Item 8 - Sheffield Health and Social Care

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101How do our structures help ensure we are able to develop our qualityimprovement capacity and capability to deliver these improvements?Our governance arrangements and structures support us to focus our efforts on improving the qualityand effectiveness of what we do, and deliver on the objectives we have setEngage and listenEnsuring we understand the experience andviews of those who use our services so wecan make the right improvements.Our Governors and membership share their experiencesand views and inform our plans for the future.We have a range of forums where service users cometogether to help us develop our services.We use a range of approaches to seek the views ofindividuals who use our services such as surveys.We have prioritised the development of service users tosurvey other service users about their experiences as thiswill give us much more reliable feedback.Monitor and assessEnsuring we evaluate how we are doing.We have a team governance programme that supportseach service to reflect on how they perform and agreeplans for development.We have prioritised the provision of information toteams so they can understand how they are doing,and we continue to improve our ability to providethem with the information they need.We periodically self-assess our services against nationalcare standards with service users, members, governorsand our non-executive directors providing their viewsthrough visits and inspections.• Service user Safety Group• Health and Safety Committee• Infection Prevention andControl Committee• Safeguarding ChildrenSteering Group• Audit committee• Mental Health Act GroupQuality and Assurance CommitteeEvaluates and makes sense of the information from the above systems,and directs actions and decision making for future actionBoard of DirectorsCouncil ofGovernorsDeliver best practiceEnsuring the care and support we provideis guided by what we know works.We have a NICE Implementation programme toensure we appraise our services against the availablebest practice and develop improvement plans.We have developed a range of care pathwaysacross services so we are clear about what weexpect to be provided.We have an established Audit programme that evaluateshow we deliver care against agreed standards.Regular Quality Improvement Group forum bringsclinicians and managers together to share best practice.Workforce developmentand leadershipSupporting and developing our staff todeliver the best care.We have an established workforce training programmethat aims to equip our staff with the skills, knowledgeand values to deliver high quality care.We have a well established culture and programme ofdeveloping our clinical and managerial leadership teamsto support them to deliver improvements in care.We use a range of service improvement and systemimprovement models to help us deliver the changes wewish to see, we continue to increase our ability to do this.• Safeguarding AdultsSteering Group• Psychological TherapiesGovernance Committee• Medicines ManagementCommittee• NICE Steering Group• Information Governance GpPart 2B: Mandatorystatements of assurancefrom the board relatingto the quality of servicesprovided2.1.Statements from the Care QualityCommission (CQC)Sheffield Health and Social Care NHS FoundationTrust is required to register with the Care QualityCommission and our current registration statusis registered without conditions and thereforelicenced to provide services.The Care Quality Commission has not takenenforcement action against the Trust during 2012/13.The Trust has not participated in any special reviews orinvestigation by the CQC during the reporting period.The CQC registers, and therefore licenses the Trustas a provider of care services as long as we meetessential standards of quality and safety. The CQCmonitors us to make sure we continue to meetthese standards.During 2012/13 we assumed the CQC registrationof Woodland View Nursing Home, which waspreviously registered by Guinness NorthernCounties Housing Association.Planned/unplanned reviewsDuring 2012/13 the CQC visited the followinglocations as part of their review of our compliancewith essential standards of quality and safety:• Residential homes for people with a learning disabilityBuckwood View, Handsworth, Mansfield View,East Bank Road, Beighton Road• Respite Care services for people witha learning disabilityLongley Meadows136a Warminster Road• Respite Care services for adultsBolehill View, Hurlfield ViewWainwright Crescent• Inpatient ServicesGrenoside Grange.All services inspected were fully compliant withthe exception of Bolehill View, where complianceactions were received for:• Consent to care and treatment and• Care records.Following the feedback received from the CQCwe took immediate improvement action over thefollowing month and the Commission confirmedfollowing a repeat inspection that we were fullycompliant with the required standards.The reports from the planned reviews of complianceare all available via the Care Quality Commissionwebsite at http://www.cqc.org.uk.At the publication date of the Trust Quality Accountall improvement and compliance actions have beenaddressed and the Trust was fully compliant withthe requirements of registration.Mental Health Act reviewsDuring 2012/13 the CQC has undertaken 9 visits toservices to inspect how we deliver care and treatmentfor inpatients detained under the Mental Health Act.They review our processes for care, the environmentin which we deliver our care and meet privately withinpatients. They have visited the following services:• Michael Carlisle CentreStanage, Burbage, Daleside,Maple, Pinecroft• Longley CentreHawthorne, Intensive Treatment Service• Forest LodgeAssessment & Rehabilitation wardsThe feedback from these visits is helpful and allowsus to ensure, and be assured, that we provide carein accordance with legislation and best practiceguidelines. These reviews and inspections confirmthat we continue to meet all essential standards.2.2 Monitors’ compliance frameworkThe Trust submits quarterly declarations to Monitor inrelation to governance and finance. Monitor reviewsthe Trust’s declaration and publishes a quarterly riskrating for each element. This information is availableat http://www.monitor-nhsft.gov.uk.The governance assessment (rated as either red,amber/red, amber/green or green) is based on theTrust’s self-declaration by the Board of Directorsagainst the following areas:• Compliance with its constitution• Growing a representative membership102
• Maintaining appropriate structures• Co-operating with other bodies• Risk management• Service performance and improvementin service quality.The tables below feature our ratings for the fourquarters of the last two years compared with theTrust’s expectation at the beginning of the yearas stated in our Annual Plans.2011/12The Trust was rated as Amber/ Red risk undergovernance following a review of its InpatientServices by the Care Quality Commission in theprevious year 2010/11. The CQC identified somemoderate/ minor areas of concern that the Trustneeded to address.The Trust implemented a development plan that wasagreed with the CQC, and the Amber/ Red assessmentremained until the action plan was completed.2011/12 Risk ratings compared to annual planAt the beginning of the year the Trust planned tohave completed the required actions by September2011, which it did so successfully.The progress made by the Trust was reviewed andacknowledged by the CQC and the Trust continuedwith a Green risk rating for Governance for the restof the year.During the 2011/12 year the Trust achieved ineach quarter all the quality standards requiredof a Mental Health NHS Foundation Trust.2012/13The Trust achieved all healthcare targets for eachQuarter with the exception of Quarter 2.During Quarter 2 the Trust failed to achieve therequirement to provide follow up care within 7days of discharge from inpatient care for peopleunder the Care Programme Approach. A rangeof improvement actions were implemented andthe Trust continued to achieve the target for therest of the year.2.3 Goals agreed with our NHS CommissionersA proportion of our income in 2012/13 was conditional on achieving quality improvementand innovation goals agreed between the Trust and any person or body they entered intoa contract, agreement or arrangement with for the provision of relevant health services,through the Commissioning for Quality and Innovation payment framework.For 2012/13 £1,639,911 of the Trust’s contracted income was conditional on the achievement of theseindicators. For the previous year, 2011/12, the associated monetary payment received by the Trust was£661,000. A summary of the indicators agreed with our main local health commissioner SheffieldClinical Commissioning Group for 2012/13 and 2013/14 is shown below.Incentivising improvements in the areas of Safety, Access,Effectiveness and User experiencesNHS Safety Thermometer Improve collection of dataWe wanted to improve collection of data in relation to pressure ulcers, falls, urinarytract infection in those with a catheter, and VTE. This was to ensure we were effectivelymonitoring safety. We were successful in implementing this programme during the year.Reducing variation in waiting times for patients referred to the IAPT servicesSome GP practices in Sheffield were experiencing longer waiting times than others.We wanted to reduce the waiting times in these practices by 10%. We were successfulwith this. Waiting times reduced from 7 weeks to 5.4 weeks.Goal during2012/13AchievedAchievedIs it acontinuedGoal for2013/14Annual plan2011/12Quarter 12011/12Quarter 22011/12Quarter 32011/12Quarter 42011/12Financial risk rating 4 4 4 4 4Governance risk rating Amber/ Red Amber/ Red Amber/ Red Green GreenReduced admissions to Acute Older Adult Wards through improvedcommunity are for people in a crisisWe had established new community services to provide alternatives to hospitaladmission. As a result of this we wanted to incrementally reduce the numbers ofpeople who needed hospital care over the year. We were partially successful inachieving this goal, with less people needing hospital care in 3 of the 4 quarterlyperiods during the year.Partiallyachieved2012/13 Risk ratings compared to annual planAnnual plan2012/13Quarter 12012/13Quarter 22012/13Quarter 32012/13Quarter 42012/13Financial risk rating 4 4 4 5 4Governance risk rating Green Green Amber/ Green Green GreenImproved recording of employment & vocational circumstances of peopleusing mental health servicesTo support our broader rehabilitation and recovery strategies we wanted to improvethe information we had about individuals circumstances to help us better understandtheir needs and the progress made in supporting their recovery. We were successfulin this, with 95.7% of service users in the target client group having the informationupdated in their care records.AchievedNoReduction in the number of falls causing harmThis goal supported our Quality Objective No 1. We successfully achieved our targetof reducing harm caused from falls by 5% this year (See Quality Objective 1 for details).Achieved103104
Page 1: ANNUAL REPORT AND ACCOUNTS2012 - 20
Page 6: 2.0 Directors’ Report2.1 Foundati
Page 9 and 10: • The directorate manages beds fo
Page 11 and 12: • Changes in demand are starting
Page 13 and 14: 2.5 An overview of our arrangements
Page 15 and 16: This development is an important st
Page 17 and 18: 2.16.5 Sickness AbsenceThe Trust re
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Page 23: B) Pension benefitsAs Non-Executive
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Page 38 and 39: Paul RobinsonACMA, CGMAExecutive Di
Page 40 and 41: 8.0 Staff SurveyThe Trust employs a
Page 42 and 43: Art therapy session on ward G1In ad
Page 44 and 45: 10.0 Sustainability ReportOur appro
Page 46 and 47: Part 2A: A review ofour priorities
Page 48 and 49: How did we do?We believe we are mak
Page 50 and 51: How did we do?We have made positive
Page 54 and 55: Improving the management of Violenc
Page 56 and 57: National audit of psychological tre
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Page 62 and 63: 3.3 Service user experienceComplain
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Page 72 and 73: of the systems of internal control.
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Page 80 and 81: SUPPORTING NOTESTO THE ACCOUNTSNote
Page 82 and 83: Revaluation gains and lossesIncreas
Page 84 and 85: of all assets less the value of all
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Item 8 - Sheffield Health and Social Care

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