The State Hospital

The State Hospital, Carstairs, Lanark ML11 8RP
Phone: 01555 840293 Fax: 01555 840024 email: tsh.info@nhs.net

High Quality Patient Care and Treatment

In this section:

Photo: Campus

 

 

 

 

 

 

 

 

 

Clinical Governance

The main objectives of the Clinical Governance Committee are to provide the Board with the assurance that clinical governance mechanisms are in place and effective within The State Hospital; and that the principles of clinical governance are applied to the health improvement activities of the Board.

Existence and effective operation of this committee is demonstrated in continuous improvement and compliance with clinical standards, in delivery of improved services for patients, and ultimately in improved outcomes for patients as evidenced through the clinical Key Performance Indicators (KPIs) reported in the Local Delivery Plan (LDP).

During 2016/17, the Committee welcomed the new Mental Health (Scotland) Act 2015 which amends the Mental Health (Care and Treatment) (Scotland) Act 2003, or where relevant to the Criminal Procedure Act 1995.

The Clinical Governance Committee Annual Report 2016/17Opens in a new window summarises the work of the Committee and highlights particular areas of good practice along with matters of concern that have been discussed throughout the year.

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Clinical Forum

An annual report covering the period 1 January 2016 to 31 December 2016Opens in a new window has been produced. The key pieces of work included: overseeing the standards and guidelines process; reviewing Clinical Governance Committee issues; annual monitoring reports for the Professional Nursing Forum, Security, Social Work, Psychology and Pharmacy; outcome measures; developing a Discharge Integrated Care Pathway (ICP); reviewing the Clinical Model; clinical audits; and overseeing the Mental Health Practice Steering Group. A review of the Clinical Forum was undertaken during 2016 resulting in the role and remit of the group changing to that of a more professional advisory group.

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Patient Safety

In 2016/17 participation in the Scottish Patient Safety Programme for Mental Health (SPSP-MH) continued. The State Hospital’s Scottish Patient Safety Programme Photo: Patient Seclusion Room(SPSP) Annual ReportOpens in a new window covering activity from July 2016 to June 2017 provides an overview of the steady progress made against all five of the agreed national workstreams:

  • Leadership and Culture.
  • Communication at Transitions.
  • Safer Medicines Management.
  • Least Restrictive Practice.
  • Risk Assessment and Safety Planning.

Work is also ongoing around Improving Observation in Practice.

Highlights during the year include:

  • Psychotropic PRN medication documentation (‘8 rights’) spot check completed with median completion of 7.38 against the ‘8 rights’. 
  • Initial Risk Assessment completion target of ‘less than four hours’ improved. 
  • The results of the Patient Safety Survey reported that the majority of patients felt safe or very safe across a series of measures; ranging from 78% to 87%.
  • Post Physical Intervention debrief was rolled out site wide in December 2016 following feedback from staff. 
  • Medicines reconciliation completion on admission continued with 80 sets completed since 2015.
  • Benchmark data and staff questionnaires were distributed in respect of the Improving Observation in Practice workstream.

Additionally, The State Hospital was successful in presenting its Pre-Weekend Safety Briefing in the ‘Improving Care for People in Scotland, a Focus on Deterioration: Prevention, Recognition and Response’ session of the National Learning Event held in Edinburgh in November 2016.

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Incident Reporting

The year 2016/17 saw a slight increase in incidents reported; from 1,878 in 2015/16 to 1,897 in 2016/17.  Two level three incidents requiring the establishment of the Incident Command Team occurred, and there were four level two incidents. 

Nineteen incidents were reported to the Health and Safety Executive during 2016/17; no change from 2015/16. These were either a health and safety incident, an injury resulting in absence of more than seven days, or an incident listed as ‘specified injury’. The most common reason for reportable injuries this financial year was patient restraint incidents.

Assault incidents decreased over the year from 74 in 2015/16 to 52 in 2016/17.

April 2016 saw the introduction of a new reporting category ‘attempted assault’ which further improved the accuracy of reporting practices and reduced the number of actual assaults recorded.

 

12/13

13/14

14/15

15/16

16/17

Total number of assaults

116

84

85

74

52

Average bed complement

134.25

131

124

122.4

114

Assaults per patient

0.86

0.64

0.68

0.60

0.46

 

 

 

 

 

Critical Incident Reports (CIRs) and Serious Untoward Incidents (SUIs) continue to be shared with interested parties, both internally and externally.  Five CIRs and 10 SUIs were commissioned during 2016/17. 

The Hospital welcomed the NHS Healthcare Improvement Scotland (HIS) Report “Public Feedback on Sharing Learning for Adverse Events” published in September 2016 and noted implications for The State Hospital.

An annual summary document on ‘learning from adverse events’ is shared with the Forensic Network.

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Child and Adult Protection

The State Hospital’s Child and Adult Protection Forum is well established and remains committed to keeping children safe and ensuring they are protected from abuse, neglect and harm.

Work continues to be driven forward in an inter-agency manner to promote the safety and wellbeing of children, both within the Hospital and as part of South Lanarkshire Council’s Multi-Agency Child Protection Framework.

All forms of contact between patients and children are thoroughly assessed and subject to six monthly examinations in line with the patient’s Care Programme Approach (CPA) reviews. In 2016/17, 34 children were approved to have some form of contact.

A total of 50 Adult Support and Protection referrals were received during the year requiring varying levels of enquiry / investigation.  All were recommended for no further action once Council Officers were satisfied that any risks of harm had been adequately minimised.

Photo: Family Centre Play Area


Social Work Leaflet (August 2014)Opens in a new window

Fact Sheet (Social Work) - Child Contact (May 2015)Opens in a new window

Keeping Children Safe PolicyOpens in a new window

Protection of Children (Scotland) Act 2003Opens in a new window

Adult Protection - Getting Help to Avoid Harm (December 2014)Opens in a new window

Adult Support & Protection Fact Sheet (May 2012)Opens in a new window

Adult Support & Protection PolicyOpens in a new window

Adult Support and Protection Act (Scotland) 2007Opens in a new window

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Photo: Campus View

 

 

 

 

 

 

 

 

 

 

 

Clean Environment

Clear arrangements, systems and structures are in place for the prevention and control of infection thus ensuring a clean and safe environment.  In 2016/17, The State Hospital continued to score above 90% compliance / satisfaction rate for both national audit systems for cleanliness and estate monitoring.

NHSScotland Assests and Facilities Report 2015Opens in a new window

Photo: Hub Dining RoomEnvironment & Sustainable Development Policy Statement (May 2015)Opens in a new window

Property & Asset Management Strategy (PAMS) 2017/22Opens in a new window (Note - all property owned by the Hospital is contained within the Hospital campus).

The State Hospital is a comprehensive smoke free environment. See the Hospital's Case Study (February 2012)Opens in new window which provides an account of the journey undertaken to become smoke free.

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Infection Control

Photo: Patient BedroomThe main driving force behind managing the risk of Hospital Acquired Infection (HAI) is the NHS Healthcare Improvement Scotland (NHS HIS) Healthcare Associated Infection Standards (2015). 

All staff are personally accountable for their actions and are responsible for ensuring that they comply with Infection Prevention and Control policies.

The Infection Control Committee Annual Report 2016/17Opens in a new window outlines the wide range of activity undertaken. Key achievements over the year include:

  • The uniform policy was reviewed.
  • Clinical waste and environmental audits were linked to Control book audits and inspections undertaken by Senior Charge Nurses or Nursing Team Leaders, with the Advanced Practitioner for Infection Control undertaking a quality assurance audit at least once per year. 
  • Two patients were diagnosed with Hepatitis C and commenced treatment. 
  • The number of patients not seen by the Advanced Practitioner for Infection Control for Blood Borne Virus (BBV) reduced.
  • BBV screening was incorporated into the admission bloods with a follow up at six months and annually thereafter. 
  • Tests for Chlamydia and Gonorrhoea became part of patient admission screening. 
  • The number of staff receiving the seasonal flu vaccination increased from 27.5% in 2015/16 to 33.7% in 2016/17. 
  • The number of primary infection control incidents remained consistent; 36 in 2016/17 and 33 in 2015/16.  Secondary Infection Control incidents reduced from 55 in 2016/17 to 36 in 2016/17.  One ward was closed, however no confirmed diagnosis received.

Together We Can Fight Infection: How to hand wash with gel (July 2010)Opens in a new window and How to hand wash with water (May 2011)Opens in a new window

Infection Control Leaflets: SyphilisOpens in a new window, Clostridium DifficileOpens in a new window, ChlamydiaOpens in a new window, GonorrhoeaOpens in a new window, Healthcare Associated Infections (HAI)Opens in a new window, Hand WashingOpens in a new window, Hepatitis BOpens in a new window, Hepatitis COpens in a new window, HIV/AIDSOpens in a new window, MRSAOpens in a new window and NorovirusOpens in a new window

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Information Governance

Information governance involves knowledge and skills such as developing and adhering to policies and regulations regarding processes and procedures for information use, while retaining an appropriate balance between information availability and information security. 

Compliance within The State Hospital has remained strong with regular audits and monitoring. 

An updated staff training programme for information governance has been delivered to all staff and plans are in place to revise this again as part of the adjustments needed for the General Data Protection Regulation due to be enforced in May 2018. A review of current data protection practices is underway to ensure alignment with this new regulation.

This is complemented by the work being undertaken for the Records Management Plan to update the business classification scheme and the tuning of Freedom of Information processes.

It is hoped that the final Records Management Plan will be agreed by the Keeper of the Records of Scotland in the second half of 2017, bringing tighter controls on the access, use, storage and retention of all data held and created by the organisation at every level. A Records Survey is planned for 2017/18 to ascertain what records are held by the Hospital.

Information Governance Walkarounds were conducted late 2016 to ensure that high standards of information governance were being maintained throughout the organisation.  Following a review earlier in the year, the Data Protection Policy introduced a clear workspace to reduce the risk of information breaches. Even with the expected standards of information security being raised, the review team was pleased to note that all areas met the standards and most exceeded them. This compared favourably to 2015 reviews and showed a good improvement around information security and working practices across the site.

eHealth / Information Governance Annual ReportsOpens in a new window

Your Personal Health Information Fact Sheet (March 2015)Opens in a new window (update underway as at September 2017).

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Specified Persons Regulations

The Safety & Security Regulations place a duty on The State Hospital to furnish the Scottish Government with an annual report on the implementation of the Specified Persons Regulations.  In the interests of openness and transparency, the annual report to the Scottish Government also includes information on the implementation of the regulations relating to correspondence and telephones.

Specified Persons Report - August 2016Opens in a new window

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Security Standards

The State Hospital has two regular security audits; an audit of practice undertaken by the Forensic Network every 18 months and an audit of the physical security measures undertaken by an independent advisorevery year.  The physical security audit for 2016/17 was undertaken in May 2016 and The Forensic Network audit was undertaken in June 2016. Both audits were positive with asmall number of minor issues highlighted for action.

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Forensic High Secure Facilities & Services

External assessments against national standards provide a guide to effectiveness and efficiency, enabling further improvement to the quality of multi-disciplinary care and treatment delivered to patients.

Reviews against the Forensic Medium and High Secure Care Standards are conducted on a three year cycle. 

During 2016/17, the standards were updated following consultation across the forensic estate, though the themes remained the same:

  • Assessment.
  • Care planning and treatment.
  • Physical health.
  • Risk management.
  • Physical environment and teams.
  • Skills and staffing.

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Prevention & Management of Violence & Aggression (PMVA)

Prevention & Management of Violence & Aggression (PMVA) Fact Sheet (June 2014)Opens in a new window

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Learning from External Inquiry Reports

We continue to learn from other organisations by reflecting on and improving current practice within The State Hospital.

Vale of Leven Inquiry Report (December 2014)Opens in a new window

Mental Welfare Commission Report: Mr O - Hard to Help (August 2012)Opens in a new window

Learning from External Inquiry Reports - Overview (February 2011)Opens in a new window: