5 Boroughs Partnership NHS Foundation Trust Annual ... - Monitor

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A series of briefings, alerts and newsletters that aim to ensure changes are made and patient safety improved are distributed throughout the Trust regularly. This includes MHRA alerts within the CAS system. Learning is further shared in the form of annual conferences such as the Service User and Carer Involvement Conference, Service User Physical Health and Well- Being Conference and the Trust’s Patient Safety Conference. Health and Safety Performance During the reporting year the Health and Safety Advisor reported a total of 43 incidents to the Health and Safety Executive under RIDDOR. Good working relations within the Health and Safety Executive continues to remain effective, with no enforcement action taken for the Trust as a whole for the last financial year. Infection Prevention and Control Infection Prevention and Control is high on the Trust’s agenda and is a key indicator of quality. The Trust continues to achieve full compliance with the Care Quality Commission and the Health Act 2008 Code of Practice for the Prevention and Control of Healthcare-Associated Infections. Overall, there has been an improvement in all the results from the Trust’s Infection Prevention and Control audit programme. Audits undertaken across all our business streams scored 90 per cent and above. The audit process involves ensuring compliance with Infection Prevention and Control procedures, cleanliness of environment, patient care equipment and hand hygiene. We won first poster prize at the North West Audit Conference ‘Bridging the Gap’ for our audit of ‘MRSA in a mental health trust’. We have been asked to look at leading on a national audit of such infections. Healthcare-Associated Infections Infection Prevention and Control of Healthcare-Associated Infections (HCAI) are monitored nationally via the Care Quality Commission (CQC) with standards based on The Health and Social Care Act 2008 (updated 2010). The Trust has declared compliance with the standards. Compliments and Complaints We are committed to doing everything possible to resolve concerns and complaints raised with us. The Complaints team and Patient Advice and Liaison Service (PALS) work closely together to ensure that concerns and complaint issues are captured and resolved at the earliest opportunity and that the complainant’s views are sought at all stages as part of the resolution process. All complaints we receive are dealt with through our Complaints and Concerns Policy and in line with current NHS complaint regulations. 38 Annual Report and Annual Accounts 2011-12
For the period 1 April 2011 to 31 March 2012 we received 1,013 compliments and 242 complaints. We closed 237 complaints - some of which relate historically to the previous reporting period. Of the 237 closed complaints 155 (65.4 percent of all complaints closed) were not upheld; 82 (34.6 percent of all complaints closed) had some or all of the issues upheld. During the period 1 April 2011 to 31 March 2012 there have been no Serious Untoward Incident reviews (SUIs) relating to data loss. We were informed of eight complaints that were referred to the Parliamentary and Health Service Ombudsman. Emergency Preparedness The Trust has a Major Incident Plan that was revised in January 2012 to reflect the NHS changes. This is to be audited by NHS Merseyside in the second quarter of 2012. This is complemented by incident-specific plans, such as fuel shortage, flooding, heatwave and winter pressures. There is also a specific Business Continuity plan, which was subject to formal audit by NHS Merseyside in February 2012. The Trust falls into three Local Resilience Forum (LRF) areas. An agreement has been reached with the Strategic Health Authority (SHA) that NHS Merseyside will act as lead primary care trust with regard to emergency planning and performance management. As such, the Trust falls under the Merseyside Lead Primary Care Trust Function Activation Plan for major incidents requiring co-ordination and mutual aid between NHS organisations and key partners (October 2008, revised January 2012). NHS Merseyside monitors the development of plans and report assurance to the Strategic Health Authority (SHA). They also host training and exercises such as the three-monthly ‘Exercise First Call’, which tests the ability of the command and control network to establish contact with on-call Directors. In the 12-month period inclusive of January 2012, 104 Trust staff have been involved in internal or external training and exercise events. In addition, the Major Incident Room was opened on the day of industrial action on 30 November 2011 and the full command and control process put in place. The incident was managed effectively and the core business of the Trust was not compromised. Annual Report and Annual Accounts 2011-12 39
Page 1 and 2: 5 Boroughs Partnership NHS Foundati
Page 5 and 6: Contents Chairman and Chief Executi
Page 7 and 8: Our Profile Formed in 2002, 5 Borou
Page 9 and 10: We are actively involved in Learnin
Page 11 and 12: Trust Board Member Ray Walker - Dir
Page 13 and 14: including Adults, Learning Disabili
Page 15 and 16: Executive Director John Kelly Direc
Page 17 and 18: Committee Member Brian Marshall - N
Page 19 and 20: key safety recommendations in respe
Page 21 and 22: Our Risk Management Our Risk Manage
Page 23 and 24: Statements of Assurance Provided by
Page 25 and 26: During the reporting year the Trust
Page 27 and 28: Christopher Ashman Diane French -
Page 29 and 30: Public Member Councillor 18/05/ 11
Page 31 and 32: Members 27/07/11 28/09/11 11/01/12
Page 33 and 34: The remit of the Committee is to be
Page 35 and 36: Our Strategic Themes and Objectives
Page 37: Joint Service User and Carer Forum
Page 41 and 42: Effective and Efficient Organisatio
Page 43 and 44: What else have we achieved against
Page 45 and 46: Increased roof and wall insulation
Page 47 and 48: Clinical Leadership and Service Imp
Page 49 and 50: in research approved by a Research
Page 51 and 52: In addition we have representation
Page 53 and 54: One of the ways we will do this in
Page 55 and 56: Well-Governed In order for any orga
Page 57 and 58: Financial Viability This theme rela
Page 59 and 60: continues to perform well and impro
Page 61 and 62: in April 2012. By April 2013 more t
Page 63 and 64: Workforce Management and Experience
Page 65 and 66: Top Four Rankings Progress 2010 to
Page 67 and 68: New Bottom Four Rankings 2011 Botto
Page 69 and 70: Jobcentre Plus has awarded the symb
Page 71 and 72: Financial Review of the Year We hav
Page 73 and 74: Details of salaries and allowances
Page 75 and 76: Speaking Your Language This Annual
Page 79 and 80: Involving Service Users in Patient
Page 81 and 82: In particular, we took part in 100
Page 83 and 84: These statements are included as Ap
Page 85 and 86: Quality & Safety priorities 2012-13
Page 87 and 88: 2.4.3 Participation in Clinical Aud
Page 89 and 90:
Name of Audit Number of cases submi
Page 91 and 92:
The percentage of records which inc
Page 93 and 94:
Part 3 - Other Information 3.1 Trus
Page 95 and 96:
Knowsley Integrated Provider Servic
Page 97 and 98:
Monitor Targets 2011-12 Threshold Y
Page 99 and 100:
Domain Patient Safety 99 Trust Qual
Page 101 and 102:
3.4 Trust-wide Achievements 3.4.1 W
Page 103 and 104:
3.5.3 Advancing Quality Programme A
Page 105 and 106:
Productive Mental Health Wards Prod
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The table below shows the Trust’s
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3.7 Engaging with and Listening to
Page 111 and 112:
3.7.4 Further examples of Engagemen
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3.8.2 Messages from Warrington LINk
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Quality Accounts - 5 Boroughs 2011/
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Warrington LINk Statement 5 Borough
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Knowsley LINk 5 Boroughs Partnershi
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Wigan Borough Local Involvement Net
Page 123 and 124:
Re: 5 Boroughs Partnership NHS Foun
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Knowsley Overview and Scrutiny Boar
Page 127 and 128:
11 May 2012 Many thanks for sharing
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Appendix 2 - National Patient Surve
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Fig 2. The results from the Trust
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Service users are asked to complete
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Appendix 4 Director’s Statement o
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Appendix 5 Monitor External Assuran
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Assurance work performed I conducte
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Appendix 6 Performance against CQUI
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Indicator Name Goal Year-end positi
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EFFECTIVENESS TCS Mental Health Pat
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Total June July August September Oc
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5 Boroughs Partnership NHS Foundati
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Independent Auditor’s Report to t
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Certificate I certify that I have c
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I have delegated responsibility for
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Policy and Guidance A range of clin
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Directors attending the Trust Opera
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Continue to publish monthly High-le
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These include Business Continuity a
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Internal and External Stakeholders
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Board throughout the year. The Qual
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The Audit Committee provides an app
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Group Chaired by Functions Business
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The Trust maintains a status of reg
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Foreword to the Accounts 5 Boroughs
Page 177 and 178:
Prior period adjustments TOTAL COMP
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Financed by taxpayers' equity: Mino
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Public Dividend Capital repaid Publ
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Statement of Cash Flows For the Per
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Notes to the accounts 1. Accounting
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Notes to the Accounts - 1. Accounti
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Page 191 and 192:
Page 193 and 194:
Page 195 and 196:
Page 197 and 198:
4. Other operating income 2011/12 2
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6. Operating leases As lessee Payme
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7. Employee costs and numbers conti
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203 7. Employee costs and numbers c
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205 7. Employee costs and numbers c
Page 207 and 208:
8. Retirement benefits continued. T
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209 9. Better Payment Practice Code
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13. Intangible assets Software lice
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14. Property, plant and equipment 2
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14. Property, plant and equipment c
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14. Property, plant and equipment c
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16. Non-current assets for sale and
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17. Capital commitments There are n
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19.3 Ageing of impaired receivables
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23. Other liabilities Current Non-c
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25. Contingences 25.1 Contingent li
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26.2 Financial liabilities NHS Trad
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Further information on the NHS Foun
Page 233 and 234:
30. Third Party Assets The Trust he
Page 235 and 236:
Annual Report and Annual Accounts 2
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