Quality Account
April 1 2009 to March 31st 2010
st
Dr Peter Calveley Chief Executive Four Seasons Healthcare
The Huntercombe Group is part of Four Seasons Health Care, one of the UK’s leading
independent healthcare operators, and shares its ethos of delivering the highest
quality professional and personal care.
The Huntercombe Groups consists of hospitals and centres throughout the UK, highly
regarded for quality of care and innovation in their respective fields. The centres
provide acute and longer term treatment in the areas of mental health and
addictions, brain injury rehabilitation, Neurodisability and learning disabilities.
This quality account covers our five hospitals in England; Frenchay and Blackheath,
who specialise in Brain Injury Rehabilitation and Neurodisability; Stafford and
Maidenhead, who specialise in eating disorders and child and adolescent psychiatry
(CAMHS) and Roehampton, which specialises in adult psychiatry and
Neuropsychiatry. These hospitals work exclusively with the NHS, and provide the
highest standard of services to our patients and their families. This high standard is
achieved by combining professional expertise with respect and care and ensuring
that the group has a strong and proactive governance structure.
Margaret Cudmore
Managing Director The Huntercombe Group
As a basic minimum of care we follow NICE guidelines, the national service
frameworks1 and the national minimum standards2
Quality is monitored through our performance by an internal audit system which as
well as reporting on elements of the domains of clinical governance, can also report
on a range of outcomes including length of stay, episode cost, incidents and readmission.
Quality assurance is supported by membership of the Royal College of Psychiatrists’
Quality Networks in relation to our CAMHS, and close links with commissioners and
their contractual visits.
Our eating disorders units’ takes part in a multi-centre research programme based at
St. George’s University of London. This is led by a Professor of Child and Adolescent
Psychiatry. The Huntercombe Group’s research team helps us and others to further
develop the quality and effectiveness of the treatment of eating disorders and has
published extensively in this field.
During the period 2009 - 2010, The Huntercombe Group developed its quality
agenda through close partnership working with other NHS organisations. This
included working with Goldsmiths University to develop an MSc in Cognitive & Clinical
Neuroscience based at the Blackheath Brain Injury Rehabilitation Unit and hosting
several conferences including the National Association of Psychiatric Intensive Care
Units (NAPICU) annual conference.
This Quality Account has been prepared by the Clinical Governance committee of The
Huntercombe Group in discussion with the Hospital Managers.
This quality account has then been presented to the board and to the best of my
knowledge the information in the document is accurate.
Part 2
During the period April 1st 2009 to March 31st 2010, the five hospitals in The
Huntercombe Group provided five NHS services, eating disorder, CAHMS, adult low
secure mental health, acquired brain injury, neurological disorders. The
Huntercombe Group has reviewed all the data available to them on the quality of
care in relation to these services
The income generated by the NHS services reviewed represents 95% per cent of the
total income generated from the provision of all NHS services by The Huntercombe
Group during this period .
1
2
From December 2009 New Horizons, plan for mental health.
Care Standards Act 2000
During April 2009 to March 2010 1 of the national clinical audits and 1 of the national
confidential enquiries covered NHS services that the Huntercombe group provides.
During that period Huntercombe Group participated in 100 % of the national clinical
audits and 100% of the national confidential enquiries of the national clinical audits
and national confidential enquiries which it was eligible to participate in.
The national clinical audits and national confidential enquiries that Huntercombe
Group was eligible to participate in during April 2009 to March 2010 are as follows:
•
National Confidential enquiry into Homicide and Suicide
•
Count me in census
The national clinical audits and national confidential enquires that Huntercombe
participated in, and for which data collection was completed during April 2009 March
2010, are listed below alongside the number of cases submitted to each audit or
enquiry as a percentage of the number of registered cases required by the terms of
that audit or enquiry.
•
•
National Confidential enquiry into Homicide and Suicide
o 0% cases to submit
Count me in census
o 100% compliance
The reports of 2 national clinical audits were reviewed by the provider in April 2009
to March 2010 and The Huntercombe Group intends to take the following actions to
improve the quality of healthcare provided.
Each unit through its own internal audit and clinical governance framework will
review its practices and provision against the findings of the audit and develop a
comprehensive and responsive action plan to address any shortcomings or quality
development opportunities arising from the national audits.
The reports of 3 local clinical audits were reviewed by the provider in the period April
2009 to March 2010 and The Huntercombe Group intends to take the following
actions to improve the quality of healthcare provided.
Audit
Action taken
Outcome
Restraint
The group committed itself
to ensuring that all staff
were provided with
training appropriate to
their needs, which was
current and in line with
national guidance
A follow up audit found
that the number of prone
restraints had significantly
reduced
Medication Errors
The group ensured that
medication training and
competency testing was
implemented in all units.
The number of medication
errors has reduced
significantly
All qualified staff were
issued with copies of the
standards for medication
Policy and procedure
Following a review of all
policies and procedures
and the process by which
they are reviewed, a new
electronic policy
management database has
been introduced to ensure
that all policies and
procedures are regularly
updated.
The pilot for the system
has proved successful with
more modules being
purchased and a role out
throughout the company
by December 2010
The number of patients receiving NHS services provided or sub-contracted by The
Huntercombe Group that were recruited during that period to participate in research,
approved by research ethics committees, was 171.
In a number of the units, 1.5% of the proportion of their income in April 2009 to
March 2010 was conditional on achieving quality improvement and innovation goals
as agreed between The Huntercombe Group and body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for April 2009 to March 2010 and for the following
12 month period are available on request from Lynn McLeish, Director of Brain Injury
and Neurodisability Services, The Huntercombe Group, Huntercombe Hospital
Maidenhead, Huntercombe Lane South, Taplow, Maidenhead, Berkshire. SL63OQ.
The Huntercombe Group is required to register with the Care Quality Commission
and its current registration status as of 31 March 2010 of the units within this report,
is that of an independent healthcare provider.
The Care Quality Commission has not taken enforcement action against The
Huntercombe Group.
The Huntercombe Group is subject to periodic reviews by the Care Quality
Commission and each hospital has been reviewed within this period. The results of
which are published on the Care Commission website. The CQC’s requirements for
the individual units were aspects of mandatory training, risk assessment and policy
and procedures to be addressed, Frenchay and Maidenhead were not reviewed
during this period,
The Huntercombe Group intends to take the following action to address the points
made in the CQC’s assessment;
•
A review of the group’s policy and procedures has been undertaken and a
new electronic database is being commissioned which will ensure that all
policies and procedure undergo a timely review.
•
All mandatory training has been reviewed and a central training matrix has
been devised by the training department- completed
•
Staff training and documentation relating to risk assessment has been
reviewed against current national guidance
The Huntercombe Group has not participated in any special reviews or investigations
by the CQC during the reporting period.
The Huntercombe Group did not submit records during April 2009 to March 2010 to
the Secondary Uses service for inclusion in the Hospital Episode Statistics which are
included in the latest published data.
Huntercombe Group did not score for April 2009 to March 2010 for Information
Quality and Records Management, assessed using the Information Governance
Toolkit.
The Huntercombe Group was not subject to the Payment by Results clinical coding
audit during April 2009 to March 2010 by the Audit Commission.
Part 3
Three local audits were undertaken from the NHS Performance Framework and cover
the three domains of Safety, Clinical Effectiveness and Patient Experience. The
figures have been broken down for each unit
Safety
Number of recorded incidents
Of patient on patient assault
80
60
40
20
0
BH
FR
MD
RH
ST
Information not available for Stafford, Frenchay records no incidents
Effectiveness
Number of Users on new CPA who have had
HONOS assessment in last 12 months.
160
140
120
100
80
60
Patient / Carer involvement
40
20
0
BH
FR
MD
RH
ST
No figures available for Frenchay and Blackheath
Patient involvement
As part of the internal audit process service users and their carers are consulted
about the standard of the care received.
How w ould you rate the quality of care you have/ your relative
has received so far?
13%
Very good
Good
25%
62%
Fair
Do you feel you/ your relative are treated w ith respect and
dignity?
19%
0%
Totally
Most of the time
19%
62%
Sometimes
Not at all
How involved do you feel you are in your / your relative's care?
13%
Totally involved
49%
38%
Fairly involved
Not involved at all
Comments from stakeholders
The results from our commissioner surveys have been split into the two service
areas: mental health and brain injury.
Mental Health Surveys – Maidenhead, Roehampton and Stafford
Overall, how would you rate the quality of service
to You? (Mental Health Hospitals only)
0% 5%
15%
30%
Excellent
Very good
Quite good
Neither good nor poor
50%
Quite poor
Brain Injury Surveys – Blackheath and Frenchay only
Overall, how would you rate the quality of our
service to you? - Brain Injury Hospitals
9%
9%
Excellent
Very good
36%
Quite good
46%
Neither good nor poor