Quality Account 2010/11
Our quality performance, initiatives and priorities
Contents
Who we are and what we do, plus commendations
1
Part 1 – Our priorities for quality
Joint statement from the Chair of Trustees and Chief Executive Officer
3
Part 2 – Our priorities for improvement
Overview
4
– Priority 1 Service user experience
5
– Priority 2 Effectiveness, safety and service user experience
6
– Priority 3 Service user safety – reporting
8
– Priority 4 Service user safety – falls
9
Part 3 – New initiatives for 2011/2012
– Priority 1 Service user experience
10
– Priority 2 Service user safety and effectiveness
11
– Priority 3 Effectiveness
12
– Priority 4 Service user safety – reporting
13
– Priority 5 Service user eating experience and nutrition
14
Part 4 – Indicators
– Service user experience
15
– Safety
18
– Effectiveness
20
Part 5 – Annexes
Annex 1 Essential information
23
Annex 2 Statements from commissioning Primary Care Trusts (PCTs),
24
Overview and Scrutiny Committee (OSC), the Sue Ryder National
Service User Advisory Group ‘Acorns’ and Local Involvement Networks (LINks)
Who we are and what we do
Sue Ryder provides compassionate care for people
living with life-limiting and long-term conditions.
We are a national charity that delivers health and
social care services to local communities in a
number of ways.
As well as day care, respite care, homecare, hospice
and hospice-at-home services and long-term
residential care, we also work in partnership
-with sheltered housing projects and help with
community integration.
This Quality Account sets out our commitment
to improving quality across all of our services.
But to start with, here are a few commendations
taken from our service user survey.
“This was the ideal stepping stone from hospital to coming home for
his last days with us.”
A relative of a hospice inpatient
“I have space to be my own person, or I can choose to be as involved
as I want to be. This is important to me.”
A resident at one of our neurological care centres
“All carers are very helpful and kind and the care I’ve received
is first class.”
A service user receiving homecare
1
2
Sue Ryder – Quality Account 2010/11
Part 1
Our priorities for quality
Joint statement from the Chief Executive and
the Chairman
Welcome to our second annual Quality Account – a summary
of our performance against selected quality measures for
2010/11 and our initiatives and priorities for quality
improvement in 2011/12.
Sue Ryder is a national health and social care charity which
provides specialist palliative care, neurological and homecare
to people living with conditions such as cancer, dementia,
Parkinson’s disease, Huntington’s disease and other
complex conditions.
This Quality Account is produced to inform service users
(current and prospective), their families, our staff, our
supporters, commissioners and the public. The contents have
been influenced and have the endorsement of our national
Service User Advisory Group known as Acorns.
Progress has continued since the publication of our first
Quality Account in June 2010. Since the appointment of a
new Director of Health and Social Care, there has been a
re-organisation of the Senior Management Team (SMT),
Sue Ryder – Quality Account 2010/11
which is now called the Senior Leadership Team (SLT). This is
set to improve the monitoring of performance relating to
quality systems and processes, compliance with Sue Ryder
policy and national standards.
This Quality Account demonstrates the progress that has
been made in relation to identified quality initiatives and sets
a further ambitious programme of quality improvement
projects for the forthcoming year. The Quality Account also
provides an honest representation of progress made during
the year, and in partnership with users of our services, it
outlines where further improvements are needed. And finally,
it celebrates the good outcomes reported by service users
and commits us to learning from reported experiences where
outcomes did not meet with expectations.
Paul Woodward
Chief Executive
Roger Paffard
Chairman
3
Part 2
Our priorities for improvement
Overview
Priorities for 2011/12 have been influenced by service user
experience and involvement, national standards and learning
from enhanced quality performance data.
The priorities for 2011/2012 are summarised below.
Priority 1
Service user experience
To work towards a personalised approach to service
delivery and care
Over the course of the last year a number of projects have
culminated in improved information relating to user
experience, incidents, complaints and compliance with Sue
Ryder policies and procedures. This, alongside national policy,
has helped to influence our priorities for 2011/12.
Priority 2
Service user safety and effectiveness
To manage the risk of harm from pressure ulcer development
The priorities detailed below do not represent all that
Sue Ryder is doing to improve a person’s experience of our
services but they give an indication of particular areas of focus.
Priority 3
Effectiveness
To support the development of our clinical leaders
Our quality strategy focuses on the same three key areas that
were identified in the previous Quality Account:
effectiveness
service user safety
service user experience
Priority 4
Service user safety and effectiveness
To further develop a culture of learning from incidents
and complaints
Priority 5
Service user experience, safety and effectiveness
To improve the eating experience and meet the nutrition
needs of the people in our care
These priorities have been approved by Acorns (our national
Service User Advisory Group), the Executive Leadership Team
(ELT) and our Board of Trustees.
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Sue Ryder – Quality Account 2010/11
Priority 1
Service user experience
Initiatives
Management of complaints
We said that we would improve how we manage
complaints by recording and learning from issues and
trends raised through complaints.
During 2010/2011 we have introduced a new procedure, in
line with new regulations, for listening and responding to
complaints in health and social care. We set up a system for
recording all formal complaints on a charity-wide database.
This has made it possible for us to see trends and share
learning between services in different locations. We have
provided training for staff to help all staff understand their
responsibilities to listen and act on complaints and to improve
investigation and management of complaints.
User involvement
We said that we would work with the Service User Advisory
Group to promote the importance of every person being
treated as an individual, and what this might mean for
people using our service.
We have completed a review of our Bixley Road service in
Ipswich, where four tenants live in a housing association
bungalow with 24-hour care supplied by us. This service has
now been open for three years. It has been reviewed during
March 2011 using an assessment tool that has been adapted
for use in neurological care from the national standards used
for learning disability services. The review incorporated
feedback from focus interviews with service users and from
commissioners of care. This process was led by one of our
operational managers and identified the areas where the
tenants were confident and happy with their home and care
support. It also identified further improvements that can be
implemented to encourage greater decision-making and
management opportunities for the tenants themselves.
This work will influence our supported living project work over
the new few years.
During 2010/2011 we have supported the new Service User
Advisory Group to hold three meetings, including one with
the Chair of Trustees sharing ideas on how we can grow
involvement and understanding between service users and
Council. The group, attended by between 12 and 17 service
users in three locations, has identified their priorities, agreed
terms of reference, and chosen a new name. Now known as
Acorns, from the saying ‘great oaks from little acorns grow’,
the name reflects their aspiration that from small beginnings
the group will continue to grow in stature and influence. Their
key achievements during 2010/2011 have been:
• helping in the appointment of a new Director of Health and
Social Care in 2010
• commenting on our new Health and Social Care Strategy
• sharing experience from local services and raising issues
such as how we support staff, and the comfort and safety
of hoists
• initiating a project for service users to interview other service
users about the importance of being treated as an individual.
Sue Ryder – Quality Account 2010/11
5
Priority 2
Effectiveness, safety and service user experience
To improve our quality ratings at inspections
Our services are inspected by two regulatory bodies:
• Care Quality Commission (England)
• Social Care and Social Work Improvement Scotland (SCSWIS)
The different services are currently inspected against a set of
Essential Standards of Quality and Safety (England) and Care
Standards (Scotland).
During 2010/2011 we aimed to improve our inspection
ratings to be rated good or above. There have been few
inspections during the course of the year, but where they did
take place, there was an improvement or no decline in the
inspection rating, as the following table demonstrates.
Summary of quality ratings for our services
Our hospices have not been included within this table as
although they are inspected by the Care Quality Commission,
they have not received an overall rating since July 2010. This is
when the rating of services by the Care Quality Commission
(as the regulator for health and social care) ceased.
Service
Date of Inspection
Current Rating
(at March 2011)
Previous rating
Direction of travel
since last inspection
Adult Care – England
Holme Hall
August 09
Good 
Good 
Standards
maintained
Improvement
(Aug 07)
Cuerden
Nov 09
Good 
Stagenhoe
March 2010
Excellent 
Adequate 
(Sept 08)
Excellent 
(April 07)
The Chantry
May 10
Excellent 
Hickleton
April 10
Good 
Excellent 
(June 09)
Good 
(Aug 07)
Adult Care – Scotland
Dee View
Nov 10
Excellent
Excellent
(June 10)
Care of the Elderly – England
Birchley
Feb 2010
Excellent 
Excellent
(annual service review)
(Dec 07)
Good
Domiciliary Care – England
Wigan (St Helen’s)
Dec 09
Good 
Lincoln
March 10 08
Excellent 
Macclesfield
Jan 2010
Good 
Wolverhampton
Jan 2010
Good 
Good
(annual service review)
(Nov 08)
Adequate
(Dec 07)
Excellent
(Dec 08)
Adequate
Standards
maintained
Standards
maintained
Standards
maintained
Standards
maintained
Standards
maintained
Standards
maintained
Standards
maintained
Improvement
(Dec 08)
Standards
maintained
Improvement
Sale (Trafford)
April 10
Good 
Doncaster/Barnsley/Rotherham
March 10
Good 
Good 
(annual service review)
(Feb 09)
Good 
Not yet rated
Not yet rated
August 08
was the first
inspection
Good
Primarily adequate
and Good (Feb 10)
Improvement
(April 00)
Bixley Rd Ipswich (Independent Living)
Newark
Bournemouth
Domiciliary Care – Scotland
Arbroath
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Sue Ryder – Quality Account 2010/11
Aug 08
Jan 11
Standards
maintained
NA
Initiatives
We said that we would carry out a further review of the
quality visit process for our hospices and neurological care
centres, based on regulatory requirements.
The homecare survey tool has been refined and is now
reported centrally to enable monitoring of outcomes by
managers and to support the setting of priorities and
service-based Quality Improvement Plans.
During 2010/2011 we have reviewed the quality visit process
for all services against the Care Quality Commission (CQC)
Essential Standards of Quality and Safety (services in England)
and the National Care Standards (Regulation of Care
(Scotland) 2001). More recently a review of the management
structure at senior level has seen both the Quality Team and
Regional Managers carrying out Quality Inspection Visits,
some of which have been themed (for example Falls Risk and
Moving and Handling policy compliance) and some take
account of all regulatory standards and outcomes for service
users using the CQC Provider Compliance Assessment tools.
Four services have been targeted with the aim of establishing
service user forums and community networks (for example
Age Concern and LINks).
We said that we would introduce a revised quality visit
process within Domiciliary Care Services.
During 2010/2011 we have revised the quality visit template
for use in inspecting the Sue Ryder Homecare Services both
in England and in Scotland in line with Essential Standards
(England) and Care Standards (Scotland). This template has
been used to inspect services and to inform the quality
improvement plan within each service
We said that we would continue quarterly reporting
of inspection findings to the Healthcare Governance
Committee and Integrated Governance Committee,
with actions taken in response to inspection and
organisational learning.
During 2010/2011 a report has been tabled at each of the
quarterly Committee Meetings outlined above and assurance
given of actions taken in response.
We said that we would increase operational support to
Care Managers in Homecare to support quality
improvement initiatives
During 2010/2011 the Quality Team have each supported a
number of homecare services by carrying out Quality
Inspection Visits and attending Quality Improvement Group
Meetings. More recently a Social Care Forum has been set up
to encourage the sharing of best practice and to promote
quality improvement initiatives.
Complaints training has been delivered to all Care Managers
and also to Care Organisers in the larger services. Incident
reporting training and audit training has been delivered to
managers in addition to training to support the use of the
electronic incident reporting tool.
Sue Ryder – Quality Account 2010/11
Arbroath – The first forum was held in November and service
users appreciated the opportunity to be involved close to
home. They suggested meetings should be held twice a year
and said they will be watching closely to see how their
suggestions are taken up.
Bournemouth – A meeting was held with the local LINk in
September 2010 with a view to working together on issues
including personalisation. Since then their first forum meeting
was held on 23 March 2011. The meeting was informal with
an opportunity for service users who attended to meet with
staff and talk about their lives.
Heyeswood – The model of care at Heyeswood is different
from other domiciliary services. Here we provide care and
support, as well as recreational activities, to tenants in their
own retirement homes. The residents hold ‘street meetings’
once a month and one of our local managers is invited. In this
way we receive first-hand insight into the issues and concerns
of residents. This contributes to the Activities Plan and the
Quality Improvement Plan. A new volunteer scheme has
recently started and this also responds to needs identified by
residents. Befriending and organised walks are two ideas that
have been suggested so far.
Sue Ryder has become a member of the local LINk in
St Helen’s and will be taking part in their Dignity and
Care project.
Trafford – development here has been slow due to other
work pressures however dedicated resource has now been
allocated to support the manager to set up the local forum.
The first meeting took place in May 2011.
Wolverhampton – Although not one of the areas identified for
development, the first service user forum at Wolverhampton
was held on 17 February 2011. Those service users spoke
about the things they value about the service such as seeing
the same carers regularly and receiving a helpful response
from the office if there are any problems. They also mentioned
areas for improvement: they would like carers to be able to
spend more time talking to them and to turn up on time.
7
Priority 3
Service user safety – reporting
To introduce an electronic incident reporting system
The way in which an organisation manages risk is a key
indicator of its competence. Managing risk, as in the
identification and effective treatment of risk and learning
from adverse events, protects those who receive care, our
staff and our assets. It also improves performance and
reputation, and helps to reduce financial loss. We set out our
proposal to introduce a more reliable system of monitoring
incidents in our Risk Management Strategy for 2008-2011.
We have now introduced an electronic risk management
tool (Datix) that is compatible with the current Sue Ryder
computer system and that meets the requirements of
incident reporting (including health and safety incidents
and service user safety incidents)
Initiatives
We said that we would further refine the Datix tool based
on feedback from services and learning from the process
of producing reports.
During 2010/2011 we have identified configuration changes
that will be needed when we apply the latest version of Datix.
Work has been carried out within the Professional Forum
(a meeting of the Heads of Care) to encourage improvements
in the categorising of incidents so that monitoring of trends
can be facilitated.
We said that we would move over to use of the latest version
of Datix that has greater functionality but does not change
the process of reporting for front-line staff.
During 2010/2011 we have not been able to introduce the
latest version of Datix however this is planned in support of
working towards the Complaints Module. The functionality
of the current Datix version has not impaired the reporting
of incidents over the course of the year.
We said that we would build a portfolio of reports to inform
the Senior Leadership Team (SLT), and we said that we
would use information to further develop the Health and
Social Care Directorate Risk Register.
During 2010/2011 we have presented a quarterly report
to the Healthcare Governance Committee and Integrated
Governance Committee. A regular agenda item has been
introduced into the monthly Senior Leadership Team (SLT)
meetings where the learning from serious incidents is
discussed. This team owns the Health and Social Care Risk
Register and therefore the Risk Register is updated in response.
We said that we would aim to use the Complaints
Module within Datix to improve monitoring and
learning from complaints.
During 2010/2011 we have prepared a project plan and
started by undertaking a process-mapping exercise to
examine the process involved when a formal complaint is
received. This is essential preparatory work before starting to
use the Datix Complaints Module. The target date for
introduction of the system is July 2011, and training will be
rolled out during August and September.
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Sue Ryder – Quality Account 2010/11
Priority 4
Service user safety – falls
To reduce the harm from falls
Falls are known to be the most reported safety incident
nationally and many falls result in harm to the person who
is receiving care. There will always be a risk of falls within
health and social care services given the nature of the people
we care for. However, there is much that can be done to
reduce the risk of falling and to minimise harm, while at the
same time enabling service users to be independent and
as mobile as possible.
An initiative started in 2009 was continued during 2010/2011
with the aim of managing the risk from falls as far as possible
without impeding a service user’s right to independence and
choice. The Clinical Quality Team has worked alongside the
Health and Safety Team to take forward the following
2010/2011 initiatives.
Initiatives
We said that we would complete and distribute a falls
prevention leaflet for people in receipt of care and
their families.
During 2010/2011 we completed this falls prevention leaflet,
which is now in use in all services.
We said that we would monitor the number of falls, and
factors associated with falls, more closely in conjunction
with the introduction of electronic incident reporting.
During 2010/2011 the use of the Datix electronic incident
reporting system has been embedded in all services and
a quarterly report to the Healthcare Governance Committee
incorporates information relating to falls involving service users.
We said that we would audit compliance with the falls risk
management policy across services.
The Falls Risk Management Policy incorporates a number of
tools to support the assessment and management of the risk
of falls. There is a requirement for falls risk training and a
training package and lesson plan has been produced to
support this. During 2010/2011 we introduced a falls audit
into the annual core audit programme that has helped us to
monitor compliance against the policy and to ensure that
actions are put in place where the policy requirements were
not being met. Particular issues that arose related to the
delivery of training because of Education Lead vacancies.
Progress is starting to be made now that these vacancies have
been filled. More recently a ‘Falls and Moving and Handling
themed quality visit’ has been developed for use by
operational regional managers to further assess compliance
against policy.
Sue Ryder – Quality Account 2010/11
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Part 3 – New initiatives for 2011/2012
Priority 1
Service user experience
Service user experience
During 2011/2012 we would like to give our service users
greater choice and control over the care that they receive so
that they consistently report to us that they feel treated as an
individual. During the course of the year we are going to
cascade and capitalise training throughout the Health and
Social Care Directorate to introduce a more person-centred
way of care planning, To achieve this we have engaged
experts via Helen Sanderson Associates and Groundswell
who will help us to:
• train staff within all centres
• design a new person-centred care planning tool and test
this in the three pilot sites
• integrate into the person-centred care planning approach
the feedback that Acorns gives us with regard to what it
feels like to be treated as an individual
• scope the work that is needed to change our policies and
reflect our aim of becoming a more person-centred
organisation
• evaluate the success of the pilot project
• work towards a personalised approach to service delivery
through continued working with our service users.
Acorns, our national Service User Advisory Group, was
formed in November 2009. They quickly identified their two
priorities were:
• to reach out to include the views of as many service
users as possible
• to promote the importance of being treated as an individual.
A project that will see service users interviewing other service
users embraces both these priorities. The project will be led
by Acorns and promote the positive achievements of Sue
Ryder to deliver person-centred care. Once interviews have
been conducted, the voice of service users talking about
what is important to them will be presented for internal and
external audiences.
Recruitment of service users to the project and training in
interview skills has commenced. The project is projected to
be delivered by October 2011.
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Sue Ryder – Quality Account 2010/11
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Programme Manager
Angela Killip, Quality Manager
Priority 2
Service user safety and effectiveness
To manage the risk of harm from pressure
ulcer development
Pressure ulcer damage and prevention of avoidable harm
from pressure ulcers (known by some as bed sores) has been
identified via incident reporting as an area of practice that is
reported variably. We want to ensure that our staff are skilled
and equipped with the right tools to identify those who are at
risk of pressure area damage and that the right equipment is
available to support the management of risk.
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Programme Manager
Lesley Bates Quality Manager
During 2011/2012 we will minimise inconsistency in care
provision by providing all services with a Pressure Ulcer
Prevention and Treatment policy to highlight the best
evidence and advice available to us. We will access the
National Institute of Clinical Evidence and the leading
European Pressure Ulcer Advisory Committee for guidance
and teaching resources. To complement the policy we will:
• produce a service user information leaflet which includes
pressure ulcer prevention and management for service
users and their families/main carers
• develop and review supporting teaching aids and links to
web resources
• standardise our approach to risk assessment and ensure
that health and social care records reflect the level of risk
for pressure ulcer development
• ensure that all people admitted to one of our care centres or
hospices are screened for risk of pressure ulcer damage and
that care plans are developed to address each risk factor
• review the existing record keeping audit tool relating to
the assessment and prevention of pressure ulcers in line
with the new policy and integrate this into our core clinical
audit programme
• continually monitor the incidence of pressure ulcers at
grade 2 and above acquired when patients are not in our
care or when they are receiving care from us
• incorporate into the serious incident policy the requirement
to report grade 3 pressure ulcers and above
• ensure that details of learning associated with the
investigation of grade 3 and above pressure ulcers will
be shared across professional forums
• present a monitoring report to the Health and Social Care
Governance Committee at least twice a year
• identify an organisational lead for pressure ulcer prevention
and management who will facilitate the sharing of best
practice with service based named leads.
Sue Ryder – Quality Account 2010/11
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Priority 3
Effectiveness
To support the development of our clinical leaders
within a range of clinical environments
We recognise that clinical leadership is fundamental to
delivering high quality, clinically effective and safe care for
our service users.
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
Under licence from the Royal College of Nursing (RCN), the
first cohort of 13 front-line clinical leaders, from specialist
palliative care and neurological care settings commenced
the leadership programme.
Programme Manager/Local Facilitator RCN Clinical
Leadership Programme
Jane Appleton, Quality and Learning Manager
This year-long programme involves workshops and action
learning groups to develop the leadership skills and knowledge
of clinical leaders to enhance the quality of the services
delivered to our service users. Module workshops include the
culture of the organisation, self-development as a leader,
quality and safety and team-working. Sue Ryder is believed to
be one of the first voluntary sector organisations to invest in
this well established and positively evaluated programme.
As part of the programme the participants will each complete
a local service improvement initiative.
A Sue Ryder Learning and Education Lead has attended the
RCN clinical leadership facilitators’ programme and is
supported by the RCN to implement the programme.
During 2011/2012 Sue Ryder will:
• present the Service Improvement Projects at a conference
day in January 2012 and will share the learning from these
projects across the whole organisation
• recruit to the second cohort of the clinical leadership
programme, commencing the programme in January 2012
• evaluate the programme and seek to identify the
differences the programme has made, particularly to
service user experiences
• use the programme to develop the expertise of our clinical
leaders to share local quality improvements and good
practice across the whole organisation to enhance the
experience of our service users.
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Sue Ryder – Quality Account 2010/11
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Priority 4
Service user safety – reporting
To further develop a culture of learning from
incidents and complaints
We would like to continue to develop a culture of learning
from all incidents and complaints, particularly those of a
serious consequence to those who use our services. So we
have started to develop a serious incident strategy that sets
out a staged process for enabling and promoting learning
from incidents and the Serious Untoward Incident Policy is
under review.
Complaints are currently recorded within each service using a
complaints monitoring form and information is sent to the
Service User Involvement Lead for inputting into a database
and then reported through to the Healthcare Governance
Committee and the Integrated Governance Sub-Committee
of the Council of Trustees. This process does not facilitate the
learning process across the organisation, is labour intensive
and does not guarantee that all data is collected. We intend to
move towards an electronic complaints reporting process of
the kind implemented for incident reporting.
Key themes from complaints:
Hospices
There are low numbers of complaints in hospices (just 10
over all sites, the same number as 2009/10) with more than
half being concerned with communication. These complaints
included speaking to other professionals about a case when
the complainant thought this was inappropriate, and a
conversation about prognosis being upsetting. Other
complaints were about quality of care, medication and
staffing levels.
Care centres
There are also a low number of complaints in care centres
(7 over all sites, compared with 10 in 2009/10) including one
on the environment, and others concerning communication
with residents or their families.
We want to improve the way that we learn from the
complaints that we receive and apply the learning across the
organisation. This will partly be achieved by improving our
personalised approach to care (New Initiatives Priority 1) and
through our investment in the clinical leadership programme
(New Initiatives Priority 3).
During 2011/2012 we will:
• incorporate into a new risk strategy actions that will improve
the way that the organisation learns from serious incidents
• revise the current serious incident policy and introduce this
across all services following consultation with staff
• refine the use of the Datix incident reporting tool to ensure
that the best possible quality of information about incidents
is available to managers so that they can learn from and take
action to prevent incidents of a similar nature in the future
• share learning from incidents via the development of
Learning for Patient Safety memos across the organisation
• further develop the Health and Social Care Risk Register
and associate Risk Plan
• introduce use of the web-based Datix Complaints Module.
This will enable more accurate monitoring of complaints
reported, learning, actions taken and response times.
Complaints leads will be trained within each service to use
the system and quarterly reports will then be reported to
the Health and Social Care Governance Committee from
2012 onwards.
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Programme Manager
Helen Press, Quality manager
Homecare
There is no comparable data from 2009/10, but 104
complaints were received in 2010/11, the top issues being
missed calls (23), quality of care (20) and staff attitude (15).
Other issues that appear regularly are communication,
problems supporting people with their medication and the
timing of calls not being appropriate. Those complaints made
about the quality of care often refer to a number of problems
combined leading to poor outcomes for the client, care not
being carried out in accordance with the care plan, or failing
to meet the expectations of the client or their family in terms
of the level of service or the way tasks are done.
Sue Ryder – Quality Account 2010/11
13
Priority 5
Service user eating experience and nutrition
To improve the eating experience and the nutrition of
the people in our care
Our service users have told us that they would like us to
improve the eating experience and would like to work with
us to do so. This has been reported within our annual survey,
by our national Service User Advisory Group (Acorns) and
by a number of our local service user involvement groups.
We recognise the importance of ensuring that the people
we care for are supported to have adequate nutrition and
hydration regardless of whether they are able to eat
independently, need support to eat, where supplements
are prescribed or where a person cannot take food and
drinks by mouth.
During 2011/2012 we will:
• work with our service users and staff to improve the
mealtime experience by setting a standards and
monitoring achievement of that standard
• ensure that service users are enabled to influence
menu options and make choices about what they eat
and when they eat
• review the existing Nutrition and Hydration Policy to ensure
that it is in line with best practice and to ensure that it
supports the standard set by our service users and staff
• provide greater support to the staff who carry out the
nutritional assessment that is appropriate to the care
environment
• review catering standards across the organisation.
We recognise the social importance of mealtimes and we
want to take advice from our service users so that we can
improve that experience. We also want to be sure that all staff
involved in preparation of meals, or involved in supporting
people to eat, understand what constitutes a balanced diet.
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
We know that some of the people who use our services are at
risk because of complex nutritional issues such as malnutrition,
swallowing difficulties or obesity. We therefore want to ensure
that our staff are skilled and equipped with the right tools
to identify those who are at risk. We want our Nutrition and
Hydration Policy and Procedure to be clear about steps to
take where our service users are identified as at risk so that
advice is then sought from appropriate experts with the
agreement of our service users.
Programme Manager
Helen Press, Quality Manager
We would like to ensure that assessments are made by our
staff so that care plans reflect personal choice and reflect
actions taken to manage any risks identified.
Sue Ryder has a Nutrition and Hydration Policy that was
reviewed in March 2011 in response to a National Patient
Safety Alert. There is however further work to do to align the
policy to national guidelines.
14
Sue Ryder – Quality Account 2010/11
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Associate Programme manager
Martin Russell, Head of Support Services, Thorpe Hall Hospice
Part 4
Indicators
1. Service User Experience – All Services
Survey and Complaints Figures
Indicator
Percentage of service users who rated overall care
as ‘Good’ or ‘Excellent’
Percentage of service users who responded ‘Yes,
completely’ or ‘Yes, mostly’ that overall they were
treated with respect and dignity
Percentage of service users who answer ‘Yes’
that they would recommend the service to
family and friends
Number of formal complaints
Percentage of formal complaints acknow-ledged
within target timescale of 3 days
Percentage of formal complaints responded
to in writing within target timescale of 20 day
Sue Ryder – Quality Account 2010/11
Year
Neurological
Palliative
Homecare
2009/10
2010/11
2009/10
2010/11
86%
87%
87%
91%
99%
99%
100%
99%
86%
83%
97%
94%
2009/10
2010/11
91%
95%
100%
100%
Data available from 2010/11
88%
2009/10
2010/11
2009/10
2010/11
2009/10
2010/11
10
7
80%
86%
80%
83%
10
10
80%
90%
70%
88%
Data available from 2010/11
104
Data available from 2010/11
66%
Data available from 2010/11
61%
15
Indicators
Service User Experience – Palliative Care Services 2010/11
Survey
Hospice
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
Percentage of service
users who answer ‘Yes’ that
they would recommend the
service to family and friends
100%
99%
98%
99%
100%
100%
100%
97%
99%
99%
99%
100%
100%
100%
100%
100%
99%
100%
Number of formal
complaints
Percentage of formal
complaints acknowledged
within target timescale of 3 days
Percentage of formal
complaints responded to in writing
within target timescale of 20 days
4
2
4
75%
100%
100%
100%
100%
75%
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
Percentage of service
users who answer ‘Yes’ that
they would recommend the
service to family and friends
89%
88%
83%
93%
88%
83%
82%
95%
88%
92%
93%
100%
82%
91%
100%
91%
95%
100%
88%
100%
90%
Number of formal
complaints
Percentage of formal
complaints acknowledged
within target timescale of 3 days
Percentage of formal
complaints responded to in writing
within target timescale of 20 days
1
1
5
100%
100%
80%
100%
100%
75%
Leckhampton
Manorlands
Nettlebed
St Johns
Thorpe
Wheatfields
Complaints
Hospice
Leckhampton
Manorlands
Nettlebed
Service User Experience – Neurological Care Services 2010/11
Survey
Centre
Birchley
Chantry
Cuerden
Dee View
Hickleton Hall
Holme Hall
Stagenhoe
Complaints
Centre
Chantry
Holme Hall
Stagenhoe
The response rate to our surveys is dependent upon those who are either willing or able to complete the survey and therefore
does not necessarily represent the experience of all.
16
Sue Ryder – Quality Account 2010/11
Service User Experience – Homecare Services 2010/11
Survey
Homecare Services
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
Percentage of service
users who answer ‘Yes’ that
they would recommend the
service to family and friends
91%
86%
83%
86%
72%
67%
88%
86%
87%
93%
95%
86%
96%
88%
94%
100%
88%
93%
93%
100%
97%
100%
100%
92%
90%
83%
85%
100%
75%
90%
92%
100%
91%
97%
100%
88%
Homecare Services
Number of formal
complaints
Percentage of formal
complaints acknowledged
within target timescale of 3 days
Percentage of formal
complaints responded to in writing
within target timescale of 20 days
Arbroath
Bournemouth
Manvers
Lincoln
Macclesfield
Newark
Rochdale
Stafford
Stirling
Wigan
2
3
52
16
5
6
5
11
1
3
100%
67%
56%
69%
60%
100%
100%
73%
100%
67%
100%
67%
58%
63%
40%
67%
100%
45%
n/a
100%
Arbroath
Bournemouth
Manvers (Doncaster, Rotherham, Barnsley)
Heyeswood
Lincoln
Macclesfield
Newark
Rochdale
Stafford
Trafford
Wigan
Wolverhampton
Complaints
Complaints tables do not include the names of services where no complaints were reported centrally.
It is important to note that Manvers is our largest Homecare Service, providing around 3,000 hours of care per week. At the
other extreme Bournemouth currently only provides 300 hours of care per week. Stirling is a service that has only recently been
taken over by Sue Ryder and Stafford has been transferred to a new provider.
Sue Ryder would like to improve its response to complaints. However, there is recognition that future data must be provided
around those more complex complaints, where an agreement has been negotiated with the complainant to extend the
investigation period to ensure a satisfactory and full response. We currently are not able to demonstrate where this has
occurred in the data that we collect.
Sue Ryder – Quality Account 2010/11
17
Indicators
2. Safety
Indicator
Neurological
Regulatory body inspection rating
(Neurological and Homecare only)
Percentage of care standards met or exceeded
by those Hospices inspected
Number of incidents resulting in permanent or
long term harm to service users per year
Number of medicines administration incidents
to service users per year
Number of medicines prescription
incidents per year
Number of service user slips trips and falls resulting in
hospital admission per year
Number of reports under RIDDOR
Palliative
Homecare
See section on Priority 2 above for details
N/A
100%
N/A
0
0
0
33
64
8
0
10
1
6
1
8
4
4
See note below
0
Please see note and table below regarding RIDDOR reports
Number of Healthcare Acquired Infections and pressure ulcers
acquired within our own service or acquired externally
See section below
There have been no incidents that have resulted in the death, permanent or serious harm to a service user in our care
during 2010/2011.
Of the 8 slips, trips or falls resulting in hospital admission in Homecare, only one fall was observed and happened when a carer
was in attendance.
While the introduction of an electronic reporting system has improved data quality there is still further work to do particularly
in Homecare where it is felt that the data represented above may not be fully representative of all incidents that have occurred.
Due to the recent introduction and work to embed the system no comparative data is given.
Number of Reports under RIDDOR 2010/11
Number of Reports under RIDDOR 2010/11
Neurological Care
Palliative Care
Centre
Number of reports
Cuerden Hall
Hickleton Hall
Stagenhoe
Total
2
1
1
4
Hospice
Number of reports
Manorlands
St Johns
Wheatfields
Total
Two incidents reported as RIDDOR incidents (at St John’s and Cuerden) did not fit into the RIDDOR reporting criteria. It has
been identified that further guidance needs to be given to staff and the Health and Safety Team are currently working on this.
18
Sue Ryder – Quality Account 2010/11
1
2
1
4
Medicines Incidents
Medicines Administration Errors
Medicines Incidents are split by
individual services below
Service
Homecare
Lincoln Homecare Service
Mexborough Homecare Service
Newark
St Helen's Homecare Service
Wolverhampton Homecare Service
Homecare Total
Neurological Care Services
1
1
1
4
1
8
Birchley Hall
Cuerden Hall
Dee View Court
Hickleton Hall
The Chantry
2
2
7
14
8
33
Leckhampton Court Hospice
Manorlands Hospice
Nettlebed Hospice
St Johns Hospice
Thorpe Hall Hospice
Wheatfields Hospice
8
13
22
3
9
9
64
Neurological Care Services Total
Palliative Care Services
Total
Palliative Care Services Total
Total
105
Medicines Prescription Errors
Service
Homecare
Homecare Total
Lincoln Homecare Service
Palliative Care Services
Leckhampton Court Hospice
Nettlebed Hospice
St John’s Hospice
Thorpe Hall Hospice
Wheatfields Hospice
Total
1
1
Palliative Care Services Total
1
5
1
2
1
10
Total
11
Sue Ryder – Quality Account 2010/11
19
Indicators
3. Effectiveness
HCAI and Pressure Ulcers
The number of infections and pressure ulcers across all neurological and palliative centres reflects the period between
April 2010 and March 2011. Cases are identified as those that were acquired by the service user while in our care and those
acquired prior to the service user being admitted to a Sue Ryder service.
Neurological
Health Care Acquired
Infections (HCAI)
Palliative
Total
Acquired
in SRC
Acquired
External to SRC
Acquired
in SRC
Acquired
External to SRC
Acquired
in SRC
Acquired
External to SRC
–
19
1
–
–
–
–
2
–
–
7
–
2
–
2
–
1
–
–
–
–
6
–
14
5
1
2
1
2
19
2
0
0
0
0
8
0
14
12
1
4
1
17
6
54
225
71
231
Clostridium Difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (colonised)
Hepatitis (A, B or C)
Influenza
Pressure Ulcers
Pressure Ulcers
Number of HCAI (2010/11) –
Hospices and Care Centres
Health Care Acquired Infections (2010/11)
l Acquired within own service
l Acquired external to service
Clostridium Difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (colonised)
Hepatitis (A, B or C)
Influenza
0
20
4
8
12
16
18
20
Sue Ryder – Quality Account 2010/11
new cases
Number of HCAI by Service
Neurological Care
Centre
Clostridium
Difficile
Norovirus
MRSA
(infection)
MRSA
(colonised)
Hepatitis
(A,B or C)
–
–
–
–
1
–
1
19
–
–
–
–
–
–
–
–
–
1
–
–
–
–
5
–
–
1
–
1
–
–
–
–
2
–
–
Birchley
Chantry
Cuerden
Dee View
Hickleton
Holme Hall
Stagenhoe
Number of HCAI by Service
Palliative Care
Hospice
Clostridium
Difficile
Norovirus
MRSA
(infection)
MRSA
(colonised)
ESBL
(colonised)
Hepatitis
(A,B or C)
Influenza
1
2
–
3
2
–
–
–
–
–
–
–
1
5
1
–
8
–
1
2
2
–
–
–
1
–
–
–
–
–
1
–
1
–
–
–
1
–
–
–
–
–
Leckhampton
Manorlands
Nettlebed
St John’s
Thorpe
Wheatfields
Sue Ryder – Quality Account 2010/11
21
Indicators
Number of Pressure Ulcers (2010/11) –
Hospices and Care Centres
Pressure Ulcers (2010/11)
l Acquired within own service
l Acquired external to service
Neurological centres
Palliative care
0
50
100
150
200
250
300
new cases
Number of Pressure Ulcers by Service
Neurological Care
Centre
Birchley
Chantry
Cuerden
Dee View
Hickleton
Holme
Stagenhoe
Total
22
Palliative Care
Acquired within
own service
Acquired external
to service
2
6
2
2
2
1
1
3
3
17
0
0
1
6
Sue Ryder – Quality Account 2010/11
Hospice
Acquired within
own service
Acquired external
to service
Leckhampton
Manorlands
Nettlebed
St Johns
Thorpe
Wheatfields
5
6
20
7
1
15
17
20
50
43
27
In excess of 68
Total
54
225
Part 5
Annexes
Annex 1
• During the period of this report, 1 April 2010 to 31 March
2011 Sue Ryder provided NHS-funded community health
services through its 6 Adult Hospices, 5 Day Hospices,
1 Hospice at Home service, 2 Community Nursing Services
and 6 Care Homes with Nursing.
• The percentage of NHS funding is variable depending on
the nature of the service and ranges from 35 per cent to
90 per cent of the total cost of providing the service.
The shortfall is met from Sue Ryder charitable income.
• Sue Ryder has reviewed all the data available to it on
the quality of care in all of the services detailed in the
preceding section.
• The income generated by the NHS services reviewed in the
period 1 April 2010 to 31 March 2011 represents 100 per
cent of the total income generated from the provision of
NHS services by Sue Ryder for the period 1 April 2010
to 31 March 2011.
• During the period from 1 April 2010 to 31 March 2011
there were no national clinical audits covering the NHS
services that Sue Ryder provides.
– Sue Ryder sets an annual core audit programme that
runs from April – March each year. The core audit
programme is risk driven, and for Hospices and
Neurological Care Centres includes record keeping,
medicines management, falls prevention, pressure ulcer
assessment and management, care at end of life,
environmental and a hand hygiene audit.
– Homecare services have more recently been given
training on the audit process and have a service specific
audit programme that began in December 2010. The
audit programme includes hand hygiene, infection
protection control policy compliance, uniform policy
compliance and record keeping.
– The monitoring, reporting and actions following these
audits ensure care delivery is safe and effective. Each
service reports audit findings into their local Quality
Improvement Group. The Healthcare Governance
Committee for Sue Ryder receives a twice yearly
overview of audit results and actions taken in response.
– Key learning from the audit programme for this year
has been that more would be achieved in terms of
improvement if the core audit programme were to
be extended over a period of two years. This has been
agreed and will ensure more time to implement
recommendations locally and more time to re-audit
where necessary.
• From 1 April 2010 to 31 March 2011 Sue Ryder was not
eligible to participate in national clinical audits.
• The number of patients receiving NHS services provided
or sub-contracted by Sue Ryder from 1 April 2010-March
2011 that were recruited during that period to participate
in research approved by a research ethics committee was
47 in total. Of these, 17 patients took part in four studies
Sue Ryder – Quality Account 2010/11
led by Sue Ryder (these studies are still in progress) and
30 patients took part in external studies (27 were recruited
from two sites for one study and 3 were recruited from one
site for one study).
• During this reporting period, Sue Ryder undertook an
organisational approach to the Commissioning for Quality
and Innovation (CQUIN) scheme. The CQUIN payment
framework enables commissioners to reward excellence
and is linked into local quality improvement goals. Sue Ryder
was successful in negotiating/agreeing 7 local schemes
whilst working in partnership with those commissioners
who wished to transfer Sue Ryder Services to the NHS
Bi lateral Community Contract. The quality improvement
and innovation goals were agreed as over and above the
main contractual requirements therefore attracting
additional income through the CQUINs payment
framework on evidence of achieved goals. In quarter 4 of
this period, 4 schemes have had confirmed payments, with
2 commissioners now advising that due to financial
pressures no CQUINs payments will be available. Further
details of the agreed quality improvement and innovation
goals can be found below:
Goal
1
2
3
4
Description of goal
To promote a positive experience for all service users
To reduce avoidable harm
To achieve patient preferred priorities at end of life
Equity of access to services and innovation
in partnership working in palliative care for
non-cancer diagnosis
• Sue Ryder services in England were re-registered with the
Care Quality Commission by 30 September 2010.
Conditions of registration apply to the numbers of service
users who can be accommodated in each location. In
addition, four services where interim management
arrangements were in place were required to have a
registered manager in place by 1st June 2011.
• The Care Quality Commission has not taken enforcement
action against Sue Ryder during the period 1 April 10 to
31 March 2011.
• Sue Ryder has not participated in any special reviews or
investigations by the CQC during the reporting period.
• Sue Ryder did not submit records during the period from
1 April 2010 to 31 March 2011 to the Secondary Uses
service for inclusion in the Hospital Episode Statistics which
are included in the latest published data.
• Sue Ryder was not eligible to be scored for the period
1 April 2010 to 31 March 2011 for Information Quality and
Records Management, assessed using the Information
Governance Toolkit.
• Sue Ryder was not subject to the Payment by Results
clinical coding audit during the period 1 April 2010 to
31 March 2011 by the Audit Commission.
23
Annexes
Annex 2
Feedback from commissioning Primary Care Trusts
(PCTs), the Overview and Scrutiny Committee (OSC),
the Sue Ryder National Service User Advisory Group
‘Acorns’ and Local Involvement Networks (LINks)
Commissioning NHS Gloucestershire Primary Care
Trust (lead commissioners for Leckhampton Hospice)
NHS Gloucestershire (NHSG) has taken the opportunity to
review the Quality Account prepared by Sue Ryder 2010/11.
In a shared vision to maintain and continually improve the
quality of specialist palliative care services in Gloucestershire,
NHSG and Sue Ryder have worked in collaboration to
establish locally agreed quality improvement targets
that include nationally mandated quality indicators
The introduction of the Commissioning for Quality and
Innovation (CQUIN) scheme has provided further
opportunities for ensuring robust quality measures are
in place in future and locally we have been in discussion
about their introduction to the existing contract.
Feedback from NHS Leeds
NHS Leeds welcomes the opportunity to comment on
this Quality Account from Sue Ryder. We currently
commission palliative care services from Wheatfields, an
18 bedded unit which provides inpatient, outpatient and
community-based care.
We can confirm that the published data relating to
Wheatfields is accurate, but are unable to verify the
accuracy of data provided by other services outside of the
Leeds area, for obvious reasons. We believe that this account
is a fair reflection of the quality of services provided and the
chosen indicators for the forthcoming year are both suitable
and relevant.
We are pleased note the achievements against the
priorities outlined last year and note that standards have
been maintained or improved for those units inspected
by the Care Quality Commission (England) or Care
Commission (Scotland).
There are regular meetings with the lead commissioner
to agree, monitor and review the quality of services
covering the key quality domains of safety, effectiveness
and patient experience. Learning from this has influenced
strategic development and quality assurance measures in
Gloucestershire across all specialist palliative care services
under a provider partnership model.
We are particularly pleased to note the introduction of
the Datix risk management and recording tool, which will
improve patient safety through better categorisation of
incidents and the identification of trends. We are pleased to
see how this has also informed the falls management work
and it would be helpful to see if a reduction in falls occurs
over the forthcoming year as this work is continued. We
would recommend that this information is included in next
year’s quality account.
The Quality Framework for 2010/11 demonstrates a
number of key improvements across services since
2009/10. In Gloucestershire NHSG has received assurance
throughout the year from Sue Ryder in relation to key quality
issues, both where quality and safety has improved and
where there have been challenges with remedial plans put
in place and learning shared wherever possible.
With regard to priorities for the forthcoming year, we
welcome the continued focus on service user engagement
through collaboration with the ‘Acorns’ user group. We
trust that this includes engagement with carers and family
members also.
NHSG endorse the proposals set out in the Quality
Account and can confirm that we consider the Quality
Account contains accurate information in relation to
the quality of services that Sue Ryder provides to the
residents of Gloucestershire.
We are also pleased to note the proposals on prevention of
avoidable harm from pressure ulcers. This reflects priorities
agreed with other local providers in their Commissioning
for Quality and Innovation (CQIN) schemes. This is also
true for the proposals on improving the eating experience
and nutrition, and is key to delivering high quality
fundamental care.
Mary Morgan, Associate Director, NHS Gloucestershire
We commend Sue Ryder care for their commitment to
develop leading clinical staff through the leadership
programme, as well-trained and developed leaders
help maintain high standards of care and drive through
service improvements.
24
Sue Ryder – Quality Account 2010/11
The proposals for learning from incidents and complaints
are also commended; we would also suggest incorporating
work to address some of the themes already identified such
as communication.
We look forward to seeing the improvements to the quality of
services provided as outlined in this Quality Account, and we
feel confident that Sue Ryder will continue to build on their
achievements and deliver successfully against the priorities
they have identified. We look forward to continuing to work
with Sue Ryder care and commend this quality account.
The Gloucestershire Health, Community and Care
Overview and Scrutiny
The Gloucestershire Health, Community and Care Overview
and Scrutiny Committee was grateful to Sue Ryder for
sharing a draft of the Quality Account for 2010/11 but did
not feel able to comment.
Camden LINk
Camden LINk received Sue Ryder’s Quality Account but were
unable to provide comments or feedback this year.
Leeds LINk
They received the Sue Ryder Quality Account but were
unable to provide any comments this year. They confirmed
they would like to see the Quality Account again next year.
Overview and Scrutiny Committee (OSC)
They were grateful for the opportunity to comment on the
Quality Account but they didn’t feel sufficiently informed of
the quality of Sue Ryder services to be able to offer a detailed
opinion.
Sue Ryder Acorns Group (National Service User
Advisory Group)
‘Acorns’ is the National Service User Advisory Group for
Sue Ryder and has representation from both service users
and their family members. The quality account priorities
for 2011-2012 were agreed by Acorns at their meeting
in March 2011. The draft Quality Account was then
circulated to members for comment and a summary of
feedback (incorporating the Sue Ryder response to that
feedback) is given below.
There was particular agreement with the focus on being
treated as an individual and the promotion of independence
and choice.
Acorns told us that the document was a little long but
that the priorities within it were the right ones. In response
Sue Ryder is to produce a 2-page summary version of
the Quality Account. This will flag up that a more detailed
document is available if required.
A suggestion was made that all staff should be kept
updated on the changing dietary needs of service
users. This will support the outcome aims for priority 5
(service user eating experience and nutrition).
This suggestion will be incorporated into the work
that will be completed this year on the Nutrition
and Hydration Policy and accompanying standard.
The draft standard will be taken to Acorns for their
comments and suggestions.
Sue Ryder – Quality Account 2010/11
25
This document is available in
alternative formats on request.
Sue Ryder
1st Floor
16 Upper Woburn Place
London
WC1H 0AF
Sue Ryder is a charity registered in England and Wales (1052076) and in Scotland (SC039578).
Ref. No. 000608.1.p/0611/B/P/H © Sue Ryder, June 2011. This document will be reviewed in June 2012.