Part 2: Priorities for improvement and statements of assurance from the Board of Directors

2.1 Quality improvement priorities

Strategic principles

The Trust is passionately committed to improving the quality of patient safety and experience; and recognises the importance of being able to evidence this by positive treatment outcomes and continually improving effective services. As such improving service quality remains our ambition through supporting the embedding of quality in all aspects of the Trust’s practice and business. The Trust is dedicated to working in partnership with service users/patients, carers, governors, staff and stakeholders to ensure delivery of highquality services, underpinned by recovery principles. The Trust is committed to the earliest identification and needs of carers, as required by the Care Act 2014, as 'partners-in-care' in the implementation of each of its priorities in the coming year 2023/2024.

2.1.1 Approach to quality improvement

The Director of Nursing, Allied Health Professionals and Quality provides executive leadership for quality improvement and quality assurance.

This year exceptional demands have continued for the Trust and wider health and social care systems as we entered the recovery phase following the COVID-19 pandemic with increasing and robust governance arrangements being re-established.

A number of key assurance meetings with both internal and external involvement are regularly held to support the quality governance process including regular ward/team meetings, Operational Division Management Team meetings, Board meetings, Operational Performance and Governance Meeting, and four committees: Infection Prevention and Control / Legislative / Patient Safety and Experience / Mortality Surveillance which in turn report to the bi-monthly Quality Committee chaired by a Non-Executive Director (NED).

The Trust’s Board assurance and escalation framework details the Trust’s clinical governance and risk management processes, including the committee structure that ensures risk and compliance concerns are reported and escalated as appropriate to the Board.

The Trust’s overall current Care Quality Commission (CQC) rating is ‘good’, with the well-led domain being ‘outstanding’. There have been no CQC inspections during the last year, although Mental Health Act visits have continued.

The Trust's fundamental Quality Improvement (QI) approach is underpinned by supporting employees to make meaningful changes to improve quality for patients/service users/carers using the Model for Improvement against the Trust priorities outlined in the Trusts Quality Strategy 2021 to 2026.

2.1.2 Our quality priorities for 2022/2023: review of achievement

The Trust identified four quality priorities for 2022/2023 and each Operational Division adopted one priority to focus on.

2.1.3 Choosing our quality priorities 2023 to 2024

The Trust Quality Committee have agreed five key quality improvement priorities for 2023/2024, two in the domain of patient safety, two in the domain of patient experience and one in the domain of clinical effectiveness. The quality improvement priorities were selected taking account of several sources including the following:

• CQC inspection 2020 and Mental Health Act (MHA) visits feedback.
• National patient and staff surveys.
• NHSE reporting requirements.
• Commissioner’s requirements and feedback.
• Serious incidents, complaints, coroner and serious case review feedback (local and national).

The detail of these improvement priorities is still being worked up within the Divisions, each improvement priority area will have several projects which will have support from the central Quality Improvement (QI) team.

Ongoing measurement throughout the year will assist in monitoring our progress; and in developing the understanding and embedding from ward/team to Board of the Trust’s quality priorities. Progress to achieve the identified quality priorities for 2023/2024 will be monitored through the Operational Performance and Governance Group; and reported quarterly in their Divisional reports to the Patient Safety and Experience Committee, a sub-committee of the Quality Committee.

The graphic below demonstrates the alignment of the quality improvement work in the Trust.

Prioritising Quality in LPFT

LPFT Quality Strategy Priorities 2021-26

• Always deliver safe care and treatment and protect people from avoidable harm.
• Evidence of an inclusive safety culture and an effective learning environment.
• Delivering nationally recognised and evidence based clinical care.
• Embedding continuous quality improvement in all we do.
• To provide responsive and accessible services for the communities we serve.
• Listen to our patients and carers to really understand how it feels to be in touch with our staff and services.

Mandated indicators 2022/23

• Improve the involvement of carers and families in patient/service users care (Adult Inpatient and Urgent Care Division ATP)

• Reduction in the number of physical restraints across all inpatient wards by 10%, LMI.

• Early Intervention in Psychosis (EIP): People experiencing first episode psychosis treated with a NICE-approved care package within two weeks of referral, NMP.

• Memory Assessment Digital Pathway to support widening of the offer for patients with cognitive issues (Older People and Frailty ATP).

• Inappropriate out-of-area placements for adult mental health services, NMP.

• To make it easier for people who use our services to share their experiences of care by providing a range of methods to provide feedback across the services. This feedback will inform service development and improvement. (Specialist Services ATP).

• Improve the involvement of carers and families in patient/service user care. (Adult Community Services ATP).

Improvement priorities 2023/24

• Safer management of self injury and suicide.

• Improving physical healthcare including falls.

• Safe and appropriate restrictive practice.

• Improving patient experience of safety.

• Improving carer involvement.

Mandated indicators 2023/24

• Safer management of self-injury and suicide (Division ATP).

• Improving physical healthcare including falls (Division ATP).

• Reduction in the number of physical restraints across all inpatient wards by 10% LMI.

• Safe and appropriate restrictive practice (Division ATP).

• Early Intervention in Psychosis (EIP): People experiencing first episode psychosis treated with a NICE-approved care package within two weeks of referral, NMP.

• Inappropriate out-of-area placements for adult mental health services, NMP.

• Improving patient experience of safety (Division ATP).

• Improving carer involvement (Division ATP).

ATP = Annual Trust Priority

NMP = Nationally Mandated Indicators

LMI = Locally Mandated Indicators

2.1.4 Service development and improvement plan progress 2022/2023

The following provides a brief summary of progress against key clinical service development and improvement plans for the Trust during 2022/2023.

2.1.5 Service development and improvement plans 2023/2024

The following provides a brief summary of key clinical service development and improvement plans for the Trust in 2023/2024. The Trust has kept the plan to a small number of large-scale projects, rather than a large number of small-scale projects, as has been done in the past. In some cases, plans will be subject to business case development, consultation and governance, identified funding and/or Board of Directors/Council of Governors approval.

2.2.1 Assurance statement

The Trust’s Board of Directors is required to satisfy itself that the Trust’s annual quality report is fairly stated. In doing so, the Trust is required to put in place a system of internal control to ensure that proper arrangements are in place based on criteria specified by NHSE, the independent regulator of NHS Foundation Trusts. The Trust has appointed a member of the Board, the Director of Nursing, Allied Health Professionals (AHPs) and Quality, to lead and advise on all matters relating to the preparation of the Trust’s annual Quality Account.

To ensure that the Trust’s Quality Account presents a properly balanced view of performance over the year, the Trust’s Quality Committee, accountable to the Board of Directors, provides scrutiny and challenge. The Quality Committee ensures robust challenge, review and the provision of assurance to the Board in respect of quality and risk initiatives and reports, including escalating risks if required, as per the Trust’s Board Assurance and Escalation Framework (2022).

During 2022/2023 the Trust provided and/or sub-contracted three relevant health services, these services being mental health, learning disabilities and autism. The Trust has reviewed all the data available to them on the quality of care in three of these relevant health services. The income generated by the relevant health services reviewed in 2022/2023 represents 100% of the total income generated from the provision of relevant health services by the Trust for 2022/2023.

2.2.2 Participation in clinical audits and national confidential enquiries

During 2022/2023 8 national clinical audits and 2 national confidential enquiries covered relevant health services that the Trust provides. During that period the Trust participated in 62.5% of national clinical audits and 100% national confidential enquiries of the national clinical audits and national confidential enquiries. During this period the Trust participated in all clinical audits and national confidential enquiries where the services were included in this round or where there were a sufficient number of eligible patients.

The national clinical audits and national confidential enquiries that The Trust was eligible to participate in during 2022/2023 are as follows.

1. National Audit of Psychosis (NCAP); Early Intervention in Psychosis (EIP) audit
2. National Audit of Inpatient Falls (NAIF)
3. National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH); Real-time surveillance of patient suicide
4. National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH); Suicide (and homicide) by people under mental health care
5. National Audit of Care at the End of Life (NACEL); 4th Round
6. National Prescribing Observatory for Mental Health UK (POMH); Topic 1h and 3e – Prescribing of antipsychotic medication in adult mental health services, including high dose, combined and PRN
7. National Prescribing Observatory for Mental Health UK (POMH); Topic 7g – Monitoring of patients prescribed Lithium
8. National Prescribing Observatory for Mental Health UK (POMH); Topic 20b – Valproate prescribing in adult mental health services
9. National Prescribing Observatory for Mental Health UK (POMH); Topic 21a – The use of Melatonin  
10. National Prescribing Observatory for Mental Health UK (POMH); Audit of anti-libidinal medication prescribing practice

The national clinical audits and national confidential enquiries that The Trust participated in during 2022/2023 are as follows:

1. National Audit of Psychosis (NCAP); Early Intervention in Psychosis (EIP) audit – data collection, case note and contextual reviews.
2. National Audit of Inpatient Falls (NAIF) – case note review.
3. National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH); Real-time surveillance of patient suicide – Suicide Prevention group working with NCISH.
4. National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH); Suicide (and homicide) by people under mental health care – NCISH & Quality and Safety Team liaise, and cross reference recorded suicides.
5. National Prescribing Observatory for Mental Health UK (POMH); Topic 1h and 3e –Prescribing of antipsychotic medication in adult mental health services, including high dose, combined and PRN – data collection and case note review.
6. National Prescribing Observatory for Mental Health UK (POMH); Topic 7g – Monitoring of patients prescribed Lithium – data collection and case note review.
7. National Prescribing Observatory for Mental Health UK (POMH); Topic 20b – Valproate prescribing in adult mental health services – data collection and case note review.

The national clinical audits that The Trust did not participate in during 2022/2023 are as follows:

1. National Audit of Care at the End of Life (NACEL), 4th Round – not eligible to take part due to Mental Health not being included in the 4th round.
2. National Prescribing Observatory for Mental Health UK (POMH); Topic 21a – The use of Melatonin – LPFT did not proceed with this audit due to the low number of patients prescribed Melatonin.
3. National Prescribing Observatory for Mental Health UK (POMH); Audit of anti-libidinal medication prescribing practice – LPFT did not proceed with this audit due to there being no eligible patients being identified.

The national clinical audits that the Trust participated in, and for which data collection was completed during 2022/2023, are listed below alongside the number of cases submitted to each audit or enquiry as required by the terms of that audit or enquiry.

NCAPOP programme

Prescribing Observatory for Mental Health (POMH (UK))

The reports for 4 of the national clinical audits were reviewed by the provider in 2022/2023, the Trust intends to take the following actions to improve the quality of healthcare provided.

Organisational and Divisional teams carry out agreed audits throughout the year, these include:

Local clinical audits are undertaken by medical, nursing and psychology staff across the four divisions (Adult Inpatient & Urgent Care, Adult Community, Older People & Frailty and Specialist). When an audit has been completed, the audit lead shares the final report, recommendations, action plan where needed and sometimes the presentation with the audit team. All actions are managed and monitored by the audit lead. The table below shows the local audits that have been completed during 2022/2023:

There are a further 19 audits that have been approved by the Clinical Effectiveness and Improvement Group where the final report and actions have not yet been shared. The reports from the clinical audits above were reviewed by the Trust in 2022/2023, and the Trust intends to take the actions identified to improve the quality of healthcare provided in the individual action plans for each audit. The Trust has also taken part in the NHS England Learning Disability Improvement Standards benchmarking which consists of three elements: an organisational survey, a staff survey, and a patient survey. We expect the results of this exercise to be available later in the year, of which we will produce an action plan for continuing improvement. The results of the benchmarking project and correlating action plan will be included in the Quality Account for 2023/2024.

2.2.3 Participation in research 2022/2023

In 2022-2023, 757 service users/patients receiving relevant health services, provided or subcontracted by the Trust, were recruited during this period to participate in research approved by a research ethics committee. The Trust has some posts within the research team funded by the National Institute for Health and Care Research (NIHR) network to support NIHR studies hosted within the Trust and the wider health and care system. The Trust used national systems to manage the studies in proportion to risk. All studies were managed under national model agreement and research passport guidance. All studies are managed under the UK Policy Framework for Health and Social Care Research, which sets out principles of good practice in the management and conduct of health and social care research in the UK. Examples of NIHR studies hosted in 2022-23:

ACER: assessing the clinical and cost effectiveness of inpatient mental health rehabilitation services provided by the NHS and independent sector (University College London)

Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. These services include inpatient units and support accommodation in the community. When people have access to local rehabilitation services, most gain the skills to manage with less support over time, progressing from inpatient care to supported accommodation. However, over the last 15 years there have been major cuts to NHS rehabilitation services across England and increasing reliance on the independent sector. The Care Quality Commission reported in 2018 that over half the 4400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that people were staying twice as long compared to people treated in NHS rehabilitation units and they were much further from their home. However, we do not know whether the services provided by the NHS and independent sector differ in quality or patient outcomes.

There have been no studies investigating the effectiveness of inpatient rehabilitation services that have included the independent sector. Our project, funded by the NIHR Health Services Delivery Research, aims to address this gap. As it is not feasible to conduct a randomised trial to compare services provided by the NHS and independent sector, we will use five different components, incorporating quantitative and qualitative methods, from which we will triangulate results.

A survey of 60 inpatient mental health rehabilitation services across England (30 NHS and 30 independent sector). In-depth interviews with users, relatives/carers, staff and commissioners of these services to explore their experiences and perspectives. Compare 18-month outcomes for 600 patients of the NHS and independent sector. Compare outcomes of all users of NHS and independent sector inpatient rehabilitation on a census date using anonymised records and cost effectiveness analysis.

MODS: multimorbidity in older adults with depression (University of York)

Older adults (65 years and over) with long-term health conditions (such as diabetes, heart problems, asthma) are more likely to experience depression, which can lead to poorer quality of life and can be very costly to health and social care services.

Behavioural Activation (BA support) is a type of support which might be useful for people who experience symptoms of low mood or depression. It aims to help people maintain or introduce activities which are important to them. Such activities may benefit physical and emotional wellbeing. This support is provided within a care framework, called Collaborative Care, that supports a practitioner (such as a nurse) to work with the patient and other health professionals, so treatments are delivered in the most effective patient-centred way.

The MODS (Managing Multiple Health Conditions in Older Adults Study) programme of research aims to find out whether this BA support helps to maintain or improve physical and emotional functioning in this group of older adults​​​​​​​.

REACH: research into emergency ambulance calls to care homes (University of Lincoln)

We need to better understand how to improve the management, outcomes and experiences of residents and others involved in medical emergencies in care homes. There are at least 30 transfers for every 100 residents from residential care to Emergency Departments each year, of which around half result in admission to hospital. It is thought that over half of emergency transfers to hospital could be prevented with better ongoing care, access to primary care and training of staff. With the current COVID-19 pandemic there have been additional pressures which will have had further impact on this problem, and this also warrants investigation.  

We will systematically review the literature on this topic and survey care homes to review their practices and policies for dealing with medical emergencies. In addition, we will analyse routine data from the regional ambulance service and care homes in the East Midlands. We will interview residents and/or relatives, care home and ambulance staff to find out about their experiences. This will enable us to develop recommendations for improvement and prioritise them according to which are most likely to be implemented.  We will communicate the recommendations widely to care homes, ambulance services, commissioners, patient groups, public health departments, and the Care Quality Commission.

Performance in initiating and delivering research The Government wants to see a dramatic and sustained improvement in the performance of providers of NHS services in initiating and delivering clinical research. The Government’s Plan for Growth, published in March 2011, announced the transformation of incentives at local level for efficiency in initiation and delivery of clinical research. The Trust publishes data on initiating and delivering clinical research on a quarterly basis on the LPFT website research page.

2.2.4 Commissioning for Quality and Innovation (CQUIN) payment framework

What are CQUINs and what do they mean for the Trust?

The CQUIN payment framework was introduced in 2009 to make a proportion of providers’ income conditional on demonstrating improvements in quality and innovation in specified areas of care. Whether the Trust receives its CQUIN payments is dependent on achieving certain quality measures. This means that some of the Trust’s income is conditional on achieving certain targets that are agreed between the Trust and our commissioners.

2.2.4.1 Performance in CQUINs 2022/2023

CCG1: Achieving 90% uptake of flu vaccinations by frontline staff with patient contact to be reported Quarter 3.

90% uptake of flu vaccinations by frontline staff with patient contact. Not achieved.

CCG9: Cirrhosis and fibrosis tests for alcohol dependent patients

35% of all unique inpatients, staying at least one-night stay, aged 16+ with a primary or secondary diagnosis of alcohol dependence to have an order or referral for a test to diagnose cirrhosis or advanced liver fibrosis: Achieved.

CCG10: Routine Outcome Monitoring for CYP and Perinatal Services and community mental health services

40% of adults and older adults accessing select Community Mental Health Services (CMHSs), having their outcomes measure recorded at least twice. Achieved.

CCG11: Anxiety Disorder specific measures in IAPT

65% of referrals with a specific anxiety disorder problem descriptor finishing a course of treatment having paired scores recorded on the specified Anxiety Disorder Specific Measure. Achieved.​​​​​​​

CCG12: biopsychosocial assessments by Mental Health liaison services (Includes CCETT)

80% of self-harm referrals receiving a biopsychosocial assessment concordant with NICE guidelines. Achieved.​​​​​​​

2.2.4.2 CQUINs 2023/2024

CQUIN schemes

01 Flu vaccinations for frontline healthcare workers

15a Routine outcome monitoring in community mental health services

15b Routine outcome monitoring in CYP and community perinatal mental health services

17 Reducing the need for restrictive practice in adult/older adult settings

2.2.5 CQC – Registration and inspection

CQC role The CQC monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and publish what they find, including performance ratings to help people choose care. They set out what good and outstanding care looks like and make sure services meet fundamental standards below which care must never fall. The fundamental standards are:

• Person centred care
• Dignity and respect
• Consent
• Safety
• Safeguarding from abuse
• Food and drink
• Premises and equipment
• Complaints
• Good governance
• Staffing
• Fit and proper staff
• Duty of candour
• Display of ratings

Inspection regime

The CQC’s main approach is to carry out inspections of certain core services followed by an inspection of a well-led key question at trust level. Sometimes they will look at all core services (a comprehensive inspection) and sometimes just look at specific areas of concern (a focused inspection).

There are five questions they ask of all care services:

• Are they safe?
• Are they effective?
• Are they caring?
•  Are they responsive to people's needs?
• Are they well-led?

Core services

Core services are the ones that most trusts provide. They are typically services that people use the most, or in some cases, the ones that may carry the greatest risk.

The Trust are registered for the following core services:

• Acute wards for adults of working age and psychiatric intensive care units
• Long stay or rehabilitation mental health wards for working age adults
• Forensic inpatient or secure wards
• Wards for older people with mental health problems
• Community-based mental health services for adults of working age
• Mental health crisis services and health-based places of safety
• Specialist community mental health services for children and young people
• Community-based mental health services for older people
• Community mental health services for people with a learning disability or autism

During 2022/2023 the Trust has not received a core, comprehensive or focused inspection. View the 2020 CQC rating summary on the CQC website.

2.2.5.1 Registration

The Trust is required to register with the CQC, and its current registration status is fully registered.

The Trust has no conditions on registration.

The Trust has been registered to carry out the following regulated activities:

• Treatment of disease disorder or injury
• Assessment and medical treatment of persons detained under the MHA 1983
• Diagnostic and screening procedures

The CQC has not taken enforcement action against the Trust during 2022/2023. The Trust has not participated in any special reviews or investigations by the CQC during the reporting period.

Mental Health Act Reviews

The CQC as a regulator also keeps the use of the Mental Health Act (MHA) under review and checks it is being used properly. MHA Reviewers perform this work by visiting all places where patients are detained under the act. The table below identifies the visits conducted during the reporting year:

The Trust is fully compliant in respect of previous MHA visits; MHA CQC visit action plans are monitored through the Trust’s Legislative Committee.

Internal Assurance

The Trust’s compliance assurance mechanisms include a schedule of 15 Steps/quality governance visits to clinical areas in both inpatient and community settings. Our commissioners attend these visits. Non-executive directors and directors carry out scheduled and non-scheduled visits to clinical areas throughout the year, informal cuppa sessions in inpatient areas happen led by the patient experience team and within the adult inpatient division matrons have commenced ‘walkarounds’ which assess a range of core clinical standards.

2.2.6 Statement on quality of data, governance assessment report scores and clinical coding

The Trust submitted records during 2022/2023 to the Mental Health Services Dataset (MHSDS) and the IAPT minimum Dataset (IAPTDS) for inclusion in the Hospital Episode Statistics which are included in the latest published data.

The percentage of records in the published data:

Which included the patient’s valid NHS number was:

• 100% for MHSDS
• 100% for IAPTDS

Which included the patient’s valid General Medical Practice Code was:

• 100% MHSDS
• 99% IAPTDS

To improve data security and protection for health and care organisations, the Department of Health and Social Care, NHS England and NHS Improvement published 3 Board Leadership Obligations:

• People: Ensure staff are equipped to handle information respectfully and safely, according to the Caldicott Principles. (Data Security Standard 1 to 3).
• Process: Ensure the organisation proactively prevents data security breaches and responds appropriately to incidents or near misses. (Data Security Standard 4 to 7).
• Technology: Ensure technology is secure and up to date. (Data Security Standard 8 to 10).

Under these 3 Leadership obligations sit 10 Data Security standards which all Health and Social Care providers must comply with. To provide evidence of this compliance health and social care organisations must make mandatory submissions to the on-line toolkit. The Data Security and Protection Toolkit (DSPT) also considers data protection updates under the General Data Protection Regulation (GDPR) as well as developments relating to Cyber Security.

For the reporting period 01 April 2022 to 31 March 2023 the Trust is working towards delivery of the 2022/2023 data security toolkit with a final complete submission due to NHS Digital on 30th June 2023 (the DSPT does not run parallel to the financial year). An independent audit of the Trusts DSPT submission took place in March 2023 and the auditors were able to give a rating of Significant Assurance. There were 3 low impact actions identified as part of the audit action plan which the Trust are acting on to ensure they are complete in readiness for the final submission that is due at the end of June 2023.

DSPT progress charts

The table below demonstrates the Trust current position in the toolkit. Of the 113 assertions required, the trust have completed 109. The remaining four assertions will be completed prior to the final submission on 30 June 2023.

Source: www.dsptoolkit.nhs.uk

During the reporting period there have been no serious incidents or complaints requiring escalation to the Information Commissioners Office.

2.2.6.1 Payment by results (PbR)

The Trust was not subject to the Payment by Results clinical coding audit during 2022/2023 by the Audit Commission. Any references to the Audit Commission are now out of date because it has closed. From 2014 responsibility for coding and costing assurance transferred to Monitor and then NHSI. From 2016/17 this programme has applied a new methodology and there is no longer a standalone ‘coding audit’ with error rates as envisaged by this line in the regulations. The clinical coding audit results are now reported as part of the Data Security and Protection Toolkit and consistently achieve a strong assurance rating.

2.2.7 Learning from deaths

Data presented within this section is for learning within the Trust and is not comparable with any other Trusts (Acute, Community or Mental Health) published data, it should not be used to provide organisational benchmarking or presented as comparators in any onward reports. The Trust Board of Directors (BoD) is responsible for assuring itself and the public that they are reporting and reviewing deaths of patients where appropriate, and any learning identified is acted upon for the purposes of continuous improvement. This ensures information regarding any deaths of patients is appropriately escalated to the BoD, supported in this role by an effective sub-committee structure, the Mortality Surveillance Committee (MSC) and Quality Committee. This process is aligned to recommendations made from the National Quality Board: Learning from Deaths. Whilst this entry is about reporting numbers it is important to remember that every death involves the loss of a loved one from family and friends’ lives. This is often a difficult and distressing time for those close to the person and as such the Trust aims to support and further develop strong family engagement. Through this we will ensure that value is gained from learning from deaths and openness and transparency is central to this process.

The total number of deaths reported in this section includes:

• people open to Trust services at the time of their death
• people who died within 6 months of contact with Trust services
• people’s deaths that are referred for Learning Disabilities Mortality Review (LeDeR)
• deaths investigated as Serious Incidents (SIs).

2.2.7.1

During Q1-Q4 2022-2023 1064 patients are reported to have died within 6 months of their last contact with mental health, learning disability and autism services provided by the Trust. Broken down per quarter:

Q.1 2022-2023 213

Q.2 2022-2023 272

Q.3 2022-2023 278

Q.4.2022-2023 301

(These figures are correct as at 24/04/2023).

2.2.7.2

Between Q.1 and Q4 2022-2023, 19 Serious Incident (SI) investigations have been completed in relation to the deaths included in item 2.2.7.1. 8 were for deaths in Q1 2022-2023, 9 for Q2 and 2 for Q3. At the time of writing there are 14 SI investigations open in relation to deaths that occurred during 2 in Q2, 3 in Q.3 and 9 in Q4 2022-2023.

Between Q.1 and Q.4 2022-2023 8 deaths have been referred by the Trusts for a LeDeR review. Between Q1-Q4 2022-2023 5 Mortality Care Reviews (MCRs) have been completed in relation to deaths included in item 2.2.7.1. 3 were for deaths in Q1 2022-2023, 2 for Q2 and 0 for Q3.

No deaths have had more than one process of review.

2.2.7.3

0% of the patient deaths during the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. This number has been estimated using the root causes identified in SI investigations and responses to “Was the patient’s death considered more likely than not to have resulted from problems in care delivery or service provision?” in the MCRs.

Given the majority of reported deaths relate to patients in receipt of care in the community or those who have died within 6 months of discharge and the often-limited information available, the Trust does not determine nor judge the probability of ‘avoidability’ of deaths. Following national guidelines, the Mortality Surveillance Committee (MSC) had decided to utilise the Royal College of Psychiatrists (RcPsych) mortality review tool, a nationally designed tool for mental health Trusts and this committee also decided the grading outcome of deaths would be stopped and replaced with “problems in care” as other Trusts have done.

The Trust is currently undertaking the follow-up work following a Learning from Deaths review by National Health Service England (NHSE), this is a voluntary process to seek any improvements that will be beneficial to the Trusts Learning from Deaths processes. The feedback from the review was largely positive but there are areas we are looking to work with them to further develop including potentially testing a refined tool for case review and the associated training.

2.2.7.4

The key areas for system improvement have been identified from the review and investigation process:

• To strengthen inpatient systems and processes to ensure all salient physical health needs of patients are appropriately understood, care planned, and communicated appropriately. Specific focus upon the involvement of carers and families and other healthcare teams involved with the patient’s care prior to inpatient admission; and joined up multi-disciplinary working/care planning with physical healthcare teams/organisations throughout inpatient admission.
• Shared system access with other organisations who provide care alongside Trust mental healthcare.
• Greater focus upon carer/family involvement in patient care plans and crisis contingency planning.
• A theme noted regarding the increasing number of ‘take home’ prescriptions given to patients upon discharge from some inpatient units and the difficulty some patients have in accessing prescription in the community following discharge.
• Greater focus upon joined up crisis contingency planning where patients are in receipt of care from different Trust teams. For example, Crisis Team, Outpatients, and Community Mental Health Teams. Work is currently ongoing in these areas.

Positive practice has also been highlighted, including

• Therapeutic relationships.
• Families spoke of the benefits of their involvement in the patient’s care and in risk contingency planning and they said they felt ‘listened to’. Highlighted exemplary practice by Older Adults Division regarding quality of falls assessments and pathway.
• Consistent and timely follow up of patients following inpatient discharge in line with national required standards.
• Community patients and their GPs are consistently and routinely sent written documentation of agreed care plan following each outpatient appointment.
• Failed planned contacts are consistently followed up across inpatient and community teams.

2.2.7.5

Lessons are identified within the bi- monthly MSC meeting and disseminated back to the Divisions and as part of SI investigations. Appropriate leads for any actions that need to be implemented are identified to oversee and ensure their completion. Information is also disseminated throughout the Trust via the ‘Safety Matters’ bulletins.

There is ongoing work to ensure learning is captured and acted on through MSC, the Organisational Learning Meeting and the Journey of learning. Extensive revision of the MSC and our Mortality Care Review (MCR) process is being undertaken to make reviews and learning more robust and align it with the changes associated with the Patient Safety Incident Response Framework (PSIRF) due to be implemented within the next 12 months. However, assurance is provided that any omissions in care would be picked up through the current SI process and therefore whilst this improvement work in our mortality care review process is undertaken, we are confident omissions are already captured.

A new project has been established named the ‘Journey of Learning’ which aims to understand the flow of information from systems, investigation and national directives and establish effective systems of information sharing to strengthen the process of learning with clinical staff. This is co-produced project with the Divisional Quality Assurance and Improvement Leads and Corporate Services (Quality, Safety and Communications). Already an A4 summary for each SI and MCR has been created which pulls out the main themes and actions. There is also a monthly summary again of all learning and actions from SIs and MCRs that will be distributed throughout the organisation, recognising that bite size learning is most effective for frontline staff.

Finally, there has been recognition that traditionally in the NHS the information obtained from PALS/Complaints, Serious Incidents, Patient Safety Incidents, Claims, LeDeR reviews, MCR and National guidance sit within different parts of the organisation with their own unique corrective action plans. This can lead to duplication of actions and focus on transactional actions with impact being limited in spread. Our monthly Organisational Learning Meeting (OLM) addresses this through safe and open discussion encouraging a just and learning culture. It is also a process that is highly compatible with the PSIRF. The meeting is a multidisciplinary meeting where all sources of learning and improvement are shared and there is open discussion on a key theme. These top themes are identified from the data, existing improvement work in relation to the theme is captured and further work identified. 

Data, learning, change and impact are vital for improvement.

2.2.7.6

As the Trust is currently undertaking the actions identified in 2.2.7.4, we will report any impact upon the safety and experience of patients through our Clinical Effectiveness and Improvement Group, Patient Safety and Experience Committee, Quality Committee, Board of Directors meetings and the future quality account.

2.2.7.7

1 serious incident investigation was completed during Q1-Q.4 2022-2023 which related to deaths which took place before the start of the reporting period, i.e., a death that occurred in the previous financial year 2021-2022. There were in addition 3 MCRs completed in Q2-Q3 22-23 that occurred before this reporting period: 2 of these deaths occurred in 2021-2022 and 1 in 2019-2020.

2.2.7.8

0% of the patient deaths before the reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. This number has been estimated using the root causes identified in SI investigations and responses to “Was the patient’s death considered more likely than not to have resulted from problems in care delivery or service provision?” in the MCRs.

2.2.7.9

0% of the number in item 2.2.7.1 of the relevant document for the previous reporting period are judged to be more likely than not to have been due to problems in the care provided to the patient. However, whilst it must be stated that although no root causes were identified in any of the SI investigations there has been many recommendations made in the SI investigations aimed at improving care, all of which have all had their own action plans owned by the relevant Divisions.

2.2.8 Freedom to Speak Up

The Trust recognises that our staff provide the best resource possible for identifying where improvements may need to be made. The Trust seeks to provide secure routes for all workers to raise concerns and this is enshrined in the Board of Directors Speaking Up Declaration 2022-2023. Staff can raise concerns via several routes, dependant on the situation and the best fit for the individual. It is hoped that one or more of these will enable staff to speak up, be heard and feel valued for raising their concerns.

Where possible, staff should raise their concerns in the first instance to their line manager or supervisor. Where a staff member would prefer or feels they need a different route, alternative options include a senior manager, a Governor, a member of the Board, including the Chief Executive Officer (CEO) and Non-Executive Director (NED), who act as Executive and Non-Executive leads for Speaking Up respectively. In addition to these, the Trust also has a dedicated Freedom to Speak Up Guardian (FTSUG) and FTSU Champions.

At Lincolnshire Partnership, the FTSUG role is full-time and substantive to allow maximum availability and consistency to staff. The FTSUG is supported by a team of 5 Freedom to Speak Up Champions, who work across the county and in a variety of roles. Staff can raise concerns direct to the FTSUG either face-to-face, using MS Teams, via email or dedicated telephone line or through the Trusts Speaking Up email address which is monitored by the FTSUG.

As well as being available to listen to concerns from staff, the FTSUG also offers ongoing support to anyone who has raised a concern, regardless of who the concern was raised to. This support continues after the conclusion of any investigation, should one take place. This guards against instances of staff suffering detriment because of speaking up.

The FTSUG Guardian also records numbers of concerns raised and provides this information to the National Guardian’s Office as well as the Trust’s board on a quarterly basis. Between the start of April 2022 and the end of March 2023, 76 concerns have been raised by staff on a wide variety of issues. The staff that have spoken up come from a full spectrum of the professions represented in the Trust and concerns have been received from most of the locations in Lincolnshire in which the Trust houses services.

Staff who raise concerns are also asked to provide feedback about their experience via a form created to gather this data. The form can be returned to the FTSUG via email, to the Speak Up email address, be posted anonymously to the FTSUG’s office address or be given verbally at the culmination of the process. Of those who have provided feedback to the FTSUG since April 2022, all have reported a positive experience and have stated that they would speak up again. The FTSUG reports concerns that are covered by the Public Interest Disclosure Act (PIDA) directly to the CEO and will help staff find the correct pathway for staff whose concerns are not covered by PIDA such as grievances.

If staff’s concerns relate to bullying or harassment of staff or patients with a Protected Characteristic, the Trust’s Equality and Diversity lead is also available to provide support and advice.

2.2.9 Performance against core quality account indicators

Since 2012/13 the Trust has been required to report performance against a core set of indicators using data made available to the Trust by NHS Digital. This feeds the Mental Health Services Data Set. This data covers the period April 2022 – March 2023.

For each indicator the number, percentage, value, score or rate (as applicable) for at least the last two reporting periods is presented below. Where available, for each indicator, the rate for the last seven reporting periods is presented. In addition, where the data is made available by NHS Digital, a comparison is made of numbers, percentages, values, scores or rates of each of the Trust’s indicators with the national average for the same, and those NHS trusts and NHS foundation trusts with the highest and lowest for the same.

2.2.10 Quality of information

The Trust generates monthly performance reports, with dashboard summaries of the Trust’s position against key performance indicators. These provide validated performance information monthly, which are shared with the Board of Directors, services, and commissioners; and are included in the Board of Directors’ monthly reports.

Where the Trust has included relevant indicators and performance thresholds within this section (part two of the quality report), in accordance with the quality accounts regulations, it has not reported these again in part three of the quality report.

In normal circumstances to review progress and prepare for the completion of a director’s statement in the published quality report in 2022/2023, the Trust would engage its external auditors to:

• Review the arrangements put in place to ensure the quality report framework is robust.
• Review the data accuracy of the proposed mandated performance measures, which are Early intervention in psychosis (EIP) access to treatment and out of area admissions in addition to the local indicator for restraint. • Identify the requirements of good practice internal control systems for data quality.
• Provide recommendations to put these best practice arrangements in place in advance of the 2022/2023 published audit opinion.
• The Trust will manage the implementation of the action plan, generated by its external auditors, through the Board committee structure.
• Review progress against the locally mandated indicator and the mandated indicators.

In line with national guidance on producing the Quality Account, “there is no national requirement for NHS trusts or NHS foundation trusts to obtain external auditor assurance on the quality account” so the data contained within this report has not been subject to external scrutiny nor will receive an action plan based upon independent testing of data quality from this report.

2.3 Summary of Rota Gaps and Quality Improvement for NHS Doctors and Dentist in Training (England) 2016

Please note, information in this section covers the period April 2022 – December 2022 only due to sign off of final data for the period January 2023 – March 2023 not being available until July 2023.

The Terms and Conditions of Service (TCS) of the new junior doctor contract require the Guardian of Safe Working (GoSW) to submit reports to the Board, together with an aggregated annual report. For the period 1 April 2022 to 31 March 2023 GoSW reports were submitted to 28/07/2022 and 26/01/2023 Trust Board meetings. The reports submitted within the last year provide a consistent account to the Board that the Trust remains complaint with the junior doctor contract with no significant breaches. There have been no fines for the Trust and junior doctors are engaging in regular meetings.

Number of trainees during the period (as per their rotation)

FY – Foundation Year     CT – Core Trainee​​​​​​​

Junior doctors rotate regularly in first week of April, August, and December. Core trainees rotate six monthly and GP and foundation trainees rotate four monthly.

Vacancies on out of hours rota

All junior doctors participate in the out of hours on-call rotas except foundation year 1 (FY1) doctors.

April – August 2022

• 1x GP absent for the whole rotation
• 5 x Vacant slots (see table)

August – December 2022

• 2x Vacant slots (see table)
• 3 x MTI’s started late in Oct 2022, but Medical Human Resources could not add them to the rota until December 2022.
• One CT trainee left in October

Use of locums and covering vacancies

The gaps in the out of hours rota were caused by absence and the vacant slots. Following are the details of number of shifts filled as locum. All locum shifts were filled by internal locum system.

• April – 6 shifts
• May – 4 shifts
• June – 7 shifts
• July - none
• August – 2 shifts
• September- 19 shifts
• October- 20 shifts
• November- 21 shifts

Rotas

There has been no change in the rota system since the last report and the Trust continues to operate 2 out of hours rotas covering South and North areas. North rota covers Lincoln area and south rota covers Boston and Sleaford which requires doctors to travel in between sites. During Covid 19 pandemic, the Trust decided to revert all residential on-call shifts to non-resident on-call on a temporary basis. This arrangement is still in place and regularly under review.

Rest

There is no change in rest periods and rest periods are included in both the rotas and juniors continue to receive an appropriate time- off during the week when on a particular shift.

Rest facilities

Junior doctors continue to use the Trust rest facilities on 2 sites (Lincoln and Boston) which are constantly upgraded as per the feedback from Junior doctors.

LTFT (Less than full time trainees)

April December 2022 - 1 LTFT

Aug to Oct 2022 - 1 LTFT who left

The issues related to LTFT trainees are regularly discussed in Junior Doctor Forum and an LTFT champion is available to support LTFT trainees. There were no major concerns highlighted during this period.

Exception reports

Exception reporting (ER) is the mechanism used by doctors to inform the employer when their day-to-day work varies significantly and/or regularly from the agreed work schedule. The reporting system gives the supervisor an opportunity to address issues as they arise and to make timely adjustments to the work schedules if needed.

In total 2 ERs were received on the system during this period.

Apr to Aug 2022  

• ER FY1 north

Aug to Dec 2022

• 1 ER FY1 north

Jan to March 2022

• TBC

Both the ERs relate to similar issue and the management are aware of this issue. ERs have been resolved by the clinical supervisor with appropriate TOIL (Time off in Lieu) if needed on both the occasions.

Fines

The Guardian of Safe Working has the power to levy financial penalties when safe working hours have breached the provisions as outlined in the Terms and Conditions of Service (TCS) of the new junior doctor contract. There have been no fines during this period.

Junior Doctor Forum (JDF)

The JDF gives junior doctors the opportunity to raise any concerns directly with the management. In addition, junior doctor representatives can attend Local Negotiating Committee (LNC) meetings to raise any issues. JDF meetings are held bimonthly through Microsoft Teams or face to face.

Junior Doctor induction and feedback

There are no concerns highlighted around this. GoSW and Freedom to Speak up Guardian attend the junior doctor induction on every rotation.

End of placement feedback

Trainees are encouraged to participate in end of placement survey (anonymous) to provide feedback about their training experience within the Trust. This also ensures any issues related to a particular post can be resolved promptly.