Item 8 - Sheffield Health and Social Care

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National audit of psychological treatmentsNational Parkinsons auditPrescribing high dose and combinedantipsychotics on adult acute and psychiatricintensive care wardsLithium monitoring – To ensure Lithium isprescribed in accordance with NICE guidelinesPrescribing antipsychotics for people with DementiaResults – We did well on waiting times, skills andtraining of staff and our monitoring of outcomesof the treatment we provided, but below averageon satisfaction and the outcomesof the treatment provided.The actions we have taken are:Reviewed the way we organise our services,improved our shared care with gp’s and reducedthe bureaucracy in our referral processes. Sincethen we have seen a 10% improvement in dnarates, 5% improvement in recovery rates andsignificant improvement in client outcomes.Data was submitted in december for 53 patients.A report will be available in june 2013.Results – We have made improvements on theprevious year’s audit (2010) regarding the numberof people who were prescribed higher dosages ofdrugs than the recommended limits, however thiswas not consistent across all of our services.The actions we have taken are:We have made it easier for staff to access toinformation regarding the effect of combiningantipsychotics on the percentage maximumdose prescribed.Results – Our monitoring of lithium side effectsis at 60%, which compared well in the audit,however we need to improve how we monitorlithium toxicity.The actions we have taken are:Services continue to monitor how we are doing.We will improve how we monitor risks relatingto toxicity, and undertake a repeat audit toevaluate progress.Results – Most people were benefiting from areview and had evidence of having a plan in placeregarding what works best if they experience acrisis. We need to improve how we communicatewhy we have prescribed the medication we haveand when different treatment plans started.The actions we have taken are:We will improve the documentation of theclinical reason for proscribing the most recentantipsychotic and the duration of prescriptionof benzodiazepine.Metabolic side effects of antipsychoticNHS Litigation Authority – Records auditDiabetes auditSuicide auditResults – We did well on monitoring peoplesblood pressure, but need to improve how wemonitor peoples weight and encourage peopleto stop smoking.The actions we have taken are:We will improve practice and the documentationof smoking cessation, obesity and BMI. We haveapproved a Trust wide plan about improvingpeoples overall physical health.Results – Compared to the previous years auditwe have made significant improvement in thequality of the information we have about peoplescircumstances, such as HoNOS assessments,sexual vulnerability, child/ adult protection issues.However we still need to improve key areas suchas advance directives, risk prevention planningand communicating plans with gp’s.The actions we have taken are:All services are developing plans to address theunderperforming standards. We are alreadyimplementing a roll out of improved electronicpatient records focussing on areas of risk andassessment, which will support improvements.Results – We are doing well in how we monitor arange of risk issues for people who have diabetes(such as weight) and the treatment they are on(such as statins and ACE-inhibitors). We weren’tdoing as well in the supporting people to accesswell-structured education programmes.The actions we have taken are:To re-launch a patient education programme.Results – We were compliant with the majorityof standards for the care plans that we audited.We need to improve how we communicate withfamilies and carers after such tragic events, makingsure they have information about what happened.The actions we have taken are:We have put plans in place to ensure informationis shared with families and carers in an appropriateand supportive way.109110
Safeguarding childrenFood and nutritionLocal audit activityLocal clinical audits are conducted by staff and teamsevaluating aspects of the care they themselves haveselected as being important to their teams. Our maincommissioner, Sheffield CCG, also asks the Trust tocomplete a number of local clinical audits each year, toreview local quality and safety priorities. On a quarterlybasis the Board review the progress of other local audits.2.9 Data qualityGood quality information underpins the effectivedelivery of care and is essential if improvements inquality care are to be made. Adherence to gooddata quality principles (complete, accurate, relevant,accessible, timely) allows us to support teams and theBoard of Directors in understanding how we are doingand identifying areas that require support and attention.External Auditors have tested the accuracy ofthe data and our systems used to monitor thefollowing indicators:• 7 day follow up – everyone dischargedfrom hospital should receive support in thecommunity within 7 days of being dischargedResults – The audit identified that the majority ofstaff have ‘some’ understanding of the kinds ofchild abuse (particularly type of abuse). Most staffknow who to contact if a child has been abused(this includes line manager, safeguard lead)The actions we have taken are:We will continue with our training programmeto maintain and improve awareness.Results – The audit has revealed that nutritionalassessments are being done on admission for96% of patients on the older adult wards. Weneed to extend this practice to our other wards.The actions we have taken are:We will extend the practice of undertakingnutritional assessments to our adult wards.• ‘Gate keeping’ – everyone admitted tohospital should be assessed and consideredfor home treatmentAs with previous years, the audit has confirmedthe validity and accuracy of the data used within theTrust to monitor, assess and report our performance.The Trust submitted records during 2012/13 to theSecondary uses service (SUS) for inclusion in theHospital episodes Statistics which are included in thelatest published data. The percentage of records inthe published data which included the patient’s validNHS number was 99.9% for admitted care. Thepercentage of records in the published data whichincluded the patients valid General PractitionerRegistration Code was 95.7% for admitted care.No other information was submitted.The latest published data from the SUS regardingdata quality under the mental health minimum dataset is for April 2012- December 2013. The Trust’sperformance on data quality compares well tonational averages and is summarised as follows:Percentage of valid records Data quality 2012/13 National averageNHS Number 99.9% 99.4%Date of birth 100% 99.7%Gender 100% 99.4%Postcode 99.6% 99.0%Commissioner code 100% 99.3%GP Code 99.5% 98.3%Primary diagnosis 100% 98.5%HoNOS outcome 100% 88.9%The data and comparative data is from the published MHMDS Reports for the Q1 – Q3 periods inclusiveClinical coding error ratesSheffield Health and Social Care NHS FoundationTrust was not subject to the Payment by Resultsclinical coding audit during 2012/13 by theAudit Commission.2.10 Information governanceWe aim to deliver the best practice standardsin Information Governance by ensuring thatinformation is dealt with legally, securely andeffectively in order to deliver the best possiblecare to our service users.Concerns were highlighted in a number of areasduring 2011/12. The Trust undertook developmentand improvement actions in response to thefollowing issues:• Information governance management -Improving the provision of training aboutinformation governance• Clinical information assurance - Completionof staff training and audit for clinical coding• Corporate information assurance - Completinga review and audit of corporate records.During the year we completed our assessmentsthrough the NHS Connecting for Health InformationGovernance Toolkit. The Trust undertook andsubmitted a baseline assessment in October2012 anda final assessment and submission in March 2013.Following the improvement actions we hadundertaken, Sheffield Health and Social CareNHS Foundation Trust’s Information GovernanceAssessment Report overall score for 2012/13was 69% for the 45 standards and was gradedsatisfactory/green.AchievedCriteria 2011/12 2012/13 Current gradeInformation Governance Management 66% 73% SatisfactoryConfidentiality and Data Protection Assurance 74% 74% SatisfactoryInformation Security Assurance 64% 66% SatisfactoryClinical Information Assurance 73% 73% SatisfactorySecondary Use Assurance 41% 66% SatisfactoryCorporate Information Assurance 22% 66% SatisfactoryOverall 60% 69% Satisfactory111112
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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
Page 19 and 20: 2.17.7. Key financial risks and cha
Page 21 and 22: SHSC Headquarters at Fulwood House3
Page 23: B) Pension benefitsAs Non-Executive
Page 26 and 27: Governors at the Annual Members mee
Page 28 and 29: Number ofseats2 YoungService user/C
Page 30 and 31: 6.0 MembershipFoundation Trust stat
Page 32 and 33: Service User artwork at Moncrieffe
Page 34 and 35: Name Position Term Number of meetin
Page 36 and 37: 7.3.4 Remuneration and Nominations
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 52 and 53: 101How do our structures help ensur
Page 54 and 55: Improving the management of Violenc
Page 58 and 59: Part 3: Review of ourquality perfor
Page 60 and 61: Drug and alcohol servicesThe servic
Page 62 and 63: 3.3 Service user experienceComplain
Page 64 and 65: Memory servicesSurveys have led to
Page 66 and 67: It was harder for the Committee to
Page 68 and 69: This report, including the conclusi
Page 70 and 71: 13.0 Annual Governance Statement13.
Page 72 and 73: of the systems of internal control.
Page 74 and 75: • Reports from External Audit;•
Page 76 and 77: We are not required to assess, nor
Page 78 and 79: The Accounts of Sheffield Health an
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
Page 86 and 87: 3.4 Operating income by type compri
Page 88 and 89: The aggregate of remuneration recei
Page 90 and 91: No assets were held under finance l
Page 92 and 93: 13. Cash and cash equivalents15. Tr
Page 94 and 95: A provision of £729,000 relates to
Page 96 and 97: The value of transactions with boar
Page 98 and 99: Actuarial gains and losses are reco
Page 100: 17.0 ContactsSheffield Health and S
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Item 8 - Sheffield Health and Social Care

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