Quality Account 2010 - 2011

“In the community - For the community”

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Foreword by Josie Spencer - Managing Director I would like to extend my thanks to all staff with in Coventry Community Health Services for their hard work and dedication through out the last year. In 2009 we published our strategic plan for 2009 - 2012 “In the Community, for the Community” which set out an ambitious road-map for the delivery of community healthcare services to the people of Coventry. Our vision statement recognised the need for improving quality through a period of rapid change, it simply states that:

“We will work in partnership to provide high quality, responsive and dependable community health services for the population we serve. Our services shall encourage recovery from illness and promotion of healthy independent living. Our services shall be - in the community, for the community.”

Coventry Community Health Services takes pride in:

• being a good steward of healthcare services within the City of Coventry, and providing the public with the services it expects and deserves. In order to achieve this, we will operate as efficiently and effectively as possible;

• being held accountable by our patients and users for our performance and the

continued development of services that meet the needs of the local population;

• our ability to identify and use innovative tools, approaches and solutions to address local healthcare challenges, and to engage extensively with our partners, stakeholders, patients and the public;

• ensuring we have the best community healthcare information available to

anticipate potential changing needs – evaluate risks, identify solutions, to enhance the safety, experience and outcomes for patients.

This report looks back on the year 2010 – 2011 and presents a balanced picture of our performance, highlighting our achievements and where we still have work to do; it looks forward to future quality improvements and developments for 2011- 2012. I am satisfied that the performance information reported in the Quality Account is reliable and accurate and that there are proper internal controls applied to the collecting and reporting of the performance measures and that the data underpinning the measures is robust and reliable, conforms to data quality standards and is the subject of scrutiny and review. The Quality Account has been prepared in accordance with Department of Health guidance.

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On 1st April 20011 Coventry Community Health Services merged with Coventry and Warwickshire Partnership Trust and the quality developments for the future are particularly exciting as we work to integrate services from the larger organisation in the community. The forward looking part of this document has been prepared in conjunction with Coventry and Warwickshire Partnership Trust. We aim to work in partnership with patients, staff and other stakeholders, as the basis for embedding a culture of quality improvement. The improvements we plan to make in 2011 – 2012 are covered in the Priorities for Improvement section.

Josie Spencer Managing Director

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Services provided by CCHS Coventry Community Health Services (CCHS) provides community health services to adults and children within Coventry. Some of our specialist services accept referrals from across the UK. We employ more than 1285 staff, working in a range of facilities including community clinics, GP practices and in peoples’ homes. The table below outlines the services we provide:

Specialist and lifestyle Services

Services for Children & Young People

Adult & Community

Sexual Health Services including HIV & GUM Walk in Centre & Urgent Care including Out of Hours Rehabilitation Services – Speech and Language Therapy, Occupational Therapy, Physiotherapy, Wheelchair Service Clinical Assessment Services Learning Disability Community Dental Services Smoking cessation Health trainers Expert Patient Programme

Health Visiting Special & Mainstream School Nursing HPV Vaccinations Children’s Therapies Complex Community Children’s Nursing Paediatric Medical Services

Long Term Conditions & End of Life services (including District Nursing, Community Matrons, Complex Care, Family Support Service Specialist Nursing Tissue Viability Continence Complex Care End of Life Team

Quality Accounts are a key component of “Transforming Community Services Quality Framework: community guidance for community services” (DH June 2009) and all NHS community service providers are required to publish Quality Accounts for the year 2010/ 2011. CCHS are proud of the services they provide and welcome the opportunity to share information on quality with interested parties. CCHS has reviewed all of the data available on the quality of care in these services. This report is an honest reflection of the quality of services we provide and considers where we could have done better as well as our successes. Feedback and comments from the public, patients, staff and wider stakeholders have provided a significant contribution to the content of this report.

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Care Quality Commission (CQC) CCHS, as the provider arm for NHS Coventry, is required to register with the Care Quality Commission (CQC). Our current registration status is “Registered without Safety and Quality compliance conditions”. We have declared full compliance with all outcomes. This means that our Board has been assured that we have sufficient evidence to demonstrate that we perform to the required standards and that the CQC has accepted this assessment. The CQC has not taken any enforcement action against CCHS in 2010/11 Participation in Clinical Audit During 2010/ 2011, 6 national clinical audits and no national confidential enquiries encompassed NHS services that Coventry Community Health Services provides.

During that period Coventry Community Health Services participated in one of the national clinical audits in which it was eligible to participate (17%).

The national clinical audits that Coventry Community Health Services was eligible to participate in during 2010/2011 are as follows:

Childhood epilepsy Diabetes Chronic pain Parkinson’s disease Heart failure National audit of falls and bone health in older people

There were no relevant confidential enquiries in which the Trust could have participated

The one national clinical audit that Coventry Community Health Services participated in during 2010/2011 was the National audit of falls and bone health in older people

A summary of the national clinical audits that Coventry Community Health Services participated in and/or was eligible to participate in is shown in the table below:

Audit Participation Cases submitted

Children Childhood epilepsy

No

NA

Long-term conditions Diabetes Chronic pain Parkinson’s disease

No No No

NA NA NA

Cardiovascular disease Heart failure

No

NA

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Audit Participation Cases submitted

Trauma Falls & non-hip fractures

Yes

None (only

organisational data was provided as no patients were

identified for audit)

The reports of 48 local clinical audits were reviewed by the provider in 2010/2011 these are listed below with an overview of the resulting actions:

Title of audit Summary of actions

2362 Partner notification of HIV-positive patients

Ensure Health Advisor presence at all HIV clinic sessions to obtain contact details.

2368 Patient survey of Physiotherapy in Intermediate Care

Reinforce staff training to remind staff about appointment time/date options and discussion of treatment options.

2370 Increase continence awareness among Coventry GPs

Target those GPs where referral numbers are low. Remind all GPs of age profile for clients of Continence Service.

2399 Referrals to Occupational Therapy of children with handwriting difficulties

Simplify referral form. Consider training of school staff.

2402 Quality of service by staff providing speech and language reviews

Investigate how to improve communication with nursery and school staff.

2403 Patient satisfaction with toenail surgery

Podiatry peer review system to be set up.

2404 Toenail surgery healing rates (re-audit)

Healing rates unchanged since 2003. Produce post-operative advice sheet for patients.

2411 On-call service for Children’s Community Nursing Team

Reinforce parent education (of when to call Team) for tube replacement – discuss involving acute Trust in handling routine tube replacement.

2423 Non-attending of children at Fostering Clinics

Create post of Co-ordinator to handle all routine administration. Set up formal communication route with Social Care.

2424 Child Protection Standards #3 (note keeping) and #6 (documentation of Conferences)

Initiatives on improving record keeping to be co-ordinated by Health Visiting Leads.

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Title of audit Summary of actions

2426 Child Protection Standards ~5 (de-registration from Child Protection Plan) and #7 (Clinical Supervision)

Initiatives on improving record keeping to be co-ordinated by School Nursing and Health Visiting Leads.

2430 Domestic violence notifications Follow-ups of notifications to be handled by qualified Health Visitor which should be actioned within 3 days of receipt. Remind Police to report domestic violence incidents in a timely manner.

2431 Hepatitis B testing among black African population

Local guidelines to be written to include routine offer of injection to non-immune clients and their contacts.

2433 Patient survey of Wound Clinics (re-audit)

Review patient information leaflets and raise awareness of pain assessments. Use patients’ preferred names and introduce “Do not disturb” signs to reduce intrusions during treatment.

2434 Nutritional risk assessments Staff training to be introduced to trigger referrals.

2437 Satisfaction and outcomes survey for clients of Biomechanics Clinic (Podiatry)

Improve patient information leaflets.

2444 Reporting of Cdiff cases to Infection Control

Review Root Cause Analysis tool for relevance and make staff aware of national guidance.

2446 Client satisfaction survey at Meridian Treatment Centre

Consider extending opening hours and investigate client waiting times.

2447 Safeguarding Children Policy (re-audit)

Ensure consent is always obtained and documented and other note-keeping improvements required.

2449 Policy for high velocity thrusts in treatment of musculoskeletal pain (Physiotherapy)

No actions required – Policy being followed.

2451 Audit of British Association for Adoption and Fostering forms for looked-after children

Liaise with all external agencies to ensure they know what information to provide.

2453 Client satisfaction survey at Anchor Centre

Ensure staff introduce themselves fully to all clients.

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Title of audit Summary of actions

2454 Asepsis Policy Carry out risk assessments to determine which types of gloves should be used and for non-latex types to be available. Staff to be reminded to decontaminate hands between glove changes.

2455 Subcutaneous infusion of Apomorphine

Devise documentation for GPs to authorise use of APO-GO Pump, this to be suitable for monitoring pump use by Nurses.

2456 Injection of Apomorphine via APO-GO Pen

Devise chart for monitoring use of pens.

2457 Assessment of foot examination for patients with type 2 diabetes (NICE CG010)

Review all record-keeping within Team and take up shortcomings with individual defaulters. Investigate method of booking review appointments.

2460 Patient survey of Speech & Language Therapy’s Head & Neck Cancer Service

Investigate further why some patients believe waiting times are too long.

2461 Dysphagia management – does it comply with National Care Pathway?

Ensure diagnosis date and duration of disease are recoded.

2462 Review of ex-dwelling voice prosthesis – information and training

Improve written documentation for patients. Increase awareness of ex-dwelling prostheses before patients have surgery.

2463 Privacy & dignity survey at Meridian Treatment Centre

Investigate waiting times and look at ways of improving privacy.

2465 Mattress cleaning and inspection Obtain information posters and display at appropriate locations. Obtain mattress information leaflets to establish cleaning regimes.

2468 Policy for Personal Protective Equipment

Specific departments to be targeted where results are poor.

2470 Infection Control Link Worker training evaluation

None – as training is acceptable.

2471 Infection Control Mandatory Training evaluation

None – as training is acceptable.

2474 Issue of Nicotine Replacement Therapy vouchers to patients who may be contra-indicated

Medical questionnaire to be re-written to avoid ambiguities and ensure all questions are answered.

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Title of audit Summary of actions

2482 Hand Decontamination Policy Provide posters of preferred washing technique to all locations.

2483 Sharps Policy Individual meetings top discuss issues around transportation of filled sharps boxes.

2484 Completion of Home Visit Sheet by Therapists in Community Rehabilitation Team

Individual discussions with those staff identified as not meeting required note-keeping standards.

2487 Diagnostic work-up for newly-diagnosed HIV-positive patients (National Audit)

No Action Plan as actions will be in individual report from British HIV Association.

2490 Patient satisfaction with Acupuncture Clinic

Improve information given to patients and investigate different clinic times.

2491 Documentation in Acupuncture Clinic Feedback (and get confirmation) of new clinic guidelines to staff.

2494 Infection Control training within Continence Team (hand hygiene)

None – as training is acceptable.

2495 Training for Infection Control clinical skills

Training is acceptable, but consider local team-based training.

2496 Assessment of patients for smoking cessation who may fall into “Cautions” category

Improve recording of pregnancy etc data. Individual discussions with those staff who do not meet standards through Clinical Supervision.

2497 Documentation of patients receiving diagnostic ultrasound (Physiotherapy)

None (quality is acceptable), but continue to monitor.

2500 Consent for Speech & Language Therapy

Re-design consent form.

2502 Hand decontamination by Vaccination & Immunisation Team staff during school vaccination sessions

Provide each member with a copy of 8-step decontamination method. Staff to take own towels etc to future sessions.

2511 Completion of joint OT/Physiotherapy assessment sheet in Community Rehabilitation Team

Re-design documentation to ensure only necessary data are recorded.

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Participation in Clinical Research

40 patients receiving NHS services provided or sub-contracted by Coventry Community Health Services in 2010/2011 were recruited to participate in research approved by a research ethics committee. Six projects were in progress during the period 2010/2011.

The projects under consideration were:

Protease Inhibitor Monotherapy vs Ongoing Triple-Therapy (PIVOT)

Sexual Health

Long-term follow-up of HIV-infected persons seen since 1996 in seven major UK centres (UK CHIC)

Sexual Health

Study of transmission risk between HIV discordant partners (PARTNER STUDY)

Sexual Health

Improving Patient Choice in Treating Low Back Pain (IMPACT – LBP)

Physiotherapy

Investigating the Potential for Occupational Performance Passports

Occupational Therapy

Coordination of care for people affected by an illness (coPAI)

Palliative Care

Participation in research demonstrates the Trust’s commitment to improving quality of care to making a contribution to wider health improvement. It helps clinical staff to remain aware of the latest possible treatment possibilities and participation in research leads to successful patient outcomes

Information Governance Toolkit attainment levels CCHS was part of NHS Coventry Information Governance Assessment Report for 2010/11. The overall a “satisfactory” score at a minimum of level 2 for each of the 45 standards included in the Toolkit was attainment with three of the standards scoring 3. This is equivalent to achieving 68%, where 65% is the minimum requirement for passing the Information Governance Toolkit.

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Statement on relevance of Data Quality and our actions to improve our Data Quality High quality information and data is critical to CCHS being able to provide high quality clinical services, to enable the effective monitoring of the services and for the continuous improvement of services. CCHS recognises that data is not just statistics but includes the recording of both numerical data and text, such as that recorded in service user records or other corporate documents. Data quality is essential for both clinical and non clinical record keeping enabling high quality care and robust business and performance reporting processes. CCHS also recognises the importance of reliable information in the day-to-day delivery and management of front line services and their management. Poor information quality leads to poor decision-making both operationally and strategically and to a poor understanding of performance. Data quality is everyone’s responsibility whether at the clinical/ care level, support functions or higher management level. Thus from initial data collection to the analysis and application of data/ information within the organisation the approach must be consistent and meet the essential criteria for data quality. CCHS was not registered to submit data to the Secondary Users Systems (SUS) for inclusion in the Hospital Episode Statistics. The majority of CCHS services being community based are not part of this process; however Genito-Urethral Medicine (GUM) and Child & Family Services, should provide this data. The merger of CCHS with Coventry & Warwickshire Partnership Trust (CWPT) in April 2011 will enable CCHS to gain expertise and to submit this data for 2011/2012 under CWPT registration. Across all CCHS Services using iPM, 91.56% of records have the NHS number included. The percentage of records which included the patient’s valid General Medical Practice code was 97.1%. Within CCHS the Information Team work is ongoing to improve systems/ processes for the collection, monitoring and reviewing of the information available ensuring good quality data is made available to all services in a timely manner. Performance and Data Quality reports – are sent monthly to each service team for information and action as appropriate. The quantity information is used to manage and improve performance, enabling the efficient use of resources and planning the development of future service delivery, therefore improving waiting times and patient care. Due to the ongoing relationship between operational teams and Information, the quality of data submitted nationally via UNIFY has dramatically improved with operational teams taking full ownership of their data. The Trust was not subject to the Payment by Results clinical coding audit during 2010/11 and was not required to submit a clinical coding error rate to the Audit Commission.

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Review of Quality Performance 2010 - 2011 Structure for Developing and Ensuring Quality In order for CCHS to provide the highest quality care to patients, quality must be at the heart of everything that we do at every level of the organisation. NHS Coventry commissions the services that we provide and monitor quality standards and improvements through the monthly Contract Quality Review process. The Integrated Governance Committee which is a formal sub committee of the Provider Board had two NHS Coventry Non Executive Directors within its membership, one of whom is the Chair of this committee and of the Provider Board. All aspects of patient safety, effectiveness, patient experience and governance are discussed at this committee. All Heads of Service attend the Operational Integrated Governance Group which is chaired by the Medical Director and which provides a forum for sharing learning and messages between the Board and frontline service. Each service area has a local governance group where service specific quality and governance issues are discussed and learning is shared within and across teams. In 2010/11 CCHS developed a performance reporting framework which enabled safety and quality indicators, collected at service level to be reported to the Board enabling a shared understanding of our performance throughout the organisation, from frontline team to Board. Priorities for quality improvements are determined through a number of different processes.

• NHS Coventry, as commissioners of the services we provide, agreed with CCHS, areas for quality improvement under the Commissioning for Quality and Innovation scheme (CQUIN). A proportion of income in 2010/11 was conditional on achieving these goals.

• A wide range of quality and performance indicators are monitored by NHS Coventry on a monthly basis.

• Feedback from patients in surveys and complaints inform changes that we need to make to our services.

• Considering the causes of clinical incidents enables us to learn lessons and make changes to reduce the likely hood of reoccurrences.

• Changes recommended as a result of external reviews Achievements have been grouped under the categories patient safety, clinical effectiveness and patient experience.

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1. Review of Patient Safety The NHS Institute for Innovation and Improvement launched High Impact Actions for Nursing and Midwifery in June 2010. Four of these actions formed the basis of CCHS CQUIN scheme for 2010-2011:

• Reduce the number of people whose pressure ulcers get worse in the care of organisation

• Preventing falls • Improving nutrition and hydration • Dying in your place of choice when the time comes.

The High Impact Actions were designed for inpatient services and aimed to improve care within the care setting. CCHS does not have any hospital beds and reducing the risks of pressure ulcers, improving nutrition within the patient’s own home set us an additional challenge. In order to improve care we needed to make sure that nurses always had the right tools to assess risk, advise patients and carers and record patient’s preferences in a single document that was concise, universal and auditable. This led to a complete remodelling of our patient held care plans and has been welcomed by staff. CQUIN Indicator 1: Reduction in the incidence of Pressure Ulcers Intended outcome:

Patients identified at risk of pressure ulceration have a risk assessment preventative action and pressure ulcers are reported as incidents or serious incidents depending on the grade.

Narrative Pressure ulcers can occur in any patient but are more likely in high risk groups such as the obese, elderly, malnourished and those with certain underlying conditions. Pressure ulcers can be acquired in any setting for example patient’s home, nursing or residential home or hospital and risk assessment and management need to be considered across organisational boundaries.

A significant amount of work has been undertaken with other health providers and with Coventry City Council to analyse the causes of each pressure ulcer, where and how it occurred, and what else could have been done to prevent it. By undertaking this work learning from clinical incidents is realised within the team where the incident happened and changes to practice are implemented and shared across teams.

Actual Outcome: Following the remodelling implementation of the new care plan, audits

have demonstrated and increase in the number and quality of risk assessments and an increase in the number and appropriateness of preventative actions.

100% of grade 2 pressure ulcers are reported as incidents and 100%

The new care plans really help us to

focus on the patient as a whole

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grade 3 and grade 4 pressure ulcers are reported as serious incidents.

As the awareness of pressure ulcers has increased, reporting has increased and this is seen as a positive result which contributes to the understanding of the impact of pressure ulcers in the health economy. The proportion of more severe (grade 3 and 4) pressure ulcers has decreased

Pathways for sharing of information and referral into safeguarding processes where there are concerns have been developed and a greater understanding of the issues and the solutions has resulted.

A considerable amount of sustainable quality improvement has been made this year which include changes to clinical practice, documentation, relationships with other organisations as partners, identification and analysis of risk and the ongoing applications of lessons learned. Work will continue to ensure that the improvements seen are built on and not lost. CQUIN Indicator 3: Improving nutrition and hydration Intended outcome:

Patients identified at risk of poor nutrition and hydration have a risk assessment and preventative action taken.

Narrative

Dehydration and malnutrition represent a major burden of sickness and quality of life for patients and are costly to the NHS. Their presence is associated with an increased risk of infection, confusion, constipation, pressure ulcers and falls particularly in the over 65 age group. As district nurses visit patients in their own homes or in residential settings they are only able to refer on to other professionals where necessary and advise relatives and carers of actions that should be taken to improve hydration and nutrition.

Actual Outcome

The implementation of the new care plan which included an overview risk assessment and a nutritional risk assessment lead to a significant rise in the number of patients assessed as being at risk of dehydration and malnutrition (from 4% to 73%). Evidence of preventative actions being taken was available in the care plans though it is clear that not all advice given is being recorded fully. Evidence based information to give to patients and their care and this rs is being developed.

A considerable amount of sustainable quality improvement has been made this year and will continue to ensure that the improvements seen are built on and not lost. CQUIN Indicator 4: Increase in advanced care planning for patients on an end of life pathway Intended outcome:

Patients on an end of life pathway have an advanced care plan in place and followed.

Narrative:

That services reflect the needs and preferences of patients and their carers is one of the principles of the NHS (NHS Constitution, DH 2009). Enabling patients to die in their place of choice is an important

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consideration. Establishing a baseline for this indicator at the beginning of the year proved difficult as although audit showed that 100% patients involved with the Family Support Service had an advanced care plan there was no way of identifying which patients on the district nursing caseload were end of life patients.

Actual Outcome

The implementation of the new care plan which contained an explicit advanced care planning section for end of life patients enabled us to demonstrate at follow up audit that at least 70% of end of life patients on the district nursing case load had a care plan and 93% of those were managed according to that care plan.

CCHS considers that a considerable amount of sustainable quality improvement has been made this year and that this indicator has been fully achieved. CQUIN Indicator 5: Reduction in falls Intended outcome:

Patients identified at risk of falling have a risk assessment, brief intervention and preventative action taken.

Narrative:

When baseline data was collected it became obvious that although therapy teams routinely assessed, advised and treated patients who were at risk of falling, district nursing teams had no risk assessment tools or patient information to support the advice they gave to patients. In order for this indicator to have the biggest impact and to be sustainable we decided to work with the nursing teams to raise awareness and develop the tools that they needed

Actual Outcome

The implementation of the new care plan provided nursing teams an assessment tool for fallers and the follow up audit shows an increase in completed risk assessment from 0% to 74%. Evidence of preventative actions being taken was available in the care plans though it is clear that not all advice given is being recorded fully. Evidence based information to give to patients and their carers is being developed.

A considerable amount of sustainable quality improvement has been made this year and will continue to ensure that the improvements seen are built on and not lost. Themed reviews During the year NHS Coventry under took 2 themed reviews of community services one related to risk management and one to safeguarding. Themed Review of Risk Management Managing risk is an important part of maintaining patient safety. In November and December 2010 NHS Coventry undertook a themed review of risk management

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The fundamental principle of this risk management quality review was to evaluate the underpinning processes to ensure that care delivery is safe, effective and ultimately improves patient experience. This can only be achieved with true collaboration and feedback from staff and stakeholders who need to be made aware of the changes effective as a result of lessons learnt. In conclusion the review panel reported that: “The findings of the review did not reveal areas of immediate concern or risk and confirmed that the organisation has basic systems and processes in place for the

management of incident and complaints. Coventry Community Health services will be merging with Coventry &Warwickshire Partnership Trust and therefore the

challenge for the team is the integration of the two organisational processes.” Themed Review of Safeguarding Maintaining the safety of young people and vulnerable adults is an inherent part of the role of staff in the community. In May and October 2010 NHS Coventry undertook a themed review of safeguarding covering the whole range of adult and children’s services provided by CCHS.

The aims of the themed review were to: • Support Coventry Community Health Services (CCHS) to review Safeguarding

Children and Young People systems, processes and practice to improve outcomes for children and young people.

• Understand, measure and examine variation in the quality and safety of safeguarding children and young people practice within and between CCHS, other health providers and across other agencies.

• Promote communication and collaboration with other health providers/commissioners and other agencies involved in Safeguarding Children & Young People.

The conclusion of the review was: “Overall the panel was delighted with the exemplar progress made. The openness and transparency of CCHS and its safeguarding team, the quality and presentation

of the evidence provided was of an exceptionally high standard. Ensuring front line staff are aware of relevant safeguarding children issues for each service

remains a challenge given the diversity of services provided.” The panel made some recommendations for improvement which have been implemented by CCHS and monitored by NHS Coventry through the contract quality review process. External reviews

Review of Urgent Care, Critical Care, Stroke (Acute Phase) & TIA, and Vascular Services by West Midlands Quality Review Service (WMQRS) In September 2010 the WMQRS undertook a review of these services across Coventry and Rugby Health Economy. The review involved the Coventry GP out of hours service which is run by CCHS.

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The review team findings were: Immediate Risks: None Concerns

Several clinical guidelines were not documented. In practice, local GPs who usually staff the service were aware of locally agreed guidelines. This issue would be a risk if locums were used and it did not enable adherence to guidelines to be audited.

Good Practice

There was a good, formal interview process for all GPs which linked well to training and development programmes and to appraisal. There were also good links between appraisal and clinical governance arrangements.

Actions have been put in place to address the concern.

Review of Services for People who have had a stroke by the Care Quality Commissions (CQC) Some services provided by CCHS were involved in the CQC review of services for people who have had a stroke and their carers for Coventry PCT area. The report, “Supporting life after stroke” which was published in January 2011, assessed the Coventry Health Economy as ‘Fair performing’ – with more areas of weakness than strength.

The review highlighted areas of good practice identified such as the use of a community rehabilitation team, patient information, specially trained staff and community allied health professional support. NHS Coventry has had a primary focus on improving care for Stoke patients on acute services and as it moves to focusing on community provision CCHS will work with them to further develop community and rehabilitation services for Coventry. Management of serious incidents requiring investigation (SIRI) CCHS adopts the definition of serious incidents as set out by the National Patient Safety Agency (NPSA) in the National Framework for Reporting and Learning from Serious Incidents Requiring Investigation (2010) and as adopted by NHS West Midlands. A serious incident requiring investigation is defined as an incident that occurred in relation to our services resulting in one of the following: -

- Unexpected or avoidable death of one or more patients, staff, visitors or members of the public;

- Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm;

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- A scenario that prevents or threatens to prevent the Trusts ability to continue to deliver healthcare services, for example, actual or potential loss of personal/organisational information, damage to property, reputation or the environment, or IT failure;

- Allegations of abuse; - Adverse media coverage or public concern about the organisation or the wider

NHS; - One of the core set of ‘Never Events’ as updated on an annual basis by the

Department of Health NHS West Midlands requires all providers of healthcare to report and investigate pressure ulcers of grade 3 and 4 as serious incidents. In the year April 2010 – 2011 CCHS reported and investigated 60 serious incidents of these 56 were pressure ulcers, 3 confidentiality information leaks and 1 delayed diagnosis. Frequency of serious incidents through the year is reported in the graph below.

7

8

6 6

9

12

4

2

7 7

2

1

0

2

4

6

8

10

12

14

Apr-10 May- 10

Jun-10 Jul-10 Aug-10

Sep-10

Oct-10 Nov-10 Dec-10

Jan-11 Feb-11 Mar-11

CCHS is continuously learning lessons from serious incident investigations. Actions resulting from learning are outlined below: Serious incident Action Pressure Ulcer Education and training including documentation, pressure ulcer

identification and grading. Named tissue viability specialist assigned to each clinical team to provide expert support and clinical supervision

Documentation loss Additional training provided for staff Delayed diagnosis Improvement in internal referral systems

Increased clinical supervision Clinical education

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2. Review of Clinical Effectiveness CQUIN Indicator 6: Caring for people with long term conditions in the community Intended Outcome

Reduction in the number of patients admitted to hospital within the month who are on a specialist nurse and community matron caseload with a long term condition

Narrative Numbers of admissions, planned, unplanned, avoidable and unavoidable have fluctuated throughout the year. It was agreed with the PCT to focus on the qualitative improvements and to initiate a process for peer review and sharing learning across the Community Matron and specialist nursing teams. The unplanned avoidable admissions are reviewed by the Community Matrons and Specialist Nurses on a regular basis with a view to sharing and identifying trends and learning points. Following this a new initiative is being implemented to peer review all admissions to ensure learning from the experience of actions in others.

Actual Outcome

It is hard to evidence a direct reduction in admissions to hospital at this point but a considerable amount of progress has been achieved in understanding why some avoidable admissions happen and systems are being put in place with GPs and the acute hospital to reduce this number in the future.

CCHS considers that a considerable amount of sustainable quality improvement has been made this year which provides a better understanding across the health economy as to why some patients are admitted unnecessarily and which will progressively impact on numbers of patients admitted. Quality Performance Indicators CCHS reports to NHS Coventry on a monthly basis on a large number of quality and performance indicators. Some of these have been consistently achieved all year, some have shown improvement and some are still not being achieved. In quarter 1 (April 2010 – June 2010) the performance target was met in 51% of indicators by quarter 4 (Jan 2011 – March 2011) this has risen to 71% of indicators met. A selection of indicators is discussed below: Assessment time for integrated musculo-skeletal service A target was agreed with NHS Coventry that 80% of new attendances to the integrated musculo-skeletal service (a specialist physiotherapy service involving staff with additional skills, extended scope practitioners) would be assessed within 21 days of receiving the referral.

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The results were Period Performance

0

10

20

30

40

50

60

70

80

90

100

Q1 Q2 Q3 Q4

PerformanceTarget

Quarter 1 (April 10 – June 10)

75%

Quarter 2 (July 10 – Sept 10)

78%

Quarter 3 (Oct 10 – Dec 10)

91%

Quarter 4 (Jan 11 – March 11)

92%

Achievement of lifestyle goals Health trainers work with people to help them make healthy lifestyle choices and to achieve goals that they set. A target was agreed with NHS Coventry that 80% of clients of Health trainers should achieve or part achieve goals contained in Personal Health Plan within an agreed timescale. The results were Period Performance Quarter 1 (April 10 – June 10)

56%

Quarter 2

0

10

20

30

40

50

60

70

80

90

Q1 Q2 Q3 Q4

PerformanceTarget

(July 10 – Sept 10) 78%

Quarter 3 (Oct 10 – Dec 10)

82%

Quarter 4 85% (Jan 11 – March 11)

Uptake of Children’s Developmental reviews Parents of young children are invited to developmental reviews at specific ages, although all children are offered an appointment for the reviews uptake is not as high as it should be. Targets were agreed with NHS Coventry that CCHS would try to achieve 95% uptake at both the 8 month to 1 year and the 2 1/2 year developmental review.

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Results for the 8 month to 1 year review were: Period Performance

0

10

20

30

40

50

60

70

80

90

100

Q1 Q2 Q3 Q4

PerformanceTarget

Quarter 1 (April 10 – June 10)

57%

Quarter 2 (July 10 – Sept 10)

46%

Quarter 3 (Oct 10 – Dec 10)

62%

Quarter 4 78% (Jan 11 – March 11)

Results for the 2 ½ year review were: Period Performance Quarter 1 (April 10 – June 10)

36%

Quarter 2 (July 10 – Sept 10)

32%

Quarter 3 (Oct 10 – Dec 10)

44%

0

10

20

30

40

50

60

70

80

90

100

Q1 Q2 Q3 Q4

PerformanceTarget

Quarter 4 61% (Jan 11 – March 11)

Although improvements have been shown against both of these indicators neither has achieved the target. In order to address this and to respond to Government initiatives to expand and strengthen health visiting services (Health visitor implementation plan 2011-15: a call to action, Department of Health, February 2011), CCHS is undertaking a radical service redesign within its health visiting service. Working with Children’s Centres and other partner organisations will be strengthened and services will be provided within the communities where parents of young children live. Allied Health Professionals (AHP) Referral To Treatment Times The recording of Referral to Treatment (RTT) for Allied Health Professional (AHP) Services was to become mandatory nationally from 1 April 2011. National guidance was issued in April 2010, which identified the rules for AHP RTT as well as indication of agreements to be established with commissioners.

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Coventry Community Health Services established a QIPP Project in order to improve the patient booking pathway and to support the reporting and achievement of the AHP RTT. At the beginning of the project the organisation was unable to report confidently on RTT times and many AHP services were experiencing long waiting times from initial referral to treatment. The work undertaken by the organisation involved individual AHP services redesigning their referral pathways, the utilisation by services of the patient administration system and the establishment of a centralised patient booking process. Key Achievements: The charts below demonstrates the great strides that have been made over the past twelve months in referral to treatment times and how many AHP services have both achieved, and in many cases exceeded referral to treatment in less that 18 weeks

AHP Services Referral to Treatment (RTT) targets

44.1

57.1 59

80.5

50.560.5

43.2

81.7

95.2 96.8 99.2 99.189.8 93.5 97.9 98.1 98.3 97.8 95.2 95.8 98.7 97.3 99.1 99.3

0

20

40

60

80

100

Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11

% S

een

with

in 1

8 w

eeks

Children's

Adults

Target

Other key achievements include the publication of a number of CCHS services on Choose and Book, the launch of direct booking and a consistent approach to data collection and reporting by the organisation.

“Given that acute trusts had three years to

achieve this, what CCHS has achieved in one year

is stunning” - NHS Coventry

Feedback from patients and other users of the service:

• GP’s are now finding it easier to access those services now published on Choose and Book

• Patients are being seen quicker and waiting times are being managed.

• Patients also have more choice of venue and appointment times, which has resulted in some reallocation of resources in some services in response to reduced demand in localities and increased demand centrally.

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Children and Young People’s Occupational Therapy Services re-design The Children and Young People’s Occupational Therapy Service works with those aged 0 – 19 years who have a physical and/or learning disability or other developmental disability affecting performance of daily occupations of childhood. The service has experienced considerable increase in demand that has outstripped capacity over the last few years leading to increasing referral to treatment times that peaked at 80 weeks during 2009/ 2010. This led to a significant growth in complaints from families who clearly expressed their concern regarding the impact of long waiting times. Parents articulated specific problems relating to managing the long term needs of their child/ young person in everyday activities of daily living whether in promoting greater independence and participation or meeting specific care needs. This situation was responded to through completion of a service review and throughout 2010, the Children and Young Peoples Occupational Therapy Service undertook a significant service re-design project with the aims of improving access times, productivity and patient experience. This was carried out under the auspices of the Department of Health’s Allied Health Professional Service Improvement Project. The redesign process encompassed national benchmarking, local stakeholder consultation and commissioner engagement. From this a new three tier model of service was derived which focuses resources where they are most effective and promotes self management and healthy living through an interactive website and education packages. The outcomes of the process have been profound. Access times from referral to treatment have been reduced from an average of 14 months to 1 - 2 weeks. Productivity has increased with the number of families accessing the service each month having tripled. The overall patient experience has improved both in terms of satisfaction with shorter access times and the way that services are delivered through new and contemporary mediums. Productive Community Services In 2009 CCHS was chosen as one of two national pilots for the Productive Community Services programme. During 2010 - 2011 we have continued to roll out the programme across community teams with significant benefit to patients, staff and the organisation. Productive Community Services (PCS) is a programme designed to deliver improvements in quality and better efficiency, releasing more time to care for patients by mobilising front line staff to deliver change. Through a series of modules and activities Staff are enabled to analyse their current performance, identify changes from their perspective and from that of patients and are empowered to make the changes happen developing a culture of enquiry and improvement.

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Status at a Glance To solve this problem 2 ‘status at a glance’ boards were created:

“One of the problems that we faced was not being able to identify patient status without looking in the patient’s

notes which are kept within the patient’s home, or asking the member

of staff who visited previously” - Nursing team

• the diabetic board, which enables us to see the patient’s type of insulin, frequency given, hba1c due, and any recent action

• A palliative board which allows us to review patient progress and update patient information in a format that is accessible for all to staff.

We find that it is easy to review the information when liaising with the multi-disciplinary team. We have found this to be very successful. Knowing how you are doing Teams develop a board to give them instant feedback on performance on agreed targets.

“We now have control of our own performance.”- Nursing team

The picture below illustrates how the team can see their performance and shows the sort of things they are measuring.

Care Plan Audit

Patient Facing Time

Patient Satisfaction

Unplanned Absence

Well organised working environment One team recognised that the cluttered store room meant that stock was hard to find and staff were wasting time trying to find the equipment/ dressings they required.

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Stock which was unused or over ordered was removed and redistributed across other teams in the city, equating to an immediate saving of £1,327.40. New shelving was put up and the stock was re-organised, labelled, photographed as a visual aid, and finally minimum and maximum stock levels agreed to ensure adequate stock levels were always maintained. Now items are always available, easy to find, and costs will be reduced over the long term due to a reduction in over ordering.

Before

After

3. Review of Patient experience CQUIN Indicator 2: Composite Indicator on responsiveness to patient experience of patients receiving community based healthcare Intended Outcome

An improvement in scores across using a survey to establish a baseline and as a follow up.

Narrative The methodology required the survey sample to be divided across 5 services, Wound care, Diabetes, Continence, COPD and a further early intervention agreed with the PCT as children on the health visiting caseload identified as receiving a service on Pathway 2 of the Healthy Child Programme, in the North East locality of the City.

Actual Outcome

The results for both surveys cumulatively and for each pathway are detailed below

Baseline survey Positive Score by Question

Pathway Q1 Q2 Q3 Q4 Q5 Q6 Wound Care 89% 88% 90% 48% 97% 94% Diabetes 88% 86% 92% 64% 96% 92% Continence 93% 93% 87% 51% 95% 96% COPD 92% 96% 96% 82% 98% 98% Early Intervention∗ 100% 100% 100% 0 100% 100% CUMMULATIVE TOTAL 90.57% 90.91% 91.81% 60.27% 96.97% 94.61%

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Follow up survey

Positive Score by Question Pathway Q1 Q2 Q3 Q4 Q5 Q6 Wound Care 88% 91% 92% 69% 100% 100% Diabetes 88% 90% 95% 46% 99% 83% Continence 88% 83% 90% 54% 96% 96% COPD 92% 92% 83% 68% 89% 84% Early Intervention∗ 93% 93% 100% 100% 93% 93% CUMMULATIVE TOTAL 88.16% 89.76% 91.50% 62.65% 93.37% 90.36% Comparison follow up to baseline

-1.42% -1.15% -0.31% 2.38% -3.60% -4.25%

Services scored very highly in the baseline questionnaire and it was recognised that it may be difficult to show any improvement on these scores. Overall the follow up survey results, although still high, appear to show a small drop in performance since the baseline survey, in 5 of the 6 questions. Some errors in calculation introduced by the spreadsheet designed to collect the data for the survey have been noted and reported to the designers. There are also concerns that comments given by some patients did not refer to services provided by CCHS but to other health care providers. The results of the survey and the scoring of it should not be treated as absolute as they may reflect views on services not provided by CCHS. Patients were given the opportunity to comment on “how could this be improved” for all questions. Comments were largely positive and supportive but did also include some negative feelings. The comments relate to individual experiences and therefore trends are not obvious. All comments and results have been fed back to the services for consideration and to inform changes in practice. It will be noted that in the baseline survey there was a very low return from the health visiting pathway. The methodology for collecting information was changed to use personal contact, face to face or by telephone and this resulted in a higher rate of return in the follow up survey (2% - 23%). The survey results are very pleasing and demonstrate an overall appreciation of services by patients.

CCHS considers that a high standard of patient satisfaction has been achieved and maintained across the year and that this indicator has been achieved. Learning through Complaints When patients and carers report concerns about our services, frontline staff and heads of service try to resolve the issues as soon as they occur. If it not possible for staff to

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resolve the issue immediately further support and advice is available from the NHS Coventry Patient Advice and Liaison Service (PALS) and where the issue remains unresolved through the formal complaints process. Our complaints process aims to address complaints in a fair, open and transparent manner and where fault is found, to put this right and ensure that lessons are learnt across the whole organisation. In 2010/11 54 formal complaints were registered with CCHS and we also contributed to 9 joint complaint responses, with other agencies including social care, University Hospitals Coventry and Warwickshire and NHS Coventry. The table below shows the breakdown of complaints by type. A complainant may register more than one issue.

Theme of complaint Number of complaints

Waiting time 6

Care and treatment provided 32 Attitude of staff Medical Nursing AHP Receptionist

5 6 1 2

Inappropriate comment in records

1

Confidentiality 3 Communication 5

The complaints process applies the Health Ombudsman’s key principles and sets out our approach to handling complaints, from ensuring that complainants are informed about how their complaint will be dealt with to the identification of where we need to improve our services as a result of the complaints we receive. At the end of each complaint, the complainant is invited to feed back on the handling of their complaint.

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Innovation Projects 1 The living legends project Young people with life limiting or threatening conditions often lose support from their peers and experience a sense of isolation

The Community Children’s Nursing team Youth Group (CCNTYG) helps to reduce these feelings of isolation by providing an opportunity for young people to have fun whilst supporting each other. Members of the group said that they wanted to help others in their position by producing a short film. 8 young people were helped to produce the film.

Outcomes • Development of a valuable education resource to help staff understand the

needs of young people. • Patient empowerment and involvement was strengthened. • Staff improved their understanding of the importance of the CCNTYG • The team is exploring other opportunities to engage young patients in shaping

their service. • The film has been shared with the regional children’s community nursing network

to inform service provision across the West Midlands and beyond 2 Stop cyber bullying project Cyber bullying is when one or more people try to threaten or embarrass someone else using a mobile phone or the internet and usually involves children or young people In this project staff worked with children and young people to raise awareness of cyber bullying by developing a drama workshop designed to educate and provide advice on how to recognise and stand up to bullying online. The workshop used peer led discussions to help young people learn about and debate the issues in a secure environment. Education sessions were delivered to teaching staff and school nurses

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Outcomes • 428 school children in 3 schools participated • Partnership working with young people and schools have been strengthened • The learning needs of children to maintain their safety in an on line environment

have been identified and shared with schools for them to continue to address the issues.

3. The Soapy - Soapy Song Teaching children how to wash their hands properly from a young age is essential for personal hygiene but for children learning to self care for dressings and catheters the principles of clinical hand washing are even more important.

Recognising that children learn best through play staff developed a fun action learning song aimed at children between 2 and 7 years. A learning pack was developed comprising CD, poster, lyrics, piano music and colouring in sheets providing teachers with the basic tools to make the song a class room activity

Outcomes • The pack has been implemented into 4 schools to date strengthening

relationships • A positive response from the children who enjoy the song and understand its

messages. The funding of these projects was provided be the Coventry and Warwickshire Locality Stakeholder Board Innovation fund for which CCHS and the young people affected are grateful.

“In addition to improving the quality of their service, individuals have learnt to use new software, to produce films, to develop

educational tools, and to promote their achievements through local press,

publication in journals and presenting at conferences – skills which will help to

build a culture of innovation in driving for better care.”

Jo Guy, Innovation Fund lead

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Patient and the public engagement Involving patients, carers and the public in feedback on the services we provide is an essential way of identifying improvements. A wide range if Patient and Public Involvement activities have been undertaken across CCHS in 2010/11 and some examples of what we were told and what we did are given here. Activity 1: The Anchor Centre is a health resource provided by CCHS for the homeless population of Coventry. In May 2010 an event was held with the aim of sharing experiences and encouraging dialogue between health policy makers and the disadvantaged. Local shops were approached to provide contributions for a BBQ which was held in the grounds of the Anchor Centre. Senior staff from CCHS and NHS Coventry were invited to meet with homeless people. The event was very well attended by homeless people across a wide age range and by senior representatives of NHS Coventry and CCHS. The senior staff reported a much greater understanding and awareness of homeless people and how they get to be in that situation. The homeless population felt that they had had the opportunity to highlight some of the problems they have when accessing health care. They raised a number of mental health issues were raised, which identified a shortfall in provision which was subsequently brought to the attention of staff at Coventry and Warwickshire Partnership Trust. A user focus group was set up in June 2010 to give the users of the Anchor Centre the opportunity of continuing to influence change within the service. Activity 2: Between April and June 2010 the podiatry service asked patients and their carers who had participated in diabetes awareness sessions to give feedback on their experience. The feedback was largely positive with patients particularly welcoming the targets set with then to improve their ability to self manage their condition and care. The service is using this evidence to encourage greater take up of the sessions. Activity 3: the school nursing service consulted with pupils in the school council at President Kennedy School about the provision of a drop in service. The young people suggested a venue, how to advertise the service and advised on potential barriers. The service was established on the basis of what they said. Staff Satisfaction Survey CCHS participated in the national Annual NHS Staff Survey between September 2010 and January 2011, with a sample survey undertaken within CCHS of 700 staff. The response rate this year was 53%, in line with the overall national response rate of 54%. Overall, the survey results were positively in line with national comparative rates for similar organisations, and as outlined below, better than the national average in most key question areas linked to Vital Sign monitoring.

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The survey includes 9 key questions linked to Vital Signs monitoring. Of these, CCHS scored above the national response rate in 6, these being:-

• Helping staff achieve the correct ‘work-life balance’ • Staff able to meet conflicting demands • Staff satisfied their work is valued by the organisation • Senior managers involve staff in making important decisions • The care of patients is the organisation’s top priority • Communications between managers and staff are satisfactory

The 3 Vital Signs indicators which fell below the national average however were:-

• Only 64% of staff reported having an appraisal in the last 12 months (national average 79%). This is disappointing given that the 2009 CCHS appraisal rate was 70% (and the 2008 figure 74%) and the national trend has shown an increased uptake of appraisals.

• ‘Staff have planned clear goals and objectives’; 68% reported positively here against 71% nationally. This appears to be linked to the relatively low appraisal rate.

• Work related stress experienced by staff (34% against the national rate of 31%). The rate in 2009 in CCHS was 31%. The upward trend was also reflected in the national figures.

The results are summarised below: The Trust has recently established a ‘Social Partnership Forum’, which brings together some of the Staff Side Representatives, some members of staff with an interest in organisational culture, staff engagement and involvement and some of the Executive Directors. This forum provides an important place to reflect on and consider both what the issues are that the organisation faces in terms of the culture and those things that we may all be able to contribute to in order to make sure we learn from the best in the Trust and elsewhere; and think about how we ensure that all staff have a positive experience when working in the Trust. The overall picture would suggest that most indicators show an overall improvement, compared to last year and we continue to ensure that staff are encouraged to participate in developing ideas to improve the Trust for example through ‘Lets Talk’ sessions whereby front line staff can meet with senior members of the Trust to ensure that their views and thoughts are captured.

0%

10%

20%

Key

30%

Trust help staff  achieve work life balance

Appraisal/review in last year

Have plannedclear goals Disagree cannot 

meet conflicting demands

Satisfied with extent Trust values work

Senior managers involve staf

40%

50%

60%

70%

80%

90%

100%

fCare of patients top priority

Management / staff 

communication effective

No work related stress in last year

 Scores Comparison

National average

CCHS

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The overall survey outcome this year for CCHS has been very positive. However, the following key areas for improvement are highlighted:-

• The systematic process for annual appraisals needs to be reviewed and strengthened. This requires a review of the appraisal hierarchy in each service and the span of review numbers for each manager and supervisor. Further training may also need to be provided to ensure all appraisers deliver this process consistently.

• Clear processes to help managers identify stress and anxiety at the earliest opportunity, and take effective action once identified, are needed. This will be pursued through the Health and Wellbeing work which is being undertaken and will include a more widespread awareness of the availability of counselling accessible by both management and self-referral.

• Infection control measures require review and staff training in this area will need to be expanded in 2011/12.

As CCHS integrates with Coventry and Warwickshire Partnership Trust, a common approach will be developed to address areas of concern from this survey, and those identified in the staff survey report relating to CWPT itself.

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Our Priorities for Improvement in 2011/12 On 1st April 2011 CCHS merged with Coventry and Warwickshire Partnership Trust (CWPT). In the Quality account for CWPT, Rachel Newson, Chief Executive said,

“The transfer of these services complements our existing portfolio of services. Our priorities for 2011/12 reflect the important work that these services provide for the local

community and we have reflected these in our Priorities for Improvement section”. This section has been written to include the priorities of the newly merged organisation as it moves forward. A new health care facility is being built near to Coventry City centre which will house many of the services provided by CCHS. The facility is due for completion at the end of 2011 will enable services to be provided for patients in a modern purpose build facility. A number of key physical health and mental health services for children and young people will be co-located within the City Centre Health Facility. Work is underway to ensure that we capitalise on the opportunity that this presents for strengthened integrated working. We are aiming to enhance patient experience through the provision of a joint reception for these services, we are moving towards a more integrated approach to health assessments and we are also exploring better approaches to information management and sharing. The Trust has undertaken a series of workshops with our Commissioners to develop, in line with the NHS Operating Framework 2011/12, a number of Commissioning for Quality Innovation (CQUIN) indicators. These indicators will be implemented over the course of the year and progress will be monitored, on a quarterly basis, through the Trusts Clinical Quality and Contractual Meetings held between the Trust and the Commissioning PCT’s. The objectives of the CQUIN indicators that the Trust will concentrate on in 2011/12 are as follows:

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Description Rationale Intended Outcome Patient Safety Objectives

To support the national initiative to reduce the number of Suicides.

Demonstrate full compliance with the National Patient Safety Agency (NPSA) 'Preventing Suicide Toolkit' in inpatient mental health settings that provide services to working age adults.

The safety of inpatients on mental health wards is a priority for all staff and service users. To maintain safety, regular audits should take place to monitor and reduce any dangers in the design, equipment and organisation of the ward, care interventions, and the service user’s experience.

The Trust has agreed to works towards achieving 70% compliance in all within the toolkit at year end.

Promoting Safe, Rational, and Cost Effective Prescribing within Mental Health: A co-ordinated approach between primary and secondary care.

This indicator has five individual, but inter-linked components, that will be managed via appropriate networks and supported by appropriate governing arrangements. The development of these indicators ensures that the important features of patient choice, side effects, individualising therapy in line with NICE guidance, and previous patient response to therapy is not lost. The indicators respond to the Department of Health National guidance on Medicines Use & Procurement.

An agreed approach to prescribing across mental health and primary care supports safe, rational and cost effective prescribing in both sectors.

Development, implementation and monitoring of the Preferred Prescribing List. The development and implementation of joint prescribing guidance. Development of Prescribing Cost Charts to aid clinical decision making. Provision of comparative prescribing information. Development of a monitoring mechanism to support appropriate use of escitalopram and pregabalin.

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Description Rationale Intended Outcome Clinical Effectiveness Objectives

To improve the transition from Child and Adolescent Mental Health Services (CAMHS) to Adult Mental Health Services (AMHS) for service users.

Improved Transitions - All Coventry and Warwickshire 16 and 17 year olds who require mental health services have access to services appropriate to their age and level of maturity. When these services transfer from CAMHS to AMHS services it is important to ensure that a Robust Care Plan is in place.

Promoting an explicit connection between CAMHS (child and adolescent mental health) and AMHS (adult mental health services) and mark the formal handover of responsibility for young people with mental illness for care co-ordination and planning to adult services.

Development and implementation of a successful structured face to face handover meeting initiated and facilitated by CAMHS with AMHS in a minimum of 75% of transition cases.

To develop a health economy wide Eating Disorder Pathway.

The Trust will support the development and implementation of a health economy Eating Disorder pathway.

Eating Disorder patients across the health economy do not currently have a seamless pathway of care and individuals presenting at early stages do not routinely receive early intervention to support them with their condition.

Improved support for services users with eating disorders, prompt access to improved community based interventions and reduced in-patient care requirements. All services users requiring a review of care will have a care coordinator allocated.

Implementation of Case Management for out of area placements

The development of clear assessment, review criteria and case management for all out of area clients with clearly established review periods.

To ensure and enhance assurance to the commissioners of the quality and governance arrangements of the services commissioned for their clients whether this be provided by CWPT or other providers

All service Users on the Out of Area Client list will be allocated a Care Coordinator and will be reviewed to bring service users into local services or where this is not possible review the provision of care currently being provided.

Development and delivery of a clinical supervision programme

Development of a clinical supervision programme for the health visiting service (Healthy Child Programme).

To ensure safe, competent practitioners and supporting workforce and to support the delivery of the Healthy Child Programme and ' A Call to Action' The Health Visiting Implementation Plan (Department of Heath 2011)

All staff within the health visiting service will participate in structured supervision programmes.

To develop and pilot the use of a family assessment tool within the Health Visiting Service

To support the use of an evidenced based tool for providing a standardised approach to assessment.

Development of a ‘good practice' assessment tool in conjunction with commissioners and partners and incorporated into the 6-8 weeks checks.

The delivery of Healthy Child Programme using an agreed Family Assessment Tool

The delivery of the Healthy Child Programme with Children’s

Health Visitors will lead on the development and delivery of the

To support the delivery of the Health Visiting Implementation Plan

Development and delivery of an agreed health action plan for the targeted

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Centre’s Healthy Child Programme. This will be targeted at 3 Children’s Centres (Hillfields, Woodend, Willenhall).

(Department of Health 2011) centres.

Long Term Conditions – Case Management

Roll out of a root cause analysis process (RCA) for all the case managed patients of the community nurses, community matrons and specialist nurses who attend hospital or are admitted to hospital due to an exacerbation of their Long Term Condition.

Reducing admissions to hospital is a key priority for the Trust and it is recognised that learning the causes of how attendances and admissions may be avoided is key.

Root Cause Analysis undertaken in 80% of attendances/admissions where an exacerbation of a patients Long Term Condition has occurred.

All LTC patients known to Community Services have an integrated care plan for all nursing and therapy services. Patient plans are to be contained in the same file and updates contemporaneously written in continuation notes.

95% of patients with a long term condition will have an integrated clinical care plan in place.

Long Term Conditions - Co-ordination/integration of all clinical care interventions to support avoidance of admissions

Development and implementation of an agreed approach and communication plan.

Establish multi-disciplinary meetings between Community Matrons/Care Co-ordinator and GP/Primary Care Clinicians for patients with Long Term Conditions to support review of case load and ongoing patient management.

Long Term Conditions - Improving integrated work with primary care

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Patient Experience Objectives Description Rationale Intended Outcome

Improvement in patient feedback to support the development of the delivery of care and treatment

The Trust will develop its arrangements for the routine collection of patient feedback through use of a survey. The survey will focus on both community and inpatient services and will provide information that will enable the Trust to take action to improve services.

This indicator helps ensure that all service activities and improvements are oriented towards improving the experience of service users. The survey questions are based upon the service user experience questions set by the Care Quality Commission and have been extended to add additional questions to focus on local issues.

It is intended that the survey be conducted at least twice during the year, with actions taken as a result of the first survey leading to a demonstrable improvement in service users experiences.

Delivery of an enhanced 6-8 week development review service

Pilot of an enhanced 6-8 week assessment, through the home visiting programme.

To increase access and positive family satisfaction with the service by reducing DNA rates, maximising continuity of care and increasing opportunities for Health Visitors.

Develop, implement and evaluate a pilot 6-8 week assessment review service and commence roll-out across all appropriate services.

Development and delivery of the maternal mental health pathway

To increase access and positive family satisfaction with the service by reducing DNA rates, maximising continuity of care and increasing opportunities for Health Visitors.

Pilot of a maternal mental health pathway

Develop, implement and evaluate a pilot maternal mental health pathway and commence roll-out across all appropriate services.

Who has been involved in the development of the Quality Account?

• The Director Management team and the Provider Board discussed the process for development of the Quality Account and its content.

• A development team which included representatives from corporate and operational services was formed to advance the project.

• Progress was monitored through the Directorate Management Team and the Quality Account approved by the Board of NHS Coventry

• Heads of service were invited to provide contributions • NHS Coventry led the Clinical Quality and Contract Review meetings

and have been invited to comment on the quality account • Local Involvement Networks (LINks) have contributed as part of a wider

programme of user and carer engagement. The Trust has jointly organised a ‘LINk up for Quality’ event at which the development of the Quality Account was debated;

• The draft Quality Account was shared with Coventry Link who have provided a written response (see below)

• The Quality Account has been submitted to Coventry Health Overview and Scrutiny Committee and senior managers from the Trust attended a formal session to answer questions.

Response to Coventry Community Health Services Quality Account 2010-11 NHS Coventry, the commissioners of CCHS have provided a statement of verification which has been included in the document verbatim. Statement of Verification by NHS Coventry

NHS Coventry welcomes the opportunity to comment on the 2010/11 Quality Account provided by Coventry Community Health Services (CCHS). This account is the first and last NHS Coventry will receive from CCHS as it formally merged with Coventry and Warwickshire Partnership NHS Trust on 1 April 2011. In reading this account we understand the ongoing commitment to improving patient quality and experience which is reflected in the ‘Our Priorities for Improvement in 2011/12’ section of the account.

The Account highlights achievements, priorities and planned actions to drive forward quality improvements focusing on areas that are important to patients and in achieving national, regional and local priorities. There is evidence to support quality as a theme through all of the strategic developments within the account, inclusive of audit, performance and quality improvement and examples of how this has led to service improvements.

As commissioners we commend CCHS patient-centred philosophy and commitment to build upon their excellent work to date in driving up quality and improving patient experience.

We would commend CCHS on several key areas of improvement during 2010/11:

Introduction of the new care plan and audit tool.

Improving the responsiveness to patients receiving community based healthcare.

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Implementing a falls prevention service to include risk assessment and clarification of appropriate interventions.

Improving the nutrition and hydration of patients in the community.

Improving end of life options thus enabling patients to die in their place of choice when the time comes.

CCHS have worked hard to ensure that these have been given priority and improvements to patient care made. We also acknowledge that an enormous amount of work has been done through CQUIN, themed reviews and audit. Some CQUIN targets have not been fully met in year, which is disappointing for all. We would suggest it would be beneficial to see this work continue through 2011/12, as it took some time to establish systems to collect the data and validate changes in practice. The implementation of a new care plan commenced in November 2010 and will provide a strong foundation and a real legacy with changed systems and sustainable processes for continued improvement in the quality of patient care within the community.

Monthly contract meetings, quality reviews and themed visits provide the PCT with a good understanding of the issues facing CCHS. Internal systems and processes are in place to provide assurance. Attendance and participation from CCHS at the monthly quality reviews continues to be excellent throughout the year.

The quality of care at CCHS, as discussed in contractual quality meetings, is good. An open approach to quality monitoring included themed reviews (risk management and safeguarding) by the two commissioners and visits by the CQC and WMQRS. Such visits have demonstrated a positive ongoing relationship that is necessary to ensure that we can validate the information provided by CCHS.

In summary, NHS Coventry is satisfied that the document contains accurate data and information where related to items contractually discussed throughout the year with commissioners. Information provided within this Account that does not form part of those quality and performance review meetings cannot be corroborated by NHS Coventry.

We look forward to continuing the well established clinical partnership working to drive up quality and innovation for our community services as part of the newly merged Coventry and Warwickshire Partnership Trust as it moves forward in the coming year.

Coventry Link has provided a response to the Quality account which is included verbatim. CCHS thank them for their comments and look forward to developing the relationship that as part of Coventry and Warwickshire Partnership Trust to the benefit of patients.

Coventry LINk’s comments Coventry LINk welcomes the role all LINks have of providing a short comment on the quality of services within local Trusts.

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The Coventry Community Health Services Quality Account details a range of work which has been undertaken over the past year to improve the quality of services. Coventry LINk is heartened to see examples of where patient/service user surveys and input, especially rated to clinical audit, has led to planned changes to how services are delivered. The examples of patient and public engagement given are also good practice. LINk has found that LINk work often leads to recommendations regarding improving information for patients/services users and is pleased to see that Coventry Community Health Services has identified steps to improve information for some of its service users. This quality account identifies a number of local priorities for work to address quality. For the work undertaken this year Coventry LINk is aware that areas detailed have been areas where there is concern locally especially: improving hydration and nutrition and increasing advanced care planning for patients in the end of life pathway. Pressure ulcers have also been picked up as an issue by the local Scrutiny Board. The steps to ensure that Coventry Community Health services are listed on Choose and Book is very important as LINk has found that Choose and Book is a key mechanism for patients to access services. The awareness of GPs of services and how to operate Choose and Book with regard to these services is vitally important and we hope that CCHS will follow this up. The patient and public involvement section would have been strengthened by further examples of involvement activities. Coventry LINk would have liked to have seen more evidence of how patients and the public have been involved in the production of this Quality Account. We wonder how patients and the public have been able to influence the areas identified for work in the coming year (which are focused on CQUIN priorities). LINk supports the inclusion of work to improve patient feedback in the coming year. The focus on long term conditions also seems worthwhile as ensuring effective care and support for people with long term conditions is very important. Points of transition between services are often identified as problematic for patients therefore work to improve the transition from Child and Adolescent Mental Health Services to Adult Mental Health Services is important. LINk finds the report to be clearly presented, although a glossary of terms would be useful. LINk supports CCHS aim of putting quality at the heart of everything they do. We hope that as the management of Coventry Community Health Services is now being transferred from NHS Coventry to Coventry and Warwickshire Partnership Trust that the drive for quality continues. We will be interested to see what structures for developing and ensuring quality are put in place. LINk looks forward the opening of the City Centre Health facility and to further building relationships with CCHS as we begin our work to transition into Local HealthWatch as per the Government’s NHS plans. The Health and Social Care Overview and Scrutiny Board have provided a response which is included verbatim. CCHS thank them for their comments and look forward to developing the relationship that as part of Coventry and Warwickshire Partnership Trust to the benefit of patients.

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Scrutiny Board Commentary

The Health and Social Care Scrutiny Board (5) of Coventry City Council welcomes the opportunity to comment on the draft Quality Account of the Coventry and Warwickshire Partnership NHS Trust. The Board considered the draft Quality Account at their meeting held on 22nd June 2011 and wish the following points to be noted:

The Board welcomes the merger of NHS Coventry's former provider arm with the Trust and looks forward to integration of these services into existing community services.

Broadly the Board welcomes the Trust's commitment to quality and continuous improvement and has no evidence to suggest the Trust should have chosen alternative priorities for its Quality Account. Data included in the Quality Account demonstrates good progress last year.

Clearly in the current financial climate for the Trust the CQUIN targets are particularly important and need to be referred to in the Quality Account. The concentration on these issues does make the document less user friendly to non-medical readers than might be the case.

Further it would be useful if the Trust articulated more clearly how service users, carers and patients had been involved in selecting the priorities within the Quality Account as opposed to commissioners or regulators.

It may be helpful for future Quality Accounts if the Trust included trend data over longer periods of time, and tried to benchmark its services with comparable trusts.

The Board welcomes the commitment of the Trust to working with Coventry and Warwickshire LINk and the event held in May was a positive step towards greater engagement.

The Board welcomes the inclusion of reference to the Healthy Child Programme. The Trust's contribution to delivery of the Healthy Child Programme is significant and at the April meeting of the Scrutiny Board it was clear that much improvement and partnership working is needed to deliver better outcomes for Coventry young people.

In considering the draft Quality Account the Trust has been requested to provide further information regarding the arrangements for patients delayed in their discharge from hospital care. Whilst understanding the complexities of arrangements for users of the Trust's services, the Scrutiny Board would like to better understand the barriers to achieving better outcomes in this area. Trend data over the last few years has also been requested.

The Scrutiny Board has also requested further information from commissioners regarding the dementia care pathway and particularly around the arrangements for the support of carers of patients with dementia.

The timetable and process for local authorities such as Coventry to participate in

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Quality Accounts is particularly inconvenient (falling over the election period and subsequent annual general meeting period) however this is a national timetable and outside the Trusts control. However the earlier Members are able to engage in a future dialogue regarding the priorities in the Quality Account the more meaningful will be the contribution of the Scrutiny Board. The Board would like to express its thanks to Coventry and Warwickshire Partnership Trust for the support it provides to the Scrutiny Board, and for it responding to queries and requests for information promptly and efficiently.