Quality Account 1st April 2014 – 31st March 2015 Glenside rebuilds lives through rehabilitation Glenside Values: Hope, Potential and Attainment CONTENTS Page
PART 1: INTRODUCTION 03 1.1 Statement from the Chief Executive 1.2 Statement from the Medical Director 1.3 Our services 1.4 Our mission, vision and values 1.5 Statement of Directors’ responsibilities 04 05 06 07 09 PART 2: REVIEW OF 2014‐15 10 2.1 Strengthening Glenside for quality 2.2 Progress with 2014‐15 quality priorities 2.3 Other quality improvements 10 16 27 PART 3: DEVELOPING QUALITY IN 2015‐16
32 3.1 Quality priorities for 2015‐16 3.2 Quality monitoring and improvement plans 2015‐16 3.3 Other improvements to continue into 2015‐16 32 34 36 PART 1: INTRODUCTION Glenside is a specialist provider for the assessment, treatment and rehabilitation of people with neurological conditions, including acquired brain injury (ABI), traumatic brain injury (TBI) and progressive neurological disorders. Services are provided from two sites situated in Salisbury and Farnborough. As evidence of Glenside’s ongoing commitment to the improvement of quality and safety of services, we are proud to publish this Quality Account for the year 2014‐15. In line with Glenside’s commitment to honesty, transparency and improvement, this document shares key information about the quality of services we provide. It looks back at the successes and learning from 2014‐15 and sets out plans for the coming year to ensure that Glenside continues to develop and improve quality, safety and service user experience. This Quality Account is intended to be read by current and potential service users and their families, wider members of the public and other stakeholders, as an honest and open account of the quality of services provided by Glenside and how we intend to continuously improve those services. If you have any comments about this Quality Account please provide your feedback to Christina Walsh, Chief Executive Officer at the address below: Glenside Warminster Road South Newton Salisbury SP2 0QD Website: www.glensidecare.com Email: christina.walsh@glensidecare.com 3 1.1 Statement from the Chief Executive 2014‐15 has been a demanding and challenging year for Glenside where we set about implementing significant change across the organisation. As a result we have achieved enormous gains with improving the quality of the service and the service user’s experience. We focused on a number of specific areas as set out in last year’s quality accounts: Christina Walsh Chief Executive Officer, Glenside 
Improved IT infrastructure 
Quality Monitoring Systems  Greater staff & service user involvement We have achieved these targets through a committed and sustained programme of change with quality being at the centre of everything we do. We have developed a culture of open, transparent communications and involvement with staff and stakeholder’s alike. We look forward to the year ahead with new quality priorities now established:  Safety Culture 
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Workforce Our aim is to continue to build on the successes of 2014‐15 and evolve our services further to ensure service users outcomes and experiences are the best that can be achieved. As well as supporting and developing our staff to ensure they are committed and delivering a high quality service. 4 1.2 Statement from the Medical Director Simon Fleminger Medical Director, Glenside Over the last year Glenside has seen a new senior management team and structure put in place. This has had a dramatic positive effect on the delivery of safe and effective services which are thoughtful of the needs of those who come to us for help. One indicator of Glenside’s commitment to good clinical governance of the quality and safety of our services, is the room where our new Quality and Patient Safety Lead and Compliance Officer are sited. Rather than having a clinical governance team sitting in an admin department hidden from clinical care, ours sit right at the entrance to the hospital in full view of clinical staff as they come and go. The monthly Quality and Governance meetings and Operations Board meetings work alongside one another to ensure that initiatives to improve our services are rolled out, while at the same time we get feedback, for example from review of complaints and untoward incidents, of things that need to be improved. Key initiatives over the last year have included better management of legal issues related to the Mental Capacity Act and Deprivation of Liberty Safeguards, better oversight of drug prescribing and administration, and greater involvement of patients / service users in decisions about their care. Over the last year there has been a massive improvement in our ability to provide a good therapy service. This is thanks to an excellent recruitment drive, such that our Allied Health Professionals (AHP) team is now essentially fully established, and a new AHP lead and management structure. But, like many other health care providers, we have continued to struggle with nurse recruitment and retention. This has meant that we have had to use a lot of agency nursing staff. One of our key targets for next year, to improve the quality of care we provide, is to reduce to our reliance on agency staff. 5 1.3 Our services Glenside is a specialist provider for the assessment, treatment and rehabilitation of people with neurological conditions, including acquired brain injury (ABI), traumatic brain injury (TBI) and progressive neurological disorders. Services are provided from two sites situated in Salisbury and Farnborough. Glenside provides two care pathways: 
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Neuro rehabilitation Neuro behavioural Individuals can be admitted for inpatient care, at any stage of the pathway. Admissions can go into either the acute neuro‐rehabilitation or neuro‐behavioural wards within the hospital. Alternatively individuals can be admitted directly into slow stream rehabilitation, long term care or simulated supported living provided by various specialised nursing and residential homes. We aim to provide rehabilitation and support to help people return to the most independent lifestyle possible. The majority of people, who undertake rehabilitation at Glenside, return home or transfer into a supported living environment. 6 1.4 Our mission, vision and values As providers of healthcare, we must never forget that everything we do must be for the benefit of the people who use our services. It is our duty to ensure the care provided to our patients and service users is consistently delivered to the highest quality, is effective, and causes no avoidable harm. People use our services at one of the most vulnerable times of their life, and expect and deserve to be treated with kindness, dignity and respect. With this in mind, during 2014‐15, Glenside reviewed, agreed and reformulated the mission, vision, values and quality objectives of the organisation for 2015‐16, utilising an interactive workshop and a consultation document discussed with Glenside staff, as well as by taking into account comments made in our service user and family surveys. The aspirations of Glenside reflect the aspirations of the people who work for Glenside and represent what is important to the people who use our services and those that care for them. Mission Glenside rebuilds lives through rehabilitation. Vision 
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To be regional leaders in neuro rehabilitation, with a reputation for delivering high quality, effective, safe care. To have a reputation as an excellent employer, valuing and supporting all employees and providing opportunities for development. To provide a person centred service, viewing people who use our services and the people who care for them as partners in care, empowering them at a time when they may feel they have few choices. To support people to reach their full potential and lead meaningful lives. Values 
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Hope – Glenside is here to offer hope for positive change no matter how small. Potential – We believe in a person’s potential and that what a person can do is more important than what they cannot. We are here to agree goals and help people reach them. Attainment – Our team of skilled professionals work with individuals to help them attain their goals and build further hope for a positive future. We believe that every positive change, no matter how small, is a cause for celebration. 7 Glenside staff said that this is what the values of Glenside mean to them in practice: “Never dwelling on the negative or abilities lost or declined post injury.” “Promoting service user involvement in their goals.” “Work alongside the team to help service users achieve their goals.” “Always supporting and offering guidance and hope to service users during their rehabilitation.” “Working on the service user’s potential.” “Encourage service users – they can do it!” “Everyone has the potential to achieve.” “Recognising when service users complete goals.” 8 1.5 Statement of Directors’ responsibilities Under the terms of the Health Act 2009, the National Health Service (Quality Accounts) Regulations 2010, and under the National Health Service (Quality Account) Amendment Regulation 2011, Directors are responsible for ensuring the preparation of a Quality Account for each financial year. Equally, the Department of Health has issued guidance on the form and content of the Quality Accounts (which incorporate the above legal requirements). In preparing this Quality Account, the Directors have satisfied themselves that: 
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The Quality Account presents a balanced picture of Glenside’s performance over the period covered; The performance information reported in the Quality Account is reliable and accurate; There are proper internal controls over the collection and reporting of measures of performance included in the Quality Account, and these are subject to review to confirm that they are working effectively in practice; The data underpinning the measures of performance reported in this Quality Account is robust and reliable, conforms to specified data quality standards and prescribed definitions, and is subject to appropriate scrutiny and review; The Quality Account has been prepared in accordance with Department of Health guidance. The Directors confirm that to the best of their knowledge and belief, they have complied with the above requirements in the preparation of this Quality Account. Approved by the Board on 29 June 2015 and signed on its behalf by: Christina Walsh, Chief Executive Officer 9 PART 2: REVIEW OF 2014‐15 2.1 Strengthening Glenside for quality 2.1.1 Strengthened operational leadership and support In February 2014, Christina Walsh joined Glenside as Chief Executive Officer. This was followed by the appointment of two Operations Managers in April 2015 supported directly by the CEO. This strengthened senior leadership providing guidance and support for Service Managers, empowering them to take ownership of their services. The support provided to the Service Managers has equally been strengthened. The Operations Managers have regular 1:1 supervision sessions with the Service Managers within their remit. Regular manager meetings are held to strengthen peer support allowing for sharing of information and ensuring consistency across services. Service Managers are now fully involved in setting, managing and reviewing resources and budgets, allowing these to be targeted where there is an operational need. To provide support to all staff out of hours, and ensure the smooth running of the service for all service users we now operate a two tier operational management on call system. This means that there is always a Service Manager and Operations Manager on call at any time. In April 2014, the roles of Quality and Patient Safety Lead and Compliance Officer were created to strengthen and embed sustainable processes for monitoring and improving quality and governance. Systems for recording and monitoring complaints, safeguarding alerts and Deprivation of Liberties Safeguards status were all strengthened. An electronic incident management system, Glenside Event Management System (GEMS) has been implemented, and has allowed Glenside to capture all incident, accident and infection data electronically. It allows supporting documents, such as CQC notification, to be uploaded and stored with the incident so that all information relating to the incident is stored together. Notifications are automatically sent to relevant individuals when incidents are reported, ensuring they are aware of the incident and to support Glenside in meeting timescales for reporting requirements. Service Managers review records of incidents online, enabling them to ensure appropriate action is taken as soon as possible. 10 Reporting of statistics in relation to incidents, accidents and infections is now more accurate, allowing trends and themes to be reviewed by the Health and Safety Committee and Quality and Governance Committee so appropriate action can be taken. 2.1.2 Medical leadership In August 2014, Simon Fleminger was appointed as Medical Director to provide leadership to the medical team at Glenside. A key improvement implemented since Simon’s appointment is the establishment of the Medical Advisory Committee. The committee meets every four months to discuss key medical concerns and to identify consultants to invite to have Practising Privileges, meaning to work at Glenside as independent contractors. This group can review the credentials of potential candidates for Practising Privileges, offer advice on clinical governance and clinical matters relating to potential candidates and ensure that Practising Privileges are offered in the best interest of service users at Glenside. As well as consultants, Glenside Hospital receives 24 hour medical onsite cover by junior doctors. These doctors are contracted to Glenside by NES Healthcare, who ensures that junior doctors employed by Glenside have necessary skills, qualifications, experience and pre‐employment checks in place before they start work at Glenside. Glenside meet with NES Healthcare at least annually to discuss this arrangement and review performance. Glenside has negotiated a Memorandum of Understanding with Salisbury NHS Foundation Trust (SNHSFT) to refer any concerns relating to the practice of senior medical members of staff, to the Medical Director of SNHSFT. This allows concerns to be fully investigated, fairly and without bias. Glenside has agreed to follow any recommendation made as a result of any such investigation unless there are exceptional circumstances. The homes within Glenside are supported by local GP services who visit regularly and provide out of hours support as needed. 2.1.3 Reorganisation of the Allied Health Professionals (AHP) team Glenside has a team of Allied Health Professionals which form the therapy department, providing Physiotherapy, Occupational Therapy, Speech and Language Therapy and Psychology services. In October 2014, Amber Johnston, Clinical Psychologist was appointed as Therapy Manager, with the main aim of effectively integrating the therapy team across the services through better collaboration and training. Amber is currently studying for a Post Graduate Diploma in Clinical Neuropsychology at the University of Bristol. Amber now attends the Operations Board Meeting, Managers Meeting, Health and Safety Meeting and Referrals Meeting, and AHPs are represented at the Quality and Governance 11 Committee Meeting and staff meetings within services, giving the team a greater voice within the organisation. A full day of the organisational induction training is now provided by the AHPs and dedicated to principles of rehabilitation and therapeutic work. Aims of Restructuring To improve the effectiveness of interdisciplinary working. To improve the training offered to assistants and the wider clinical team. To standardise a structure of skill mix and experience. To ensure appropriate hierarchical availability of supervision and training. Achieved     A new structure of competencies has been developed for assistants working within the AHP team with multi‐disciplinary training. 5 generic therapy assistants were appointed, to work across occupational therapy, physiotherapy and speech and language therapy, although initially they are aligned to one discipline while competencies are achieved. There is the potential for assistant promotion to one fixed technician position within each discipline, which will offer specialist assistant support. For qualified staff within each discipline, a new banding / supervision structure has been introduced with new job descriptions, ensuring that responsibility and accountability within the team is clear. For both qualified staff and assistants, new posts have been created to increase the number of therapists within the therapy team. This restructure has resulted in the following improvements: 
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A clearer chain of expertise offering better supervision and training to each department Greater delegation of line management duties are spread out so that more people get experience of this responsibility Clarity with similar organisational structures across disciplines within the AHP team Assistants are able to gain greater experience regarding the similarities and differences of different disciplines to aid their education and to promote interdisciplinary working Qualified staff receive more support for projects from assistant level Service user and families benefit from more knowledgeable and supported AHP staff A continuing professional development (CPD) structure is now in place for therapists allowing them to support each other 12 
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The therapy team has improved its overall recruitment and retention, increasing therapy team numbers significantly and eradicating the need for locums Virtually full staffing across the team has allowed improved assignment of therapists to specific services within Glenside to create more stability within that service Work is ongoing with the HR team to carve out an element within the organisational training budget that better supports the CPD requirements of therapists to ensure that the requirements of the Heath and Care Professions Council are met. There is a new budget structure for capital expenditure and petty cash items to allow for the more appropriate acquisition of needed equipment and resources. 2.1.4 Recruitment Until October 2014, recruitment was handled by an external provider. In August 2014, Glenside appointed Lisa Jennings as Recruitment Coordinator and recruitment was brought in‐house. This has seen a 43% increase in the number of new starts at Glenside for the period 1st October 2014 – 31st March 2015 compared with the previous 6 months. This period has also seen a decrease in people leaving Glenside resulting in a net increase in the number of staff, compared to a net decrease for the previous 6 months. STAF F MO V EMENTS ‐ APR‐14 TO MAR‐15
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80
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NET S TAF F MO VEM ENT
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Prior to Lisa’s appointment, there was no formal route for vacancies to be advertised internally, and applied for by people already working at Glenside. Since October 2014, 20 vacancies have been advertised internally, with 15 roles being successfully filled by existing staff. Glenside is committed to continuing to support, develop and offer opportunities to existing staff. 13 2.1.5 Training and development To ensure we have a quality workforce, committed and able to deliver high quality care, it is essential that we focus on the training and development given to our staff. Within the last year, induction training delivered to new staff has been strengthened, and is now delivered to all staff before they start work on the wards and now includes rehabilitation specific training. This will ensure all staff are equipped with the skills they will need to fulfil their role. In 2014‐15, mandatory training was completed by 89% of applicable staff on average, compared to the 80% target. Within the services delivered by Glenside, situations occur when potential harm could be caused to service users or to our staff because of challenging, aggressive or violent behaviour. Management of Actual or Potential Aggression (MAPA), is a range of physical interventions, de‐escalation and disengagement techniques designed to enhance personal safety of service users and staff when risky or harmful behaviours are presented. Glenside now has in house MAPA instructors who deliver regular full and refresher training to staff. The Glenside psychology team has been delivering training to staff around some key issues surrounding our services such as memory, fatigue and attention. This has helped our staff to gain a greater understanding of the service users at Glenside. A Glenside consultant has run a short course on respiratory and tracheostomy management for Senior Staff Nurses, and now these nurses are training and supervising other qualified nursing staff. This ensures there are more nurses able to manage some of the more complex service users at Glenside, improving service user safety. This year, more of our staff have accessed courses delivered by external providers, including some courses that have been delivered on site such as catheterisation and catheter care, diabetes, tracheostomy, enteral feeding and talks from Stewarts Law. Cognitive Rehabilitation Therapy (CRT) is the process of relearning cognitive skills that have been lost or altered as a result of damage to the brain. If skills cannot be relearned, new skills must be taught to enable the person to compensate for their lost cognitive functions. Increasing numbers of our rehab staff have received training in CRT provided externally by Brain Tree Training, and this is set to continue throughout the next year. Recently, three rehab staff have been approved to receive sponsorship through the Glenside sponsorship scheme to undertake nursing training. This training will begin in September and is a long term investment by Glenside to develop our current staff to undertake roles of greater responsibility. 14 2.1.6 Referral and admission Historically, there have been occasions when service users have been admitted to Glenside when the services on offer were not appropriate to their need, or to a service within Glenside which was not the most appropriate of Glenside’s services. At times there was conflict and lack of communication between the referrals team and the clinical teams. The role of referrals administrator has been created to ensure that there is one main point of contact for all referral information. Clinical teams and Operations Managers are now involved in a referral when an initial enquiry is made. This improvement in communication ensures that an assessment is only offered when appropriate, reducing the amount of time spent on inappropriate referrals. Service managers are now involved from the pre‐admission assessment of individuals whenever possible. Glenside believes that the Service Managers are best placed to advise whether an admission to their service would be appropriate. Since Service Managers have been involved in this process, there has been a significant reduction in the number of inappropriate admissions. The pre‐admission assessment itself has been updated and improved. It now includes information about history and risk of abuse, so that appropriate plans of care and support can be put into place to ensure the safety of service users. It gathers information about dietary requirements, food allergies and food and drink likes and dislikes. This information is shared with the kitchen before admission, so that a diet can be provided that meets the needs of each service user, without delay. The Therapy Team has worked closely with the Admissions Team and Service Managers to clarify the amount of therapy input available to different services, to ensure that families and funders have accurate expectations prior to admission. Systems for goal planning, multi‐
disciplinary team (MDT) meetings and clinical keyworkers continue to be updated and enhanced to improve communication and person centred working. Once a service user is admitted to Glenside, their care is regularly reviewed to ensure the service continues to meet their needs. Once funding for a placement has been approved, a date for the initial review is requested from the funding authority, usually within the first six to twelve weeks of admission. This review is attended by the MDT, service user, funding authority and with the permission of the service user, members of the service user’s family or friends. Previously, reviews were carried out sporadically, and sometimes would not take place if commissioners were not able to attend. There is now a tracker in place that is maintained by the Pathway Coordinator, to ensure that a review of care is carried out every six months as a minimum, or more frequently if requested by the funding authority. If commissioners do not attend, reviews still take place in their absence. The number of reviews now taking place has significantly increased. 15 2.2 Progress with 2014‐15 quality priorities 2.2.1 Improved IT infrastructure Rationale: To ensure effective communication it is important to ensure that there is a robust IT infrastructure to support new developments and ensure accurate timely information is available. Significant investment was made into a new server infrastructure to improve Information Governance systems with the view to attaining Level 2 compliance with the NHS Information Governance Toolkit. Other benefits include:  Continuing investment in wireless technology for service user access to internet  Electronic incident management system to give real time incident, accident and infection data  Increased number of email addresses for staff members to improve communication Progress: During June 2014, the server infrastructure was upgraded. A new file structure is now in place which has been designed to ensure that NHS confidentiality requirements are met, and a more robust back‐up system was implemented to minimise the chances of data being lost. Additional user accounts have been created for all Senior Staff Nurses and Therapists allowing individualised email to improve communication across teams and further accountability / traceability within company systems. The Wi‐Fi infrastructure is continually being improved to facilitate service user access to such things as Skype and social media sites. All wards and communal areas within the Salisbury hospital are now covered and Newton House, Pembroke Lodge and Limetree Salisbury homes and Farnborough have good coverage. Improvements to the remaining areas are slowly being rolled out. Towards the end of the year, an online solution was identified to communicate details of rotas and available shifts with the workforce. It is planned that this will be rolled out in the summer of 2015. Staff will be able to access rotas from their mobile or PC devices. They will be able to accept shifts via text message or web based apps. The aim of this is to ensure that shifts are first offered to permanent, part time or bank staff prior to resorting to using agency staff. This will improve consistency of care for service users and reduce the financial outlay to agencies so that funds can be reinvested in the services. 16 2.2.2 Improved quality monitoring systems Rationale: It is important that the Board receives assurance related to the quality of care provided across Glenside and in order to achieve this there needs to be a robust quality monitoring and reporting system in place. Target: A Key performance indicator (KPI) dashboard will be regularly reviewed during Operations Board meetings and a local audit programme will be introduced with evidence of action taken where key performance indicators fall below the targeted standard. Progress: Following the appointment of the Quality and Patient Safety Lead and Compliance Officer in April 2014, a review was carried out of the systems in place for governance and quality monitoring and improvement. From July 2014, the Quality and Patient Safety Lead took on the role of Chair of the Quality and Governance Committee. In August, the committee was renewed with an updated terms of reference and standing agenda. The purpose of the Quality and Governance Committee was defined as: 
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To ensure information about the quality of services in comparison to regulatory and local requirements is gathered, shared and acted on. To ensure lessons are learned and shared as a result of incidents and accidents, safeguarding alerts, meds management issues and any other patient safety issue as deemed appropriate. To ensure feedback from service user or those acting on their behalf from complaints, compliments, forums and experience questionnaires is acted on. To share good practice guidelines and initiatives. The committee meets monthly and reviews the results of audits and quality monitoring, discuss incident and accident trends and themes focussing specifically on safeguarding, infection control and medicines management, reviewing the themes of complaints and compliments and any other service user and family feedback to identify opportunities for learning, and reviewing any high profile documents, publications and local good practice initiatives to identify opportunities for improvement. Any actions identified have been added to an action plan and monitored to ensure implementation. At the beginning of the 2014‐15 year, the Audit and Quality Monitoring Timetable was set. This ensured that all services within Glenside were carrying out standardised audits throughout the year, measuring their services against the same set of standards as other services. Audits against the Care Quality Commission (CQC) Essential Standards of Quality and Safety took place, incorporating questions asked to staff, environmental observations and reviews of records to replicate, as far as possible, a real CQC inspection. In most cases, 17 these were completed by peer review by the manager of another service. Other audits were completed by services themselves or by the identified Infection Control Link within a service. Throughout the year, 22 audits took place. Key changes implemented as a result of these audits are summarised below: Audit Essential standard outcome 1: Respecting and involving people who use services. Key actions implemented  Service user guide developed.  Service user and family forums implemented and feedback on action taken as a result of issues raised given.  Care plans to include prompts to include information about personal preferences, privacy and dignity, promoting independence and meeting diverse needs. Essential standard outcome 2: Consent  Specialist advice sought from the DoLS team to care and treatment. as to what requires a mental capacity assessment and best interest decision meeting Essential standard outcome 4: Care and  Care plans rewritten to ensure they are Welfare of people who use our person centred and concise. services. 18 Audit (continued) Essential standard outcome 5: meeting nutritional needs Key actions implemented  All services now ensure there is a process whereby snacks can be accessed outside of meal times.  The admissions checklist has been reviewed to ensure that it asks for a nutritional assessment to be completed within the required timescale.  Menu cards to enable service users to remember what they have ordered for meals are currently being developed. Essential standard outcome 6:  The process for receiving consent to share Cooperating with other providers. information has been reviewed. Essential standard outcome 7:  Pre‐admission assessment documents have Safeguarding people who use services been updated to include history and risk of from abuse. abuse.  Recommendations from safeguarding meetings are discussed at the Quality and Governance Committee. Essential standard outcome 8:  Infection control links and Service Managers Cleanliness and infection control. have been made aware of the location of risk assessments for infection control and infection information leaflets. Essential standard outcome 9:  Administration plans for PRN medicines have Management of medicines. been developed for service user records. Essential standard outcome 10: Safety  Policy for actions to take in the event of an and suitability of premises. emergency have been reviewed.  Scheme to improve external lighting implemented. Essential standard outcome 11: Safety,  Store room for equipment has been availability and suitability of constructed at Old Vicarage. equipment.  AEDs have been redistributed across the Salisbury site and one is to be located in Farnborough. These are clearly signposted throughout site as to nearest location.  Distribution list set up for sending out safety alerts and central log kept of applicable alerts and action taken. Essential standard outcome 12:  Staff handbook developed for staff and Requirements relating to workers. information included for staff about their responsibility to adhere to professional codes of conduct. Essential standard outcome 13: Staffing  A record of the movement of staff from one service to another to cover any shortages is recorded and logged. 19 Audit (continued) Essential standard outcome 14: Supporting workers. Key actions implemented  Induction training has been reviewed.  The policy and template used for appraisals is currently being reviewed.  The policy and template used for 1:1 supervision has been reviewed. Essential standard outcome 16:  Audit and quality monitoring timetable now Assessing and monitoring the quality of displayed in all services. service provision.  Information about quality displayed in each service.  The terms of reference and standing agenda of the Quality and Governance Committee have been reviewed to ensure there is an emphasis on continuous improvement through sharing of and acting on information. Essential standard outcome 17:  The complaints policy has been reviewed. Complaints  This included the capturing, reviewing of all informal complaints too.  The logging system for complaints has been reviewed to ensure that response times, lead investigators and actions are recorded. Essential standard outcome 21: Records  Service user records have been reviewed to (x2 audits) make them user friendly and person centred.  Secure storage for records has been installed. Documentation  The expected contents of each service user file has been agreed and a specific index developed.  The record keeping policy has been reviewed to ensure instructions for creating records, the expected contents of records, acceptable documentation standards and storage of records are clear. Medicines management  Checks of clinic room and drug fridge temperature recording to be completed monthly in 2015‐16 audit.  New BNFs distributed to services.  Medicines Management Policy is currently being reviewed. Controlled drugs  Wards ensure all records of controlled drugs stored in controlled drugs cupboards are accurate.  Daily stock checks carried out and documented. 20 Audit (continued) Infection control hand hygiene Infection control environment Key actions implemented  Uniform policy updated and staff reminded of expected standards with respect to jewellery and nails.  Personal dispensers of alcohol rub purchased for staff at Farnborough and Horizon.  New hand washing facilities identified and installed at Old Vicarage.  Procedure for regular washing and decontamination of curtains and blinds to be formalised for long term placements at the Health and Safety meeting.  Working patterns of domestic staff on some units to be discussed with HR to ensure meeting service specific needs. As well as the above audits, environmental walkabouts based on the NHS 15 steps challenge were piloted. These involved Glenside staff visiting a service and recording their first impressions against a series of prompts. A total of four pilots were completed. Key actions implemented as a result of these walkabouts are described below: 
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Signs displayed on the hospital wards to indicate where the doorbells are. Signing in books were removed from individual hospital wards and visitors to the hospital are now all required to use the signing in book at reception located at the main entrance. Staff have been reminded that the doors to offices should be closed when unoccupied. The storeroom of Hospital NRU was reorganised with surplus stock removed and other stock tidily stored. A new temperature probe for Bourne Ward was sourced. A sign was placed on the front door of Limetree to indicate the location of the signing in book and the unit. The process for laundry to be collected from wards was reviewed to ensure laundry was not left on the floor. Broken dishwasher on Nadder Ward repaired. Each month, a report is produced that is received by the Operations Board and the company Board. The front of this report is a dashboard displaying performance against a number of KPIs. This ensures that the Board are aware of performance against key quality areas. The report includes the following: 
A summary of incident and accident trends 21 
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An overview of quality issues in terms of medicines management and infection control A summary of safeguarding alerts Progress against the audit and quality monitoring programme A summary of feedback received from service users and those acting on their behalf in the form of complaints and survey feedback The Board regularly review the action plans that result from quality monitoring activity. 2.2.3 Greater staff involvement Rationale: Staff Satisfaction is a key quality performance indicator. A more satisfied workforce is likely to be more sustainable and provide better patient care, with motivated and involved staff being better placed to know what is working well and how to improve services for the benefit of patients and the public. Improved staff satisfaction levels should improve retention and ultimately cut recruitment costs. Target: Staff Survey to facilitate staff involvement and identify key areas for improvement. Progress: The Glenside staff survey was conducted during May 2014, with the aim of collating feedback from all levels of employees, to understand the key perceptions relating to Glenside values, leadership, management, training, communication and teamwork. The main areas for improvement identified were: 
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Communication with staff about the strategy of Glenside and future plans Structure of 1:1 supervision and appraisals Pay and benefits were seen as uncompetitive Lack of training preparing new joiners for roles A working party group being led by the Head of HR was formed to receive feedback on the results of the staff survey and create a plan to improve areas highlighted for improvement. Currently the following improvements have taken place across Glenside in response to the points raise: 
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A series of staff roadshows took place presented by members of the senior management team. This was to update staff on changes that have been made in the organisation, challenges still facing the organisation and future plans. The appraisal system is currently under review to ensure it is meaningful to staff and to ensure it identifies learning and development needs. A pay review has taken place. The induction training has been reviewed and will be extended to prepare new starters for roles within the services. 22 The next staff survey will go ahead in May/June 2015. The Staff Consultative Group (‘SCG’) has been re‐established and meets every 3 months. The SCG provides a forum for Glenside staff to share information and perspectives on issues affecting employee experience at Glenside. It is attended by representatives of each service and from each of the business units of the management team, although the meeting is owned and chaired by the services reps. It allows staff to have input into decision making on organisational issues that are likely to affect all employees and to ensure adequate consultation is occurring through the necessary channels. Aims of the SCG: Share information about strategic issues facing Glenside and the impact on employees.
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Share information and progress updates on key developments within Glenside. Hear concerns raised by employees from suggestions or common issues agreed for agenda items.
Provide an opportunity for regular contact between management and staff representatives working in partnership to achieve common goals.
2.2.4 Greater service user involvement Rationale: Service user involvement is an important element of patient centred care and wherever possible service users should take part in the decision making process related to their care. Increased involvement will lead to greater service user satisfaction and may improve service user communication skills in some cases. Target: Survey to be undertaken every six months as a minimum, specialising on different areas of the overall survey. Progress: Everything we do must be for the benefit of the people who use our services. It is therefore important that when reviewing the quality of the service we provide and targeting resources for improvement, we take into account the opinions and priorities of service users and their families. As receivers of our services, they hold a unique and valuable perspective, and can tell Glenside about the aspects of the service that really matter to them and where they feel improvements can be made. 23 The service user survey was reviewed by the Quality and Governance Committee in September 2014. The questionnaire was greatly reduced in length compared to the previous service user survey, to try and make it more user friendly, and easier for service users to complete. It was agreed that, as such a large number of Glenside service users would not be able to give feedback, the questionnaire would be adapted and a family experience questionnaire would be completed. The service user and family experience questionnaire were distributed to 115 service users and 107 families, with 11% and 30% response rate respectively. The results of the questionnaires were published in March 2015. 92% 92% 94% 100% 100% 97% of service users agreed that they are treated with kindness, dignity and respect by staff. of service users agreed that they can take part in activities and hobbies if they want to. of relatives agreed that their relative is treated like an individual. of both service users and relatives felt they were / their relative was safe and secure at Glenside. of service users agreed that their bedroom is kept clean and tidy. of relatives said they knew who to contact if they had a complaint or question. 24 The friends and family test was included in the service user experience questionnaire. Service users were asked if they would be happy for a member of the family to be treated at Glenside. Answer Response  Yes ? Don’t know X No 77% 8% 15% Overall, the comments made by service users and their families were positive: “Of all the places I have been this is 1st by a long way. Everyone is more than happy to help.” Service user, Salisbury “Farnborough has a great family / homely feel about it. Whilst remaining clean it never feels sterile. The food is fantastic and the atmosphere is positive.” Family member, Farnborough “It is very well run and the staff are very good and caring.” “We are sure our relative feels happy, cherished and secure in a friendly and family like environment, with caring staff who are always attentive and cheerful and who respect him and are fond of him.” Family member, Salisbury “The thing I like most about the service is the accommodation and decoration within the unit, the type of staff employed and the relaxed, un‐institutional atmosphere. Staff are always willing to help and I have never seen rudeness to service users or visitors.” Service user, Farnborough Family member, Farnborough
25 Some of the feedback given in the service user and family experience questionnaires showed there was room for improvement in the service delivered by Glenside. Improvements to be implemented as a result of the service user and family experience questionnaire include: 
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Full implementation of the new service user file system and ongoing audit to ensure care plans are person centred and personal preferences are specified. The HR team are currently reviewing the appraisal system, and the 1:1 supervision system is being reviewed to ensure that any concerns about performance are addressed. Operations Managers will receive monthly updates about staff who have completed training, absences and probationary reviews outstanding to ensure all issues are promptly addressed. The HR team are currently employing a number of different methods to recruit high calibre staff, including advertising all vacancies internally and looking at international markets for qualified nurses. The menus at Salisbury have been reviewed with service user input at the Salisbury service user forum. The replacement of unsuitable furniture in service user areas has been identified and is built into budget for this year. Service users on Ebble Ward are able to access the secure courtyard when appropriate. The service user survey is to be reviewed by the Quality and Governance Committee to ensure the questions asked are appropriate and to identify effective means of getting feedback from the service user group before it is repeated. As well as feedback from service users in the form of the service user experience questionnaire, each service now holds a regular service user forum, or in services where there are limited numbers of service users with the ability to attend a forum, service users who are able to speak about their experience are regularly spoken to, allowing them the opportunity to give any feedback on the service provided by Glenside. Issues raised in these forums are actioned within the service or referred to the relevant person within Glenside for action, and the action taken is fed back at the next forum. In addition to the service specific forums, there is a Salisbury site wide forum that meets every other month facilitated by Activities Organisers. Issues raised at this forum are discussed by the Quality and Governance Committee and actioned as appropriate. Action taken is fed back at the next forum. 26 2.3 Other quality improvements 2.3.1 Discharge procedures Glenside has looked closely at discharge procedures. The format used for the discharge summary has been reviewed to ensure that information from all disciplines is incorporated into the overall discharge summary. This will improve the reliability of information being given to clinicians involved in the aftercare of service users. A discharge tracker has been introduced and is regularly monitored by the Pathway Coordinator. When Glenside has provided the services it is able to deliver for a service user and is no longer able to meet their needs, it is important that an alternative placement is found to ensure that they are in the most appropriate environment. The tracker highlights discharges that are progressing slower than desired, and Glenside is able to step in earlier to assist if required. 2.3.2 Comments boxes In April 2014, comments boxes were installed across all services and public areas within Glenside. These allow service users, staff and other visitors and stakeholders to anonymously submit comments and suggestions for improvement or change. All comments are reviewed monthly by the Operations Board, and wherever possible and appropriate, suggestions are implemented. Feedback is always given in a monthly ‘You said … we did!’ newsletter showing what changes have been made, and why it has not been possible to implement others. Changes implemented as a result of the comments boxes include: 
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New flooring has been laid in the nursing office on Bourne Ward. A direct line was set up between vending machines and the kitchen so that any problems with vending machines or other catering facilities can be reported and resolved. Staff were reminded to request the correct colour laundry bag from laundry if they do not have the right colour available. Bed linen and towels used by service users are being reviewed and replaced. Additional signage was put in place to direct visitors to reception. A high chair was purchased for the coffee shop and baby changing facilities were installed in the hospital. Staff photo notice boards have been added to all services. Large gazebos were purchased to cover benches on site in the summer so there are large shaded areas accessible to wheelchair users. 27 2.3.3 Service user guides Glenside recognises that being admitted into the hospital or a home is potentially a daunting and scary experience, so a service user guide was developed to be given to all service users for them to keep. The guide is intended to orientate service users to Glenside, giving them information about the services provided and things they need to know such as action to take in the event of a fire and security. The guide answers questions that people may have when they are admitted such as how they can personalise their room, how and when family can visit and contact them, how their clothes are cleaned and what activities they can take part in. 2.3.4 Complaints and compliments Glenside published a reviewed Complaints and Compliments Policy in January 2015. Glenside is committed to providing high quality, safe services; however we recognise that there will be times when the service provided does not meet the expectations of service users or their representatives. Glenside welcomes complaints and views them as opportunities to learn and improve services. Formal complaints, whether made in writing or verbally, are fully investigated. Following the review of the Complaints and Compliments Policy in January, the investigation into all complaints and the action taken as a result is recorded and logged centrally, and are then discussed by the Quality and Governance Committee. This sharing of practice allows changes and improvements to be made in other services when necessary, reducing the likelihood that the event that led to the complaint will reoccur. The new policy introduced the requirement to record all informal complaints. Informal complaints are small issues that do not need to be formally investigated and can usually be dealt with in a short period of time by staff within the services. Although many informal complaints may seem insignificant when viewed individually, when combined, they provide valuable information about our services. Patterns and themes of issues can be revealed which are often simple to put right, but which have a positive impact on the experience of service users. Glenside introduced a system for recording compliments. Although it is important to learn from things that go wrong, it is equally important to learn from the things that go well. Compliments are reviewed by the Quality and Governance Committee to identify if there are opportunities to share good practice across services. 28 2.3.5 Family forum As well as seeking feedback on service from our service users, it is equally important to receive feedback from the families of service users. The families of all service users have been through a life changing event resulting in their family member being admitted to Glenside. Families want to be sure that the care being provided to their loved ones is of the highest quality. The family forum first began in September 2014 and takes place quarterly. It is a chance for families to support each other and share their experiences. Although there is always a member of the senior Operations Team present at the meetings, they are run by the families. 2.3.6 Internal communication In an organisation with large numbers of staff, it is important that two‐way communication within the organisation is effective; both to frontline staff about organisational issues and back to senior management about operational issues. Regular Staff News publications are distributed to all staff within Glenside, informing them of any organisation changes, staff updates and operational changes. Communications are sent out when there are any changes to organisational policies, and to advertise staff vacancies to allow internal candidates the opportunity to develop. An annual newsletter was produced in December 2014, with updates from the key operational and central support services. As well as installing the comments boxes across Glenside, a new staff ideas email address has been launched. This allows staff to suggest any ideas for change or improvement to services to the senior management team. A series of staff roadshows took place presented by members of the senior management team. This was to update staff on changes that have been made in the organisation, challenges still facing the organisation and future plans. 2.3.7 Service user records As a result of a review of compliance against the CQC Essential standard outcome 21: Records, and observations of the CQC during an inspection in July 2014, it was decided to review the way in which service user records were filed. Previously, the files used for service user records were very large. Information used daily to help staff understand the care needs of service users and to document care were in the middle of the file and was hard to find. It was observed that care plans telling staff how to care for service users were very task orientated. There was inconsistency between services in the order in which records were filed, making it difficult for staff to find relevant information when coming from other services. 29 Services have now started to use a new format for service user records. It has allowed the records to be separated out into smaller files making it easier to find the relevant information you are looking for. All information which is used regularly, such as current care plans and risk assessments, multi‐disciplinary notes and regular monitoring information is all kept together in an active file meaning it is easily accessible at all times. All paperwork used within the files has been reviewed. Each service user at Glenside is an individual, and has their own history and personal preferences. As such, each service user deserves to be treated as an individual with their care personalised to ensure it meets their needs both physically and personally. Care plan templates now prompt staff to write care plans with reference wherever possible to how privacy and dignity will be maintained, the personal preferences of the individual, how the individual will be supported to be as independent as possible and any applicable diverse needs and how these will be managed and respected. The plans include space to record how the service user or those acting on their behalf were involved in writing the care plan, as it is the belief of Glenside that service users and their families should be treated as equal partners in planning care. A new personal profile form has been implemented. This can be completed with input from either the service user or those that care for them, and includes information about the personality and history of the individual prior to injury. This can provide valuable information for care staff to engage with and provide meaningful interactions with the service user and to ensure that the care provided is delivered taking their personal preferences into account. 2.3.8 Events In May 2014, Glenside staff members organised Glenside Salisbury’s Fun Day. The day was attended by Glenside service users, staff and families. The day was facilitated by staff and service users. There were stalls selling cakes, books and crafts, activities and entertainment, and the day was a huge success enjoyed by all, and raising over £1300 for the Headway Salisbury and South Wiltshire local brain injury charity. 30 In June 2014, staff from Kennet organised a “Bric a Brac” sale in Salisbury and raised £140 for the Huntington’s Disease association. In August 2014, Glenside hosted a garden party and scarecrow competition. Staff and service users from all services took part by building scarecrows and attending the garden party for tea and cake. In November 2014, a “Celebration of Art” took place organised by Glenside staff, bringing together the artwork and crafts of service users from the various activity groups across the Salisbury site. In December 2014, a Christmas fair, initiated by service users, took place, supported by Glenside Activities Coordinators. The day included a Christmas church service, Santa’s grotto, festive refreshments, carol singing and arts and crafts. 31 PART 3: DEVELOPING QUALITY IN 2015‐16 3.1 Quality priorities for 2015‐16 During the development of the Quality Strategy 2015‐16, utilising an interactive workshop and a consultation document, staff were consulted on what they felt were the key quality priorities that Glenside should focus on in the coming year. The Francis Report set out the lessons from the public enquiry into failings at Mid Staffordshire NHS Foundation Trust between January 2005 and March 2009. It was clear that the incidents identified at Mid Staffordshire were not isolated incidents, but that the culture had become so damaged that such occurrences had become normal practice. The report challenges healthcare organisations to care for patients in a safe, effective and compassionate way, learn lessons when things go wrong, and ensure accountability is in place. The suggestions of frontline staff, recommendations of the Francis Report and the themes from incidents, accidents and complaints were all taken into consideration when deciding the quality objectives for 2015‐16. 32 3.1.1 Quality Objectives Safety culture: deliver care without causing avoidable harm, with an organisational culture which promotes reporting of safety concerns, is open, honest and transparent when things go wrong, and learns from mistakes. Rationale: the Francis Inquiry into the failings at Mid Staffordshire NHS Foundation Trust revealed that quality of care was suffering because of a culture of secrecy and defensiveness. There was a failure to report failings and to learn from mistakes. It is important that, in order to reduce the likelihood of harm to our service users, incidents and mistakes are reported, investigated and learned from to prevent the same thing from reoccurring. Person centred: recognising each person who uses our services as an individual and an equal partner in their care, planning and delivering their care based on their preferences and choices. Actively seeking and acting on feedback of people who use our services and treating all patients and service users with kindness, dignity and respect. Rationale: each service user is an individual person with their own preferences, likes, dislikes, values and beliefs. It is important that these are recognised and respected when a service user is admitted, and that they retain control over the way in which care is delivered by expressing choice whenever possible. Workforce: recruit based on values and service need, providing opportunities for personal and professional development, with clear structures of responsibility, accountability, support and communication. Rationale: good quality care can only be delivered by a workforce properly equipped with the skills and personal qualities they need to carry out their role. A workforce that is well supported will ensure performance issues are identified and remedied and that areas for development are identified. A workforce that is clear about their aims and responsibilities with clear channels of communication will ensure that everyone is working towards shared goals. 33 3.2 Quality monitoring and improvement plans 2015‐16 Until recently, a large proportion of the quality monitoring undertaken at Glenside has measured practice against the CQC Essential standards of quality and safety. From April 2015, these standards have been replaced with the Fundamental Standards. The CQC will measure compliance with these standards by inspecting against five questions. 
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Are services safe? Are services effective? Are services caring? Are services responsive? Are services well led? Each question has key lines of enquiry attached to it which the CQC use when making their judgement about each of the five questions. Glenside has reviewed the way in which it monitors quality to ensure these standards are reflected. As of May 2015, each service will be required to complete an audit each month which will include the following areas: 
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Safeguarding Medicines management Medicine administration record chart review Implemented action from pharmacy audits Deprivation of Liberties Safeguards Documentation, including person centred planning Management of tracheostomies, catheters and PEGs Rota review Environmental walkabout Completion of MRSA screening, nutritional assessment and VTE assessments Each month there will be a focus on one of the five CQC questions. Each audit will include questions to be asked to staff, standards for records and observational questions to be completed to make an assessment of compliance with the key lines of enquiry. Once the audit is completed, it will provide Service Managers and Operations Managers with comprehensive information about the quality of their services, which they can use to devise local action plans. The results of the audits and the local action plans will be reviewed by the Quality and Governance Committee to contribute to an organisational Quality Improvement Plan. This Quality improvement Plan will be regularly reviewed for progress and updated. Alongside the monthly audit, there will be a number of quality improvement projects set up to focus on aspects of care for improvement in line with the quality objectives. Each project 34 will have an identified lead and groups will be formed with representatives from the services to identify objectives and plan and implement improvements. Glenside recognises that quality improvement is a continuous process, and as such, there will always be aspects of the service that can be improved. It is acknowledged that for change to be meaningful and to be sustained, it must be planned and implemented gradually. If too many things were implemented at once, nothing would be implemented fully or properly. With this in mind, while there will be an active Quality Improvement Plan, there will be another plan sitting alongside this detailing aspects of care that have been identified as needing to be focussed on as part of the quality improvement process, but are not actively being improved. The aspects of care on this plan will be prioritised depending on the risk posed to service users, themes of incidents and complaints, intelligence of poor or variable practice and the extent of the expected impact of improvement. The plan will be regularly reviewed and when appropriate, items will move onto the active Quality Improvement Plan. Aside from the Glenside audit programme, services sometimes undertake local audits. These audits often highlight areas for improvement that can be relevant to other services. A new local audit report form has been devised for use when a local audit is completed to summarise the reason for the audit, the findings and the actions to be implemented as a result. These can then be discussed at the Quality and Governance Committee and actions implemented in other services if appropriate. A full inspection of all Salisbury services was carried out in February 2015 assessing all regulations and measuring the services against the new fundamental standards. At time of writing we are still awaiting the final report although the draft report was positive and encouraging of the progress and improvements that have been made across the organisation. 35 3.3 Other improvements to continue into 2015‐16 3.3.1 Retention To ensure that good quality staff stay with Glenside once they are recruited, it is important that each individual is offered opportunities to develop their skills in line with their personal aspirations, and the needs of the service. Each staff member currently undergoes an annual appraisal. It is planned that during 2015‐
16, the appraisal system will be developed to ensure it links performance with objectives in terms of development needs for the individual and the service. This will ensure that the workforce is developing to meet the changing needs of the service, and that key development needs can be budgeted in advance accordingly. 3.3.2 Induction and training Following the Francis Inquiry, there was a review of the recruitment, learning and development, management and support of healthcare assistants and social care support workers. The report found that the preparation of these staff for their roles was inconsistent. A recommendation to arise from this review was the introduction of the Care Certificate. This is an element of training and education designed to prepare care staff for their roles. The Glenside induction has been reviewed in light of the introduction of the Care Certificate, and has been extended to ensure all required elements are covered. The Care Certificate standards that will be covered in induction are: 1. Understand your role 2. Your personal development 3. Duty of care 4. Equality and diversity 5. Work in a person centred way 6. Communication 7. Privacy and dignity 8. Fluids and nutrition 9. Awareness of mental health, dementia and learning disabilities 10. Safeguarding adults 11. Safeguarding children 12. Basic life support 13. Health and safety including fire and moving and handling 14. Handling information 15. Infection prevention and control 36 The induction will include training in the Mental Capacity Act, Deprivation of Liberties Safeguards and MAPA. In addition the induction process includes working alongside experienced staff for a period of at least two weeks (shadowing) to familiarise themselves with the service, service users and to gain a greater understanding of the responsibilities and expectations of their role. This new induction will be implemented at Glenside from May 2015. It is planned to review the way in which training is delivered and learning is assessed in 2015, moving away from presentations and towards in‐house assessments of performance and knowledge. The aim will be to develop and support new starters who are then more knowledgeable and able to have a big positive impact on the service when they start work. 3.3.3 Goal planning A review of the goal planning system on the Hospital NRU wards showed that there were several areas that could be improved. It is important that service users have goals to work towards that are meaningful to them, agreed amongst the MDT, that are regularly reviewed for progress. A goal planning working party was set up for the Hospital NRU to review the process, and a guideline was produced for goal planning. Goal planning meetings are now held more frequently and are more systematically run. The work undertaken by this group will be discussed at the Quality and Governance Committee to see whether this is something that can be replicated across other areas of Glenside. 3.3.4 Service user files The new format for service user files has now been implemented at Salisbury for some months. A how to guide for the use of the records will be developed to ensure that the records are used consistently across the organisation. A working group with representatives from all services will meet to discuss each document in the file to assess its appropriateness and any required amendments and its placement in the file. Monthly audits focussing on documentation will then take place utilising standards set out in the how to guide and looking at how records are person centred. 3.3.5 Therapy team In the coming year, the therapy team plan to improve links with Activities Organisers and Rehabilitation Assistants to improve the quality of care plan implementation and therapy provision. They plan to focus on developing greater vocational opportunities for service users and links with the local community, greater opportunities for group work and increased socialisation for service users. 37