annual notice of election of Lead and Deputy Lead
Governors. John Tonkin advised that one nomination had been received in respect of
each of the two appointments from incumbent Governors. No other nominations were
received and therefore Council was asked to approve the continuation of current
appointments for 2014/15
Proposed:
Seconded:
Bob Pitts
Verity Murricane
Accordingly Council unanimously approved the election, uncontested, of Mavis
Henley as Lead Governor and Philip Brooks as Deputy Lead Governor. John Hedger
thanked both candidates for their continued commitment.
12.
Chair’s Remarks
John Hedger advised Council that during 2015 an external review of Trust
governance would be commissioned. Governors will be invited to comment and will
possibly also be the subject of enquiry. The timetable is unclear as yet but the Board
is beginning the process of self-assessment.
Peter Bestley enquired as to the process of appointment of an external investigator.
He was advised that a competitive tendering process would be undertaken as there
are exacting criteria and previous experience required by Monitor. The company
would be appointed by the Board; however any company previously engaged by the
Trust during the prior 3 years would not be eligible to bid.
13.
Draft Schedule of 2015 Meeting Dates
The schedule of 2015 meeting dates was provided for information and taken as read.
14.
Any Other Business
Governor Visits
Peter Bestley advised that during visits, it was brought to his attention that in some
cases, the number of therapy sessions provided to patients did not fit their needs. He
enquired if there was any flexibility as to the maximum number of sessions offered.
Julian Emms advised that if the patient needs require additional therapy then this can
be provided but this is over and above contracted funded sessions.
Trust Falls Strategy
Julia Prince requested an update on the Trust Falls Strategy; it was agreed that this
would be provided at a future meeting.
ACTION:
15.
Helen Mackenzie
Date & Time of next Council meetings
26 November – Joint Meeting Trust Board/Council of Governors (subsequently
cancelled)
11 December – Council of Governors
I certify that this is a true, accurate and complete set of the Minutes of the business
conducted at the meeting of the Council held on 24 September 2014.
7
Signed:………………………………………
(John Hedger, Chair)
Date:
11 December 2014
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Report of Living Life to the Full Group
Council of Governors meeting - Thursday 11th Dec 2014
Since the last Council of Governors meeting on 24th September 2014 there has been one
meeting of the Living Life To The Full Group on 30th October 2014.
1. Actions from the 29th July 2014
5th December Conference – “Angels & Devils in all of us!” – What makes otherwise
caring people do unkind things.
Mark Hardcastle provided a brief written update on the final detailed programme for the
conference plus abstracts for the guest speakers. Helen Mackenzie has agreed to open
the conference at the Reading Hilton.
Mental Health First Aid Courses
The Trust trainers for MH First Aid have both independently questioned the benefits of
the 3hr Mental Health First Aid Lite Course. The group suggest it would be worthwhile
any Governor wishing to understand more about mental health to attend the full 2 day
course (or possible option of 3 shorter sessions is being considered). Details of Mental
Health First Aid England website disseminated to all group members.
2. Guest Speaker – Nikki Malin, Head of Marketing & Communications
The Group had invited Nikki to update members with regard to event awareness and
actions by the Trust in relation to national awareness days or weeks.
Over the year 40 to 50 such days are normally supported. Not a systematic approach as
such with some based on historical activities e.g. World Mental Health Day. Other
awareness days have been used when they coincide with something being promoted by
the Trust e.g. Alzheimer Month and National Carers Day when the Dementia Handbook
was launched. Trust is planning to launch diabetes education programme on 14th
November, World Diabetes Day.
Nikki noted the need is based on promoting a service offered by the Trust where there
are available resources and the will within services to do something pertinent at that
particular time. Location for stands can be effected by cost.
Collaborative working is helpful but it is difficult to get input and interest from other Trusts
or services. Events also have a long lead time so Governors are encouraged to start
talking with locality managers about upcoming events. It was suggested that other areas
could follow the model of Wokingham Locality Meetings by including the Appointed
Governor in the quarterly meetings to help develop collaborative working.
Going forward the group are keen to help promote awareness and in particular would like
to see more events looking at the physical health of people with mental health issues.
More links with local authority public health and the voluntary sector.
1
3. Memory Services Update – Vicki Matthews
Vicki updated the group on the progress across the Trust with the Royal College of
Psychiatrist’s accreditation process to ensure best practice. This rigorous and robust
evidence based process examines all areas including management systems, resources,
assessment, diagnosis and use of medication, signposting, support and interventions.
Peer reviewers, that can include carers and service users as well as staff from other
memory services, provide basic feedback on the day of the inspection with the final
outcome taking about 2 months.
Wokingham and Bracknell accredited as excellent (from only 20 in England with that
rating). Reading peer review 5th December, WAM working towards accreditation.
Newbury & Slough have applied for affiliated membership of Royal College with
commitment to starting accreditation process. A service is reviewed again 2 years after
accreditation as ongoing process of assurance.
Dementia Handbook for Carers was launched in West Berks in late September.
West Berks CCG confederation offered support after an unsuccessful bid for funding
from the dementia challenge. A collaborative project led by Dr Luke Solomons, BHFT
consultant psychiatrist and produced by Reading University’s Centre for Information
Design Research, working with carers to include their feedback in the final design.
4. Who Cares? Faith, Culture & Mental Health Conference
John Barrett attended this recent conference which was a joint initiative between the
Oxford Diocesan Committee or Inter-faith Concerns, the South East England Faiths
Forum, BHFT and Art Beyond Belief.
Speakers included Rachel Wadey, Trust Chaplin and Dr Khadija Masood, Locum
Consultant Psychiatrist, from Reading CMHT.
Boundaries between faith and spirituality in mental health care were discussed.
5. Events and Services – highlights across the county
New idea: a quarterly update of relevant events to the groups’ terms of reference. In
Slough Dolly Bhaskaran is running a small group called Living in Harmony.
In Maidenhead CMHT are facilitating CAB Money Savvy sessions for people on their
books.
Alison Durrands advised that the Centre for Mental Health, with funding from The
Department of Health, are providing 2 full time workers to BHFT for 18 months to assist
in setting up a model around helping people with long term conditions back into work.
The Trust is planning to provide a worker in each CMHT to learn the model. Hope to
start next year.
6. AOB
Alison Durrands thanked Governors who had attended the Allied Health Professionals
conference on 9th October. The Chair noted that Governors interacting with staff is
equally important as with outside members.
John Barrett – Co-Chair, Living Life to the Full Group - 24th November 2014.
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Council of Governors - Membership & Public Engagement, November 2014
1.Trust Website
Nikki Malin requested digital photographs of Governors which can be added as part
of the improved information available on the website.
John Tonkin advised that the email address link has been in place for 2 months with
one email received. Further progress will be made over time; Jon Burton is still
working on structuring information pages to ensure ease of navigation for Governors
in terms of general reference material and Trust information.
2. Governor Profile
Further work is required to raise the profile of Governors and this initiative was well
supported at the last Council meeting. This could take the form of a map to local
constituency Governors, pictures/biographies on notice boards etc. However it was
noted there is a cost implication and is an ongoing programme of work.
3. Local Meetings
Nikki Malin advised that consideration was given to events being held across the
Trust e.g. Newbury Show but significant costs are involved; ‘piggy backing’ events
may well be possible going forward.
4. Community Mapping
Jenny Vaux advised that the responsible officer in place for the 3rd Sector project has
found that each local authority website offers a list of all the 3rd sector organisations
in their area. The Trust is looking at how links can be made between their websites
and that of BHFT. It is important that staff know what is available in their areas but
BHFT must ensure the credibility of external links. John suggested that the Living Life
to the Full group would be best placed to take this forward.
5. Governor Visits
15 Governors had taken part is 23 visits and had been encouraged to write a few
lines outlining the experience. Feedback will be provided at the Council meeting in
December.
6. Capita Links
Nikki Malin advised that the contract is under negotiation with re-tendering in train for
the database function. Philip Brooks noted his concern about quality of statistics and
their credibility. Nikki Malin to ask Capita to identify the sources of the eligible
population data.
7. Membership & Communications Group Strategy
There are two main strands: ensure retention of the Monitor declared 10,000
members and looking to increase the meaningful engagement of the membership
particularly around development of services. There are budgetary constraints. Jenny
Vaux commented that the organisation needs to decide what is affordable and
ensure a budget in place to support activities but this does need to be in the context
of a formal strategy the draft of which will come to member Governors at their
January meeting. Mavis Henley highlighted the Trust membership as a valuable
resource and the need to engage people in terms of making a contribution and
volunteering but this would need someone employed to manage the project.
governors\membership public engagement report 04 11 14.docx
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Governors need to think how best to get a group of volunteer members working with
the Trust but to also understand what ‘engaged membership’ actually means.
8. Membership & Communications Update
Noted the relatively high turnover of members particularly in Reading, possibly
related to university students. Discussions noted the importance of mental health for
young people and suggested inviting Craig Steel (appointed Governor for the
university) to the meeting to consider engaging them more fully.
9. Nikki Malin
Jenny Vaux advised members that Nikki Malin would be leaving the Trust to take a
promotion closer to home. Members formally thanked her for her contribution.
10. Chairmanship of the Group
Philip Brooks advised he had been Chair of the group for a year and wondered if
another Governor would like to take the role but perhaps ‘shadow’ for a short while
prior to taking the chair.
11. Date and Time of next Meeting:21 January 2014, FWH Meeting Room 2
governors\membership public engagement report 04 11 14.docx
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Quality Assurance Group report to the Council of Governors
We have had one meeting since the last Council of Governors meeting. This was held last
week on the 20th of November.
QAG Membership
Paul Corcoran was admitted to the group.
Memory Services Update
Vicki Matthews was invited as guest speaker to our last meeting. She gave a very useful
presentation of BHFT care pathway for dementia patients from GP referrals via CPE to local
memory clinics. The services offered to the patient by the memory clinic once referred, from
full assessment of mental health and cognitive testing to carer interviews through diagnosis
and possible interventions were also covered.
Vicki also briefed us on the successful launching of Dementia Handbook for Carers. We had
the opportunity to browse through copies of the handbook and we were all equally
impressed.
Vicki concluded by giving us a quick overview of the MSNAP accreditation process for
memory clinics, an update of on the current stage of accreditation for each of our 6 memory
clinics and how best practices derived from the accreditation process is now being leveraged
for continuous quality improvement throughout BHFT memory services.
Update from previous meeting
The group had an update from Nancy Barber on Rose Ward following the previously
disappointing 15 Step Challenge visit made to that ward. We were assured that there has
now been a very noticeable improvement in the ward.
Patients Experience Quarter 2 2014/15
Nancy presented the patients experience Quarter 2 document to the group which was
followed by a general discussion and QA session on the contents. There was a fairly
detailed discussion on three complaints associated with staff attitude on Oakwood Ward.
This discussion was inconclusive as investigations are still in progress on this issue.
The discussion of different issues on different wards led to a suggestion to compile a
comprehensive list of the hospital wards within the trust. Such a list should ideally contain a
brief description of the ward, where it is located and what type of patients it looks after. This
could then be used as a source of reference by members who do not currently have this
information to engage more effectively in quality discussions concerning these wards. Nancy
kindly took an action to provide the group with such a list.
Compliments and complaints documented within the Patient experience Quarter Two report
were also discussed.
Compliments and Complaints
Compliments and complaints documented within the Patient experience Quarter Two report
were discussed. A number of heart-warming letters of compliment from service users were
most appreciated by all members.
Anonymised Complaints
One recent anonymised complaint was also presented and analysed in detail with the help of
Nancy Barber. The group was satisfied with the sensitivity and openness that that it has
been investigated.
Quality Visits
1
Visits Completed
The following reports on visits completed prior to the last COG were reviewed:
1. Winterbourne House - Paul Myerscough (attachment)
2. Adult Mental Health Team in Bracknell – Ali and June (attachment)
3. Slough CAMHS – Gray & June
4. Health Visiting Team, Bracknell – Verity (Awaiting report)
5. Manor Green Children’s Respite Care. Maidenhead – Veronica & June (Awaiting
report)
Paul Myerscough explained how the members of the Winterbourne House give each other
support with very moving examples.
The issue of staffing within the Adult Mental Health Team in Bracknell was discussed in
detail, with Nancy Barber explaining some of the underlying reasons such as sick leave.
Dr Guy Northover, CAMHS Consultant Psychiatrist and clinical director was in attendance to
answer questions raised in the report for CAMHS Slough quality visit. He helped the group to
reach a much better understanding of the precarious CAMHS quality situation nationally and
at CAMHS Slough in particular. He was hopeful for the future and confident that there will be
no crisis despite the current pressure on the services.
Visits in the pipeline
1. CPE - Paul M & Veronica
2. Slough District Nursing Services 3. Jubilee Ward, Slough - Ruffat and June
4. Crisis Response Home Treatment Team, East Berks – Amrik & Veronica
5. Campion Unit, PPH – Mavis and Paul
6. Sexual Health Service, Slough – June & Dolly
7. Rowan Ward, PPH – Ali and Paul
8. Reading CAMHS, Craven Rd – Gray & Paul M
9. Heart Failure Team, West Berkshire – Verity & Paul M
10. Community Matron service, Bracknell – Ali & Mavis
11. Slough Walk-in Centre – Dolly & Ruffat
12. Slough School Nursing Team – Dolly & Amrik
2
Governor Visit Programme
Presented by:
John Tonkin, Company Secretary
Report Author:
Caroline Comer-Stone, Executive Assistant
k:\company secretary\governors\governor meetings 2014\11 december formal council of governors\governor visit
programme final.docx
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1. Introduction
Following the success of the Governor Visit programme in 2011, it was agreed that a further
schedule of service visits should be arranged. This would enable Governors to achieve a broader
understanding and knowledge of the diversity of services offered by the Trust in both the
community and in mental health.
The visits commenced in May 2014 running through to the end of November 2014 in a wide
variety of services across the county:
West Berks School Nursing:
Adult Mental Health:
Sexual Health:
Diabetic Eye Screening:
Continence Service:
Vulnerable/Homeless Families:
Looked after Children:
Oakwood Launch:
West Berks School Nursing:
Respiratory Team:
Podiatry:
Intermediate Care:
Henry Tudor Ward:
Older People’s Mental Health:
Health Visitors Team meeting:
Health Visitors Team meeting:
Community Mental Health:
Community Neuro Rehab:
Complex Needs/Psychotherapy:
Older People’s Mental Health:
Woodley
Church Hill House
Upton Hospital
Old Forge, Wokingham
Wokingham Hospital
Upton Hospital
Whitley Centre
Prospect Park Hospital
Thatcham
Bath Road, Reading
Thatcham
Reading
St Mark’s Hospital
Nicholson House, Maidenhead
Thatcham
Wokingham
New Horizons, Slough
Prospect Park Hospital
Winterbourne House
Jubilee Ward, Upton Hospital
Distribution of Service Visits
The table below indicates the service visit distribution with the majority of the 20 visits taking
place in Reading, Slough, west Berkshire and Wokingham. Some difficulties have been
encountered in achieving diary dates in WAM and Bracknell although visits have been made.
Services by Locality
35%
15%
15%
10%
20%
Bracknell (East)
Slough (East)
WAM (East)
Reading (West)
West Berkshire (West)
Wokingham (West)
5%
2
2. Governor Participation
There are currently 30 Governors in post as follows:
Public:
Appointed:
Staff Clinical:
Staff non-Clinical
18
8
2
2
A total of 17 Governors took part in visits:
Number of participating Governors
Number of Governors visiting
Not visiting
Staff Non-Clinical
1
Staff Clinical
1
Appointed Governors
Public Wokingham 0
Public West Berkshire
Public Windsor, Ascot…
Public Slough
1
Public Reading
Public Bracknell
1
0
13
4
3
3
3
5
10
15
Staff were extremely pleased to be able to not only meet the Governors, but to give them a brief
overview of the services offered.
3. Visit Feedback
Although written feedback from visits was not a pre-requisite, some Governors provided
comments some of which are noted below:
Waingels School Immunisation
Thank you very much for inviting me to your HPV immunisation clinic at Waingels College this
morning. The clinic had been set up in the school library which provided ideal facilities and the
atmosphere was one of tranquil control.
It was a pleasure to meet you all and to see how efficiently your service is run. The
three injection stations worked quickly and calmly so that the girls having their immunisations
felt confident and at ease with the process. I was very impressed with the excellent database
managed by another BHFT colleague who was kind enough to explain the consent, recall and
follow up systems to me. I also observed you and a colleague managing one girl who became
3
anxious about the procedure and was dealt with most sympathetically. It was also very nice to
see Debbie, one of our most valued WestCall nurses, who was working in your team.
I felt reassured that this aspect of the Trust's service provision was in very safe hands and
working at a commendably high level.
Churchill House
Thank you to you and Ruth for your time and making me so welcome last Thursday. It was useful
at the beginning of our meeting to have you explain the setup of your department both staff
wise and how you operate.
I felt very privileged to be invited to sit in at your MDT Meeting, you felt it was a good way for
me to understand how your team worked and what they faced day to day and you were so right.
It would be a difficult thing to explain but sitting there listening to members of your team
relating situations and difficulties with some of their patients/clients left me under no illusion as
to exactly what they face day by day at work. I was impressed with the professionalism of your
young team and the way they talked through the problems as a group with advice/suggestions
as to how clients lives could be improved, with the Consultants present also benefiting them
with advice.
It was obvious from the discussions that some of their cases were quite distressing and your
team must find them quite stressful at times. You did explain that that was certainly the case
when you come across a problem that is not in your remit to deal with and that can be quite
upsetting.
It was a pleasant surprise to listen to a presentation by Stuart Gray and Mark Hardcastle at the
beginning of the meeting. You and your team enabled me to learn a great deal at my visit and I
am truly grateful to you for opening you doors to me. I hope to meet you again during my term
as a Governor.
Vulnerable & Homeless Families Tulip HV Team
We would like to thank you for the warm reception we received during our visit to the
Vulnerable Families Team (Tulip Team) yesterday the 18th of June 2014 at your location in Cedar
House within the Slough community hospital. It was very interesting to learn about the practical
details involved in seeking and looking after vulnerable families in the Central Slough area,
particularly families with children under 5 years old. It was a pleasure to meet Judith and Sarah
especially, and other members of your team including your admin staff. We were also delighted
to be introduced to the Crystal Team and other co-located Health Visiting teams who were all
warm, friendly and professional in the description of the services they provide, and how they
work collaboratively with the Tulip Team.
Thank you also for allowing us to attend your team meeting. It gave us an insight to the day-today operation of your team particularly record keeping and key contribution by your admin staff.
We also learned about how you use RIO for managing your records and track vulnerable
families.
Finally, I would like to thank you for allowing us to accompany you on your home visits. It was a
very useful experience which clearly brought into focus the value of your services to the
vulnerable families that you look after. You were very patient throughout, friendly, assuring and
very professional in your interaction with the families that we visited. Overall, we were
impressed with the efficiency of you and your staff.
4
Intermediate Care Team, Tilehurst
We were warmly welcomed by the Team Manager, Jade Taylor, who invited us into the Team
Meeting. It was obviously a hardworking, dedicated Team who care for patients recently
discharged from acute hospitals requiring further care in the Community. They also provide a
Rapid Response seven days a week till 8 p.m., following that time patients can call on Out of
Hours, Westcall, if needed. The Team had also been expanded recently incorporating staff from
other services. The Team has been coping with a shortage of staff and was happy to welcome
two new team members, however others were leaving. They have been working short staffed
for some time and Jade thanked the Team for all the extra work done in covering for those who
have left. It was obvious that they need more staff, and they were disappointed that one of the
advertisements placed was incorrectly worded.
The Team was informed of new NICE guidelines and that CQC inspections were changing. There
was to be a focus on Patient Experiences with regular feedback of results. The waiting list for
Physio was highlighted; 136 currently on the waiting list. It was also announced that the Team
was asked to trial two patients requiring Home Care nursing; these would be patients discharged
from hospital sooner than had been done before. (We have since heard about this new practice,
now being called "Hospital at Home"). A Consultant would approve which patients would be
suitable. Funding would be set aside by G.Ps. Questions were raised by Team members, such as,
these patients could require 24 hour care, how is this to be covered? Three members of staff are
required for 24 hour care. There appeared to be no facilities for extra staff. A number of the
Team appeared to be cautious about this idea, already working with staff shortages. However, it
was made clear that this is going to happen as a trial run or 'proof of concept'.
We were asked to say a few words and we explained the reason for our visit, not a Quality
Assurance visit, but to learn more about what Teams in the Community provide for our patients.
Berkshire Healthcare Foundation Trust was previously caring for Mental Health Patients. From
two years ago it is also responsible for all Community Health and Governors are visiting a
number of Community Teams in order to learn more about what they do and provide for
patients within the Community.
Jade thanked us for attending and, what I thought was extra nice, three members of the Team
came up to me individually and thanked us for taking an interest in what they do.
Health Visiting Team, West Berkshire Community Hospital
Thank you for arranging the invitation for BHFT Governors to attend the Health Visitor Monthly
Team Meeting on August 7th when we enjoyed our role as observers. Please pass on our thanks
to all members of the team.
The meeting was ably led by Gaynor Ross and by the time everyone had arrived there was an
attendance of over thirty Health Visitors, Nursery Nurses and HV trainees. Everyone seemed
cheerful, morale was high and participation was excellent.
A wide range of subjects was discussed amongst which I noted:
The difficulties posed by some recent staff vacancies concerning which Gaynor congratulated
everyone on the way in which they had covered the necessary extra work. Against a background
of increasing domestic violence across Berkshire the number of child protection conferences had
increased from 47 the previous year to 60 this year. There were some important messages about
the difficulties in receiving payment for working overtime and some new strategies for managing
5
this was put forward, with priority to be given to new births and child protection. There was an
excellent presentation from Michelle Lovesey about Child and Families Integrated Therapies,
now developing from Speech and Language Therapy.
Annette Shore explained the new protocol for blood spot screening process for nine conditions.
Ways of HVs receiving, assessing and distributing information from the A&E departments were
discussed. I undertook to arrange for automatic notification to be made to the Named
Safeguarding Nurses of children for whom a child protection plan was in place and who had
been seen by WestCall doctors during the OOH period.
Overall we were very impressed by the highly motivated and engaged team members that were
present at this meeting. Participants joined in with energy and attention to detail and it was
reassuring to see how responsibly they took their duty to make patients their priority.
Health Visitors’ Team Meeting Wokingham
This was a well-attended and engaging meeting with excellent discussion of key service
improvement issues, significant risks and staff concerns. The work towards alignment of practice
and procedures across all BHFT localities was evident. Staff concerns were around ability to meet
increasingly high demands of record-keeping, and some challenges with knowledge of RiO
functionality. There was a generally high level of confidence in the benefits of the incoming
Open RiO system. New influx of HVs welcome but demands of training and mentoring
significant.
General Comments
I have done some 15 step challenges, place assessments and quality visits. For me these visits
are an eye opener to me and mostly I enjoy doing them. We can also see the good and bad
practice.
When we see the wards where the good standard of care is given I feel quite proud about our
services. I have also checked the quality of the food delivered to the patients in the past during
my visits. I was also talked to some of the patients to find out how they are treated what is their
opinion about the standard of care they received and also about the quality of the food. When
we hear the good feedback many times I felt very proud and I appreciate the staff for their hard
work. I was surprised to see the actions taken by the trust to rectify and improve the working
standards in such a short notice based on our feedback in certain areas.
6
11 December 2014
Listening into Action - Patient, Public & Carer Big Conversations
Putting patients, public and carers at the centre of the development of Berkshire
Healthcare
SUMMARY:
In support of the Trust’s patient, carer and public participation agenda, a number of ‘Big
Conversations’ were held during the period September to November so that the Trust could
hear directly from service users and others and seek to convert feedback into action.
A copy of the letter sent to participants following the events is attached to give a flavour of
the output and the LiA Lead will be attending Council to provide further information about
this important initiative and to answer questions.
Elaine Williams
LiA Lead
2.12.14
1
27th November 2014
Dear participant
Fitzwilliam House
nd rd
2 /3 Floors
Skimped Hill Lane
Bracknell
Berkshire
RG12 1BQ
Tel:
01344 415600
Fax:
01344 415666
http://www.berkshirehealthcare.nhs.uk/
Listening into Action - Patient, Public & Carer Big Conversations
Putting patients, public and carers at the centre of the development of Berkshire Healthcare
We would like to say a big thank you for taking the time to attend and contribute to the success of
the Big Conversation events held across Berkshire between September and November. We held 6
listening events in total and 160 people attended.
These events gave us the perfect opportunity to listen to you and to capture your valuable
feedback. The feedback from all the events is available to view on our Trust website
at http://www.berksirehealthcare.nhs.uk
This information has been analysed into key themes and messages and we are now working on
converting these into effective actions at Trust level as part of this project. We would like to assure
you however, that all of the participants’ feedback and messages are available to our staff for
service level discussion and actions accordingly.
The 6 common priority messages from all the Listening Events are:
1. Staff Communication Skills
-- Patient feeling listened to
-- Non-verbal: smiling, welcoming
2. Staff Attitude
-- Respectful
-- Being treated as an individual (rather than a set of symptoms)
-- Knowledgeable about patient story (to avoid repetition)
3. Keeping patients informed
-- about what to expect during consultation
-- about expected waiting times
-- about next steps in their management
4. Technology
-- better use of technology (texting to provide information – clinic running late etc)
-- use of social media to engage with various populations (facebook, twitter)
www.berkshirehealthcare.nhs.uk
5. Patient Feedback
-- enabling patients to give positive feedback about treatment/staff
-- patients able to see visible outcomes of positive feedback
6. Innovations
-- Devise ‘PatientMail’ akin to ParentMail
-- Aspirational innovations to be explored
-- Develop a charity within the Trust to explore:
--- engaging private organisations in decorating our estates
--- ‘crowdfunding’ initiatives
--- Charity shop
Timeframes for their implementation are being determined into: Quick wins: 3 month timeframe
for implementation; Early implementation: 6 month timeframe for implementation; Longer term
actions.
Your feedback has been most valuable and we would like to continue to engage and work with you
wherever possible. We would therefore like to invite you to express your interest in contributing
to the development of our actions. You can do this in two ways:
1. Email your suggestions to [email protected] or
2. Attend one of our meetings to make a personal contribution (email your interest
to [email protected] )
We will continue to update on the progress of these priority actions so please do keep a look out
on our website and for posters and news articles in community settings.
We hope you find this feedback useful and we very much look forward to hearing from you and
working together with you.
Thank you once again.
Best wishes.
Yours sincerely
Minoo Irani
Senior Clinical Director
Elaine Williams
Listening into Action Lead
Council of Governors
Committee Meeting
Date
December 2014
Title
Quality Account Indicators and Draft Quality Account 2015
Purpose
The purpose of this paper is twofold;
•
To present options and a recommendation for the council of
governors to review and agree the indicator they wish to be
reviewed as part of the mandated quality report requirements
by Monitor (The foundation trust regulator).
•
To provide the Governors with assurance that the 2015
Quality Account is in development and that the key priorities
are being implemented, ensuring that the Trust meets its
statutory obligations for submitting and publishing the Quality
Account in line with both Monitor and the Department of
Health’s requirements. NHS foundation trusts must publish a
quality account each year, as required by the NHS Act 2009,
and in the terms set out in the NHS (Quality Accounts)
Regulations 2010 as amended by the NHS (Quality
Accounts) Amendments Regulations 2011 and the NHS
(Quality
Accounts)
Amendments
Regulations
2012
(collectively “the Quality Accounts Regulations”).
Business Area
Trust Wide
Author
Head of Clinical Effectiveness / Medical Director
Relevant Strategic
Objectives
1 – To provide accessible, safe and clinically effective services that
improve patient experience and outcomes of care.
CQC
Registration/Patient
Care Impacts
Quality Account priorities and quality indicators support maintenance
of CQC registration
Resource Impacts
N/A
Legal Implications
Statutory requirement of the Health Act 2009
1
SUMMARY
The purpose of this paper is to present options and a
recommendation for the council of governors to review and agree the
indicator they wish to be reviewed as part of the mandated quality
report requirements.
This is the first draft of the 2015 Quality Account which is in
development. The draft includes all mandated sections which
consists of three main parts in line with Department of Health and
Monitor requirements. Part 1 is the Chief Executive’s statement.
Part 2 is a report on the priorities for improvement and statements of
assurance from the Board. This section must also cover specified
areas in relation to clinical audit, research, CQUINs, CQC, data
quality and information governance. Part 3 is a Review of Quality
Performance in 2013/14 and must include at least 3 measures in
each of the areas of quality - patient safety, clinical effectiveness and
patient experience.
The information included within the report is as of quarter two. There
are a number of sections within the draft which will not have any
information until Q3 and Q4 due to external and national reporting
time frames. These are clearly highlighted in yellow. In addition all
completed sections will be revised and updated in Q3 and Q4 with
revised data. It will also be ensured that charts are consistent and
clear before the final version is agreed in April 2015.
There has been significant progress to date with respect to all key
quality priorities which were identified in the previous account
ACTION REQUIRED
Recommendation:
All three indicators are important, it has been five years since we
tested the additional mandated indicator and therefore it seems
sensible due to its significance that this indicator is tested by KMPG.
The council are asked to consider this recommendation and confirm
the indicator which they wish to be tested.
The council is invited to note the draft developmental Quality
Account and seek any clarification required. Recommendations for
changes or amendments prior to the final publication can be
incorporated if needed.
2
1. Introduction
Quality of care is vital to patient experience, and therefore closely connected to Monitor’s core duty of
protecting and promoting the interests of patients. Accurate and comprehensive quality reporting allows an
NHS foundation trust itself and all interested parties a clear view of the quality of care being delivered to
patients. To help achieve this, NHS foundation trusts must include a report on the quality of care they
provide (the “quality report”) within their overall annual report. The quality report specifically aims to
improve public accountability for the quality of care. NHS foundation trusts must also publish quality
accounts each year, as required by the NHS Act 2009 as amended. The quality report incorporates all the
requirements of the Quality Account Regulations as well as a number of additional reporting requirements
set by Monitor.
2. Mandated Performance Indicators (Part 3 of the Quality Account)
As in previous years our external auditors will be required to provide governors with a limited assurance
report on whether two mandated indicators included within the quality report have been reasonably stated
in all material respects. Auditors will undertake substantive sample testing of the mandated indicators
included in the quality report, this will be undertaken in January 2015.
For Mental health NHS foundation trusts two indicators from the following three are required:
1.
100% enhanced Care Programme Approach (CPA) patients receiving follow-up contact within
seven days of discharge from hospital;
2.
Minimising delayed transfers of care; or
3.
Admissions to inpatient services had access to crisis resolution home treatment teams
(gatekeeping).
The Quality Assurance Committee will be asked to confirm the two indicators for which a limited assurance
report will be sort. The two proposed indicators for review will be CPA follow up and Gatekeeping.
Locally Determined Indicator
NHS foundation trusts also need to obtain assurance through substantive sample testing of one local
indicator included in the quality report, as selected by the governors. Below are the indicators which have
been reviewed in previous years:
•
2010/11 Minising delayed transfers of care
•
2011/12 C Difficile (Infection Control)
•
2012/13 Complaints
•
2013/14 Incidents resulting in severe harm death (mandated)
•
2014/15 Medication Errors
The following indicators have been chosen for consideration by the council of governors. They have been
chosen based on their potential impact to quality of care and also indicators which can be substantially
tested.
1. The optional mandated indicator as the local indicator minimising delayed transfers of care
3
2. Emergency re-admission of patients to hospital within 30 days of previous discharge.
3. 95% of patients will receive physical healthcare checks & be offered a health action plan
Recommendation:
All three indicators are important, it has been five years since we tested the additional mandated indicator
and therefore it seems sensible due to its significance that this indicator is tested by KMPG.
An alternative approach is to amend the mandated indicators this year to include delayed transfers of care
but exclude gatekeeping. This will allow the Governors to choose an alternative additional measure for
testing.
The council are asked to consider this recommendation and confirm the indicator which they wish to be
tested.
4
Quality Account
2015
What is a
Quality account?
A Quality Account is an annual report
about the quality of services provided by
an NHS healthcare organisation. Quality
Accounts aim to increase public
accountability
and
drive
quality
improvements in the NHS. Our Quality
Account looks back on how well we have
done in the past year at achieving our
goals. It also looks forward to the year
ahead and defines what our priorities for
quality improvements will be and how we
expect to achieve and monitor them.
About the Trust
Berkshire Healthcare NHS Foundation
Trust provides specialist mental health
and community health services to a
population of around 900,000 within
Berkshire. We operate from more than
100 sites across the county including our
community hospitals, Prospect Park
Hospital, clinics and GP Practices. We also
provide health care and therapy to people
in their own homes.
The vast majority of the people we care
for are supported in their own homes. We
have 252 mental health inpatient beds
and almost 200 community hospital beds
in five locations and we employ more than
4,000 staff.
1
Table of Contents
Section
Content
Page
Quality Account Highlights 2014
Part 1
Part 2
Part 3
To be
completed Q3
Statement on Quality by the Chief Executive of Berkshire Healthcare
Foundation Trust
Priorities for Improvement and Statements of Assurance from the Board
2.1 Priorities for improvement 2014/15
2.2 Priorities for improvement 2015/16
2.3 Statements of Assurance from the Board
2.4 Clinical Audit
2.5 Research
2.6 CQUIN Framework
2.7 Care Quality Commission
2.8 Data Quality and Information Governance
Review of Performance
3.1 Performance Assurance Framework 2014/15
3.2 Statement of directors’ responsibilities in respect of the Quality Account
Appendix A
Appendix B
National Clinical Audits: Actions to Improve Quality
Appendix C
Local Clinical Audits: Actions to Improve Quality
Appendix D
Patient Safety Thermometer
Appendix E
CQC Trust Quality & Risk Profile
Appendix F
CQUIN Achievement 2014/15
Appendix G
CQUIN Framework 2015/16
Appendix H
Statements from Clinical Commissioning Groups, Healthwatch, Health and
Wellbeing Boards, and Health Overview & scrutiny Committees
1
Quality Account Highlights 2015
To be completed at Q3 and updated at Q4
2
1. Statement on Quality from the
Chief Executive
Julian Emms CEO
To be completed at Q3 for review by stakeholders
3
2.1 Priorities for Improvement 2014/15
This section of the Quality Account details our achievements against the 2014/15 priorities and information on the
quality of services provided by the Trust during 2014/15.
2.1.1 Patient Experience
Outcome: to show an increased rate of positive
experience over time
Aim: To continue to ensure patients and carers have a
positive experience of care and are treated with
dignity and respect.
To date at Q2 there is a significant increase on the
overall percentage of patients wo would recommend
our services to their friends and family.
Primary Measures.
1. Friends and Family Test
2. Learning from compliments and complaints
Figure 1. Percentage of Patients Extremely likely or likely to recommend the service to a friend or family member
Percentage
100
90
80
70
60
50
40
30
20
10
0
Community Services
(Mental and Physical
Health combined)
Mental Health
Inpatients
2012/ 13 Average
84
66
2013/14 Average
86
74
2014/15 Average
96
72
Figure 2 Percentage who would recommend to a friend or family member (no figures are available for 2012/13).
100
90
98
93
98
Percentage
80
60
40
20
0
Community Hospital Inpatients
Percentage Average 2013/14
Minor Injuries Unit West Berkshire
Community Hospital
Percentage Average 2014.15
Target
* National Acute methodology Response rates were 100% for Community Hospital Inpatients and MIU has seen an
increase in response rate from 19% in August 2014 to 34.47% in September 2014.
4
Percentage
Figure 3 percentage of patients who rated the service they received as very good or good.
100
90
80
70
60
50
40
30
20
10
0
*Community Mental
Health
Community Physical
health
Mental health
Inpatients
Community health
inpatients
2012/13 Average
97
85
74
94
2013/14 Average
94
86
75
97
2014/15 Average
93
95
82
96
(Year end average rounded to nearest whole number. 2012/13 Community mental health results only include
learning disability and older people’s services as data for adult and children services are unavailable. Community
Mental Health Teams and Electroconvulsive therapy included for 2013/14).Source: Figure 1-3 Trust Patient
Experience Reports.
Learning from Complaints
The main themes continue to be care and treatment,
attitude of staff, communication and waiting times.
Of the complaints received about care and treatment
during quarter two, 54% were attributed to mental
health services and 46% to community health. This is a
shift as 62% attributed to mental health in quarter
one.
However when the trust upholds (19%) or partially
upholds (25%) complaints it is clear that patient
perception of service delivery differs from ours and
the Trust needs to do further work to explain what
patients can expect from our services. Equally as part
of Listening into Action work is underway to launch a
‘smile’ campaign. The Trust needs to ensure staff take
time to check a patient understands the level of care
and treatment they will receive because naturally we
all make unforeseen assumptions
The independent complainant survey undertaken by
the Patients Association, as recommended by the
Francis Report reported earlier in quarter two and
although the number of responses was low, it was
disappointing to see that 86.7% of complainants felt
that their complaint was not handled well and only
40% said that it was resolved. The complaints team
continue to try and support managers to negotiate
and investigate complaints well. The trust is in the
process of commissioning new investigation training
to cover serious incidents, complaints and human
resource issues and part of this will include how
investigating officers work with patients, families and
carers.
Figure 4
(Source Patient experience report charts to be re
formatted for Q3)
Examples of actions made following complaints closed
during quarter two and found to be upheld are:
•
A carer complained that the gradient of the
slope going into the Parkinson's Clinic at St Marks
Hospital was too steep. She explained that it was
difficult to push her husband up and it was difficult to
obtain assistance. Patients are being advised to use
the main entrance to Community Health Clinic rather
than side entrance in future to address this problem.
Minor modifications will be made to the building to
5
facilitate this and signage will be updated. Additional
reception staff will also be available to assist patients
into the building.
A questionnaire was sent to 850 people who received
community mental health services.Responses were
received from 238 people (28%).
•
The family of a patient open to Psychotherapy
and Complex Needs complained about the booking
process. A new message taking protocol has been put
in place ensuring that staff are informed of
cancellations in a timely manner with a robust system
for audit. A new process has been introduced to
ensure that client appointment availability is
highlighted on service waiting list, not just recorded,
so that this is clearly marked when offering
appointments, ensuring clients are offered
appointments they are able to attend.
A grace period of three days is allowed if a client fails
to attend before a discharge letter is sent to the
client’s GP. A recommendation has been taken
forward that a review of joint working practice is
undertaken. In this specific case, a letter was sent to
the patients GP clarifying that a message had been
received cancelling his appointment and that a letter
to them was sent too quickly. An apology has been
given to both the GP and the complainant and the
patient’s referral has been has been reinstated.
This year the Trust has not received any ratings where
our performance has been judged to be lower than
the majority of other Trusts, last year there were 12
questions rated in this category
•
The family of an inpatient on one of our
Learning Disability inpatient wards raised a complaint
about specific clinical issues about their loved one’s
care as well as an update following an incident on the
ward. Initial funding for a placement has been agreed
at a more appropriate placement for the patient and
is being facilitated. Feedback from the incident was
fed back by the Head of Service and the items such as
black out blinds have been purchased to enable the
existing ward environment to be more therapeutic
and relaxing for the patient while the placement is
being arranged.
National Community Mental Health Survey
We use national surveys to find out about the
experiences of people who receive care and
treatment. The annual Community Mental Health
Patient survey was published in September 2014. This
year’s survey asks different questions to previous
years and therefore the results are not directly
comparable overall.
There is one question which is identical to previous
years where patients were asked whether services
involved a member of your family or someone else
close to you, as much as you would like. Previously
we were rated as performing lower than the majority
of other Trusts in this area and this year we are rated
as performing at the same level as the majority of
other Trusts. It is not unusual for families to tell us
that they do not feel sufficiently involved or listened
to so we wish to improve further in this area.
We would like to see improvement in how patients
rate our performance in supporting them to manage
in a crisis in their illness next year and the initiative, in
conjunction with the Centre for Mental Health, to get
service users back into employment also gives us the
opportunity to improve patient experience and our
survey results.
Figure 5
(Source: DoN CMHS overview report)
Additional analysis will be provided in Q3 data is
currently being re analysed by the clinical audit dept
so that the charts are clear and accessible for all
within the QA.
The survey this year had 33 questions (compared with
38 last year), categorized within nine Sections. A score
for each question is calculated out of 10.
6
2014 National Staff Survey
Figure 6
Question
reference
Q12a
To be published early 2015
Question
Trust
2012
%
Trust
2013
%
62
71
National
average for all
mental health
trusts %
63
69
75
71
58
62
53
64
69
59
Care of patients / service users is my organisations top
priority
My organisation acts on concerns raised by patients
and service users
I would recommend my organisation as a place to
work
If a friend or relative needed treatment, I would be
happy with the standard of care provided by this
organisation
Q12b
Q12c
Q12d
Trust
2014 %
Figure 7
Overall Staff Engagement
(the higher the score the better)
Trust score 2014
Trust score 2013
3.83
Trust score 2012
3.83
National 2013 average…
1
3.71
2
3
4
Scale summary score
1 Poorly engaged staff to 5 Highly engaged staff
5
Figure 8 Staff recommendation of the trust as a place to work or receive treatment
KF24 (Q12a, 12c-d)
(the higher the score the better)
Trust Score 2014
Trust score 2013
3.61
Trust score 2012
3.76
National 2013 average…
1
3.54
2
3
4
5
Scale summary score
1 Unlikely to reccomend to 5 likely to reccomend
7
2.1.2 Patient Safety
In 2013 we participated in the South of England Improving Safety in Mental Health Collaborative. This programme
has been set up to improve safety in mental health. The aim of the programme is to develop and build a culture of
patient safety and quality improvement with the support of a Patient Safety Faculty with expertise in Improvement
Science. The programme focuses on four key areas to reduce harm to users of mental health services.
Aim: to continue to protect patients from avoidable harms
Primary Measure:
1. To have a positive patient safety culture within the trust.
Safety Culture
To add following the results of the staff survey early 2015 mapped to number of incidents reporting and evidence of
learning from incidents
2. Our aim is to achieve no developed pressure ulcers on community and mental health wards. We will report on the
number of days without a developed pressure ulcer on each of our wards and aim to exceed 120 days on all wards
during 2014/15.
Overview of Pressure Ulcer Events during the last 12 months.
Figure 9
The chart opposite details the number of days since
the last developed pressure ulcer on our inpatient
wards both Jubilee and Henry Tudour have exceeded
a year without a patient developing a pressure ulcer in
thir care. Two wards, Windor and Highclere have not
yet achieved 120 days without a pressure ulcer
(achieved 64 and 69 respectively to date).
Figure 10
8
The NHS Safety Thermometer is the measurement
tool for a programme of work to support patient
safety improvement. It is used to record patient
harms at the frontline, and to provide immediate
information and analyses for frontline teams to
monitor their performance in delivering harm free
care.
The Trust has just completed a pilot of a similar
mental health tool which will be reported separately.
The NHS Safety Thermometer records the presence or
absence of four harms:
•
Pressure ulcers
•
Falls
•
Urinary tract infections (UTIs) in patients with
a catheter
•
New venous thromboembolisms (VTEs)
These four harms were selected as the focus by the
Department of Health’s QIPP Safe Care programme
because they are common, and because there is a
clinical consensus that they are largely preventable
through appropriate patient care. The concept of
Harm Free Care was designed to bring focus to the
patient’s overall experience. Patients are assessed in
their care settings. Measurement at the frontline is
intended to focus attention on patient harms and
their elimination.
The national average is 93.72%. BHFT may have a
lower number of harm free patients due to the
significant number of ‘aquired’ pressure ulcers. This
means that patients have acquired the pressure ulcers
in another setting before coming in to the care of
BHFT.
When compared nationally the data shows that
compared to all organisations BHFT has a higher % of
pressure ulcers reported.
For newly developed pressure ulcers we have a higher
percentage than nationally. Our percentage of falls
with harm has been lower than the national
percentage in 2 months out of 3.
The percentage of new harms is a good gauge of how
BHFT is improving as these are the harms that the
Trust can influence, however this quarter for each
month our harms have been higher than the national
percentage.
BHFT has a lower percentage of harms due to
catheters and UTI but a higher percentage due to VTE.
Figure 11 –Percentage of Harm free care
All eligible patients seen on one day of the month. Data is collected on a monthly basis from the inpatient
community hospital wards, older people’s mental health wards, learning disabilities units and community teams, and
all community nursing and older people’s mental health nursing.
All individaul charts to be added by Q3 as an appendix
9
Figure 12
100
98
96
94
92.2 92.4
Percentage
92
93.8 93.7 93.7
93.4 93.6 93.5 93.5 93.4 93.6 93.5 93.6 93.6
92.5
92.2 92.4
91.1 91.3
90
88
92.8 92.8 93
93.1
90.42
90.4
89
91.6
92.1
91.4 91.4
90.4
91.6
90.9
89.61
89
87.85
86
84
82
80
BHFT Harm Free 2013/14
Harm free across all organisations 2013/2014
10
2.1.2 Clinical Effectiveness
In line with NICE recommendations we will strive for
100% against quality measures within the quality
standards and aim to fully implement smoke free
services for 2015. We will demonstrate increasing
access to psychological therapies for people with
more severe mental health problems. This was
requested by the Trust Governors and is also included
as a Trust CQUIN (Commissioning for Quality and
Innovation)
2. Implementation of PH48: Smoking cessation in
secondary care: acute, maternity and mental health
services.
To be added Q3 following senior mangers event, work
is in progress to introduce a staged approach in 2015.
3. Increasing access to psychological therapies in
secondary care this will include mapping of skills
within the workforce training and supervision of staff.
The skills mapping, however, will be met from the
Pathways Project where a skills audit is currently in
progress across all secondary care mental health
services, led by Geoff Dennis and Anthony Shipley. It
should report by the end of November
Quarter 1: Development Quarter to produce training
packages (content and format), establish reporting
strategies and agree locality arrangements for training
and supervision.
1.
Workshop and engagement with locality
managers, CMHT clinical leads and psychological
trainers & supervisors has been successful. Locality
leads and champions have been identified.
2.
Three techniques have been chosen based on
their suitability as brief, stand-alone intervention to
address specific difficulties commonly presenting as
part of the complex problems experienced by clients
in the Pathways teams (Problem Solving; Behavioural
Activation; and Graded Desensitisation).
3.
Psychologists from within each Pathway team
volunteered to develop and teach the training
packages.
4.
The content of the three training programmes
(including e-learning, podcasts and manuals) are being
developed to enable staff to understand and utilise
the psychological techniques with suitable clients.
These will provide the essential learning but the
teaching methods in each locality will be according to
local requirements.
5.
The trainers are working with Learning &
Education and Informatics to create three elearning/podcast
teaching
packages
and
accompanying manuals.
6.
Supervisors have been identified to facilitate
group supervision in teams to support and consolidate
learning and ensure/monitor quality standards for
delivery of the interventions.
7.
Outcome and satisfaction measures have
been agreed.
8.
Informatics arrangements for recording,
collation and reporting of the CQUIN data have been
established.
The specific targets this year are:
1.
Minimum of 70% of BHFT Care Pathways staff
with clinical contact and not employed as a qualified
psychologist or psychotherapist to have completed
training in three psychological techniques.
2.
Minimum of 40% of Care Pathways clients,
who have been open to the teams for more than 4
months at the end of the year, to have been offered a
psychological package.
3.
Minimum of 75% of those clients who accept
and complete a psychological intervention, to have
completed outcome and satisfaction measures.
1.
Three protocols were identified as suitable
brief, stand-alone interventions to address specific
difficulties commonly presenting as part of the
complex problems experienced by clients in the
Pathways teams. These include:
Problem Solving
Behavioural Activation
Graded Desensitisation.
2.
The Trust committed funding to engaging a
production company to create three training modules
when it was identified that no training packages
currently on the market were suitable for the
audience or purpose of the CQUIN. In addition,
psychologists from all localities and L&D, as well as
Comms, staff have been released to develop the
content of the training packages and facilitate their
production.
3.
The training packages consist of the following
modules for each of the three interventions:
- Internet based teaching, including slides and video
that provide the rationale and aims for each
11
intervention, as well as clear guidance on how to work
through the techniques with clients and examples via
role plays.
- Manuals for clinicians to guide them through the
intervention; how to engage clients, working safely,
the required steps, how to overcome obstacles, and
endings.
- Manuals for clients that outline the purpose and
steps of the interventions, as well as providing work
sheets and self-help hints.
These modules have been developed for all three
interventions and the internet production by a
specialist company is near completion.
The
distribution method for the manuals is currently being
agreed.
The modules will be available for review by end of
November.
Subsequent to the teaching, psychologists in all
localities will provide a minimum of six group
supervision sessions for CMHT staff. This aims to
facilitate appropriate selection of clients to work
through the interventions, discuss application of the
materials and any obstacles so as to support safe and
effective care.
5.
E-learning /ESR reporting is in place to
evidence uptake of the training packages in locality
teams.
6.
Informatics arrangements for recording,
collation and reporting of the CQUIN data have been
established and is being tested.
Outcomes to be detailed and added Q3 and Q4
4.
The three training modules (including elearning and manuals) provide the essential
information to enable staff to understand and utilise
the psychological techniques with suitable clients. In
order to ensure that staff understand the materials
and to support skilled application, the teaching will be
supported by additional psychology input in each
locality.
The delivery of this is according to local requirements.
The majority of localities have agreed a team teaching
or workshop day based around the internet training
packages and facilitated by locality psychologists, one
locality have an external psychologist contracted to
provide teaching and supervision.
12
2.1.5 Health Inequalities
Aim: to ensure that services are based on need.
Primary Measures:
1. Following the identification of the baseline
assessments by services in 2014 to ensure that the
actions identified are implemented.
2. Local health inequalities initiatives will be reported
on
3. Achievement against the target of 185 whole time
equivalent health visitors by April 2015 allocated to
best meet population need.
The Trust has a growth target of 52 whole time
equivalent (wte) new health visitor posts to achieve
between April 2013 and April 2015. This is in addition
to filling all vacant existing health visitor posts which
totalled approx. 9.3 wte in April 2013. So a total of at
least 61.3 wte more health visitors to recruit by 2015.
The total target is 184.8 wte Health Visitors.
The numbers of HVs recruited for this month have just
been completed and we continue to progress towards
meeting the target in March 2015 . We are currently
on 165.95 wte and have just finished interviewing the
last cohort of trainee health visitors who finish the
course in Jan 2015 and have recruited another 23.8
wte ( subject to them passing the course ) which
brings us to 189.75 wte which meets our target which
is now 186.6 wte .
We have allocated the health visitors across BHFT as
they have been recruited based on a model agreed
with public health and our 6 LA directors who will be
our commissioners next year and we plan to allocate
the remaining skill mix in the HV teams based on this
same model by March 2015. This ensures that the
areas of greatest need have the greatest part of the
resource.
The health visitor subgroup has continued to focus
efforts on meeting the targets already set and
transforming the service delivered to good effect.
will be now be used on a regular basis as well as the
Saturday review slots in a Slough children’s centre .
The next steps for the 2 year reviews are to link up
with those children in childcare settings to ensure the
results of their health reviews contribute to the early
years development assessment undertaken which is
work we are doing with our local authority colleagues.
Within Windsor, Ascot and Maidenhead the health
visiting teams are in the process of reviewing how
they run the drop in clinics and they have undertaken
additional surveys of clients to contribute to this
work. They will be sharing what works best with all
teams at the end of the project and this will be used
together with the client survey results to help improve
the clinic experience for all clients . Meantime they
have produced a Health visitor newsletter for clients
in response to feedback which is already proving
popular.
In response to client feedback the visit will be a
combination of client focused conversations as
described in the documents below:
An holistic assessment to identify those families
needing additional support - the antenatal , new birth
and post natal assessments have now been combined
into one document to help ensure that clients are not
asked the same questions repeatedly as the
information from the first assessment follows through
into the others .
The next steps for this document is to build this into
the new Open RIO which BHFT has opted for in 2015
thus enabling staff to have easier access to it whilst
mobile working .
Other client experience ongoing this quarter is the
newborn hearing audit which will be reported on next
time .
To improve accessibility of the 2 year reviews
especially for working parents and hence improve
uptake the evening clinic trialled at Bracknell has
proved very successful and will become a permanent
feature. In Slough the team have used the new
community room in the large Tesco store in the centre
of town which has also had excellent attendance and
13
Figure 13
14
2.2 Priorities for Improvement
2015/16
2.3 Statements of Assurance from the
Board
2.2.1 Patient Safety
During 2014/15 the Trust provided XX NHS services.
The Trust Board has reviewed all the data available to
it on the quality of care in all XX of these NHS services.
The income generated by the NHS services reviewed
in 2014/15 represents XXX% of clinical services and
XX% of the total income generated from the provision
of NHS services by the Trust. Figures to be added and
confirmed Q3
The Trust’s first goal is to provide accessible, safe and
clinically effective services that improve patient
experience and outcomes of care.
To be drafted for discussion for Q3
2.2.2 Clinical Effectiveness
2.2.4 Patient Experience
2.2.3 Health Inequalities
Monitoring of Priorities for Improvement.
By the end of July 2016 we will have agreed the
detailed action plans and improvement targets that
will deliver the priorities. They will be monitored on a
quarterly basis by the Quality Assurance Committee
as part of the Quality report and the Board of
Directors will be informed of performance against
agreed targets. We will report on our progress
against these priorities in our Quality Account for
2015.
The data reviewed aims to cover the three dimensions
of quality – patient safety, clinical effectiveness and
patient experience. Improvements in the metrics
used and processes in place to gather good quality
data in these areas were implemented early in
2014/15. The key quality performance indicators
presented to the Board have been further reviewed.
Details of a selection of the measures monitored
monthly by the Board which are considered to be
most important for quality accounting purposes are
included in Part 3. These incorporate more than three
indicators in each to the key areas of quality.
15
2.4 Clinical Audit
During 2014/15, 13 national clinical audits and 1 national confidential enquiries covered relevant healthcare services
which Berkshire Healthcare Trust provided.
During 2014/15 Berkshire Healthcare NHS Foundation Trust participated (or is due to participate) in 100% (n=13)
national clinical audits and 100% (n=1) national confidential enquiries of the national clinical audits and national
confidential enquiries which it was eligible to participate in2.5
1.
NCAPOP - Diabetes (Adult) ND(A), includes National Diabetes Inpatient Audit (NADIA)
2.
NCAPOP - National Chronic Obstructive Pulmonary Disease (COPD) Audit Programme
3.
NCAPOP - Sentinel Stroke National Audit Programme (SSNAP)
4.
NCAPOP - Falls and Fragility Fractures Audit Programme (FFFAP) - Incl. Hip fracture database, and National audit
of falls and bone health
(TBC – query may only be relevant to acute services this time)
5.
NCAPOP - Specialist rehabilitation for patients with complex needs
6.
NCAPOP - Chronic kidney disease in primary care
7.
NCAPOP – Ophthalmology
(TBC – still not confirmed details)
8.
NCAPOP - Epilepsy 12 audit (Childhood Epilepsy)
a.
No relevant patients
9.
Non-NCAPOP - Severe trauma (Trauma Audit & Research Network, TARN)
10.
Non-NCAPOP - National Comparative Audit of Blood Transfusion programme
11.
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH) National Audit - Prescribing Observatory for
Mental Health (POMH): Topic 14: Prescribing for substance misuse: alcohol detoxification
12.
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 12: Prescribing for people with
personality disorder
13.
Non-NCAPOP - National Audit of Intermediate Care
1.
Mental health clinical outcome review programme: National Confidential Inquiry into Suicide and Homicide for
people with Mental Illness (NCISH)
Four National audits were removed from the quality account list in-year.
1.
Non-NCAPOP - National Audit of Seizures in Hospitals (NASH) Removed 9/7/14
2.
Non-NCAPOP - Parkinson's disease (National Parkinson's Audit) Removed 2/6/14
3.
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 6: Assessment of side effects of depot
antipsychotic medication Postponed in light of national CQUIN – September 2014
4.
Non-NCAPOP - Prescribing Observatory for Mental Health (POMH): Topic 15: Use of Sodium Valproate
(provisional) Postponed to September 2015
The reports of 2 (100%) national clinical audits were reviewed in 2014/15. This included 2 national audits that collected
data in 2012/13 or 2013/14 that the report was issued for in 2014/15.
•
•
POMH - Topic 4: Prescribing antidementia drugs
POMH - Topic 10: use of antipsychotic medication in CAMHS
16
The national clinical audits and national confidential enquiries that Berkshire Healthcare Foundation Trust participated
in, and for which data collection was completed during 2014/15, are listed in table 1 alongside the number of cases
submitted to each audit or enquiry as a percentage of the number registered cases required by the terms of the audit or
enquiry.
Table 14
NCAPOP Audits
Diabetes (Adult) ND(A), includes National Diabetes
Inpatient Audit (NADIA)
National Chronic Obstructive Pulmonary Disease
(COPD) Audit Programme
Sentinel Stroke National Audit Programme (SSNAP)
Falls and Fragility Fractures Audit Programme (FFFAP) Incl. Hip fracture database, and National audit of falls
and bone health
Specialist rehabilitation for patients with complex
needs
Chronic kidney disease in primary care
Ophthalmology
Epilepsy 12 audit (Childhood Epilepsy)
Non-NCAPOP audits
Severe trauma (Trauma Audit & Research Network,
TARN)
National Comparative Audit of Blood Transfusion
programme
Prescribing Observatory for Mental Health (POMH)
National Audit - Prescribing Observatory for Mental
Health (POMH): Topic 14: Prescribing for substance
misuse: alcohol detoxification
Prescribing Observatory for Mental Health (POMH):
Topic 12: Prescribing for people with personality
disorder
National Audit of Intermediate Care
Other audits reported on in-year (data collected in
previous year(s)
POMH - Topic 4: Prescribing antidementia drugs
POMH - Topic 10: use of antipsychotic medication in
CAMHS
Registered to participate.
Project noted as relevant to primary care – to be confirmed for SWIC.
(TBC – still not confirmed details)
No relevant patients
Project noted as relevant to primary care – to be confirmed for SWIC.
Data collected March – April 2014
54 patients submitted, across 6 teams.
Data collected June-July 2014
Report yet to be received.
Data collected June-July 2014
14 service elements included. Report yet to be received.
Data collected October 2013
88 patients submitted, across adult and CAMHS services
Data collected March 2014.
48 patients submitted, across CAMHS services.
The reports of all the national clinical audits were reviewed in 2014/15 and Berkshire Healthcare Foundation Trust
intends to take actions to improve the quality of healthcare which are detailed in Appendix A.
Local Audits
•
Registered – (157 last year) 60
•
Completed- (56 last year) 48 (may have started in previous year)
•
Active – (159 last year) 183(may have started in previous year)
•
Awaiting action plan – (19 last year) 22
The reports of 21 local clinical audits were reviewed by the Trust in 2014/15 and Berkshire Healthcare Foundation Trust
intends to take actions to improve the quality of healthcare which are detailed in Appendix B. (NB: Projects are only
noted as ‘completed’ after completion of the action plan implementation, which is why there are more local projects
‘reviewed’ than total ‘completed’
17
2.5 Research
The number of patients receiving NHS services provided
or sub-contracted by the Trust that were recruited to
end of September 2014/15 to participate in research
approved by a research ethics committee was as
follows:
The number of patients receiving NHS services provided
or sub-contracted by the Trust that were recruited to
end of September 2014/15 to participate in research
approved by a research ethics committee was as
follows:
521 patients were recruited from 78 active studies, of
which 154 were recruited from studies included in the
2.6 CQUIN
A proportion of the Trust’s income in 2014/15 was
conditional upon achieving quality improvement and
innovation goals agreed between the Trust and the
Clinical Commissioning Groups (CCGs) through the
Commissioning for Quality and Innovation payment
framework. Further details of the agreed goals for
2014/15 and for the following 12 month period can be
found in Appendix F and G.
The income in 2014/15 conditional upon achieving
quality improvement and innovation goals is £to be
confirmed. The associated payment received for
2013/14 was £to be confirmed.
2.7 Care Quality Commission
The Trust is required to register with the Care Quality
Commission and its current registration status is
registered without conditions. The Care Quality
Commission has not taken enforcement action against
Berkshire Healthcare Foundation Trust during 2014/15.
The Trust has not participated in any special reviews or
investigations by the Care Quality Commission during
the reporting period.
The CQC inspected X of our services during 2014/15; to
be added to if received by Q4
The current quality intelligence draft report which has
replaced the CQC Quality & Risk Profile (Appendix E)
published in November 2014.) Data quality and impact
National Institute of Health Research (NIHR) Portfolio
and 367 were from non-Portfolio studies.
Figure 15 R&D recruitment figures 2014/15
Type of Study
No of
Participants
Recruited
NIHR Portfolio
154
Student
313
Other Funded (not
31
eligible for NIHR
Portfolio & Own
Account (Unfunded)
Source: R&D department.
No of
Studies
40
26
11
is currently under review by the patient experience
team.
2.8 Data Quality
The Trust submitted records during 2014/15 to the
Secondary Uses Service (SUS) for inclusion in the
Hospital Episode Statistics which are included in the
latest published data.
The percentage of records in the published data which
included the patient's valid NHS Number was:
99.1% for admitted patient care
100% for outpatient care.
The percentage of records which included the patient's
valid General Practitioner Registration Code was:
100% for admitted patient care
100% for outpatient care.
100% for emergency care (Minor Injuries Unit)
2.9 Information Governance
The Trust Information Governance Assessment Report
overall score for 2013/14 was (68%) and was graded
satisfactory (Green).
The Information Governance Group is responsible for
maintaining and improving the information governance
Toolkit scores, with the aim of being satisfactory across
all aspects of the IG toolkit for Version 11. An action
plan was agreed to achieve this. This has led to an
improved score from 2012/13 66% (Amber).to be
confirmed at Q4 when submission for 2015 is due
18
2.10 Data Quality
The Trust has taken the following actions to improve
data quality.
The Trust has invested considerable effort in improving
data quality. An overarching Information Assurance
Framework (IAF) provides a consolidated summary of
every performance information line and action plans.
Data quality audits were carried out on all lines that
were rated as low (‘red’) quality in the IAF. The findings
of these data quality audits were shared with the Data
Quality Group and the Trust Senior Management Team
The key measures for data quality scrutiny mandated by
the Foundation Trust regulator Monitor and agreed by
the Trust Governors are (Full descriptions Appendix X to
be added):
•
100% enhanced Care Programme Approach
(CPA) patients receiving follow-up contact
within 7 days of discharge from hospital
•
Admission to inpatients services having access
to crisis resolution home treatment teams
•
To be confirmed, paper to be presented to
Governors in December 2014, KPMG have offered to
send some examples to help guide the decisison.
BHFT was not subject to the Payment by Results clinical
coding audit during the reporting period by the Audit
Commission
19
3.1 Review of Quality Performance 2014/15
In addition to the key priorities detailed, the Trust Board receives monthly Performance Assurance Framework
reports related to key areas of quality. These metrics are closely monitored through the Trust Quality Governance
systems including the Quality Executive Group and the Board Audit Committee. They provide assurance against the
key national priorities from the Department of Health’s Operating Framework and include performance against
relevant indicators and performance thresholds set out in the Compliance Framework. The data source for all
information within this section is the Trust assurance performance framework unless otherwise stated
Patient Safety
Berkshire Healthcare aims to maximise reporting of
incidents whilst reducing the severity levels of
incidents
through
early
intervention
and
organisational learning. Organisations that report
more incidents usually have a better and more
effective safety culture.
Never Events
Never events are a sub-set of Serious Incidents and
are defined as ‘serious, largely preventable patient
safety incidents that should not occur if the available
preventative measures have been implemented by
healthcare providers. The trust has not reported any
never events in 2014/15.
Incidents
and
Serious
incidents
requiring
investigation (SIRI)
Reporting levels remain consistent over recent
quarters, with 2,407 incidents reported in Q22. The
severity model is as expected, with near miss / no
harm incidents accounting for the largest proportion
of reports, followed by minor, then moderate
incidents. Major and severe incidents are relatively
rare, and are reported as SIRIs when they involve our
services
The top 5 incident categories for Q2 Trust-Wide:
1. Pressure ulcers
2. Assualts
3. Behavioural
4. Non physical assults
5. Falls
2.
Work is also now in progress to provide
further support for mental health professionals in
assessing and treating suicide risk; lead professionals
are involved in promoting best practice with reference
to the Interpersonal Theory of Suicidality (Joiner,
2005); this is also being piloted as an evaluation
framework in SIRI investigations.
3.
The Trust is reviewing its operational model in
relation to Crisis Resolution and Home Treatment. SIRI
cases have exemplified the systemic challenges faced
in delivering this service, and have informed the
decision to undertake an operational review.
There have been no inpatient suicides during
2014/15. 10 suicides occurred in the community
(Figure 21). Clinicians have worked hard to improve
processes for assessing and managing risks for
patients in relation to suicide and self-harm.
2014/15 began with a further reduction in suspected
suicide cases; however, Q2 figures are more in line
with the higher level seen in 2012/13. This was due to
a spike in September 2014, rather than a spread
across all months of the quarter. It is not, therefore,
certain that a higher trajectory will be maintained in
2014/15. These Q2 cases are still under investigation
at the time of writing, so conclusions around
contributory factors at this stage would be premature.
Trust-Wide Initiatives Informed by SIRI Learning
1.
One of the key recurrent findings in mental
health SIRIs is around the quality of risk assessments
and clinical record-keeping. The Trust is launching a
new record-keeping strategy in 2014/15, and has
revised the Risk Assessment Policy and training.
Auditing and one-to-one peer supervision are being
extended from mental health inpatient units out into
the community teams to support improvement.
20
Figure 16 Suicides
25
Number
20
15
10
5
Suicides in 12 Months (rolling year total)
41883
41852
41821
41791
41760
41730
41699
41671
41640
41609
41579
41548
41518
41487
41456
41426
41395
41365
41334
41306
41275
0
Mental Health: Suicides in Month
Linear (Mental Health: Suicides in Month)
To be provided by Q3 outstanding.
Patient Safety on Mental Health Wards
(Mental Health Collaborative Programme)
Absence Without Leave (AWOL)
There have been fluctuations in patients AWOL from the ward and in episodes of absconding. There has not,
however been any clear trend in these areas. There has been an increase in the number of absconsions on a MHA
section.
Figure 17 Absent Without Leave (AWOL) and Absconsions on a Mental Health Act (MHA) Section
30
20
15
10
5
AWOLS on MHA section (RQ)
Absconsions on MHA section (RQ)
Target AWOLS and Absonsions less than
Linear (AWOLS on MHA section (RQ))
41883
41852
41821
41791
41760
41730
41699
41671
41640
41609
41579
41548
41518
41487
41456
41426
41395
41365
41334
41306
0
41275
Total Number
25
Linear (Absconsions on MHA section (RQ))
21
Slips Trips and Falls
The number of slips, trips and falls is now being recorded since April 2014 per 1000 bed days, and therefore
comparative data is not presented.
Figure 18
Slips, trips and falls (monthly per 1,000 Occupied Bed Days) : Number
16
14
Total Number
12
10
8
6
4
2
0
Apr-14
May-14
Jun-14
Jul-14
Aug-14
Sep-14
Slips, trips and falls (monthly per 1,000 Occupied Bed Days) : Number
Linear (Slips, trips and falls (monthly per 1,000 Occupied Bed Days) : Number)
Figure 19 Medications Errors
670
660
650
640
630
620
610
600
590
580
570
Apr-14
May-14
Jun-14
Medication total numbers
Jul-14
Aug-14
Sep-14
Linear (Medication total numbers)
22
Medication errors
To recalculate total numbers for previous years to add in Q3 as PAF has changed to total numbers from
rolling quarter figures.
Physical Assaults
There have been fluctuations in the level of physical assaults on staff by patients with a increase in trend over time.
Often these changes reflect the presentation of a small number of individual inpatients.Fluctuations in the level of
patient on patient assults appear to show no trend
Figure 20 Patients to Patient and Patient to Staff Physical Assaults
70
60
Total Number
50
40
30
20
10
0
Physical assults on staff (RQ)
Physical Patient to patients assults (RQ)
Target less than
(Assaults on staff)
Target less than
(patient assults)
23
Figure 21 Compliments
350
300
Total Number
250
200
150
100
50
Mar-14
Feb-14
Jan-14
Dec-13
Nov-13
Oct-13
Sep-13
Aug-13
Jul-13
Jun-13
May-13
Apr-13
Mar-13
Feb-13
Jan-13
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
0
Figure23
22Compliments
Complaints
Figure
30
26
25
23
23
Total Number
20
15
10
25
23
19
16
16
19
16
14
11
20
15
15
14
20
21
19
15
12
5
0
Source complaints annual report 2013/14
24
Monitor Authorisation to be completed at Q3
Performance in relation to metrics required by Monitor, the Foundation Trust regulator, has achieved the required targets. This relates to mental health 7 day follow up
(96.02%), delayed transfer of care (2.6%), community referral to treatment compliance (98.1%), Care Programme Approach review within 12 months (96.4%) and new early
intervention in psychosis cases 136 (154 12/13).
Figure 23
2010/11
2011/12
2012/13
The percentage of patients on Care Programme Approach who were
98%
96%
95.8%
followed up within 7 days after discharge from psychiatric in-patient
care during the reporting period
Berkshire Healthcare trust considers that this percentage is as described for the following reasons:
2013/14
National
Average
Highest and
Lowest
-
National
Average
Highest and
Lowest
-
National
Average
Not available
nationally
Highest and
Lowest
96.2%
Berkshire Healthcare trust has taken the following actions to improve this percentage, and so the quality of services:
Figure 24
2010/11
2011/12
2012/13
The percentage of admissions to acute wards for which the Crisis
100%
94%
97.6%
Resolution Home Treatment Team acted as a gatekeeper during the
reporting period
2013/14
97.6%
Berkshire Healthcare trust has taken the following actions to improve this percentage, and so the quality of services, by:
Figure 25
The percentage of patients aged— (i) 0 to 15; and (ii) 15 or over, readmitted to a
hospital which forms part of the trust within 28 days of being discharged from a
hospital which forms part of the trust during the reporting period
2011/12
2012/13
2013/14
9%
12%
11%
25
The data presented here includes only emergency readmissions within 28 days
(67) in the last 6 months as a percentage of discharges (527) in the same period
and excludes any readmissions coded as planned.
.
Berkshire Healthcare trust intends to take the following actions to improve this percentage, and so the quality of services:
Figure 26
2011/12
The indicator score of staff employed by, or under contract to, the trust during
3.55
the reporting period who would recommend the trust as a provider of care to
65%
their family or friends
Berkshire Healthcare trust considers that this data is as described for the following reasons:
2012/13
2013/14
3.61
64%
3.76
69%
National
Average
Highest and
Lowest
-
Berkshire Healthcare trust has taken the following actions to improve this data, and so the quality of services, by:
Figure 33(New section score for 2012/13)
Patient experience of community mental health services indicator score with regard to a
patient’s experience of contact with a health or social care worker during the reporting period
Berkshire Healthcare trust considers that this data is as described for the following reasons:
2011/12
-
2012/13
8.5
2013/14
8.7
National Average
Not published
nationally
Highest and Lowest
Berkshire Healthcare trust has taken the following actions to improve this data, and so the quality of services, by:
26
Figure 27
2011/12
2012/13
2013/14
The number of patient safety incidents reported
3995
3661
3754
Rate of patient safety incidents reported within the trust during the reporting period per 1000 bed days
19.7
30.2
32.7**
29 (0.7%)
42 (1%)
33 (0.9%)**
The number and percentage of such patient safety incidents that resulted in severe harm or death
National
Average
Highest
and
Lowest
st
*NRLS report 1st October 2012 – 31 March 2013 **Trust figure
Berkshire Healthcare Trust considers that this data is as described for the following reasons:
Berkshire Healthcare trust has taken the following actions to improve this percentage, and so the quality of services, by the following:
27
Figure 28 Annual Comparators
Patient Safety
Target
CPA review within 12 months
Never Events
Infection Control (MRSA bacteraemia)
Infection Control (C.difficile)
95%
0
< 2 per annum
<10 per annum (reduced
from <19)
Increased reporting
Medication errors
Clinical Effectiveness
Minimising delayed transfers of care
Mental Health: New Early Intervention cases
A&E: maximum waiting time of four hours
from arrival to admission/ transfer/
discharge***
Completeness of Mental Health Minimum
Data Set
Completeness of Community service data
Referral to treatment information
Referral information
Treatment activity information
Patient Experience
Referral to treatment waiting times – non
admitted -community***May 2013 Updated figure to include Slough WIC
RTT (Referral to treatment) waiting times Community: Incomplete pathways
2012/13
2013/14
97.6%
0
1
15
97.9%
1
0
5
96.4%
0
0
5
179
574*
562
614
<7.5%**
99
95%
1.86%
N/A
3%
155
99.6%
1.1%
154
99.9%
2.6%
136
99.9%
average % in year Range 0.1-4.6%
Year to date
Year average
1) 97%
1) 99%
1) 99.6%
1)99.8
1)99.8
2) 50%
2) 86%
-
2) 97.9%
-
2)98.62
-
2)97.8
New Monitor target for Identifiers 97% for
2012/13, target for 2011/12 was 99%.
N/A
99.9%
99.9%
98.1%
-
-
-
99%
50%
50%
50%
95% <18 weeks***
92% <18 weeks
2010/11
2011/12
0
0
0
70%
67%
99%
Commentary
For patients discharged on CPA in year
Full year
Full year
Full year
Cumulative total
Year end average (new 2013/14)
Waits here are for consultant led services in
what was East CHS, Diabetes, and Consultant
Led Paediatric services from referral to
treatment (stop clock). Notification has been
received from NHS England to exclude Sexual
Health services from RTT returns
Year end average (new 2013/14)
28
Figure 29 Annual Comparators
Target
2010/11
Access to healthcare for people with a Score out of 24
22
learning disability
Complaints received
<25 per month
134
Complaints
100%
Acknowledged
100%
within 3 working days
80% Responded within 25
working days (% within an
agreed time)
2011/12
22
232
100%
2012/13
22
250
91.3%
2013/14
Green 22
193
93.3%
Commentary
Cumulative in year
Final quarter
64%
(82%)
*Community Health services joined the Trust**Delayed transfers of care (Monitor target) is Mental Health delays only (Health & Social Care), calculation = number of days delayed in month divided by OBDs (Inc HL) in month. New
calculation used from Apr-12
29
3.2 Statement of directors’ responsibilities in respect of the Quality Report
The directors are required under the Health Act 2009 and the National Health Service Quality Accounts Regulations
to prepare Quality Accounts for each financial year.
Monitor has issued guidance to NHS foundation trust boards on the form and content of annual quality reports
(which incorporate the above legal requirements) and on the arrangements that foundation trust boards should put
in place to support the data quality for the preparation of the quality report.
In preparing the Quality Report, directors are required to take steps to satisfy themselves that:
The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual Reporting
Manual 2013/14; The content of the Quality Report is not inconsistent with internal and external sources of
information including:
1.
Board minutes and papers for the period April 2014 to May 2015
2.
Papers relating to Quality reported to the Board over the period April 2014 to May 2015
3.
Feedback from the commissioners dated XX 2015
4.
Feedback from governors dated XX/XX/XXXX
5.
Feedback from Local Healthwatch organisations dated XX/XX/XXXX
6.
The trust’s complaints report published under regulation 18 of the Local Authority Social Services and
NHS Complaints Regulations 2009, dated XX/XX/XXXX
7.
The national patient survey 18th September 2014
8.
The national staff survey XX/02/2015
9.
The Head of Internal Audit’s annual opinion over the trust’s control environment dated 05/2015
10.
CQC quality and risk profiles dated XX/04/2015
The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the period covered;
the performance information reported in the Quality Report is reliable and accurate; there are proper internal
controls over the collection and reporting of the measures of performance included in the Quality Report, and these
controls are subject to review to confirm that they are working effectively in practice; the data underpinning the
measures of performance reported in the Quality Report is robust and reliable, conforms to specified data quality
standards and prescribed definitions, is subject to appropriate scrutiny and review; and the Quality Report has been
prepared in accordance with Monitor’s annual reporting guidance (which incorporates the Quality Accounts
regulations) (published at www.monitor-nhsft.gov.uk/annualreportingmanual) as well as the standards to support
data
quality
for
the
preparation
of
the
Quality
Report
(available
at
www.monitornhsft.gov.uk/annualreportingmanual).
The directors confirm to the best of their knowledge and belief they have complied with the above requirements in
preparing the Quality Report.
By order of the Board
XX/XX/XXXX Date
XX/XX/XXXX Date
John Hedger Chairman
Julian Emms Chief Executive
30
Appendix B National Clinical Audits Reported in 2013/14 and results received that were applicable to Berkshire Healthcare NHS Foundation Trust
National Clinical Audits Reported in 2014/15 and results received that were applicable to Berkshire Healthcare NHS Foundation Trust
National Audits Reported in
2014/15
NCAPOP Audits
Non-NCAPOP audits
POMH - Topic 4: Prescribing
antidementia drugs
POMH - Topic 10: use of
antipsychotic medication in
CAMHS
Other audits reported on
in-year (data collected in
previous year(s)
Recommendation (taken from national report)
Actions to be Taken
Data were submitted on over 9,000 patients with dementia, nearly 70% of whom were
prescribed an anti-dementia drug. Donepezil was by far the most commonly prescribed AChE
inhibitor. There was marked variation in the prevalence of anti-dementia drug prescribing
across the 54 participating mental health Trusts, from 35% to 98% in the samples submitted.
The proportion of patients prescribed an antipsychotic drug also varied markedly across
Trusts, from 0% to almost 70%. Multivariable analysis revealed that the variables significantly
associated with being prescribed an anti-dementia drug included living at home (with or
without a carer), being in the 66-75 age group, female gender and White ethnicity. Both
severity and sub-type of dementia were also significantly associated with prescription of antidementia medication: these drugs were most commonly prescribed for patients with
Alzheimer's, followed by mixed dementia and Parkinson's disease/Lewy body dementia, and
for patients with dementia of moderate severity rather than mild or severe illness
The audit shows an improvement in the number of young people having undertaken
appropriate investigations prior to initiating antipsychotic medication and an improvement in
the monitoring of side effects since the baseline audit. However in comparison to other trusts
BHFT performed worse than average with clear room for improvement. BHFT fared well in
regards to recording the reasons for medication to be started and in following up young
people in appropriate time scales however fared very poorly in recording of baseline measures
and follow up measures.
Produce Trust Guidelines for prescribing of antidementia drugs (to include the standards set by the
POMHUK audit.)
Improve monitoring as part of memory clinic processes.
Intermediate –time re-audit.
Creation and adoption of antipsychotic initiation
monitoring pack. Training for staff on above.
Exploration of adoption of RiO based e-system to record
above information.
31
Appendix C Local Clinical Audits Reported in 2013/14:
1
Audit Title
Audit of Quality of Initial Assessments
Conclusion/Actions
This audit aimed to measure against an agreed standard, the quality of initial assessments carried out by the Urgent Care Team in East Berkshire.
Actions: Urgent Care to draft an assessment template in discussion with senior clinicians.
32
Appendix D Safety Thermometer Charts
Figure 1 Percentage of all Pressure Ulcers
12
Percentage
10
8
6
4
2
0
PU all 2012/13
BHFT PU 2012/13
BHFT PU 2013/14
Linear (BHFT PU 2013/14)
PU all 2013/14
Figure 2 Percentages of New Pressure Ulcers
3
Percentage
2.5
2
1.5
1
0.5
0
New PU all 2012/13
BHFT PU New 2012/13
BHFT PU New 2013/14
Linear (BHFT PU New 2013/14)
New PU all 2013/14
Note: reporting of new PU started September 2012/13
Figure 3 Percentage of Venous Thromboembolism (VTE)
1.2
Percentage
1
0.8
0.6
0.4
0.2
0
Venous Thromboembolism all 2012/13
BHFT Venous Thromboembolism 2012/13
Venous Thromboembolism all 2013/14
BHFT Venous Thromboembolism 2013/14
33
Figure 4 Percentage of Falls with harm
3
Percentage
2.5
2
1.5
1
0.5
0
Falls with harm all 2012/13
BHFT falls with harm 2012/13
Falls with harm all 2013/14
BHFT falls with harm 2013/14
Figure 5 Percentage of patients with a catheter and a urinary tract infection (UTI)
Percentage
2.5
2
1.5
1
0.5
0
Catheters with UTI all organisations 2012/13
BHFT Catheters with UTI 2012/13
Catheters with UTI all organisations 2013/14
BHFT Catheters with UTI 2013/14
34
Appendix E
Trust Quality & Risk Profile 09.04.2014
Quality and Risk Profiles (QRP) enable CQC to assess where risks lie and prompt
front line regulatory activity, such as site visits. They do not direct front line
regulatory activity. They support teams to make robust judgments about the
quality of services. They are used alongside CQC's guidance about compliance,
including the judgment framework, and additional information known to
inspectors
35
Appendix G CQUIN 2014/15 (Subject to final agreement)
Expected Financial Value of Goal
(subject to agreement of weighting)
£43,204.45
Goal Number
1a
Description of Goal
Friends and Family Test – Implementation of staff FFT
1b
£14,401.48
1c
Friends and Family Test - Early Implementation – Outpatient and Day Case
Departments
Friends and Family Test - Phased Expansion
2
Safety Thermometer - Reduction in pressure ulcers
£100,810.37
4a
Cardio Metabolic Assessment for Patients with Schizophrenia
£57,605.93
4b
Patients on CPA: Communication with GPs
£28,802.96
Local 5a
Frail Elderly - HWPFT
£180,018.52
Local 5b
Frail Elderly - FPFT
£144,014.82
Local 5c
Local 6
Participation in integrated working with the Frimley System
Care Planning - EAST
£108,011.11
£144,014.82
Local 7
7 day working
£100,810.37
Local 8
Psychological Interventions in Secondary Care
£86,408.89
Local 9
Employment Support
£86,408.89
Local 10
Smoking
£100,810.37
Local 11
CRHTT/Urgent Care
£100,810.37
Local 12
CAMHS
£100,810.37
£43,204.45
£1,440,148.18
36
Appendix H Statements from Stakeholders
37
Introduction Q2 2014/15 Governors' Key Performance
Indicator Report
Dear Governor
Enclosed are details of key indicators of trust performance in line with targets laid down by Monitor, (the body responsible for regulating NHS Foundation Trusts) and the Care
Quality Commission. Please find below an explanation of what the targets mean.
The Continuity of Services is a measure of our risk based on the trust's cash position and current surplus/deficit, this is our position at Quarter 2 2014/15.
The Key National targets mentioned here relate to the Department of Health National Service Framework targets which the trust should achieve and are measured as follows:RTT 18 Weeks This is referral to treatment waiting times for consultant led services where there is a requirement for patients to be seen within 18 weeks. There are two measures
completed pathways (that those patients who have been seen) and incomplete pathways (those who are still waiting to be seen). The two consultant led services in the trust are
Paediatrics and Diabetes.
Early Intervention
This is the number of new confirmed cases of first episode psychosis against the annual target set by the Department of Health for this service.
7 Day Follow Ups
This is the percentage of clients on enhanced CPA who have received a follow up within 7 days from their discharge from inpatient care measured against
the Department of Health target for the prevention of suicide.
HTT Gate Keeping
This is the percentage of acute adult mental health admissions which have been assessed by the Home Treatment Teams prior to admission to an acute
inpatient ward.
Delayed Discharges This is the percentage of beds occupied by clients who were deemed to be clinically fit for discharge.
CPA Review
This is the percentage of clients on CPA who have received a review within the past 12 months.
Total Time in A&E
This refers to the patients waiting to be seen within 4 hours at the Slough Walk In Centre and the Minor Injuries Unit at West Berks Community Hospital.
The Care Quality Commission has introduced a new registration system with which all providers of health and social care must comply. Details of the Trusts assessment of
compliance against the regulations and outcomes are shown on page 2 with full details in Appendix B page 7. The Trust was reinspected on 26th August 2014 and found to be
compliant.
Contract Versus Performance is the activity measured against the contracted activity for the same period. There are now well over 100 contract lines and some service requirements
for this financial year are being discussed with commissioners.
Information on Complaints and Compliments will now be shown in a separate report. Membership details now include a breakdown of ethnicity of members against that of the
Berkshire population.
As a merged organisation of Mental Health and Community Health Services the Corporate Risk Register indicates the current severe risks to the Trust
For Community Health Services, the indicators required for this financial year relate to the Referral to Treatment times within 18 weeks for Consultant led services. In addition the
Trust are required to provide information on compliance levels with 2 national data sets which will be used in future to monitor the performance of both Mental Health and Community
Services. Details of the Trusts compliance of both these indicators can be found on page 5.
As part of the 2014/15 Risk Assessment Framework there are additional indicators for this financial year, these relate to cases of Clostridium difficile. To encourage reporting of
Clostridium difficile (C.Diff) cases, Monitor have asked all Trusts of to report all occurrences of C.Diff on our wards rather than those that are due to lapses in care, there are 3
categories i) those due to lapses in care , ii) total C.Diff YTD (including: cases deemed not to be due to lapse in care and cases under review) iii) C. Diff cases under review.
Julian Emms
Chief Executive
Page 1 of 7
Q2 2014/15 Governors' Key Performance Indicator Report
Continuity of Services Risk Rating at end of Q2.
Plan
Actual
4
4
Care Quality Commission Registration:
Regulation Outcomes as at 30th September 2014
Compliance
Involvement and Information
Personalised Care Treatment and Support
Safeguarding and Safety
Suitability of Staffing
Quality and Management
Suitability of Management
Risk rating is awarded on a scale of 1 to 5
(5 being lowest risk rating)
Net Surplus/(Deficit) Run Rate
Budget - Month
Actual - Month
Budget - Cumulative
Actual - Cumulative
Forecast incl Reserve Release
Worst Case
Best Case
√
√
√
√
√
√
All services V Contract Quarter 2
Performance V Contract Quarter
On plan
Overperforming
33%
Underperforming
34%
Full details can be found on page 7
1000
1. Clinical Record System Replacement
500
0
Apr May Jun
Jul
Aug
Sep
Oct
Nov Dec
Jan
Feb Mar
-500
Responsible Director: Alex Gild
2. Financial Sustainability - medium efficiency
& CIP Planning
3. Implementation of Payment by Results
Referral To Treatment waiting times 18
Weeks: Non admitted
Referral To Treatment waiting times:
18 Weeks incomplete pathways
Early Intervention New Cases
7 Day Follow Ups
HTT Gate keeping
Delayed Discharges
CPA Review within 12 months
Total Time in A&E
Total C. Diff Cases including those not
due to lapses in care and cases under
review
33%
Severe
Severe
Key National & Local Targets for Mental Health & CHS Services 4. Ongoing registration with the Care Quality
Target Details
Severe
Q2
DOH Target
100.00%
95%
Responsible Director: Helen Mackenzie
100.00%
51
99.0%
98.2%
1.2%
96.7%
99.80%
92%
99
95%
95%
7.5%
95%
95% < 4 hours
5.Physical Assault/Violence
Responsible Director: Helen Mackenzie
6. CAMHS Commissioning
Responsible Director: David Townsend
7. Demand and Capacity
8. Workforce
6
N/A
Severe
Commission for all services
Page 2 of 7
Severe
Severe
Severe
Severe
There are now well over 100 service lines to
report against contract. East and West
Community Health Services are reporting no
major issues with levels of activity against
contracted levels of activity. In Mental Health,
Adult Community Services and Specialist services
have significant levels of over activity. The graph
above reflects an estimate of reported activity
against contract lines.
Q2 2014/15 Governors' Key Performance
Indicator Report
Berkshire Healthcare NHS Foundation Trust membership has gained by 792 since the previous report in January and is now 10,501 as at 10th
November 2014. The target was to reach membership of 10,000 by 31st March 2013. The target of 10,000 membership will be retained again
for the financial year 2014/15.
Membership by Age
0 to 16
years
0%
Unknown
19%
17 to 21
years
5%
Membership by Category 10th November 2014
Category
Public Out of Catchment
949
22 years +
76%
Public In Catchment
5,277
Staff
4,275
Membership by Ethnicity
0
1,000
2,000
3,000
4,000
5,000
No of members
Constituency
Bracknell Forest
Newbury
Reading
Slough
Windsor and Maidenhead
Wokingham
Outside Catchment Area
Members
1,258
1,088
2,121
1,180
1,056
1,686
2,092
Eligible Population
91,538
122,529
122,274
99,299
114,091
126,789
N/A
6,000
Other Ethnic
Group
1%
% of Members
1.37%
0.89%
1.73%
1.19%
0.93%
1.33%
N/A
Page 3 of 7
Black or Black
British
4%
Asian or Asian
British
7%
Mixed
2%
Not specified
17%
White
69%
Ethnicity of Membership v Population of Berkshire
Membership
Berkshire Population
89%
69%
17%
2%
1%
White
Mixed
7%
7%
Asian or Asian British
4%
Black or Black British
Ethnic Category
Page 4 of 7
2%
1%
1%
Other Ethnic Group
0%
Not specified
Governors' Key Performance Indicator
Report Data sets
As mentioned in the introduction Monitor have issued the Compliance Framework which will be replaced by the Risk Assessment Framework from 1st October 2013, and included the list of
indicators which will be used to measure governance going forward. Many of the indicators are shown on Page 2 of the report however there are two indicators which are linked to data sets that the
Trust must comply. The first is the Mental Health Minimum data set and the Trust is required to give data on demographics (Identifiers) such as NHS number, date of birth, postcode, gender,
General Practitioner and commissioner details. The target is 97% of information to be completed In addition the Trust is required to provide outcomes data for clients on care plan approach with a
target of 50% of data to be completed.
For the Community Information Dataset, the Trust is asked to provide information on data completeness for community services. These include information on referral to treatment times, community
treatment activity service referrals, data completeness and identifiers. The target is 50% completion of information.
Mental Health Minimun Data Set
Area of Care
Metric
Mental Health Inpatient and Community
Identifiers
99.8%
Mental Health Clients on Care Plan Approach (CPA)
Outcomes
99.3%
Data completeness
Community Health Data Set
Area of Community Care
Metric
Referral to treatment times - admitted and non admitted
Community treatment activity service referrals
Data completeness
Community care referral to treatment information.
Referral information completeness
Activity information completeness
Data completeness
Page 5 of 7
73%
63%
98%
Indicator Report Appendix
Extreme / Severe Corporate Risks: Additional Information
Risk
Clinical Record System
replacement.
Clinical record system replacement; programme to procure and replace current national contract for RiO fails to deliver.
Financial Sustainability
Financial sustainability - medium term efficiency & CIP planning gaps.
Implementation of Payment By
Results
Implementation of Mental Health Payment by Results destabilising current block funding arrangements and increasing organisation financial risk.
On-going Registration with Care
Maintaining registration of all activities and services without conditions.
Quality Commission for all services
Physical Assaults/Violence
CAMHS Commissioning
The risk is a member of staff will be injured and that they have not received the appropriate training to manage violence and aggression. The would expose the trust to litigation proceedings.
Fragmentation of commissioning of CAMHs services in Berkshire across Tiers and difference in locality priorites and service provision which is increasing the volume and acuity of children needing support from Trust services
Demand & Capacity
Lack of visibility of demand and capacity pressures in services in a timely way to manage service delivery and identify trends requiring remedial plans, leading to increased waiting times.
Workforce
Shortage of staff with appropriate skills to deliver services in some roles and some services due to lack of availability and / or the Trust’s inability to attract and retain sufficient suitable qualified staff.
Key To Risks
E
S
H
M
L
Extreme risk; Chief Exec/Non Exec immediate action
Severe risk; Exec directors immediate attention
High risk; senior management attention required
Moderate risk; Operational managers attention required
Low risk; manage by routine procedures within work teams
Page 6 of 7
Indicator Report Appendix 2.
Care Quality Commision Regulation Outcomes as at 30th September 2014.
Outcomes
Outcome 1 (R17)
Outcome 2 (R18)
Outcome 4 (R9)
Outcome 5 (R14)
Outcome 6 (R24)
Outcome 7 (R11)
Outcome 8 (R12)
Outcome 9 (R13)
Outcome 10 (R15)
Outcome 11 (R16)
Outcome 12 (R21)
Outcome 13 (R22)
Outcome 16 (R10)
Outcome 17 (R19)
Outcome 21 (R20)
Respecting and involving people who use the services.
Consent to care and treatment.
Care and welfare of people who use services.
Meeting nutritional needs.
Co-operating with other providers.
Safeguarding people who use the service.
Cleanliness and infection control.
Management of Medicines.
Safety and suitability of premises.
Safety, availability and suitability of equipment
Requirements relating to workers
Supporting staff
Assessing and monitoring the quality of service
Complaints
Records
Description
Patient Experience Quarter Two Report
Overview
This overview report is written in response to the Board’s request that the Director of Nursing and
Governance to give an Executive ‘so what does this all mean for the services’ opinion on the
quarterly patient experience report. Similar to the last report I have considered each element of
feedback and then drawn conclusions.
The requirement for Boards to consider detailed patient experience feedback remains and it’s
important for the Board to remember commissioners receive more detailed information as part of
our contractual requirements.
During quarter two we achieved an average of 87% of complaints responded to within the
timescale agreed with the complainant which is good but of course this means that 13% of
complaints were not managed on time and work is in progress to support investigating officers to
negotiate and meet timescales. Some complaints still take a long time to investigate and therefore
when a response is received a long time after the complaint was originally lodged, I am sure that
patients and their families find this frustrating
When reading the details about complaints it was disappointing to see three complaints associated
staff attitude on Oakwood Ward in the same quarter and I have asked for further detail so that I
am able to understand more fully the issues and therefore the actions needing to occur. The main
themes continue to be care and treatment, attitude of staff, communication and waiting times
however when the trust upholds (19%) or partially upholds (25%) complaints it is clear that patient
perception of service delivery differs from ours and the Trust needs to do further work to explain
what patients can expect from our services. Equally as part of Listening into Action work is
underway to launch a ‘smile’ campaign. The Trust needs to ensure staff take time to check a
patient understands the level of care and treatment they will receive because naturally we all make
unforeseen assumptions.
The independent complainant survey undertaken by the Patients Association, as recommended by
the Francis Report reported earlier in quarter two and although the number of responses was low,
it was disappointing to see that 86.7% of complainants felt that their complaint was not handled
well and only 40% said that it was resolved. The complaints team continue to try and support
managers to negotiate and investigate complaints well. I am in the process of commissioning new
investigation training to cover serious incidents, complaints and human resource issues and part of
this will include how investigating officers work with patients, families and carers.
I think the report demonstrates how well the Trust works with other public sector bodies to answer
complex complaints that cross more than one organisation. Having worked in the NHS for many
years I can remember when cross organisational complaints were not accepted and patients had
to complain to each organisation separately, this is good progress.
The important thing to note in the complaints element of this report is that whatever the complaint
is about it is taken seriously, investigated and learning shared.
In my last overview report I indicated that the Parliamentary and Health Service Ombudsman
(PHSO) Annual Report was due to be published and that this would enable benchmarking,
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Berkshire Healthcare NHS Foundation Trust
unfortunately they have changed their format and I am only able to conclude across England,
similar to the Trust, the number of complaints referred to the PHSO has increased.
The Trust continues to respond well to posts on NHS Choices and our Friends and Family test
results continue to be very positive. FFT will be rolled out to our other services by the end of this
calendar year.
The 15 steps programmes, where a small team arrive unannounced to visit a service from a
patient’s perspective, continue to provide useful insight. All the visits went well. Although not
reported as it has only recently taken place a follow up 15 step visit to Rose Ward, where the team
were accompanied by the East Berkshire CCG Director of Nursing went very well. The previous
visit had been very poor.
I commissioned a ‘deep dive’ survey into the patient experience of services provided by the Slough
Walk – in Centre because patient feedback sources were indicating that the service did not
provide a consistent good patient experience. The survey showed that levels of satisfaction were
generally high, which was reassuring however there is work today following the clear
recommendations. The Locality Director for Slough will take responsibility for ensuring the
recommendations are implemented.
The patient and public involvement information shows that when patients are asked by services
how they rate their experience, 90.2% said it was good or better than expected which is an
improvement on quarter one. This is as a result of some services significantly improving their
scores. 80% of our learning disability service users said that they would recommend our services
to their friends.
Conclusion
In terms of volume the amount of positive feedback received by services far outweighs the
negative feedback found in complaints and on NHS Choices. There are no significant changes in
trend or overall picture since the quarter one report. I believe that services and individuals strive to
provide the best possible care and generally patients have a good experience in our services but
as a result of a number of variables, for some patients their experience is not good and care falls
below the standard of care expected. I do not take these lapses in care lightly and it is important
services recognise and take steps to prevent similar incidents and that this is shared across the
organisation. This continues to be work in progress.
Helen Mackenzie
Director of Nursing and Governance
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Executive Summary
This report details the complaints, Patient Advice and Liaison Service (PALS) and compliments
received by the Trust up to an including quarter two 2014/15. As an organisation, the Trust
recognises that by responding well to complaints and feedback from patients we improve the
patient and carer experience and increase public confidence in the services that we provide.
Complaints
In Quarter two, the Trust received 67 formal complaints in comparison with 61 in quarter one. In
addition, nine complaints were received which were being led by a different organisation (in
comparison with five in quarter one).
The Services that received the highest number of formal complaints during quarter one were Child
and Adolescent Mental Health Services (six), Community Mental Health Teams (nine) and
WestCall (Out of Hours GP) (eight).
The main themes from the complaints were care and treatment (24), attitude of staff (17),
communication (11) and waiting times for treatment (4).
The formal complaint response rate, including those within a timescale re-negotiated with
complainants is 87% for quarter one. The response rate during the quarter was 85% in July, 84%
in August and 92% in September. The longest time taken to respond to a complaint in quarter two
was 79 days (in comparison with 126 days in quarter one). This was a complaint about the
Psychotherapy and Complex Needs Service that was closed in September. The complaint was
about various aspects of the patient’s care including that the Psychotherapist they saw did not
explain their treatment plan. They felt that the end of therapy was inappropriate, unethical and
unprofessional. The investigation was Upheld and found that the patient was not give the level of
information that is expected. Feedback about the environment within Winterbourne House has led
to a review which will see improvements to the internal signage. During the investigation process,
the investigating officer was in regular contact with the patient about the complaint and they
agreed with the timescales.
NHS Choices
There have been ten comments posted; eight experiences were about acute Mental Health
Services relating to care and two were about community mental health services. One of these was
by a patient who had been treated on Daisy Ward who was complimentary about our staff,
explaining that they maintained her dignity and showed her respect. The mother of patient shared
her experience that the support for her daughter had been inadequate. Their case was closed and
they were advised to go back to their GP. On being aware of this post, contact details were put up
with a message asking for the patient and her family to contact the Trust to discuss her discharge
and assessment. In the main those who post comments do not respond further or contact the
Trust formally.
Patient and Public Involvement
3,787 service users have provided feedback re the internal patient survey programme, with 90%
saying their experience was good or better. In addition 98% of patients with a Learning Disability
who gave feedback said that they found their meeting with us helpful.
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Introduction
The Trust is committed to improving patient experience, using complaints and other forms of
feedback to better understand the areas where we perform well and those areas where we need to
do better.
This report details the complaints, Patient Advice and Liaison Service (PALS) and compliments
received by the Trust during quarter two (July to September 2014). As an organisation, the Trust
recognises that by responding well to complaints and feedback from patients we improve the
patient and carer experience and increase public confidence in the services that we provide. The
Trust is also committed to ensuring that the national learning from reviews such as the Keogh
Review, Francis Report and ‘Hart’ Report (complaints) are embedded locally into the core values
of our staff.
1.
NHS Choices
The internal monitoring of NHS Choices postings is important because this activity is monitored by
the CQC and the National Quality Team as part of our quality risk profile. Similar to complaints, for
an individual to take the time to post on a website their experience, means they feel very strongly
about their position and therefore the Trust needs to take these comments seriously and respond
appropriately.
There have been ten comments posted on NHS Choices during quarter two; all being associated
with mental health services. All posts are individually responded to and are discussed at the
Service User Feedback Implementation Group.
The feedback posted during quarter two was:
- Lack of support as a carer. Unhappy with support from Crisis Team (CRHTT) and
Community Mental Health Team (CMHT) following discharge.
We provided details for carer support that is available and invited the individual to contact us
for a full response
- A patient at Prospect Park Hospital felt that they were not listened to during their stay.
We invited them to contact us to discuss opportunities for service user involvement.
- A patient was unhappy with service they received and felt depressed.
Our Crisis Resolution/Home Treatment Team were informed and made direct contact with the
patient.
- A patient was pleased with care they received on Bluebell Ward. They felt accepted and
safe.
We thanked them for their feedback and invited them to share their experiences in more detail.
- A patient felt ignored at Prospect Park. They explained that staff spent lots of time in the
office.
In our response we apologised that this was their experience and explained that more one to
one sessions have been implemented.
- A Mother reported that she feels that support for her daughter at Prospect Park is
inadequate. Her case has been closed and she has been discharged back to the care of her
GP.
We responded asking for the patient and her family to contact us discuss her assessment and
discharge.
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- A patient reported that they did not feel valued during an assessment at Prospect Park
Hospital. They explained that they were left to wait in Reception.
We have responded asking the patient to contact us to discuss their experience in greater
detail.
- A patient reported that a physical problem was not diagnosed at Prospect Park Hospital.
We responded asking for them to contact to discuss their assessment and discharge.
- A patient explained that they found staff at the Community Mental Health Team based at
Church Hill House in Bracknell to be unhelpful.
We invited the patient to make contact to discuss their experience further.
- A patient was complimentary of the staff on Daisy Ward. They explained that staff preserved
their dignity and showed them respect.
We thanked patient for their feedback and shared this with our staff.
2.
Formal complaints
The Trust has received 67 formal complaints in quarter two, an increase from 61 in quarter one. In
addition, the following complaints have been received by alternate organisations with an element
relating to Trust services:
A CCG led complaint was about the advice given by a WestCall Doctor over the telephone to a
patient who was having difficulty with temporary visual lenses. The investigation showed that the
correct advice was given and that the patient had been seen by multiple healthcare professionals
in regards to this prior to contacting WestCall.
Another complaint raised through the CCG was about discharge arrangements and Continuing
Healthcare (CHC) Placement arrangements. The information requested gave the impressions that
the CCG were fact finding and we have asked for further information from them alongside our
response, which showed that the staff acted appropriately, in the best interests of the patient in
terms of an appropriate placement and kept open communication with the CHC team.
There was a multi-agency complaint involving the CCG and West Berkshire Council. Following a
review of the complaint, applicability to BHFT and consent, the decision was made not to take the
complaint forward for investigation and the complainant was notified of this as part of a joined up
approach with the other organisations involved in the complaint.
The Ambulance Service led a complaint about WestCall as following a family’s initial contact with
paramedics they contacted 111 again and were advised that a Doctor from WestCall would call.
When the Doctor called the patient was asleep and the family decided not to wake them. The
complainant wanted to know why the Doctor had not been briefed on what was wrong. The
investigation showed that the Doctor called within one hour within receiving the call from 111 and
tried to ascertain clinical details but complainant was abusive and a home visit was declined.
A complaint was led by Wokingham Borough Council as the family of a young person felt that
CAMHS let them down after suggesting family therapy and then offering an appointment during
school hours. The investigation showed that alternatives were offered however these were either
not suitable for the family or they chose not to attend. The complaint was not formally responded
to as consent was not received.
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A complaint was received that was being led by a neighbouring mental health trust which
requested confirmation that they would not would not share information about a patient when it
was requested by our staff upon a their admission to Prospect Park Hospital. The investigation
showed that information was received within five days of the request being made.
A patient complained to an Acute Trust following their discharge to Henry Tudor ward for
physiotherapy. They reported that during their stay, they spoke to a physiotherapist but that no
physiotherapy was given. They were informed that it would be arranged for when they got home.
Our investigation showed that the patient was admitted during a Thursday afternoon and assessed
by a Physiotherapist the following day. As our Physiotherapists do not currently work over the
weekend therapy was provided by nursing staff over the weekend. The patient was assessed by a
Physiotherapist on the following Monday where she mobilised with close supervision. The patient
said she felt she was now mobile enough to go home and rehabilitation physiotherapy was to be
given at home which was agreed. The patient was discharged home the next day. There was no
evidence to suggest that the husband had been misinformed during the investigation.
A complaint was received about a patient with Multiple Sclerosis with limited mobility that has been
told they will need to wait over a year for an electric wheel chair; this is having an adverse effect
on their independence. The waiting times are acknowledged to be an issue and the Trust is
working with our commissioners to address waiting times and additional staffing resources are
being put in place.
There is an open complaint investigation about a patient who feels the waiting times for
physiotherapy are too long and there is no one available to ask questions. He has waited 5 months
for a nerve block injection.
For reporting purposes, services which operate across the Trust are logged under one Locality, for
example Child and Adolescent Mental Health Services (CAMHS). Westcall Out of Hours GP
services are managed by Wokingham. This should be taken into account when looking at the
Locality information because these services are covering more than one locality.
As previously noted when interpreting the information it is important to take into account that
WestCall see large numbers of patients and the number of complaints that they receive are
proportionately low.
Graph One shows the number of formal complaints over a rolling period from quarter one 2013/14
and alongside the total received over the last two years.
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Graph One: Number of Formal Complaints received since quarter one 2013/14
The West Berkshire and Mental Health Inpatient and Urgent Care Localities saw a decrease in
formal complaints received in comparison with quarter one. Corporate (including policies and
access to medical records) also saw a decrease from 4 to 1.
Bracknell saw an increase of 6 to 10, Reading of 6 to 7, Slough of 4 to 6, Wokingham of 12 to 13
and Windsor Ascot and Maidenhead saw an increase from 4 to 11 in comparison with the previous
quarter.
Table One shows the grading of complaints received during quarter two by Locality. This
information is detailed as Appendix 1.
Table One: Formal complaints received by Locality
Mental Health Inpatients & Urgent
Care
Bracknell
West Berkshire
Reading
Slough
Windsor, Ascot & Maidenhead
Wokingham
Other inc Corporate
Total
Q2
2013/14
Q3
2013/14
Q4
2013/14
Q1
2014/15
Q2
2014/15
19
4
4
3
4
8
7
1
50
16
7
3
4
4
8
3
0
45
10
2
11
8
2
12
10
1
56
16
6
9
6
4
4
12
4
61
13
10
6
7
6
11
13
1
67
The Services that received the highest number of formal complaints during quarter two were Adult
Acute Mental Health Inpatients (five), Community Mental Health Teams (nine), Crisis
Resolution/Home Treatment Team (seven) and Out of Hours GP (eight) and CAMHS (six).
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The main themes of the complaints received during quarter two is in table two.
Table Two: Theme of formal complaints received during quarter two
Theme
Alleged abuse; Bullying, Physical, Sexual,
Verbal
Access to Services
Admission
Attitude of Staff
Care and Treatment
Communication
Environment, Hotel Services, Cleanliness
Medical Records
Patients Property and Valuables
Waiting Times for Treatment
Grand Total
Number of formal
complaints
4
2
1
17
24
11
1
2
1
4
67
Attitude of staff (17) – three attributed to WestCall, three within Oakwood community inpatient
ward, two within the Talking Therapies service, two within Health Visiting (one in Reading and one
in West Berkshire) and two within the Crisis Resolution/Home Treatment Team (one in the East
and one in the West). The remaining complaints received about staff attitude were about
Psychotherapy and Complex Needs, Slough Adult Community Mental Health Team, the Slough
Walk in Health Centre, Common Point of Entry and contact with the corporate Governance Team.
Care and Treatment (24) – the highest number of complaints (four each) were attributed to
WestCall and the Adult Community Mental Health Teams (across Bracknell, West Berkshire,
Reading and Windsor, Ascot and Maidenhead). Three were received within Acute Adult Admission
wards at Prospect Park Hospital and CAMHS (two in Reading and one in Wokingham). District
Nursing in Slough received two formal complaints about care and treatment as did the Crisis
Resolution/Home Treatment Team in Reading. The remaining complaints were about Common
Point of Entry, the Minor Injuries Unit at West Berkshire Community Hospital, Children’s Speech
and Language Therapy, Podiatry in Wokingham, the Slough Walk in Health Centre and Garden
Clinic sexual health clinic.
Of the complaints received about care and treatment during quarter two, 54% were attributed to
mental health services and 46% to community health. This is a shift as 62% attributed to mental
health in quarter one.
There were four secondary complaints received during quarter two, in comparison with eleven in
quarter one; these are complaints which the Trust has previously responded to and the
complainant remains dissatisfied. As part of the complaints process, complainants are advised to
return to the Trust in the first instance with their concerns and when local resolution has been
exhausted, approach the Parliamentary and Health Service Ombudsman.
The outcome of two of these secondary complaints was not upheld, and one was resolved locally
with the service with a reallocation of a care coordinator. The remaining secondary complaint was
still in the process of being investigated, within timescale, at the end of quarter two.
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2.1
Action Taken
The actions identified to improve the service we provide to our service users and their carers
arising from complaints continue to be discussed at the Locality Patient Safety and Quality
Groups. Whilst learning from individual complaints is led by the Service, it is recognised that
themes need to be addressed by all Localities.
As part of the process of closing the formal complaint, a decision is made around whether the
complaint is found to have been upheld (referred to as an outcome).
Of the 69 complaints closed in quarter two, 13 were found to be fully upheld (19%). This is an
increase from 17% in quarter one and 12% in quarter two. As with quarter one, five cases were
not pursued further by complainants. In cases such as this we leave the option of returning to the
Trust at a later time.
17 complaints (25%) were found to be partially upheld. Partially upheld complaints are where the
investigation into these complaints identified that there was an aspect where the Trust fell short of
the high standard of service we strive to achieve.
The majority of formal complaints closed during quarter two were found to be not upheld (46%).
Two formal complaints were resolved through local resolution; where following a discussion
between the investigating officer and complainant, a swift resolution is brought to the complainant
and the complainant states that they do not require a formal response.
Examples of actions made following complaints closed during quarter two and found to be upheld
are:
• Parents of child seen by CAMHS want to know why it has taken so long to secure a meeting
when they had the personal assurance of the service manager that this would take place.
The service has acknowledged there have been some delays in providing a service to the
family. Also poor communication regarding the cancelling and rescheduling of an
appointment.
• A patient who attended the Garden Clinic (Sexual Health clinic) presented with a growth to
left forearm and right elbow. The Doctor used cryogenic spray on these which the patient
reacted badly to. An incident report was completed at the time and new ‘cryo jets’ have
been found to be more efficient. Staff have been reminded that guidance needs to be
followed appropriately. The patient experienced a reaction to cryotherapy and sustained a
burn to their arm. This is healing however staff have been advised to only treat genital
warts in future. Any patient asking for treatment to any other area to be referred to their GP
• A patient open to Psychotherapy & Complex Needs made a complaint about their
assessment and the record keeping by their Therapist. The patient disagreed with the
content of one particular letter which they state contained information shared without their
consent. The investigation showed a lack of appropriate treatment plan and the letter to the
GP has been replaced with an amended version. The patient has been informed that they
can add an entry to their patient records if they dispute the contents. The performance of
the Psychotherapist is being managed internally.
• A carer complained that the gradient of the slope going into the Parkinson's Clinic at St
Marks Hospital was too steep. She explained that it was difficult to push her husband up
and it was difficult to obtain assistance. Patients are being advised to use the main
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entrance to Community Health Clinic rather than side entrance in future to address this
problem. Minor modifications will be made to the building to facilitate this and signage will
be updated. Additional reception staff will also be available to assist patients into the
building.
• The family of a patient open to Psychotherapy and Complex Needs complained about the
booking process. A new message taking protocol has been put in place ensuring that staff
are informed of cancellations in a timely manner with a robust system for audit. A new
process has been introduced to ensure that client appointment availability is highlighted on
service waiting list, not just recorded, so that this is clearly marked when offering
appointments, ensuring clients are offered appointments they are able to attend.
A grace period of three days is allowed if a client fails to attend before a discharge letter is
sent to the client’s GP. A recommendation has been taken forward that a review of joint
working practice is undertaken. In this specific case, a letter was sent to the patients GP
clarifying that a message had been received cancelling his appointment and that a letter to
them was sent too quickly. An apology has been given to both the GP and the complainant
and the patient’s referral has been has been reinstated.
• The family of an inpatient on one of our Learning Disability inpatient wards raised a
complaint about specific clinical issues about their loved one’s care as well as an update
following an incident on the ward. Initial funding for a placement has been agreed at a
more appropriate placement for the patient and is being facilitated. Feedback from the
incident was fed back by the Head of Service and the items such as black out blinds have
been purchased to enable the existing ward environment to be more therapeutic and
relaxing for the patient while the placement is being arranged.
2.2
Response Rate
Whilst the Complaint Regulations 2009 state that the timescales for complaint resolution are to be
negotiated with the complainant, the Trust monitors performance internally against both a 25
working day timeframe and formally, the renegotiated timescale. The investigating managers
continue to make contact with complainants directly to renegotiate timescales for complaints
where there has been a delay and these are recorded on the online complaints monitoring system.
The response rate for quarter two is 87% within a timescale re-negotiated with the complainant.
This is in comparison with 91% in quarter one and 81% in quarter four.
Table Three: Response rate during quarter one
Month
July
August
September
Quarter Two
Including re-negotiated
85%
84%
92%
87%
By monitoring the response rates by Locality, the Trust is able to identify any specific areas which
are having difficulties in undertaking prompt complaint investigations and where a locality is not
making contact with complainants to renegotiate timescales accordingly.
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There continues to be targeted work with services around making contact with complainants both
early in the complaints process and to re-negotiate timescales where appropriate.
A revised internal response rate target of 65% resolved within 25 working days and 90% within
negotiated timescale have been set for 2014/15.
The average number of days taken to resolve formal complaints during quarter two was 28, a
reduction from 29 in quarter one and 33 in quarter four. There were 16 more direct formal
complaints closed during quarter two which demonstrates the commitment by the Trust to give
complaint investigations a priority. The numbers of working days formal complaints take to resolve
are monitored within the Trust on a monthly basis.
Table Four: Response Rate by working days for complaints closed in quarter two
Locality
Bracknell
Corporate
Mental Health
Inpatient and
Urgent Care
Reading
Slough
West Berks
Windsor,
Ascot &
Maidenhead
Wokingham
Grand Total
0 to 15
days
Working days open
16 to 25
26 to 40
41 to 59
days
days
days
3
2
2
2
2
6
5
2
1
1
4
2
5
1
3
1
2
2
2
6
1
7
8
32
3
21
6
60 to 80
days
1
Grand
Total
8
2
2
17
8
6
6
3
10
12
69
The Trust continues to aim for a resolution within 25 working days, unless this is not possible due
to complexities of the complaint. By monitoring complaint response times we are able to identify
any localities which show a longer resolution timescale than generally expected.
2.3 Parliamentary and Health Service Ombudsman (PHSO)
The Trust continues to work with the PHSO as the second stage within the complaints process.
An update of the PHSO complaints is attached as Appendix 2.
The Patient Experience and Engagement Group are actively monitoring the action plans that arise
from PHSO investigations on a quarterly basis, which acts as a forum to share practice and
learning across the different specialities and geographical localities.
Unlike previous reports, the PHSO Annual report 2013/14 does not contain data at Trust level so
we are not able to compare.
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Over the last year BHFT has been an increase in the number of complaints referred to and
investigated by the PHSO. The annual report shows that the PHSO completed 2,199
investigations, compared with 384 in the previous year. Of these:
854 were upheld in part or in full
1,179 were not upheld
3.
The Friends and Family Test
The Friends and Family Test (FFT) continues to be collected across the Community Inpatient
Wards and the Minor Injuries Unit (MIU). The Trust is using a ‘postcard’ method of collecting this
feedback. The full results are shown in table five and six however the quarter two average for
community inpatients was 92.31% and MIU 98.14%.
Table Five: Community Inpatients Results
Community
Inpatients
April
May
June
July
August
September
October
November
December
January
February
March
April
May
June
July
August
September
% response rate
58.86
75
74.58
71.53
79.41
77.87
68.60
73.10
72.81
81.10
68.50
61.42
87.70
80.00
76.19
74.31
80.95
74.40
% Extremely &
likely
95.7
94.44
95.45
76.53
88.89
92.63
96.39
95.28
90.36
92.23
95.4
89.74
92.52
93.48
96.88
95.06
89.41
92.47
Table Six: MIU
Minor Injuries Unit
April
May
June
July
August
September
% response rate
17.68
18.77
7.09
10.32
16.25
13.27
% Extremely &
likely
97.79
98.44
98.46
98.07
96.53
98.35
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October
November
December
January
February
March
April
May
June
July
August
September
12.93
35.62
43.29
54.33
39.50
26.98
33.77
38.56
39.36
15.08
19.10
34.47
98.59
98.83
97.98
98.93
98.46
98.36
98.43
98.88
98.00
97.44
99.69
97.30
When interpreting the percentages, it is important to take the number of patients into
consideration, particularly in community inpatients where the number of discharges is low in
comparison with acute trusts.
The roll out of the Friends and Family Test is underway, with messaging being used within mental
health inpatient wards during October 2014. The main methodology for collecting the Friends and
Family Test will be by postcard, and there is an implementation plan to roll out to Trust services in
line with national guidance.
4.
15 Steps
2014/15 is the third year of the 15 Steps rolling programme.
Eight visits have been undertaken during this quarter, four inpatient wards (Berkshire Adolescent
Unit, Ascot Ward, Rowan Ward and Campion Ward) and four outpatient departments (Podiatry –
Reading and Hungerford) and CAMHS (Reading and Wokingham Hospital). All the visits were
positive with the main points listed below:
• Teams are attentive and listen to staff
• Visits support managers to reinforce observations and identified issues to staff
• The teams give staff an opportunity to demonstrate good practice, initiatives and the pride
they have in their area.
• Ensuring staff remain alert to unannounced visits supporting maintenance of core standards
Appendix 3 contains the full quarterly report showing identifying the feedback and themes from the
15 Steps visits which took place during quarter two.
5. Deep Dive
The Deep Dive Survey was undertaken at the Slough Walk in Health Centre between May 2014
and July 2014.
This survey was commissioned as previous patient satisfaction results were poor. The deep dive
has identified that, in some areas, levels of satisfaction are fairly high. This apparent shift in
patient satisfaction has been discussed with the Centre Manager who has cited a number of
changes that have been recently made, which aimed to improve interaction with patients and
provide more personable care from front-line staff. However, there is also significant room for
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improvement in a number of areas and recommendations have been made which are included
within the Executive Summary (Appendix 4). These include staff training, displaying waiting times
and better site signage.
6. Complainant Survey
The Trust is currently commissioning the Patients Association to undertake a survey of the
complaints process. The survey is sent to complainants six weeks after the final response is sent
to allow time for a considered response and reflection on their experience. A report is shared with
the Trust bi-annually; the next results are due in December. The number of people who completed
the survey was very low and not necessarily representative of the experience of the complaint
process as a whole. 30 complainants were sent the survey and of these 15 responded (50%). The
results received to date show that:
73.3% of the respondents raised a complaint on behalf of a friend or family member. The
Complaints log the source of complaints which show that during this period, 62% of complaints
were received from family members on behalf of patients (this includes Grandparents and
siblings).
40% of respondents stated that their complaint was resolved. The survey was sent to people at the
end of the complaints process in terms of Local Resolution (at Trust level).
Out of the 15 responses to the question, 86.7% felt that their complaint was handled poorly or very
poorly. There is no further information about why the respondents gave this answer which would
help us to quantify this further; e.g. is this about the initial person the complaint was raised with,
access to information on how to make a complaint, contact with the Complaints Office or final
response. Feedback has been shared with the Patients Association about the further value of this
follow up information with a view to being included if the survey is revised.
21.4% felt that staff were helpful in supporting them to make a complaint. 28.5% felt comfortable
or very comfortable with the staff handling their complaint. This Investigating Office has
responsibility to make contact with the complainant early in the complaint process or the
Complaints Office, as some complainants have more contact with the Complaints Office.
57.2% were worried that the quality of care would be reduced if they made a complaint. As a Trust
we work hard to work against this to give reassurance. Our learning from experience posters are
about gathering patient experience as a whole and balancing.
33.3% said that timescales regarding the complaint were discussed, 20% were unsure. As part of
the acknowledgement letter an initial timescale is noted however at the point of discussion with the
IO, the timescale for a response should be discussed with the complainant directly. The number of
initial conversations has increased as these are noted within the progress of the complaint file
within the Datix file however this is not consistent.
7.1% felt they were well informed during their complaint. 21.4% did not have an opinion. The
remaining respondents reported that communication could have been improved.
20% reported that they found the process either rarely or not stressful at all.
We are committed to improving the experience of people who access the complaints process and
are looking at different sources of information to use to evolve the way that work with people to
ensure that we are accessible and easy to use.
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7. Informal Complaints and Local Resolution
The complaints office has been working with services to devise ways of resolving complaints that
meet the expectation of patients and their families whilst capturing the information for staff in a use
friendly and manageable way.
Informal complaints are complaints which come into the complaints office and are not formal
complaints. Historically, the Trust was keen to promote formal complaints as the predominant form
of resolution and management, and this is not appropriate in all cases or to all people. The
complaints office received specific feedback from some people who had raised complaints and
were surprised to receive a formal acknowledgement from our Chief Executive, explaining that
they didn’t expect, or want their complaint to be managed in this way.
The complaints office will discuss the options for complaint management when people contact the
service give them the opportunity to make an informed decision on if they are looking to make a
formal complaint or would prefer to work with the service to resolve the complaint informally.
Table Nine shows the number of Informal Complaints received and managed in this way during
quarter two.
Table Nine: Informal Complaints received
Service
Number of Informal Complaints
Received
CMHT/Care Pathways (2 x Bracknell, 1 x West
Berkshire)
3
Windsor, Ascot and Maidenhead Older Adults
Community Mental Health Team
1
Review showed not BHFT - forwarded to NHS
England
1
Rowan Ward
Physiotherapy (Adult)
PICU - Psychiatric Intensive Care
Psychotherapy & Complex Needs
Speech and language therapy
Walk in Centre
Grand Total
1
1
1
1
1
1
11
It is also recognised that services are managing concerns effectively on a daily basis and that it
would be beneficial to have a consistent way of collecting and monitoring this information. An
online form has been created as a mechanism for these concerns to be captured. There has been
an initial issue identified where this was being completed in error by staff trying to complete an
online incident form. As a result of this, a request has been made for the patient experience
modules of Datix to be moved away from the incident reporting form on the intranet.
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Table Ten shows the number of local resolution contacts reported by services during quarter two.
Table Ten: Local Resolution contacts received
Service
Admin teams & office based staff
Adult Acute Admissions
CAMHS - Child and Adolescent Mental Health
Services
Children's Community Nursing
Children's Speech & Language Therapy
CMHT/Care Pathways
Common Point of Entry
Community Dental Services
Community Respiratory Service
Diabetic Eye Screening
District Nursing
Equipment/Medical Loans
Speech and language therapy
Health HUB
Health Visiting
Minor Injuries Unit
Other
Phlebotomy
Physiotherapy Musculo-skeletal
Podiatry
Walk in Centre
Grand Total
8.
Number of Local Resolution recorded
4
1
10
1
3
2
1
1
1
5
9
1
1
1
5
1
2
1
5
5
2
62
PALS Contacts
The role of PALS is to offer a signposting service as well as to facilitate the resolution of concerns
with services at the first stage of the complaints process.
There have been 321 contacts during quarter two, an increase from 233 in quarter one.
65% of contacts were resolved by PALS on the same day, this is the same as quarter one. The
majority of contacts (49.5%; an increase from 36% in quarter one) were made following people
gaining contact details from the internet.
The themes of contacts received during quarter two is broken down as follows:
• Information requests
• Communication issues
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9. Compliments
Graph Two shows the number of compliments received since quarter one 2012/13 by Locality.
Since quarter four 2012/13 compliments have been routinely reported directly by services through
the web based Datix system. This method of collating feedback enables the Trust to capture
compliments other than the traditional thank you card.
Graph Two: Number of compliments received since quarter one 2012/13.
Table Eleven shows the number of compliments received during quarter one, by month and
locality.
Table Eleven: Compliments received during Quarter Two
Locality
Bracknell
Mental Health
Inpatient and
Urgent Care
Other
Reading
Slough
West Berks
Windsor Ascot
and Maidenhead
July 2014
142
Month Received
August 2014
111
September 2014
143
Grand Total
396
5
6
41
16
50
7
16
38
14
46
3
17
42
17
64
15
39
121
47
160
34
31
42
107
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Wokingham
Grand Total
34
328
23
286
48
376
105
990
August saw the lowest number of compliments received since the beginning of the 2014/15 year
which had a negative impact on the overall number of compliments received during quarter two.
10. Patient and Public Involvement
We continue to work closely with Healthwatch organisations to gather feedback on the services we
provide and ways we can improve this further. We hold a meeting every three months where we
give an update on patient experience and incidents, and invite services that Healthwatch have
asked for further information on.
Services are using a combination of devices and paper surveys as well as a mixture of surveying
continually throughout the year, rotation of devices between localities and targeted times to
survey.
In quarter two there has been a consistent number of patients responding in comparison with
quarter one, although this is a decrease from quarter four. We are working with Clinical Directors
to move this forward and have implemented a process of informing the Clinical Directors of the
services we feel need to improve so that this can be addressed.
At the end of quarter two we have received feedback from 3,787 patients and carers compared to
3,724 in the last quarter. Total feedback relevant to the good or better rating has been received
from 3,698 patients and carers, of those that provided feedback 90.2% reported the service they
received as good or better compared to 82% for last quarter, meaning the percentage has
significantly increased. The vast majority of services reporting lower than 75% for good or better
last quarter have improved their satisfaction ratings.
Slough Walk In Health Centre had a large drop in the number of responses this quarter which the
service reports was due to the concurrent Deep Dive survey; assurance has been given that the
number of responses will increase rise again next quarter. The satisfaction figures for this service
remain very low, this impacts greatly on the overall satisfaction rating, and this has been discussed
and continues to be addressed. The number of responses continues to be closely monitored and
services kept informed of the numbers still required to achieve this.
Phase Two of the Patient Experience Dashboard is complete and Clinical Directors, Locality
Directors along with Head of Service have access to an additional view for the inpatient wards and
Slough Walk in Health Centre (SWIHC). This additional view includes a summary report based on
all of the services questions, inclusive of their service specific questions. This has been
incorporated for the Wards and SWIHC to enable feedback collected in real time to be acted upon
as soon as it is received, to have a positive impact on the patient at that time.
Learning Disabilities Responses
Currently we use a different set of questions for Learning Disabilities in a more accessible format.
We will be working with the service to develop new questions that can be included in the
comparison table. The questions and results for quarter two is detailed in Table Twelve.
This continues the dramatic drop in figures for the Learning Disabilities service we saw in quarter
two. This has been discussed with the service and we expect this level of responses to continue as
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the service no longer asks their patients to complete the survey each visit; they are only requested
to do so once. Learning Disabilities results are detailed later on in the report.
Table Twelve: Learning Disability Service results
Question
A Lot
A little
Not at all
Question not
answered
Total
My meeting
with you was
helpful
81
6
0
2
89
I would tell my
friends that my
meeting was
helpful
71
12
3
3
89
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You Said, We Did
Below are examples of evidence that patient feedback has impacted on the service that the Trust
provides:
You said…
…We did
Wokingham Cardiac Rehabilitation we
would like clearer instructions on
exercise cards and a larger room to
exercise in
We feel that access to Sexual Health
services in Maidenhead is limited
We would like an email address on the
appointment letters to contact the West
Berkshire Musculo-Skeletal (MSK) Physio
Service
As patients of West Berkshire Cardiac
Rehabilitation, we want to be more aware of
our heart rates and performance
New laminated exercise cards have been made
to make exercises clearer and the service is
exploring other venues to try and improve the
space available
We have increased our clinic time in
Maidenhead by 2 hours. This has resulted in
127% increase in male attendances
reflecting increase in screening and
treatment for sexually transmitted infections
Our email address has been added to our
appointment letter templates
We are trialling a new heart rate monitor to
help you to monitor your heart rate
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As an inpatient on one the older person’s
mental health wards, I have not received
a copy of my care plan and there should be
more water jugs available
A patient commented that the Bracknell
MSK Physio telephone line is really busy
and it is hard to get through
We checked at our Community meetings and
patients have confirmed that they are receiving
copies of care plans and are aware of them.
We are buying more water jugs so water will
be more available.
We are looking into getting a new
telephone system to help us to manage
calls to the service more efficiently and
effectively
West Berkshire MSK Physio sent a letter to
patients that had the wrong postcode on it.
We have amended the postcode on the
letters.
A Doctor at the Acute Trust also told us that
there was a lack of demographic information
on discharge letters
We are also going to add the patient’s date
of birth and address to the discharge report
letter
Patients on Snowdrop Ward have asked
for more resources to use during the
evenings and weekends and requested
the opportunity to have a cooked
breakfast at the weekends
We have provided more books, DVDs and
art and craft materials on the ward. The
ward is currently trialling patients cooking
themselves breakfast one day at the
weekend
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11 December 2014
Annual Report of Trust Audit Committee
SUMMARY:
In line with the NHS Foundation Trust Code of Governance, it is regarded as best practice for
the Audit Committee to provide a report annually to the Council of Governors to:
•
•
Highlight any relevant audit issues identified during the year in respect of which the
Committee considers action or improvement is warranted and setting out the steps
to be taken.
Comment on the quality of the auditors work and on the reasonableness of the fees.
(The guidance states that the Audit Committee “must make a recommendation to
the Council of Governors with respect to the reappointment of the auditor”).
AUDIT ISSUES:
There are no substantial issues that the Audit Committee needs to draw to the Council’s
attention from its work in 2014 but set out below are key activities that have featured within
the Committee’s work programme that will be of interest to Governors:
•
•
•
•
•
The Committee continued to undertake in-depth reviews of severe risks on the
corporate risk register to gain assurance that action being taken to mitigate was
appropriate and proportionate – areas included patient records/RiO, health visiting,
physical assaults and search policy.
Committee membership during the year included Keith Arundale (Committee Chair),
Mark Lejman, Angela Williams and Ruth Lysons (Mrs Lysons subsequently
transferred to the Quality Assurance Committee following the departure of Peter
Warne).
The Committee piloted a performance evaluation process for the internal and
external auditors. The results demonstrated a very high level of satisfaction.
The Committee continued to monitor closely the development of the Trust’s Board
Assurance Framework to ensure it delivers robust assurance around the
management of key risks to the Trust’s strategic objectives. During the year the BAF
was reviewed in detail by the Executive to ensure it remained fully aligned to the
Trust’s strategy, including developments arising from the strategy refresh activity.
Close monitoring continued of the Trust’s information assurance framework which
provides assurance over the completeness and accuracy of key data. There is an ongoing programme of data quality checks and audits and, whilst there is still much to
do before we have full assurance on the quality of our data, both internal and
1
•
•
•
•
•
•
external auditors have commented that the Trust’s approach to auditing and
reporting on data quality is leading edge amongst other Foundation Trust clients.
In late May the Committee formally reviewed and approved, on behalf of the Board,
the 2013/14 annual accounts. KPMG, the Trust’s external auditor, issued an
unqualified opinion on the financial statements for 2013/14 and an unqualified
value for money conclusion on the use of resources.
Review of 2013/14 Charitable Fund annual report and accounts.
Consideration of internal audit reports and reports of counter fraud activity.
Receipt of regular reports on clinical audit activity highlighting progress against
annual plan and key audit findings. The internal and external auditors commented
on how advanced the Trust is compared to other Trusts with the focus by the Audit
Committee on the clinical audit programme.
The Committee received the internal audit annual report for 2013/14. Some 22
audits had been completed:
o 4 Advisory only reports
o 5 Green assurance rated reports
o 9 Green/Amber assurance rated reports
o 4 Amber/Red assurance rated reports – procurement x 2, health and safety
home visits and patient experience (complaints)
In all cases, the Committee was satisfied that recommendations raised in reports
were being adequately addressed via management action plans and that the
internal auditor followed up on recommendations to ensure implementation
within an acceptable timescale.
At the time of writing this report, the internal auditors, will have completed and
issued final reports in respect of four separate audits during the 2014/15 year to
date. The resulting assurance ratings are shown in the table below and
recommendations have been or are in the process of being implemented:
Audit Area
Capital Programme (audit conducted 13/14)
Monitor Returns
Risk Rating
Green
Amber/Green
Internal CQC Compliance Process
Green
Budgetary Control & Financial Control
Green
Baker Tilly have confirmed that as at October 2014, no issues have been identified
from their work so far which would adversely impact on the annual Head of Internal
Opinion report.
The remainder of the internal audit programme is on track in line with plan and will
be completed by the end of March 2015.
•
The Audit Committee is able to confirm that its terms of reference have been
reviewed formally during the year and are fully compliant with the guidance
contained in the national NHS Audit Committee handbook. The Committee has also
undertaken its annual self-assessment review to ensure it remains fit for purpose
and has received the results of the self-assessment evaluations of other Board
Committees.
2
ACKNOWLEDGEMENTS
The Audit Chair wishes to pay tribute to Mark Lejman, Angela Williams and Ruth Lysons,
NEDs, for their commitment and support throughout the year.
The Committee also wishes to commend the sterling work carried out by the Trust’s finance
teams on the annual accounts this year.
AUDITORS’ CONTRIBUTION:
Throughout the year, the Audit Committee has been supported fully by the Trust’s internal
and external auditors. The Committee is fully satisfied with the quality of the work
undertaken by the Internal Auditors, Baker Tilly and the External Auditors, KPMG.
In a new development, the Committee piloted a performance evaluation assessment process
for both internal and external auditors during the year. The results were very positive and
established that overall Committee members considered that the auditors are performing
effectively. The process will become an annual feature and will be refined in light of the pilot
exercise.
The Committee remains very satisfied with the support and professionalism of both
organisations and in the case of the external auditor the Committee formally recommends
their continuation in line with the contract award.
External Auditor - Non-Audit Work Activity
The separate consultancy arm of KPMG has been engaged by the Trust for some non-audit
work, primarily in support of the Trust’s Strategy refresh programme.
In light of best practice on the use of the organisation’s Auditor for non-audit activity, such
as consultancy, a policy has been developed and approved by the Audit Committee (copy
attached as Appendix to this report) which sets out the situations when engagement of the
Auditor for non-audit work would be acceptable, subject to Audit Committee agreement.
Following Board approval, the Council of Governors is now invited to formally approve this
policy which will ensure appropriate governance around non-audit work that might be
commissioned from the external auditor (this would most often be the non-audit part of the
company but the policy would still apply).
ACTION:
The Council of Governors is invited to:
1. Note the report and to seek any clarification.
2. Note and formally endorse the Audit Committee recommendation regarding the
continuation of KPMG as Trust external auditor under their existing contract with
the Trust.
3. Approve the policy on the engagement of the External Auditor for non-audit work.
Prepared by:
John Tonkin
Company Secretary
Presented by: Keith Arundale, NED
Chair of Audit Committee
December 2014
3
APPENDIX
Non Audit Work Conducted by Independent (External) Auditor
1. Under the Audit Code for NHS Foundation Trusts, the independent (external)
auditor, is permitted, with the approval of the Council of Governors, to provide the
Trust with services which are outside the scope of the audit as defined in the
Code (additional services). It is regarded as good practice for each Foundation
Trust to adopt and implement a policy for considering and approving any
additional services to be provided by the external auditor. This paper sets out a
draft policy and process for consideration in the first instance by the Audit
Committee.
2. Section 2.14 of the Code states that it is the auditors’ decision to determine who
are “those charged with governance” at the Foundation Trust. It is expected,
however, that this will be the Audit Committee in the first instance and the Council
of Governors, if the auditors feel the issue is significant.
3. In respect of additional services, it is proposed that the Council of Governors be
presented with the policy to confirm their approval for the external auditors to
provide additional services which are outside the scope of the audit. It will be for
the Audit Committee to determine what will constitute additional services.
Proposed Policy
4. The policy is aimed at ensuring the independence of the external auditor is not
compromised whilst ensuring that the Trust is not deprived of expertise where it is
needed. Potential threats to independence, as described by the Institute of
Chartered Accountants, include self-interest, self-audit, advocacy and familiarity
or trust.
5. It is proposed, subject to Committee, Board and Council agreement, that in order
to provide a transparent mechanism by which non-audit work can be reviewed
and progressed without too great an administrative burden falling on the Trust,
the following three categories of work apply to the professional services available
from the external auditor:
•
Statutory and audit related work not requiring Audit Committee approval – this
would cover projects where the work is clearly audit related and the external
auditor is best placed to do the work – e.g. acting as agents for a regulator.
Where the audit fee for this exceeds £50k then Audit Committee approval
would be sought.
•
Audit related and advisory services requiring prior Audit Committee approval
– this would be for projects where the external auditor is best placed to
perform the work due to their network within and knowledge of the business
or due to their previous experience or market leadership.
•
Projects that would not be permitted to be performed by the external auditor
are those where there would be a real threat to the independence of the audit
team such as where the external auditors would be in a position where they
were auditing their own work
4
The attached appendix 1 provides further examples of work types.
6. The Audit Committee would report to the Board all additional work undertaken by
the external auditors, providing assurance that in authorizing the additional work,
the auditors’ independence has not been compromised.
7. The external auditor would also be required as a matter of course to summarise
in their ISA 260 any work undertaken as part of additional audit services for the
Trust.
8. The Annual Audit Committee Report to the Council of Governors would
summarise any additional services agreed under this policy.
9. The policy will be reviewed annually by the Audit Committee to determine
whether it is functioning appropriately and effectively.
5
Appendix 1
External Audit Non-Audit Work
Examples of Work Types
Characteristics
Statutory & Audit
Related (not requiring
Audit Committee
approval unless in
excess of £50k)
Audit & Assurance
Related and Non Audit
Advisory Services
Projects not
permitted
Advice on areas core to
the financial statement
audit.
•
Requiring independent
objective assessment
of information or
procedures
Other advisory
services
Due diligence and
related advice
Completion accounts
audit
Advice on integration
activity
Preparation of
forecast of investment
proposals
Participation in
management
Provision of specialist
skills/training
Advice on
methodology and
systems
Co-sourcing
Advice and design of
policies, systems and
procedures
Preparation of draft
returns
Advice on tax matters
Valuation for purposes
of taxation
•
•
Full outsourcing
Systems
implementation
•
Preparation of
accounting entries
for tax
Handling taxation
payments
Advice on accounts
preparation and
application of
accounting standards
•
•
Acquisitions/
disposals
Accountant’s reports.
Reporting on financial
assistance.
Audit of carve out
financial statements.
•
•
•
•
Internal audit and
risk management
services
None
•
•
•
•
Taxation
None
•
•
•
General
accounting
None
•
•
•
Preparation of
accounting entries
Preparation of
financial
information
6
Annual Audit Letter
2013-14
Berkshire Healthcare NHS
Foundation Trust
External Audit 2013-14
09 July 2014
Content
The contacts at KPMG
Page
in connection with this
plan are:
Fleur Nieboer
1. Purpose of the Annual Audit Letter and scope of work
2
Director
2. Key messages
3
Tel: +44 (0)20 7311 1879
Appendices
KPMG LLP (UK)
[email protected]
A.
Reports issued and recommendations
Jo Lees
KPMG LLP (UK)
Senior Manager
Tel:
+44 (0)20 7311 1367
joanne lees@kpmg co uk
[email protected]
Emily Tiernan
KPMG LLP (UK)
Assistant Manager
Tel:
+44 (0)20 7694 4492
[email protected]
This report is addressed to Berkshire Healthcare NHS Foundation Trust (the Trust) and has been
prepared for its use only. We accept no responsibility towards any third parties. Monitor has issued
a document titled Audit Code for NHS Foundation Trusts. This summarises where the
responsibilities of auditors begin and end and what is expected from the audited body. We draw
attention to this document.
External auditors do not act as a substitute for the audited body’s own responsibility for putting in
place proper arrangements to ensure that public business is conducted in accordance with the law
and proper standards,
standards and that public money is safeguarded and properly accounted for
for, and used
economically, efficiently and effectively.
If you have any concerns or are dissatisfied with any part of KPMG’s work, in the first instance you
should contact Fleur Nieboer who is the engagement lead who will try to resolve your complaint.
© 2014 KPMG LLP is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms
affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved. This document is confidential and its circulation and
use are restricted. The KPMG name, logo and 'cutting through the complexity' are registered trademarks of KPMG International
Cooperative (KPMG International)
1
Section One
Purpose of the Annual Audit Letter and scope of work
Purpose of this letter
This letter summarises the key issues arising from our audit of Berkshire Healthcare NHS Foundation Trust (the Trust).
We highlight areas of good performance and provide recommendations on areas of improvement. All issues summarised
herein have previously been reported to the Trust and a list of all reports we have issued in 2013-14 is provided in
Appendix A. Although this letter is addressed to the Directors and Governors of the Trust, it is also intended to
communicate key issues to relevant external stakeholders, including members of the public.
Responsibilities of the auditor
The statutory responsibilities and powers of appointed auditors are set out in the National Health Service Act 2006 (‘the
Act’). In discharging these specific statutory responsibilities and powers, auditors are required to carry out their work in
accordance with Monitor’s Audit Code for NHS Foundation Trusts (the Code) which is available at www.monitornhsft.gov.uk. This outlines where our responsibilities begin and end and what is expected from the audited body.
External auditors do not act as a substitute for the Trust’s own responsibility for putting in place proper arrangements to
ensure that public business is conducted in accordance with the law and proper standards, and that public money is
safeguarded and properly accounted for, and used economically, efficiently and effectively.
The scope of our work
Under the Code we are required to review and report on:
■ the use of resources – whether the Trust has made proper arrangements for securing economy, efficiency and
effectiveness (value for money) in its use of resources; and
■ the accounts – the financial statements and the Annual Governance Statement.
In addition, we were required by Monitor to provide independent assurance on the content of the Quality Report and two
mandated indicators.
Adding value through our external audit
We have added value throughout the year through:
■ A proactive and pragmatic approach to issues arising in the production of the financial statements to ensure that our
opinion is delivered on time;
■ Meetings and discussions throughout the year with key staff on the quality report, the indicators for audit and how the
Trust can enhance the quality report and the underlying data;
■ Engaging with the Trust on developing approaches to technical accounting queries and agreeing in advance of final
accounts key accounting estimates made by management;
■ Provision of technical updates and sector guidance to the Audit Committee to ensure that they remain briefed on
matters relevant to them; and
■ Maintaining an effective working relationship with the Trust’s internal auditors to maximise assurance to the Audit
Committee, avoid duplication and provide joint value for money.
Fees
Our fee for the financial statements and use of resources audit in 2013-14 was £60,215 excluding VAT. This fee was in
g g
in our audit p
plan issued 9 January
y 2014. Our fee for the external assurance on the q
quality
y report
p
line with that highlighted
in 2013-14 was £10,785 excluding VAT.
As in previous years, we also undertake the external audit of Berkshire Health Charitable Fund. Our fee for the Charity
audit in 2013-14 is £4,500 excluding VAT in line with our Audit Plan.
In addition to this, KPMG undertook a piece of non-audit work. Our Advisory team was engaged to work with the Executive
and Senior Management Team in the strategy redesign for 2014-15 onwards. The fee for this piece of work was £372,000
excluding VAT.
Acknowledgement
We thank the Trust for its support throughout the year.
2
Section Two
Key Messages
USE OF
RESOURCE
OPINION:
UNQUALIFIED
Use of
Resource
Opinions and
Annual
Governance
Statement
(AGS)
QUALITY
ACCOUNTS
OPINION: A
CLEAN
LIMITED
ASSURANCE
OPINION.
Quality
Accounts
■ We are required to certify that we have completed the audit of the Trust financial statements in
accordance with the requirements of the Code. If there are any circumstances under which we
cannot issue a certificate, then we must report this to those charged with governance. There
are no matters that caused us to delay the issue of our qualified certificate of completion of the
audit.
■ We have been able to conclude that the Trust has made proper arrangements for securing
economy efficiency and effectiveness in its use of resources for the year ending 31 March 2014
economy,
and as such have issued an unqualified use of resource opinion.
■ We reviewed the 2013-14 AGS and were able to confirm that it reflected our understanding of
the Trust’s operations and risk management arrangements. We also took into consideration the
work of internal audit.
We completed our audit of the Trust’s 2013-14 Quality Report. Headlines from our work include:
■ The Trust achieved a clean limited assurance opinion on the content of its Quality Report. This
represents an unqualified audit opinion on the Quality Report;
■ This year we tested ‘100% enhanced Care Programme Approach (CPA) patients receiving
follow-up contact within seven days of discharge from hospital’ and ‘admissions to inpatient
services had access to crisis resolution home treatment teams’ as the two mandated indicators.
Based on our detailed testing of the indicators we were able to give an clean limited assurance
opinion on their presentation and recording;
■ Our work on the local mandated indicator ‘Medication Errors’ did not identify any issues in the
sample of data we tested ; and
■ Our detailed findings following the audit of the Quality Report were presented to the Trust in a
separate private report. This report included one medium priority recommendation in relation to
the misclassification of some exempt cases in compiling the indicator. The Trust reviewed all
data in this category and amended the calculation of the indicator. We recommended that data
quality checks be extended to include exemptions. We also re-raised and increased the priority
of our recommendation from 2012-13 in relation to compliance with the seven day follow up
rules for CPA patients. Whilst our sample testing for this indicator did not identify any cases that
had been incorrectly calculated, as with the prior year, we found some instances where contact
patient ((for example
p a carer)) had been flagged
gg as the follow up,
p,
with someone other than the p
though in all cases a subsequent follow up with the patient had also been conducted within the
seven day period.
FINANCIAL
STATEMENTS
OPINION:
UNQUALIFIED
Overall
Fi
Financial
i l
Results and
Financial
Statements
Opinion
■ The Trust reported a Continuity of Services Rating of 4 as at 31 March 2014. A surplus of £1.6m
was achieved for 2013-14, against a forecast position of £0.75m surplus. This favourable
variance resulted from additional income of £2.3m from commissioners in relation to the Trust’s
mobile working programme which had not originally been planned for.
■ Despite the favourable year end position, the Trust faced continued financial pressure during
the yyear and under-achieved its CIP for 2013-14 byy £
£0.8m,, relating
g mainly
y to two schemes of
secondary commissioning and MH inpatient configuration. The CIP for 2014-15 is equally
challenging and a programme of £8.6m has been identified, which contains approximately £1m
of non-recurrent schemes. A gap of approximately £9m has been identified for 2015-16, even
after the identification of circa £5m of CIP schemes. The strategy refresh is being used to
identify both efficiency and transformational schemes to bridge this gap.
■ Whilst the current financial position does not indicate any immediate concerns in respect of
liquidity or the going concern assertion, this does remain an area of significant risk to the Trust.
On the basis of the work we have undertaken in respect of the financial position of the Trust, we
did not consider at the date of our opinion
p
that there were any
y circumstances which would
impact on our ability to issue an unqualified audit opinion.
3
Appendix A
Reports issued and recommendations
The table below provides details of all our audit reports issued in 2013/14. We also summarise all the recommendations
that we issued in 2013/14. These recommendations have all been communicated to the Audit Committee. All
recommendations were agreed with Management and action plans have been put in place for implementation. We will
follow up progress against all recommendations made as part of our 2014/15 audit.
Number of recommendations made
Report
Date issued
High priority
Medium priority
Low priority
Audit plan
January 2014
n/a
n/a
n/a
Audit highlights memorandum
May 2013
0
0
0
External assurance on the Quality Report
May 2013
0
1
0
0
1
4
TOTAL
All high priority and medium priority recommendations are summarised below alongside management responses:
New medium priority recommendation raised in 2013-14
Data Quality of exempt
cases in calculating
the ‘admissions to
inpatient services who
had access to crisis
resolution home
treatment teams’
teams
indicator
Our testing of exempt gatekeeping cases identified 62/72 were incorrectly classified as
‘exempt’ due to locality staff recording the incorrect admission type on RiO. We recognise
that of these cases, had been appropriately gatekept with the exception of four which had
originally been treated as exempt but subsequently classified as within scope. By excluding
these as exempt the Trust had very marginally overstated performance against the indicator.
During our review the Trust recalculated the indicator taking these into account. As a result,
reported performance moved from 97.7% to 97.6%.
We recommend the data quality audits currently in place at the Trust are to be extended to
include cases recorded as exemptions. In addition ward staff should be reminded of the
importance of selecting the correct admission type on RiO and where necessary additional
training should be provided.
Number of recommendations made
Status of 2012-13
Recommendations
High risk
Moderate risk
Low risk
Implemented
1
2
4
In progress
1
0
0
Outstanding
0
0
1*
TOTAL
2
2
4
* Please note: this recommendation has been re-raised in 2013-14 and the priority increased to medium. We have
provided an update on this recommendation below:
Recommendation re-raised from 2012/13
CPA: compliance with
seven day follow up
Our initial testing of seven day follow up identified one case which was non-compliant as the
team had not had direct contact with the patient, instead liaising with staff at the patients care
home. We recommended that locality staff were reminded of the requirements of seven day
follow up i.e. That direct contact with the patient must occur in order to ensure compliance.
While discussions with the Trust identified that locality staff were reminded of the
requirement, our substantive testing for 2013/14 has identified the recurrence of the same
issue. It is essential that staff continue to be reminded and consideration should be given to
spot checks throughout the year to assess accuracy.
We have increased the priority of this recommendation to medium.
4
© 2014 KPMG LLP is a subsidiary of KPMG Europe LLP
and a member firm of the KPMG network of independent
member firms affiliated with KPMG International
Cooperative, a Swiss entity. All rights reserved. This
document is confidential and its circulation and use are
restricted. The KPMG name, logo and 'cutting through the
complexity' are registered trademarks of KPMG
International Cooperative (KPMG International)
2013/14: External
assurance on your
quality report
23 May 2014
Contents
Page
The contacts at KPMG
in connection with this
report are:
Executive summary
2
Fleur Nieboer
Director
Section one: Detailed findings – content of the quality report
4
KPMG LLP (UK)
Tel: 020 7311 1897
Section two: Detailed findings – our review of selected performance indicators
6
[email protected]
Appendices
Joanne Lees
Senior Manager
KPMG LLP (UK)
Tel: 020 7311 1367
[email protected]
Emily Tiernan
Assistant Manager
KPMG LLP (UK)
Tel: 020 7694 4492
10
■ Scope
S
off workk performed
f
d and
d approach
h
■ Recommendations raised
■ Follow up of prior year recommendations
■ 2013/14 Limited Assurance Opinion on the content of the quality report and
performance indicators
■ Responsibilities of the Board of Directors and Council of Governors and limitations
associated with this engagement
[email protected]
This report is addressed to the Board of Directors and the Council of Governors of Berkshire NHS Foundation Trust (“the Trust”) and has been prepared for your use
only. We accept no responsibility towards any member of staff acting on their own, or to any third parties.
This engagement is an assurance engagement over the content of the quality report and mandated indicators conducted in accordance with generally accepted
assurance standards.
In preparing our report, our primary source has been information made available and representations made to us by management. We do not accept responsibility for
such information which remains the responsibility of management
management. We have satisfied ourselves
ourselves, so far as possible
possible, that the information presented in our report is
consistent with other information which was made available to us in the course of our work in accordance with the terms of our Engagement Letter dated April 2014.
© 2014 KPMG LLP, a UK limited liability partnership, is a subsidiary of KPMG Europe LLP and a member firm of the KPMG network of independent member firms affiliated with KPMG International Cooperative, a Swiss entity. All rights reserved.
1
Executive summary
Headlines
Introduction
In February 2014, Monitor released their ‘2013/14 Detailed guidance for external assurance on quality reports’. This document provides an overview of the external assurance
requirements for the quality report and forms the basis for our approach to reviewing your quality report and performing testing over performance indicators. The output of our work is
a ‘limited’ assurance opinion as well as this report to your Council of Governors on our findings and recommendations for improvements concerning the content of the quality report,
the mandated indicators and the locally selected indicator.
Conclusion
You have achieved a limited assurance opinion (see Appendix E) on whether anything has come to our attention which leads us to believe that:
• your quality report does not comply with the requirements set out in the NHS Foundation Trust Annual Reporting Manual;
• your quality report is not consistent with specified documentation; and
• either or both of the indicators we have tested has not been reasonably stated in all material respects.
Key findings
Our work is substantially complete, subject to our team carrying out final checks to ensure you have reflected our comments in the quality report and to review changes made by the
Trust after the date of this report. . We have set out the key headlines from our work below.
Content – the content of your quality report complies with the requirements
set out in the NHS Foundation Trust Annual Reporting Manual
Consistency – the content of the quality report is not inconsistent with
other information sources specified by Monitor
The content of the quality report was accurately reported]in line with the quality report
regulations.
We reviewed the information sources specified by Monitor and identified that:
We noted minor matters concerning the availability of specified information for certain
prescribed indicators and presentation.
See section one for our detailed findings.
■ Significant matters in the specified information sources were/reflected in the quality
report where appropriate;
■ Significant assertions in the quality report were supported by the specified
information sources.
See section one for our detailed findings
findings.
Mandated Indicator 1 – 100% enhanced Care Programme Approach (CPA)
patients receiving follow-up contact within seven days of discharge from
hospital (Seven Day Follow Up)
We did not identify any issues that impact on our ability to issue a limited assurance opinion
in respect of this indicator.
We have identified minor areas for improvement in relation to training of staff regarding
accurate reporting of 7-day follow-up. We have raised one recommendation in Appendix A
to this report.
See section two for our detailed findings.
g
Key
Significant issues identified which impact on your opinion
Opportunities to improve
No issues/ minor areas of improvement identified
2
Executive summary
Report structure and next steps
Mandated Indicator 2 – Admissions to inpatient services had access to
crisis resolution home treatment teams (Gatekeeping)
We did not identify any issues that impact on our ability to issue a limited assurance
opinion in respect of this indicator.
Local indicator: Medication Incidents
W are nott required
We
i d to
t provide
id a lilimited
it d assurance opinion
i i on the
th locally
l
ll selected
l t d
indicator. We did not identify any issues to report in respect of this indicator.
We have identified one area for improvement in relation to classification of exempt
cases and have raised one recommendation in Appendix B to this report.
Recommendations raised
We have raised one medium priority recommendation as a result of our work. Detailed recommendations are included in Appendix B. We have followed up prior year recommendations
in Appendix C. Of five recommendations raised, three have been fully implemented. Of the remaining two, one has been upgraded from low to medium priority as a result of the issue
being re-raised from our testing in 2013/14
2013/14.
Structure of this report
The remaining sections of this report cover the:
■ Detailed findings: Content of the quality report – this section outlines the work we performed, summarises our findings and concludes on whether a limited assurance opinion has
been issued; and
■ D
Detailed
t il d findings;
fi di
our review
i
off ttwo selected
l t d performance
f
iindicators–
di t
thi summarises
this
i
our work
k performed
f
d on th
the ttwo mandated
d t d iindicators
di t
subject
bj t tto a lilimited
it d assurance reportt
specified by Monitor and the locally selected indicator. It concludes on whether a limited assurance opinion has been issued for the mandated indicators and whether improvements
are needed before you could seek a limited assurance opinion on the safety incidents indicator.
Next steps to conclude the 2013/14 quality report assurance process
1)
The Trust needs to provide us with its Statement of Directors’ Responsibilities in respect of the Quality Report (see Appendix D of this report) and a signed letter of management
representation.
2)
In line with Monitor’s reporting requirements, we will provide a final signed opinion by 30 May 2014. This will be in addition to a finalised version of this report concluding our work up
to that date.
3)
The Trust needs to include our limited assurance opinion on the content of the quality report and the mandated indicators (see Appendix C) in the Annual Report which the Trust will
submit to Monitor on 30 May 2013.
3
Section one
Detailed findings – Content of the quality report
Conclusion
Subject to carrying out our final checks to ensure you have reflected our comments in the quality report and reviewing changes made by the Trust after the date of this report, we are
satisfied that there is sufficient evidence to provide a limited assurance opinion on the content of the quality report.
We have
ha e not raised any
an recommendation s in relation to this req
requirement.
irement
We have included our opinion in Appendix D to this report.
Work performed and findings
In this section, we report our work on the content of the quality report against two criteria:
1) A review of content to ensures it addresses the requirements set out in the NHS Foundation Trust Annual Reporting Manual; and
2) A review of content in the quality report for consistency with the content of other information specified by Monitor.
We have set out in more detail the scope of this work in Appendix A.
q
of the q
quality
y report
p
Regulations
g
1)) Content addresses requirements
We reviewed the content of the quality report against the requirements set out in the NHS Foundation Trust Annual Reporting Manual. Our findings are set out below:
Issue considered
Findings
Inclusion of all mandated
content
Minor areas of mandated content had not been reflected in the report. This included disclosure of the Trust with the highest and lowest score for
four of the mandated indicators
indicators. However
However, we note that the Trust has reported that this data is not available nationally
nationally.
4
Section one
Detailed findings – Content of the quality report (cont.)
2) Consistency of quality report content with specified other information
We were required to review the consistency of the quality report against specified information. Our findings are set out below:
Issues considered
Findings
Are significant matters in the specified
information sources reflected in the quality
report?
We identified that the Trust reflected its significant matters, relevant to the selected priorities from the specified information sources, in
its quality report.. At the time of issuing this report, the Trust was still awaiting data from the following sources:
■ Feedback from commissioners;
■ Feedback
F db k ffrom Governors
G
■ Feedback from Local Healthwatch organisations;
The Trust is intending on including the information from these sources within its quality report. We will review this ahead of issuing our
opinion.
Are significant assertions in the quality report
supported by the specified information
sources?
Significant assertions in the quality report are supported by the relevant information sources.
5
Section two
Detailed findings: our review of two selected performance indicators
Introduction
We carried out work on two mandated indicators, chosen by the Trust from a list of three available indicators as specified by the Monitor in its guidance:
1
1.
100% enhanced Care Programme Approach (CPA) patients receiving follow-up
follow up contact within seven days of discharge from hospital (Seven Day Follow Up)
2.
Admissions to inpatient services had access to crisis resolution home treatment teams (Gatekeeping)
In addition, we carried out work on a locally selected indicator chosen by your Council of Governors. The indicator selected was Medication Incidents. This indicator is not subject to a
limited assurance opinion.
We have set out in more detail the scope of this work in Appendix A.
Conclusion
Our work on the indicators requiring a limited assurance report suggests there is sufficient evidence to provide a limited assurance opinion in respect of both of the indicators
elected by the Trust. We have included our opinion in Appendix D to this report. Please note that the extent of the procedures performed is reduced for limited assurance. The nature
of the procedures may be different and less challenging that those used for reasonable assurance. Therefore, our work was not a reasonable assurance audit of either the
performance indicators or the processes used to collate and report them.
Results of our work
We have set out overleaf the key findings from our work as described above in relation to the two mandated indicators and the locally selected indicator.
6
Section two
Detailed findings: Our review of two selected performance indicators (1)
Indicator
Area of our work
Key findings
Overall
conclusion
Mandated indicator 1: 7 Day
Follow Up
Definition and
guidance
We identified one area of improvement with regard to the recording of the follow up date
date.
We have not
identified any
issues which
impact our
overall opinion
Definition:
The number of people under
adult mental illness specialties
on CPA receiving
g follow up
p (by
( y
phone or face to face contact)
within seven days of discharge
from psychiatric in-patient
care/The number of people
under mental illness
specialities on CPA
Trust systems to
discharged from psychiatric
produce
the indicator
in-patient care less
exemptions
Performance as at 31 March
2014: 96.2%
Target: 95%
Substantive testing
In two out of 30 cases reviewed we identified the date of follow-up was recorded as the date contact
was made with an acquaintance of the patient and not with the patient themselves, as per Monitors
guidance.
This issue has the potential to impact on the accuracy of the data used for performance reporting,
however in each of these cases, we were able to verify that a follow up had occurred with the patient
l within
ithi the
th seven day
d period,
i d and
d there
th
was therefore
th f
no impact
i
t on the
th indicator.
i di t
also
It is essential that the date of the follow up contact with the patient, and not an associate, is the one
used in calculating the indicator. We raised a recommendation in relation to this in 2012/13. As a
result of further findings in 2013/14, we have increased the priority of our prior year recommendation
to medium.
We did not identify any improvements required with regard to the systems and processes the Trust
uses to produce the indicator.
Of 30 records traced back from the numerator, the date of follow-up was correctly captured on the
RiO system in 28 cases.
A d
As
described
ib d above,
b
in
i two
t
cases, the
th date
d t off contact
t t with
ith an associate
i t off the
th patient
ti t rather
th than
th the
th
patient had been used in assessing the case as a ‘pass’. In both cases, staff had understood that the
follow up had to be with the patient (and had been) within seven days to comply with the definition.
We raised a recommendation in relation to this in 2012/13, so we have not raised this again. See
Appendix C
7
Section two
Detailed findings: Our review of two selected performance indicators (2)
Indicator
Area of our
work
Key findings
Overall
conclusion
Mandated indicator2:
Gatekeeping
Definition and
guidance
We identified an issue in relation to how staff were identifying patients as ‘exemptions’
exemptions from this indicator
indicator, and
found that the guidance had been incorrectly applied. This was happening at ward level where incorrect codes
were being entered onto the system. A review of all exclusions was undertaken by the Trust and a correction
made to the calculation of the indicator.
We have not
identified any
issues which
impact our
overall opinion
Definition: The number
of admissions to the
trust's psychiatric
inpatient
p
wards that
were gatekept by the
crisis resolution home
treatment teams./The
total number of
admissions to the
trust's acute wards
excluding exemptions.
Performance as at 31
March 2014: 97.6%
We have raised a recommendation in relation to this at Appendix B.
Trust systems to
produce the
indicator
We did not identify any other issues relating to the six specified dimensions of data quality in this area of our work.
Substantive
testing
Of 25 records traced back from the numerator, 100% of cases were recorded accurately regarding the occurrence
of gatekeeping activities.
We identified that p
patients recorded as exempt
p from inclusion in relation to this indicator had been incorrectly
y
identified. The Trust reviewed 100% of the exempt population and recalculated the indicator based upon the
findings. This moved the outturn performance from 97.7% to 97.6% against a target of 95%.
We sampled both the cases that remained exempt following this exercise and also those that had become
included in the calculation and did not identify any further issues.
Target: 95%
W did nott identify
We
id tif any issues
i
relating
l ti tto th
the six
i specified
ifi d di
dimensions
i
off d
data
t quality
lit iin thi
this area off our work.
k
8
Section two
Detailed findings: Our review of the Locally selected performance indicator
Indicator
Area of our
work
Key findings
Overall
conclusion
Locally selected
indicator:
Medication
Error
Definition and
guidance
We did not identify any improvements required with regard to the Trust’s
Trust s understanding and application of the guidance
associated with and the definition of the indicator.
We have not
identified any
significant
areas for
improvement.
Definition: The
number of
medication
errors
Performance as
at 31 March
2014: 614 errors
We did not identify any issues relating to the six specified dimensions of data quality in this area of our work
Trust systems
to produce
the indicator
We did not identify any improvements required with regard to the systems and processes the Trust uses to produce the
indicator.
Substantive
testing
Of 25 records traced back , we found the supporting information to corroborate with the reported outturn.
We did not identify any issues relating to the six specified dimensions of data quality in this area of our work
We did not identify any issues relating to the six specified dimensions of data quality in this area of our work.
Target: there is
no target for
this indicator
9
Appendix A
Scope of work performed and our approach
Background
In February 2014, Monitor released their ‘2013/14 Detailed guidance for external assurance on quality reports’. This document provides an overview of the external assurance
requirements for the quality report.
Th publication
The
bli ti off High
Hi h Q
Quality
lit Care
C
for
f All in
i 2008 placed
l
d quality
lit and
d quality
lit iimprovementt att th
the h
heartt off currentt d
debate
b t iin th
the NHS
NHS. The
Th Health
H lth A
Actt 2009 and
d associated
i t d regulations
l ti
require all providers of NHS healthcare services in England to publish a quality report each year about the quality of NHS services they deliver.
Scope, approach and outputs
Our work has been based on the principles of ISAE 3000 (Assurance Engagements other than Audits and Reviews of Historical Financial Information) in order to provide an independent
assurance opinion. We have set out our approach below
R
Requirement
i
t
Review the content of the quality
report against the requirements
specified by the quality reports
R
Regulations
l ti
Review the content of the quality
report for consistency against the
other information sources detailed in
Monitor’s guidance.
A
Approach
h
■ Desktop review of the Trust’s quality report against the checklist of requirements as set out
in Monitor’s guidance. This work addressed:
■
–
Significant matters in the specified information sources relevant to the priorities selected
by the Trust for the quality report to be reflected in the quality report; and
–
Significant assertions in the quality report to be supported by a suite of specified
information sources.
Desktop review of the Trust’s quality report against the Trust’s file of evidence.
■ We will:
Testing
g of two indicators agreed
g
with
the trust
Testing of a locally selected indicator
as chosen by the Council of
Governors
O t t
Output
■
–
confirm the definition and guidance used by the Trust to calculate the indicator;
–
d
document
t and
d walk
lk th
through
h th
the NHS ttrust’s
t’ systems
t
used
d tto produce
d
th
the iindicator;
di t and
d
–
undertake substantive testing on the underlying data against six specified data quality
dimensions.
See above. Our approach is consistent with our approach for the mandated indictors.
Limited assurance
opinion over:
■ Compliance with
the regulations
■ Consistency with
specified
documentation
■ Two indicators in
the quality report
Report to the Council
of Governors
10
Appendix B
Recommendations
We have raised one recommendation, none of which are high priority. The Trust has agreed to this recommendation and has provided management responses. We will follow up
these actions during 2014/15.
We have followed up prior year recommendations in Appendix B

High priority
#
1
F d
Fundamental
t l issues
i
which
hi h h
have
resulted or could result in a
qualification of the limited
assurance opinion and require
immediate action
Priority

Medium

Medium
priority
I
Improvements
t which
hi h are required
i d but
b t may nott
need immediate action. In isolation this issue may
not prevent an assurance opinion being issued
but it may contribute to a group of issues that
could prevent an assurance opinion being sought

Low priority
Minor improvements
Mi
i
t which,
hi h if corrected,
t d
would benefit the organisation but
would not in isolation be likely to
prevent an assurance opinion being
sought
Responsible Officer/Due
Date
Issue and Recommendation
Management Response
Data quality audits of exempt cases
Ian Hayward – Assistant
Director of Information
The Trust data quality audits will be extended Service & Performance.
to include cases recorded as exemptions.
exemptions
Ward staff will be reminded of the importance 31st July 2014
of selecting the correct admission type on
RiO and additional training provided where
necessary.
Our testing of exempt gatekeeping cases identified 62/72 cases to be
incorrectly classified as exempt due to locality staff recording the wrong
admission type on RiO. We recognise that of these cases, had been
appropriately gatekept with the exception of four of these cases - originally
treated as exempt but subsequently classified as within scope – which had
not been appropriately gatekept. By excluding these as exempt the Trust
had overstated performance against the indicator. During our review the
Trust recalculated the indicator taking these into account. As a result overall
reported performance moved from 97
97.7%
7% to 97
97.6%.
6%
Accepted
We recommend the data quality audits currently in place at the Trust are to
be extended to include cases recorded as exemptions. In addition ward staff
should be reminded of the importance of selecting the correct admission type
on RiO and where necessary additional training should be provided.
11
Appendix C
Follow up of prior year recommendations
In 2012/13, we raised five recommendations. Of these three have been fully implemented.
In the table below, we have set out the two recommendations which have not been fully implemented by the Trust.
#
Priority

1
Medium
Management
g
Response
p
and
due date
Status as at May 2014
Compliance with seven day follow up
Agreed
Not Implemented
Our initial testing of seven day follow up identified
one case which was non-compliant as the team
had not had direct contact with the patient,
instead liaising with staff at the patients care
home.
Recommendation is
accepted. Locality staff will be
reminded of this requirement.
q
We recommend that locality staff are reminded of
the requirements of seven day follow up i.e. That
direct contact with the patient must occur in order
to ensure compliance.
Deadline: 30 June 2013
Owner: Vicki Taylor
While discussions with the Trust identified that locality staff were reminded of
the requirement, our substantive testing for 2013/14 has identified the
recurrence of the same issue.
It is essential that staff continue to be reminded and consideration should be
given to spot checks throughout the year to assess accuracy.
We have increased the priority of this recommendation to medium.
12
Appendix C
Follow up of prior year recommendations
#
Priority
Patient safety incidents
As patient safety incidents is likely to remain a
high profile indicator we have identified the
following enhancements to the Trust’s local
arrangements to ensure that it has more robust
assurance over the completeness and accuracy of
incidents reported:
■ Adopting a robust consistently applied
approach to reconciling and triangulating
patient safety incidents to complaints data,
NHSLA data and CQC reports issued in
respect of the Trust;
2

High
■ Ensuring there are regular robust internal
reviews and quality assurance audits on patient
safety incidents that are scheduled and
reported as part of the information assurance
framework (see recommendation five below)
and that the results are reported to Board subcommittee(s) – for example the Audit
Committee;
■ Ensuring that any incident reclassifications
made by NRLS are investigated rigorously on a
timely basis and that action points and learning
are cascaded to all staff and built into relevant
training programmes;
■ Codifying the above steps into the Trust’s
standard operating procedures and ensuring all
staff are aware of their obligations to report,
which could potentially be enforced through
clear disciplinary procedures for any staff found
not to be reporting
g incidents.
The suggestions above are intended to strengthen
the control environment so as to ensure that the
Trust’s approach reflects industry practice.
Management Response
and due date
Status as at May 2014
Agreed in principle
Implemented in the year:
The Trust patient safety
team will fully consider
the suggestions made.
This will be done as part
of its continuing review to
enhance the assurance
over the completeness
and accuracy of incidents
reported and the
dissemination of lessons
learned from these.
Owner: Helen Mackenzie
Deadline 30 June 2013
■ All incidents reported are subject to a monthly analysis report which are
reviewed at monthly locality quality meetings. These meetings feed discussion
and analysis into the monthly Quality Executive Group (QEG) where there is
further review, challenge and monitoring of quality and patient safety issues.
This group reports into the Quality Assurance Committee, a sub-committee of
the Board.
■ The QEG receives quarterly incident trend analysis reports and a separate
quarterly SIRI analysis report including key learning from SIRIs, alongside
quarterly complaints and patient experience reports. These reports are fed
down to the locality groups and front line services for discussion and further
actions / monitoring. This sits alongside reporting to QEG on the biannual CQC
self-assessments and internal mock CQC inspections for triangulation.
■ There is a two-way exchange of analysis, action planning and monitoring
between the localities and the central executive function designed to pull
together and integrate qualitative intelligence.
■ A clear policy and procedure on incident reporting has been updated and
reviewed as part of the organisation's NHSLA accreditation in 2013. The Trust
is clear in policy and through its clinical governance framework about the
responsibility of individuals to report incidents, and it supports and fosters this
through the promotion of a 'fair blame' culture.
■ There is a triple-checking review process for all incidents; reviewed at
management stage, quality team stage and risk team stage before uploading of
relevant incidents to NRLS is in place. Proactive liaison between the risk team
and NRLS on data quality is in place. There have been no instances of the
NRLS coming back to BHFT with reclassifications.
Further developments to be implemented:
■ Revision of Incidents / SIRI policy. Implementation is imminent following an
external review
■ Development
p
work to refine triangulation
g
of q
qualitative intelligence
g
in line with
NHSLA accredited triangulation policy. The triangulation reports are starting
from end of Q1 as per commissioner requirements for 2014/15.
13
Appendix D
2013/14 Limited Assurance Opinion on the content of the quality report and
Independent Auditor’s Report to the Council of Governors of Berkshire Healthcare NHS Foundation Trust on the Quality Report
We have been engaged by the Council of Governors of Berkshire Healthcare NHS Foundation Trust to perform an independent assurance engagement in respect of
Berkshire Healthcare NHS Foundation Trust’s Quality Report for the year ended 31 March 2014 (the “Quality Report”) and certain performance indicators contained therein.
Scope and subject matter
The indicators
Th
i di t
ffor th
the year ended
d d 31 M
March
h 2014 subject
bj t to
t limited
li it d assurance consist
i t off the
th national
ti
l priority
i it iindicators
di t
as mandated
d t db
by M
Monitor:
it
For mental health NHS foundation trusts:
Two indicators from the following three:
1) 100% enhanced Care Programme Approach patients receiving follow-up contact within seven days of discharge from hospital;
2) admissions to inpatient services had access to crisis resolution home treatment teams.
We refer to these national priority indicators collectively as the “indicators”
indicators .
Respective responsibilities of the Directors and auditors
The Directors are responsible for the content and the preparation of the Quality Report in accordance with the criteria set out in the NHS Foundation Trust Annual Reporting
Manual issued by Monitor.
Our responsibility
p
y is to form a conclusion,, based on limited assurance procedures,
p
, on whether anything
y
g has come to our attention that causes us to believe that:
• the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual;
• the Quality Report is not consistent in all material respects with the sources - specified in the Detailed Guidance for External Assurance on Quality Reports; and.
• the indicators in the Quality Report identified as having been the subject of limited assurance in the Quality Report are not reasonably stated in all material respects in
accordance with the NHS Foundation Trust Annual Reporting Manual and the six dimensions of data quality set out in the Detailed Guidance for External Assurance on
Quality Reports.
We read the Quality Report and consider whether it addresses the content requirements of the NHS Foundation Trust Annual Reporting Manual, and consider the
implications for our report if we become aware of any material omissions.
We read the other information contained in the Quality Report and consider whether it is materially inconsistent with:
• Board minutes for the period April 2013 to May 2014;
• Papers relating to Quality reported to the Board over the period April 2013 to May 2014;
• Feedback
F db k ffrom the
th Commissioners
C
i i
d t d 23 M
dated
May 2014;
2014
• Feedback from local Healthwatch organisations dated 22 May 2014;
• The Trust’s complaints report published under regulation 18 of the Local Authority Social Services and NHS Complaints Regulations 2009, 2013/14;
• The 2013/14 national patient survey;
• The 2013/14 national staff survey;
• Care Quality Commission quality and risk profiles/intelligent monitoring reports 2013/14; and
• The 2013/14 Head of Internal Audit’s
Audit s annual opinion over the Trust
Trust’ss control environment
environment.
14
Appendix D
We consider the implications for our report if we become aware of any apparent misstatements or material inconsistencies with those documents (collectively, the
“documents”). Our responsibilities do not extend to any other information.
We are in compliance with the applicable independence and competency requirements of the Institute of Chartered Accountants in England and Wales (ICAEW) Code of
Ethics. Our team comprised assurance practitioners and relevant subject matter experts.
This report, including the conclusion, has been prepared solely for the Council of Governors of Berkshire Healthcare NHS Foundation Trust as a body, to assist the Council
of Governors in reporting Berkshire Healthcare NHS Foundation Trust’s quality agenda, performance and activities. We permit the disclosure of this report within the Annual
Report for the year ended 31 March 2014, to enable the Council of Governors to demonstrate they have discharged their governance responsibilities by commissioning an
independent assurance report in connection with the indicators. To the fullest extent permitted by law, we do not accept or assume responsibility to anyone other than the
Council of Governors as a body and Berkshire Healthcare NHS Foundation Trust for our work or this report save where terms are expressly agreed and with our prior
consent in writing.
writing
Assurance work performed
We conducted this limited assurance engagement in accordance with International Standard on Assurance Engagements 3000 (Revised) – ‘Assurance Engagements other
than Audits or Reviews of Historical Financial Information’ issued by the International Auditing and Assurance Standards Board (‘ISAE 3000’). Our limited assurance
procedures included:
p
• Evaluating the design and implementation of the key processes and controls for managing and reporting the indicators.
• Making enquiries of management.
• Testing key management controls.
• Limited testing, on a selective basis, of the data used to calculate the indicator back to supporting documentation.
• Comparing the content requirements of the NHS Foundation Trust Annual Reporting Manual to the categories reported in the Quality Report.
• Reading the documents.
A limited assurance engagement is smaller in scope than a reasonable assurance engagement. The nature, timing and extent of procedures for gathering sufficient
appropriate evidence are deliberately limited relative to a reasonable assurance engagement.
Limitations
Non-financial performance information is subject to more inherent limitations than financial information, given the characteristics of the subject matter and the methods used
f determining
for
d t
i i such
h iinformation.
f
ti
The absence of a significant body of established practice on which to draw allows for the selection of different but acceptable measurement techniques which can result in
materially different measurements and can impact comparability. The precision of different measurement techniques may also vary. Furthermore, the nature and methods
used to determine such information, as well as the measurement criteria and the precision thereof, may change over time. It is important to read the Quality Report in the
context of the criteria set out in the NHS Foundation Trust Annual Reporting Manual.
The scope of our assurance work has not included governance over quality or non-mandated indicators which have been determined locally by Berkshire Healthcare NHS
Foundation Trust.
15
Appendix D
Conclusion
Based on the results of our procedures, nothing has come to our attention that causes us to believe that, for the year ended 31 March 2014:
• the Quality Report is not prepared in all material respects in line with the criteria set out in the NHS Foundation Trust Annual Reporting Manual;
• the Quality Report is not consistent in all material respects with the sources specified above; and
• the
th iindicators
di t
iin th
the Q
Quality
lit R
Reportt subject
bj t tto lilimited
it d assurance h
have nott b
been reasonably
bl stated
t t d iin allll material
t i l respects
t iin accordance
d
with
ith th
the NHS Foundation
F
d ti Trust
T t
Annual Reporting Manual.
KPMG LLP, Statutory Auditor
Chartered Accountants
15 Canada Square
Canary Wharf
London
E14 5GL
28 May 2014
16
Appendix E
Responsibilities of the Board of Directors and limitations associated with this
engagement
It is important that the Board of Directors and Council of Governors, as the intended users of this report, understand the limitations associated with the procedures
performed for this engagement:
•
Procedures designed to assess the content of the Quality Report in order to be able to provide a ‘limited assurance’ opinion have been performed. Where an
opinion has been issued, we have carried out sufficient work to ensure that there is nothing that has come to our attention in the Quality Report that is not
inconsistent with other information as specified in Monitor’s Detailed Guidance for External Assurance on the Quality Report. This is not as detailed as providing
a reasonable assurance opinion because we only have been required to review a limited amount of information. We have set out this limited information on the
following page.
•
Procedures designed to assess readiness for a ‘limited assurance’ opinion on the mandated indicators requiring a limited assurance report are not as detailed
or as challenging as those designed for ‘reasonable assurance’. A limited assurance opinion on a performance indicator does not mean that indicator has been
confirmed as accurate only that, based on the limited procedures performed including identification of controls and walkthroughs of systems nothing has come
to our attention to suggest the indicator is inaccurate.
The Statement of Directors’ Responsibilities in respect of the Quality Accounts outlines the directors’ responsibilities under the Health Act 2009 and the National
Health Service (Quality Accounts) Regulations 2010 in preparing Quality Accounts and the expectations of Monitor, the Independent Regulator. This work, and any
subsequent
b
t workk to
t provide
id an assurance opinion
i i iin ffuture
t
periods,
i d iis nott a substitute
b tit t ffor th
these responsibilities
ibiliti which
hi h remain
i with
ith the
th Board
B d off Directors
Di t
off th
the
Trust.
As set out in the Executive Summary next steps paragraph, we will require a management representation around the responsibility of the Board for data quality and
the inclusion of all relevant content, as well as a signed Statement of Directors’ Responsibilities before we issue any opinion.
17
The information contained herein is of a general nature and is not intended
to address the circumstances of any particular individual or entity. Although
we endeavour to provide accurate and timely information, there can be no
guarantee that such information is accurate as of the date it is received or
that it will continue to be accurate in the future. No one should act on such
information without appropriate professional advice after a thorough
examination of the particular situation.
© 2014 KPMG LLP,
LLP a UK limited liability partnership
partnership, is a subsidiary of
KPMG Europe LLP and a member firm of the KPMG network of independent
member firms affiliated with KPMG International Cooperative, a Swiss entity.
All rights reserved.
The KPMG name, logo and “cutting through complexity” are registered
trademarks or trademarks of KPMG International Cooperative (KPMG
I t
International).
ti
l)
Produced by Create Graphics
11 December 2014
Partnership Organisations represented on Council
SUMMARY:
Presently, BHFT’s Council of Governors has partnership organisation representatives from:
•
•
•
•
•
•
Each of the six Berkshire local authorities
The University of Reading
The University of West London
The Berkshire Autistic Society (BAS)
The Alzheimer’s Society (Triple ‘A’)
Age UK Berkshire
Since Anne Taylor stood down from representing BAS a number of attempts have been
made to secure a successor but this has proved fruitless. Similarly, since Colin Preston
stopped representing Age UK Berkshire, no-one has been found to take up the vacant
Governor position. It is also proving difficult to find a replacement for Professor Gwen
Bonner who is no longer able to represent the University of West London since she has
taken up employment with the Trust.
In light of this current situation the opportunity arises for consideration to be given to
replacing some or all of these organisations with others that will be able to contribute to the
work of Council. The alternative is that the constitution is changed to reduce the number of
partnership organisations.
In light of the Trust’s commitment to greater integration and enhancing collaboration with
the voluntary sector, it is suggested that, provided representation can be secured, that the
Chairman approaches the Red Cross organisation to explore their interest in joining Council.
Governors are invited to offer suggestions for other potentially useful organisations that
might be approached. These need to offer real value to the Trust and have a broad relevance
to the work of the Trust.
For completeness, Governors are also advised that whilst we continue to press them, the
Royal Borough has so far failed to appoint a successor to their last partnership Governor
since Council elections earlier this year.
1
ACTION:
Governors are asked to note the current position with regard to partnership organisations
and to:
1. Support an approach to the Red Cross by the Chairman
2. Consider and offer any suggestions of other potential partnership organisations to
the Chairman for consideration.
John Hedger
Chair
1.12.14
2

agenda - Berkshire Healthcare NHS Foundation Trust

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