Castlebeck.com
Quality Account
2011/2012
Quality Account 2011/2012
Contents
Page
Part 1: Statement on quality from the Executive Chairman
3
Part 2: Priorities for quality improvement for 2012
4
Governance Review Process
4
Service User Involvement and Feedback
4
Patient Safety
4
Views of Services from a Staff Perspective
5
Advocacy
5
Key Policy Dissemination
5
Review of Services 2012
5
Statements from the CQC
6
Data quality
6
Part 3: Clinical Effectiveness, Patient Safety and Patient Experience & Service User Involvement
6
Clinical Effectiveness
6
Patient Safety
7
Patient Experience & Service User Involvement
7
Annex Statement from a Castlebeck purchaser
7
2
PART 1: Statement on quality from the Executive Chairman
Castlebeck provides person centred health and social care for people with learning disabilities, autism, acquired
brain injury and associated mental health problems. Castlebeck publishes a Quality Account for our independent
mental health hospital services every year.
Castlebeck has a renewed approach that focuses on care pathways, outcomes and discharge planning from
the point of admission onwards. We are committed to be being transparent and answerable in all we do.
This year’s Quality Account summarises areas where we have improved and the steps taken to assure key
stakeholders of reforms to the three key areas of Clinical Effectiveness, Patient Safety and Patient Experience
and Service User Involvement.
Through this document we wish to convey the volume and depth of meaningful change in our business.
This ranges across the topics covered here and also the foundations that have been prepared for further
work. None of this is possible without the views of the people who use our services and their families,
and the dedication of the professionals we now have as colleagues working within Castlebeck.
Sean Sullivan
Executive Chairman
3
Quality Account 2011/2012
PART 2: Priorities for Quality Improvement during 2012
Governance Review Process
Following an independent review of patient safety across all Castlebeck Services, a new Group Director of Nursing
and Patient Safety was appointed. Also a new post that heads up Governance, Compliance and Risk has been
created and this person leads a new team of Audit & Governance Leads for each region. The team is currently
completing and reporting on audits throughout the organisation as well as reinforcing reformed policies and
procedures. The Governance Team produce monthly analysis across key indicators for each service. This data is
also shared at service review meetings and the Internal Whistle Blowing and Safeguarding Meetings.
Service User Involvement and Feedback
We have national contracts in England and Scotland with Independent Advocacy Services. We also undertake
surveys of service user views and exit questionnaires that inform our policies and practice. We are currently
developing improved links with family carers including undertaking a family carer survey.
A revised policy and protocol for Multi Disciplinary Team (MDT) meetings has been developed and is used
across the company. This ensures greater participation for service users in the active planning of their treatment.
All service users have a comprehensive MDT review at least once a month to review their action plan. There is
an increase in the number of clinicians at unit level which has improved and enabled greater clinical contribution
at each MDT meeting.
The MDT process is subject to a review audit, results of which are in the process of being finalised. External
involvement in MDT meetings is welcomed and takes place regularly. Families are invited and encouraged to
attend. Care Programme Approach (CPA) meetings are chaired by clinicians and take place twice a year.
Clinical reports are made available for all CPAs and families are actively encouraged to attend CPAs.
Patient Safety
We are constantly improving our systems to enable us to take a proactive approach to patient safety. This includes
work to improve electronic reporting of incidents, improved analysis and feedback including the use of restrictive
physical interventions. This information is analysed and discussed at national, regional and unit level.
There is an externally sourced, independent Whistle Blowing procedure. Staff are encouraged to report concerns
of any kind in confidence. Any concerns are then considered at the Whistle Blowing and Safeguarding Committee
attended by Board members.
4
Views of Services from a Staff Perspective
To communicate better with our staff we have created staff forums, commissioned surveys and undertaken
consultations to engage with staff. There is regular attendance by senior management at our services to allow
staff to contribute their views, concerns and ideas.
The use of the company intranet and the new staff newsletter keeps all members of staff up to date with new
policies, progress and improvements as we continue to improve upon patient safety and the quality of services
we provide. Team briefings have been introduced to cascade information to all our staff. Staff views are recorded
and included within subsequent Board discussions.
Advocacy
Following an independent advocacy review of all Castlebeck services, national contracts have been established
to provide advocacy services to all service users. Quarterly reports are provided from these third party companies
to the Castlebeck Board.
Key Policy Dissemination
All new staff are trained on policies such as Whistle Blowing Policy, Safeguarding Policy, Health & Safety and
Information Governance during induction. Policies are referred to during other training courses including Personal
Safety and Conflict Management. Policies are regularly reviewed and updated through Policy Committee
meetings. Where there are major changes/revisions to policies we communicate this to staff via team briefings,
letters from the Executive Chairman and other updates.
Review of Services during 2012
Castlebeck has a range of services which can support people’s individual needs. These include services which
support people with learning disabilities and complex needs, those on the autistic spectrum and a specialist
brain injury hospital.
During the course of the year we are working on clear service definitions for each service and clearer,
more defined statements of purpose.
Each of the services/units have had their environment and service provision inspected, the units continue to be
visited and reviewed monthly by the Regional Operations Directors and their teams. A significant number of
units have commissioned contractors in order to improve the environment for service users.
New staff with operational, commissioning and clinical experience have been recruited to review the future
function of each unit. Independent industry experts have been commissioned to review hospitality and
medication management. Progress has been made with commissioners in defining clearer service specifications
for each service. A clear example would be Thornfield Grange in the North East, where we have a defined
pathway, from hospital to care home with nursing for service users with autism.
5
Quality Account 2011/2012
Statements from the CQC
Castlebeck is required to register its 11 hospitals in England with the Care Quality Commission, and its
current registration status is:Mental Health establishments taking people liable to be detained (MH(D))
Mental Health treatment establishments, not including those where people are liable to be detained (MH)
Castlebeck has no conditions on registration
All our service CQC and corresponding action plans are available to view on the CQC website or at
www.castlebeck.com
Data quality
Castlebeck has been collecting detailed Clinical Governance data, which is used to improve patient safety and
which are reported monthly to the Board. We analyse and monitor information closely and are able to respond
quickly to trends.
An electronic incident reporting system has been implemented to ensure the effective analysis of data. This will
allow for the effective tracking of every serious incident, incident trends and patient safety reviews. An electronic
risk register enables us to improve our ability to track and evidence all areas of risk in a systematic way.
PART 3: Clinical Effectiveness, Patient Safety and Patient Experience
& Service User Involvement
The following is a summary for the above three key areas:
Clinical Effectiveness
Each hospital service user is offered an assessment process which includes the following standards:
Pre admission assessment includes an agreement on expected outcomes desired by the referrer and service user
and an estimated length of stay agreed
During the first week of admission a full psychiatric review, a GP registration and a health check is completed
along with onward referrals to other clinicians organised at an initial MDT review and risk assessments completed
By week two, a weekly individualised activity programme is devised with the service user and a person centred
plan has begun
By week three, an initial HoNOS LD is completed
By week four, initial risk assessments have been updated
In preparation for the service user’s CPA review being held at week 12, the multidisciplinary CPA report is
sent out to relevant personnel at least one week in advance
Minutes of the CPA meeting are sent to external attendees within one week of the meeting being held
This process will be monitored by an audit process, checking these standards are fully met for every new admission.
We will ensure that we can evidence that every service user receives structured, individualised and appropriate
activity for a minimum of 25 hours per week including as much physical exercise as appropriate. We will ensure
the delivery of the newly implemented Positive Behavioural Support (PBS) training, to all services. This has been
developed in liaison with expertise from the British Institute for Learning Disabilities. We will measure its success by
reference to data on patient outcomes and incident numbers. Staff will be trained in the use of the Life Star outcome
measure, which will be in use by Autumn 2012.
6
Patient Safety
The Governance and Patient Safety Team will continue to focus and review patient safety processes at all services.
They are responsible for ensuring effective audit processes, quality checks and compliance requirements are in place.
The team will incorporate service users and carers and involve external, independent expertise.
A full and comprehensive review of our physical intervention policies has been undertaken to improve the quality
of training, and increase the skills of staff in managing complex and high risk situations safely.
Patient Experience & Service User Involvement
The Patient Experience via User Feedback Programme feeds back to Service Users, Families and Carers. Reviews and
improvements are made following the Service User Consultation Questionnaires.
An important part of our reforms is the new Service User Involvement Forum whose remit is to have sight of all
service user involvement projects/initiatives across the organisation and co-ordinate roll-out of best practice areas.
This includes the implementation and extension of a number of projects including relative/carer involvement
initiatives.
Castlebeck are implementing a new Care Plan Approach programme which evidences person-centred working at
all levels. This involves the implementation of new key documents for CPAs. We will measure this via audits to be
undertaken of Care Plans and CPA’s.
Annex Statement from a Castlebeck purchaser
Newark and Sherwood CCG on behalf of the five CCGs across Nottinghamshire County has reviewed
Castlebeck’s Quality Account and in light of our commissioning experience I can confirm that the Quality
Account is correct although they have not been fully audited by Newark and Sherwood CCG.
Karon Glynn, Assistant Director,
Mental Health and Learning Disabilities, Newark and Sherwood CCG.
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Castlebeck.com
Quality Account
2011/2012