Item 8 - Sheffield Health and Social Care

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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
Incident type 2010/11 2011/12 2012/13All incidents 5981 6408 (a) 6260All incidents resulting in harm 1627 1689 1508Serious incidents (investigation carried out) 38 45 34Patient safety incidents reported to NRLS (d) 3359 3598 3340Patient safety incidents reported as ‘severe’ or ‘death’ 28 41 42Expressed as a percentage of all patient safety incidentsreported to NRLS0.8% 1.1% 1.3%Slips, Trips and Falls incidents 1449 1652 1180Slips, Trips and Falls incidents resulting in harm 554 558 420Self-harm incidents 365 (a) 369 (a) 425Suicide incidents (in-patient or within 7 days of discharge) 1 2 (b) 0 (c)Suicide incidents (community) 24 13 5 (c)Violence, aggression, threatening behaviour and verbal abuse incidents 1485 1644 1930Violence, aggression and verbal abuse incidents resulting in harm 267 276 240Medication Errors 354 (a) 360 (a) 321Medication Errors resulting in harm 0 0 1Infection ControlInfection incidentsMRSA Bacteraemia 0 0 1Clostridium difficile Infections 0 0 0Periods of Increased infection/Outbreak• Norovirus• Rotavirus• InfluenzaShowing number of incidents, then people affected in bracketsPreventative measuresMRSA Screening – based on randomised sampling to identifyexpected range to target7 (52)1 (5)07 (60)003 (28)01 (3)n/a 2% 39%Staff Influenza Vaccinations 20% 37.6% 56%(a) The incident numbers have increased from those reported in the 2011/12 Quality Account report due to additional incidents being enteredonto the information system after the completion of the report.(b) The figure has decreased from that reported in last year’s Quality Account report due to an HM Coroner’s inquest which has not yet beenheld. It is likely that this figure will increase in next year’s report(c) Figures are likely to increase pending the conclusion of future HM Coroner’s inquests. This will be reported in next year’s report.(d) The NRLS is the National Reporting Learning System, a comprehensive database set up by the former National Patient Safety Agencythat captures patient safety information.3.2 EffectivenessThe following information summarises ourperformance against a range of measures ofservice effectiveness.Primary Care Services – Clover GroupGP PracticesThe Quality Outcomes Framework (QoF) providesa range of good practice standards for the deliveryof GP services. Traditionally the 4 practices thathave formed the Clover Group have been belowthe Sheffield averages in their performance againstthese standards have previously been in the lowestquartile in the city. The practice serves a majoritymulti-ethnic migrant population in areas of socialdeprivation within Sheffield. This brings a numberof acknowledged challenges for the service todeliver the range of standards.Over the last 2 years, significant progress andachievements have been made. In 2011/12 theClover Group of practices improved to be in thePrimary Care – Clover Gp’sFlu vaccinationshighest quartile in Sheffield and their challenge thisyear was to sustain this improvement. They haveachieved this, which is an excellent achievementand demonstrates that real improvements arebeing implemented for the longer term benefitof the communities the practices serve.In 2011/12 the service achieved a total of 98.7% ofall the QoF standards, with a Sheffield-wide averageof 97%. This year in 2012/13 the service achieved98.2% of the standards.The following table summarises performanceagainst national standards for GP services. Healthscreening for the practice population is challengingand influenced by the high proportion of the patientgroup being from BME communities. The servicehas been working closely with its community groupsto increase awareness and access arrangementsfor health screening programmes to supportimprovements. Uptake in the programmesgradually increases over the years.This yearstargetHow did wedo in year2011 – 12How did wedo this yearVaccinate registered population aged 65 and over 75% 75% 78%Vaccinate registered population aged 6 monthsto 64 years in an at risk populationVaccinate registered population who arecurrently pregnantChildhood immunisations70% 50%* 56%70% 45%* 51%Two year old immunisations 70-90% 90% 90%Five year old immunisations 70-90% 81% 85%Cervical cytology 60-80% 66.7% 66.4%*Note: The target for 2011/12 was 50% & 45% respectivelyInformation source: System One and Immform115116
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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 56 and 57: National audit of psychological tre
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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