the state hospitals board for scotland ... reports...the chp introduced a standard approach to...

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THE STATE HOSPITALS BOARD FOR SCOTLAND

Complaints and Feedback Annual Report

1 April 2019 - 31 March 2020

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CONTENT

Foreword and Introduction Page 3

Section 1

Encouraging and Gathering Feedback Page 4

Welcoming and Supporting Feedback from all Page 6

Equality Groups

Recording Feedback Page 7

Type / Source of Feedback Received Page 7

Section 2

Encouraging and Handling Complaints Page 8

Complaints Received Page 8

Main Issue Raised in Complaints Page 9

Themes Emerging Page 9

Involving the Complainant in Early Resolution Page 9

Patients’ Advocacy Service Page 9

Alternative Dispute Resolution Page 10

Complaints Closed and Outcomes Page 10

Response Times Page 12

Focus on Quality Page 12

Complaint Process Experience Page 13

Scottish Public Services Ombudsman Page 14

Section 3

The Culture, Staff Awareness, Training & Development Page 15

Training – Complaints and Feedback Modules Page 15

Duty of Candour Page 16

i-matter Page 17

Quality Improvement Initiative Page 17

Staff Excellence Awards Page 18

Section 4

Learning from Complaints and Feedback Page 19

Complaint Outputs Page 19

Outputs arising from Feedback Page 20

Staff and Volunteer Recognition Awards Page 20

TSH3030- ‘What’s On?’ Page 21

Section 5

Accountability and Governance Page 22

Summary Page 23

Appendix 1 Page 24

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Foreword

The State Hospitals Board (the Board), staff and volunteers have a unique and long-term relationship

with our patient population, carers and stakeholders.

The Board actively gathers feedback, listens to patients and carers, and importantly takes appropriate

action in response. Clinical Governance Committee (CGC) receives quarterly reports on Learning

from Complaints and Feedback, and the ‘Patient Voice’ is now embedded in the work of the

Committee and the wider Board.

As CGC Chair I am grateful to all the staff and volunteers who care for our patients and support our

stakeholders every day, and the Committee very much appreciates the work of the colleagues who

ensure that our complaints and feedback processes are effective and meaningful.

This Report demonstrates real involvement, positive change and improvement in service provision

and practice, and shows that feedback, comments, concerns and complaints continue to inform

practice within the State Hospital.

Nicholas Johnston

Non-Executive Director and Chair, Clinical Governance Committee

June 2020

Introduction

The Board, one of NHS Scotland’s Special Health Boards, is a high secure forensic mental health

facility. The State Hospital (TSH) provides care and treatment for up to 140 male patients with a

catchment area covering Scotland and Northern Ireland.

Involving stakeholders is considered key to ensuring our services are designed to deliver safe,

effective, person-centred care and treatment.

This report provides details of feedback and complaints received during the period 1 April 2019 to 31

March 2020, demonstrating meaningful stakeholder involvement at The State Hospital (TSH).

This report reviews performance in relation to managing feedback and complaints, (incorporating

compliments, comments, concerns and complaints) aligned the NHS Model Complaints Handling

Procedure (CHP). The CHP supports a person centred approach to complaints handling across NHS

Scotland, adopting a standard process, ensuring staff and people using NHS services have

confidence in complaints handling and encouraging NHS Boards to learn from complaints in order to

continuously improve services.

Engaging TSH unique patient group, in terms of eliciting feedback in a meaningful way, is often very

challenging. In particular, managing the aspirations of complaint outcomes for this patient group is

complex and often closely linked to mental health presentation and ongoing negative symptoms of

mental health conditions.

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Section 1

Encouraging and Gathering Feedback

TSH aims to create an organisational culture in which stakeholders are recognised and meaningfully

involved as equal partners in service delivery. Feedback is welcomed from patients, carers, staff and

volunteers, as this data enables the Board to improve its understanding of what we are doing well,

what we are not doing so well, and what we could do better.

Our patients experience a range of difficulties relating to the impact of mental health conditions on

their ability to communicate effectively. Barriers to communication including Intellectual Disability,

Autism, Dementia, language and sensory impairment, presenting additional challenges which call for

specialist skills and knowledge to support a tailored approach to enabling all patients to have the

opportunity to share their views. Given the need to ensure patients have the level of support required

to be meaningfully involved in service development, the role of the Person Centred Improvement

Team (PCIT) is pivotal to providing dedicated support, tailored to individual need.

The Board acknowledges carers as valued partners in service design and delivery. The Hospital

values the wealth of knowledge and experience carers can offer to support the role of the clinical

teams, and are committed to empowering carers to be actively involved in service delivery. Due to the

nature of the services provided, this group of carers are unique as they do not provide ‘substantial

and regular care’ to patients, however carer input is considered to be a vital role in promoting

recovery. In recognition of the specific needs of carers who support patients within this setting, the

Board maintains the full-time post of Person Centred Improvement Advisor (PCIA), whose remit

relates primarily to carer support.

The role of volunteers is also recognised as a valuable contribution to our work in terms of enriching

the quality of everyday life for patients. The input of this group is important as a means for patients to

interact with people other than staff and therefore particularly beneficial for many patients who receive

no social visits. This mutually beneficial relationship complements the delivery of person-centred care

and treatment. The Person Centred Improvement Lead (PCIL) is responsible for managing volunteer

input across the Hospital, ensuring this very unique perspective is actively sought and incorporated

within service design.

Within the context of TSH, the Board recognises external supporting organisations including

Community Engagement, Healthcare Improvement Scotland (HIS), European Human Rights

Commission, Forensic Network, Scottish Government Person-centred Team, Mental Welfare

Commission (MWC), Patient Advocacy Service (PAS), Volunteer Scotland, Volunteer Health

Scotland, Carers’ Trust, Support in Mind, and other Third Sector providers as ‘the public’ in terms of

stakeholders. Therefore actively seeking feedback as a part of involvement and engagement is

effected through partnership working with a wide range of external organisations, for a number of

purposes including statutory requirements, providing information, collaborative service design, shared

learning, networking, measuring and reporting participation levels, outcomes and outputs, as part of

national comparison activities.

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TSH has a wide range of well established methods through which our stakeholders are actively

supported to share their views including:

Patients

Patient Partnership Group (PPG) Meetings which this year included discussions relating to: - Research proposals; - Digital Inclusion; - Review of Forensic Mental Health Services; - Policy / protocol development and updates; - Autism and Intellectual Disabilities Review; - Contributing to development of new menus; - Installation plan for indoor CCTV; - Review of Clinical Care Service Delivery Model; - Patient Day Project Group; - Development of TSH 2019 ‘What Matters to You?’ initiative (Appendix 1).

Comments/Suggestion Boxes

Meal Feedback Forms

Policy consultation groups

Membership of short life consultation forums (e.g. Clinical Care model)

Membership of Person Centred Improvement Steering Group (PCISG)

Narratives/ Emotional Touchpoint presentations included as part of reporting via the PCIL (the Board, Clinical Forum, Clinical Governance Group/Committee)

Direct telephone line to the Person Centred Improvement Team (PCIT)

Ward Outreach Service

Direct telephone access to the Mental Welfare Commission (MWC)

PAS (based on site) direct telephone access, ward outreach and Skye Centre drop in service. Annual Patient Satisfaction Questionnaire, PAS Board patient representative, via video link to PAS AGM

Leadership Walkrounds.

Annual ‘What Matters to You?’ initiative

This year, the PPG were asked ‘What Matters to You about PPG?’ enabling those with significant

barriers to contribute through the use of concept modelling using Lego:

A patient who has Autism reflecting on what matters to him about his recovery journey.

“I’m not alone, it’s important that I

have people I can go to in here that I

trust to help me. Sometimes that’s

staff but sometimes it’s other

patients, who are getting out soon,

who know what it’s like for me to be

not long in.”

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Carers

eCarers’ Support Group Meetings


Carers’ Newsletter

Direct telephone line to the PCIA.

Electronically direct to PCIA

In person to PCIA, who attends the Carers’ Reception during visiting hours

Membership of PCISG

Membership of short life consultation forums (e.g. Clinical Care Model)


Narratives using Emotional Touchpoint presentations to share feedback with the Board

‘What Matters to You?’ / Carers’ Week event

Volunteers

Volunteer Service Group Meetings

Direct telephone line to the PCIL

Electronically direct to the PCIL


Membership of PCISG

Membership of short life consultation forums (e.g. Clinical Care model)


‘What Matters to You?’ / Volunteer Week event

External Partners

PAS Board Meetings

Monthly meetings with PAS Manager

NHS networks (e.g. Equality Leads, Scottish Government Person-centred Stakeholder Group,

Strategic Volunteering Leads, National Spiritual and Pastoral Care Leads)

Regular Community Engagement update meetings

Collaborative interactive projects with Healthcare Improvement Scotland (HIS) (e.g. What

Matters to You?)

Regular MWC update meetings

Forensic Network Carer Co-ordinator / skill sharing meetings

Welcoming and Supporting Feedback from all Equality Groups

In recognition of the challenges of enabling this very vulnerable patient group and their carers to

engage, TSH has a dedicated involvement team with specific remit to ensure that, regardless of the

stage of the recovery journey, both patients and carers understand that their views are important

and, as such, are welcomed. A proactive approach is adopted to ensure that stakeholders are

supported to contribute to organisational learning.

We recognise that the Hospital is the patients’ home and that, as detained patients, this brings

challenges when sharing negative feedback in terms of the impact on patient/staff and carer/staff

relationships. The Board therefore acknowledge the need to ensure that a range of processes exist

to demonstrate that all feedback is welcome, including those which protect patient and carer

confidentiality.

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For this particular group of patients (and, on occasions, their carers), engaging in the complaints

process is often detrimental in terms of mental health. The focus is therefore on informal resolution.

This approach is viewed by patients and carers as the preferable option in the majority of early

discussions within the complaints process in this setting. The CHP supports this ‘real-time’

approach, empowering staff to act on feedback where possible at the initial point of contact,

complying with the 5-day timeframe.

The PCIT maintain a list of patients whom have been assessed as having specific communication

needs (e.g. Intellectual Disability, Dementia, Autism, sensory impairment, literacy skill deficits,

language barriers). A wide range of additional support mechanisms are used to elicit feedback (e.g.

translators, interpreters, Graphic Facilitation, Talking Mats, creative medium e.g. the River Model,

the Recovery Game, construct modelling). Additionally, the ward outreach service ensures that

‘hard to reach’ patients, whose mental health is of significant concern, are supported to engage on a

1:1 basis within the ward environment.

Carers who may experience challenges in respect of sharing feedback are encouraged to apprise

the PCIA of any support mechanisms which would enable them to more meaningfully engage.

Recording Feedback

The Datix system is used to record complaints. Feedback is recorded within a locally tailored database

developed to support analysis through which person-centred themes are identified aligned to national

initiatives including ‘Excellence in Care’, ‘Realistic Medicine’ and ‘What Matters to you?

Type / Source of Feedback Received 2017/18 2018/19 2019/20

Complaints 121 61 52

Concerns / Enquiries 6 35 35

Compliments 4 4 3

Comment / Suggestion Boxes 12 14 32

Meal feedback Forms (via feedback/suggestion boxes) 104 77 59

Event Evaluation Forms 100 204 *149

Totals 347 395 330

*reduction in number of events

Complaints accounted for 16% of the overall feedback received this year, compared to 15% in

2018/19 and 35% in 2017/18.

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Section 2

Encouraging and Handling Complaints

The CHP introduced a standard approach to managing complaints across NHS Scotland, which

complies with the Scottish Public Services Ombudsman (SPSO) and meets all the requirements of

the Patient Rights (Scotland) Act 2011. The two-stage model enables complaints to be handled

either locally, by front line staff, allowing for Early Resolution (Stage 1) within 5 working days, or for

issues that cannot be resolved quickly, or are more complex, by Investigation (Stage 2) within 20

working days.

Complaints Received

The total number of complaints received this year was 52. The table below shows the numbers

received over the last 3 years.

Number of Complaints Received 2017/18 2018/19 2019/20

Total number Received 121 61 52

Average number of Patients throughout the year 109 107 106

Total number of Complainants 56 35 21

Due to the nature of the environment as a long-term health care setting, it is normal that

stakeholders will inevitably submit more than one complaint during their time in TSH, which

averages 6/7 years.

52 complaints were received from 21 complainants;

7 (13%) complainants made one or more complaints this year, compared to 35 (77%)

complainants in the previous year.

3 carers submitted 21 complaints (1) (4) & (16) respectively, this year, accounting for 40% of

all complaints received. Although there was a decrease in the number of carers who made a

complaint this year compared to the previous year (9), there was an increase in the number

of complaints received from carers compared to the previous year (16).

One carer accounted for 76% (16) of the total number of complaints made by carers. Eight of

the complaints related to staff attitude/behaviour/conduct. Five related to clinical treatments

including the cancellation of patient placements (4) and lack of access to fresh air (1). A

further 3 complaints related to oral communications with staff (3). Concerns relating to this

level of dissatisfaction resulted in escalation to director level.

Of the 16 complaints received, 14 were closed in this reporting year, 2 of which were fully

upheld and 5 partially upheld.

The independent PAS continue to support patients who wish to make a complaint but do not

wish to do so direct. This year they supported 48% (25) of all complaints received, similar to

46% (28) in the previous year.

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The table below shows the main issue raised in complaints received over the last 3 years:

Main Issue Raised in Complaints 2017/18 2018/19 2019/20

Staff Attitude/Behaviour/Conduct 27 15 22

Clinical Treatment 18 9 13

Shortage/availability 12 8 4

Communication (Oral) 0 2 3

Aids & appliances, equipment 13 2 2

Patient Privacy/Dignity 7 3 2

Patient Property/Expenses 5 1 2

Failure to follow agreed procedure 27 8 2

Communication (Written) 4 8 1

Catering Services 2 3 1

Complaint Handling 1 0 0

Premises (including access) 0 1 0

Personal Records 0 1 0

Policy and Commercial decisions 3 0 0

NHS Board Purchasing Procurement 1 0 0

Transport Arrangements 1 0 0

Total 121 61 52

Themes Emerging

The increase in the number of complaints in 2017/18 was expected with the introduction,

promotion and embedding of the CHP raising the awareness of complaints and feedback across

the hospital. In addition to this, changes to specific policies/practices in December 2018

contributed to the increase in the numbers received. The average number of complaints per year

prior to the implementation of the CHP was 42.

Recurring issues this year related to Staff Attitude/Behaviour/Conduct (42%) and Clinical

Treatment (25%) similar to previous years and accounting for 67% of all issues raised. Following a

decrease last year, an increase is evident in both areas this year.

Involving the Complainant in Early Resolution

The 5-day local resolution stage continues to be a positive step in encouraging the resolution of

issues quickly, and is welcomed by staff and patients. 70% of complaints were resolved through

early resolution this year.

The independent PAS, based on site, regularly supports patients to

resolve issues through early resolution. PAS also provide full

support and guidance to patients who wish to escalate their

complaint. PAS work closely with the Complaints Officer and PCIT

to highlight themes and identify opportunities to share best practice

in relation to learning emerging from complaints and feedback.

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Alternative Dispute Resolution

The Board also support the use of alternative dispute resolution e.g. mediation to conclude cases

which were unable to be resolved locally. There were no requirements for this service in the last 12

months.

Complaints Closed and Outcomes

A total of 43 complaints were closed this year. All complaints closed are categorised as either

upheld, partially upheld or not upheld.

The number of complaints ‘received’ and number ‘closed’ in the reporting period are not expected to

match. Complaints received in March may not be closed until April which is the next reporting year.

These complaints are recorded as being ‘received’ in one reporting year however ‘closed’ in the next

reporting year. The table below shows the number of complaints closed at each stage this year and

the previous 2 years:

Total Number of Complaints Closed 2017/18

Total

2081/19

Total

2019/20

Total

% of total

Closed

20/19/20

Number closed at Stage 1 89 37 30 70%

Number closed at Stage 2 23 14 7 16%

Number closed after escalation to Stage 2 3 12 6 14%

Total Closed 109 63 43 100%

70% (30) of complaints received this year were resolved at Stage 1 this year with the

remaining 30% (13) being investigated at Stage 2.

20% (6) of complaints investigated at Stage 2 this year were escalated from Stage 1, in

comparison to 46% (12) in the previous year.

18 complaints closed this year related to Staff Attitude/Behaviour/Conduct; 1 was upheld, 2 were

partially upheld and 15 were not upheld. 11 of these complaints (61%) were from carers.

In comparison to the previous year, when 49% of complaints were upheld, this year only 19% were

upheld.

Complaint outcomes are sense checked and any trends identified are highlgithed to the

Complaints Manager.

Outcomes of Complaints Closed 2017/18

Total

2081/19

Total

2019/20

Total

As % of

all closed

2019/20

Upheld 51 31 8 19%

Partially Upheld 12 3 6 14%

Not Upheld 46 29 29 67%

Total 109 63 43 100%

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Complaint Outcomes at each Stage 2019/20

This is the Outcomes of all complaints closed at Stage 2

Stage 1 - Early Resolution 2017/18

Total

2018/19

Total

2019/20

Total

% of all

S1

Upheld 38 17 7 23.3%

Partially Upheld 11 2 4 13.3%

Not Upheld 34 18 19 63.4%

Total 83 37 30 100%

Stage 2 Investigation 2017/18

Total

2018/19

Total

2019/20

Total

% of all

S2

Upheld 11 9 1 14%


Not Upheld 11 4 4 57%

Total 23 14 7 100%

Upheld , 8, 19%

Partially Upheld , 6, 14%

Not Upheld , 29, 67%

Complaint Outcomes 2019/20

Upheld Partially Upheld Not Upheld

Upheld , 7, 23%

Partially Upheld , 4,

13%

Not Upheld , 19, 64%

Stage 1 - Early Resolution Outcomes


Upheld , 1, …

Partially Upheld , 2,

29%

Not Upheld , 4,

57%

Stage 2 - Investigation Outcomes


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Closed after Escalation to Stage 2 2017/18

Total

2018/19

Total

2019/20

Total

% of all

Esc

Fully Upheld 2 5 0 0%


Not Upheld 1 7 6 100%

Total 3 12 6 100%

Response Times

The Hospital continues to adhere to the CHP guidelines with the target for resolving complaints

locally within 5 working days and completing investigations within 20 working days. The table

below shows the average number of days taken to respond to complaints this year and for

comparison purposes, the previous year:

Average Response Times 2017/18 2018/19 2019/20

Average number of days taken to resolve a complaint at Stage 1 3 3 3

Average Number of days taken to respond to a complaint at Stage 2 15 13 18

Average Number of days taken to respond after escalation to Stage 2 14 17.5 20

The number of days to respond to a Stage 1 complaint remained consistent at 3 days over the last 3

years. The number of days to respond to a Stage 2 complaint increased this year to 18 days. The

number of days to respond to a complaint after escalation to Stage 2 also increased from 17.5 days

to 20 days. As this increase is now at maximum national response time limits, this will be closely

monitored through quarterly reporting via the Clinical Governance Committee where any concerns

will be discussed.

Complaints closed in full within timescales 2017/18 2018/19 2019/20

Number of complaints closed at Stage 1 within 5 working days 79 32 29

as % of the total number of Stage 1 complaints closed this year (30) 88% 89% 97%

Number of complaints closed at Stage 2 within 20 working days 27 22 8

as % of the total number of Stage 2 complaints closed this year (13) 93% 85% 62%

Focus on Quality

Whilst always being mindful of the target response times, importance is placed on ensuring that the

response fully addresses all of the issues raised. The Board are committed to ensuring that the

focus is about the learning opportunities that arise from complaints, therefore on occasion an

extension has been required to allow a more comprehensive response to be provided. An internal

quality assurance process has been established to ensure compliance with the requirements of the

CHP.

Extensions Authorised Total No

Number of Stage 1 complaints where an extension was authorised 1

as % of the total number of Stage 1 complaints closed (30) 3%

Number of Stage 2 complaints where an extension was authorised 5

as % of the total number of Stage 2 complaints closed (13) 38%

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The Board acknowledges that extensions to the CHP response times should be an exception and

this is part of our required process. To ensure compliance, all complaints where the response time

exceeds CHP guidelines are reported to and monitored through our governance groups.

Complaints Process Experience

As part of the CHP, we are required to ask people their views about the procedure. A local feedback

pro-forma was implemented with a view to seeking the feedback of those using the complaints

process. Where appropriate, PAS assist patients to complete this feedback.

A total of 22 responses were received in 2019/20, compared to 25 in 2018/19 and 22 in 2017/18.

Questions Asked 2017/18

Total

2018/19

Total

2019/20

Total

Finding information about how to make a complaint was easy 86% 88% 70%

Making a complaint was easy 95% 96% 70%

Staff were helpful, polite and professional 82% 92% 80%

Staff listened and understood my complaint 82% 88% 80%

The letter advising me of the decision was easy to read and understandable 86% 76% 70%

All my issues were answered 50% 68% 70%

I raised concerns about how my complaint was handled 8% 40% 30%

The table above indicates that there has been an improvement in some areas with respondents

saying that all their issues were answered (from 68% to 70%) and less respondents raised concerns

about how their complaint had been handled (from 40% to 30%).

Collecting this feedback requires to comply with national practice. This means that the feedback is

provided anonymously. This creates a challenge in terms of understanding more about the issue(s)

and learning from experience. Attempts locally to identify specific issues have highlighted some

anecdotal examples of where a complainant has had concerns e.g. was unable to speak directly to

the Complaints Officer who was on leave and therefore required to share initial feedback about ward

based issues directly with staff responsible. Patients have been reminded that when the Complaints

Officer is on leave another member of the Risk Management Team or the PAS is available to meet

with the patient.

A small number of forms completed this year included the respondent’s name, which provided the

opportunity to seek further information on areas of concern. It became evident when meeting with

the respondent that in instances where they had made more than one complaint, they were unsure

which complaint they were providing feedback about.

Due to the nature of the environment as a long-term health care setting, it is to be expected that we

will received multiple complaints from the same person. It remains a challenge therefore

encouraging complainants to complete the feedback forms on each occasion.

There are some areas for the Board to explore further in terms of better understanding the reason

why some complainants felt it was not easy to make a complaint and/or why they felt staff were not

helpful. Both are difficult to validate given the anonymity of this process.

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Scottish Public Services Ombudsman (SPSO)

Complainants who remain unhappy with the response to their complaint from TSH can ask the

SPSO to review their complaint. During 2019/20 two complaints were referred to the SPSO.

The first complaint escalated to the SPSO related to wording in the Mail Policy not being in the same

order as that in the Mental Health (Care and Treatment) (Scotland) Act 2003. On initial assessment

of the complaint file, the SPSO concluded that they could not achieve anything further than what the

Board were doing and would not take the complaint forward for investigation. However, after further

contact from the complainant the SPSO concluded that the Board had not fully addressed all issues

raised. They asked for this to be further considered and an apology issued to the complainant. This

was duly done. The SPSO were satisfied with the outcome and closed the complaint without further

investigation.

The second complaint was raised by an MSP, on behalf of a carer and related to the Board's care

and treatment of a patient and our handling of their complaints. Following initial assessment, the

SPSO were unable to obtain consent to consider the issues raised relating to the patient's care and

treatment. Following a review of evidence provided by the Board relating to our complaints handling

the SPSO concluded there was no requirement to investigate the matter further and closed the

complaint.

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Section 3

The Culture, staff awareness, training and development

The State Hospitals Board for Scotland

Culture, Values, Behaviours & Leadership

Ensuring values based organisational culture and leadership skills is at the heart of person-centred

service delivery is one of our key strategic priorities. This year a major piece of work has been

undertaken to review the Clinical Services

Delivery Model. The need for a review arose

from issues raised through a staff engagement

exercise focused on the readiness for change.

An extensive programme of engagement,

options development and appraisal was carried

out with staff, patients, carers and

stakeholders. A preferred option for a new

clinical model emerged and was approved by

the Board in October 2019. Planning

mechanisms were put in place to prepare for

transition to the new model of service delivery.

One of the work streams, led by the Chief Executive, has prioritised Culture, Values, Behaviour and

Leadership as critical to ensuring the views of staff, patients and carers are embedded within service

design informed by this change project.

Training

We continue to encourage staff to complete the e-learning Complaints and Feedback training

modules. In addition to the e-learning training modules a Complaints and Feedback Awareness

session forms part of the mandatory Health and Safety induction day for all new staff.

Complaints and Feedback Training Modules Completions

2017/18

Completions

2018/19

Completions

2019/20

Module 1: Value of Feedback 90 252 110

Module 2: Encouraging and Using Feedback 80 260 112

Module 3:Complaints and Feedback Process 72 266 114

Module 4: The Value of Apology 71 267 112

Module 5: Managing Difficult Behaviour 70 268 112

Modules 5 Modules 98 269 123

Total number of staff at year end 670 671 665

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Duty of Candour

The Health (Tobacco, Nicotine etc. and Care)

Scotland Act 2016 (“The Act”) introduced an

organisational Duty of Candour on health, care

and social work services. The Act is

supplemented by the Duty of Candour

Procedure (Scotland) Regulations 2018, which

highlight the procedure to be followed whenever

a Duty of Candour incident has been identified.

97% of the target staff group have now completed the Duty of Candour e-learning training module.

Duty of Candour - e-Learning Modules

Group Total Within Target Group

Number Completed Module

% Uptake

Year 2018/19 2019/20 2018/19 2019/20 2018/19 2019/20

Registered Practitioners

243 286 208 278 86% 97%

Non-Registered Practitioners

162 156 133 152 82% 97%

Total 405 442 342 430 84% 97%

The proposed Training Plan for 2019-20 targeted all front-line clinical staff with regard to completion

of the Duty of Candour e-learning module. The table shows 97% of staff required to complete this

module have completed it, an increase from the 87% in the previous year.

The Duty of Candour Group ensure all incidents meeting the Duty of Candour criteria are

investigated in line with Scottish Government guidance and timescales and action taken, where

required to prevent/minimise a recurrence. The Group meet on a monthly basis (or more frequently,

if required) to discuss potential Duty of Candour incidents.

During this period the Duty of Candour Group met on 12 occasions. 43 incidents were considered by

the Duty of Candour Group, compared to 128 in the previous year. The group identified that one

incidents fulfilled the criteria for Duty of Candour, i.e. an unintended or unexpected act incident that

resulted in death or harm, as defined within the Act and did not relate directly to the natural course

of a person’s illness or underlying condition.

The incident in question met the outcome criteria of ‘the person experiencing pain or psychological

harm which has been, or is likely to be, experienced by the person for a continuous period of at least

28 days.’ This was allegedly caused by an injection having been administered incorrectly.

The Duty of Candour Report 2019-20 can be viewed on the State Hospital Website.

http://www.legislation.gov.uk/asp/2016/14/contents/enacted

http://www.legislation.gov.uk/asp/2016/14/contents/enacted

http://www.legislation.gov.uk/ssi/2018/57/made/data.pdf

http://www.legislation.gov.uk/ssi/2018/57/made/data.pdf

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i-Matter

TSH performed well in the annual NHSScotland iMatter staff engagement process. In 2019 there

was an increase of 24% in the number of action plans developed when compared to the previous

year. Management changes and movement of staff between teams prompted a change to a smaller

number of teams overall, creating a more consistent environment for answering the questionnaire.

iMatter 2017 iMatter 2018 iMatter 2019

(96 teams) (92 teams) (92 teams)

TSH / NHSScotland TSH / NHSScotland TSH / NHSScotland

Participation levels 78% / (63%) 77% / (59%) 79% / (62%)

EEI 76 / (75) 77 / (76) 77 / (76)

% Action plans 78% / (43%) 55% / (56%) 79% / (58%)

Adjusted to 92.7% after 12 week deadline



% Progress plans 15.6% 7.6% 6.3%

Nationally the participation figures are reported after 12 weeks. Our staff however continue to

complete plans after that date and an adjustment has been included to reflect staff participation after

the 12-week deadline.

TSH is performing positively against the Staff Governance Standard. Demonstrable steady

performance against the staff governance standards with a slight improvement in a couple of areas:

iMatter 2017 iMatter 2018 iMatter 2019

TSH / NHSScotland TSH / NHSScotland TSH / NHSScotland

Well Informed 80% / (80%) 81% / (80%) 82% / (80%)

Appropriately Trained & Developed 76% / (73%) 77% / (74%) 79% / (74%)

Involved in Decisions 72% / (71%) 73% / (71%) 73% / (71%)

Treated Fairly 77% / (77%) 78% / (77%) 78% / (77%)

Safe Environment 76% / (76%) 77% / (77%) 77% / (77%)

Quality Improvement Initiative

TSH implemented the Quality Improvement (QI)

initiative TSH3030 again in 2019 to support the

embedding of QI Hospital wide. Patients were

again at the heart of the initiative, and with their

involvement empowered staff to shape and impact services that resulted in improvements to the

overall quality of care within a safe, effective person centred, environment.

The overall Best Project of 2019 was awarded to the team which consistently delivered excellent

improvements. Their aim was to increase the level of patients’ physical activity by 10%, a creative,

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engaging and well thought out process which achieved the aim. The team used a comprehensive

suite of QI tools and methods including fishbone analysis, PDSA cycles and force field analysis.

Staff Excellence Awards Staff and volunteers from across the Hospital were recognised for their hard work, dedication and

compassionate patient care at the inaugural Staff and Volunteer Excellence Awards Ceremony in

October 2019.

Patients were encouraged to participate in the voting process in addition to staff. Staff who were

shortlisted as finalists attended along with staff who had reached either 20, 30 or 40 years dedicated

service to the NHS. The PPG chair presented the Outstanding Volunteer Award.

Around 100 staff, volunteers, patients and guests gathered for the celebration, joined by guests from

the Scottish Government, NHS Lanarkshire, Community Engagement and the Mental Welfare

Commission

The event received positive feedback from many attendees:

“Sometimes in a busy working day, there is an event that lifts your spirits and reminds you of the incredible work that staff do and the appreciation that is shown by patients and carers. This was absolutely true of the Excellence Awards. It was an

exciting, uplifting and emotional event. I’m looking forward to next year.”

“I was honoured to receive the Outstanding Volunteer Award for 2019, especially since so many volunteers have given consistent and loyal service over many years. It is indeed a good feeling to know that others, whether patients or

staff, notice and value your contribution.”

“it was fantastic and I felt proud to

be part of such an event.”

“Many thanks for putting on

such a great event. I felt

privileged to have been part

of such an exciting process.

As a new member of staff, I

thought that the ceremony

was a lovely way to mark the

value that our staff bring to

the hospital and can say that

I truly felt recognized.”

“The presentation of the Excellence Awards is a great idea and the

inaugural event was a fitting occasion. I believe it will become an important

highlight of the State Hospital calendar.”

“I think the Staff Awards event was a huge success and a very fitting way to recognise the amazing

work undertaken by The State Hospital employees.”

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Section 4

Learning from Complaints and

Feedback

Patients, carers and volunteers share their

views, representing a wide range of

stakeholder. Those views have contributed to a

wide range of service improvements, which

have already been made and are informing

planned improvements:

When any aspect of a complaint is upheld or

partially upheld, we look to identify if improvements can be made to prevent the same thing

happening again.

Complaint Outputs

70% of complaints (30) were resolved at Stage 1

this year. Many of these were resolved on an

individual basis with the complainant where an

apology is offered as appropriate, but did not

involve implementing improvements or changes to

ways or working.

Issue Raised Outcome Output

Communal exercise bike is still not working despite being reported some time ago.

The bike had been repaired but was located in a ward and not the communal area therefore not accessible to patient. Senior Charge Nurses asked to review situation to ensure all 3 wards have equal access to the bike.

The hub exercise bike was returned to the communal area so that it can be accessed by all 3 wards. Since then each ward has also been provided with an exercise bike.

Patient had no electrical supply to some of the sockets in his room for several days.

Staff had accidentally turned off the wrong switch when temporarily isolating the water supply. This went unnoticed when the water supply was restored. This role is normally carried out by Estates staff and ward staff were unfamiliar with the switches.

Each of the supply switches have now been labelled by the Estates department.

https://www.google.co.uk/url?sa=i&url=https://www.rooftopgroup.org/post/listening-to-our-customer-s-voices&psig=AOvVaw2aSw9_FER083PtwijjnWc1&ust=1589548371045000&source=images&cd=vfe&ved=0CAIQjRxqFwoTCOCf8Ku3s-kCFQAAAAAdAAAAABAD

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The ‘Patients’ Active Day’ timetable does not offer anything different than what patients can do locally on the ward or in the communal hub area.

Staff met with patient group to discuss the issues raised and to encourage patients to offer suggestions on how to improve the day and their experience to make the day more enjoyable.

A wider range of activities, as suggested by patients, were considered and introduced to the programme.

The replacement single use disposable razors are poor quality and cutting patients’ faces.

Razor tested by staff and found to be adequate to shave with. However, in order to offer more choice alternative single use disposable razors were sourced and reviewed in conjunction with Security and the Patient Partnership Group to find a suitable alternative which patients could choose to purchase from the Hospital shop.

Suitable alternative disposable single use razors are now stocked in the Hospital shop should patients wish to purchase an alternative.

7 complaints were received over the past year that related to staff shortages which affected services. 4 relate to the cancellation of patient placement sessions in the Skye Centre. 2 related to the wards/hubs.

A recruitment programme was commissioned to fill vacant positons which were affecting the team’s ability to run the services to maximum capacity and/or offer drop-in sessions. In addition, Skye Centre staff were also being deployed to work in the wards on occasion to fill shortages to ensure the wards were suitably staffed.

Following a recruitment programmes the vacancies have now been filled.

All complaints closed, along with the findings and outcomes, are reported to the Clinical Governance

Group, Clinical Governance Committee and the Senior Management Team each quarter. The

Person Centred Improvement Steering Group also reviews the report to see if there are any

opportunities for wider learning.

Examples of Outputs Arising from Feedback

Staff and Volunteer Recognition Awards

Patients were asked to nominate staff and volunteers in a number of different categories in the first

Staff and Volunteer recognition awards held in October 2019. Patients were asked to nominate but

initially were not invited to the event. After writing to the Chief Executive a decision was made that

those patients who voted for a short listed nominee would be able to attend the event.

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TSH3030 – ‘What’s On?’

As part of the TSH3030 quality improvement initiative, patients from the PPG were engaged with

ward staff, the PCIT and Security Department to help support newly admitted patients, whose risk

assessment allows, to access a TV/DVD/radio in their bedroom.

PPG members are aware of the financial inequalities of patients living in TSH. Patients who receive

“pocket money” of £20 per week find it difficult to save enough money to purchase a TV / DVD

player, especially if they do not have any support from friends and family.

The aims of the ‘What’s On?’ Team were to:

Develop an appropriate protocol to permit patients access to this equipment as soon as

possible after being approved to do so by their Clinical Team.

Purchase 4 TV / DVD combi sets, pre-approved by Security, available for loan to patients

who are financially challenged and meet specific eligibility criteria.

The group identified that 40% of patients admitted to the Hospital could potentially benefit from this

scheme. In March 2020, the COVID-19 global pandemic meant that all patients required to spend

longer within their bedrooms. 20 patients were subsequently identified as having no form of

entertainment within their bedrooms and have since benefited from implementation of this scheme.

Clinical Care Delivery Model: Patient Stakeholder Forum

A further two dedicated PPG sessions were facilitated in October 2019 and February 2020, where

group members received confirmation of the preferred Hub and Ward configuration and agreed to

dedicate a monthly session to support patient engagement in this project.

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Section 5

Accountability and Governance

The Board recognise that effective and meaningful involvement supports the organisation to

demonstrate:

A culture of practice in which patients and carers are informed and meaningfully involved in all

decisions about their care and treatment.

Safe, effective, person-centred approaches to care and treatment which respect the views of

patients and carers as ‘experts by experience’.

Service design which incorporates stakeholder feedback.

Staff who understand the value of actively seeking feedback.

Stakeholders are supported to develop the skills, knowledge and confidence to share their

views.

Any barriers to involvement are identified and individual needs are met in this respect.

Methods of engagement are fit for purpose and inclusive.

Internal governance of feedback and complaints is undertaken by the Board, who receive an annual

report, including recommendations for key priorities for the next twelve months. Feedback data is

reported quarterly to the Person Centred Improvement Steering Group (chaired by the Director of

Nursing and AHP), the Clinical Governance Group and Committee (chaired by a Non Executive

Board Member). Complaints data is also shared with the Clinical Governance Group and Committee

and the Senior Management Team (SMT). Members of the Hub and Skye Centre Leadership

Teams attend the SMT and are tasked with discussing feedback relating to their areas as part of the

local forum agenda.

External support is provided by a range of partner organisations including HIS, Community

Engagement, the MWC, the Forensic Network, Carers’ Trust Scotland, the Strategic Volunteer

Leads Group and the Scottish Government Health and Social Care Directorate, Person-centred

Team.

The PCIL and Complaints Manager are members of the SMT, enabling direct support / advice to

inform discussions relating to implementation processes as well as having the opportunity to ensure

patient, carer and volunteer feedback is considered. Participation at this level also helps to inform

robust discussions around the equalities agenda, specifically decisions impacting upon the

protected characteristic groups. The PCIL also forms part of the membership of a wide range of

service change stakeholder groups including the ‘Patient Day’ Project Group, and the Clinical Care

Delivery Model Group, in addition to ensuring the patient voice is shared within the Clinical Forum,

the Mental Health Practice Steering Group, Patient Safety Group, Skye Centre Leadership Team

and Clinical Governance Group.

Summary

TSH is committed to encouraging stakeholders to share their views and ensures support

mechanisms are in place to enable patients, carers and volunteers to make use of a wide range of

methods, through which they may share their feedback. The Board embraces the CHP in terms of

supporting the organisation to enhance processes which support early resolution of issues which

are of concern to our stakeholders. This process, in addition to ensuring negative feedback is

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addressed, enables us to more effectively record and share the considerable positive feedback we

receive about staff.

There is a need for the organisation to encourage staff to embrace all types of feedback and be able

to demonstrate the outcome of conversations, during which our stakeholders share their views. This

calls for a consistent approach, which requires all staff to engage meaningfully and view all

feedback as a learning opportunity. The ‘Learning from Feedback’ Report demonstrates evidence of

feedback driving change and improvement across the Hospital.

We continue to strive to better understand the issues such a static group of patients’ / carers

experience in terms of being able to share their views. Challenges in this respect include the impact

of sharing negative feedback on patient / carer / staff relationships which is a significant concern for

stakeholders.

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Appendix 1 What matters to Patients in the State Hospital? (2019) All hubs and the Skye Centre participated in this year’s WMTY event which was facilitated across the Hospital on 6 June, 2019. A variety of methods were adopted to support patients to share their feedback including creative medium, feedback questionnaires, 1:1 conversations and group discussion. Teams were asked to review the feedback shared and agree on a maximum of three actions for their area in collaboration with patients. In order to manage aspirations, they were reminded that emerging actions should be realistic in terms of timeframes and cost neutral unless a revenue source has been identified. All areas submitted their outcomes, with the majority including action plans, which will be updated on a quarterly basis through Hub / Skye Centre Leadership Team Meetings and monitored by the Person Centred Improvement Steering Group. Hub teams were encouraged to adopt their own approach to engaging in the process, resulting in a diverse range of outputs. The Skye Centre Team facilitated an event in the Sports Hall involving patients who had sessions booked that morning, (with an open invite to the wider patient group to attend) who were encouraged to move around the room sharing their feedback in response to three questions:

“When you really enjoy a placement, why is this, what makes it good?” “When your experience is not so good why do you think this is?” “What would make your experience at this placement even better?” What did we learn?

1. Routine is important to patient well-being and settled mental health.

2. Department closures are a disruption to routine causing an increase in anxiety for patients.

3. Placements, including art / music therapies are viewed as positive and beneficial. 4. Patients are looking for increased access to placements and the opportunity to utilise the outdoor spaces

more regularly including social events and sports activities. What did we agree would improve the patient experience?

Reducing the wait for access to the grounds.

Being able to see items on a screen rather than having a black and white print out when buying goods.

Having more ward based activities.

Having more access to the ward garden.

Having exercise equipment in the ward day areas.

Facilitating more social events.

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‘What Matters to You’? 2019 Outcomes Area Actions Agreed Timescale Arran Hub Increased access to fresh air: more walking groups, patio open when possible. Jul 19

Increased opportunities for exercise: open hub gym when possible, walking groups, look into pedometers, exercise bike for Arran 1 Aug 19

Healthy eating: more fruit on ward, healthy eating programme as part of Hub education. Sep 19

Iona Hub Prioritise access to fresh air by support from wider disciplines to maintain walking groups. Jul 19

Support more regular 1:1 conversations with Key / Associate Key Worker. Oct 19

Develop processes to support visiting within the hub area. Jan 20

Lewis Hub Awaiting Actions

Mull Hub Increase range of Hub activities, ensuring they are fit for purpose. Dec 19

Alternative arrangements to ensure patients are occupied when placements are cancelled. Mar 20

Develop information for patients which details projected pathway through / out of the Hospital. Mar 20

Skye Centre

Crafts More themed sessions e.g. 1 day workshops Nov 19

Pop up shop to sell items produced Nov 19

Exhibition of patient work: rotate cabinet items regularly Nov 19

Gardens Ensure access to gardens placements are maximised over summer period Jul 19

Consider potential external funding opportunities for projects e.g. allotments Sep 19

Explore possibility of patients using fruit and veg in therapeutic cooking sessions Jul 19

Atrium Recruit patient café volunteer Oct 19

Xbox to be more regularly available during Patient Day sessions Jul 19

Facilitate a minimum of two evening social activity events Aug 19

Sports Tea / coffee available within sports area Jun 19

Recruit patient volunteers / mentors Oct 19

Consider weekend / evening activities Dec 19

PLC Water cooler / dispenser Jul 19

Reduce noise levels within a number of sessions Dec 19

Offer new interactive learning opportunities Oct 19

PPG More robust succession planning process Dec 19

Ensure patient representation from every ward Aug 19

Influence progress to supervised internet shopping project Jul 19

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