"I really like the forum and would
like to come again"
Service User, National User
Forum 2015
Quality Account
2014/15
2|Quality Account
2014/15
Contents
About Danshell Healthcare Group Limited
Statement on Quality from the Chief Executive Officer
Statement on Quality from the Group Clinical and Nursing Director
Section 1: Danshell pledges from last year
Section 2: Danshell Services, Our Model of Care
Section 3: Service User & Family Involvement and stakeholder feedback
Section 4: Patient Safety
Section 5: Information Governance overview
Section 6: Quality Performance, Regulatory Compliance, Medical Revalidation,
Awards, Recognition and Partnerships
Section 7: Danshell: learning and development
Section 8: Clinical effectiveness
Annex Statements from Danshell Purchasers (Neil Harrison & Donna Owens,
Commissioners, Hartlepool)
Caring and supporting adults
through specialist hospitals and
residential services.
............................3
............................3
............................4
............................5
............................8
...........................12
...........................17
...........................18
..........................21
..........................25
...........................27
...........................32
3|Quality Account 2014/15
Statement on quality from the Chief Executive Officer
Danshell is publishing its Quality Account 2014/15 for the group’s 10 independent hospital
services within England. This Quality Account reflects the hard work and commitment in
improving standards to meet the needs of the people we serve, their families and the people who
commission our services. The Board and our service based teams are committed to delivering the
highest standard of quality care and support and this is achieved by ensuring that the users of our
services are at the centre of everything we do.
The Quality Account this year demonstrates how we have responded to the priorities raised by all
our stakeholders. It reviews how our interventions have improved service delivery and where we
need to focus in the coming years and months. Our focus continues to be on ensuring we can
measure outcomes and to enable people to progress along their chosen care pathway. At the
heart of this is our passion to make a difference for the people we support and their families and
to do this in an honest and respectful way.
Chief Executive Officer
Andrew Murray
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4|Quality Account 2014/15
Statement on quality from the Group Clinical and Nursing Director
It is our primary goal to do our best for every individual in our care and to ensure that we do that
in a way that is:
Safe: person centred and rights based
Sound: high quality and appreciative
Supportive: empowering and transforming
Some of the people we work with have had a long history of failed placements or institutional
care. It can be hard for them and their family to imagine that ‘getting a life’ may be possible. By
this we mean to do the everyday things that most of us take for granted. To live in a place of our
own, to spend time with our family and friends, to have something worthwhile to do during the
day and to feel included in our own communities. We aim to ensure that ‘getting a life’ is the
primary goal for everyone who we serve and that we never forget that everyone has dreams and
wishes for themselves, their families and friends. We want everyone in our services to feel that
they matter and every staff member in our services to feel that they can make a real difference to
the lives of the people they serve. One way we can do this is to really listen to what they tell us and
to act on what they say.
Group Clinical and Nursing Director
Debra Moore
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5|Quality Account 2014/15
Section One: Danshell pledges from 2014
In last year’s Quality Account we said that we would report on the following:
1. Outcome star tool
2. Health equality framework
3. Positive behaviour support
4. Mandatory staff training compliance
5. HoNOS LD audit results
6. Service user and staff one page profile compliance
7. Staff satisfaction surveys
1. Outcome stars
Danshell uses the Outcomes Star™ to measure
outcomes. All nursing staff have received training
in the use of this tool and its electronic recording
system. In addition, the HoNOS LD continues to
be used in all services alongside the Outcome
Stars. At the time of reporting 53 service users
across hospitals in England have completed
Outcome Stars.
2. Health equality framework
Danshell uses the Health Equality Framework (HEF)
which is an evidence based outcomes framework
developed by four members of the UK Consultant
Learning Disability Nurse Network*. We use it to
measure the impact of exposure to known
determinants of health inequalities in order to
demonstrate the effectiveness of our services in
reducing inequalities and achieving better outcomes
for the people who use our services. The HEF
informs our health action planning processes and,
in addition from aggregated anonymised data, we
will better understand service user needs across
broader populations. At the time of reporting, 60
service users across hospitals in England have HEF
profiles completed.
*Atkinson et al., 2013
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HEF ow
.
6|Quality Account 2014/15
3. Positive behaviour support
Positive Behaviour Support (PBS) is part of the mandatory
induction schedule for all new starters to the organisations. All
direct care staff have to complete the Improving Positive
Practice Workbook with every service being assigned a staff
mentor. They are introduced to the Workbook as part of their
company induction, once back in the workplace the unit PBS
mentor supports them through the workbook to completion.
Non-direct care staff are offered the Skills for Health, Positive
Behaviour Support e-learning module as an alternative to the
Improving Practice Workbook. Qualified nursing staff
or a senior support worker (who has already completed their
QCF level 3 full diploma/SVQ) will be given the opportunity to
complete the PBS standalone unit level 4. Each service invites
nurses/managers to apply for the PBS Diploma (distance
learning) accredited through Cardiff University.
Each region has a Community of Practice set up where nurses
can share best practice. It is through the regional Community
of Practice that mentorship is available to the nursing teams
from the seven regional Consultant Nurses
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4. Mandatory staff training compliance
plem
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the
HEF ow
Alongside the publication of the Danshell Academy Learning and Development Strategy
2015
.
2018 the organisation has released its Danshell Academy Training Plan 2015. This is a calendar of
Training and Development sessions throughout the year which supports services to comply with
regulatory and mandatory training requirements for its staff. Across the organisation mandatory
staff training compliance stands at an average of 75% this includes staff trained at induction and
in Active Support.
7|Quality Account 2014/15
5. HoNOS LD audit results
At the time of compiling our Quality Account for 2014/15, HoNOS audit results are still being
analysed and we will report on findings more fully in our next Quality Account.
6. Service user and staff one page profile compliance
Approximately 80% of service users across hospitals in
England have a One Page Profile in place. This figure
fluctuates with discharge and admission activity.
Nine out of the ten Danshell hospitals in England have One
Page Profiles in place for their permanent staff teams. It is
now company policy that all agency staff provide the
company with a One Page Profile prior to starting work
within a Danshell hospital.
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7. Staff satisfaction surveys
At the time of compiling our Quality Account for 2014/2015, staff survey results are being analysed
and we will report on the findings more fully in our next Quality Account.
45%
*N.B. Data for section 1, correct as of 1st June 2015
96
qualifications have been
achieved by staff
in the last year
100%
of new staff complete
PBS training
on induction
8|Quality Account 2014/15
Section Two: Our Services, Personal PATHS – model of care
Our services
Danshell has 10 independent specialist hospitals across England, to support adults who are living
with a learning disability, autistic spectrum condition or mental ill-health.
45%
9|Quality Account 2014/15
Personal PATHS Model of Care
At Danshell we believe that we must be fully accountable to
those we serve, their families and to those who commission
services on their behalf. In order to do this we have described
what we do in a straightforward and transparent manner
based on five key principles.
These five key principles form the foundation stones of our model of care and are:
1. Positive Behaviour Support
2. Appreciative Inquiry
3. T herapeutic Outcomes
4. Healthy Lifestyles
5. S afe Services
Positive Behaviour Support
Many of the people we serve have behaviours which are perceived as challenging. We believe that
we have to make a long term commitment to providing the right support for each individual to
improve their quality of life.
45%
This does not mean that people need to remain in the same place but rather we continue to
support them in a person centred way along their care pathway and ensure that what we learn
about the person and the best way to work with them, is respected, applied and built on.
Importantly, our way of working supports people to be included in their own communities and
promotes choice and control, the development of skills and alternative strategies for coping with
challenging situations.
To enable this to happen we implement a range of interventions including:
• Functional Assessment of Behaviour
• Personal Positive Behavioural Support Plans
• Individualised activity and skill acquisition programmes
• Education and employment opportunities
• Specialist assessments of need and risk e.g. HCR-20
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10|Quality Account2014/15
Appreciative Inquiry
At Danshell we are clear that our values and beliefs are the foundation on which our work is
founded. If our foundations are strong our care and support will be too. We believe that we take a
strength based approach to the people we serve and the staff that support them. To enable us to
do this we have taken an appreciative approach to care delivery and organisational development.
How we do this for individual service users and families is through a range of measures that
include:
• Involving the service user in the design, development and evaluation of Danshell services.
• Using person centred approaches in our assessment and care planning processes e.g. what
makes a good day/bad day for the individual.
• Employing person centred tools to capture what we like and admire about them, their strengths
and talents and how best we can support them e.g. One Page Profiles.
• Listening to the individual and their families and using tools to capture their compelling vision for
the future e.g. MY CPA, Person Centred Care Plans, Wonderfiles and Life Story books.
Therapeutic Outcomes
A core belief of our organisation is that we are accountable for everything we do with the service
user, their family and those who commission on their behalf. To do this we must demonstrate good
outcomes and measure them in ways that are valid and inclusive.
At Danshell we use a range of clinical and risk assessments depending on need but most important
to this methodology is the use of comprehensive outcome tools, these are:
• The Outcomes Star™ - using relevant version depending on age and needs
• The Health Equality Framework (HEF)
• Clinical Outcome measures such as HoNOS,
45%
These tools place the person and their family central to the process and enable us to support and
measure change with each individual.
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11|Quality Account 2014/15
Healthy Lifestyles
We know there is a solid body of evidence about the positive effects that
diet and exercise can have on mental health and also that people with
learning disabilities and mental health problems are more likely to
experience ill health and premature death.
At Danshell we want to ensure that the people we serve have the best
chance of living a healthy life and that we do all we can to enable this by
providing:
• Robust individualised activity programmes for everyone
• Health Action Plans and Hospital Passports
• Healthy lifestyles groups and health improvement interventions such as
smoking cessation, relaxation classes, anger management, weight
reduction programmes etc.
• Implementation of the Health Equality Framework (HEF)
• Access to national initiatives to promote sport and exercise e.g. Special
Olympics
Safe Services
We serve many vulnerable children and adults who need to feel and experience care that is safe,
sound and supportive. We take this need very seriously and have developed a quality assurance
and governance system that provides us with the measures and tools to ensure we can monitor,
improve and check our services robustly.
45%
By setting targets and working directly with service users and families we are clear about ‘what
good care and support looks like’ and strive to deliver to their expectations. We check and support
this goal by:
Applying a robust Quality Assurance System (QDR’s) and
annual audit programme
Training and working with service users and families to
check the quality of our services
Measuring and monitoring different aspects of clinical care
e.g. reducing the use of restrictive physical interventions,
incidents
Providing an extensive library of accessible information for
service users
Service user and family carer feedback systems
National Managers' Meeting
2014
12|Quality Account
2014/15
Section Three: Service User & Family Involvement and
stakeholder feedback
Service user and family involvement
We continue our work developing accessible materials in different formats to facilitate the
participation and choice of service users and their families. In particular, we focus on ensuring
information is available to support involvement within the care planning and CPA process. In
addition to this, Service User Forums are held regularly at local, regional and national levels. We
have a National Family Carer Forum which is run by Family Carers for Family Carers. Danshell
supports this forum by offering teleconferencing facilities and the printing and circulation of
regular newsletter which the Family Carer Forum write and edit.
Danshell has a Family Involvement policy which supports the work it does to involve family carers
in many aspects of support, services and improvements. Outlined within the policy are the ways in
which we would like to communicate with families and involve them in their family members care
pathway. Unless there is compelling reason not to, families are embraced as full members of the
care team, provided with information and consulted about the following:
• Meaningful involvement in assessment and care planning
• Involvement in CPA and MDT meetings
• Informed about serious incidents involving their relative
• Provided with photos or film clips etc. that demonstrate their persons progress
• Receive at least weekly phone calls
• Meet/speak regularly with the named nurse and responsible clinician
• Be involved in the discharge plan
• Involvement and included in access to general information such as service newsletters
• Informed how to make a complaint and or compliments
• Have access to information about the Mental Capacity Act and the Mental Health Act. (Available
from each service or access through the Danshell website)
• Regularly make sure family carers are happy with the service through questionnaires and other
methods
• Regularly ask family carers to tell us how we can improve services
45%
13|Quality Account
2014/15
National User Forum 2015
The Danshell Group held its first National User Forum at the Park Inn hotel in York on the 11th June 2015.
The forum aimed to gain insight into the ‘Danshell Experience’ through the eyes of those who use Danshell
services. Service users, family carers and the senior management panel gathered to listen to one another to
gain greater understanding of the care and support provided from the point of view of the person using the
service.
Representatives from the regional service user and family carer forums attended. They shared questions
and opinions of their local forums with the people who manage Danshell on a day-to-day basis.
Led by Karen Flood, Co-chair of the National Forum for people with learning disabilities, the forum began
with a group exercise discussing what was important to them. It was interesting to see that each group
independently agreed that money, getting a job and having a place of their own were amongst the most
important things.
Next, the groups worked together to make posters about what they wanted to see from Danshell services,
and what would mean the most to them. Each groups focus was different and included becoming more
independent, communicating with family members and having jobs and meaningful work placements.
At the end of these group activities, everyone was aware of what people really valued, and this set the tone
for the day. Karen Flood said, ‘everyone in this room is equal’ and ‘being close to family and friends is
important to us all’.
The afternoon session saw the Danshell senior management team form a panel whereby people who use
the Danshell services could ask questions about their care and support. The panel was made up of; Andrew
Murray; Chief Executive Officer, Debra Moore; Group Clinical and Nursing Director, Resh Hirani; Acting
Director of Finance and Ori Zaidman; Director of Corporate Development.
45%
Within group work many ideas were discussed with service users, such as travel buddies to enable people to
see families which may be dispersed. Questions from service users included; ‘Can we have a pet?’, ‘How will
we keep good staff?’, and from the family carer forum ‘How can you showcase work from inspiring managers
and share it with the group?’
The panel provided the opportunity for service users to ask the senior management team questions that
they believed would improve the 'Danshell Experience'.
Jenny Anderton; User Involvement Lead and organiser of the day said, “The forum has been a great success.
It’s incredibly encouraging to see representatives from each regional forum here putting forward those
questions that matter most to those in charge. The day was informal and everybody came away feeling
positive. The representatives are now going back to their respective regional forums and will feedback on
the outcomes of the day”.
Below: We made sure that everyone who wanted to be involved on the day was represented.
14|Quality Account
2014/15
Service User, Family Carer and Commissioner Feedback
After each Care Programme Approach (CPA) meeting satisfaction questionnaires are given to service users
“My CPA Step Three”, family carers and commissioners. These are a valuable way in which we can measure
how well we are doing in making sure a CPA meeting can be the best it can be for the individual. The
questionnaires are completed and sent back to the Chief Executive and reported back to the Board. We also
have annual service user and family carer questionnaires in addition to service user exit questionnaires
which are completed by service users with support from the people who know them best. All of these
methods in which we can ensure people’s views and concerns are heard are fed back to the board by the
Chief Executive.
Summary from annual service user
feedback questionnaires 2015
Each year we ask the people we serve at Danshell
to tell us what they think about the support and
care they receive. We use two types of
questionnaire for this purpose: Talking Mats
Questionnaires is one option and Observation
Questionnaires are the other option. The
analysis shown is taken from a total of 39 people
who use hospital services in England and who
used the Talking Mats method to feedback to us.
For each questions there are three possible
responses: 1. Happy, 2. Unsure, 3 .Unhappy.
Categories:
People
84%
of people asked were happy with the
staff teams who cared for them.
Personal needs and rights
84%
of people asked were happy with their
rights and getting access to the things
they needed.
Activities
81%
of people asked were happy with the daily
activities on offer and what they took part
in.
Redland's Red Nose Day
Fundraiser 2015!
15|Quality Account
2014/15
Categories:
Environment
81%
of people are happy with the
environment in which they are being
supported.
Care and Treatment
81%
of people asked are happy with the
care and treatment that they receive.
Coming to Danshell
88%
of people asked were happy with their
transition to a Danshell service.
Sensory Gardens at Newbus
Grange in Darlington
Comments from the questionnaires
I can hold my bank card and be independent.
Chesterholme service user June 2015
I get a good variety of healthy food provided all day every day.
Chesterholme service user June 2015
I feel comfortable making a complaint when I need to
Knightsbridge House service user April 2015
I do my own laundry
Yew Trees service user May 2015
Staff listen to me
Thors Park service user April 2015
Paul at work in the York Regional
Office, March 2015
16|Quality Account 2014/15
Quotes from Families (taken from the 2015 Family Carer Questionnaire):
“Someone commented that my son was a pleasure to be with and, smart and well mannered. I
couldn’t believe it, it made my day!”
From Family Carer Annual Survey 2015
“I feel everyone concerned do all they can. They listen if I have
any concerns about anything and try to sort it out”
From Family Carer Annual Survey 2015
“My thoughts and opinions are sought out, which makes me feel as if I am involved.”
From Family Carer Annual Survey 2015
“From the first meeting with the manager it was clear she was a dedicated and very caring person.
When we eventually met the rest of the staff, it was obvious they were also very caring.”
From Family Carer Annual Survey 2015
“Staff very professional, caring and very understanding.”
From Family Carer CPA Questionnaire 2015
Family Carer Forum 2014
17|Quality Account
2014/15
Section 4: Patient Safety: Governance Audits
What is involved
The Governance team continually focus and review processes at all services. They are responsible
for ensuring that effective audit processes, quality checks and internal compliance requirements
are in place. The team includes service users and involves external, independent expertise as
required. They collect and analyse data on a number of patient safety indicators which inform
care planning, MDT Review, and CPAs. Trend analysis and lessons learnt are reviewed at Internal
Service Reviews, Complaints and Compliments Committee, Health and Safety Committee,
Safeguarding and Whistle Blowing Committee, Clinical Governance Committee, National Clinical
Governance Forum and the Board.
Systems enable them to take a proactive approach to patient safety. They have an electronic
incident reporting system, which provides improved analysis of incidents which helps them to act
quickly and understand the lessons learnt from incidents. This enables close analysis of the use
of restrictive physical interventions at unit level during the care provision reviewing process, as
well as enabling scrutiny at regional and national level for reviewing practice and trends. Danshell
employs MAYBO as their preferred provider of physical intervention training. Danshell have
adopted the safe administration method for intramuscular injections without the use of
prone restraint across all services.
There has been a significant reduction in the use of restrictive physical restraints during this
reporting period.
18|Quality Account
2014/15
Section 5: Information Governance Overview
Governance Overview
The Group Clinical and Nursing Director is responsible for nursing, governance and training
within the organisation. She leads a team that includes expertise in nursing, governance, training,
compliance, policy, audit and risk management. This includes a Head of Governance, Head of
Training, Compliance and Risk, a Compliance Manager, Audit and Governance Co-ordinators and
Data Analysts. There are also seven Consultant Learning Disability Nurses supporting every
region across the UK.
The focus for the Governance Team is to provide assurance of patient safety, the delivery of high
quality care and measurable positive outcomes through a number of key initiatives which include
the implementation of the company’s Quality Strategy, the Annual Audit Plan and the Internal
Quality Development Reviews. The Quality Development Review (QDR) is a key vehicle for internal
assurance undertaken regularly and comprises unannounced visits by a team of experts that
include external and service user representation. This work is supported by the Consultant
Nurses who also provide professional nursing leadership, clinical expertise and supervision. The
whole team oversee and maintain a number of key processes including the development of
company policies and procedures, and risk registers.
The Governance Team undertake monthly analysis across key proxy indicators of patient safety
and outcomes for each service and region. This is examined and analysed by the Senior
Management Team led by the Group Clinical and Nursing Director and discussed at the Internal
Whistleblowing and Safeguarding meeting and reported at Board level. This information is used
to monitor and continually improve the quality of care provision and to support and inform the
operational management of services via Individual Service Review (ISR) meetings and at unit,
regional and national governance meetings.
19|Quality Account 2014/15
Key policy dissemination
All new staff coming to work at Danshell undergo a
two week induction training period. This includes
training on key polices such as: Positive Behaviour
Support, Whistleblowing, Safeguarding and how we
keep service users safe. We provide training and
support on new policy rollout and the implementation
of policies is monitored through supervision and
audit.
Review of Services during 2014/2015
We undertake Quality Development Reviews (QDRs, internal regulatory audits) based upon regulatory standards to provide internal compliance assurance by staff external to the unit. This
includes Service Users as Experts by Experience. Reports and action plans where required are
monitored by Directors of the Board
We have committed to a programme of training and support to enable service users and family
carers to participate as ‘Experts by Experience’ in the design and implementation of Quality
Development Reviews. Service users and families are actively involved in the recruitment and
interview process of new staff in both services and head office level.
Internal Service Reviews (ISRs) are Danshell’s method of monitoring and supporting units
between unit management staff and MDT members and Danshell directors. Patient safety proxy
indicators are analysed and discussed, as well as QDRs, audit, regulatory compliance and other
key performance indicators.
There is an Annual Integrated Audit Plan which includes Antipsychotic medication audit, CPA,
Infection Control, Physical Intervention, Dysphagia, Confidentiality and MDT audits. In addition
there are audits provided by external companies including medicines management and
administration, fire safety and health and safety.
The last 12 months have been about preparing ourselves for the future. We have consulted with
stakeholders and it is clear that we need to develop our care pathways and ensure our
environments are more fit for purpose. Over the next 12 months we will work towards making
sure our hospitals are redesigned in to smaller, more homely units and that all our bedrooms are
fully en-suite.
20|Quality Account 2014/15
Danshell Quality Objectives 2015-2016:
The forces that influence health and social care are constantly changing and Danshell plans to act
proactively. This includes policy changes, commissioner and regulatory requirements and
importantly, the expectations of the people who use our services and their families. Accordingly,
the priorities listed below may adapt depending on service requirements. One constant Danshell
quality objective, is we will continue to work in partnership with the people who use Danshell
services and their families to ensure they have increased choice and their voice is heard and
acted on at all levels of the organisation.
Our Objectives:
1. Quality: Deliver all the improvement interventions within the Danshell Quality Strategy and
achieve regulatory compliance in all services.
2. Care: Ensure that Personal PATHS and the objectives within are achieved and embedded in our
day to day delivery of care.
3. Delivery: Continue to work in partnership with commissioners to develop bespoke local
solutions.
4. Estates: Continue to invest in our services to ensure safe, sustainable environments that
promote a positive service user experience.
5. Workforce: Deliver the Danshell Academy objectives and stabilise employment costs, reducing
agency use through recruitment and improved retention.
6. Finance: Ensure we are a cost effective provider who delivers best value to those who
commission our services and those who use them. This includes improved resource
management and expenditure control.
7. Knowledge Management and IT: Improve on the current infrastructure and systems to ensure
services can successfully report and receive data which supports decision making. To guarantee
that each service will have the infrastructure and equipment for each service user to have contact
with their family carers.
8. Growth: Review business opportunities as they arise including opportunities to strategically
increase or decrease our estate to further the aims of the organisation.
Data Quality
Danshell continues to collect and monitor key governance data sets which are informed by
relevant agencies such as NPSA, NICE, IHAL and other appropriate guidance and research.
Clinical Governance data is used to improve patient safety and the information is utilised for
service user’s care planning, MDT and CPA reviews and is reviewed at Internal Service Reviews
(ISRs). Trends are reviewed at unit, regional and national levels and reported at Board Level.
21|Quality Account 2014/15
Section 6: Quality Performance: Regulatory Compliance, Medical
Revalidation, Awards, Recognition and Partnerships
Regulatory Compliance
Danshell is required to register its hospitals in England with the Care Quality Commission. We are
very proud of the work done to achieve the standards we now have. As of June 2015 all 10 adult
hospitals within England are 100% CQC compliant against the outcomes assessed.
All the services regulatory and corresponding action plans are available to view on the relevant
websites, details of which can be found at:
http://danshell.co.uk/cqc-regulator-reports.aspx
Medical revalidation
We have fully implemented the national Medical Revalidation process for all of our doctors. A
Responsible Officer is in place and continues to revalidate Danshell doctors.
Awards, Recognition and Partnerships
Strengthening the Commitment
At the Strengthening the Commitment, Sharing Success conference held in Derby in June we
shared a lot of our best practice. This included the following abstracts and poster presentations
for which from our nursing and training staff.
• "Building links between different branches of nursing" from Amy Childs, Clinical Nurse Manager:
highlights the importance of partnership working with general nursing in A&E, in order to have
plans in place for PWLD who at times need multiple admissions.
• "Prone not required" from Yvonne Butterfield, Consultant Nurse: a nurse led training
programme which eliminates the use of prone/face down restraint for the purpose of
administering intermuscular injections. A poster of the abstract can be seen on the next page.
• "Strengthening the workforce" from Clare Staley, Consultant Nurse and Natasha Furness, Head
of Training: rolling out the Danshell training strategy and providing the nursing workforce with
leadership the skills to ensure safe sound supportive care is delivered through evidence based
quality training and development.
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"Prone not required" - an abstract by Yvonne Butterfield, Consultant Nurse
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The National Learning Disability and Autism Awards 2015
Rebecca Hill receiving her award for
breaking down barriers, 2015
Nursing Times Awards 2015 - Shortlisted
Debra Moore and Dave Atkinson have been
recognised for their leadership and contribution
to two key initiatives implemented within our
services. They have been short-listed in the
prestigious Nursing Times Awards 2015.
The first initiative, training and engaging Experts
by Experience to improve the internal assurance
of the quality of the services, was instigated by
Debra Moore as a commitment within the
organisation’s Quality Strategy.
The second initiative was the implementation
of the Health Equalities Framework (HEF), was
led by Dave Atkinson (one of the authors of the
HEF).
Danshell Group are proud winners of The
National Learning Disability and Autism Awards
2015. The Breaking Down Barriers Award was
received by Rebecca Hill, Head of Strategic
Relationships and Special Projects Lead. The
award recognised the work Rebecca has done
around establishing and supporting the Family
Carer Forum, producing accessible CPA
documentation which feeds in to the CPA
process and which can feedback at board level.
She has also been part of the team which have
trained service users to become Experts by
Experience in the checking of services. Chris
Shield, Clinical Nurse Manager from the North
East, was also nominated for the Learning
Disability Nurse Award for his work around care
plans and protected time for nurses and support
workers to input in to care plans.
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Laing Buisson Awards - Danshell Finalists
Danshell Group were proud to be finalists for
two categories in the Laing Buisson Independent
Care Sector Awards 2015.
The first category for which we were shortlisted
was for Innovation. This recognised the
innovative person-centred approaches that have
been documented in our Personal PATHS and
Safe, Sound and Supportive documents.
The second listing recognised Debra Moore as
an outstanding contributor to her field. Debra is
committed to providing high quality, personcentred care to all those who use our services.
Partnerships with Universities
Danshell Group have developed partnerships
with universities across the UK and have a
long standing commitment to their
partnership with Positive Choices. This helps
us with the recruitment of newly qualified
nurses and promotes us as the employer of
choice. This year the stand at Positive
Choices 2015 in Cardiff, a conference
attended by 500 student LD nurses from
across the UK, was manned by the
recruitment and events team. This included
Bev Hunter, a lady who lives at a Danshell
service and also works at the Danshell
support office in York. Bev was presented
with a gift from Helen Laverty, Positive
Choices organiser.
Bev getting an award from Helen
Laverty at Positive Choices 2015
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Section 7: Danshell: Learning and Development
Learning and Development
In order to build on the energy and commitment from our staff we have published the Danshell
Learning and Development Strategy which outlines the investment Danshell is making to its staff,
service users and their families. The Danshell Academy is a unique opportunity for staff, service
users and family members to develop their personal skills and knowledge. It is also an assurance
for the organisation that everyone knows they have the right skills and knowledge to make their
unique contribution to those we serve. Having confident and competent staff is our best
assurance of delivering safe, high quality and person centred care.
Danshell Academy is passionate about ensuring people have access to the development they
need to fulfil their potential, as an accredited and approved City and Guilds centre staff can
access a variety of qualifications from QCF level 2’s to level 5’s. These are available in a range of
various subjects including Health & Social Care, Customer Service, Professional Recognition,
Autism, Positive Behaviour Support and Leadership and Management.
Any new staff to Danshell will be encouraged to attend the 2 week Induction programme which
will equip them with the skills and knowledge to succeed. This programme will not only equip
staff with mandatory training requirements it will embed the values of working in a safe, sound
and supportive environment.
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2014/15
Danshell is registered with ASDAN to enable service users
to gain awards and assist them in their aspirations to get
the life they want. Over 90 of the people we serve have
signed up to ASDAN courses and over 24 staff are now
registered as ASDAN assessors. “Independent Living Skills”
means people are working towards meaningful
qualifications in subjects such as meal preparation,
managing money and using transport.
Over 10% of
the people we
serve are in
paid or
voluntary
work
placements
within the
community.
Kevin on his first day of
work placement, June 2015
Advocacy
Danshell have national contracts with independent advocacy services. Each
service user has access to an independent advocate. Quarterly reports are
provided to the Danshell Board.
“The care provided for my client strives to meet his needs. His needs are
continually under review and care is taken to ensure he is happy” .
Advocate, May 2014.
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Section 8: Clinical Effectiveness and Audits: an Overview
Clinical Effectiveness
We aim to facilitate admissions to Danshell services for the shortest possible period of time to complete an
assessment and rehabilitation process. In order to do so we jointly complete comprehensive assessment
and agree treatment goals prior to admission and monitor these weekly for the first 12 weeks leading up to
the initial Care Programme Approach (CPA) review meeting via a planned series of MDT reviews.
Danshell use a CPA system which focuses on the service user, who takes a lead in preparation for these
meetings using the easy read “Your CPA” Steps 1 - 3 booklets to input in to the CPA meeting. All clinical CPA
reports are outcome focused and concentrate on discharge needs from the point of admission. CPA
reports are sent to attendees 2 weeks in advance and attendance proactively encouraged, meetings are
arranged at a time and date to meet service user and family needs and not those of the units.
Quality Monitoring/ Audit
We have an integrated audit programme which includes unit led,
corporate and external audits. This assists us to measure progress
against implementation of new initiatives and embedding of good
practices to support effective care for our service users. Where
audit results do not meet company minimum requirements, action
plans are developed and monitored through Internal Service
Reviews (ISRs) and
re-audited as required.
Active participation is encouraged and facilitated in the meeting
and feedback of the meeting sought from service users, family
members and commissioners of services. Danshell has developed a
CPA framework which is audited annually. We have seen an
improvement of 12% since last year.
The MDT meeting remains the regular forum to monitor service user’s progress. We continue to review
treatment goals using a structured template which ensures all areas of physical and mental health are
regularly reviewed. Danshell hospitals are supported by a clinical team of Psychiatrists, Psychologists,
Occupational and Speech and Language Therapists. Where service users have additional needs we actively
involve external clinical experts. To maximise physical health care of people using our services we ensure
that all service users receive an annual health check from their registered general practitioner. We
undertake an annual audit on MDT.
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Danshell continues to work with national pharmacy suppliers whose expertise provide training to
clinical, nursing and support staff. We undertake an annual audit on medication management to
ensure that staff are adhering to company policy and NMC standards for medicines
management.
Danshell undertakes an anti-psychotic medication audit annually to establish whether the Royal
College of Psychiatrists Consensus Statement Standards for high dose anti-psychotic use, NICE
(CG82) guidance and BNF recommendations have been achieved.
Danshell completes an infection prevention and control audit twice a year to monitor the
effectiveness of measures to protect service users and staff against infections and crossinfections.
Danshell undertakes annual MHA, Mental Capacity Act and DoLs Audits to ensure that we comply
with regulation and to safeguard our service users.
Danshell monitor the implementation physical intervention policy to ensure that we take a
positive proactive approach to the prevention and management of behavioural
distress/challenging behaviours and always utilise physical intervention only as a last resort
through the use of risk assessments, care plans and positive behaviour support plans.
*results available for 5 hospitals only
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Danshell check to ensure that all monies held on behalf of service users are kept secure and
transactions properly recorded.
Danshell monitor person centeredness and partnership approaches to support care planning.
Danshell monitors equity of access to health care, health promotion and endorses healthy
lifestyle opportunities through its Physical Health Audit.
Danshell monitors that service users have individualised and meaningful activities.
Danshell monitors that service users contribute to service delivery and design and receive
appropriate feedback on the actions taken.
Thornfield Grange take a trip to
Lake Windermere
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Safe, Sound, Supportive
The systems and structures within Danshell provide what we believe to be a ‘gold standard’
approach to securing patient safety.
Executive responsibility for patient safety within Danshell is vested in the Group Clinical and
Nursing Director who manages a directorate that includes expertise in compliance, audit, data
analysis, research and the design and collection of clinical outcome measures and other relevant
metrics.
Within this Directorate the Head of Governance leads a skilled team that provides, on a monthly
basis, detailed data to inform every level of the organisation from unit through to board of the
progress we are making towards improving patient safety and care delivery in our organisation.
In developing our approach to Quality and Safety we engaged with those who use our services
and work on the frontline of services of all grades and disciplines. We asked them what good care
looked like and a review of responses revealed 3 key descriptors – namely that is was:
Our systems enable us to take a proactive approach to patient safety. We have an electronic
incident reporting system, which provides improved analysis of incidents which helps us to act
quickly and understand the lessons learnt from incidents. This enables close analysis of the use
of restrictive physical interventions at unit level during the care provision reviewing process, as
well as enabling scrutiny at regional and national level for reviewing practice and trends.
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There has been a significant reduction by
60% from June 2012 (Base=100), in use of
high level physical restraints. Over the
same period, there was nil face down
(prone) restraint.
A full and comprehensive review of our physical intervention policies has been undertaken which
includes improvement to our quality of training, and increasing staff skills to manage complex
and high risk situations safely. Positive Behaviour Support (PBS) training is being rolled out across
all services.
There has been a significant reduction by 54%
from June 2012 (Base=100) in service user
accidents. During the same period no service
user accident has resulted in death or
prolonged hospitalisation of service user.
*This index (PRI/PAI) for the two graphs above is constructed using a collection of data in on a monthly basis since June 2012 (base
period). It serves as a benchmark for measuring changes in the number over a period. Data collected in June 2012 (“the Base”) is
assigned an arbitrary value of 100 and all subsequent data is expressed in relation to this base.
Data collected for these index’s covers Danshell’s adult hospitals in England and includes number of physical restraint incidents/
service user accidents since June 2012.
We collect a number of quality indicators including compliments and complaints. This
information is reviewed in the Complaints Committee and lessons learned are shared at National
Clinical Governance Forums. The number of complaints in England have reduced over the past 12
month period by 32% compared to the last reporting period.
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The Danshell Workforce
Views of Services from a Staff Perspective
The use of the company intranet and the staff newsletter keep members of staff up to date with
new policies, progress and improvements as we continue to improve upon patient safety and the
quality of services we provide. Regular team briefings continue to cascade information to all our
staff. Staff views are recorded and included within subsequent Board discussions.
Danshell have developed an on line nurse and support forum so that staff across the UK can
share best practice and supported one another on line. We will publish the results of the 2015
staff survey in our next Quality Account report.
Annex statements from Danshell purchasers
Hartlepool Borough Council, Child and Adult Service have kindly reviewed Danshell’s Quality
Account and in light of our experience, I can confirm that the Quality Account is correct although,
they have not been fully audited by Hartlepool Borough Council.
Signed by
Neil Harrison
Head of Service - Child & Adult Services
Hartlepool Borough Council
North of England Commissioning Support Unit have kindly reviewed Danshell’s Quality Account
and in light of our commissioning experience, I can confirm that the Quality Account is correct
although, they have not been fully audited by North of England Commissioning Support Unit
Signed by
Donna Owens
Joint Commissioning Manger
North of England Commissioning Support Unit
Danshell Group Quality Account
More information
As part of our commitment to involving and making ourselves accountable to those we serve and
their families we have endeavoured to write this report in plain English. We have also used a size
14 font improve accessibility under the requirements of The Equality Act 2010. If you required
this Quality Account in another format such as Makaton, Easy Read, larger font or a different
language then please contact:
rebecca.hill@danshell.co.uk