Quality Account 2014/15
01
Contents
Part One
Statement on Quality from the Chief Executive
03
Part Two
Priorities for improvement 2015/16
08
Statement of Assurance from the Board
11
Review of services
12
Participation in clinical audits
12
Part Three
Review of quality performance in 2014/15
27
Complaints and compliments report
32
Friends and Family Tests
35
Statements from local CCG and Healthwatch
39
Glossary
42
Part One
Statement on Quality from the Chief Executive
03
03
Statement on Quality from the Chief Executive
I am pleased to introduce The Retreat’s Quality
Account for 2014/15.
This Quality Account is our annual report to
the public and to people who use our services
about the quality of the care we deliver. It
includes examples of improvements we have
already made to the quality of the services
we provide and our plans to make further
improvements. It also describes some of the
systems we have in place to measure quality.
The Retreat is a not-for-profit provider of
specialist mental health services. We work
closely with the NHS to provide services for
people with complex and challenging needs.
The Retreat was established over 200 years
ago by Quakers and was the first place where
people with mental health problems were
treated humanely, with dignity and respect.
Long before today’s focus on recoveryorientated, inclusive services The Retreat was
providing care based on the belief that, given
the right environment and if treated as equals,
people using our services can be empowered to
take responsibility for their own recovery.
We are proud of our longstanding reputation for
excellence and for providing
care of the highest quality.
We are very proud of our long-standing
reputation for excellence and for providing
care of the highest quality. We are committed
to working with those who use our services
to improve the quality of the services we
deliver and enable us to evidence that quality
improvement.
Looking back over 2014/15, I am pleased to
report that we made solid progress with the
priorities we identified in last year’s Quality
Account. Where we have not progressed as
far as we would have liked, such as with the
electronic patient record system, there are good
reasons for this. You can read more about these
items on pages 27-31. Another pleasing feature
of 2014/15 was the progress we made with
implementing our new governance structures.
These, alongside the introduction of the Board
Assurance Framework, ensure our Board
focuses on the important areas of quality, safety
and risk.
I am particularly pleased with the feedback
we have received from the people who use
our services and you can read some of their
comments throughout the report. In the main it
is extremely positive and we are committed to
addressing those areas of concern.
Our aim is that all our services receive external
accreditation and three of them have already
done so. You can read more about this on page
16. Other services continue to work towards
accreditation and this is an area where we may
need to push harder to accelerate progress.
All services have been routinely collecting
outcome data and producing an annual clinical
review for some years. In the last twelve months
we have moved to six monthly reporting
of outcome measures. We are particularly
interested in finding out what happens to people
post discharge and are thinking about how we
might obtain regular and systematic information
on this. We want to assist people to achieve a
recovery that is sustainable.
Particularly encouraging in 2014/15 is the
increase in research activity, driven by a
comprehensive strategy. We continue to develop
links with a range of universities and to take
students from a number of clinical disciplines
on placements. We are really looking forward
to taking on our first medical student in the
summer of 2015.
We recognise that highly
trained, committed and
valued staff teams are
pre-requisites of any
quality service
We recognise that highly trained, committed
and valued staff teams are pre-requisites of any
quality service. We work hard to support, listen
to and value our staff and it was disappointing
that the results of the recently conducted Staff
Survey were not as good as last year’s. Equally,
the results of the Staff Friends and Family Test
were disheartening as only 51% of staff would
recommend The Retreat as a place to work and
24% would not recommend it. We know that
staff are dissatisfied with the level of pay they
04
05
receive, particularly when compared with that
offered by the NHS, and we have taken steps
to address this for nursing staff, our largest
staff group. Our staff also complain about poor
communication from the Leadership Team so we
are embarking on a project to look at how we
can improve this and thereby raise levels of staff
engagement and satisfaction.
In 2014/15 we conducted the annual round of
appraisals, having further modified this following
feedback from staff. The appraisal includes
a grading for all staff and, whilst this remains
unpopular, we believe this is an important part
of any appraisal and are keen to retain it. We
continue to carry out our quarterly face-to-face
team briefings and these are well received.
We were not inspected by the Care Quality
Commission in 2014/15 but were found to be
fully compliant when they inspected our services
in 2013/14. We are working hard to familiarise
ourselves with the new system of inspection
and have implemented a programme of internal
inspections using the Key Lines of Enquiry.
I remain confident that The Retreat will rise to the
challenges ahead
This past year has been every bit as challenging
as we predicted and the coming years will
be even more so. I remain confident that The
Retreat will rise to the challenges ahead and
continue to provide high quality services which
represent value for money.
On behalf of The Retreat, I affirm my
commitment to providing high quality services
and confirm that, to the best of my knowledge,
the information contained in this report is
accurate.
Jenny McAleese
Chief Executive
04/06/2015
Part Two
Priorities for improvement 2015/16
08
Statement of Assurance from the Board
11
Review of services
12
Participation in clinical audits
12
07
“The staff almost
always find time for you if you need it. The staff are approachable and kind.”
08
Priorities for improvement 2015/16
Having spent 2014/15 improving the governance
systems and processes across the organisation,
the priorities for 2015/16 mark a year of
consolidation and change for the organisation.
Change will be focused on developing links with
the local community and seeking opportunities
to work with partners. The exciting Café+
initiative will incorporate both these aspirations.
The management and monitoring of risk will be
further developed to incorporate strategic risks.
The investment we have made in developing
outcome measures and supporting staff who
wish to undertake research will be embedded.
A new pilot nursing structure will be
implemented in May 2015 and this offers great
opportunity to not only develop the potential of
nurses across The Retreat but also think about
introducing new roles and ways of working
across multi-disciplinary teams.
Patient Safety
Objective
Continue to further
develop and
embed robust
risk management
systems and
processes across
the organisation.
Rationale
The organisation
needs to identify and
manage all risks.
2015/16 Activities
Indicators for success
Lead, monitoring
and reporting
Increase the scope of the
Risk Register to include
strategic risks.
The Risk Register will
include strategic risks,
signed off by the Board.
Associate Director
of Governance and
Change.
Increase the number of
staff that can add risks to
the Risk Register.
All clinical staff will have
been trained in entering
risks on the Risk Register
and will be doing so as
appropriate.
09
Clinical Effectiveness
Objective
Develop and
implement evidence
based outcome
measures to
demonstrate the
effectiveness of our
interventions.
Rationale
2015/16 Activities
Indicators for success
Ensure we are able
to demonstrate the
positive impact of
our interventions for
patients.
The Research and
Clinical Outcomes
Strategy will be
implemented across The
Retreat.
A robust approach to
supporting research
and developing
meaningful outcome
measures is embedded
across The Retreat.
Drive ongoing
improvement in clinical
practice.
Outcomes will be
reported on at six
monthly intervals in a
format that can be shared
with commissioners.
Provide evidence to
commissioners that
our interventions are
effective
Lead, monitoring
and reporting
Medical Director.
“Have been made very welcome and involved from day one - very impressed by the calm and efficient manner of everyone that works there.”
Patient Experience
Objective
Develop a new
community
recovery facility in
partnership with
local organisations.
Rationale
To create a sanctuary,
a place that offers
respect, safety and
similar people to meet.
It will offer a range
of activities that can
promote recovery.
2015/16 Activities
Working in partnership
we aim to develop the
idea of establishing a
café type safe space
which allows service
users and others to relax
and socialise.
Indicators for success
Funding is identified
to support the
establishment of a safe
space for service users
and others to utilise.
Lead, monitoring
and reporting
Tuke Centre
Manager.
“Nothing is too much trouble and support given to the families of their patients is also very good.”
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11
Statement Relating to Quality of NHS Services
Provided
Statement of Directors’ responsibilities in
respect of the Quality Account
The Directors are required under the Health Act
2009, National Health Service (Quality Accounts)
Regulations 2010 and National Health Service
(Quality Account) Amendment Regulation 2011
to prepare Quality Accounts for each financial
year. The Department of Health has issued
guidance on the form and content of annual
Quality Accounts (which incorporate the above
legal requirements).
In preparing the Quality Account, Directors are
required to take steps to satisfy themselves that:
• The Quality Account presents a balanced
picture of the organisation’s performance
over the period covered;
• The data underpinning the measures of
performance reported in the Quality Account
is robust and reliable, conforms to specified
data quality standards and prescribed
definitions, is subject to appropriate scrutiny
and review; and
• The Quality Account has been prepared
in accordance with Department of Health
guidance.
The Directors confirm to the best of their
knowledge and belief they have complied with
the above requirements in preparing the Quality
Account.
By order of the Board
• The performance information reported in the
Quality Account is reliable and accurate;
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Account,
and these controls are subject to review to
confirm that they are working effectively in
practice;
David Peryer
Chair of Directors
04/06/2015
12
Review of Services
During 2014/15 The Retreat provided eight NHS
services in three service areas.
The Retreat has reviewed all the data available
to them on the quality of care in eight of these
services.
The income generated by the NHS services
reviewed in 2014/15 represents 100% of the
total income generated from the provision of
NHS services by The Retreat for 2014/15.
Participation in Clinical Audits
The Retreat undertakes an annual programme
of Clinical Audit which is included within our
overall three-year Clinical Audit Strategy. We
reviewed the list of National Clinical Audits and
enquiries for inclusion in the Quality Account
2014/15. There are three National Clinical Audits
applicable to the services provided by The
Retreat, but due to insufficient patient numbers
The Retreat did not participate in them.
The three audits, which are contained in the
Prescribing Observatory for Mental Health
(POMH-UK) framework, were:
• Prescribing for substance misuse: Alcohol
detoxification.
• Prescribing for bipolar disorder (use of
sodium valproate).
• Prescribing for ADHD in children, adults and
adolescents.
The results of 24 Local Clinical Audits were
reviewed in 2014/15 and the organisation has
taken action as a result of these findings to
improve the quality of care and treatment it
provides.
“The Retreat does
a fantastic job of
caring for all their
patients. ”
13
Local Clinical Audits Conducted
Audit
NICE Quality Standard 1:
Dementia
Key quality improvement actions
•
•
•
Bank Staff Record Keeping
•
•
Recovery Plans and Record
Keeping*
•
•
•
•
NICE Clinical Guideline 136:
Service User Experience In Adult
Mental Health
•
•
•
CPA Reports (10 day target)**
*7 Audits carried out in 2014/15
•
•
Improve recording of Carers’ assessments being offered as part of the CPA
documentation. Nursing staff to record when such an assessment is offered and
document evidence of liasion with our social work team. Dissemination within the
unit teams.
Greater use of assessment tools to monitor improvement in a target symptom
when behaviours challenge. Psychology staff to investigate and implement an
appropriate tool to capture this information.
Greater use of cognitive tools to monitor changes in cognition when
pharmacological methods are used to manage behaviours that challenge.
Psychology staff to investigate and implement an appropriate tool to capture this
information.
Bank staff (both RMNs and Support Workers) to ensure they follow correct
guidelines on documentation ensuring they sign their entries on the Electronic
Patient Record System (FACE).
Maintain the FACE training session in the new starters Induction Programme and
continue with unit based training schedule.
Ensure that all patients have a clearly structured Recovery Plan in place that is
reviewed and updated within agreed timeframes.
Named Nurses to address the areas for improvement in their own documentation
following each bi-monthly audit.
Ensure that all patients have the opportunity to develop Advance Statements.
Ensure that repeat Risk Assessments and other relevant assessments are
completed within the agreed time frame of one month.
Crisis Plans - for people who may be at risk of crisis, a crisis plan should be
developed by the patient and their care coordinator. The crisis plan should include
specified areas as per NICE guidance.
Use of Advanced Statements to be increased. Increase use of the Respect My
Wishes document on those units showing a lack of uptake. Re-audit use of Respect
My Wishes documents to get a benchmark across the organisation.
Recovery Plan to include social care and crisis plan. This will ensure care planning
supports effective collaboration with social care and other care providers during
endings and transitions, and includes details of how to access services in times of
crisis.
Implementation of a new electronic CPA recording system.
Unit Administrators standards awareness training.
Local Clinical Audits Conducted
Audit
Mental Capacity Act/Consent To
Treatment
Key quality improvement actions
•
•
Improved documentation of Consent to Treatment, Advanced Decisions and
Lasting Power of Attorney on the FACE EPR System. Completion of Capacity
Assessment Forms. If a patient lacks capacity to consent to the care plan a
Capacity Assessment should be recorded.
Mental Capacity Act Training. Ensure all staff have received training appropriate to
their roles.
Risk Profile Assessments
•
Ensure Naomi unit staff are aware of need for Risk Profiles to be reviewed every
three months as part of NHS England contract.
Physical Healthcare**
•
Annual and physical examinations on admission are recorded on the agreed
assessment sheet.
Influenza vaccinations documentation. Accessibility of a record of a discussion of
administration of influenza vaccinations to patients. Add to physical assessment
sheet.
GPs to record Retreat patients’ consultation on FACE.
•
•
Hand Hygiene/Infection Control*** •
•
•
Introduce new audit tool and process to be carried out across all units.
Unit based hand hygiene training carried out by Infection Control representatives
for all staff including use of an ultra violet machine.
Improve hospital wide signage for use of hand gels as best practice.
Health of the Nation Outcome
Scale (HoNOS)
•
Quarterly report for Patient, Safety and Experience Group.
Respect My Wishes
•
•
Ensure all patients have a Repect My Wishes document.
Agree and implement a standard for review of Respect My Wishes.
Subject Access Requests
•
•
•
Remove from Risk Register.
Central Subject Access Requests Log to ensure requests are dealt with efficiently.
Amend Access To Health Records Policy to include Access to Health Records
(AHR) Application Forms. Review current suitability of AHR forms as part of the
Access to Health Records policy.
T2/T3 Forms (Mental Health Act)
•
Only the current T2 form should be in the patient’s notes. Issue guidance to unit
clinical staff.
Route of medication to be indicated on T3 forms.
•
Nursing & Midwifery Council
Record Keeping Standards (Tuke
Centre)
**2 Audits carried out in 2014/15
***3 Audits carried out in 2014/15
•
•
•
Develop guidance on writing defensible patient records, highlighting in particular
the key areas of improvement noted.
Develop a checklist for clinicians to use, based on the Audit tool.
Purchase of an Electronic Patient Record System.
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15
“Everyone I have met, either therapist
or admin staff, have been extremely
supportive, efficient and welcoming.”
16
External Acceditation
The Royal College of Psychiatrists Centre for
Quality Improvement (CCQI) aims to raise the
standard of care that people with emotional
or mental health needs receive by helping
providers, users and commissioners of services
assess and increase the quality of care they
provide.
In October 2014 The Acorn Programme was
awarded the 2014 Independent Healthcare Apex
Specialist Provider of the Year award.
Units’ continued accreditation:
• The Acorn Programme - Community of
Communities
• Naomi unit - Quality Network for Eating
Disorders
• Katherine Allen unit - In-patient Mental Health
Services for Older People (AIMS-OP)
Looking forward during 2015/16 Hannah Mills,
Allis and Strensall units are working toward
accreditation through The Royal College of
Psychiatrists Enabling Environments Award.
“They’re great. Very professional. Always seem to know what they’re doing, which makes me calmer!”
17
Participation in Clinical Research
The number of patients receiving NHS funded
treatments that were recruited during 2014/15 to
participate in research approved by a Research
Ethics Committee was zero.
Four projects have been initiated and approved
by The Retreat Virtual Research Group during
this year across the range of our services:
• Talking about shame without talking about
shame - a thematic analysis of interviews
with carers of individuals with an Eating
Disorder;
• What does The Retreat do? Intersubjective
workplace goals of The Retreat Strensall;
• Where is the emotion in dementia?
• An evaluation of the use of The Retreat
labyrinth.
A staff survey of all research-related activity
generated a list of additional ongoing projects:­
• A long-term follow-up evaluation of the Acorn
Programme;
• The impact of introducing Compassion
Focused Therapy into DBT (Dialectical
Behaviour Therapy);
• Integrated Care Pathways in an inpatient unit
for women with eating disorders;
• Medical risk study of Naomi Pathways to
Recovery;
• Focus group project on running
psychotherapy groups in the older adult
service;
• Development of the Dementia Card Sort
assessment;
• What it means to recover: service users’
perspectives on recovery within an inpatient
unit;
• Evaluating the service user experience of a
Compassion Focused Therapy group.
Research has been disseminated internally
through The Retreat’s Clinical Development
Group and externally via national conference
and scientific journal publication.
Commitment to Research as a Driver for
Improving the Quality of Care and Patient Experience:
The Retreat has continued to develop research
links with a number of Universities including
the University of Nottingham, Bangor University,
University of York, York St John University,
University of Sheffield and the University of
Leeds.
There is current involvement with research
networks within the Institute of Mental Health
and the Centre for Social Futures (University
of Nottingham), the College of Occupational
Therapy, the Research Centre for Occupation
and Mental Health (York St. John University)
and the Physiotherapy with Eating Disorders
network.
Retreat staff members have had involvement in
clinical training at Hull University, University of
Leeds, University of York, Leeds Metropolitan
University and Hull York Medical School.
Developing research-derived clinical innovation,
clinical outcomes and our training of others are
to be key aspects of our organisational strategy
for the coming years.
The Retreat’s enquiring and collaborative
stance, together with a combination of
quantitative and qualitative approaches, help
facilitate continued exploration of the key
factors in mental health recovery. Our aim is to
maximise the contribution The Retreat’s services
provide to this stage of an individual’s pathway.
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19
Use of the Commissioning for Quality and Improvement (CQUIN) payment framework
A proportion of The Retreat’s income in
2014/15 was conditional on achieving quality
improvement and innovation goals agreed
between The Retreat and NHS England North
of England Specialised Commissioning Team,
Yorkshire and Humber, with whom we entered
into a contract for the provision of Specialised
Eating Disorder Services (Adult), through the
Commissioning for Quality and Innovation
payment framework.
CQUIN
The Retreat was successful in achieving the
CQUIN target for 2014/15.
QTR1
QTR2
QTR3
QTR4
Friends and Family Test
100%
100%
100%
TBA
Improving Physical Healthcare to Reduce Premature Mortality in
People with Severe Mental Health Illness
100%
100%
100%
TBA
MH8 Outcome Measures
100%
100%
100%
TBA
MH9 Optimising Resource Use in the Specialised Adult Eating
Disorder Services
100%
100%
100%
TBA
MH22 Quality Dashboard
100%
100%
100%
TBA
“Patients seem to be involved in all elements of their care package.”
20
During 2014/15, The Retreat also entered into
a contract with NHS Cumbria CCG for the
provision of residential rehabilitation through the
CQUIN framework
CQUIN
QTR1
QTR2
QTR3
QTR4
Friends and Family Test
100%
100%
100%
100%
Improving Physical Healthcare to Reduce Premature Mortality in
People with Severe Mental Health Illness
100%
100%
100%
100%
Capturing Patient Outcomes
100%
100%
100%
100%
Improved Effectiveness
100%
100%
100%
100%
“I think the staff [at The Retreat] work extremely hard to help me with my recovery. They are very dedicated and hard working people.”
21
Statements from the Care Quality Commission
The Retreat is required to register with the Care
Quality Commission and its current registration
status is in respect of:
•
•
•
Assessment or medical treatment for persons
detained under the Mental Health Act 1983;
Diagnostic and screening procedures;
Treatment of disease, disorder or injury.
The Retreat has not been inspected by the CQC during the 2014/15 period.
The Care Quality Commission has not taken
enforcement action against The Retreat during
2014/15.
The Retreat York - 22 October 2013
Outcome
Judgement
Outcome 2 (Regulation 18)
Consent to care and treatment
Outcome 4 (Regulation 4)
Care and welfare of people who use services
Outcome 9 (Regulation 13)
Management of medicines
Outcome 14 (Regulation 23)
Supporting workers
Outcome 17 (Regulation 19)
Complaints
“During our visit we had the opportunity to speak with seven people who use the service. People were very
positive about the care and treatment they had received. Comments included, “They have really supported
me here and now I am so much better” and “Staff are lovely. They listen to you. Unlike some places I’ve been
before.” We looked at the records and talked to the staff working in the hospital. We confirmed that people
were supported to give their consent to care and treatment. People also told us they felt involved and included
in decision making within the service. We confirmed that care records were person centred and reflected
individual choices in their rehabilitation. We talked with the staff and they confirmed they felt well supported
and confident in their role with good training and development plans in place. We saw that there were good
systems in place to listen to people’s concerns and everyone was supported to access advocacy services and
other help networks. We also saw there were effective systems in place to monitor complaints. People who use
the service told us that if they wanted to make a complaint they would know how to. We saw that the hospital
recorded all complaints and resolved them where they could to the complainants’ satisfaction.”
Quote from CQC inspection report
The Retreat Strensall - 18 November 2013
Outcome
Judgement
Outcome 2 (Regulation 18)
Consent to care and treatment
Outcome 4 (Regulation 4)
Care and welfare of people who use service
Outcome 9 (Regulation 13)
Management of medicines
Outcome 14 (Regulation 23)
Supporting workers
Outcome 17 (Regulation 19)
Complaints
“During our visit we had the opportunity to speak with several people who use the service. People told us
that they felt the staff were ‘helpful’ and ‘friendly’ and supported them to have a varied and inclusive life at
Strensall. Comments included, “The staff are alright here, they are really supportive and talk to you.’’ We
looked at the records and talked with some of the staff. We confirmed that people were supported to give
their consent to care and treatment. People also told us they were offered copies of their care programme
and felt involved and included in decision making within the service. We confirmed that care records
were person centred and that they included people’s individual choices and aspirations. We looked at the
medication systems in the unit and confirmed that medication was stored, administered and managed safely.
This was important to make sure people’s health needs were safely met. We talked with the staff and they
confirmed they felt well supported and confident in their role. They also said that there were good training
and development plans in place. We confirmed that there were good systems in place to listen to people’s
concerns and everyone was supported to access advocacy services and other help networks. We also saw
there were effective systems in place to monitor the quality of the service complaints.”
Quote from CQC inspection report
“I feel very privileged to have got a place on this program. It has saved my life in more ways than one.”
22
23
Information Governance and Data Quality
Data Quality
The Retreat did not submit records during
2014/15 to the Secondary Uses service for
inclusion in the Hospital Episode Statistics which
are included in the latest published data.
Statement on relevance of Information Quality
and actions to improve Information Quality
The Department of Health (DoH) requires
hospitals to ensure they hold accurate, reliable
and complete information. Clear processes
and procedures need to be in place to give
assurance that information is of the highest
quality.
High quality information is important for the
following reasons:
• It helps staff provide the best possible care
and treatment on the basis of accurate and
up-to-date information;
• It ensures efficient service delivery,
performance management and the planning
of future services.
In 2014/15 we have continued our work to
improve the quality of information across the
organisation. The Information Governance
Steering Group and the IT & Systems Group are
responsible for ensuring that the organisation’s
data collection systems operate in line with the
requirements of national standards such as the
Information Governance Toolkit and the Care
Quality Commission’s Essential/Fundamental
Standards. In particular over the last year we
have:
• Implemented a more robust Information
Governance policy framework;
• Improved our Information Governance/
Information Technology Risk Register;
• Reviewed the effectiveness of our Electronic
Patient Records System (FACE) and agreed
to implement a new system in 2015/16
to improve the efficient management of
information;
• Implemented a three year Clinical Audit
Strategy and annual Clinical Audit
Programme;
• Developed an electronic recording and
monitoring system for dealing with Subject
Access Requests;
• Implemented a new Clinical Audit Action Plan
template, giving a Risk Rating to all actions
as well as recording the learning from each
audit undertaken and associated outcomes;
• Developed the Ulysees Electronic
Incident Reporting System to assist our
internal performance reporting and the
implementation of additional modules
including one for Safeguarding Alerts;
• Developed a new Governance Performance
Management reporting framework;
• Improved internal data recording systems in
order to more efficiently produce information
to satisfy datasets as part of our NHS
contracts’ compliance.
This programme of work will continue into
2015/16 with a focus on raising the profile of
information quality through staff awareness,
training and monitoring. Our performance
metrics will continue to be reported and
monitored through the Governance Committee
and its associated sub-groups and reporting to
the Board of Directors.
The Information Governance Toolkit
The Information Governance (IG) Toolkit is an
annual self-assessment audit that The Retreat
is required to complete and submit to the
Department of Health (DoH) via the Health
and Social Care Information Centre (HSCIC)
to ensure that the necessary safeguards
are in place for managing patient and staff
information.
The levels of compliance against each of the 17
requirements range from Level 0 to Level 3, with
Level 3 being the highest level of compliance
and Level 2 being the minimum target level of
compliance set by our NHS contracts.
Initiatives included within the IG Toolkit:
• Information Governance Management;
• Confidentiality and Data Protection
Assurance;
• Information Security Assurance;
• Clinical Information Assurance.
In our 2014/15 self-assessment The Retreat
maintained Level 2 compliance against each
of the toolkit requirements. This demonstrates
to the people who use our services and our
commissioners that The Retreat has robust
controls in place to ensure the security of
patient and staff information.
In accordance with national guidance and
recognised good practice, Information
Governance must be in place as part of
mandatory training programmes to ensure
that staff are appropriately trained. The
Retreat achieved its target of 100% in the
training of staff whose role was identified as
requiring them to complete the ‘Beginners
Guide to Information Governance’.
As of May 2015 The Retreat has achieved 92%
in the training of staff whose role was identified
as requiring to complete the ‘Introduction
to Information Governance’ or ‘Information
Governance - The Refresher Module’. This was
below the 95% target set by the IG Toolkit. As
a result of this the organisation is addressing
Information Governance training as a priority
action to ensure this target is met.
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25
Clinical Coding Error
The Retreat was not subject to the Payment by
Results Clinical Coding Audit during 2014/15 by
the Audit Commission.
National Core Indicators of Quality
The National Quality Board has recommended
a national core set of quality indicators be
included in the Quality Account for 2014/15.
This comparative information is intended to set performance in context and to explain whether that performance is strong or weak.
Reporting against these indicators is not mandatory for independent providers, with the exception of the staff element of the Friends and Family Test. The Retreat considers it good
practice to report against those that apply to the
care and treatment we provide.
In the Staff Survey, conducted in February 2015, 84% of respondents were satisfied with the quality of care given to patients. 84%
“Staff are excellent, they go so out of their way to help anyone with anything and never fail to help. ”
Part Three
Review of quality performance in 2014/15
27
Complaints and compliments report
32
Friends and Family Tests
35
Statements from local CCG and Healthwatch
39
27
Review of quality performance in 2014/15
This section provides a summary of the progress we have made towards achieving on our 2014/15
priorities.
Patient Safety
Objective
Ensure the
organisation has IT
systems which are
fit for purpose and
enable the
efficiencies available
from IT systems to be
gained.
Actions taken
Outcome
Conduct a review
of the underlying IT
network structure and
make any changes
which are
necessary to ensure
the system is robust
and fit for purpose.
Discussions with external suppliers completed and
steps are being implemented.
Implement wireless
capability across the
main site.
Wireless capability implemented throughout the
buildings.
Achieved
Evaluate options for
Work completed and decision take to trial a web
a new EPRS and
based version of our current system.
recommend a selected
supplier to the Board.
Implement new EPRS.
Expected to be implemented in early 2015/16.
“Everyone is always friendly and helpful when we visit or ring. We are grateful for the excellent care that Dad receives.”
Patient Safety
Objective
Actions taken
Outcome
Further develop and
embed robust risk
management systems
and processes across
the organisation.
Conduct Board
Development Days to
further develop the
Board’s awareness
and confidence in
using the Board
Assurance Framework
(BAF).
Board Development Days have been conducted
throughout the 2014/15 year. They have addressed the
management of risk and an awareness raising session
about the new CQC regulatory system.
Further Development Days are planned in the coming
year.
The BAF has been used throughout the year and
revised to ensure it continues to be fit for purpose.
Ensure the Risk
Register is maintained
in a timely and
accurate manner.
The Risk Register is being used across the
organisation and is routinely reviewed by the Risk
Management Group.
Ensure that Action
Plans are developed
and implemented in a
timely manner.
An integrated action plan was developed and used to
plot progress against key workstreams.
Extend the number of
staff able to add risks
to the Risk Register.
Training has taken place and continues to take place
to ensure all clinical staff can add risks to the Risk
Register.
Achieved
28
29
Patient Experience
Objective
Establish a Recovery
College, open to
everybody in York.
Actions taken
Outcome
Launch a Recovery
College with a
curriculum of at least
12 different courses.
The Recovery College was launched in April 2014 with
35 different courses available.
Deliver courses to 45
students and have
60% satisfactorily
completing their
course.
The Recovery College welcomed 63 students onto its
courses, with 91% completing the course.
Monitor the
improvements in
students health and
wellbeing and have
75% of students
demonstrate
improvements.
The Recovery College had an outcomes framework
in place. However, these outcome measures were
not routinely collected and we therefore cannot
demonstrate an improvement in students health and
wellbeing.
In December 2014, we took the decision to change our
strategy for the future development of the Recovery
College. The decision was prompted by two key
issues:
• Uptake of courses was much lower than predicted.
• Potential partners saw the Recovery College
as competition rather than an opportunity for
collaboration.
Achieved
Patient Experience
Objective
Roll out the Family
and Friends Test
(FFT) across the
organisation aiming
to achieve an 80%
response rate for all
patients discharged.
Actions taken
Outcome
Implementation of
staff FFT as per
guidance, according
to the national
timetable.
Staff FFT was implemented as per the national
guidance.
Full delivery of FFT
across all services
delivered as outlined
in guidance.
We have failed to meet this target. The target is high
and should be regarded as aspirational. Our results
reached an average return rate of 43% over the year.
We will follow up
with focus groups
to understand the
results we receive
through The Retreat
Involvement Forum.
Feedback from action plans are reviewed through the
bi–annual Involvement Forum.
Achieved
Clinical Effectiveness
Objective
Actions taken
Outcome
Conduct and
implement a review of
the nursing workforce.
To support nurses to
become Independent
Prescribers.
Register of Independent Prescribers in place. Two
Nurses are currently on the register. One nurse is in
training and one has been accepted onto the next
available course. We also have a Pharmacist Prescriber.
Expand the number
of staff trained in
phlebotomy and
performing an ECG.
Phlebotomy – In addition to staff trained in previous
years,11 staff have completed training in 2014/15.
Electrocardiogram (ECG) – Eight qualified and Support
Workers are on this register. We are awaiting training
dates for 2015/16.
Annual rolling
programme for pre­
Pre-registration Nurse Practitioner – Three accepted in
2014/15. Another Support Worker is awaiting interview
registration students,
to support unqualified for the 2015/16 programme.
staff to progress
towards a professional
nurse qualification.
Achieved
30
31
Clinical Effectiveness
Objective
Ensure all patients
have full access to
physical healthcare
assessments
and screening
programmes.
Actions taken
Physical Healthcare
Assessments
All patients are offered
a physical healthcare
assessment on
admission.
This assessment
is repeated as a
standard, dependent
on length of stay.
Outcome
100% patients received a physical healthcare
assessment after admission.
69% of patients were offered an annual physical
review.
Personal Care
Strategy
In collaboration
Assessment documents have been changed to
with the person,
include Podiatry, Dental and Ophthalmic care as
individual strategies
necessary.
are developed and
reviewed as part of the
CPA process. This will,
as appropriate, indicate
dental, ophthalmic and
podiatry needs.
Smoking Cessation
On admission each
patient will be given:
• A ‘smoking
cessation’ pack
and referral to a
Smoking Cessation
Advisor.
• Increase the
number of
Smoking Cessation
Advisors.
• Enable and
support staff to
stop smoking.
Three patients have successfully stopped smoking this
year.
All Pharmacy Technicians are trained to provide
Smoking Cessation Advice.
Four members of staff have successfully stopped
smoking. The hospital site became totally non-smoking
for staff on 11 March 2015.
Achieved
32
Complaints Report
The Retreat is carrying out ongoing work to
make it easier to raise a complaint or concern.
As part of this work The Retreat has already
added an online complaints, comments and
compliments form to its website.
A total of 13 complaints were received during
2014/15.
Learning from the complaints:
• The communication process between staff
and ex-patients has been changed to ensure
that any correspondence is sent to current
addresses and that ex-patients have given
their consent to receive any correspondence.
• Unit staff are now providing better
information about the groups that are
available to newly admitted patients.
The table below shows the reasons for the
complaints:
Reason for the Complaint
Number
Number Upheld
All aspects of clinical treatment
6
6 Upheld
Communication/Information to Patients (Written or Oral)
2
2 Upheld
Other – Behaviour of a patient towards another patient
5
5 Upheld
13 complaints received were dealt with within 25 working days
(Complaint Categories are as defined by the Department of Health)
“I am not happy with the way in which I feel your staff speak to me or treat me when I call.” (Patient’s mother)
33
Compliments
The Retreat’s Compliments Policy works across
the organisation with the aim of providing clear
information on how individual compliments are
reported and logged, in addition to the ways in
which they will be used.
Each clinical unit keeps a log of all compliments
which is forwarded monthly to the Contracts
and Policies Officer. Compliments reports are
collated and submitted to NHS Commissioners
on a regular basis in line with contractual
reporting requirements. In total we received
39 compliments in 2014/15, an improvement
on the 29 received in 2013/14. Key themes
emerging from the compliments received this
year were satisfaction with the quality of care
and treatment received by the patients, as well
as praise for the quality of the environment of
The Retreat.
“I think the level of care offered by all the staff on
George Jepson
is absolutely
superb. All treat
my relative
excellently and
with considerable dignity.”
“I am now looking forward to going out there and living my life, when I first came in I didn’t think that would be possible.”
34
Performance Measures
Patient Experience
The Retreat openly encourages patients and
carers to give their feedback on all aspects of
their care and treatment. This ensures that we
can constantly improve the services we offer.
In order to gather these views more formally,
we have implemented an annual programme of
Patient and Carer Experience Surveys as part of
our annual Clinical Audit Programme.
These surveys ensure that patients’ and carers’
voices are heard and are used to help deliver
better care and treatment, provide evidence to
commissioners of the quality of our services
and ensure we can drive service improvements
in relation to CQC standards.
For 2014/15 the recommendations agreed
following each survey’s results were as follows:
Survey
Quality improved actions
Inpatient Survey
•
•
•
•
•
•
Increase response rate to the survey from Hannah Mills, Allis and Katherine Allen units;
Lockable personal storage facility for Naomi and Acorn patients;
Choice of Named Nurse for Naomi patients;
Review the effectiveness of the survey tool and its questions;
Dissemination of survey results and action plan to relevant patient and staff groups;
Ensure patients are aware of the complaints procedure and improve visual information across the
units.
Out Patient Survey
(Tuke Centre)
•
•
•
•
•
•
•
Methods of increasing participation in the survey;
Car Parking;
Waiting room, reception area and welcome;
Information given to patients about our services, their problems and our procedures;
Communication with patients;
Privacy and Confidentiality;
Affordability.
Carers’ Survey
•
Improve carers’ understanding of who they can talk to in order to pass comment on any aspect
of the service;
Review how carers are supported at the point of discharge and in particular if discharge is early
or unexpected;
Disseminate more widely information on appropriate local and national services that carers could
turn to for support;
Review the friendliness and helpfulness of staff when carers visit as to how this could be
improved.
•
•
•
35
Patient Friends and Family Test
The Patient Friends and Family Test (PFFT)
aims to provide a simple measure which, when
combined with follow-up questions, can drive
a culture change of continuous recognition of
good practice and potential improvements in the
quality of care received by patients. The PFFT
is given to all patients as part of the discharge
process and uses a six point response scale
as follows: (1) Extremely Likely, (2) Likely, (3)
Neither likely nor unlikely, (4) Unlikely , (5)
Extremely unlikely or (6) Don’t know.
Important Change - NHS England Brief
(Oct 2014): ‘A review of the PFFT was
published in July 2014 and made a number of
recommendations. The PFFT Review suggested
that the presentation of the data should move
away from using the Net Promoter Score (NPS)
as a headline score and use an alternative
measure. In line with this recommendation, the
NHS England statistical publication will move to
using the percentage of respondents that would
recommend/wouldn’t recommend the service in
place of the NPS’.
This change took place from 1 October 2014
and this was reflected within our subsequent
two Quarters’ performance reports on the PFFT.
Therefore, the first two quarters’ reports show
the PFFT as a numerical score and the last two
quarters as the percentage recommend/not
recommend.
We aimed to give the PFFT to all patients
discharged from our services in 2014/15 and set
an internal target of achieving a minimum 80%
return rate. We did not achieve this target in any
of the quarters over the last year although we
did show improvement quarter on quarter with
the return rates as follows:
Quarter
Return Rate
1st Quarter (Apr-Jun 2014)
47%
2nd Quarter (Jul-Sept 2014)
47%
3rd Quarter (Oct-Dec 2014)
51%
4th Quarter (Jan-Mar 2015)
67%
The scores we achieved for the PFFT are
shown in the table below. These generally
show a high level of patient satisfaction with
the care and treatment offered by The Retreat.
The information generated from the PFFT has
also been used to benchmark against other
organisations each quarter.
Quarter
PFFT Score
1st Quarter (Apr-Jun 2014)
47%
2nd Quarter (Jul-Sept 2014)
47%
% Recommend
% Not
Recommend
3rd Quarter (Oct-Dec 2014)
93%
0%
4th Quarter (Jan-Mar 2015)
60%
3%
36
Staff Friends and Family Test
From the 1 July 2014 The Retreat has been
required to carry out the Staff Friends and
Family Test (SFFT) on a quarterly basis as part
of our NHS England contract. The SFFT is a
tool which allows staff to give feedback on
The Retreat’s services based on their recent
experience.
The ‘Work’ question asks how likely staff would
be to recommend the service they work in to
friends and family as a place to work. Staff
are given a six point response scale for each
question as follows: (1) Extremely Likely, (2)
Likely, (3) Neither likely nor unlikely, (4) Unlikely,
(5) Extremely unlikely or (6) Don’t know.
Staff are asked to respond to two questions.
Scores are produced relating to feedback as a
place for ‘Care’ and as a place to ‘Work’.
The ‘Care’ question asks how likely staff are
to recommend the services they work in to
friends and family if they needed similar care or
treatment to that offered by The Retreat.
Results for the SFFT over 2014/15 were as
follows:
The Retreat
(Jul - Sep)
Quarter 2
The Retreat
(Oct - Dec)
Quarter 3
The Retreat
(Jan - Mar)
Quarter 4
58
45
44 - Care Question
45 - Work Question
83%
91%
84%
5%
0%
5%
66%
49%
51%
10%
24%
24%
Total number of responses to the SFFT
% of staff who would recommend their
organisation to friends and family in need of
care/treatment (the ‘Care’ question)
% of staff who would not recommend their
organisation to friends and family in need of
care/treatment (the ‘Care’ question)
% of staff who would recommend their
organisation to friends and family as a place
to work (the ‘Work’ question)
% of staff who would not recommend their
organisation to friends and family as a place
to work (the ‘Work’ question)
37
Staff Friends and Family
Test
With regard to the feedback received for the
‘Care’ question over the three quarters, the
response from staff has been favourable in
terms of whether they would recommend The
Retreat’s clinical services to friends and family.
With regard to the ‘Work’ question, however, this
has shown unfavourable feedback from staff, in
terms of whether they would recommend the
organisation as a place to work most, notably in
the last two quarters.
Staff made a number of comments against their
responses for the ‘Care’ and ‘Work’ questions
and these are sent to the Senior Management
Team each quarter for review as part of the
SFFT action plan and in order to determine any
particular trends arising and any changes to
practice required.
“As a patient I
feel respected,
listened to and
very involved in
my own care and
recovery.”
38
Staff Survey
Every year The Retreat conducts a
comprehensive survey of its employees in
order to establish their satisfaction with their
employment and to seek feedback on areas
that might be developed or improved. This is
only one tool that we use in order to talk to
our workforce. We also carried out a range
of different briefings, surveys and feedback
sessions throughout the year.
Once again, the design and distribution of the
Staff Survey was undertaken by a group of
employees nominated by the Staff Consultative
Committee. This approach enables us to draw
on wider experience for the design of the
survey and offers a visible demonstration that
The Retreat wants to genuinely engage all of
its employees in its ambition to become an
employer of choice.
Following the survey in 2014 a number of
changes were introduced, including:
• Occupational sick pay re-introduced for
employees with six to twelve months service;
• An engaging Change Management
Programme started to communicate changes
within the organisation;
• New Employee Assistance Programme
introduced, along with various salary
sacrifice schemes and Well-being initiatives;
• Reward Statements issued for all employees;
• New and improved internal newsletters
launched.
In March 2015 we had a 45% response rate to
the survey which is a drop of 7% on the previous
year, although only five fewer individuals filled
out the survey. The headline indicators from the
staff survey show that:
• 83% of staff said they were enthusiastic
about their role;
• 73% of staff said they were happy to work at
The Retreat;
• 73% of staff believed that The Retreat’s top
priority was patient care;
• 84% of staff were satisfied with the quality of
care given to patients.
A number of themes were identified within the
survey for further action. These included:
• Internal communications being more open
and giving all staff an understanding of the
future of the organisation.
• Communicating the value of the work in
terms other than financial.
• Reviewing pay scales across the
organisation.
These issues will be explored over the coming
months, with solutions being developed through
consultation with the staff team, before being
taken forward for further consideration.
39
Statement from the local CCG and Healthwatch
Partnership Commissioning Unit
Healthwatch
“The Partnership Commissioning Unit on behalf
of the North Yorkshire CCGs have a solid
commissioning history of working closely and
effectively with The Retreat in commissioning
services for a vulnerable patient group.
The transparency of the services provided
demonstrate a high quality of care delivery, this
is consistently assured year on year.
“Thank you for giving us the opportunity to
review and comment on your Quality Account
2014/15. We feel it is an open and honest
report.
We welcome the inclusion of a glossary, which is
very helpful in helping make the document more
readable for members of the public.
Throughout 2014/15 we have continued to
witness positive outcomes for our patients
moving through in-patient services to positive
discharge.
As in previous years we have maintained
effective relationships to explore and discuss
service developments that meet the needs of
the North Yorkshire population that complement
existing NHS commissioned services.
We look forward to continuing our support to
The Retreat through 15/16.”
Among the priorities for 2015/16 we particularly
welcome the focus on developing links with the
local community and seeking opportunities to
work with partners. We look forward to seeing
the development of the Cafe+ initiative.
It is good to see that feedback from patients
and carers is encouraged and used to improve
the quality of services. Using quotes of positive
feedback received from people who have used
the services provides a reminder of the personal
stories behind the figures and statistics.
We welcome the ongoing work to make it easier
for people to raise a complaint or concern and
are pleased to see that complaints are used as a
learning opportunity.
Healthwatch York looks forward to working with
The Retreat in the coming year. We very much
appreciated being invited to the first ‘Retreat
Open To All’ event in May and hope there will be
other opportunities.”
40
“Everything is done with you in mind
and you have a say in your care which is
incredibly empowering.”
Glossary
42
Glossary
CCG
EPRS
Clinical Commissioning Group
Electronic Patient Record System
Is a statutory NHS organisation, representing
groupings of GP Practices, that are responsible
for designing local health services In England.
They will do this by commissioning (or buying)
healthcare services.
A digital patient record stored in an online
database.
CPA
A talking therapy designed to help people
change patterns of behavior that are not helpful.
Care Programme Approach
A framework used by all units to monitor patient
progress and set new outcomes and goals.
DBT
Dialectical Behavior Therapy
FACE
Functional Analysis of Care
Environments
CQC
Care Quality Commission
The independent regulator of health and social
care in England. It regulates health and adult
social care services, whether provided by the
NHS, local authorities, private companies or
voluntary organisations.
CQUIN
Commissioning for Quality and
Innovation
Measures which determine whether we achieve
quality goals or an element of the quality goal.
These achievements are on the basis of which
CQUIN payments are made.
Electronic Patient Record System used by The
Retreat.
HoNOS
Health of the Nation Outcome Scale
A widely used routine clinical outcome measure
used by English mental health services.
MDT
Multidisciplinary Team
A group of different types of clinicians who
work together as a team.
01904 412551 01904 430828
Heslington Road York YO10 5BN
info@theretreatyork.org.uk
www.theretreatyork.org.uk
If you would like to make any comments regarding the content of this report, or make any suggestions for future reports, please
contact our Marketing Department at the address below.
Electronic copies of this Quality Account can be obtained from our website (www.theretreatyork.org.uk) and the NHS Choices
website (www.nhs.uk).
Printed copies can be obtained by contacting the Marketing Department.
If you require this report in another language please contact the Marketing Department.
Marketing Department
The Retreat
Heslington Road
York
YO10 5BN
t: 01904 412551
e: marketing@theretreatyork.org.uk