SOUTHAMPTON UNIVERSITY HOSPITALS NHS TRUST
Learning Disabilities Compliance Report (Including CQC Performance Assessment Criteria 2009/10 Report to:
Trust Board 29th March 2011
Report from:
Julia Barton, Associate Director of Nursing & Patient Experience
Sponsoring Executive:
Judy Gillow, Director of Nursing and Quality
Sponsoring Divisional Director: Aim of Report/ Principle Topic:
N/A 1. To provide board members with an update on progress with actions identified from the previously reported gap analysis from the Six Lives Report (2009) and the Michaels Report. 2.To highlight risks in compliance. 4. To provide a briefing on CQC registration compliance (Performance Assessment 2009/10) for access to healthcare for people with a learning disability
Review History to date:
Recommendation(s):
5. To provide an updated trust plan for improving the care treatment and experience of people with learning disabilities accessing acute care (2011). Previous Report: 1) Trust Learning Disabilities Group 11th January 2010. 2) CSCSG 3rd February 2010 3) TEC 23rd June 2010 This Report 1) Trust LD Group 1st February 2010 2) QGSG 16th February 2011 3) TEC 2nd March 2010 Board members will note the progress made int he last 2 Qs in order to achieve compliance with CQC requirements and the Michaels report, and approve the updated LD improvement plan set in place to achieve full compliance.
1. Strategic context: This report provides an update on the previous gap analysis in hospital learning disabilities (LD) care, which was initiated from the recommendations of the Michaels Report, from the CQC outcomes specific to acute hospital care for people with LD and from the PHSO report in 2009. The report also details actions taken in the previous two quarters to improve care and treatment for people with LDs attending Southampton University Hospitals NHS trust. The Trust’s LD Improvement plan has been updated in the light of progress made and actions taken (see appendix A). 2. PPI: People with learning disabilities access all trust services. Consultation with service users is available the following routes: ♦ Via the chair and representatives of the Southampton City LD Health Strategy group ♦ Via Community LD Service User groups of HPFT (via SUHT LD Liaison nurses) ♦ Via “the Biog Health Talk” service user events held across Hampshire ♦ Via Choices advocacy service
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3.0 Specific Detail: 3.1 CQC Learning Disabilities Access Performance Indicators In January 2010 the CQC released six performance indicators to ensure equality of access and equity for all people with a learning disability.
No CQC Criteria 1
2
Performance Scoring
Does the trust have a mechanism in place to identify and flag patients with learning disabilities* and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these patients?
Protocols/mechanisms are not in place. (2) = Protocols/mechanisms are in place but have not yet been implemented. (3) = Protocols/mechanisms are in place but are only partially implemented. (4) = Protocols/mechanisms are in place and are fully implemented.
In accordance with the Disability Equality Duty of the Disability Discrimination Act (2005), does the trust provide readily available and comprehensible information** (jointly designed and agreed with people with learning disabilities, representative local bodies and/or local advocacy organisations) to patients with learning disabilities about the following criteria: treatment options (including health promotion)
Scoring: 1. Accessible information not provided 2. Accessible information provided for one of the criteria 3. Accessible information provided for two of the criteria 4. Accessible information provided for all three of the criteria.
• •
SUHT Self Assessment in June 2010
Update on Self Assessment in February 2011
Currently – We are able to identify patients with learning disabilities via the complaints and PALS system but not via PAS and the AER system. Plans to include in new ereporting form on safeguard and PAS coding requires development with the new inpatient module work programme. Score = 2 Whole organisational review required Score = 1
Completed ♦ New PAS alert for patients with LD in place but issues re: consent. In Progress ♦ Patient record sticker system to alert staff to patients known to the community LD team. ♦ Electronic reporting will have a field included.
RAG
A Updated Score = 3
Completed ♦ Review of accessible information completed ♦ Accessibility to information provided on all patient information ♦ New policy for producing patient information and style guidelines takes account of patients with LDs.
A In Progress ♦ Development of leaflets, story boards and photo booklets in progress
Updated Score = 2
complaints procedures,
appointments
2
3
4
5
Does the trust have protocols in place to provide suitable support for family carers who support patients with learning disabilities, including the provision of information regarding learning disabilities, relevant legislation*** and carers' rights?
Does the trust have protocols in place to routinely include training on learning disability awareness, relevant legislation***, human rights, communication techniques for working with people with learning disabilities and person centred approaches in their staff development and/or induction programmes for all staff? (1-4)
Does the trust have protocols in place to encourage representation of people with learning disabilities and their family carers within Trust Boards, local groups and other relevant forums, which seek to incorporate their views and interests in the planning and development of health services? (1-4)
(1) = Protocols/mechanisms are not in place. (2) = Protocols/mechanisms are in place but have not yet been implemented. (3) = Protocols/mechanisms are in place but are only partially implemented. (4) = Protocols/mechanisms are in place and are fully implemented. (1) = Protocols/mechanisms are not in place. (2) = Protocols/mechanisms are in place but have not yet been implemented. (3) = Protocols/mechanisms are in place but are only partially implemented. (4) = Protocols/mechanisms are in place and are fully implemented.
SUHT – no formal protocols in place. Working group reviewing transitional arrangements in place. Score = 1
(1) = Protocols/mechanisms are not in place. (2) = Protocols/mechanisms are in place but have not yet been implemented. (3) = Protocols/mechanisms are in place but are only partially implemented. (4) = Protocols/mechanisms are in place and are fully implemented.
Currently exploring opportunities via choices advocacy service (IMCAs) to use LD reference group for consultation and feedback.
Learning disabilities awareness sessions and training sessions planned for 2010 and e-learning via induction is planned. All wards and departments now have Leaning disabilities resource folders to assist in local staff induction. These include training packages and these are available via the SUHTRANET. Score = 3
NHS SC Health Strategy Group also includes LD service user reps and SUHT a member of this group.
Completed ♦ Transitional arrangements guidelines and patient information now in place. In progress ♦ New trust LD policy drafted – section on provision of support for carers included. ♦ February 2011 Carers support awareness project to commence.
Completed ♦ Training programme now on rolling half day ♦ Mandatory training requirements now in trust educational requirements matrix. ♦ All wards have LD Resource folders In progress ♦ E-Learning programme being reviewed ♦ Resources on staffnet under development ♦ IPLU audit of awareness of resource folders reveals further awareness-raising required. ♦ Mencap “Getting it right” campaign to be launched 2011. Completed ♦ Service user reference group for health issues being accessed by LD liaison nurses (HPFT) ♦ New LD patient experience survey being launched in February 2011 ♦ Continued membership of SC LD service User group ♦ Specific feedback on LD patient’s perceptions of SUHT received via NHS Hants “Big Health Talk events
A Updated Score = 3
A Updated Score = 3
G Updated score = 4
Picker adapted patient experience questionnaire for vulnerable adults being planned. Suggested score = 3
3
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Does the trust have protocols in place to regularly audit its practices for patients with learning disabilities and to demonstrate the findings in routine public reports? (1-4)
(1) = Protocols/mechanisms are not in place. (2) = Protocols/mechanisms are in place but have not yet been implemented. (3) = Protocols/mechanisms are in place but are only partially implemented. (4) = Protocols/mechanisms are in place and are fully implemented.
No specific work streams identified for this. Suggested score = 1
Completed ♦ LD standards of care and treatment set out in draft LD policy with 2 yearly audit programme to measure these.
A Updated Score = 3
Summary Of the 6 CQC standards, the trust’s current position is that 5 are rated at score 3 (protocols in place but only partially implemented) and 1 is rated at green (protocols in place and fully implemented). This is a significant improvement from the first self assessment in June 2010 and the progress made will enable full compliance to be reached with CQC standards in 2011.
3.2 SUHT Gap Analysis for Six Lives Ombudsman Report N Area for Review o 1 Communication The dissemination of policy and information to staff about standards and best practice Staff training Multidisciplinary communication Inter-organisational communication
SUHT Progress
Gaps Identified
Progress at February 2010
2008/9: Production of Communication Handbook available at every bed space.
There is currently no Acute Care LD pathway in place to facilitate multi disciplinary and cross organisational communication – to be added to improvement plan
♦ LD Care Pathways under development and will be included in new LD policy.
There is currently no specific LD training programme for staff provided internally and no expertise to deliver this – already an action in improvement plan
♦ Ward LD Resource Folders in place
2009/10: Production of Ward and Department Learning Disability Resource Folders including key policy documents, tools and contacts Learning Disabilities Awareness day held in December 2009, including
A plan to develop an effective learning method to include
RAG
♦ LD awareness training now included on rolling half day.
G ♦ LD e-learning under review ♦ Hospital grab sheet in place. LD patient pass port being implemented by HPFT.
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launch of resource folders. Attendance low for some sessions. The Trust LD Group has been developing the use of a LD “Passport” to aid communication.
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Partnership Working and Co-ordination Transition arrangements from paediatric to adult services Discharge Planning Appointment of care coordinators
2010/11: Plans are in place to use a theatre company to raise awareness of the needs of patients with LDs 2009/10: transitional arrangements are normally initiated by paediatricians and agreed with the relevant services involved. Care coordination is provided by the relevant learning disability service where this is available.
LD/Vulnerable adults awareness raising at Trust induction is required (PCT contract) – already in improvement plan There is minimal written or specific patient information available for people with learning disabilities – already in improvement plan
There is currently no formalised multidisciplinary or interorgansiational process or pathway for transitional arrangements – added to improvement plan. Carer involvement in planning transitional arrangements should be strengthened – as above
♦ 1 WTE LD liaison nurses from Community LD Team commenced at SUHT in October 2010. ♦ Review of LD patient information completed and plans underway to develop core information in accessible format.
♦ Transition arrangements now in place. ♦ Discharge planning standards included in new LD policy
G ♦ LD liaison nurses now in post and advising on specific LD patient care and treatment issues.
The effectiveness of discharge arrangements for people with learning disabilities is unknown. As per above, there is no tool or pathway used across the organisation to facilitate this process – added to improvement plan (under integrated pathway) Finding has not been available form PCT commissioners to appoint a LD Liaison Coordinator as yet in 2009/10 – already in improvement plan.
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3
4
5
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Relationships with Families and Carers Involvement of family members and carers as part of the MD team
2009/10: Involvement with families and carers occurs at service level. Staff appear to expect family and carers to support patients with learning disabilities by having a constant presence at their bedside.
Following Routine Procedures Following agreed standards and guidance Discharge Care Planning Nutrition & Hydration Discharge
2009/10: The new learning Disabilities resource folder includes useful information about associated health conditions.
Quality of Management Staff understanding of personal accountability Proactive approach to addressing poor practice Challenging inadequate systems Management support for these staff concerns/actions
2009/10: the Trust LD agenda is led by one of the ADNS roles and is clearly linked into the vulnerable adults agenda.
Advocacy Use of independent advocates
The Trust Learning Disabilities Group has membership from commissioners, LD service providers and care group representatives. 2009/10: The Trust is developing strong working relationships with the Choices Advocacy service in relation to the use of IMCAs.
There are no clear guidelines for staff on family and carer involvement – added to improvement plan There have been miscommunications about the availability of carer support for inpatients with learning disabilities causing friction on several fronts – added to improvement plan. There are no, pathways or guidelines for fundamental care and treatment for people with learning disabilities – KPIs already included in improvement plan. There are no specific service standards or KPIs for people with learning disabilities – added to improvement plan. There are no specific LD champion roles or lines of accountability or responsibility identified at care group or ward/department level – added to improvement plan. Care group attendance at the Trust LD group is consistently poor – Added to improvement plan. There has been 1 incident of lack of IMCA referral in 2009 – included in Safeguarding Adults work stream.
♦ New LD policy sets out standards for carer and family involvement and support. ♦ Carers support awareness project in Feb 2011.
G
In progress Memorandum of agreement for paid/commissioned carer support for hospitalised patients to be developed. ♦ All included in care standards for LD patients in new LD policy now drafted.
G
♦ Staff roles and responsibilities clearly set out in new trust LD policy. In Progress Care group attendance at trust LD group has remained patchy. Links with specific matrons and medical staff being developed via liaison roles.
♦ Advocacy arrangements in place but further incidents of staff not ensuring IMCAs are appointed when patients are unbefriended.
G
A
6
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Complaint Handling & Remedy Confused and fragmented systems Little effort made to understand and clarify complaints Poor investigations Defensive explanations Reluctance to offer apologies Failure to address the heart of the complaint Unremedied Injustice
The Trust’s Safeguarding Adults and Mental Capacity policies and training are fully implemented. 2009/10: A member of the PALS team is a key member of the Trust LD group and along with the Head of Complaints are regular attendees.
The AER incident reporting form does not include space to indicate whether a patient has learning disabilities or not, therefore the number of incidents relating to people with learning disabilities in un-reportable – included in current improvement plan.
♦ LD complaints and PALs analysis available In Progress ♦ Incident reporting not yet available but being developed via e-reporting project.
A
The Head of PSS provides a detailed report of the number of PALS inquiries and complaints relating to people with learning disabilities every quarter. 2010/11: Discussions are underway to include a LD category in the new Safeguard E-Incident reporting system currently being implemented.
4. Financial Information: Failures in care and treatment could result in significant clinical negligence and remedy claims. There is currently no specific Trust budget for training, information or human resources for any element of the LD agenda. 5. Legal Implications: Failure to provide equitable care to people with learning disabilities could result in organisational or individual practitioner legal proceedings under the Disability Discrimination, Human Rights or Mental Capacity Acts. In 2010, failure to meet CQC performance indicators could impact on Trust CQC registration status.
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Appendix A: SUHT Improvement Plan for People with Learning Disabilities (Updated January 2011) Area for Improvement
Improving Attitudes & Awareness • •
Raising staff awareness Training.
Improving Care Pathways
Work Stream 1) LD Champions to be appointed and developed via NMG paper Their learning to include: • Attitudes • Referral • Capacity, consent • Communication 2) Implement Mencap “Getting it Right” campaign 3) Deliver rolling half day LD training 4) Develop e-learning LD programme and include in trust induction mandatory requirements
Lead
Timescale
Progress February 2011
AMc/TH/AT
1) March 11
1) In Progress
AMc/TH/JB AMC/TH AMC/TH
2) March 11 3) ongoing 4) March 11
2) In progress 3) Completed but minimal uptake so will cease after elearning implemented. 4) In progress
Deliver a theatre session to a wide SUHT staff audience via Blue Apple theatre Company
JB
September 2011
In progress - To be linked to GIR Campaign
Ensure effective information and resources to staff, patients and the public on staffnet and public web pages about how the trust caters for people with learning disabilities
JD/SC/LMc
February 2011
In progress via Vulnerable Adults Web Pages Working Group
Review Q2
Unable to capture incidents from safeguard at present. Field will be added to new PAS module and safeguarding e-reporting First draft of policy distributed to Trust LD group in January 2011.
Quarterly Report to trust LD group re: complaints, AERs/ incidents
GC and JD
Safety & Quality of care for Patients with LDs Develop and implement new policy for the care and treatment of people with learning disabilities to include guidance on reasonable adjustments by appropriate department. Include prompt sheet as appendix. Set up pre hospital visiting programme for OPD and PRe Op Assessment Develop an integrated care pathway for patients with learning disabilities in acute care, including clear guidance and actions for effective discharge arrangements.
JB
April 11
Matron Yvonne Strange/TH AMc/TH
June 11
July 2011
Occurring ad hoc but need to link in GPs, Admissions Clerks etc as well. Not yet commenced.
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Area for Improvement
Work Stream
Improving Information and Communication
Develop patient information specifically for patients with learning disabilities • Coming Into Hospital (? leaflet and photo board) • Your Say (Leaflet) • Giving consent • Having an operation (leaflet) • Safeguarding Adults Ensure needs of LD patients are addressed in wider trust initiatives to improve staff awareness of mental capacity assessment and best interests decision making processes.
LD Liaison and communication
Service Use/Family and Carer Involvement
Regulation and Assurance
Lead
Timescale
Progress February 2011 In progress
AMc/JD
May 2011
Ongoing – review Q2
In progress
JY
Implement Patient Passports to improve pathways, handover and communication between organisations
AMc/TH DMC/KA
July 2011
Not yet commenced.
Develop sticker “Known to community learning disabilities team) for patient notes.
AMC/TH
May 2011
Draft sticker developed.
SUHT LD User Group/Consultation Via Choices Advocacy Group
JD
July 2011
Planning stages.
Agree framework for user/family carer consultation and involvement with planning services.
JD
Include LD requirement sin SUHT carer’s strategy
JB
Continue work to meet CQC LD requirements by March 2011
JB
Ongoing
JB
Review Q2
JD
February 2011
Work in progress – draft 1 at Jan 2011 group
JB
Review progress end of Q2
Not yet commenced but now urgent.
Report to QGSG/TEC/TB FEB 2011
Submit paper to TB Feb 2011 and then Quarterly
Capturing LD Patient Experience Data Making Reasonable Adjustments
Complete self assessment against SHA LD Assurance Framework and participate in peer review process. Develop and implement LD patient experience survey and present results to LD group. Run 2 focus groups. Develop a memorandum of agreement with partners to ensure the right patient support is available during inpatient stays
Not yet commenced
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