Priority 3: Effectiveness – Improve our outcomes Our aim: Improve the outcomes and personalisation of our services Table 3: Quality Improvement Priority (Effectiveness) measures for 2016/17 Measures for 2016/17 Why this is important 2016/17 Target Number of teams utilising outcome measures. Focussing on outcomes allows us to test the effectiveness of the care we deliver. Key services collect and analyse outcome data, and have for improving the outcomes of their service, in line with our rollout of our electronic care records system (RiO). Qualitative Goals: Continue to collect and monitor outcomes where we now have a baseline Improve data collection where existing recording is in place, including use of electronic systems Care plan audits: proportion of people receiving a copy of their care plan or equivalent care plan information The ADASS national survey highlighted good practice around copying care plans to service users, compared with our 2014/15 baseline audit. We want to apply this good practice in an integrated way across all services. Care plan audits (whole trust measure): Social care: continued trajectory increase (stretch target) to 75% Health (new): Baseline to be developed with intention to combine into single Health & Social Care target in 2017/18 Feedback from service users and carers that they feel involved in decisions regarding their individualised plans of care. Focussing on service user and feedback on the quality of care enables us to target service improvement against key themes. 90% of our service users and carers agree that they feel involved in decisions regarding their individualised plans of care. Mortality – Review all unexpected deaths in our community services the death has been reported as unexpected. Review all deaths in community hospitals Monitoring and investigating unexpected deaths occurring within our services enables us to learn and apply lessons Review to be completed for all deaths within Community Services reported as unexpected via the online incident reporting system Review to be completed of all deaths in our community hospitals. trial
How we will make improvements Monitoring our progress Each frontline team is responsible for the quality of the care they provide. If a team has an issue around quality they cannot resolve they will escalate this to their team or service manager, who can either help resolve the issue, or raise it at the relevant neighbourhood or area meeting. Neighbourhood and areas managers are required to offer assurance of quality or escalate issues to the Divisional Business Meeting, which is chaired by the Chief Operating Officer for the division. Each Division reports its assurance or escalations to the Quality Governance Committee, the principal committee by which our Trust Board assures itself of the quality of our services. Methods we will use to improve quality in 2016/17 Our strategies for quality are the main way we will address our quality improvement priorities. We have revised our safety, effectiveness, and experience strategies ensuring that: Key measures for each strategy directly support our quality priorities for 2016/17 Each strategy is offered as a ‘strategy on a page’ Each strategy is focussed on guiding quality improvement at the frontline In addition to our strategies for quality, we will: Act on the recommendations of our regulators, following their inspection of our services. Ensure our services are Safe, Caring, Responsive, Effective, and Well-led through our quality assurance visit programme. Work to create a more open and honest culture in the NHS, including supporting our staff to speak out to raise concerns. Support frontline staff to deliver quality improvements. Provide tailored leadership development and support for team leaders, in line with our team development governance framework. Help each of our divisions to develop their service priorities, including reviewing the impact of service developments on quality. Develop our service line reporting, allowing our frontline teams to see integrated finance, performance and quality information. Provide leadership, support and advice to frontline staff, helping them to promote best practice and excellent customer service. Manage and promote our research portfolio, helping our staff to contribute to the evidence base for health and social care.
Information on the Care Quality Commission (CQC) registration and periodic/special reviews Staffordshire and Stoke on Trent Partnership NHS Trust is required to register with the Care Quality Commission and its current registration status is registered without conditions. The Partnership Trust has no conditions on registration. The Care Quality Commission has not taken enforcement action against the Trust during 2015/16. The registration details are available on the Care Quality Commission website: CQC inspections and ratings Partnership Trust overall rating The Care Quality Commission inspected Staffordshire and Stoke on Trent Partnership NHS Trust between 2 and 6 of November 2015. On 11 May 2016 the CQC issued its inspection report, giving the Trust an overall rating: Requires Improvement. How the CQC generated this overall score is identified below: CQC rating Safe Safe Effective Caring Responsive Well-led Overall Community health services for adults Inadequate Requires Improvement Good Requires Improvement Inadequate Inadequate Community health services for children,(CYF) Good Requires Improvement Good Good Requires Improvement Requires Improvement Community health inpatient services Requires Improvement Good Good Good Good Good End of life care Requires Improvement Inadequate Good Requires Improvement Inadequate Inadequate Community Sexual health services Requires Improvement Good Good Requires Improvement Requires Improvement Requires Improvement Community dental services Good Good Good Good Good Good Overall Requires Improvement Requires Improvement Good Requires Improvement Inadequate Requires Improvement The Care Quality Commission provided their initial feedback in writing to the Trust on 13 November 2015. The Trust responded on the 20 November with its initial action plan. On 15 December 2015, the Care Quality Commission issued a warning notice under Section 29A of the Health and Social Care Act 2008. The has developed a comprehensive Quality Improvement Plan identifying the key improvement actions associated with the CQC feedback in all its forms and specifically with respect to delivering the improvements identified within the warning notice.
Patient safety incidents Table 10: Mandatory quality indicators for patient safety Quality Indicator 1 Oct 2013 to 31 Mar 2014 1 April 2014 to 30 Sept 2014 1 Oct 2014 to 31 Mar 2015 1 2015 to 30 Sept 2015 National 1 April 2015 to 30 Sept 2015 The data made available to the National Health Service trust or NHS foundation trust by the Health and Social Care Information Centre with regard to the number and, where available, rate of patient safety incidents reported within the trust during the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. Number of patient safety incidents 1609 1635 3,857 5,344 33,796 (all Community Trusts) Range: 542 to 5,344 Rate of patient safety incidents per 1,000 bed days 28.2 32.44 77.53 98.1 Median: 146.03 Range 38.22 to 267.74 Number of safety incidents that resulted in severe harm or death 14 15 10 20 Average 16.4 incidents per Community Trust Range 0 to 67 (312 incidents across 19 Trusts) Percentage of Patient safety incidents that resulted in severe harm or death 0.9% 0.9% 0.3% 0.4% 0.9% (all NHS Community organisations) Staffordshire and Stoke on Trent Partnership Trust considers that this data is as described for the following reasons: Latest available data from the Health and Social Care Information Centre is for the period 1 2015 to 30 September 2015. Our reporting rate has increased from 77.53 to 98.1, an increase of 26.5% and we are now in the middle 50% of reporters when compared with other NHS community organisations. We have reported 5,344 incidents during April 2015 – September 2015 in comparison to the 3857 incidents reported October 2014 – March 2015. Staffordshire and Stoke on Trent Partnership Trust intends to take the following actions to improve this percentage, and so the quality of its services, by: Continuing to improve our incident reporting process by promoting web-based electronic incident reporting for our staff, making it easier for them to report incidents
promote learning and high quality teaching of British Sign Language and other methods of communication used by Deaf and Hard of Hearing people support Deaf and Hard of Hearing children and families ensure staff working with Deaf and Hard of Hearing people can communicate effectively in British Sign Language and other methods of communication Consult with our local Deaf and Hard of Hearing communities on a regular basis. Supporting people with Dementia Staff from the Partnership Trust, along with members of the public, have knitted over 120 ‘twiddle mitts’ for patients with Dementia at the Haywood Hospital. The are knitted cuffs with added accessories and textures which people with Dementia can hold and ‘twiddle’ to provide stimulation and help combat any restlessness and agitation they may experience during a visit to hospital. Nutrition and Hydration Week As part of Nutrition and Hydration Week 2016 we held many events to raise awareness of the Trust’s nutrition policy and the importance of eating and drinking well. Staff from across the Trust held tea parties, presented nutrition and hydration stands in our community hospitals, hosted quizzes and webinars, and encouraged service users to learn more about good nutrition and hydration. Experience surveys updated based on feedback It is important that all those who access the services provided by the Trust have the opportunity to provide feedback on their experience and tell us what is working well and what can be improved. Ahead of the new reporting year, the service user and carer experience team have reviewed the Trust’s experience surveys, taking into account comments and feedback from staff and service users. Statements from our Partners Formal comment and consultation During May 2016 we circulated a draft of this quality account for formal comment to: