The six CQUIN areas (and measures) were: Safety Thermometer Improving dementia prescribing Recovery Goals Physical Health Smoking Cessation Frequent Attendees The following table gives the year end performance position against these CQUIN requirements: CQUIN Indicator Year end performance Safety 1a) Pilot the mental health safety thermometer Successfully completed Improving dementia care and prescribing 2a) POMH-UK audit Successfully completed 2b) Prescription review to take place and prescription review letter to be sent to GP every 3 months Successfully completed 2c) Local, sustainable QIP to be developed and agreed with local CCGs and commissioners Successfully completed 2d) Discharge summaries to be sent to GP & family within 1 week of discharge from Trust (2 weeks in contract) Successfully completed Recovery Goals 3a) Audit of Care Plans for patients on CPA to show evidence of recovery focused care planning Successfully completed 3b) 50% of all service users on CPA to have 2 self-defined recovery outcomes recorded on RiO Successfully completed Physical Health 4a) Sharing of CPA Register with Primary Care twice a year Successfully completed 4b) QOF - 95% of service users on CPA to have a full set of mental & physical health high mortality ICD10 codes by end of Q4 Successfully completed
4c) All service users on CPAs to have had a PHA with their GP within the last 12 months Successfully completed 4d) Audit of care plans to demonstrate medicines reconciliation within 72 hours of admission Successfully completed 4e) Discharge summary to be sent to the GP and service user within 7 days of inpatient discharge Successfully completed 4f) CPA Outcome Review Letter to be sent to GP within 2 weeks of CPA Review Achieve throughout the year except for the last quarter - 92.7% at year-end compared to target of 95% Smoking Cessation 5a) Smoking status of all service users to be recorded Successfully completed 5b) Smokers to be referred to a Smoking Cessation Advisor (SCA) Successfully completed 5c) Smokers referred to a Smoking Cessation Advisor to set a quit date Successfully completed Frequent Attendees 6a) Identify frequent attendees from Kingston, St George’s and St Helier Hospitals Successfully completed 6b) Review care plans of frequent attendees; agree appropriate future crisis management plans Successfully completed The following CQUIN goals for 2013-14have been agreed: CQUIN Indicator and description Intended Outcome
South West London and St George’s Mental Health NHS Trust met the deadline for submission of its annual Information Governance Toolkit score for 2012-13. The Trust achieved an overall score of ‘satisfactory’ for the second year running. The Trust scored Level 2 or higher in all of the 45 requirements. ]. Information governance personal data loss Personal data loss risk is managed by the Trust Information Governance Group and overseen by the Senior Information Risk Officer (SIRO). The Trust is obliged to report any serious incidents (SIs) involving personal data loss in its annual report. Department of Health guidelines classify such SIs in terms of severity on a scale of 0-5, requiring SIs classified at a severity of 3-5 to be reported to the Information Commissioners Office (ICO). In 2012-13 the Trust recorded reported seven at a severity rating of 0-2 as follows: Department of Health Category (Level or grade of incident) Nature of Incident Total Incidents 2 Inappropriate disclosure of Patient Identifiable Information (PID) – internal 2 0 PID sent to wrong address 2 0 PID lost in transit 2 0 PID found in public place 1 Clinical coding error rate South West London and St George’s Trust was not subject to a Payment by Results clinical coding audit during 2012-13.The Trust has continued to focus on the coverage of clinical coding of primary diagnosis for inpatient episodes of care. During the financial period 2012/2013, the figure was 98.8 per cent, against a national average of 98.5 per cent. Part 3: Review of quality performance 2012-13 Progress against quality priorities identified for 2012-13 Indicator Target Year end performance Priority 1: Safeguarding Children 95% 94.5% Priority 2: Safeguarding Adults 95% 94.6%