Item 8 - Sheffield Health and Social Care

Part 3: Review of ourquality performance3.1 SafetyOverall number of incidents reportedThe Trust traditionally reports a high numberof incidents compared to other organisations.This is viewed as a positive reflection of the safetyculture within the Trust. It helps us to be able to reallyunderstand what the experience of care is like, spottrends and make better decisions about what wewant to address and prioritise for improvement. TheNational Patient Safety Agency consistently assessesour performance, using the data supplied through theNational Reporting Learning System (NRLS) as in thehighest (best performing) 25% of Trust’s for activelyencouraging the reporting of incidents. For the 6month period April - September 2012, SHSC was the10th highest performer of 56 mental health trusts.Nationally, based on learning from incidents anderrors across the NHS, the National patient SafetyAgency has identified a range of errors that shouldalways be prevented. These are often referred toas ‘never events’, because with the right systemsto support care and treatment in place they shouldnever need to happen again. None of the incidentsthat occurred within the Trust over the last yearwere of this category.Patient safety alertsThe NHS disseminates safety alerts through a CentralAlerting System. The Trust responded effectively toall alerts communicated through this system. During2012/13 the Trust received 70 non-emergency alertnotices, of which 100% were acknowledged within48 hours, 4 were applicable to the services provided bythe Trust and all were acted upon within the requiredtimescale. In addition a further 37 emergency alertswere received an acted upon straight away.Patient safety information on types of incidentsSelf-harm and suicide incidentsThe risk of self-harm or suicide is always a seriousconcern for mental health and substance misuseservices. The NPSA figures show 11.3% of allpatient safety incidents reported by the Trust wererelated to self harm, in comparison with 18.1% formental health trusts nationally. This is similar to theprevious year where the figures were 11.4% and18.7% respectively.During the last two years clinical risk trainingwas provided for SHSC staff and new clinical riskassessment and management tools have beenintroduced throughout the Trust. Last year 1,329staff from all professional groups received thetraining, which covers the principles and practice ofrisk assessment and management. We had plannedto train 2,000 members of staff. The main reasonleading to our under achievement of our target hasbeen capacity to support the release of staff fromfront line service delivery. We are reviewing ourapproaches to this for next year to ensure wecan deliver improvements.Violence, aggression and verbal abuseIn previous years the Trust has reported relativelylow incidents of disruptive and aggressive behaviourwithin our services compared to other mental healthorganisations. This has increased during 2012/13in line with the position reported in Section 2.20.6% of patient safety incidents reported by theTrust were for aggressive behaviour in comparisonwith a national average of 18.2%, based on NPSAbenchmarking data for first 6 months of the year.In the previous year, 2011/12 the figures were15.4% and 19% respectively.Medication errors and near missesStaff are encouraged to report near misses anderrors that do not result in harm to make surethat they are able to learn to make the use andprescribing of medication as safe and effective aspossible. 6.1% of patient safety incidents reportedby the Trust related to medication, compared with8.4% in mental health trusts nationally. There hasbeen little change in the number of medicationincidents reported by the Trust over the last 3 years.Cleanliness and infection controlThe Trust is committed to providing clean safe carefor all our service users and ensuring that harm isprevented from irreducible infections.To achieve this an annual programme is producedby the Infection Prevention and Control Team thatdetails the methods and actions required to achievethese ends.The programme includes:• Processes to maintain and improve environments• The provision of extensive training and education• Systems for the surveillance of infections• Audit of both practice and environment and• The provision of expert guidance and informationto manage infection risks identified.The efficacy of this programme is monitored bothinternally and externally by the provision of quarterlyand annual reports detailing the trusts progressagainst the programme. These reports are publiclyavailable via the internet.Single sex accommodationThe Trust is fully compliant with guidelines relatingto providing for appropriate facilities for menand women in residential and inpatient settings.During 2012/13 we have reported no breachesof these guidelines.SafeguardingThe Trust fully complies with its responsibilitiesand duties in respect of Safeguarding VulnerableAdults, and Safeguarding Children. We have aduty to safeguard those we come into contactwith through the delivery of our services. Wefulfil our obligations through ensuring we have:• Robust systems and policies in place thatare followed• The right training and supervision in placeto enable staff to recognise vulnerabilityand take action• Expert advice available to reduce the risksto vulnerable people.Reviews and investigationsWe aim to ensure that we review all our seriousincidents in a timely manner and share conclusions andlearning with those effected, and our commissioners.We monitor our performance in respect ofcompleting investigations within 12 weeks andundertaking investigations that are assessed asbeing of an ‘excellent/ good’ standard. Historicallywe have experienced challenges in this area andwe continue to prioritise our efforts to improveour review processes.Improvements and lessons learntAll incidents are reviewed to ensure we are able toidentify how we can make improvements and takecorrective action to maintain and improve safety.We formally review all serious incidents and theTrust’s Quality Assurance Committee and Board ofDirectors reviews the findings and lessons learnt fromthe incidents. We review and share all findings withour Commissioners and review our improvementplans with them.Examples of the types of improvement actions wehave been able to take following reviews of seriousincidents are• Involving service user families/carers in theircare/decision making• Comprehensive and timely record keeping,ensuring the rationale for decisions madeis recorded• Making sure that urgent referrals into theTrust are easily identified• Communication between NHS professionalsto be strengthened to ensure information isshared appropriately.Using incident data to prioritiseimprovement actionsFrom the incident data on the next page, and ourreview of the types of incidents that occur acrossour services, we prioritised falls and violent incidentsfor attention. Our plans, and progress against thoseplans is reported in detail in Quality Objectives 1 and2 in this report.Overview of incidents by typeThe table on the next page reports on the fullnumber of incidents reported within the Trust. It thenreports on the numbers of those incidents that werereported to result in harm for service users and staff.113114