Quality Report 2015/16

The Leeds and York Partnership NHS Foundation Trust's Quality Report for 2015/16 is now available.

Quality Report Summary


NHS Improvement (NHSI – formerly MONITOR) require all NHS foundation trusts to produce reports on the quality of care (as part of their annual reports). Quality reports help trusts to improve public accountability for the quality of care they provide. In support of this, guidance is produced by NHSI as to what should be the content of this report. NHSI also require trusts to obtain external assurance on their quality reports. Subjecting them to independent scrutiny improves the quality of data on which performance reporting depends.

The Trust has three priority areas which are based on the three domains of Quality, namely:

Priority 1 (clinical effectiveness) – People achieve their agreed goals for improving health and improving lives
Priority 2 (patient safety) – People experience safe care
Priority 3 (patient experience) – People have a positive experience of their care and support

Significant events

The transfer to Tees, Esk and Wear Valleys NHS Foundation Trust (TEWV) of general mental health and learning disability services commissioned by the Vale of York CCG, while not materially affecting the Trust’s financial position, led to a substantial review and reflection on the long term future for the Trust and how to work differently with partners local to Leeds, and across a wider geographic area.

In addition, the Trust was informed that it will receive a comprehensive inspection from the Care Quality Commission (CQC) in July 2016. This full inspection presents the Trust with a great opportunity to improve its ratings, both as a Trust and for the individual service areas, and to showcase all the great work and innovations that have taken place since the inspectors were last here.

Achievements in 2015-16

During 2015-16 the Trust proudly launched a new Memory Support and Liaison service that was developed in partnership with the Alzheimer’s Society in 2015.

A revised complaints procedure was also implemented. The improved system and process have resulted in a significant improvement in complaint response times and reduction in reactivated complaints.

A quarterly complaints review panel has been established, including people with lived experience of mental health services.

The Trust reviewed and strengthened its processes for investigating all deaths following the publication of the Mazaar’s report following the “Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015”.

The Trust has been working with partners from primary care, adult social care, commissioners and third sector to develop the Leeds Mental Health Framework. This framework is developing a model for local organisations to work together to provide a diverse range of services to meet the needs of our service users. These services will offer service users choice in terms of both which interventions they receive and who provides them.

Where we need to improve/continue improvement already commenced

In 2015-16 a serious concern was discovered in the administration of the Mental Health Act (MHA). A full audit of processes has taken place and, in 2016-17, work to implement the action plan and to provide assurance that we are fully compliant with all requirements of the MHA and Code of Practice will continue to be our priority.

Working closely with Leeds Commissioners, third sector and Adult Social Care partners, we commenced a review our Community Mental Health Teams to develop more effective pathways into social care and voluntary sector support. We have needed to take a longer term view of this work and accept that that by pausing the implementation of parts of the work we will finish with a better and more sustainable solution in the long run. This is likely to see a greater focus on recovery and choice of treatment for service users, with clear pathways into a ‘scaffolding’ of support provided on a locality basis by the third sector. As part of this work, we are developing plans to integrate Adult Social Care mental health services more closely with our services.

Whilst the Trust is not achieving its target in reducing musculo-skeletal sickness, there is a sustained reduction in the rate through the proactive management of musculoskeletal absence by the focussed work and interventions of an in house Staff Physiotherapist.

The current rate of stress-related absence continues to be a challenge. A multi-faceted approach to supporting staff with stress related absence has been developed using the stress pathway tool developed through the OH Department, providing support to managers and teams with high levels of absence through use of HSE stress questionnaires, team coaching and resilience training.

In addition, the Commissioning for Quality Innovation scheme (CQUIN) for 2016-17 includes initiatives to improve staff health and well- being and the Trust is engaged in this work involving staff to identify relevant schemes.

Initiatives for 2016-17

In addition to continuing the work outlined above, the Trust has committed to the following initiatives in 2016-17 based on the Strategic Plan (2014-19) and Operational Plan (2014-16):

To roll out the “Triangle of Care” which is an approach to working with service users and their carers to ensure that carers and relatives feel engaged in the care and support of their loved ones. This programme is nationally recognised and the Trust will work closely with the central team.

To complete a review of learning disability services and implement changes agreed with commissioners including community services; assessment and treatment and respite.

To continue to support staff to demonstrate compliance with CQC fundamental standards and test compliance through a process of Quality Reviews with the stated aim of achieving a “good” rating at the CQC inspection in July 2016.

To implement the new urgent/emergency/crisis care model in line with commissioner plans and Mental Health Urgent Care Vanguard.