THE RETREAT YORK
QUALITY ACCOUNT
2009/2010
1
PART ONE
STATEMENT ON QUALITY FROM THE CHIEF EXECUTIVE
The Retreat operates from two sites in York and is a not-for-profit provider of specialist
mental health care services. We work with the NHS to provide care to people with
complex and challenging needs.
We are very proud of our reputation for excellence and for providing care of the highest
quality. We are committed to continuing to improve the quality of the services we
deliver and to being able to evidence that improvement.
2009/2010 saw some major changes to our reporting structures and systems to ensure
that quality and its measurement lie at the heart of everything we do. These included
the formation of our Governance Committee (replacing our Clinical Governance
Committee), chaired by one of our Trustees and the introduction of a clearly defined
reporting framework for our sub-committees linked to the areas of patient safety, clinical
effectiveness and patient experience.
At the time of writing we are going through the process of re-registering with the Care
Quality Commission in line with the new Essential Standards of Quality and Safety. We
are also working with a range of Commissioners on CQUIN targets so that the quality of
our services is recognised in the fees we receive. All of these ensure that our focus
remains on quality and the challenge for us is to streamline our data collection and
reporting systems so that we do not add to our cost base in these financially
challenging times.
Undoubtedly the next few years will be testing for all of us working in the healthcare
sector as the NHS has to make significant financial savings. I am confident that The
Retreat will continue to provide high quality services with positive outcomes, both for
those who use our services and those who commission them, and that these services
will 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
2
QUALITY OVERVIEW
Current View of The Retreat’s Position and Status on Quality
2009/2010 has been a very positive year for The Retreat, one in which we have
seen significant improvements in key quality measures. Our focus on patient safety
was rewarded with the achievement of a glowing report from the Care Quality
Commission reflecting our progress in making our hospital an increasingly safe
place for our patients.
Minimising the potential for infectious outbreaks remains a high priority for us and
we know it is important to our patients. Focus during the year on hand washing,
cleanliness and treatment regimes has enabled us to reduce the number of
outbreaks on units and to minimise problems associated with the outbreak of swine
flu. Hand hygiene audits before and after staff awareness sessions saw an increase
in the use of hand gels of 60%.
The nutritional need of our patients has been something that we have focused on in
2009/2010. Menus have been updated to include healthier options and our nutrition
forum is constantly looking at ways to improve the patient experience at meal times.
We have also introduced protected meal times on all units to ensure that patients
can eat their meals undisturbed.
Our IT structure was updated in 2009/2010 which has led to better internet access
for patients. An example of this is the introduction of wi-fi to the Quaker Pantry
which allows patients to use the area in a similar way to internet cafés.
Our electronic patient record system (FACE) has now been fully implemented
across all units and staff have received training on its use.
The system ensures that there is a consistent approach to patient record keeping
and will produce the information and outcome measures that will influence the
future development of quality in clinical areas.
Spring Lodge was opened in 2009/2010 to promote independent living and provide
a “step on” facility to develop the skills needed by Acorn and Naomi patients, who
are near completion of their programme, to look after themselves prior to discharge
into the community.
A therapeutic kitchen has been added to a unit within Adult Services which allows
our OT and MDT staff to work with patients and develop their cooking skills. Due to
the success of this we are also planning to develop two more kitchens, one within
Adult Services and the other on a unit in the Older People’s Services this year.
The planned building upgrade to modernise the facilities within our Outpatient
service at the Tuke Centre has started and will be completed in the summer of
2010. The upgrade will improve the current experience provided to patients of this
service and will also enable us to increase the number of patients able to access
the service.
3
Three new bedrooms were added to the Acorn unit and our programme for the
updating of facilities for patients on this unit and Naomi through the conversion of
bathrooms and shower units to wet rooms continued in 2009/2010. This upgrade
programme is part of the work to improve patient safety on these units.
Two additional Service User Consultants were recruited in 2009/2010 bringing our
total to three. Service User Consultants attend a variety of meetings such as our
Risk and Governance groups and present the views of patients as part of the
decision making process for these groups.
We have continued throughout the year to develop our Quality and Safety systems
to provide the means for units to investigate events and spread learning throughout
the organisation.
A number of committees have begun the development of quality dashboards to
monitor the important quality indicators and will build on this work in the coming
year.
Members of The Board of Directors have undertaken a specific development
programme to enhance their understanding of, and ability to, improve quality and
prepare the Board for their responsibilities with regard to future Quality Accounts.
In 2009/2010 The Retreat maintained its high level of performance which was
reflected in the assessment carried out by the Care Quality Commission (previously
the HealthCare Commission). The patient satisfaction surveys have also indicated
an improvement in a variety of areas across the organisation.
Our achievements to date have not made us complacent and we will continue to
build on the excellent work and introduce initiatives that will further improve quality
in 2010/2011.
4
PART TWO
PRIORITIES FOR 2010/2011
For 2010/2011 we have again assessed what our priorities should be and have
identified three key priorities for this year. We have selected one priority for each of the
areas of patient experience, patient safety and effectiveness. Further work will also be
done throughout the year in developing unit quality priorities.
In setting our targets we have consciously set stretching goals and expect to deliver a
minimum of two thirds of the improvement target by October 2010.
In selecting our priorities we have been mindful of the national and local picture as well
as those issues which are of concern to our Directors, our workforce and our local
healthcare partners.
It is proposed that in the next 12 months the following areas will be targeted for
improvement.
1. Improve our Outcome Measures and link them into the CQUIN Scheme.
Progress on this will be monitored by the Governance Committee and reported
to our NHS Commissioners through the monthly data submissions as required
by NHS Contracts.
2. Continue to improve staff awareness, compliance and training on
Safeguarding Vulnerable Adults
Monitoring of the training progress will be undertaken by the Workforce
Development Group. The Learning & Development Manager will include this
data in the training report for the Risk Management Group.
3. Appoint Carer Consultants
In line with good practice two carer consultants will be recruited to provide
support for Carers, Family and Relatives.
Review of Services
The Retreat provides in-patient services in two specialties (Adult Services and
Older People’s Services) and an Outpatient service. The Board has reviewed their
annual outcome reports and the available data on the quality of care in all of these
services. The results of this review have been used to develop a plan for improving
the quality of these services.
During 2009/2010 The Retreat provided six NHS services.
The Retreat has reviewed all the data available to them on the quality of care in six
of these NHS services.
The income generated by the NHS services reviewed in 2009/10 represents 92%
per cent of the total income generated from the provision of NHS services by The
Retreat for 2009/2010.
5
Participation in Clinical Audits
During 2009/2010, 11 clinical audits and related clinical quality data collection
programmes were carried out on the services that The Retreat provides. The full list
of audits is listed at the end of this report.
The Retreat undertakes a programme of local audit on clinical performance which is
reported to the Board.
Participation in Clinical Research
The number of patients receiving NHS funded care recruited during 2009/2010 to
participate in research approved by our Research and Audit committee was five.
The level of participation in clinical research demonstrates The Retreat’s commitment
to improving the quality of care we offer and to making our contribution to wider health
improvement.
Use of Commissioning for Quality and Innovation (CQUIN) payment Framework
During 2009/10 The Retreat was not involved in any CQUIN payment framework.
Further detail of the agreed goals and new goals agreed for 2010/2011 is available
on request from the Director of Clinical Services.
Statements from the Care Quality Commission (CQC)
During 2009/2010 The Retreat was registered with the CQC and had four
conditions on the registration which were met.
The CQC has not taken enforcement action against The Retreat during 2009/2010. We
were not subject to any periodic reviews nor did we participate in any special reviews or
investigations by the CQC during the reporting period.
In the last report the CQC made the following comments;
“The Retreat continues to perform well against the National Minimum Standards,
overall providing good care for its patients”
“Since the last inspection the establishment has continued to invest in improving
the facilities and environment for its patients”
“A sensory garden has been developed and a new patient lift has been installed.
Data Quality
The Retreat did not submit records during 2009/2010 to the Secondary Uses
service for inclusion in the Hospital Episode Statistics which are included in the
latest published data.
6
In 2009/2010 The Retreat did not use the NHS Information Governance Toolkit but
had adopted a local version (based on the toolkit) which we scored 80%. The NHS
Information Governance Toolkit has been adopted in 2010 and work is taking place
to score and action plan any areas of non compliance.
The Retreat was not subject to the Payment by Results clinical coding audit during
2009/2010 by the Audit Commission.
Priorities for Improvement in 2009/2010
Throughout 2009/2010 we identified and developed programmes for a number of
quality and safety projects which we then worked on throughout the year.
Priority 1
Priority 2
Priority 3
To reduce the
number of
patient falls
across all units
To introduce
and complete
an internal
Infection
Control Audit
on all units
To enhance
the patient
experience
on all units
The details for these priorities are described on the following pages.
7
PRIORITY 1
REDUCE THE PATIENT FALLS INCIDENCE RATE WITHIN ALL UNITS
Description of Issue and Rationale for Prioritising
It had been identified that the categories Slips, Trips and Falls and Found on Floor
accounted for approximately 19% of reported incidents in the period July 2008–June
2009. Introducing measures to reduce the number of incidents and the resulting
injuries to patients will have a major impact on the delivery of care.
Aim/Goal
To reduce the number of falls related incidents that result in the level of harm being
classified as Moderate or above to Low or No Harm.
Current Status
18
12
16
10
14
12
8
6
STF
10
FoF
FoF
8
STF
6
4
4
2
2
0
0
Jul-08
Oct-08
Jan-09
Apr-09
Jul-08
Oct-08
Jan-09
Apr-09
Note: Approximately 40% of reported incidents were unobserved falls, i.e. the patient
was found on the floor.
Identified Areas of Improvement
§
§
An appropriate Falls Risk Assessment Tool was identified for use in all units.
Falls Risk Assessments were carried out on all identified vulnerable groups.
Current Initiatives in 2009/2010
Initiative
Identification of suitable Falls tool for use on Older
People’s Services
2009 Status
65%
2010 Status
100%
New Initiatives to be Implemented in 2010/2011
1.
2.
3.
4.
5.
6.
Adoption and use of the tool on all Older People’s Service units.
Roll out the tool to all other units in Adult Services.
All new admissions to be assessed for Falls potential.
Units to submit progress reports to the Risk Management Group.
Individual care plans will be amended where risk is indicated.
Environmental changes will be made where a significant cause of risk is
indicated.
7. Equipment and aids will be sourced and supplied where assessed risk indicates
a significant need for either an individual or a group of people.
8. Changes to practice and procedures will be made where appropriate.
8
Board Sponsor
Director of Clinical Services
Implementation Lead
Chris Dawson, Clinical Service Manager – Older People’s Services
Project Lead
Joyce Latimer, OT – Katherine Allen Unit
9
PRIORITY 2
DEVELOP AND INTRODUCE A LOCAL INFECTION CONTROL AUDIT TOOL
Description of Issue and Rationale for Prioritising
The Retreat currently has infection control audits carried out annually by an external
company with no internal auditing being carried out between these annual audits.
Actions taken to ensure compliance with the Code of Practice for Health and Adult
Social Care on the Prevention and Control of Infections and Related Guidance will
have a major impact on reducing the unit closures due to infectious outbreaks and it will
ensure that standards are maintained throughout the year.
Aim/Goal
To carry out an internal audit at least once on each unit before the next external audit
(due Aug 2010).
Introduce a programme of audits that will be carried out on a regular basis throughout a
12-month period, and reported to the Infection Control (IC) Committee.
Current Status
2009 Audit Res ults
100%
98%
98%
98%
98%
Acorn
Hannah
Mills
George
Jepaon
Blair Atholl
50%
Note: The above graph shows the external audit results for 2009. Katherine Allen and
Naomi were not audited this year.
Areas Identified for Improvement
§
§
An appropriate audit tool was identified for use in all units.
A regular audit programme was set up and implemented, the results monitored
by the Infection Control Committee.
Current Initiatives in 2009/2010
Initiative
Identification of suitable audit tool for use on all units
2009 Status
75%
2010 Status
100%
All units now have an identified suitable audit tool to be used for regular internal audit.
10
New Initiatives to be Implemented in 2010/2011
1. Regular use of the tool on all units
2. Action plans to be produced to deal with identified risks, and to be monitored by
the Infection Control Committee staff to be trained to carry out audits on units.
3. Audits to be carried out twice a year on all units.
Board Sponsor
Director of Clinical Services
Implementation Lead
Maggie Scott, Clinical Service Manager – Adult Services
Project Lead
Bruce Wilson, Risk Manager
11
PRIORITY 3
FURTHER ENHANCE THE OUT PATIENT EXPERIENCE
Description of Issue and Rationale for Prioritising
The completion of patient surveys to show the level of satisfaction amongst patients
during their treatment as an out-patient at The Retreat would allow us to plan services
which respond to patients’ preferences. Further work on this issue would improve
standards and levels of satisfaction.
Aim/Goal
To carry out a review on the Outpatients Service to determine satisfaction levels for the
out-patient service.
Current Status
100%
80%
60%
40%
20%
0%
100%
80%
60%
40%
20%
0%
1
2
3
4
5
6
7
8
9
10
28
29
11
12
13
31
32
14
15
16
17
34
35
36
37
18
19
20
21
22
23
24
25
26
100%
80%
60%
40%
20%
0%
27
30
33
38
39
Note: The above graphs show the results for 2009/2010 across 39 standards. The
results averaged out to a 90% satisfaction rate.
Identified Areas of Improvement
§ Car parking (Standard 9)
§ Length of wait for an initial appointment (Standard 3)
§ Choice of appointment (Standard 4)
Current Initiatives in 2009/2010
Survey carried out January 2010. A new building project is now in train and further
initiatives will be implemented when the upgrade is completed.
New Initiatives to be Implemented in 2010/2011
1. Review car parking facilities and satisfaction of people using service when
building work is complete and the full car parking area is available again.
12
2. Appoint additional staff to increase number of assessment appointments
available, increase choice of times and decrease time between initial contact
and appointment.
3. Extend opening hours when extension is completed.
Board Sponsor
Director of Clinical Services
Implementation Lead
Chris Powell, Clinical Service Manager – Outpatient Services
Project Lead
Chris Powell, Clinical Service Manager – Outpatient Services
13
PART THREE
REVIEW OF QUALITY PERFORMANCE
The following is a list of Audits carried out in 2009/2010.
Patient Charter Survey
Patient Survey
Star Wards (Hannah Mills Only)
Outpatients Survey
NICE Dementia
NICE Technology Appraisal (No 43) – Typical/Atypical drugs
for Schizophrenia
Lorazepam/Diazepam (Usage and Documentation)
T2/T3 Forms (Consent to Treatment)
Section 17 (Leave Forms)
Section 18 (AWOL)
Z – Drug Usage
CPA Records Documentation
Section 132 Patient Rights
Resuscitation Equipment
Serious Untoward Incidents
Complaints
82% (Satisfaction)
83% (Satisfaction)
84% (Satisfaction)
90% (Satisfaction)
84%
74%
51%
97%
99%
100%
Qualitative Data
only
78%
84%
95%
Qualitative Data
only
Qualitative Data
only
The following metrics have been chosen to measure our performance against:
Patient Safety Measures Reported
1.
2.
3.
4.
5.
6.
Number of Incidents that resulted in being
classified as an SUI
Assaults by category
Patient to Patient (No Harm)
Patient to Patient (Low Harm)
Patient to Patient (Moderate Harm)
Patient to Patient (Severe Harm/Fatality)
Patient to Staff (No Harm)
Patient to Staff (Low Harm)
Patient to Staff (Moderate Harm)
Patient to Staff (Severe Harm/Fatality)
Total Patient to patient, patient to staff
assaults
Medication Management Incidents
Incidents reported to CQC
Use of MOVA (physical restraint)
Use of MOVA (Level 1)
Use of MOVA (Level 2)
Use of MOVA (Level 3)
Use of MOVA (Level 4)
Total number of use of MOVA
Use of seclusion
2
31
48
8
0
58
81
21
0
247
48
2
31
80
2
0
113
0
14
Clinical Outcome Measures Reported
7.
8.
Outcomes – HoNoS and recovery orientated
patient satisfaction measure
Use of ECT
Not available at present
1 course
Patient Experience Measures Reported
9.
10.
Complaints
25-hour week activity
10
Not available at present
Staff Experience Measures Reported
11.
12.
Sickness levels
Staff off sick with stress
13.
Use of bank/agency
14.
Vacancies (Average for 1st Quarter 2010 Data
Only)
Appraisals completed (1st Quarter 2010 Data
Only)
Training completed
Safety – Management of Violence & Aggression
Experience – Infection Control
Effectiveness – Mental Health Act
15.
16.
4.85%
3 (Work Related)
17 (Other external Issues)
3589 shifts (equates
approx to 15 WTE)
14.3
28%
70%
90%
85%
15
STATEMENTS FROM PRIMARY CARE TRUST AND LOCAL INVOLVEMENT
NETWORK
Statement from NHS York Yorkshire and York
NHS North Yorkshire and York continue to enjoy a long standing positive working
relationship with The Retreat.
The Retreat year on year continue to deliver high quality care to vulnerable and
complex mental health patients whose care is commissioned by NHS North Yorkshire
and York.
The Retreat is one of NHS North Yorkshire and York's key partners in the overall
delivery of mental health services and The Retreat have continued to be responsive to
both the changing presentation and needs of the local population and in supporting
NHS North Yorkshire and York to deliver Local and National mental health policy.
16
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YORKLINK
Rof and woodward
DifeCtOf Of CliniCal SefViCeS
E-mail: admin@yorklink.org.
uk
The RetreatYork
Heslington
Road
York
YOl OsBN
23t0610
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yoRK yo24 4AB
Hotgate
vifta,22
Hotgate
Road,
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Phone:
01e04
621631 Mobile:
o7e71054
82e
Web: www.yorklink.org.uk
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QualityAccount
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requirefurtherinformation.
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