South London and Maudsley NHS Foundation Trust Quality ... · South London and Maudsley NHS Foundation Trust Quality Account for 2013/2014 10 7. Patient Safety Priority This is a

South London and Maudsley NHS Foundation Trust

Quality Account for 2013/2014

South London and Maudsley NHS Foundation Trust Quality Account for 2013/2014 3

Part 1:

Statement on quality from the Chief Executive of the NHS Foundation Trust

The purpose of the quality report is to enable the Trust to be transparent and accountable for the quality

of the services we provide. The annual quality account gives us an excellent opportunity to promote the

importance of quality, as users of the service experience it, by setting priorities for the coming year and

highlighting achievements over the past year.

This year we once again welcome the engagement and input of our partners and stakeholders in the

development of our quality account. The comments and responses from all stakeholders will be included in

section five of the account. We are grateful for the contribution made by our Foundation Trust’s Council of

Governors to this report, through its quality sub-committee.

We know that 2013/14 will be a challenging year for all NHS services but we also know that our

commitment to quality will enable us to improve the efficiency and effectiveness of our services, and

continue to provide users of our services with a positive and therapeutic experience. This quality report

reflects our ambition to deliver continuous quality improvement in all our services.

To our best knowledge the information presented in this report is accurate. We hope you will find it

informative and stimulating.

Dr Matthew Patrick

Chief Executive Officer


A summary of successes and developments in 2013/2014

n We are engaging staff, service users and commissioners in the restructuring and investment in our

adult Community Mental Health Teams. The aim of this is to focus on improving the quality of patient

assessments and in so doing to deliver more effective engagement and evidence based interventions

with service users. The outcome will be to intervene quicker when relapse threatens a patient’s recovery,

so keeping patients out of hospital.

n 2013/14 saw the launch of the Recovery College sponsored by the Maudsley Charity. The Recovery

College offers a wide range of courses and workshops which are designed to help people recovering

from mental illness become experts in their own recovery. Courses range from; understanding psychosis

to building confidence in social situations, and using social media to find a job. Courses and workshops

are held in a number of venues across South East London.

n There have been a number of exciting collaborative projects with colleagues in Kings College and

Guys and St Thomas’ Hospitals. These have seen SLaM staff working alongside acute hospital colleagues

to screen, assess and support people with mental health problems. The 3D4D Diabetic service,

the St Thomas’ Emergency department service for street homeless people and the mental health

screening project in outpatients in Kings are just three examples.

n Our forensic services have established a chronic disease register for our medium and low secure patients.

This means that at a glance we know what serious physical health conditions our patients have. With this

predictor we can target the care given and focus resources on those most in need. Supporting patients to

make healthy lifestyle choices is built into the therapeutic programme.

n In March 2014, our forensic in-patient services at River House celebrated a year of being smoke-free in all

in-patient clinical areas. These were the first services in the Trust to do so. Despite the challenges, this has

been a huge success and has heavily influenced the development of the NICE guidance on smoking in

secondary care (published in November 2013).

n Our addictions services have established ‘recovery progress check-ups’ where patients whose benefit of

treatment is less than should be achieved, are given special MOT-test scrutiny to try to find out how to

improve their recovery gains.

n The Affective Disorders Recovery Unit team was a finalist in the BMJ Mental Health team of the

Year award. The Head of the Unit won the NHS Quality Champion/Innovator of the year award

at the Leadership recognition awards 2013 for developing the first Cognitive Behavioural Therapy

compassionate focused community service to treat Obsessive Compulsive Disorder, and Body

Dysmorphic Disorder.

n We have begun a Street Triage pilot in Lambeth. This is a collaborative initiative with the Metropolitan

Police and provides a 24 hours helpline for Police Officers with the option of a second level face to

face contact with a SLaM clinician if necessary. The project aims to reduce the use of Section 136 of

the Mental Health Act, and support Police Officers on the ground to manage people with mental

health problems.

n In the borough of Lewisham we are developing a dedicated team to support older patients in care

homes through providing consultation and support to the care home staff and GP services. The service

is designed to teach care staff in these settings to manage residents with dementia and other mental

health problems and avoid unnecessary referral and admission to hospital. Plans are afoot to extend this

development into Lambeth, Southwark and Croydon.


…..and what we can do better.

n Because of demands on our services leading to high bed occupancy levels, some of our patients have

to be admitted to overspill beds managed by private sector organisations and other NHS Trusts and FTs.

We recognise that this is not ideal and may have an impact on patient’s safety, clinical outcome and the

level of satisfaction patients and carers have with their care and treatment. In 2014/15 we aim to put a

stop to this practice.

n Violence and aggression remains a threat to the safety of patients and staff on our in-patient units.

In 2014/15 we will be doing more to help patients feel safer, by continuing to press forward with

our violence reduction strategy which includes a range of evidence based intervention that are being

embedded in to practice.

n Our patient survey results show clearly that many patients are unable to access the support and advice

they need to quickly when in a crisis or emergency. We will be taking steps to improve access to good

quality advice and support.

n People with mental illness are more likely to suffer from serious diseases such as diabetes and coronary

artery disease. We will be continuing to taking steps to improve the routine physical health screening of

patients with a serious mental illness.

n Helping to stop people smoking is a national health priority. The Trust is moving to having a totally smoke

free environment for patients and staff in November 2014. In order to achieve this we are improving the

availability of advice and support and nicotine replacement therapy available to patient who smoke, both

in the community and when admitted to hospital.

n We can improve the quality of our in-patient environments. A recurring theme of CQC inspections in

2013/14 was that clinical environments were not always up to the standards that patients should expect.

All these have been translated into quality priorities for 2014/15.


Part 2:

Priorities for Improvement and statements of assurance from the Board

2.1 Our priorities for improvement for 2014/2015

Over the past year we have listened to feedback from service users, their families and carers, our staff,

as well as commissioners and regulators, this has helped us to identify our future priorities. This process of

gathering feedback has included:

n Listening to questions, concerns and complaints from patients and their families and carers

n Listening to service users and carers at Trust Wide and borough based events

n Receiving reports on our services from the Care Quality Commission, following inspections of our services

n Listening to the views of commissioners at contract quality and serious incident monitoring meetings

n Listening to the views of the Health Overview and Scrutiny Committees of Lambeth, Southwark,

Lewisham and Croydon

n Listening to the views of Healthwatch in each of our four main boroughs

n Reviewing audit results, research findings, service reviews and assessments and service user surveys

n Continuing discussions with a quality working group of the Council of Governors which has looked

at quality issues over the year

n We have also reviewed national guidance and service quality themes and issues which are

emerging nationally

In addition we have been mindful of the work that we have done so far to improve the quality of our

services and our desire to build upon what has been done so far.

In consulting and agreeing on our quality priorities for next year we have taking into account a number of

national frameworks and guidance, and local priorities on quality including:

n The national Mental Health Strategy – ‘No Health Without Mental Health’

n The Francis Report into the failing at Mid Staffordshire NHT FT, and the government response to the

Francis report

n The Commissioning for Quality and Innovation framework [CQUIN]

n Quality schedules in our contracts with Clinical Commissioning Groups

n The Trust Equality Objectives 2013-16

The priorities for 2014/2015 which are set out below have been arranged under the three broad headings

which put together provide the national definition of quality in NHS services: patient safety, clinical

effectiveness, and patient experience.


Our Quality Priorities for 2014/15

1. Patient Safety Priority This priority continues from previous years

Quality

Priority

Violence and aggression on in-patient wards continues to be a challenge to ensuring

that all patients benefit from a safe and therapeutic stay in hospital.

Our quality priority this year is to work to increase the number of patients who

feel safer when in our hospitals. This is our top clinical Risk, there is a new

National strategy, and new NICE clinical guideline imminent.

Target Our target is to Increase the number of people who when asked say they feel

safe in our services. Target >90% of patients feel safe.

Measure We will measure this by asking the questions in our patient surveys;

“Do you feel safe?” The question will also be asked as an element of the MH safety

thermometer. We will also measure the number of teams who are actively adopting

the Care Delivery system .

How we will achieve this

We will continue to push forward with our violence reduction strategy.

We will adopt the care delivery system (CDS) in all in-patient areas to reduce

violence and aggression on in-patient units (all wards over two years)

2. Patient Experience Priority This priority continues from previous years

Quality

Priority

We will improve the quality of the environments within our in-patient wards.

This priority was identified following and CQC inspectors comments about the

environments on some in-patient units in 2013/14.

Target Improvement in environmental PLACE audit scores by 5% in 14/15 across all

in-patient areas.

Measure PLACE - Patient Led Assessments of Care Environments. We will also monitor the

progress against the plan to redecorate and refurbish wards.


We will refurbish six wards a year, of which at least two wards will be major

refits, the others being décor, and sanitary improvements. This is a five year

programme. We also plan a ward and department spring clean campaign for all

wards so that redundant furniture, unused equipment and unclaimed patient

belongings can be removed.


3. Patient Experience Priority This priority continues from previous years

Quality

Priority

We will ensure that all patients receive individual service at medication and

mealtimes when in hospital. This priority was identified through patient feedback

and the SLaM privacy and dignity strategy work.

Target No patient will queue for medication or meals when in hospital.

Measure We will measure this by observation audits of practice on in-patient units.


Review and design of ward processes. Each Clinical Academic Group CAG will CAG

produce their own plans about how this change in practice will be maintained.

4. Clinical Effectiveness Priority This priority continues from previous years

Quality

Priority

We will continue to improve our screening of patients for cardio-vascular and

metabolic disease. This is a NICE guideline requirement, and a continuation of the

CQUIN work during 2013/14. This target will now include patients with bi-polar

mood disorders as well as schizoaffective disorders.

Target 90% of eligible patient (patients with psychosis, bi-polar illnesses and all in-patients)

six key cardio metabolic test results recorded for:

n Smoking status

n Lifestyle (including exercise and diet)

n Body Mass Index

n Blood pressure

n Blood Glucose

n Blood lipids.

Measure We will measure this through a process similar to the 13/14 National Audit of

Schizophrenia, on cardio metabolic risk factors in patients with schizophrenia.

A mini audit in June will give us a baseline to work from.


We plan to have additional nursing support for ‘catch up’ clinics (for physical health

screening). We are providing more education and training opportunities for staff.

We have produced physical health leaflets for patients, and will be feeding back

performance against the target to clinical staff.



Quality

Priority

We will help patients to quit smoking and move to no smoking across all Trust

sites and in all clinical environments by November 2014.

Target We will record the smoking status of 85% of all patients seen. 50% of smokers will

be offered nicotine replacement therapy or counselling.

Measure Number of patient whose smoking status is recorded. Number offered intervention.

Take up of NRT, and psychological interventions.


We plan a programme of activity over the summer in preparation for the total

smoking ban on all Trusts sites. This includes 121 training at level 1, and level 2,

and a level 1 e-learning package, a practice guide for clinical staff and a revised

HR staff smoking policy.


Quality

Priority

We will improve GP access to SLaM assessments, so that more patients are seen

quicker for first assessment at home and in the GP surgery. The priority has been

identified through patient feedback, and is a part of our Easy In Easy Out Strategy,

in Lambeth and Lewisham.

Target Our target is to see 20% more patients for first assessment in GP surgeries and at

home than in 2013/14.

Measure We will measure this by extracting data on patient assessments from our health

records system.


GPs will be able to discuss and make referrals during surgery hours. This will

improve access between 5-7 p.m. each week-day evening and Saturday mornings.


7. Patient Safety Priority This is a new priority for 2014/15

Quality

Priority

We will stop the transfer of acute patients to private sector hospital beds

outside the Trust. There are clinical risks associated with this practice.

Feedback from patients is that most patients prefer to stay in SLaM wards.

Target Our target is that by end of June no more than six PICU patients will be in overspill

placements and that, no more than two general AMH patients will be in overspill

placements. This position will be held throughout 2014.

Measure We will measure the number of patients transferred to acute overspill beds outside

the Trust.


We will to improve acute bed management by; temporary in-house overspill bed

provision, a bed management control centre, more senior clinical involvement in

admission decisions, and the Adult Mental Health transformation project which is

focussing on creating more capacity in community teams.

8. Patient Safety Priority This priority continues from last year

Quality

Priority

We will make it easier for patients to access help in a crisis. No one should

experience being turned away when in a crisis. This priority has been identified as

a theme from patient feedback.

Target Target is that at least 70% of all community patients asked will respond positively

to this survey question ‘Have you been able to access help when in a crisis?’.

Measure We will measure this by asking patients about their experience, in the form

of surveys.


Will we work to increase the capability of our community services to be able to

respond to patients in crisis, this will include a review the function and capability of

our Home Treatment Teams.


9. Patient Experience Priority This priority continues from last year

Quality

Priority

We will improve the way we involve patients and their carers in their care planning

and make sure patients understand their care plans. Patient survey finding. This is

also a CQUIN target, (commissioning for quality and innovation).

Target Target - at least 80% of all adult patients will have been encouraged to co-produce

their care plans with staff.

Measure We will measure this by extracting data from our health records system.

We will also conduct an audit of the quality of these care plans.


We will do this by providing training and publicity for clinical staff, and feedback

of performance throughout the year.


2.2 Statements of assurance from the Board

2.2.1. During 2013/14 the South London and Maudsley NHS Foundation Trust provided a broad spectrum

of mental health and addictions services. At the end of the year there were 238 clinical teams

providing in-patient, out-patient, community and liaison services (which are based in our partner

acute Trust hospitals; Guy’s and St Thomas’, King’s College Hospital, Lewisham University Hospital

and Croydon University Hospital). Our services are structured into seven Clinical Academic Groups:

Psychosis services, Psychological Medicine, Mood Anxiety and Personality Disorders (MAP), Behaviour

and Developmental services (BDP), Mental Health in Older Adults and \Dementia (MHOAD), Child and

Adolescent Services (CAMHS), and Addiction services.

The Trust Board has reviewed all the relevant data available to them on the quality of care in all these

services.

The income generated by the NHS services reviewed in 2013/14, represents 100% of the total

income generated by the provision of NHS services by the South London and Maudsley NHS

Foundation Trust for 2013/14.

2.2.2 Participation in National Quality Improvement Programmes

National quality accreditation schemes, and national clinical audit programmes are important for

a number of reasons. They provide a way of comparing our services and practice with other Trusts

across the country, they provide assurances that our services are meeting the highest standards set by

the professional bodies, and they also provides a framework for quality improvement for participating

services.

During 2013/14, five national clinical audits and two national confidential enquiries covered NHS

services that the South London and Maudsley NHS Foundation Trust provides.

During that period SLaM participated in 100% of national clinical audits and 100% of national

confidential enquiries of the national clinical audits and national confidential enquiries which it

was eligible to participate in.

The national clinical audits and national confidential enquiries that the SLaM was eligible to

participate in during 2013/14 are listed below:

n The national audit of schizophrenia

n The 4 national, Prescribing Observatory for Mental Health - POMH-UK audits:

i. Monitoring of patients prescribed lithium

ii. Anti-psychotics in dementia

iii. Prescribing for ADHD

iv. Anti-dementia drugs

n The national confidential enquiry into suicide and homicide by people with mental illness

n The national confidential inquiry into maternal and child deaths


The national clinical audits and national confidential enquiries that the SLAM participated in,

for which data collection was completed during 2013/14, are listed below.

Participation in the National Audit of Schizophrenia

Number of cases Number of Percentage submitted by SLAM cases required returned

Clinician questionnaire 87 100 87%

POMH-UK audits

Participation in the four Prescribing Observatory (POMH-UK) managed by the

Royal College of Psychiatrist’s Centre for Quality Improvement

SLAM pharmacy has collected and submitted data for the 2012-13 POMH-UK audits, as required.

i. Monitoring of patients prescribed lithium.

ii. Anti-psychotics in dementia

iii. Prescribing for ADHD

iv. Use of anti-dementia drugs

Below is a summary of the findings from those audits:

i) Monitoring of patients prescribed lithium

Results of the June 2013 audit showed an overall improvement in the physical health and plasma level

monitoring for patients prescribed lithium. Monitoring of renal and thyroid function was found to be

better in SLAM than in the national sample. The improvement in monitoring followed a programme in

January 2013 in which pharmacy identified all trust patients prescribed lithium and ordered directly from

phlebotomy any outstanding blood tests for these patients.

ii) Anti-psychotics in dementia

Results of the October 2012 audit showed an increase in the proportion of patients in SLAM, with a

diagnosis of dementia, prescribed an antipsychotic (14% vs 7% in 2011 audit). The rate of prescribing

of antipsychotics in SLAM was comparable to the national sample. The audit in 2011 included only in-

patients. In 2012 data were collected for all SLAM patients (including those in community continuing care

teams), which may in part explain the difference in prescribing practices.

The Mental Health of Older Adults and Dementia CAG has introduced a plan to ensure appropriate

prescribing of antipsychotics for patients with dementia. The health record ‘events’ section will in future

provide prompts for the assessment and monitoring of patients prescribed an antipsychotic. This will be

re-audited in 2015.

iii) Prescribing for ADHD

Patients prescribed medication for ADHD should have their physical health (weight, height, blood pressure

and heart rate) monitored on initiation of medication and at least every 6 months after initiation of

medication. Results of the March 2013 audit showed that only 60% of patients prescribed medication for

ADHD had evidence in the health record of the recommended physical health monitoring. This compares

to the total national sample mean of 79%. An improvement programme produced by pharmacy and the

service will be implemented in 2014/15.


iv) Use of anti-dementia drugs

Data have been submitted to POMH-UK. Results are expected later in 2014.

Result received in 2013/14 from data collected in 2012/13

The National Audit of Psychological Therapies

The National Audit of Psychological therapies published its second report in December 2013 and the results

were reviewed with the MAP CAG Executive team in January 2014. The summary feedback in the Trust

level report demonstrated that SLaM performed in the middle range on most of the key standards. Six

SLAM teams participated and 3472 cases were submitted. Areas where we performed better compared

with the national sample included:

i) A person who is assessed as requiring psychological therapy does not wait longer than 18 weeks from

the time at which the initial referral is received to the time that treatment starts.

SLAM score: 98% vs. Total national sample 91%

ii) The therapy provided is in line with that recommended by the NICE guideline for the service user’s

condition/problem


In terms of service user experience, we performed similar to the national sample:

iii) Service users report a high level of satisfaction with the treatment that they receive.

SLAM: Access 82% & Experience 81% vs. Total national sample: Access 82% Experience 80%

Areas our Trust did less well compared to the national sample were:

iv) Treatment for high intensity psychological therapy is continued until recovery or for at least the

minimum number of sessions recommended by the NICE guideline for the service user’s condition/

problem.


iv) Therapists are delivering therapy under supervision and have received formal training to undertake

the therapy.


The majority of responses in this category were from our IAPT services, which provide psychological

therapies in primary care. The NICE guidelines address psychological service in secondary care where

more sessions are usually indicated. We will review this provision in 2015 and also the level of supervision

opportunities available to our therapists.


Trust Clinical Audit Programme

The reports of 33 local Trust wide clinical audits were reviewed by our Quality Governance Committee in

2013/14 and a number of actions have been taken to improve the quality of health care provided. Here are

descriptions of four of them:

n Suicide Prevention - following publication of a review of SLAM suicides in August 2013, a suicide

prevention working party was convened and action plan developed. A literature search of international

suicide prevention research was conducted and there are plans to develop small pilots of high impact

interventions in community and inpatient settings in 2014/15. The SLAM suicide prevention strategy

has been reviewed and now includes training for staff, reviewing care pathways (e.g. crisis care,

affective disorders and personality disorders) to ensure better detection and management of suicide risk,

improving access to dual diagnosis (drug users with mental illness) workers in Assessment and Treatment

Teams and implementation of NICE guidelines for long term management of self harm.

n Rights of Informal Patients - Following an audit on the rights of informal patients, a new Mental

Health Act practice note (no.9) offering guidance to staff, was drafted and circulated to all staff.

A summary of the audit findings and recommendations to teams was also sent trust wide encouraging

teams to; provide all informal patients with the ‘Being an Informal Patient leaflet’ and document

discussions about rights in health records, to clearly display the Informal Patient Poster in an accessible

way for patients on wards, and include the Leave for Informal Patients Policy in the local induction for

all staff. These and other recommendations will be evaluated in a re-audit in June 2014.

n Nutrition - A Mealtime Standards working group have undertaken a number of actions since the

Nutrition audit was reported in October 2013. Ordering guidelines are being developed and is work

being carried out on computerised ordering so as to simplify the process. The menu is currently under

review. The menu will be displayed for the week in addition to the menu on the day. The new nutrition

screen has been added to the health record which now includes cultural, religious and health related

needs. Nutrition screening/care planning training has been delivered to wards starting in February 2014.

n Do not Attempt Resuscitate Decisions - following the audit, a patient information leaflet on

cardio-pulmonary resuscitation (CPR) decisions for patients, carers and relatives has been produced.

Patients participating in research

The number of patients receiving relevant health services provided by SLaM in 2013/14 that were recruited

during that period to participate in research approved by a research ethics committee was 3603.

Commissioning for Quality and Innovation

1.7% of SLaM income in 2013/14 was conditional on achieving quality improvement and innovation goals

agreed between SLaM and any person they entered into an agreement with for the provision of relevant

health services, through the Commissioning for Quality and Innovation payment framework. The value of

these payments for 2013/14 was £6m.

Further detail of the agreed goals for 2014/15 and for the following 12 month period are available on the

SLaM website.


Care Quality Commission CQC

SLaM is required to be registered with the CQC and its current registration status is registered, without

condition. The CQC has not taken enforcement action against SLaM during the period 2014/15.

CQC reports of inspections of SLaM services in 2013/14 can be found on the CQC website.

SLaM has participated in a special review of admissions and assessment arrangements in 2014/15.

SLaM intends to take the following action to address the conclusions or requirements reported by the CQC.

n With our Local Authorities we have introduced a letter to patients with guidance on applying to the

County Court for a nearest relative

n We are reviewing our arrangements for interpreting services

n In-patient wards have been asked to display the ‘Informal Patient’ poster which explains the rights

of informal patients

n We are exploring how to ensure that out of area patients admitted to the Bethlem Hospital can be

provided with an Independent Mental Health Advocacy (IMHA) service

Hospital Episode Statistics Data - HES

SLaM submitted records during 2014/15 to the Secondary Users services for inclusion in the Hospital

Episode Statistics which are included in the latest published data.

In-Patients - SUS data Out-patients and Community - MHMDS

NHS No 99.1% 99.5%

GP Practice code 99.8% 98.8%

Table 1. The percentage of records relating to patient care which included the patient’s NHS No and GP practice code

Information Governance

SLaM’s information governance assessment report overall score for 2013/14 was, 91% and was graded

green/satisfactory.

Payment by Results Clinical Coding

SLaM was not subject to payment by results clinical coding audit by the Audit Commission during the

2013/2014 financial year. However there is focus to improve the completeness and accuracy of the

Mental Health Clustering Tool which may become the payment by results currency in mental health.”

Improving Data Quality

SLaM will be taking the following actions to improve data quality:

n Key data items are routinely monitored and clinical services are held account at monthly performance

management meetings

n Email alerts have been introduced to alert clinical care coordinators where key clinical items are below

expected performance

n The clinical system will be developed to display visually alerts to clinicians and administrators

n Management Information Dashboards will be introduced to give better visibility of key clinical

indicators within the organisation.


2.2.3. National indicators 2013/2014

NHS Outcome Framework Indicators

SLaM is required to report performance against the following indicators under the terms

of the National NHS Outcomes Framework:

1. Care Programme Approach (CPA) 7 day follow-up

2. Access to Crisis Resolution Home Treatment (Home Treatment Team)

3. Re-admission to hospital with 28 days of discharge

4. Service Users Experience of Health and Social Care Staff

5. Patient safety incidents resulting in severe harm or death

1. Care Programme Approach (CPA) 7 day follow-up

Follow up within seven days of discharge from hospital has been demonstrated to be an effective way of

reducing the overall rate of death by suicide in the UK. Patients on the care programme approach (CPA)

who are discharged from a spell of inpatient care should be seen within seven days.

7 Day Follow-up

SLaM2011/12

SLaM 2012/13

SLAM 13/14

National Average 13/14

National Target13/14

Highest Trust % or Score13/14

LowestTrust % or Score13/14

CPA – 7 day follow-up 96.3% 96.8% 96.94% 98.32% 95% 100% 93%

Table 2. Seven day follow-up

2. Access to Crisis Resolution Home Treatment (Home Treatment Team)

Home treatment teams provide intensive support for people in mental health crisis, in their own home.

Home Treatment is designed to prevent hospital admissions and give support to families and carers.

The numerator here is the percentage of admissions to the Trust’s acute wards that were assessed by

the crisis resolution home treatment teams prior to admission.

Access to crisis resolution

SLaM2011/12

SLaM 2012/13

SLAM 13/14

National Average 13/14

National Target13/14



Number of admissions to acute wards that were gate kept by the CRHT teams

98.4% 99.4% 94.12% 97.26% 95% 100% 82.8%

Table 3. Access to crisis resolution


SLaM considers that this data is as described for the following reasons:

The fall in the percentage from 99.4% in 2012/13 to 94.12% in 2013/14 can be explained by that fact

that the Trust has changed the way this this performance is calculated, by using the Monitor definitions and

excluding exemptions previously applied. The under performance in Q1 is due to the transition in moving

from the old Trust definition to being fully compliant with the Monitor definition. Note that Psychiatric

Liaison Nurse assessments of patients in Emergency Departments are included in the gatekeeping

performance figures.

SLaM intends to take the following actions to improve this percentage, and so the quality of its services:

By enhancing staffing level in our home treatment teams, and by transforming our adult mental health

acute care pathway with the aim of ensuring that all admissions to in-patients beds are through Home

Treatment Teams.

3. Readmissions to hospital within 28 days of discharge

Re-admissions SLaM2011/12

SLaM 2012/13

SLAM 13/14

Patients readmitted to hospital within 28 days of being discharged

5.1% 5.4% 5.8%

Table 4. Re-admissions within 28 days – adult acute patients only

SLaM considers that this data is described for the following reasons:

5.8% of adult mental health patients admitted to acute hospital units were readmitted within 28 days of

discharge. This equates to 238 patients from a total number admitted in the year of 4099.


Our adult mental health service transformation project is designed to prevent relapse and catch patients

who are relapsing earlier. We will do this be provide training in relapse prevent to community staff and

investing more in our community teams to ensure they have the capacity to work proactively with all

patients on supporting their recovery.


4. Service Users Experience of Health and Social Care Staff

SLaM 2012/13

SLAM 13/14



Service users experience of Health and Social Care Staff

8.5 8.7 9.0 8.0

Table 5. Patient survey scores


The patient survey responses to the question of how users of services found the health and social care staff

of the Trust show that in 2013, overall SLAM scores were slightly higher compared to other mental health

Trusts. The average Health and Social Care Worker section score for SLAM patients was 8.7 with other

Trusts performing in a range of 8.0 to 9.0. This is a small increase from the 2012 SLAM responses which

gave an average score for this section of 8.5.

Survey of people who use community mental health services 2013



Survey of people who use community mental health services 2013


Health and Social Care Workers

Our performance against the patient survey questions relating to Health and Social Care workers was in the

mid range and slightly higher than average compared with other mental health trusts.


SLAM intends to strengthen the ‘culture of compassion’ and thus drive improved scores in this area in

2014/15 is to further promote and market the SLAM ‘Five Commitments’ which are paramount to building

mutual and respectful relationships with staff and service users. The five commitments are:

n be caring, kind and polite

n be prompt and value your time

n take time to listen to you

n be honest and direct with you

n do what I say I am going to do

These SLAM Five Commitments to provide a quality service are being embedded throughout the

organisation in the following ways. These have been part of the appraisal process since April 2013 and are

also advertised on doors and corridors. There is a plan to refer to the Five Commitments in the Friends &

Family test that is being introduced for staff, and the 360o feedback process, which is being introduced to

make managers better at giving and receiving feedback, will also include the question ‘Does your manager

live the Five Commitments?’ The Five Commitments are also being added to the Health Care Assistant code

of conduct to show what is expected in practice.

Another key challenge as highlighted in the Francis Report is to ensure that the organisation, CAGs,

teams and individuals within it, are supported by positive working relationships, staff support systems,

organisation factors, and strong senior leadership. In 2014/15 the Trust is undertaking a range of activities

to improve staff engagement including: implementation of the Professional Practice Model Nursing

Portfolio to ensure SLAM nurses feel supported, engaged with and able to develop professionally with us.


This portfolio is a tool to use in everyday practice to support and enable nurses to actively reflect on and

continually improve their practice.

More detail on the results of the staff survey can be found on page xx.

5. Patient safety incidents resulting in severe harm or death

The Trust records all reported incidents on a database, in order to support the management of, monitoring

and learning from all types of untoward incident. In addition patient safety incidents are uploaded to

the National Reporting and Learning Service (NRLS) for further monitoring and inter-Trust comparisons.

The NRLS system enables patient safety incident reports to be submitted to a national database which is

designed to promote understanding and learning.

During 2013/2014 there were 6686 incidents reported by the Trust fitting the NRLS criteria for a patient

safety incident. Of these 68 (1.0%) are expected to be categorised as ‘severe harm’ and a further 34

(0.5%) as deaths.

The process of reporting Trust data to the NRLS and NRLS publication of national data is retrospective by

nature. NRLS publication of 2013/14 benchmarking data is not expected to be complete until October

2014. The latest available benchmarked data is for period Q1-Q2 2012/13. For this period SLaM reported:

NRLS Data Q1-Q2 13/14SLAM 13/14

Average for Mental Health Trusts

Highest Trust % or Score 13/14

LowestTrust % or Score 13/14

Reported Incidents per 1000 bed days

18.4 26.8 99.8 0

Percentage of incidents resulting in severe harm

0.9% 0.5% 1.8% 0%

Percentage of incidents reported as deaths

0.3% 0.8% 4.5% 0%

Table 6. NRLS data on reported incidents

SLAM had a slightly lower rate of incident reporting per 1000 bed days and combined percentage of

severe harm or death incidents in 2013/14 compared to other MH trusts. There were no ‘Never Events’

[DH, 2010] reported by the Trust in 2013/14. Never Events are serious, largely preventable patient safety

incidents that should not occur if the available preventative measures have been implemented.


As there is not a nationally established and regulated approach to reporting and categorising patient

safety incidents, different trusts may choose to apply different approaches and guidance to reporting,

categorisation and validation of patient safety incidents. The approach taken to determine the classification

of each incident, such as those ‘resulting in severe harm or death’, will often rely on clinical judgement. This

judgement may, acceptably, differ between professionals. In addition, the classification of the impact of an

incident may be subject to a potentially lengthy investigation which may result in the classification being

changed. This change may not be reported externally and the data held by a trust may not be the same as

that held by the NRLS. Therefore, it may be difficult to explain the differences between the data reported

by the Trusts as this may not be comparable.


Full reports can be found here http://www.nrls.npsa.nhs.uk

SLaM intends to take the following actions to improve this performance, and so the quality and safety of

its services:

n continue implementation of the national patient safety thermometer to encourage staff to report

categories of physical health incidents,

n review the policy on incident reporting and a communication plan to accompany the policy review, and

n improve the way that we feedback incident patterns and trends to clinical teams.

Monitor Risk Assessment Framework Indicators

SLaM is also required to report quarterly to Monitor (the Foundation Trust regulator) against a list of

published indicators which link to existing commitments and national priorities within the periodic

review 2013/2014. They are:

IndicatorOverall SLaM performance 2013/14

National Target

Percentage of patients seen with seven days after discharge from hospital

96.94% 95%

Percentage of patients who had a 12 month care review (patients on the Care Programme Approach - CPA)

96.90% 95%

Percentage of admissions to the Trust’s acute wards that were assessed by the crisis resolution home treatment teams prior to admission

94.12% 95%

Percentage of new patients with a diagnosis of psychosis who had Early Intervention service

100.00% 95%

Percentage of patients whose transfer of care (from hospital) was delayed

3.19% <7.5%

Data Completeness, Mental Health: identifiers -NHS Number, Date of Birth, Post Code, Gender, GP code, Commissioner code

97.00% 97%

Data Completeness, Mental Health: outcomes (for patients on CPA) - accommodation and employment status

50.00% 50%

Table 7. Monitor Risk Assessment Framework Indicators


Part 3

Review of quality performance

Review of progress made against last year’s quality priorities

Our 2013/2014 quality priorities were selected after consultations with stakeholders and staff from our

services. The following summarises progress made against each priority over the year.

Priority One - Helping patients in our hospitals feel safer

We recognise that for patients in our hospitals, it is crucial to their wellbeing and recovery that they feel

safe at all times. Violence and aggression in our in-patient services continues to remain a significant

obstacle to ensuring that all patients benefit from having a safe and therapeutic experience of in-patient

care. For 2013/14 we said we would embed simple, research proven interventions into the routine practice

of the ward to improve safety.

Target We said that in 2013/14 at least 90% of patients would respond positively to the question

“Do you feel safe on the ward?”

Measure Patient survey responses. There were 1698 responses to this question across the inpatient

services in 2013/14.

Headline 80.1% of patients responded positively to the question, “Do you feel safe on the ward”.

This is not significantly different to preceding years and is below the target of 90%.

There was variation by CAG and borough. Factors limiting improvements in this area include

increased numbers of patients detained under Mental Health Act, complaints regarding

property loss and ongoing implementation of our violence reduction strategy.

Chart 1. “Do you feel safe on the ward?” – Trustwide response


The following chart shows the responses of inpatients with different protected characteristics during

2013/14 to the question “Do you feel safe on the ward?”. The number in each bar is the sample size of

patients who disclosed a particular characteristic (demographic characteristic protected by the Equalities

Act 2010).

Chart 2. Patient Survey Scores ‘Do you feel safe on the ward?’

The proportion of positive responses was highest for inpatients aged ‘over 65’ and lowest for inpatients

with ‘other disabilities’.

Patients on Older Adults ward and Croydon Wards generally responded more positively to this question.

All Older Adults wards exceeded the target of 90% of patients feeling safe on the ward.

Croydon Triage ward hit the target of 90% and Gresham 1 and 2, came close to the target.

Croydon Lambeth Lewisham Southwark

MHOA and Dementia 91.7% 93.2% 92.1%

Psychological Medicine 90.2% 80.7% 84.7%

Psychosis 88.8% 78.1% 75.2% 74.3%

Total 89.4% 79.4% 81.2% 80.4%

Table 8. Do you feel safe on the ward?” 2013/14 – Response by CAG and borough (ward location).

Helping in-patients to feel safe will continue to be a quality priority during 2014/15. As well as pushing

forward with our violence reduction strategy and Care Delivery System, we will be exploring with patients

why they feel unsafe and taking action to improve.


Priority Two - Accessing support in a crisis

All patients should have a crisis plan which they can refer to for accessing support in a crisis.

A key component of the new Support and Recovery Care Plan is the Crisis Plan. Implementation of the

Recovery Model and training to clinical teams has ensured the crisis plan is developed jointly with service

users and that they receive a copy.

Target We said that in 2013/14 at least 60% of community patients would respond positively to the

question, “Have you been offered a crisis plan for emergency mental health situations?”

Measure Patient survey response data. There were 2903 responses to this question across community

services in 2013/14.

Headline 66.6% of patients responded positively to the question, “Have you been offered a crisis

plan for emergency mental health situations?” We have achieved this target. Next year we

will be focussing on whether patients are able to access help when in a crisis, that is a quality

priority for 2014/15.

The following chart shows the experience of outpatients with different protected characteristics during

2013/14 to the question “Have you been offered a crisis plan for emergency mental health situations?”.

Chart 3. Patient Survey Scores

The proportion of positive responses was highest for ‘Asian/Asian British’ and lowest outpatients aged

‘over 65’.

The low score for older people and patients with dementia is consistent with other survey scores for this

group where responses depend on recall of events and level of cognitive function and physical wellbeing.

Services are encouraged to ask family and carers to help patient respond to these questions. The data

presented here does not separate the patient’s responses from responses where family and carers

contributed.


Priority Three - Improve our screening for early detection of long term physical health conditions

More people with schizophrenia will develop cardio vascular disease and metabolic conditions (such as

diabetes) than the general population. Early detection of long term physical health conditions enables

interventions to reduce the risk and impact of these diseases. Interventions to improve physical health

care in 2013/14 have included working with SLaM clinical staff and GPs to improve clinical protocols,

feeding back performance to clinical staff, disseminating guidance in emails and posters, Pharmacy have

led an intervention into long-term inpatient checks and training has been delivered on recognising and

treating diabetes.

Target Quarterly targets rising to 75% of inpatients receiving all appropriate physical health

checks on admission.

Quarterly targets rising to 85% of long-term inpatients receiving lipid and glucose checks

within 4 months of admission.

Measure Records of screening on admission to include: glucose levels (or HbA1c), lipids, blood

pressure, ECG and weight. Recorded tests of glucose/HbA1c and lipids within 4 months

of admission for those patients admitted that length of time.

Headlines All quarterly targets were achieved for Adult Mental Health services. There was a

substantial increase in the number of inpatients receiving appropriate physical health

checks (e.g. 22% up to 92% receiving all tests on admission).

Chart 4. Physical Health Checks: New Admissions


Chart 5. Physical Health Checks: For patients prescribed anti-psychotic medication

This work will continue into 2014/15 as a quality priority, and incentivised by a refreshed CQUIN

programme and a broadening of the target patient group to include people with bi-polar mood disorders,

schizophrenia and schizoaffective disorders.


Priority Four – Helping patients to quit smoking. Offering nicotine replacement therapy or smoking cessation counselling

This target recognises the damage done by smoking tobacco. All Trusts sites will eventually become smoke

free and our quality priority was designed to support our smoke free strategy by helping patients to quit.

This year patients who were ready to quit were identified, supported, and offered nicotine replacement

therapy NRT or smoking cessation counselling. To support this, smoking cessation training was delivered to

clinical staff.

Target 85% of all patients will have their smoking status recorded.

60% of inpatients (>6 days in hospital) who smoke will be offered brief smoking

cessation intervention.

60% staff to do e-learning smoking cessation package.

Measure The number of inpatients whose smoking status has been assessed and recorded in the

Physical Health Screen.

The number identified as smoking who were offered intervention.

The number of staff trained to level 1

Headlines Audit of Quarters 3 and 4 found 80% of a random sample of inpatient admissions had

smoking status recorded in their clinical record - 56.7% recorded as part of the Physical

Health Screen.

Further samples found higher compliance where the physical health screen had been

completed:

- 100% of a sample of inpatients with physical health screens had smoking status recorded

- 86.7% community patients with a Physical Health Screen had smoking status recorded

Audit of Quarters 3 and 4 found 26.7% inpatients that smoke had the offer of brief

intervention recorded.

60.1% current eligible staff had completed smoking training by 31st March 2014

(48% level 1 e-learning, and 12% level 2/3 face to face training)

Performance against this quality priority fell short of the target in 2013/14. The Trust is committed

to being totally smoke free in all areas from 1st October 2014. Therefore this quality priority will be carried

forward into 2014/15. This year there will be a comprehensive programme to support the priority including

many more training opportunities for staff; at level 1, and level 2 smoking cessation, a level 1 e-learning

package, a practice guide for clinical staff, a revised HR staff smoking policy, and a group directive to enable

nursing staff to prescribe and administer nicotine replacement therapy products.


Priority Five - Family and friends test

Included in our inpatient surveys for 2013/14 will be the question “Would you recommend this service to

your family and friends?” This is known nationally as the Family and Friends test. We will be using the

results of the surveys to compare our services and make improvements to the experience that our patients

have of our hospitals

Target We said that in 2013/14 we would include the Family and Friends test in our inpatient

surveys, with a target to be set following review of Quarter 1 uptake. The responses to

this question were to inform comparison of services and local improvements to the

patient experience.

Measure Inclusion in inpatient surveys delivered during 2013/14.

Headline The Family and Friends test was piloted in one inpatient service, where improvements

were made to the delivery and wording of the question. The rollout to other services has

been delayed, partly in response to the Department of Health guidance, Closing the Gap:

Priorities for Essential Change in Mental Health, which postponed national implementation

to December 2014.

Of the local responses to the pilot project the average score was 2.6/5 ‘Neither likely nor

unlikely’. Comparison of scores between services was not possible due to the lack of

roll-out into other services.

A related measure of patient satisfaction was provided by the 2013 National Patient Survey. The response

to the overall item, “I had a very good experience” was 7.1 out of 10, which is the average national

score (range 6.6 to 7.6). When comparing SLaM’s overall performance against 20 Trusts with a similar

demography SLaM would have finished 5th, and 9th when compared against all the 58 mental health

Trusts nationally.

The friends and family test will be mandatory for all Mental Health NHS Trusts and FTs from April 2014.

All services will be expected to be conducting friends and family tests for patients by the end of 2014/15.

SLaM will be including a friends and family test question as one of its core patient survey questions, to be

included in all patient surveys.


Priority Six - Reviewing clinical outcomes scores to improve outcomes

The collection of clinical outcome data gives our clinical teams a great opportunity to look at their data and

compare it with other similar services to see if improvements in outcomes for patients can be made.

Target We said that 50% clinical teams would review their outcome data at least once during

2013/14.

Measure We said that we would measure this by the proportion of teams collecting outcomes data

which have had a dedicated session examining their outcomes and context data, including

comparison with similar teams in the Trust, during 2013/14.

Headlines We missed our target for 2013/14. There were 51 facilitated team reviews of outcome

scores in 2013/14, 21.4% of the 238 clinical teams in the Trust.

Chart 6. Number of clinical teams who had the benefit of a full review of their clinical outcome data by quarter – last two years 2012-14.

We will continue to encourage clinical teams to review their clinical outcome scores and

analyse and compare against other similar teams.


Priority Seven - Recovery and Support Care Plans

For many patients, the path to recovery is about identifying life goals and support mechanisms necessary

to achieve those goals. Good quality, recovery and support care plans can be essential to achieving those

goals and achievement plans. A quality priority this year was to support patients to develop their recovery

and support care plans using the new collaborative template (released December 2012). Roll-out was

supported by team-based training, intranet guidance and the introduction of the SLaM Recovery College.

Target We said that by Quarter 4 2013/14 at least 50% of CPA community patients would have

a completed Support and Recovery Plan.

Measure Number of CPA community patients in Adult Mental Health services with a completed

Recovery and Support Care Plan (in the correct template)

Headlines This target was achieved. There was improvement each quarter with 54% CPA community

patients having a completed Recovery and Support care plan by Quarter 4.

Chart 7. Completed Recovery and Support Care Plans, 2013/14


Priority Eight - Improving our standard of customer service

This target supports the principle of a ‘culture of compassion’ as recommended in the Francis Report. In

2013/14, we focused on reducing the number of complaints about staff attitude. Interventions included

customer service training, promotion of the 5 SLaM Commitments, RCN Leadership Program and

implementing the Privacy & Dignity policy.

Target Percentage of complaints regarding staff attitude to be under 20% of the total complaints

in all categories.

Measure The number of complaints in the category of staff attitude and behaviour as a proportion

of the total complaints received

Headline This target was achieved. The proportion of complaints received in the category staff

attitude/behaviour was maintained at or below 20% for each quarter of 2013/14.

The mean value for the year was 17.6%.

Chart 8. Proportion of complaints received in category ‘Staff Attitude and Behaviour ’

– by quarter 2013-14

Chart 9. Proportion of complaints received in category ‘Staff Attitude and Behaviour’

- last five years


Chart 10: Five most common categories of complaint, 2013/14

We recognise that the attitude and behaviour of our staff is a vital component in the delivery of

compassionate care. We will continue to ask patients for their feedback about staff and will

continue to ensure that we do everything we can to support staff in order that they are able to meet

the needs of patients.


Priority Nine - Focus groups and quality improvement plans

This year we held focus groups with patient representatives about the quality of service they receive.

Quality improvement plans were then produced for each borough to respond to concerns raised.

Target Hold patients focus groups in each borough. Produce service improvement action plans

as a result of focus groups. Implement action plans.

Measure Number of boroughs in which a focus group was held. Action plans produced in

response to focus groups for each borough. Action plans updated with progress

against implementation.

Headline Focus groups with Link Workers/Peer Support Workers were held in each borough and

reports from these submitted by the end of July 2013. Improvement plans were produced

by service managers in response to findings by the end of September 2013. All plans were

implemented and all improvements were completed by the end of March 2014.

This target was achieved.

Quarter 1

Four borough based focus groups were held, attended by either Link Workers or Peer Support Workers

– ‘Hear Us’ Link Workers gave feedback in Croydon, SLaM Link Workers in Lewisham, Lambeth and

Southwark Mind Workers in Southwark and Missing Link Peer Support Workers in Lambeth (there is

currently no Link Working Scheme in Lambeth)

The focus groups looked at five themes set by commissioners (Safety, Environment, Equity, Treatment and

Intervention and Respect and Dignity) and aimed to identify where wards were performing well and where

there they need to improve. Feedback from the focus groups was then grouped into themes and used as

the basis of each Borough’s Improvement Plans.

Quarter 2

All Ward Managers attended a Project Planning session run by the Nursing Directorate to look at their

Borough’s improvement plans and to share ideas on addressing the improvement areas.

Each ward (21 in total) was then required to submit their action plans, stating:

n How they were going to address the improvement area

n Who was responsible

n What was the deadline

n How they were going to measure their success.

The action plans were signed off by the appropriate Clinical Service Leader and submitted to

Commissioners by the end of quarter 2.


As part of this process, several wards successfully bid for over £90,000 from the SLaM CQUIN pot to

fund their improvement plans:

n Lewisham was awarded money to install Wi-Fi, reprint their discharge booklet and refurbish the

Ladywell café

n Southwark was awarded money to re-vamp ES1 garden space and to set up a discharge planning

group across all the wards using IPads to access up to date information on groups

n Croydon was awarded funds to purchase garden equipment

n Lambeth was awarded money to revamp Luther King and Nelson’s garden areas and set up gardening

groups in two more wards.

Quarter 3

On a monthly basis Wards submitted progress updates against their action plans to demonstrate the work

being undertaken and to ensure deadlines were achieved.

Link Workers and Peer Support Workers were asked to give informal feedback on how they felt wards

were addressing the improvement areas. This helped Ward Managers to identify any areas which needed

further work.

Quarter 4

Feedback sessions were run in each Borough with either Link Workers or Peer Support workers. The work

undertaken by Wards to address each of the five improvement areas was presented. The Link Workers/

Peer Support workers were then asked if they felt improvements had been made.

The feedback from these sessions has been very positive and there has been an acknowledgement that

things have improved over the past 12 months. Closer working relationships have been forged between

Ward Managers and their Link Workers/ Peer Support Workers. It has also acted as a stimulus for SLaM to

review the Link Working Scheme in Lewisham and pilot a scheme in Lambeth.


National patient survey of people who use community mental health services: SLAM report 2013

The national patient survey was returned by 199 SLAM patients giving a response rate of 24% which is just

below the national average for all mental health trusts of 29%.

Overall, SLAM’s results fell in the amber section in 7 out of the 8 sections of the survey meaning, our

results were ‘about the same’ as most other trusts in the survey. In the remaining ‘Medications’ section

we performed ‘better’ than the majority of trusts – our responses falling in the green section of the graph.

In the final ‘Overall’ section, SLAM performed ‘about the same’ as other trusts. In the graphics below

the Trust score is represented by a small diamond. If the score is placed in the amber section of the Red,

Amber, Green (RAG) rating then that result is considered ‘about the same’ as most other trusts. If the score

is in the red section of the RAG, the result is considered ‘worse’ than most other trusts and likewise if the

score is in the green section, the result is considered ‘better’ than most other trusts

Out of the 38 individual questions in the survey, the top ranking scores for SLaM compared to other mental

health trusts in England were found for the following questions:

Section 1. Health and Social Care Workers

Section 2. Medications

The following are the questions in which South London and Maudsley NHS foundation Trust was among

the worst performing Trusts:

Section 5. Care Plans

Section 7, Crisis Care

Section 8. Day to Day Living


Improvement Plans

The implementation and delivery of training on the Recovery Model and Support and Recovery care plans

in adult mental health, older adult and CAMHS services in 2014/15 and linked CQUIN targets for 14/15

will help drive improvements in care planning overall including improving our scores on the question of

whether NHS staff can help patients start achieving their recovery goals.

In terms of improvements to crisis care and improving our scores on the question of whether patients have

number of someone from NHS mental health service they can phone out of hours, this is being addressed

broadly through service redesign across Adult Mental Health Services (the AMH model) in 14/15 which

includes improving how patients can access mental health services in a crisis. In addition new SLAM patient

information leaflets on’ What to do in a mental health crisis’ have been published in February 2014 and

have been disseminated to teams. Performance and improvements in this area will also be monitored

closely throughout the following year as this measure of accessing services in a crisis is one of our 9 quality

account priorities for 14/15.

National Staff Survey 2013 - Results

This year a sample of 850 employees of Trust’s eligible workforce was asked to complete the survey.

The response rate to the survey was 309 staff which gave an overall response rate of 37%, a reduction on

the response rate of the previous year which was 49%.

Key Findings - overall Trust

The following are the top five ranking scores for the Trust compared to Mental Health Trusts in England:

Percentage of staff able to contribute towards improvements at work.

Trust Score: 75% National Average: 72%

Effective team working.


Percentage of staff reporting errors, near misses or incidents witnessed in the last month.


Percentage of staff receiving job-relevant training, learning or development in the last 12 months.


Percentage of staff feeling satisfied with the quality of work and patient care they are able to deliver.


The following are the lowest five ranking scores for the Trust compared to Mental Trusts in England:

Percentage of staff experiencing physical violence from staff in the last 12 months.


Percentage of staff experiencing discrimination at work in the last 12 months.



Percentage of staff working extra hours.


Percentage of staff experiencing harassment, bullying or abuse from patients, relatives or the public in the

last 12 months.


Percentage of staff having equality and diversity training in the last 12 months.


The following is the area where the experience of staff has improved on the previous annual survey:

Percentage of staff appraised in the last 12 months.

Trust Score 2013: 84% Trust Score 2012: 77%

Percentage of staff having equality and diversity training in the last 12 months.

Trust Score 2013: 45% Trust Score 2012: 36%

In addition, our Trust score for overall staff engagement was 3.74 (3.77 in 2012) compared to a score of

3.71 which was the national average for all mental health/learning disability Trusts.

From the 28 categories within the survey covering the four pledges, staff satisfaction and equality and

diversity, the following were reported:

n 2 categories remain unchanged from the previous year

n 15 categories were less positive than previous year

n 11 categories were more positive than previous year


AREAS FOR ACTION

A comprehensive Communications Plan will be developed to feedback the results of the survey. This will

include dissemination through SLaM News and the intranet with regular reminders about the importance

of appraisals and staff feedback.

Each CAG has been asked to develop an action plan in relation to the responses in the staff survey and

there will be regular updates on progress through the CAG HR Business Partners.

Areas of particular focus are violence and aggression towards our staff and discrimination at work. We will

continue to engage with the Prevention and Management of Violence and Aggression (PMVA) Group to

monitor and review our approaches to managing violence and aggression. In addition, Equality, Diversity

and Human Rights have been made a mandatory training requirement for staff.

It is noted that whilst the number of staff receiving an appraisal has increased, the quality of that appraisal

has diminished so ensuring appraisals are of a high quality will be of paramount importance. We will also

be working to ensure that staff have the opportunity to offer feedback about their work and the Trust, and

that the feedback provided is listened to and acted upon.

SLaM Equality Objectives 2013-16

Last year we worked in partnership with our service users, carers, staff, local communities and partner

organisations to review our equality performance and set the following equality objectives:

1. All SLaM service users have a say in their care

2. SLaM staff treat all service users and carers well and help them achieve the goals they set for their

recovery

3. All service users feel safe in SLaM services

4. Roll out and embed the Trust’s Five Commitments for all staff

5. Show leadership on equality through our communication and behaviour

Much of the work to been taken to achieve these objectives supports delivery of our quality priorities. You

can find more information about this work and how will monitor and report our progress on our website

at: SLaM Equality Objectives.


Annex 1

Statements from the Foundation Trust Board of Governors and local Health watch organisations

Council of Governor’s response to the Quality Accounts 2013/14

The Council of Governors and we as members of the Quality group in particular, appreciate the opportunity

to contribute to the development of Trust’s Quality Account. The Governors are involved in identifying the

quality priorities for 2014/15 and suggesting the local quality indicator for the assurance report. Several

of our observations and suggestions have already been included the Account’s final version which we

reviewed. A group of governors and the lead governor will also be meeting with the External Auditors to

obtain further independent view of the Account. The following comments are put forward as a perspective

drawn on lived experiences of the governors with an intention to enhance the reported statistics.

1. Overall the Account is considered to be an informative and objective summary of the Trust’s continuing

efforts to deliver quality improvements in all of its services. It is impressive that the Trust achieved the

majority of the set priorities given the enormous changes in the NHS commissioning landscape and the

general socio-economic climate. The Account evidences the Trust’s actions to prioritise the quality and

safety of the service it provides.

2. The Account brings out the fundamental importance of good quality data. The governors

acknowledged the complexities inherent in achieving robust quantifying data systems to evaluate the

quality of care that is provided by the Trust to its service user and their carers and the local population.

As governors we are aware of the importance of the data collection for the locally set Commissioning

for Quality and Innovation (CQUIN) targets as well as for the Trust’s licensing agreement and SLaM’s

own quality priorities. Among the governors, quantitative data collection is not equally accepted as

means of describing quality of care. Therefore, we suggest that alternative forms of regular feedback

are being considered to broaden the overall feedback base.

3. As governors we welcomed the invitation to influence the new quality priorities in collaboration the

main stakeholders on an involvement day. Arising from this work, the Trust has confirmed four new

quality priorities for development in 2014/15. Given the Trust’s focus on health care provision, it is

understandable that most quality priorities concern service-user-related targets. The Account includes

quality measures relating to staff satisfaction, however, carers’ experiences have not found their place

into new quality priorities nor the main body of the Account. We suggest, to allow for separation in

some of the interventions and evaluations offered to service users and carers.

4. The governors acknowledged the demonstrated successes in physical health monitoring on the

inpatient wards addressing existing inequalities in health care provisions. Considering that many SLaM

service users will be seeking physical health care in other King’s Health Partners CAGs, the governors

see an opportunity to integrate physical and mental health care in the upcoming years. Thus, instead of

superimposing physical health aspects, they become part of the underlying fabric. In this context, the

Quality Group is also awaiting the initiatives of valued based health care and commissioning which are

championed within the partnership.


5. The newly opened Recovery College has been celebrated as an educational opportunity for service user,

carers and staff alike. The governors have been observant of the interdependence of mental health

and social care and the availability of suitable environments supporting wellbeing and recovery. Joint

planning across organisations should ensure the availability of suitable accommodation and community

resources. This is of similar importance as the targeted improvement of the inpatient health care

environments the Trust provides. The governors recognise the value of peer support in both of these

environments.

6. The Account illustrates how the changing and significantly increasing demands on the Trust’s services

can influence quality performance. With the introduced service innovations, the governors welcome

the closer collaboration between mental health services and primary care. The governors hope that the

on-going Board level review of quality parameter will assure that the already achieved high standard

of health care is maintained for the service user, who will be more intensively supported by primary

care providers. We are confident that the already existing structures to promoting public and patient

involvement (EPIC) can further enhance this.

27th May 2014


Healthwatch Lambeth, Healthwatch Lewisham, Healthwatch Southwark joint response to South London and Maudsley NHS Foundation Trust’s Quality

Accounts for 2013/2014

1. General points

This is a joint response to the South London and Maudsley NHS Foundation Trust Quality Account 2013-14

from the Healthwatch organisations in Lambeth, Lewisham and Southwark.

The Trust has demonstrated they have involved Healthwatch in choosing the 2014/15 Quality Priorities

within the Quality Account and we agree that the priorities reflect the priorities of the local population.

We believe that there is still room for improvement in the way that the Trust involves patients and the

public in the production of the Accounts. Last year we said that we would welcome the production of

a Service User Involvement Policy in 2013-14 and whilst we appreciate that a review Patient and Public

Involvement Review has taken place in the last few months the Trust has still not made this a reality.

Though the amount of information in the QA is vast and we recognise the difficulties in getting all

information ready to send out stakeholders we would appreciate more detail in the drafts that are sent to

us to comment on.

We agree that the Quality Account is a fair reflection of the healthcare services provided by SLaM and that

it is a representative account of the full range of services provided. As we said last year we would also

like to see the report in an easy to read & plain English versions of the document as this may increase the

number of people who read the report. We are keen to continue meeting and liaising with the Trust to

monitor the quality of your services especially in light of the Francis Report.

2. Review of 2013-14 Priorities

One - patients feeling safer

It is noted that 80.1% responded positively to the question about feeling safe which is below the target of

90%. We are pleased that SLaM is carrying over this priority into 2014-15.

Two - Accessing Support in a crisis

The results of 66.6% of people responding to the survey with a target of 60% is good and the provision of

a breakdown of respondents by most of the protected characteristics is useful

Three - Improve screening for early detection of long term physical health conditions.

With there being an increased focus on the parity of esteem regarding mental health and physical health

and an increase in the number of ‘all the tests’ over 2013/14. It will be useful to know the outcome of

these health checks for the patients.

Four - Helping patients to quit smoking

We are pleased that the Trust has been successful with the smoke- free pilot to support people to quit

smoking and note the difficulties around implementing this. As illnesses caused by smoking are prevalent in

our boroughs this issue is of great concern. It is good news that this is continuing as a 2014-15 priority.


Five - Family and Friends Test

We note the difficulties with this, as it has not been rolled out to all areas and look forward to seeing future

scores.

Six - Reviewing Clinical outcomes scores to improve outcomes

It is disappointing that only 21.4% out of the targeted 50% clinical teams reviewed outcome scores. We

would recommend this be improved for 2014-15 though we note that it is not a priority for 2014-15.

Seven - recovery and Support Care Plans

We raised issues regarding care plans last year and are pleased that the target has been met and that this

is a priority for this year with the focus being on co- produced care plans; both with service users, families,

carers and staff.

Eight - Improving our standard of customer service

We are pleased that the target was met and would like to meet with staff to discuss the breakdown of

complaints by categories.

Nine - Focus groups and quality improvement plans

We congratulate the Trust with the progress on the focus groups and the funding that was awarded to the

services in the different boroughs.


3. Comments on 2014/15 priorities

We applaud the commitment to increase the number of patients who feel safe. From talking to people

who use inpatient services, we found that people feel safer in some wards than others and that in some

cases people tell us that it is other patients that contribute to not feeling safe. It is important that patients

have access to independent, confidential support to express any safety concerns they may have. All staff,

permanent and temporary should have a compassionate nature.

We note some problems with staff motivation and that the culture of compassion is difficult to mandate

however, we welcome the Trust’s intention to strengthen the ‘culture of compassion’. Healthwatch would

like to see the SLAM Five Commitments advertised throughout the clinical sites as they were not seen

during recent visits to the Ladywell unit. We recommend that staff contracts should contain a clause

specifying the Trust’s commitment to providing safe and effective care and staff requirements to upholding

this commitment. It would be useful to obtain information on the turnover of their SLaM staff to gain an

understanding on whether this is linked to what service users have said about their satisfaction rates.

The priority to stop using private sector hospital beds is welcome. Patients tell us they prefer to stay local

to their home environment where friends and family can visit. They also tell us that they want to be kept

informed of where they will be staying. Our concern is capacity to ensure people get the support they need.

We would also like to see local children being cared for locally and not outside of London unless absolutely

needed i.e. local services not specialist enough.

For ease of read are collective ‘we’ statements are below. We….

n Are interested in the Street Triage pilot in Lambeth and look forward to this service being available in

Lewisham and Southwark.

n Support the Trust’s aim to improve access to good quality advice and support in crisis or emergency

situations.

n Agree with the priority to support patients to improve their physical health by improving health screening

and information. Patients have told Healthwatch Lewisham that they make use of the gym at the

Ladywell Unit. We recommend that the garden area may benefit from an outside gym.

n Welcome improved access to primary care and improved communication between the Trust and GP’s and

would like initiatives to be run across the three boroughs. In addition to this, Healthwatch Lambeth and

Southwark looks forward to SLaM’s progress with the Southwark & Lambeth Integrated Care Programme.

n Hope the lessons learnt on the pilot of the smoke free policy will be useful when it is rolled out to the

Ladywell Unit and other clinical areas.

n Agree with the priority to improve the quality of the environments within our in-patient wards.

The decor of the Ladywell Unit on the whole urgently needs improving. The choice of colours is not

mentally uplifting at all. This also reflects some of the recommendations that Healthwatch Lambeth

and Southwark gave following a visit to Aubrey Lewis 1 ward whereby we said that patient rooms

were quite blandly decorated.

n Would have liked to see a priority regarding children and young people’s services in all the boroughs as

there is very little information in the Account about CAMHS. In particular Healthwatch Lewisham is aware

that parents and carers say that there are appointment access issues for CAMHS in the borough

in particular, autism support services.

n Agree that recovery and support care plans should be a priority for this year with the focus being on

co- produced care plans; both with service users, families, carers and staff.

n Would also like to see improvement in recording incidents and safeguarding procedures.


Additional points

Generally we are impressed with the increase in the number of information leaflets made available to

patients across the Trust. We also congratulate the Trust for successes that have been achieved. Further

down we have provided comments on the review of 2013-14 priorities and the new 2014/15 priorities.

The Quality Account shows the proportion of SLAM patients with a diagnosis of dementia were twice as

likely to be on anti-psychotic medication in the October 2012 audit than 2011 (14% compared with 7%).

Community patients were included in 2012 and only inpatients in 2011. We would like the statistics that

are directly comparable and for a fuller explanation about the impact of the Home Treatment Team on the

prescribing of anti-psychotics - particularly in future years but preferably for 2011 and 2012 as well.

We look forward to meeting with the Trust in the near future to discuss this comment and other issues.

Healthwatch Lambeth, Healthwatch Lewisham, Healthwatch Southwark

Responses to this Quality Account were requested from the Local Authority Overview and Scrutiny

Committees of the four Boroughs; Lambeth, Southwark, Lewisham and Croydon on the 17th April.

No comments were received by 29th May.


NHS Croydon CCG, NHS Lambeth CCG, NHS Lewisham CCG and NHS Southwark CCG Joint Statement on South London and Maudsley NHS Foundation Trust’s Quality Account

June 2014

The Clinical Commissioning Groups contracting with the South London and Maudsley NHS Foundation

Trust have reviewed the Trust’s Quality Account for 2013/14. We thank the Trust for the opportunity to

comment on the 2013/14 Quality Account and for seeking the views of the CCG in its development.

It is encouraging that the Trust is performing well against national averages in many of the cases given

and we commend the trust for its successes in 2013/14. It is helpful to see comparable statistics and

benchmarking.

There remain some significant challenges for the Trust and we will continue to prioritise in our

commissioning arrangements the best outcomes and health care systems in the services we commission.

Specifically, we are pleased to see a target to stop the transfer of acute patients to private sector hospital

beds outside the Trust. Commissioners have been aware of potential safeguarding issues for patients

placed with private providers and the CCGs will aim to develop a greater understanding of the Trust’s

governance structures to monitor and investigate any issues that arise with health care services provided by

sub-contracted service providers. We support the emphasis on improving access to services, as well as care

planning. Only 85% of older adult patients are given a copy of their care plan in Southwark for example,

against a target of 95%. We expect the Trust to focus on involving this group of people more in their care

planning across all four Boroughs.

We note that four of the 2014/15 quality priority areas are the same from 2013/14. We support the

commitment in the Quality Account to continue to improve these outcomes for patients, but it would be

valuable to reflect on why the improvement from last year was not adequate and how this year will be

targeted more effectively.

The report demonstrates progress against last year’s priorities, but ideally there could be inclusion of a

summary section that demonstrates how the Trust is doing on key metrics of patient experience, safety, and

effectiveness e.g. mixed sex accommodation, CPA standards, emergency readmission, delayed transfers,

early intervention. We would also like to see action around prioritising patient discharge through discharge

planning on admission, and facilitating a multidisciplinary approach with local authorities and primary care.

Additionally, the level and quality of discharge planning and related interface with primary care is variable

and inconsistent.

We note that a number of inpatients have been in hospital for more than 12 months without having a

physical health check. Monthly reporting also shows limited access to HIV tests for patients admitted to

hospital and limited numbers of patients having access to nutrition screening and we shall seek to assure

ourselves that the Trust improves in these areas.

We shall also monitor the actions that the trust intends to take to improve the quality of healthcare as a

result of audit outcomes and shall also work with the Trust to look at the underlying causes of patients in a

crisis and to what extent waiting times have been a contributing factor.

Southwark commissioners have visited in-patient wards where staff have reported that there have been

potentially unsafe situations due to not enough staff being on shift when an incident occurs, or during

admission, or when physical health checks are being carried out and we shall work with the Trust to ensure

that these situations do not arise.

We welcome the data presented regarding patient safety incidents, but would like to see evidence of wider

learning and improvements that have been taken as a result of the incidents, and the same for complaints

and PALS.


Finally, we are pleased to see the Trust’s commitment to help people to stop smoking by becoming a smoke

free environment by November this year. This will help improve the health of patients and staff.

The CCGs look forward to continuing to work with South London and Maudsley NHS Foundation Trust

in 2014/15 to provide improving mental health services for residents of the four boroughs; Croydon,

Lambeth, Lewisham and Southwark.

Annex 2

Statement of Directors’ Responsibilities In Respect of the Quality Report

The directors are required under the Health Act 2009 and the National Health Service (Quality Accounts)

Regulations 2010 to prepare Quality Accounts for each financial year.

Monitor has issued guidance to NHS foundation trust boards on the form and content of annual Quality

Reports (which incorporate the above legal requirements) and on the arrangements that foundation trust

boards should put in place to support the data quality for the preparation of the Quality Report.

In preparing the Quality Report, directors are required to take steps to satisfy themselves that:

n The content of the Quality Report meets the requirements set out in the NHS Foundation Trust Annual

Reporting Manual 2013/14;

n The content of the Quality Report is consistent with internal and external sources of information

including:

- Board minutes and papers for the period April 2013 to June 2014, including

- Papers relating to Quality reported to the Board over the period April 2013 to June 2014;

- Feedback from commissioners was requested on 17/04/2014

- Feedback from Governors received 27/05/2014

- Feedback from local Health watch organisations 20/05/2014

- The Trusts complaints report published under regulation 18 of the Local Authority Social Services

and NHS Complaints Regulations 2009, to June Board

- 2013 national patient survey results

- 2013 national staff survey results

- The head of internal audit’s annual audit opinion over the Trust’s control environment dated

20/05/2014.

- CQC quality and risk profiles published throughout the year

n The Quality Report presents a balanced picture of the NHS foundation trust’s performance over the

period covered;

n The performance information reported in the Quality Report is reliable and accurate; there are proper

internal controls over the collection and reporting of the measures of performance included in the

Quality Report, and these controls are subject to review to confirm that they are working effectively

in practice; the data underpinning the measures of performance reported in the Quality Report is robust

and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to

appropriate scrutiny and review; and,


n The Quality Report has been prepared in accordance with Monitor’s annual reporting guidance (which

incorporates the Quality Accounts regulations) as well as the standards to support data quality for the

preparation of the Quality Report.

The directors confirm to the best of their knowledge and belief they have complied with the above

requirements in preparing the Quality Report.

By order of the Board

Madeliene Long

Chair


Dr Matthew Patrick

Chief Executive



Notes

South London and Maudsley NHS Foundation TrustTrust HeadquartersMaudsley HospitalDenmark HillLondonSE5 8AZ

T. 020 3228 2830F. 020 3228 2021E. [email protected]. www.slam.nhs.uk

Switchboard: 020 3228 6000

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