BARCHESTER HEALTHCARE’S
INDEPENDENT HOSPITAL SERVICES
QUALITY ACCOUNT
2015–2016
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
Introduction
Barchester Healthcare is pleased to report back on the 2014 to 2015 Quality Account from our independent
hospital services, and to set new targets for 2015 to 2016.This document provides a basis for all stakeholders
involved with our hospitals to look back over and reflect upon the quality initiatives we have worked on over
the past year and to plan actions for the improvements we have set ourselves going forward into next year.
I want to ensure that Barchester delivers the very best in quality care. Our independent hospitals’ Quality
Account for 2014 to 2015 was an important contribution to positive change. We met almost all our targets,
making significant progress on each one.
Moving forward to the Quality Account for 2015 to 2016, we have identified five areas of improvement that
we believe will improve quality within our services, based on discussions with the individuals we support, their
families and carers, our staff and other stakeholders.
It might be tempting to ask what value there is in a Quality Account given how many targets we are set and
set ourselves – we are entering the first year of the Care Quality Commission’s ratings system, for example,
Monitor are asking for complex analysis of the relationship between treatment and finances and we have our
own Quality First initiative, a core strategic initiative, to mention just the tip of a very large iceberg. But a
Quality Account adds the views of our stakeholders directly and is accountable to them, which makes it
something special.
I can formally confirm that the content of this report has been reviewed by the Barchester Operations Board
and to the best of our knowledge the information contained in it is accurate.
I would like to take this opportunity to thank all those involved in providing feedback, ideas or actions for our
Quality Account. Without their input the progress we have made towards our aims and objectives would not
have been possible.
Dr Pete Calveley
Chief Executive Officer, Barchester Healthcare
2
“The management
and staff
are wonderful
and they have
sorted all of the
concerns I had.”
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
Statement of Accuracy of our Quality Account
Directors of organisations providing hospital services have an obligation under the 2009 Health Act, National
Health Service (Quality Accounts) Regulations 2010 and the National Health Service (Quality Accounts)
Amendment Regulation 2011 to prepare a Quality Account for each financial year. Guidance has been issued by
the Department of Health setting out these legal requirements.
We can formally record that over 2014 to 2015 Barchester Healthcare provided NHS mental health services
within its seven independent hospital sites, which provided 100% of their income.
Monitoring and reporting progress
The Barchester Board sub-committee for Quality and Clinical Governance regularly reviews the quality and risk
profiles covering all service provision, including mental health service provision. As Barchester’s Director of
Quality and Clinical Governance I am responsible for its link to the sub-board Quality and Clinical Governance
group.
The Hospital Quality and Governance Committee is the key body for driving quality improvements across all
our independent hospitals. Its meetings are quarterly and there are a number of sub-work groups to the main
committee, which drive forward quality and governance projects in between the national committee meetings.
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
We have seven independent hospitals based primarily in the north of England. They are: Arbour Lodge in
Stockport, Billingham Grange in Billingham, Castle Care Village in Hull, Forest Hospital in Mansfield, Jasmine
Court in Waltham Abbey, Hazeldene in Billingham and Windermere House in Hull.
Our hospital services are commissioned by the NHS and we work closely with our commissioners to deliver local
services for people with mental health needs that provide a care pathway into the community. We have
collaborative partnerships with NHS mental health foundation trusts who we, in turn, commission through a service
level agreement contract for the provision of psychiatry and other clinical services into our hospitals.
We value our shared working relationships with our partners in the NHS and appreciate the contribution that
accurate reporting through our Quality Account makes to it, and to the quality of the services we offer.
Trish Morris-Thompson
Director of Quality and Clinical Governance
On behalf of Barchester Healthcare
Our committee reviews and plans its performance to meet the requirements of NHS commissioning bodies and
Quality Account priorities. Plans are to some extent shaped by Commissioning for Quality and Innovation
(CQUIN) standards and its agreed priorities.
Barchester’s independent hospitals work hard to continually improve patient experience through monthly
clinical governance meetings, patient forums, input from clinical review teams and quality improvement
initiatives. As with Barchester’s corporate clinical governance more generally, local governance committees
are made up by multi-disciplinary representatives.
Throughout 2014 to 2015 the Independent Hospitals ran monthly clinical audits as part of quality checks
based on our Quality Account.
4
5
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
Part One
How we performed last year (2014 to 2015)
This section of the Quality Account for Barchester's independent hospitals reviews our performance over the
last year, running from March 2014 to March 2015 but reported on in June, following Department of Health
guidelines. Overall, we worked hard to meet the targets we set ourselves. Comparing the 2014 to 2015 Quality
Account to its predecessors shows that we have met more targets, that we are better focused on the issues and
that our reporting has improved. There is still progress to be made, however: in particular, Quality Account
meetings need to become part of our routines and to be linked informally to all meetings with commissioners
and medical staff. Nonetheless, for 2014 to 2015 our hospitals achieved almost all their goals, an achievement
in which to take pride.
6
"Really do
like it here."
Priority for
improvement
Action planning
points
Our targets
Were targets met?
Is further action
required?
Priority for
improvement
Action planning
points
Our targets
Were targets met?
Is further action
required?
1. To improve
review of data
and Quality
Account planning
for the Hospital
Quality and
Clinical
Governance
Committee
All hospitals to send
clinical governance data
to the responsible
Regional Director two
weeks prior to the
Hospital Quality and
Clinical Governance
Committee meeting
Establish a pattern of data
management and digest
format within six months
This target was partially
met. A broad framework
for reporting is in place
but data flow was
disrupted by recent
senior management
changes and needs to be
re-established. Some
hospitals established
action points and
planning but not all
Digest framework to be
discussed with the new
Regional Director and the
Clinical Governance
Committee. To be tied in
with Patient Level
Information and Costing
Systems (PLICS) data if
possible. All hospitals to
establish action point for
improvement
2. To establish a
reporting
framework on
relevant data
that involves
commissioners
and drives
forward recovery
wherever
appropriate
Form a sub-committee
and agree a core report
for commissioners on
recovery statistics and
information, with
explanatory narratives
where required
To produce an agreed core
report for commissioners
with ‘bolt-on’ information
required by commissioners
for particular hospitals
within 3 months
Targets were partially
met. Core information
was gathered
Yes. Core information has
been gathered but has
proved very difficult to
tailor for commissioners
as requirements are so
diverse
The Regional Director will
circulate a digest version
of the data, matching it to
relevant policy and
regulatory initiatives and
picking out important
areas for service
improvement for
discussion, review and
action planning
Establish at least two
action points for service
improvements arising
from review of data and
stakeholder involvement,
to be auctioned or carried
forward into the 2015 –
2016 Quality Account
Demonstrate service
improvements or
change towards service
improvements within
12 months
Ask individual hospitals
to agree information
specific to commissioner
requirements with the
sub-committee
Individual hospitals to
review information
produced (with
commissioners if
possible) and link to
recovery-based action
planning
To review recovery
statistics (with
commissioners, if possible)
and to agree revised
recovery plans for
individuals who require it
within 6 months
100% of the individuals we
support recovery plans
reviewed and refreshed
within 12 months
All plans were reviewed
and refreshed
We will continue to
review information
requirements with
commissioners when
they carry out hospital
visits
Codes and national tariffs
to be explored (PLICS)
Priority for
improvement
Action planning
points
Our targets
Were targets met?
Is further action
required?
Priority for
improvement
Action planning
points
Our targets
Were targets met?
Is further action
required?
3. To improve
review of data on
physical restraint
and increase the
number of staff
trained to manage
and reduce
physical restraint
Form a sub-committee
to agree new methods
of recording restraint,
grading incidents from
1 to 4, with 3 and 4
representing physical
interventions
Agree a new method of
incident recording
including grading, with
clarity, transparency and
relevant narrative within
3 months
All targets were met
Yes. Changes at Regional
Director level mean that
recording and reporting
need to be reviewed.
Some refinements to
process are necessary
4. To improve
screening for
physical health,
review and
improve
well-being
Form a sub-committee
and agree a format for
physical health reviews
An agreed format for
physical health reviews
after 3 months
All targets were met
Review the physical
health of all the
individuals we support
who do not
refuse consent
Physical health reviews
for all patients who do not
refuse it within 12 months
Yes. Reviews of care
plans for physical health
must be ongoing and
should feed into the
planned 2015-16
Independent Hospital
audit and/or the Quality
First audit tool
To agree methods of
recording, improving
clarity and transparency
with a narrative
explanatory element
To agree review methods
for incidents for the
Regional Director
Ensure that the Regional
Director is aware of
training records on
restraint for all staff
members at each hospital
individually
Ensure the Regional
Director can review all
incidents, request multidisciplinary meetings and
increase numbers of staff
with formally accredited
restraint training
Ensure all incidents are
reviewed by the Regional
Director, beginning after 3
months and ongoing
Facilitate multi-disciplinary
meetings and action
planning for incidents that
require it after 3 months
and ongoing
Put in place individual
action plans for
individuals for whom
restraint is an issue after
6 months
Increase the numbers of
staff with accredited
restraint training within
12 months
Individual action plans
based on a root cause
analysis need to feed
into digest reporting
to the Regional Director,
Clinical Governance
review and
commissioners.
Risk registers to be
regularly updated.
GMs to take responsibility
Any new Regional
Director requirements
to be incorporated
Based on physical health
reviews, agree action
plans for the individuals
we support to increase
well-being
Agreed plans for improved
well-being in place for all
reviewed individuals
within 12 months
Priority for
improvement
Action planning
points
Our targets
5. To broaden the
experience and
training of Mental
Health Act
Administrators,
improving
services,
strengthening
services to and
relationships with
service users
Review the training
records of all Mental
Health Act Administrators
All Mental Health Act
Administrators’ training
records reviewed after 3
months and training plans
agreed
Agree training plans with
all Mental Health Act
Administrators, working
towards acquiring the
Certificate of Mental
Health Law
Agree ongoing
supervision with all
Mental Health Act
Administrators
incorporating reviews
of training progress
Facilitate the formation
of a group meeting for
peer support for all
Mental Health Act
Administrators
Agree a resource section
to be placed on the
intranet for Mental
Health Act Administrators
and deliver it through the
peer group meeting
At least 70% of Mental
Health Act Administrators to
be awarded the Certificate
of Mental Health Law within
the specified training period
All Mental Health Act
Administrators to have
regular supervision
incorporating review of
training progress after 3
months and ongoing
At least 3 monthly peer
group meetings to take
place for Mental Health Act
Administrators, commencing
after 3 months
An agreed resource section
to be placed on the intranet
after 6 months
Robustness of reporting
mechanisms to be improved
and discussed with the
individuals we support and
at Quality Review meetings
within 12 months
Were targets met?
All targets were met
Is further action
required?
Yes – the priority
is ongoing. As new
Mental Health Act
Administrators are
appointed training
towards acquiring the
Certificate of Mental
Health Law must be
a key development
action point
"I feel safe here”
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
Part Two
Targets for 2015 to 2016
Targets for 2015 to 2016 were agreed by the Independent Hospitals’ Clinical Governance Committee following
discussions with patients, relatives and other stakeholders. They are also based on the Department of Health’s
‘No health without mental health’ initiative.
Priority for improvement
Action planning points
Our targets
1. To reduce medication errors by
improving staff competency
Sub-committee to tailor the medication
competency assessment tool to the
specific needs of the independent
hospitals and establish a baseline for
errors within 2 months
Medication errors to be reduced by 10%
within 12 months
Training on medication dispensing to be
given to all members of staff based on the
Nursing and Midwifery Council Standards
for medicines management guidelines
within 9 months
Training on review of anti-psychotic
medication to be refreshed within
9 months
"We have just had
a carers’ meeting
and everyone is
extremely happy
with the care and
support offered."
14
All staff carrying out medicine rounds to
be assessed through formally supervised
medication rounds and ad hoc supervision
within 12 months
Priority for improvement
Action planning points
Our targets
Priority for improvement
Action planning points
Our targets
2. Patient well-being to be improved
through targeted health
interventions
Physical health reviews for all patient who
do not refuse it over 12 months
All reviews achieved and targets in place
within 12 months
4. To ensure equality and diversity
issues are understood and
integrated into working practice
Sub-committee to identify available
training resources and recommend a
trainer or trainers to the Hospital Clinical
Governance Group within 3 months
Awareness of equality and diversity issues
to improve over 12 months
Agreed plans for improved well-being in
place for all reviewed individuals over
12 months
Trainer to audit staff understanding of
equality and diversity issues and working
practices within 5 months
2 targets for improving overall well-being
in each hospital chosen and in place
within 12 months
Equality and diversity training to be
delivered to all staff within 8 months
Trainer to audit staff understanding of
equality and diversity issue within
10 months
Priority for improvement
Action planning points
Our targets
3. Quality of services to be
improved through targeted audits
Sub-committee to review existing audit
documentation through and with the
Quality First audit
Sub-committee to report back to the
Hospital Clinical Governance Group within
3 months
Sub-committee to identify where changes
are needed and report back to the
Hospital Clinical Governance Group
Sub-committee to report back to the
Hospital Clinical Governance Group within
4 months
Hospital-specific audits to be tailored
and agreed
Hospital-specific audit to be agreed with
Professor Trish Morris-Thompson,
commissioners and service users in
5 months
Hospital-specific audits to be implemented
within 6 months
Hospital Clinical Governance Group to
review within 11 months
Priority for improvement
Action planning points
Our targets
5. Establish a hospital-specific food
and drink strategy, addressing
existing health needs, poor diets
and a preventative agenda, based
on the Mental Health Act Code of
Practice, Chapter 24
Form a sub-committee to:
Good nutrition and access to dietary advice
is available to all patients in compliance
with the NHS standard contract
• Devise a tool for assessing special
dietary requirements for individual
patients within each hospital
• Agree broad preventative health goals
for each client group
Sub-committee to:
• Review currently available Barchester
Healthcare guidance on food and drink
with specialist help from the Barchester
Healthcare Chef Academy
• Decide on a framework for individual
hospitals to establish action plans for
improved nutrition and hydration,
involving individual hospital chefs and
patient/relative input on choice
• Ensure sustainable procurement of food
and catering services
Sub-committee to report back to the
Hospital Clinical Governance Group within
3 months
Sub-committee to report back to the
Hospital Clinical Governance Group within
4 months
Individual hospitals to agree and implement
a strategy within 5 months
The current NHS contract requirements
on food, diet and nutrition to be exceeded,
reviewed and agreed by Chef Academy
specialists, commissioners and a patient
or relative
"My husband
is doing well."
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
Part Three
About Barchester Healthcare – Funding, Registration, Research, Staffing and Commissioner’s Comments
Barchester Healthcare has not participated in any special reviews or investigations by CQC during the
reporting period.
Funding: Barchester Healthcare provides services to about 11,000 people in over 200 service sites. Our
CQC issued three warning notices of action required at Forest Hospital, all of which are being actioned. All
Barchester Healthcare’s other independent hospitals were compliant with CQC’s regulations during 2014 to 2015.
commissioners are the individuals we support, who fund their choices through personal budgets, private income or
resources provided by local authorities, Clinical Commissioning Groups and the NHS Commissioning Board.
Research: We have participated in national audit work, though not directly connected to delivery of mental health
Our overall health income fluctuates on a daily basis because most of it comes through individual nursing or
continuing healthcare funding. In developing this account we have specifically reviewed the Quality Accounts of our
seven independent hospitals, reporting back as a composite. Their income represents approximately 3% of the total
income for Barchester and is generated from the provision of NHS services over 2014 to 2015.
Over the course of 2014 to 2015 we have met requirements for being an approved provider for 'locked and
unlocked' rehabilitation services for Yorkshire and Humber strategic health authority, which included an element of
Commissioning for Quality and Innovation (CQUIN) payment. Patients in our hospitals are funded through individual
contracts. Some commissioners have set broad targets to be achieved in relation to CQUIN, which is now part of the
standard mental health contract.
Barchester Healthcare was not subject to the Payment by Results clinical coding audit during 2014 to 2015.
Registration: Barchester Healthcare is licensed by Monitor, the health service regulator with particular
hospital services.
Barchester Healthcare did not submit records during 2014 to 2015 to the Secondary Uses service for inclusion in
the Hospital Episode Statistics.
Staffing: Barchester Healthcare’s excellent service quality was recognised by our short listing for ‘The Health
Investor Award for Best Residential Care Provider’ in 2015.
Barchester Healthcare featured in ‘The Sunday Times Top 25 Best Companies to work for’ for 2014, the only care
organisation to feature in this list. The list is based on confidentially researched employee recommendations.
Commissioner and stakeholder’s feedback: Here are some views expressed by stakeholders, primary care
commissioners and mental health foundation trusts with whom we work collaboratively. They were requested from
PCTs where we have hospital sites and commissioners who support large numbers of the individuals we support on
our previous Quality Account.
responsibility for patient welfare, value for money and financial oversight.
"I am involved in decisions regarding my relative every step of the way."
Barchester Healthcare is required to register with the Care Quality Commission (CQC). Across the services
Barchester provides, our services are subject to different registration for different regulated activities. For our
independent hospitals our current registration status is in respect of: ‘Regulated Activity: Accommodation for
persons who require nursing or personal care’ and ‘Regulated Activity: Assessment or medical treatment for persons
detained under the Mental Health Act 1983’. This covers assessment and treatment of disease, disorder or injury;
diagnostic and screening procedures.
"I like the food here, and can ask for snacks when I fancy a biscuit."
‘The Commissioning for Quality and Innovation (CQUIN) payment framework enables commissioners to reward excellence by linking a proportion of providers’
income to the achievement of local quality improvement goals.’, Department of Health website, 2008, http://www.dh.gov.uk
1
20
Barchester Healthcare’s Independent Hospital Services, Quality Account 2015–2016
"I like to go for walks and to the shops."
"The consultant psychiatrist is very approachable; my relative always looks clean and he is
looked after well”
Barchester Healthcare would like to thank all commissioners and others for their contribution to this
quality account. We look forward to working with all stakeholders over the coming year to deliver the
improvements to which we are committed.
21
"Staff do their
best and they
keep me updated,
the staff are all
very good".
Action
plan
Age issues
Gender
issues
Disability
issues
Ethnicity and
cultural issues
Religious or
belief issues
Sexual
orientation
1. To reduce
medication
errors
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
A reduction in
the number of
patients who
are given or
not given
medication
inappropriately
A reduction in
the number of
patients who
are given or
not given
medication
inappropriately
A reduction in
the number of
patients who
are given
or not given
medication
inappropriately
A reduction in
the number of
patients who
are given
or not given
medication
inappropriately
A reduction in
the number of
patients who
are given
or not given
medication
inappropriately
A reduction in
the number of
patients who
are given or not
given medication
inappropriately
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
None expected
None expected
None expected
None expected
None expected
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Older people are
a high-risk
group and must
be carefully
monitored
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Negative
impact:
None expected
Action plan:
Ensure
implementation
and evaluate
Action
plan
Age issues
Gender
issues
Disability
issues
Ethnicity and
cultural issues
Religious or
belief issues
Sexual
orientation
Action
plan
Age issues
Gender
issues
Disability
issues
Ethnicity and
cultural issues
Religious or
belief issues
Sexual
orientation
2. Improve
patient
well-being
through
targeted
health
interventions
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Improved health
and lessened
discomfort
Improved health
and lessened
discomfort.
Improved health
and lessened
discomfort
Improved health
and lessened
discomfort
Improved health
and lessened
discomfort
Improved health
and lessened
discomfort
3. Quality of
services to be
improved
through
targeted
audits
Demonstrably
improved
services
Demonstrably
improved
services
Demonstrably
improved
services
Demonstrably
improved
services
Demonstrably
improved
services
Demonstrably
improved
services
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact::
None expected
None expected
None expected
None expected
None expected
None expected
None expected
None expected
None expected
None expected
None expected
None expected
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Hearing and
sight issues to
be particularly
addressed
Ensure
implementation
and evaluate
Hearing and
sight issues to
be particularly
addressed
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
People living
with dementia
may require
advocates to
ensure their
views are taken
into account
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Ensure
implementation
and evaluate
Action
plan
Age issues
Gender
issues
Disability
issues
Ethnicity and
cultural issues
Religious or
belief issues
Sexual
orientation
4. To ensure
equality and
diversity
issues are
understood
and acted
upon
Positive impact
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Positive impact:
Improved
understanding
will improve
quality of life
Improved
understanding
will improve
quality of life
Improved
understanding
will improve
quality of life
Improved
understanding
will improve
quality of life
Improved
understanding
will improve
quality of life
Improved
understanding
will improve
quality of life
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
Negative
impact:
None expected
None expected
None expected
None expected.
None expected
None expected
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
Action plan:
People living
with dementia
may require
advocates to
ensure their
views are taken
into account
Ask patients,
relatives and
stakeholders
for views
Ask patients,
relatives and
stakeholders
for views
Ask patients,
relatives and
stakeholders
for views
Ask patients,
relatives and
stakeholders
for views
Ask patients,
relatives and
stakeholders
for views
"I like to go
next door
to sing."
www.barchestermentalhealth.com