High Quality Patient Care and Treatment
In this section:
- Clinical Governance
- Clinical Governance Group
- Risk and Resilience
- Child and Adult Protection
- Infection Control
- Information Governance
- Information Technology
- Security
- Forensic Network Medium and High Secure Care Review Visit - Action Plan
- Prevention & Management of Violence & Aggression (PMVA)
- Learning from External Inquiry Reports
The underlying principle of effective clinical governance is that systems and processes provide the framework for patients to receive the best possible care.
The Clinical Governance Committee is supported by the Clinical Governance Group which has a quality assurance / improvement remit, and the Clinical Forum which continues to act as a professional advisory group.
The Clinical Governance Annual Report for 2019/20 provides a comprehensive overview of clinical governance activity.
As well as overseeing the reports that go to the Clinical Governance Committee, in 2019/20 the Group ensured:
- The Patients’ Day Project was progressed and will continue into 2020/21.
- The review of the Clinical Model was robust and engagement was at the forefront of the project.
- The next phase of the Supporting Health Choices Plan would include a workshop to agree new recommendations.
- The RSM Audit results were progressed through Skye Activity Centre data.
- A discussion forum for digital inclusion within The State Hospital was created.
- A review of the Psychological Therapies Service to enable service improvement and development.
- All action plans were closed in a timely manner through more regular progress updates.
Risk management continues to be embedded within all functions and disciplines across the organisation through the effective monitoring of risk information by groups and committees, regular monitoring of patient-specific risks by clinical teams, and sharing learning from incidents with local action being taken to minimise recurrences.
Areas of good practice during 2019/20 related to continued development of the Corporate Risk Register with risk owners and associated enhancement of local departmental risk registers, testing of resilience plans through resilience exercises, learning from incidents through effective incident reporting, close scrutiny of health and safety control book audits including workplace inspections, and the delivery of staff training and education aimed at reducing risk.
Work-steams relating to the Scottish Patient Safety Programme for Mental Health (SPSP-MH) were progressed:
- Review and update of the Improving Observation Practice policy.
- Ongoing delivery of Post Incident Debriefs with work planned for 2020/21 through the Senior Charge Nurse development programme around training for those leading the debriefs.
- Weekly undertaking of Pre-Weekend Safety Briefings.
- Programme of Leadership Walk-rounds and review of associated documentation.
Highlights of resilience measures strengthened during the year include State Hospital representation at the Beyond EU Exit: Integrating Resilience Across Health & Social Care event on 21 January 2020, and Golden Hour training for new Senior Charge Nurses (SCNs) on 28 January 2020.
Additional resilience activity included the review and testing of contingency plans and the Incident Command Structure by way of a multi-disciplinary pandemic influenza table top exercise on 5 December 2019 with resultant Loss of Staff plan review, and a Scottish Fire and Rescue Service (SFRS) exercise held on 20 January 2020 involving three fire appliances on scene.
The protection of children and adults from harm remains a key priority for The State Hospital, with clearly defined responsibilities for staff from all disciplines. This work is led by the Child and Adult Protection Forum within The State Hospital and as part of South Lanarkshire Council’s Multi-Agency Child Protection Framework.
The State Hospital has Corporate Parenting responsibilities for all patients, up to and including the age of 25, who were looked after by their local authority at any point up to their 16th birthday. A three-year Corporate Parenting Plan is in place. During the year one patient met the identified criteria and liaisons with the relevant local authority took place to ensure that corporate obligations were satisfied.
In 2019/20:
- Five patients who were parents of children had some form of child contact.
- 26 patients had contact with children.
- 78 children were approved to have some form of contact with a State Hospital patient.
- There were two Child Protection referrals.
- Three Adult Support and Protection (ASP) inquiries were responded to.
Corporate Parenting
State Hospital Corporate Parenting Plan 2018/20 (January 2018)
Corporate Parenting (June 2018) - Patient Information Sheet (Social Work)
Child Protection
Child Contact (November 2018) - Patient Visitor Information Sheet (Social Work)
Keeping Children Safe Policy 2017/20
Protection of Children (Scotland) Act 2003
Adult Support & Protection
Named Person (February 2019) - Patient Visitor Information Sheet (Social Work)
Appropriate Adult Scheme (July 2018) - Patient Information Sheet (Social Work)
Adult Support & Protection (Scotland) Act 2007 (June 2018) - Patient Information Sheet (Social Work)
Adult Support & Protection (Scotland) Act 2007 (June 2018) - Staff Information Sheet (Social Work)
Adult Support & Protection Policy 2017/20
Adult Support and Protection Act (Scotland) 2007
Social Work Service
Social Work Service (July 2018) - Patient Information Sheet (Social Work)
The Hospital’s Infection Control Committee promotes the highest standards of practice within the organisation for infection prevention and control, ensuring compliance with the Healthcare Improvement Scotland (HIS) Healthcare Associated Infection (HAI) 2015 standards. The Board noted the following achievements in 2019/20:
- As per previous years, the results of quarterly audits undertaken as part of the NHS Scotland National Cleaning Services Specification, were in the ‘green’ category indicating a result of 90% or above.
- A significant increase in the total number of flu vaccinations from 35.8% in 2018/19 to 43.9%. In addition, there was an increase in uptake among nursing staff from 26.8% in 2018/19 to 41.8%.
- Blood Borne Virus (BBV) testing was incorporated into admission blood screening, resulting in a high uptake by patients.
- 27 exposure incidents of infection control issues were cited as secondary; a decrease from 53 the previous year.
- Significant improvement in compliance with the Management of Loose Stools Policy.
- 100% compliance for the management of Healthcare Waste pertaining to sharps; consistent with the previous year.
- High levels of hand hygiene compliance across the hubs ranging from 80% to 98% with nursing staff consistently achieving in excess of 90% and the Health Centre consistently achieving 100%.
- Continued promotion of food hygiene and food safety online training modules with positive results.
Infection prevention and control remains a high priority for The State Hospital and is monitored through the Board’s Risk and Governance Structure. During March 2020 the Hospital’s Incident Command Structure was enacted
in response to the Covid-19 pandemic, with the Senior Nurse for Infection Control becoming a key member of the Covid-19 Support Team.
NHSScotland Assests and Facilities Report 2015
Environment & Sustainable Development Policy Statement December 2017)
Property & Asset Management Strategy (PAMS) 2017/22 (Note - all property owned by the Hospital is contained within the Hospital campus). PAMS Interim Update Report - June 2019
The State Hospital is a comprehensive smoke free environment. See the Hospital's Case Study (February 2012) which
provides an account of the journey undertaken to become smoke free.
The State Hospital has a three year Healthcare Acquired Infection (HAI) Education Training Plan which is reviewed every six months.
Together We Can Fight Infection: How to hand wash with gel (July 2010) and How to hand wash with water (May 2011)
Infection Control Leaflets: Syphilis, Clostridium Difficile, Chlamydia, Gonorrhoea, Healthcare Associated Infections (HAI), Hand Washing, Hepatitis B, Hepatitis C, HIV/AIDS, MRSA and Norovirus
Focus over the course of the year was on improving Information Governance standards and practices across the Hospital to ensure compliance with the national Information Governance Framework. Matters relating to data protection, records management, Caldicott issues (including incident reporting), and mandatory training remained a top priority as did the monitoring of Freedom of Information (FOI) and Subject Access Requests.
Additionally, Information Governance Walk-rounds took place to staff and patient areas, and work associated with the Electronic Patient Record (EPR) system and the outcomes of the FairWarning system (together with ad hoc issues such as record retention and email scams) were all addressed.
In 2019/20:
- There were 21 Information Governance Risk Assessments on the Risk Register; 14 were at or below their target risk rating of medium, with action plans in place to reduce or eliminate the remaining seven risks.
- Levels of compliance for mandatory training continued to be high as in previous years.
- There were 16 recorded personal data breaches; none of these required notification to the Information Commissioner’s Office.
- A review of the Records Management Plan was undertaken between January and March 2020 with actions arising being addressed.
- For the third year, the Scottish Information Commissioner’s Self-Assessment Toolkit was used to assess FOI management at the Hospital and indicated a trend of continuing improvement.
- Subject Access Requests doubled with requests being evenly split between staff and patients (past and present); from 22 in 2018/19 to 49 in 2019/20.
- Forty eight policies were delivered through the MetaCompliance cyber security, training and compliance awareness platform; a rise of 26%.
- MyCompliance, a complimentary system to MetaCompliance, was introduced in the fourth quarter providing staff with a mechanism for acknowledging policies prior to MetaCompliance enforcing a response.
- There were no Category 1 or Category 2 investigations related to Information Governance.
Your Personal Health Information (February 2021) - Patient Information Sheet (Health Records)
Information systems were enhanced during 2019/20, with the development of new dashboards for the Tableau Business Intelligence platform, to help frontline staff better understand data and use it to inform decisions. At the annual national Tableau ‘Vizathon’ event, the Information Team won (following a public vote) the ‘top dashboard award’ with their Christmas themed viz.
The RiO Electronic Patient Record (EPR) was also further developed with a range of new modules, and numerous new RiO reports were established to capture data for new daily and weekly monitoring reports.
The year also saw upgrades to the infrastructure including servers and networks.
The State Hospital is committed to maintaining a modern, effective, and robust security infrastructure that enables the safe delivery of patient care within a high secure environment. The Hospital’s secure environment is provided by three domains of security:
- Physical security - provided through high quality physical barriers and sophisticated electronic detection and observation systems.
- Procedural security - provided through policies, procedures and working practice.
- Relational security - provided by clinical staff working closely with patients to deal with illness and offending behaviour.
Maintaining a safe and secure environment for patients, staff, volunteers and visitors is a key component of effective patient care and treatment. During 2019/20:
- Work to upgrade the Hospital’s security systems was taken forward through the Security Refresh capital project.
- A Security Governance Group was established with representation from a variety of disciplines.
- Multi-disciplinary involvement in the review of Security policies and procedures increased.
- State Hospital Negotiators attended the Police Training College at Tulliallan to support Police Scotland deliver national training for Police Negotiators.
- In line with environmental and safety improvements, a mock Modified Strong Room (MSR) was built with over 100 staff participating in the ‘MSR layout’ consultation.
- Visits were made to the English high security hospitals to further strengthen relationships and enhance information sharing.
The Hospital has its own Security Standards which are aligned to the national High Secure Care Standards. The next audit is not due until 2021.
Forensic Network Medium and High Secure Care Review Visit – Action Plan
By February 2020 there were 10 actions outstanding from the original 37 with work planned to progress these in 2020/21.
We continue to learn from other organisations by reflecting on and improving current practice within The State Hospital.
Review into Cultural Issues related to allegations of a bullying culture at NHS Highland - The Sturrock Report (April 2019) and The Scottish Government Response to the Sturrock Report (May 2019)
Vale of Leven Inquiry Report (December 2014)
Mental Welfare Commission Report: Mr O - Hard to Help (August 2012)
Learning from External Inquiry Reports - Overview (February 2011):
- Investigation into Mid Staffordshire NHS Foundation Trust - May 2013 August 2010
- Independent inquiry into the
care and treatment of Peter
Bryan and Richard Loudwell (NHS London) (September 2009)
- Investigation into West London Mental Health NHS Trust (July 2009)