Quality Account 2011/12
Our quality performance, initiatives and priorities
Contents
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Who we are and what we do
Commendation
Joint statement from our Chief Executive and Chair of Trustees
Part one: Our priorities for quality
Our services map
Our vision and values
Part two: Our priorities for improvement
Our progress against our priorities for improvement 2011/12
Priority 1: Service user experience. To work towards a
personalised approach to service delivery and care
Priority 2: Service user safety, and effectiveness. To manage the
risk from pressure ulcer development
Priority 3: Effectiveness. To support the development of our
clinical leaders
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
Part three: Our priorities for improvement 2012/13
Priority 1: Service user experience. To develop tools to measure
how person-centred support is delivered in our services
Priority 2: Service user safety. To manage the risk of harm
from medication
Priority 3: Effectiveness. To further develop partnerships
in care delivery
Priority 4: Service user experience. To measure the meal
time experience
Priority 5: Service user experience. To ensure service users and
staff safety by reducing the risk of sharps injury
Part four: Indicators
Part five: Annexes
Annex 1: Legal requirement
Annex 2: Statement from commissioning Primary Care Trusts
(PCTs), Overview and Scrutiny Committee (OCS) and Local
Improvement Networks (LiNks)
Who we are and what we do
Sue Ryder provides care and support for people living with complex*,
end of life and specialist palliative care needs.
We are a large national charity in England and Scotland. We are
passionate about giving people the care they want. We deliver
services within local communities through our day care, respite care,
hospices, specialist palliative care, community nurse specialists and
Hospice at Home provision along with long-term residential
care, extra-care housing support, homecare in Scotland and
community integration.
This document, the Sue Ryder Quality Account demonstrates our
continued commitment to quality improvement. It outlines our quality
improvement measures over the last year and our priorities for the
year ahead.
Our approach to quality is shown below
Organisational
values
Operational
and clinical staff
Commendation
Audit
programme
“The help and support which you gave will never be
forgotten. We could not have done it without you.
Your care and compassion was first class, and Mum
loved you all.’’
Relative of a service user from one of our
community support services
“During my time at Sue Ryder my life was turned
around from feeling so isolated and frightened to
being made so safe and cared for.’’
A patient at one of our hospices
External
validation
“Quality of care is excellent not only for the resident
but also the wider family”
A resident at one of our neurological services
*
conditions that severely affect normal, cognitive abilities and physically caring for yourself.
Sue Ryder – Quality Account 2011/12
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Part one: Our priorities for quality
Position and status on quality
Joint statement from our Chief Executive and the
Chairman of Trustees
Welcome to the third annual Quality Account, a summary of
our performance against selected quality measures for
2011/12 and our initiatives and priorities for 2012/13.
Sue Ryder is a national health and social care charity, which
provides care and support to people living with complex, end
of life and specialist palliative care needs.
This Quality Account is produced to inform current and
prospective service users, their families, Sue Ryder staff,
our supporters, commissioners and the public, of our
commitment to ensure quality across all our services.
The contents has been influenced by and has the
endorsement of our national Service User Advisory Group,
which is a representative body of our service users known
as ACORNS. As an organisation we produce this information
across all of our services, enabling us to benchmark our
quality standards.
The delivery of person-centred care, in a manner which is both
measurable and meaningful to all who use our services is a key
priority for all our teams.
The 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 aim is to provide an
honest representation of progress made during the year and
to recognise where improvements are needed. The Quality
Account celebrates the good outcomes reported by service
users and commits to learning from reported experiences
where outcomes did not meet with expectations.
Quality is important to us, alongside partnership working,
innovation, workforce development, service user involvement
and working as one organisation. Our trustees report for
2011/12 outlines our vision, mission and key activities for the
past 12 months across the whole of the charity, and can be
found on our website.
We hope you find our Quality Account useful. We welcome
ACORNS meets three times a year and is supported by
suggestions for future accounts.
locally run groups that help us with our planning and
decision-making. We connect service users by video and
teleconference to embrace communication across many sites.
We have made a lot of progress since our first Quality Account
in 2010. In August 2011, we decided as an organisation to
withdraw from the provision of homecare in England. This
decision means we can focus our efforts on complex, end of
life and specialist palliative care needs.
Supporting Me
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Sue Ryder – Quality Account 2011/12
Paul Woodward
Chief Executive
Roger Paffard
Chairman of Trustees
Our service map
Aberdeen 11
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1.
Head Office
Central Office, London
2.
Registered Office
Sudbury Office, Sudbury
3.
Extra Care
Sue Ryder – Heyeswood, Merseyside
4.
5.
6.
7.
8.
9.
10.
Palliative Care
Sue Ryder – Manorlands Hospice, West Yorkshire
Sue Ryder – Wheatfields Hospice, West Yorkshire
Sue Ryder – Thorpe Hall Hospice, Peterborough
Sue Ryder – St John’s Hospice, Bedfordshire
Sue Ryder – Nettlebed Hospice, Oxfordshire
Sue Ryder – Leckhampton Court Hospice, Cheltenham
Sue Ryder – Duchess of Kent House, Reading
11.
12.
13.
14.
15.
16.
Complex Needs
Sue Ryder – Dee View Court, Aberdeen
Sue Ryder – Holme Hall, East Yorkshire
Sue Ryder – Hickleton Hall, South Yorkshire
Sue Ryder – The Chantry, Suffolk
Sue Ryder – Stagenhoe, Hertfordshire
Sue Ryder – Cuerden Hall, Lancashire
Elderly & Dementia
17. Sue Ryder – Birchley Hall, Lancashire
Homecare services (in Scotland)
18. Angus Homecare
19. Stirling Homecare
Supported Living
20. Supported living unit, Suffolk
Leeds
4
16
5
12
Other services
21. Continuing Health Care, Doncaster
22. Befriending schemes (dementia and volunteer),
Doncaster
Liverpool
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13
3
21 22
Nottingham
6
Birmingham
20
7
9
2
14
15
Oxford
London
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1
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Our vision
We are passionate about giving people
the care they want
Our values
• do the right thing
• push the boundaries
• make the future together
Sue Ryder – Quality Account 2011/12
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Part two: Our priorities for improvement
Our progress against our priorities for
improvement 2011/12
Priorities for 2012/13 have been influenced by service users
experience and involvement, national standards and learning
from enhanced quality performance data.
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.
In October 2011 Sue Ryder commissioned Demos, a leading
think-tank, to produce a report which would explore the
national policy drivers surrounding personalisation (personcentred care) and examine their impact on our service users,
to better understand how these policies affect and influence
our current service delivery.
The priorities do not fully represent all that Sue Ryder is
doing to continue to improve the person’s (and family’s)
experience of our services at a local level, but they give an
indication of particular areas of focus.
The priorities for 2011/12 were
Priority 1
Service user experience
To work towards a personalised
approach to service delivery
and care
Priority 2
Service user safety and
effectiveness
To manage the risk from
pressure ulcer development
Priority 3
Effectiveness
To support the development
of our clinical leaders
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
The priorities for 2012/13 are summarised below
Our quality strategy focuses on the same three overarching
key areas identified in previous Quality Accounts and
these are:
• service user experience
• service user safety
• effectiveness
Priority 1
Service user experience
To develop tools to measure
how person-centred support
is delivered in our services
Priority 2
Service user safety
To manage the risk of harm
from medication
Priority 3
Effectiveness
To further develop
partnerships in care delivery
Priority 4
Service user experience
To measure the meal time
experience
Priority 5
Service user experience
To ensure service users and
staff safety by reducing the
risk of sharps injury
These priorities have been approved by ACORNS (our Service
User Advisory Group), the Executive Leadership Team (ELT)
and our Board of Trustees.
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Sue Ryder – Quality Account 2011/12
Priority 1: Service user experience
Progress made in 2011/12
To work towards a personalised approach to service
delivery and care
We said, we would engage with Helen Sanderson and
Associates to introduce a more person-centred approach to
care planning in our centres.
We said, we would work with service users via ACORNS,
to develop a project which would see service users interview
other service users, focusing on what it feels like to be treated
as an individual and receive care from us.
The ACORNS group on reflection agreed that this was not
the most helpful approach. Based on their feedback we have
We successfully engaged with Helen Sanderson and Associates, changed our approach. Our service users were interviewed
who are nationally recognised leaders in personalisation.
as part of the work we did on the Demos report, looking
We worked with them to roll out a staff training programme in specifically at what is important to them for individualised
person-centred care. We trained 412 staff during 2011/12.
care. During these interviews service users told us that the
The training was well received; ‘interactive’ and ‘enjoyable’.
attitudes of staff providing care are as important as
Staff were provided with a series of useful tools to help
qualifications. We are exploring how our service users
monitor progress and develop actions plans for the users
can be further involved in the recruitment of staff.
of our services.
Our service users’ stories of care and the impact of these are
We said, we would review our documentation to
central to our care delivery. We have a database of stories that
incorporate new methods of recording and capturing
we use to help raise awareness of the different conditions we
individual preferences whilst still meeting regulatory
treat and some of our ACORNS members are featured on our
requirements.
new website, launched in June 2012.
We finalised our neurological documentation and in April
2012 this was rolled out to all our neurological centres.
All our neurological staff were trained in its use. We will audit
its use six months post implementation and report our
findings in January 2013.
We said, we would work towards a personalised
approaches to our services and involve our service users in
the recruitment and selection of our workforce.
This has been piloted within one of our neurological centres
with service users taking a more formal role.
We said, we would at the work needed to change our
policies to become more person focused.
In March 2012, using the best practice guidance from Think
Local, Act Personal we formed a task group to shape this work
across all parts of the organisation.
Sue Ryder – Quality Account 2011/12
“Before the course I didn’t want Janice* to go
home, but now I feel she could be safe and
it’s her wish to do that”
response from a staff member receiving
person-centred risk training, referring to
one of our service users with extremely
complex care needs.
* name has been changed.
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Priority 2: Service user safety, and effectiveness
Progress made in 2011/12
To manage the risk from pressure ulcer development
From our electronic incident reporting system we identified
that reporting of any skin damage was needed in all our
services. It is an area where we would wish to ensure our staff
are skilled and equipped with the right tools to identify those
at risk and to ensure our equipment to manage the risk is in
the right place at the right time.
Initiatives
We said, we would produce a service user information
leaflet for service users and their families.
This was issued to all services in October 2011.
We said, we would support practice educators and
education leads in each centre.
We issued guidance with recommended training material
to support education and training to education leads in
September 2011.
We said, we would ensure all patient records reflected
the level of risk for pressure ulcer development and all
patients admitted to healthcare settings would be screened
for risk of pressure ulcer damage, with care plans developed
to address each risk factor.
We incorporated checks in this area as part of our quality visit
programme in 2011/12 and have integrated this aspect of
documentation into our core documentation audit
programme.
We said, we would report pressure damage in our
healthcare settings at “grade 2” and above, including recording
any pressure damage on admission to our care settings.
We continually monitor incidents of pressure damage,
identifying any existing conditions and/or pressure damage
on admission to our service via our electronic reporting
system. Quality improvement is monitored within local
meetings on a monthly or bi-monthly basis.
During 2011/12 the number of reported incidents (including
pressure ulcers) had increased by 32%. Pressure ulcers are
reported through a monthly performance process, which we
have had in place for the last two years. There has been a
significant increase in reporting due to awareness raising.
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Sue Ryder – Quality Account 2011/12
We said, we would report incidences of severe pressure
damage at “grade 3” and above, and that these would be
investigated as outlined within our serious incident policy.
This will help us share the learning across the organisation.
In 2011/12 we had three incidents of “grade 3” damage.
We use a root cause analysis approach (one of the
recommended National Patient Safety Agency tools) to
review such incidents. In all instances the care was assessed
to be of a high quality, with damage directly linked to a
pre-existing irreversible condition.
A monitoring report incorporating pressure ulcers is
presented to our Healthcare Governance Committee every
six months. A specialist reviewer has been identified in the
quality team to ensure themes and trends from incident
reporting are learnt from and acted upon. In May 2012, we
introduced a balanced scorecard reporting system to ensure
we are aware of all incidents and any patterns that develop.
The new reporting system is presented at monthly health
and social care senior leadership team meetings.
Priority 3: Effectiveness
Progress made in 2011/12
To support the development of our clinical leaders
We recognised that effective clinical leadership in all of our
care settings is fundamental to deliver high quality, safe,
effective care. Front line staff, well trained, equipped and
supported will enhance the experience of our service users
and their families. In January 2012 our first cohort of clinical
leaders undertaking the Royal College of Nursing (RCN)
Clinical Leadership Programme (delivered under licence by
Sue Ryder) completed the course. 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 our services.
We said, we would recruit to the second cohort for the
Clinical Leadership programme.
During the autumn of 2011 we advertised and recruited to
the second cohort, asking mangers to nominate and support
staff. The final recruitment took place in January 2012 and the
group first met in February 2012.
We said, we would work in partnership with local
independent providers who would wish to support staff via
a leadership programme. We have promoted the leadership
programme locally and we are pleased that our second
cohort includes a clinical leader outside of Sue Ryder.
Initiatives
We said, we would present the service improvement
projects, developed as part of the leadership programme
to a wider audience.
Lizzie is establishing nurse and consultant
led outpatient clinics in the rural setting of
the Yorkshire Dales. In her presentation,
Lizzie told us how she identified the need
for this service.
“Nurse specialists from the hospice were travelling
up to 700 miles a month to deliver care in people’s
homes. They were struggling to deliver the same
service in rural areas that was available closer to
the hospice. All the travelling was stressful for them
and costly for the organisation. We were offering
a limited choice of services for patients.
During January 2012 the participants shared their
improvement projects at a celebration event at RCN
Headquarters which some of the trustees and senior
managers attended. The participants shared their
improvement stories across the wider organisation via
our internal newspaper ‘Ryder News’. The newspaper is
available within all our health and social care services,
retail shops and offices for all staff and volunteers.
Some people aren’t keen on home visits, because
they’d like to keep home a ‘normal’ place, for
example if they have children. Being able to visit
an outpatient clinic instead makes patients feel
in control. We’ve set the clinics up in a way that
enables patients to see complementary therapists
during the same visit as their appointments, if they
wish. It’s been a great example of partnership
working – we wanted to make sure we weren’t
doubling up on services. We are aiming to build
links with occupational and physiotherapy services
within the NHS, and develop closer links with GP
services. The clinics we’ve set up in GP practices
are really cost-effective. They charge us a nominal
rate for room hire, with all facilities such as phone
and internet access included.”
“This new service means patients can get support
when they need it; in the way they need it. I’m
really pleased we’ve been able to increase the
choices available to them.”
Sue Ryder – Quality Account 2011/12
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Priority 4: Service user safety and effectiveness
Progress made in 2011/12
To further develop a culture of learning from incidents
and complaints
We said, we would share learning across the
organisation by using a system of Learning for Safety memos.
A monitoring report is presented to our healthcare
governance committee every six months. A specialist reviewer
function has been identified from the quality team for the key
themes of pressure damage, falls, safeguarding adults (adult
protection) and medication, to ensure themes and trends
from incident reporting are identified and acted upon.
During 2011 we have issued Learning for Safety memos in
the following areas:
• safeguarding vulnerable adults and the importance of
adherence with local health and social care agreed
procedures
• medical gases, their storage and safety (audit findings
summary)
• infection prevention and control management of
infections and the importance of documented cleaning
schedules (audit findings and incident report)
• management of medicines (audit findings)
• use of petroleum based creams and oxygen
Initiatives
We said, we would introduce electronic reporting
of complaints.
During 2011/12 we have introduced the complaints module
of our Datix system. All key staff with responsibility for
reporting and responding to complaints have been trained on
the system and ongoing support in its use is available to
centre managers from their assigned quality manager. It is
expected that the system will be used more fully from April
2012 onwards.
We said, we would revise the Serious Incident Policy.
Following staff consultation and engagement we introduced
the revised Serious Incident Policy across all areas in
September 2011. We simplified the policy whilst ensuring it
gave clarity and support for staff in recognising and
responding appropriately to serious incidents. The current
policy builds on best practice in this area as defined by the
National Patient Safety Agency (NPSA). During October and
November 2011 we reviewed our on-call support systems
and provided refresher training for managers in healthcare
responsible for second on-call arrangements.
Out-of-hours calls made to the second on-call managers
are recorded in a shared access file and a review of calls
made from April 2011– March 2012 showed that the most
frequent support requests relate to medicines management,
safeguarding and estates/equipment issues. This resulted in
a revision of the On-Call Policy which was reissued in
January 2012.
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Sue Ryder – Quality Account 2011/12
We cascaded the Learning for Safety memos via our cascade
alert system to ensure they were received and any actions
required locally were reported via local quality improvement
groups in each centre.
We said, we would further develop the Health and
Social Care (HSC) risk register and associated risk plan.
During 2011/12 the HSC risk register was presented as a
live document, discussed monthly at each health and social
care senior leadership meeting, and updated to reflect actions
taken to mitigate risk. The HSC risk register is reported through
the healthcare governance committee and integrated
governance sub-committee of the council of trustees.
We said, we would use the web based complaints
reporting process to produce regular reports to the
healthcare governance committee.
During 2011/2012 we have presented a combined service
user experience report. This included six monthly reports to
the healthcare governance committee through to the
integrated governance committee.
Priority 5: Service user experience, safety and effectiveness
Progress made in 2011/12
To improve the eating experience and meet the
nutrition needs of people the in our care
We said, we would support staff that carry out
nutritional assessments.
Our service users told us via survey and via our ACORNS group
that they would like us to improve the mealtime experience in
all of our centres. This focused on a number of key areas and
included getting the nutritional content right and increasing
service user choice both over menus and access to snacks at
all times over a 24-hour period. A key feature of this priority
area was the co-production of menus with service users and
their families. We also committed to supporting staff by
improving their assessment skills in identifying service users
who may be a risk due to complex nutritional issues such as
malnutrition, swallowing difficulties, or obesity.
We have reviewed the means by which our services receive
support and guidance in using the Malnutrition Universal
Screening Tool and further work is planned to review a tool
developed by one of our hospices that is specifically designed
with the objectives of specialist palliative care in mind.
Initiatives
In addition to the work that was planned, work has taken
place to update the job descriptions of the cooks and
catering assistants, giving more clarity to the essential and
desirable criteria for future recruitment. In addition, the
charity has also commissioned an external company to
audit food safety standards across our services providing
an external assurance of our food safety standards.
We said, we would work with service users and staff
to produce a mealtime standard against which we could
measure and evaluate across all locations in the charity.
Following a themed service user survey asking for
information on what matters most with regard to mealtimes,
the ‘Our Mealtimes’ standard was developed and has been
further adapted based on feedback from service users and
staff across the charity. A launch of the standard is planned
for the summer, with cooks and catering assistants from all
services in attendance. The themed service user survey is
set to be repeated once the ‘Our Mealtimes’ standard is
introduced in practice.
We said, we would ensure service users are able to
influence menu choices and have greater choice about what
they eat and when they eat.
During the year we have developed a menu that has a wider
range of choices, makes available a 24-hour snack menu and
promotes the involvement of service users in influencing
these choices. The menu is currently being introduced across
our services.
We said, we would review the Nutrition and
Hydration Policy.
The policy was initially revised to incorporate new national
guidance in May 2011. A further update has been agreed that
makes a link to the newly developed ‘Our Mealtimes’ standard.
The ACORNS group have told us that monitoring and
embedding this standard is important so we have continued
this priority to 2012/13.
Sue Ryder – Quality Account 2011/12
9
Vanessa, Head of Care, explains how the leadership
programme linked to nutrition and eating experience
priority made a difference:
“We split our project into three sections – the eating
environment, choice and quality of food, and nutrition.
I wanted to improve the eating environment, because our
dining room was dull and dark. Finances restricted us to doing
the best we could with the existing room, so we brightened it
up with flowers and cloths, and made sure we were only using
good quality, matching crockery. Importantly, we obtained
sectioned plates for serving liquidised meals in. Service users
who eat liquidised food are able to enjoy it so much more
now it’s not all mixing together. I wanted to tackle the problem
of staff being interrupted at mealtimes. Sometimes, service
users who needed help eating were left waiting for staff
who’d been interrupted to return before they could eat.
We implemented a strict rule not to answer the phone during
mealtimes any more, and we let service users’ relatives know
we were making that change.”
One of the senior nurses, Dorte, took on the challenge
of improving the quality and choice of food. She says:
“Because we bought food in bulk, there was a lack of fresh
produce. I looked at buying food from more local suppliers
and it worked out well financially. We now buy smaller
amounts of food more often, so it’s much fresher when it’s
served. We’ve also been able to improve the choice on offer,
particularly with vegetarian food. The same meal won’t
appear on our menu more than twice a month now.
The culture in the kitchen has really improved. Before,
they didn’t have enough information about individual
needs, but now they’re much more flexible.”
Another senior nurse at the centre,
Richard explains:
“As part of this project, we’ve made staff aware of the
nutritional standards we should be achieving. Changing
suppliers has helped us to give service users their five-a-day.
We identified some specific needs that weren’t being met.
For example, people with Huntingdon’s disease need more
than 3000 calories a day, and not all care staff were aware
of that need. But now they’ve all had training and they’re
much more knowledgeable.”
Richard sums up the success of the improvements
in the eating experience in one centre –“The feedback
from our monthly service user meetings has been positive.
And taking time to stand back and focus on one priority
area has definitely helped us to improve.”
10
Sue Ryder – Quality Account 2011/12
Part three: Our priorities for improvement 2012/13
Priority 1: Service user experience
To develop tools to measure how person-centred
support is delivered in our services
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
During 2011/12, we engaged the services of Helen
Sanderson and Associates to train staff in each of our centres
in a person-centred approach to care delivery.
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
In doing this, we:
• reviewed and renewed our care records in neurological
care settings
• delivered training in new methods of capturing an
individual’s preferences
• captured patient stories and used these stories to illustrate
what personalisation means to individuals (“Tailor made”,
a Demos report commissioned by Sue Ryder)
• invested in our clinical leaders, equipping them to
champion changes within their own clinical practice area
Programme Manager
Angela Killip, Quality Manager service user experience
During 2012/13 we will use findings from the Think Local,
Act Personal benchmarking audit to change our policies and
procedures to reflect the person-centred approach to all our
care and support activities.
We will measure personalisation in practice using a tripartite
approach:
1. observations of care, reviewing how staff demonstrate
empathy and compassion in care delivery
2. detailed service user survey questions focusing on what it
feels like to be treated as an individual and actions from
care givers which illustrate this
3. use of our volunteers as mystery shoppers in questioning
staff attitudes and values towards compassion, dignity and
person-centred approaches to care
We will engage further with ACORNS and our 2012/13
Clinical Leadership Programme leads in developing evidence
based tools, refining and adjusting these based on feedback
and observations of care delivery.
Using quality-themed visits to explore and report on the
service user experience of care and support, we are planning
to focus on this within visits planned for October 2012.
Sue Ryder – Quality Account 2011/12
11
Priority 2: Service user safety
To manage the risk of harm from medication
Most of our incidents are relating to falls, closely followed by
medication incidents. This reflects national reporting incident
rates in the NHS. Serious harm from medication incidents is
low, however a focus on increasing awareness and robust
review of training for nursing and medical staff following all
medication incidents are paramount. Our top five medication
errors are drugs being administered late or omitted without
sound clinical reasons, medication administration records not
being fully completed, the wrong dose, the wrong drug (such
as wrong preparation), and the wrong quantity.
A medicines management audit is part of the quality themed
visits conducted by the clinical quality team. The programme
of audit ensures that:
• a review of the completeness of medication administration
records, including recording of allergy status on medication
charts is completed
• all medicines are procured, stored, dispensed and
administered in accordance with the Medicines Act and in
line with National Standards, professional guidelines and
Sue Ryder Policy
• administration of medicines compliant with the Nursing
and Midwifery Council Standards for Medicines
Management
• all medicines are administered by a medical practitioner or
a registered nurse against a valid order
• suitable arrangements are in place for controlled drugs
and that hospices have an accountable officer
• medicines incidents are reported and appropriate actions
taken in response
The results of this audit have been shared widely across the
organisation and locally via the Quality Improvement Groups
(QIG) within centres with detailed local action plans and
annual re-audits scheduled. The audit checked that the risks
associated with the management of medicines were
incorporated into service based risk registers so that they
were included as a standing agenda item on all local QIGs.
The programme of audit is constantly reviewed to ensure we
encompass all areas and the reports support development of
evidence to meet our regulatory requirements.
Key to ensuring safe and effective medicines management is
the support given to staff involved in this process. Registered
nurses have reviews of their medicines competencies as part
of their induction and every two years. This is supported by
organisational polices in the management of medicines.
12
Sue Ryder – Quality Account 2011/12
We require all staff to report any incidents or near misses to
the clinical quality team, including any such events involving
medicines. The team will review trends or themes to inform
learning or identify where staff development may be required.
The clinical quality team are suitably trained to carry out root
cause analysis investigations where it is necessary.
All incidents relating to controlled drugs are reviewed and the
accountable office role within hospices is clearly defined.
We have procedures in place to be able to respond to medicine
alerts. These procedures include what action is needed. Alerts
can relate National Patient Safety Agency or similar alerts,
which relate to medicines. Within the medicines policy there
is a flow chart for the management of medication errors.
As part of our priorities for improvement during 2012/13
we will:
• ensure 100% of medicine related incidents will be
overseen by a member of the clinical quality team and that
medicine management incidents are a standing item on
every centres QIG
• ensure that the recording of “other” as a subcategory
within our electronic incident reporting system (Datix) is
made to help reduce the number of medication errors by
75%. This will help us to better analyse incident trends.
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Priority 3: Effectiveness
To further develop partnerships in care delivery
Our 5R service is a good example of a service developed in
response to the needs of service users. A survey of people
Partnership working to date
with Multiple Sclerosis (MS) helped to identify the type of
We would like to continue to develop a culture of partnerships service that was needed to help them manage their condition,
in care delivery, supporting our NHS and social care partners. build confidence and reduce feelings of isolation. Each week
We will continue to work with other third sector organisations different activities are offered based around five basic
and partners when it is appropriate to do so to deliver our
principles: Relax, Re-build, Re-energise, Re-integrate and Restrategic plan ‘Supporting Me’.
generate (representing 5R’s). The service is led in partnership
with the local MS Society in Suffolk. Our successful national
Working with Housing Associations, we are able to deliver
lottery funding bid in 2009 made it possible for the 5R service
alternative care services. In St Helens we work with Arena
to continue for five years. We have plans for ongoing
Housing for the care provision within Heyeswood Retirement sustainability, and the potential to expand this initiative.
Living – an older person extra care housing complex, with
residents who have age-related needs and an early diagnosis In 2011/12, we’ve introduced an end of life Motor Neurone
of dementia. The facility provides greater independence for
Disease (MND) coordinator within one of our hospices, which
service users, living within their own accommodation whilst
supports service users and their families. The coordinator
care and support is available to meet their needs.
works alongside the patient’s GP and other professionals.
The service provides patient care through coproduction
We have developed services in partnership, where there is the working with the local MND service for out-of-hours support,
demand and no current provision. For example, our Synergy
enabling service users to receive care in their place of choice.
Café (‘not for profit’) enterprise which operates in partnership
with the Alzheimer’s Society, and invites involvement from
other local organisations to provide a supportive environment
for people with dementia and their carers.
In Doncaster, we provide volunteer befriending for older
people and a specific service for those with dementia. The
service was audited by the commissioner (Doncaster Council)
in January 2012. The audit was to ensure our records and
audit trail were maintained and the project was on track with
key activities. The audit looked at training, marketing,
recruitment (including CRB checks) and expenditure. We
successfully passed the audit. A short film was made by one
of our volunteers as a way of promoting how her role is
making a difference to the individuals she supports as part of
her role working with the scheme. Available from our website,
the film helps to demonstrate how truly valuable the service is
to both dementia sufferers and their carers.
We work in partnership with Sue Ryder Care Centre for the
Study of Supportive, Palliative and End of Life Care at the
University of Nottingham with a chair of palliative care (Jane
Seymour), working to increase awareness and understanding
of the relationship between end of life care and neurological
conditions.
Sue Ryder – Quality Account 2011/12
13
Priority 3: Effectiveness (continued)
Care home education and palliative care education
On 1st April 2011 we appointed an end of life care education
facilitator in Berkshire West, whose specific remit is to provide
educational, practical, and clinical support to care homes,
social care staff and community nursing teams.
The aim of this post is to develop an anticipatory approach to
End of Life Care (EoLC) and promote the use of best practice
EoLC tools, for example, Gold Standards Framework, Liverpool
Care Pathway, Preferred Priorities for Care in the community.
This has involved collaborating with others, including the
Thames Valley Cancer Network, local NHS Community and
Acute Trusts, Social Services, the voluntary sector and service
user groups, in order to develop an integrated approach to
specialist palliative and EoL care. The delivery of educational
programmes that will help to meet the learning needs of staff
delivering EoLC in care homes has been key in developing the
high quality nursing skills required to meet the care needs of
people at the end of life. The first wave of 10 nursing homes is
just completing one of the programmes, and a further cohort
is planned for later this year.
In October 2011 we ran the first Sue Ryder Introduction
to Palliative Care module, at Nettlebed Hospice. We just
supported a second cohort from Thorpe Hall. This is an
academic course at degree level which is open to all
registered nurses, and has been validated by the University
of West London. It is delivered by tutors and clinical specialists
employed by Sue Ryder, with the assignments and academic
standards monitored by the University. The module
comprises 6 study days which are also open to other
healthcare professionals. In total, 31 students have taken
the course – 16 employed by Sue Ryder and 15 from external
organisations such as community hospitals, other hospices,
acute and community NHS Trusts. We have also had more
than 25 other attendees at the study days, ranging from
nurses to physiotherapists and dieticians working in the
community, nursing homes and acute hospitals. The module
is planned to run twice each year in a Sue Ryder hospice, thus
demonstrating our commitment to be an expert resource in
EoL and palliative care.
Partnership working in 2012/13
In 2012/13 we will continue to look for more opportunities to
work in partnership. We are in the early stages of developing
dementia services in Suffolk working alongside Age UK. This
includes a dementia advisor service (Age UK are the lead
organisation working with us and Suffolk Family carers),
dementia helpline (which we are leading, working with Age
UK), and a dementia enabled village project which is a joint
initiative between us and Age UK.
In December 2011, we launched our new service
coordinating 24-hour palliative care and support throughout
Bedfordshire, ensuring round the clock access to symptom
control, nursing care and specialist advice. In 2012/13 we
will continue to deliver this service and evaluate in December
2012. This service is commissioned by NHS Bedfordshire.
We provide patients, families, carers and health and social
care professionals with a single point of contact for support,
advice and assessment. Using a shared patient record
between independent providers, district nurses and GPs
we have developed an end of life register that allows us to
work together to collate patient activity, and inform local
commissioning. The service reduces barriers to access for
patients, delivering responsive integrated and coordinated
care around the needs and wishes of the patients.
We will continue to explore partnership working and
approaches to our care delivery when we develop
new services.
We will review our service evaluation in 2012/13, and look
at satisfaction levels amongst service users and their families,
satisfaction levels amongst staff, achievement of key
outcome measures, and stakeholder engagement.
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*
Jo Marshall, Business Development Manager
*
Programme Manager for the projects mentioned on this page.
The Programme Manager will be dependent on the geographical area
where programmes are developed.
14
Sue Ryder – Quality Account 2011/12
Priority 4: Service user experience
To measure the meal time experience
We plan to extend the Service User Nutrition and Eating
Experience projects to embed the ‘Our Mealtimes’ standard
and then analyse the success of the project using the themed
survey. We would like to incorporate a review of compliance
with the revised Nutrition and Hydration Policy into our
themed quality visit process and continue to consult with our
national service user advisory group on nutrition and
mealtime priorities.
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 and Risk Manager
Following on from the food safety audit the health and safety
team and clinical quality team are planning a review of the
food safety procedures that are currently in place.
Our mealtimes
A series of standards designe
d by people
who use our services with
the aim of the
best possible mealtime exp
erience for all
General mealtime principl
es
(continued)
We would like:
• our menu presented in the
way a good restaurant would
• drinking glasses that are
clear and sparkling clean or
good
quality plastic drinks conta
iners
• our food to be served piping
hot where it is meant to be
a
hot dish
• the option of eating healt
hy foods (for example, low
in salt
and/or sugar)
• the option of having guest
s at mealtimes
• portions in keeping with
our individual needs and choic
es
• the option of ordering a
takeaway
• a description available of
any dishes where we are not
sure
of the content
• the time to enjoy our meal
s at our own pace
• our meals to be served in
a courteous way
• warnings (for example wher
e food may contain traces
of nuts)
• to feel able to say if we are
not happy and feel that we
are
taken seriously when we do
Sue Ryder – Quality Account 2011/12
When we eat at a table
We would like the table
s in the dining area
to have:
• matching table cloths unsta
ined and of good quality
or matching table mats and
coasters
• napkins available that comp
lement the table
cloths/table mats
• disposable place settings
available (for those of us
who may need them)
• table decorations that are
appropriate for the time
of year
• table design to facilitate
wheelchair use (where
needed)
• a surface that is in good
condition where table cloth
s
are not in use
• tables that are wiped down
in a timely way
• food that is removed from
the floor and surrounding
area in a timely way
15
Priority 5: Service user experience
To ensure service users and staff safety by reducing
the risk of sharps injury
Executive Leadership Team (ELT) sponsor
Steve Jenkin, Director of Health and Social Care
Our our electronic incident reporting system we have
identified that the response to needle stick injuries can
be variable.
Implementation Lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
We will adhere to the European Union (EU) directive to
standardise sharps assessment and increase awareness for
all front line staff on better sharps management by May 2013.
We wish to ensure our staff are suitably skilled and equipped
with the right tools to minimise the risk of needle stick injury
and that any incident is managed according to local policy
and standard sharps emergency treatment plan.
We aim to assess the risk of sharps injury in every centre and
identify safer sharps equipment and clinical practice to
minimise injury. We also aim to offer consistent teaching
programmes, identify those at risk and ensure they are
offered appropriate immunisation.
16
Sue Ryder – Quality Account 2011/12
Programme Manager
Lesley Bates, Quality and Effectiveness Manager
Part four: Indicators
1. Service user experience – all services
Service user experience is measured within the annual service user surveys in the following ways
• percentage of service users who rated overall care as ‘Good’ or ‘Excellent’
• percentage of patients who responded ‘Yes, completely’ or ‘Yes, mostly’ that overall they were treated with
respect and dignity
• percentage of service users who answered ‘Yes’ that they would recommend the service to family and friends
Neurological care
Palliative care
l 2010/11
l 2011/12
l 2010/11
l 2011/12
rated overall care
rated overall care
treated with respect and dignity
treated with respect and dignity
recommend the service
recommend the service
0
20
40
60
80
100
%
0
20
40
60
80
100
%
Community support and homecare services
l 2010/11
l 2011/12
rated overall care
treated with respect and dignity
recommend the service
0
20
40
60
80
100
%
The survey results for ‘community support and homecare services 2010/11’ shown above reflect all homecare services
within Sue Ryder. The results for 2011/12 reflect the remaining homecare services in Arbroath and Stirling and the
Heyeswood extra care service.
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.
Sue Ryder – Quality Account 2011/12
17
1.1 Neurological care 2011/12
Survey
Centre
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
84%
68%
89%
92%
63%
100%
78%
90%
83%
93%
92%
70%
95%
85%
94%
83%
96%
100%
71%
94%
87%
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%
100%
100%
100%
98%
97%
100%
95%
100%
100%
99%
97%
97%
98%
100%
100%
100%
100%
100%
98%
97%
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
94%
83%
80%
97%
100%
100%
97%
100%
96%
Birchley Hall
Chantry
Cuerden Hall
Dee View Court
Hickleton Hall*
Holme Hall
Stagenhoe
1.2 Palliative care 2011/12
Survey
Hospice
Duchess of Kent House (DOKH)
Leckhampton Court
Manorlands
Nettlebed
St Johns
Thorpe Hall
Wheatfields
1.3 Community support and homecare services 2011/12
Survey
Service
Angus
Heyeswood
Stirling
* Hickleton Hall is closing as part of a planned re-provision of services within the local area.
The service users may have felt unable to comment in light of the news of the planned closure at the time of the survey.
18
Sue Ryder – Quality Account 2011/12
1.4 Formal complaints
A formal complaint at Sue Ryder is defined as ‘an expression of discontent’ to which a response is required. The complaint is
considered formal when it is received orally, in writing or electronically and cannot be resolved within 24 hours of receipt.
45% of Sue Ryder services had no complaints between April 2011 and March 2012. The target in the Complaints Policy for the
initial holding response to complaints is 3 working days.
The target for the final written response to a complaint is 20 working days however the policy does acknowledge that in some
instances this is not possible, perhaps where the investigation is complex, and in these cases all services aim to maintain
contact with the complainant where written response within 20 working days is not possible.
The table below shows figures for all services:
Neurological care
Complaints
Centre
Number of formal
complaints April
2011 – March 2012
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
Birchley Hall
Chantry
Cuerden Hall
Dee View Court
Hickleton Hall
Holme Hall
Stagenhoe
No complaints
2
2
No complaints
1
No complaints
3
–
100%
100%
–
100%
–
2 out of 3 = 66%
–
–
100%
–
–
–
2 out of 3 = 66%
Number of formal
complaints April
2011 – March 2012
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
Leckhampton Court
5
Thorpe Hall
1
Wheatfields
No complaints
St Johns
2
Duchess of Kent House and Berkshire West services
8
Nettlebed
3
Manorlands
1
100%
100%
–
100%
7 out of 8 = 87.5%
100%
–
4 out of 5 = 80%
100%
–
100%
5 out of 8 = 62.5%
2 out of 3 = 66%
100%
Palliative care
Complaints
Hospice
Sue Ryder – Quality Account 2011/12
19
Community support and homecare services
Complaints
Service
Number of formal
complaints April
2011 – March 2012
Supported living unit, Suffolk
Angus
Heyeswood
Stirling
Doncaster Befriending Service
Doncaster Community Service (CHC)
No complaints
No complaints
No complaints
8
No complaints
No 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
100%
100%
2. Safety
2.1 Incidents
There have been no incidents that have resulted in the death, permanent or serious harm to a service user in our care during
2011/12. As an organisation we have increased our reporting of all incidents by 32%. The reporting of incidents will continue
to be a priority for us in 2012/13. We commend our staff for ensuring that all accidents, incidents and near misses are
appropriately reported so that we can learn from such incidents and strive to improve our care in order to minimise patient
safety issues. The National Patient Safety Association recognises that high reporting is a mark of a ‘high reliability’ organisation.
Research shows that providers with significantly higher levels of incident reporting are more likely to demonstrate other
features of a stronger safety culture.
2.2 Number of incidents affecting service users
Indicator
Number of incidents resulting in permanent
or long term harm to service users per year
Number of service user slips trips and falls
resulting in hospital visit per year
Number of reports under RIDDOR*
Neurological
Palliative
Homecare
–
–
–
13
1
10
1
–
–
Within our homecare services, slips, trips and falls have been reported by the service but have not occurred during active
care delivery.
Our health and safety team review all incidents reported by services. They have supported frontline staff to ensure guidance
regarding RIDDOR reporting is understood.
* RIDDOR – Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
20
Sue Ryder – Quality Account 2011/12
2.3 Number of medication incidents
Neurological care
Centre
Birchley Hall
Chantry
Cuerden Hall
Dee View Court
Hickleton Hall
Holme Hall
Stagenhoe
Total
Minimal harm, person required extra
observation or minor treatment
Moderate (short term harm – person
required further treatment)
1
3
3
1
3
–
–
21
–
–
–
–
–
–
–
–
There have been no medication incidents causing moderate or severe harm to service users in neurological care. We encourage
reporting of all incidents involving medicines, for example, any issues with late administration or of obtaining prescriptions to
identify trends and learning across care settings. The above represents 16% of all medicine incident reports in neurological care.
Palliative care
Hospice
Duchess of Kent House
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Wheatfields
Total
Minimal harm, person required extra
observation or minor treatment
Moderate (short term harm – person
required further treatment)
4
1
1
4
–
7
4
21
–
–
2
–
–
–
–
2
There have been no medication incidents causing moderate or severe harm to service users in palliative care. We encourage
reporting of all incidents involving medicines. These include, for example, any issues with late administration or of obtaining
prescriptions to identify trends and learning across care settings. The above represents 8.4% of all medicine incident reports
in palliative care.
Community support and homecare (England)
Location
Heyeswood
Doncaster Community Service (CHC)
Total
Minimal harm, person required extra
observation or minor treatment
Moderate (short term harm – person
required further treatment)
1
3
4
–
–
0
There have been no medication incidents causing moderate or severe harm to service users in homecare. We encourage
reporting of all incidents involving medicines, for example any issues with late administration or of obtaining prescriptions to
identify trends and learning across care settings. The above represents 50% of all medicine incident reports.
Sue Ryder – Quality Account 2011/12
21
2.4 Regulatory inspection results
Palliative care
Hospice
Date of last
check from CQC
Duchess of Kent House
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Wheatfields
Standards of
treating people
with respect and
involving them
in their care
*
23 December 2011
18 November 2011
29 March 2012
10 March 2011
*
18 November 2011
Standards of
providing care,
treatment and
support which
meets people’s
needs
Standards of
caring for
people safely
and protecting
them from
harm
Stadards of
staffing
Standards of
management
–
–
–
–
–
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
✓
–
–
–
–
–
✓
✓
✓
✓
✓
* CQC have yet to inspect this service. All standards found to be met following CQC assessment of declarations and evidence
supplied to the commission during registration.
Neurological care
Centre
Birchley Hall
Chantry
Cuerden Hall
Dee View Court
Hickleton Hall
Holme Hall
Stagenhoe
Date of last
check from CQC
Standards of
treating people
with respect and
involving them
in their care
Standards of
providing care,
treatment and
support which
meets people’s
needs
Standards of
caring for
people safely
and protecting
them from
harm
Stadards of
staffing
Standards of
management
06 June 2011
*
*
**
28 June 2011
*
*
✓
✓
✓
✓
✓
–
–
–
✓
–
–
–
–
–
✓
–
–
–
–
–
✓
–
–
–
–
–
✓
–
–
–
–
–
✓
–
–
* CQC have yet to inspect this service. All standards found to be met following CQC assessment of declarations and evidence
supplied to the commission during registration.
** Dee View Court is inspected by the Care Inspectorate in Scotland
Centre
Dee View Court
Date of last
quality visit
Quality of Care
and Support
Quality of
Environment
Quality of
Staffing
Quality of
Management and
Leadership
29 Nov 2010
6 – Excellent (I)
Not Assessed
Not Assessed
Not Assessed
(I) Grading resulting from an inspection
22
Sue Ryder – Quality Account 2011/12
Community support and homecare services in England
Continuing Health Care services (Doncaster) and Scotland (Angus and Stirling)
Service
Supported living unit, Suffolk
Heyeswood
Doncaster Community Service (CHC)
Date of last
check from CQC
Standards of
treating people
with respect and
involving them
in their care
Standards of
providing care,
treatment and
support which
meets people’s
needs
Standards of
caring for
people safely
and protecting
them from
harm
Stadards of
staffing
Standards of
management
*
*
*
–
–
–
–
–
–
–
–
–
–
–
–
–
–
–
* CQC have yet to inspect this service. All standards found to be met following CQC assessment of declarations and evidence
supplied to the commission during registration
Service
Angus
Stirling
Date of last
quality visit
Quality of Care
and Support
Quality of
Environment
Quality of
Staffing
Quality of
Management and
Leadership
21 January 2011
17 August 2011
4 – Good (I)
4 – Good (I)
*
*
Not Assessed
5 – Very Good (I)
4 – Good (I)
Not Assessed
(II) Grading resulting from an inspection
* not applicable
For more information about our inspection results for our palliative, neurological and home care services in England, please
visit the Care Quality Commission website.
For more information about our inspection results for our services in Scotland, please visit the care inspectorate website.
3. Effectiveness
HCAI and pressure ulcers
The number of infections and pressure ulcers across all neurological and palliative centres reflects the period between April
2011 and March 2012.
Cases are identified as those which were acquired by the service user whilst under the care of Sue Ryder and those acquired
prior to the service user being admitted to a Sue Ryder service.
Sue Ryder – Quality Account 2011/12
23
Number of HCAI (2011/12)
Health Care Acquired Infections (HCAI) (2011/12)
l Acquired within own service
l Acquired external to service
Clostridium Difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (infection)
ESBL (colonised)
Hepatitis (A, B or C)
Tuberculosis
Influenza
0
4
8
12
16
18
20
new cases
Neurological care
Health Care Acquired
Infections (HCAI)
Total
Aquired within
own service
Acquired external
to service
Acquired within
own service
Acquired external
to service
Aquired within
own service
Acquired external
to service
1
–
–
–
–
–
–
–
–
1
–
–
1
2
–
–
–
–
–
3
4
–
1
–
2
1
–
–
–
8
10
–
9
11
2
–
2
2
–
36
5
–
1
–
2
1
–
–
–
9
10
–
10
13
2
–
2
2
–
39
Clostridium Difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (infection)
ESBL (colonised)
Hepatitis (A,B or C)
Tuberculosis
Influenza
Total
24
Palliative care
Sue Ryder – Quality Account 2011/12
Number of HCAI by service (2011/12)
Neurological care
Centre
Constridium
Difficile
MRSA
infection
MRSA
colonised
–
–
–
–
–
–
1
1
–
–
–
1
–
–
–
1
–
–
–
–
–
1
1
2
Birchley Hall
Chantry
Cuerden Hall
Dee View Court
Hickleton Hall
Holme Hall
Stagenhoe
Total
Palliative care
Hospice
Constridium
Difficile
MRSA
infection
MRSA
colonised
ESBL
infection
ESBL
colonised
Hepatitis
(A,B or C)
Tuberculosis
4
2
3
1
–
2
2
14
1
–
3
–
1
5
–
10
9
–
1
–
1
–
–
11
–
–
4
–
–
–
–
4
–
–
–
–
–
1
–
1
2
–
–
–
–
–
–
2
1
–
1
–
–
–
–
2
DoKH
Leckhampton
Manorlands
Nettlebed
St Johns
Thorpe Hall
Wheatfields
Total
3.1 Pressure ulcers 2011/12
The number of pressure damage reports has increased over 2011/12. It is important to note that 2011/12 saw a focus on
education and recognition of pressure damage across all services. The increase of reporting reflects the overall increase in
reporting; all incidents of pressure damage are investigated. All service users have an assessment of their skin integrity.
Pressure relieving equipment is available readily within all care settings.
In 2011/12 we had three incidents of grade 3 damage; two of these occurred in our hospice care (Wheatfields Hospice and
Duchess of Kent House). We use a root cause analysis approach (one of the recommended National Patient Safety Agency tools)
to review such incidents. In all instances the care was assessed to be of a high quality, with damage directly linked to a pre- existing
irreversible condition. These instances are reported to identify trends and themes and will be one of our priorities for next year.
Pressure ulcers (2011/12)
l Acquired within own service
l Acquired external to service
Neurological care
Palliative care
0
50
100
150
200
Sue Ryder – Quality Account 2011/12
250
300
new cases
25
Number of pressure ulcers by service 2011/12
Palliative care
Neurological care
Centre
Aquired within
own service
Acquired external
to service
5
4
–
3
4
3
1
20
–
2
1
4
–
1
4
12
Birchley Hall
Chantry
Cuerden Hall
Dee View Court
Hickleton Hall
Holme Hall
Stagenhoe
Total
Hospice
Aquired within
own service
Acquired external
to service
2
15
14
11
13
2
12
69
11
23
29
9
51
23
14
160
DoKH
Leckhampton
Manorlands
Nettlebed
St Johns
Thorpe Hall
Wheatfields
Total
Number of pressure ulcers (compared to last year)
Pressure ulcers (acquired within Sue Ryder)
l 2010/11
l 2011/12
Pressure ulcers (acquired external to service)
l 2010/11
l 2011/12
Neurological care
Neurological care
Palliative care
Palliative care
0
20
40
60
80
100
new cases
0
50
100
150
200
250
Neurological care
Palliative care
Pressure ulcers (acquired within Sue Ryder)
l 2010/11
l 2011/12
Pressure ulcers (acquired within Sue Ryder)
l 2010/11
l 2011/12
Birchley Hall
DoKH
Chantry
Leckhampton
Cuerden Hall
Manorlands
Dee View Court
Nettlebed
Hickleton Hall
St John’s
Holme Hall
Thorpe Hall
Stagenhoe
Wheatfields
0
2
4
6
8
10
new cases
0
5
10
15
20
25
new cases
new cases
No figures available for DoKH from 2010/11
No pressure ulcers were acquired in Cuerden in 2011/12
26
Sue Ryder – Quality Account 2011/12
Part Five: Annexes
Annex 1
There is a legal requirement to report on this section:
•
•
•
•
•
•
•
during the period of this report, 1 April 2011 to 31 March
2012 Sue Ryder provided NHS-funded Community
Health Services through its 7 Adult Hospices, 8 Day
Hospices, 1 Hospice at Home service, 3 Community
Nursing Services, 6 Care Homes with Nursing*. In
addition to these services we also delivered care within 1
Care Home without nursing, 1 Supported Living Service
and 1 Extracare Service.
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 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
the income generated by the NHS services reviewed in
the period 1 April 2011 to 31 March 2012 represents 100
per cent of the total income generated from the
provision of NHS services by Sue Ryder for the period 1
April 2011 to 31 March 2012
during the period from 1 April 2011 to 31 March 2012
there were no national clinical audits or national
confidential enquiries 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, manual
handling, pressure ulcer assessment and
management, care at end of life (neurological centres),
infection prevention and control including
environmental and hand hygiene audit
– 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.
Learning from audits is summarised and shared across
health and social care via Learning for Safety Memos
from 1 April 2011 to 31 March 2012 Sue Ryder was not
eligible to participate in national clinical audits
the number of patients receiving NHS services provided
by Sue Ryder from 1 April 2011-March 2012 that were
recruited during that period to participate in research
approved by a research ethics committee was 20
patients
•
•
•
•
•
•
•
Sue Ryder income in this reporting period for three
Hospices was conditional on achieving quality
improvement and innovation goals through the
Commissioning for Quality and Innovation payment
agreed via local commission groups from PCTs
Sue Ryder is required to register with the Care Quality
Commission and its current status is registered. Sue
Ryder’s registration is subject to conditions. These
conditions include the registered provider, number of
beds for the following areas:31 March 2012
– Accommodation for persons who require nursing or
personal care
– Diagnostic and screening procedures
– Nursing care
– Personal care
– Transport services, triage and medical advice provided
remotely
– Treatment of disease, disorder or injury
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 2011 to 31 March 2012 to the Secondary Uses
service for inclusion in the Hospital Episode Statistics
which are included in the latest published data
Sue Ryder will be eligible to be scored for the period April
2011 to 31 March 2012 for Information Quality and
Records Management, assessed using the Information
Governance (IG) Toolkit. The eligibility to be scored this
year is due to a change in our organisation type and
amendments to the IG Toolkit. Previously the only option
that was available to Sue Ryder, when first taking NHS
services, was as a “Commercial Third Party”. This did not
focus on Information Quality and Records Management.
Last year a new organisation type within the IG toolkit,
“NHS Business Partner”, was introduced and, since it is
applicable to us, we self assessed and submitted our
evidence for level 1 (Amber).
Sue Ryder was not subject to the Payment by Results
clinical coding audit during the period 1 April 2011 to 31
March 2012 by the Audit Commission
Sue Ryder will be taking appropriate actions to improve
data quality, we will do this through
– Increased awareness in the importance of reporting
– Training including how to use our documentation
templates
– Identifying trends through our balanced scorecard
reporting system
– Learning for safety memos for when systems and
processes change
* Some of the people we support may be local authority-funded, dependent
on their needs.
Sue Ryder – Quality Account 2011/12
27
Annex 2
Statements from Lead Commissioning Primary Care
Trusts (PCTs), the Overview and Scrutiny Committee
(OSC) and Local Involvement Networks (LiNk’s)
Feedback from NHS Airedale, Bradford and Leeds
“NHS Airedale, Bradford and Leeds commissions services from
Wheatfields and Manorlands Hospices, and welcomes the
opportunity to comment on this quality account from Sue
Ryder.
We believe the Account to be a fair representation of the
quality of services provided by the hospices. As none of the
information included is reported to the PCT as part of the
contractual arrangements, we are unable to verify accuracy,
although we have no reason to believe otherwise.
With regard to the priorities set out in the 2011–12 Account,
we are pleased to note the progress made. We note the
progress made in providing person-centred support,
including the roll out of a training programme delivered to
412 staff. We are pleased to note the work that has taken
place in ascertaining users’ opinions of the care they received
and what is important to them.
We are also pleased to note the work that has taken place
with regard to the monitoring and reporting of pressure
ulcers and it would be helpful to have the results included in
future reports. We are pleased to note the root cause analysis
of ulcers at Grade 3 and above using National Patient Safety
Agency tools. We’re also pleased to note the proposed
development of an electronic complaints reporting system.
We commend the progress made on improved systems to
support patient safety, including a system for the
dissemination of learning.
The progress made in improving users’ mealtime experience
is commendable. We are particularly pleased to note the work
that has taken place with regard to developing greater choice
for users and in nutritional assessment. We believe that
nutritional screening should be performed as a matter of
routine on all patients; the Account does not make this clear if
this is in place or proposed.
We are supportive of the proposed priorities for 2012-13;
however we believe that the Account could be more specific
in terms of goals and outcomes. It is not always clear what the
proposed improvement will be or how it will be measured.
28
Sue Ryder – Quality Account 2011/12
We support the proposal to continue work in providing more
personalised care. We are very pleased to note the intention
to ensure that 100% of medicine related incidents will be
overseen by a member of the clinical quality team and that
medicines related incidents will be a standing item on every
centre’s Quality Improvement Group. This focus on reducing
medicines related incidents is in keeping with similar work in
the local acute hospital. For the sake of transparency, it would
be helpful for the report to show numbers of all medication
errors, not just those where harm is caused.
Similarly we are pleased to note the proposal to continue
focus on safety, and the intention to minimise the risk of
needlestick injury through education, risk assessment and
identification and of safe practice, and immunisation of staff
where appropriate.
We are also supportive of the intention to explore further
partnership working during the forthcoming year, and the
intention to develop the work that has taken place in
improving the quality of the mealtime experience.
This forthcoming year will see the introduction of significant
changes in the way that services are commissioned and
provided. With regards to palliative care, commissioners in
Leeds would wish to see a move towards more standardised
service models, and greater collaborative working with other
palliative care providers, particularly in relation to equity of
service and access.
We would like to thank Sue Ryder for asking us to comment
on this Quality Account, and look forward to the
improvements in service quality and patient care as a result of
the priorities outlined within it.”
Feedback from NHS Bedfordshire
“Thank you for the opportunity to comment on Sue Ryder’s
2011/12 Quality Account. As a local commissioner, NHS
Bedfordshire work closely with the services delivered from St
John’s Hospice in Bedfordshire.
We are unable to verify the accuracy of data provided for St
Johns Hospice but do feel it 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 to see the new service we launched in 2011 in
partnership with Sue Ryder (Bedfordshire Partnership for
Excellence in Palliative Support) have made a mention within
the Quality Account.”
NHS Gloucestershire
NHS Gloucestershire received Sue Ryder’s Quality Account
for 2011/12 but were unable to provide comments or
feedback this year.
Camden LINk
Camden LINk received Sue Ryder’s Quality Account for
2011/12 but were unable to provide comments or feedback
this year.
Leeds LINk
The Leeds LINk would like to thank Sue Ryder for submitting
its Quality Account for comment to the Leeds LINk Steering
Group. Although due to time constraints Leeds LINk will not
be commenting directly on Sue Ryder Quality Accounts it
would like to make arrangements to work more closely with
Sue Ryder over the next year.
Gloucester LINk
Gloucester LINk received Sue Ryder’s Quality Account for
2011/12 but were unable to provide comments or feedback
this year.
East Riding of Yorkshire Overview and Scrutiny Committee
The East Riding of Yorkshire Overview and Scrutiny
Committee were sent the draft Quality Account for 2011/12
but were unable to provide comments or feedback this year.
ACORNS
The Quality Account priorities for 2011/12 were agreed by
ACORNS at their meeting in March 2012. The draft Quality
Account was then circulated for comment. A summary
version of the Quality Account will be developed for service
users, their families and for display within our centres, as this
has proved popular. It flags up that a more detailed document
is available if required.
Sue Ryder – Quality Account 2011/12
29
Sue Ryder
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16 Upper Woburn Place
London
WC1H 0AF
For more information
call: 0845 050 1953
email: healthandsocialcare@sueryder.org
visit: www.sueryder.org
This document is available in
alternative formats on request.
Sue Ryder is a charity registered in England and Wales (1052076) and in Scotland (SC039578).
Ref. No. 001133/0412/B/NP/H © Sue Ryder. June 2012. This document will be reviewed in June 2013.