Item 8 - Sheffield Health and Social Care

Part 2A: A review ofour priorities for qualityimprovement in 2012/13and our goals for 2013/14We established our priorities for quality improvementin February-March of 2012. The people who useour services and the membership of our foundationtrust have been instrumental in deciding what ourpriorities are. When we identified our priorities weagreed a two year plan to deliver improvementsover the longer term.In order to establish these areas as our prioritiesour Board of Directors:• Reviewed our performance against a rangeof quality indicators• Considered our broader vision and plansfor service improvement• Continued to explore with our Council ofGovernors their views about what they feltwas important• Engaged with our staff to understand theirviews about what was important and whatwe should improve.This report confirms how we have progressed overthe first year of our two year plan. It also confirmswhat actions we will continue to take and focus onnext year to make further progress and improvement.In reviewing our progress over the first year andfinalising our plans for next year we have continuedto engage with our members. Our Governorshave undertaken this on our behalf and we havereceived comments and feedback from over 150of our members about our proposals for next year.From this review the Council of Governors havereviewed our plans and we have taken on boardtheir feedback.Through next year we will report on progressagainst our quality improvement objectivesthrough the following ways:• The Board’s Quality Assurance Committee• The Board of Directors• To our Council of Governors formally at theirmeetings during the year• To our Commissioners.We identified 5 quality improvement prioritiesfor this year and the year ahead. They cover thefollowing areas:Quality objective 1: To reduce thenumber of falls that cause harmto service usersWe chose this priority becauseFalls cause direct harm to service users because ofinjury, pain, restrictions on mobility and communityparticipation. This harm impacts on people’s qualityof life and well-being. Three years ago, the NationalFalls and Bone Health Audit in 2011 showed thatduring 2010/11 falls were higher in the Trust’s olderpeople’s inpatient areas than the national averagerate of falls. There were 13.5 falls per 1000 bednights compared with 8.4 falls nationally.Our own data showed that during 2011/12 1,605incidents of slips, trips and falls for service userswere reported by the Trust. 32.1% (n=516) resultedin harm or injury to the service user concerned.Guidance was available on how to reducethe severity, frequency and impact of falls fromNICE. We believed there were clear opportunitiesto deliver real improvements in this importantarea. This was also a priority area for SheffieldClinical Commissioning Group who incentivisedimprovement in this area under the Cquin scheme)(see section 2.3 within this Quality Report).We said we wouldIntroduce a two year plan that started in 2012/13and will continue into 2013/14. Within this planwe said we would:• Implement MFRA (Multi-factorial RiskAssessment) screening tool for falls for allolder people admitted to inpatient areas• Carry out environmental falls risk assessmentsin all inpatient and residential areas• Identify appropriate training packages for staffand deliver a programme of training.The outcome we wanted to achieve was• To reduce the number of falls that result in harmto service users by 5% by the end of this yearand by 10% next year• To reduce the level of harm experiencedby service users from falls, as measured byreduction in number of falls resulting in A&Eor hospital admission• That by the end of this year all older peopleadmitted to inpatient areas will be assessed tosee if they are vulnerable to experiencing a fall.We then consulted on our proposed areasfor quality improvement with a range of keystakeholders. These involved our local ClinicalCommissioning Group, Sheffield City Counciland members of LINk (now Healthwatch).Improving safetyImproving clinical effectivenessImproving the delivery of positiveservice user experiencesImproving access, equality and inclusionQuality objective 1: To reduce the number of fallsthat cause harm to service usersQuality objective 2: To reduce the incidence ofviolence and aggression and the subsequent use ofrestraint and seclusionQuality objective 3: To improve the identificationand assessment of physical health problems in at-riskclient groupsQuality objective 4: To improve the experience offirst contact with the Trust’s servicesQuality objective 5: To improve access to the right carefor people with a dementiaBeighton Road, Learning Disability Service8990