Quality Account
2011/12
Contents
Page
PART ONE
Statement on Quality from the Chief Executive
2-3
PART TWO
Priorities for improvement 2012/13
4-7
Statements relating to quality of NHS services provided
8
Review of services
9-10
Participation in clinical audits
11-14
PART THREE
Review of quality performance in 2011/12
15-21
Statements from PCTs and York LINk
22
Glossary
23
1
PART ONE
Statement on Quality from the Chief Executive
I am pleased to introduce The Retreat’s Quality Account for
2011/12.
This Quality Account is our annual report to the public and
to people who use our services about the quality of care we
deliver. It includes examples of improvements we have
already made to the quality of the services we provide and
our plans to improve the quality of our services. It also
describes some of the systems we have in place to
measure quality.
This year’s Account has been prepared by a Project Group
representing a cross section of our community, including
our Involvement Team.
The Retreat is a not-for-profit provider of specialist mental health services. We work
closely with the NHS to provide services for people with complex and challenging
needs. The Retreat was established over 200 years ago by Quakers and was the first
place where people with mental health problems were treated humanely and with
dignity and respect. Long before today’s focus on recovery-orientated, inclusive
services, The Retreat was providing care based on the belief that, given the right
environment and if treated as equals, people using our services could be empowered
to take responsibility for their own recovery.
We are very proud of our long-standing reputation for excellence and for providing care
of the highest quality. We are committed to working with those who use our services to
improve the quality of the services we deliver and to being able to evidence that quality
improvement.
Looking back over 2011/12, I am pleased to report that we made solid progress with
the priorities we identified in last year’s Quality Account. You can read more about
these items on pages 15-17. Both the work in relation to “Respect My Wishes” and that
of the “S” Group illustrate how we try to involve those who use our services in all that
we do.
I am pleased to report that we successfully opened The Cottage, our new facility for
Older Adults in the grounds of The Retreat, and also that we completed the move from
Haxby to a single storey facility in Strensall. Both these represented significant
improvements in the quality of the environment for people who use our services.
2
Our Clinical Governance systems continue to develop and in 2011/12 were assisted
greatly by the creation of the Quality, Compliance and Business Unit, which led the
work on the production of our Quarterly Governance Report, the content and
presentation of which have been recently much improved. Information Management is
an increasingly critical part of the organisation and a reflection of this is our decision to
move to an electronic incident reporting system, one of our targets for 2012/13.
All services have been routinely collecting outcome data and producing an annual
clinical review for some years. The challenge is to identify the one or two important
outcome measures for each service and to focus on these, making sure that they
reflect the needs and objectives of both those who use and those who commission our
services. All services produce an annual Quality Improvement Plan.
We recognise that highly trained, committed and valued staff teams are pre-requisites
of any quality service. Whilst the results of this year’s Staff Survey were better than the
previous year, there were still concerns raised about communication, consultation and
levels of pay. We have been able to go some way towards addressing the latter, and
have recently worked closely with the Staff Consultative Committee on a staff
consultation on The Retreat’s sick pay benefits. We also carried out a staff
consultation exercise on the appraisal system introduced in 2011 and made changes to
the system in response to feedback from staff. We continue to carry out our quarterly
face-to-face team briefings.
We were inspected by the Care Quality Commission in November 2011 and were
disappointed to hear that, whilst the inspectors witnessed a high level of patient
involvement in care and care planning, this was not reflected in our clinical records. We
are working hard to address this and that it why it is also one of our priorities for
2012/13.
This past year has been every bit as challenging as we predicted and the coming years
will be even more so. I remain confident that The Retreat will rise to the challenges
ahead and continue to provide high quality services that represent value for money.
On behalf of The Retreat, I affirm my commitment to providing high quality services and
confirm that, to the best of my knowledge, the information contained in this report is
accurate.
Jenny McAleese
Chief Executive
3
PART TWO
Priorities for improvement 2012/13
PATIENT SAFETY
Priority 1 - Improve our current process for annual environmental assessments on
units to reflect the NHS Patient Environment Action Team (PEAT) tool.
Rationale
Monitoring
Our current approach to environmental
assessments focuses on ligature risks
and the condition of patient rooms and
common areas on our units. By
adopting the PEAT approach other
aspects such as cleanliness and
nutrition, which are measured and
reported independently, can now be
included in one assessment and report.
The monitoring of the actions resulting
from the assessment will be monitored
by the Facilities Manager and the
Director of Finance and Facilities.
Plan
Project Lead: Risk Manager

Develop the tool for reporting and
scoring all aspects of new
approach.

Carry out the assessments in
2012/13 and produce a new style
report.

Review the results of the
assessments to ensure that the
approach will provide information
for the Quarterly Governance
Report.

Update the report as actions are
completed throughout the 12 month
period.
Reporting
Reporting with be through the
Governance Committee via the Infection
Control Committee and via the quarterly
Governance Report to the Board.
Senior Management Lead: Associate
Director of Quality, Compliance and
Business
4
PATIENT SAFETY
Priority 2 - To improve our current process for incident reporting across the hospital.
Rationale
Monitoring
Our current approach to incident
reporting is carried out using a paperbased system. Over the last year there
has been an increase in reporting which
has led to approximately 200 incident
report forms being produced every
month. This system has become
unwieldy which has led to delays in the
analysis of the data due to the time it
takes to process the incident report
forms and input them onto a local
database. This is having an impact on
actions being taken to deal with the
issues raised and hinders the way in
which managers receive information on
any progress. An electronic system will
allow for real time analysis and the
improved management of incidents.
The progress on the implementation
plan for the installation of the software
and the local configuration will be
monitored by the Risk Management
Group.
Reporting
Progress reports with be provided to the
Governance Committee via the Risk
Management Group reports.
Project Lead: Risk Manager
Senior Management Lead: Director of
Clinical Services
Plan

Research and purchase electronic
reporting software.

Configure software to meet The
Retreat’s incident reporting system.

Pilot the new software on one unit.

After review of the pilot roll out the
software across the organisation.
5
CLINICAL EFFECTIVENESS
Priority 3 - To ensure that the people who use our services have access to good
physical healthcare.
Rationale
Monitoring
Our goal is to ensure people using our
services are encouraged to maximise
their physical wellbeing, through regular
health checks, screening programmes,
vaccinations and healthy lifestyle
options including smoking cessation.
The organisation will monitor progress
through means of audit and patient
feedback.
Reporting
Progress will be reported through the
Governance Committee.
Plan

Increase dedicated nurse
practitioner time to work closely
with senior nurses and increase
awareness of health promotion.

Introduce monthly clinics facilitated
by specialist practice nurses for
respiratory and diabetic needs.

Increase smoking cessation
promotion and support.

Ensure all patients receive a
physical assessment on admission
and an annual physical review.
Project Lead: Practice Development
Nurse
Senior Management Lead: Associate
Director of Quality Compliance and
Business
6
PATIENT EXPERIENCE
Priority 4 - To ensure that the people who use our services have the opportunity to be
involved in all aspects of their care plans.
Rationale
Monitoring
The Care Quality Commission
suggested that our systems do not
illustrate the collaborative work that
happens on our units particularly around
care planning. In order to ensure that
the people who use our services have
good experiences of quality care
planning we will seek their feedback
directly.
The organisation will develop processes
to ensure that the information contained
in the Advanced Statements is included
in the care planning and risk
assessments of the people using the
services. The Statements will be
reviewed at intervals and will be held by
the individuals. Audits will ensure that
they are being completed. It is
estimated that the statements will be
repeated every six months or at the
request of the service users.
Plan

Continue to deliver awareness
raising sessions and training to
management teams and staff on
involving patients in care planning
and recording this involvement.

Continue the monthly audits of the
care planning process

Ask the Involvement Development
Worker to interview people whose
care plans are being reviewed to
get their feedback on the process.

Reporting
Progress reporting will be to the
Governance Committee through the
Involvement Report and to the Senior
Management Team.
Project Lead: Involvement
Development Worker
Senior Management Lead: Director of
Clinical Services
Ask the Involvement Development
Worker to share feedback with the
Senior Management Team to
ensure that a match between
process and experience is
apparent.
7
Statements relating to quality of NHS services provided
Statement of Assurance from the Board
The Retreat’s Board of Directors welcomed the
introduction of an annual Quality Account and continues
to find it valuable in providing it with a focus on its
responsibilities for quality.
The Board receives regular reports from the
Governance Committee. This Committee reports
directly to the Board and includes two Directors in its
membership. The reporting mechanisms are
continuingly reviewed, with particular reference to the
frequency of reports and the highlighting of key issues.
The Governance Committee’s terms of reference have
also recently been updated so as to clarify its role and
its membership.
In addition to their involvement in Board meetings and Sub-Committees, individual
Directors play an important role in special studies which are important in relation to
quality. In the last year such subjects have included Spirituality and a review of how
The Retreat’s Quakers roots can be better understood in the context of our patient
care.
The priorities for 2012/13 set out in this Quality Account have the Board’s total support
and the Board will actively monitor their implementation in collaboration with the
Governance Committee and The Retreat’s Senior Management Team.
Stuart Humby
Chair of Directors
Chair of Governance Committee
8
Review of services
During 2011/12 The Retreat provided nine NHS services in three service areas.
The Retreat has reviewed all the data available to them on the quality of care in nine of
these services. In addition to clinical audits and clinical research, each named service
produced an annual clinical report which was presented to the Board for review.
The income generated by the NHS services reviewed in 2011/12 represents 100% of
the total income generated from the provision of NHS services by The Retreat for
2011/12.
The services we provided are as follows:
Specialist Adult Services
Naomi is a service offering assessment and treatment packages for women with
complex eating disorders. We specialise in treating people with more than one
diagnosis which may include personality disorder, obsessive compulsive disorder and
post traumatic stress disorder.
The Acorn Programme is a Therapeutic Community (TC) which uses Dialectical
Behaviour Therapy (DBT) for women with complex needs, predominantly women who
meet the criteria for borderline personality disorder and / or complex post traumatic
stress disorder.
Hannah Mills is an intensive recovery and rehabilitation unit working collaboratively
with men and women to understand the problems that cause repeated or ongoing
hospital admissions. People using the service may have used alcohol, drugs, self
harm or suicide attempts as a way of managing their experiences. They may have
psychotic experiences, dual diagnosis, personality disorder, mood disorders or
complex trauma.
Specialist Older Adult Services
George Jepson Unit provides care and treatment for men who have a primary
diagnosis of a functional or organic disorder. They present with behaviours which
cannot be managed in a community or non-hospital setting due to the severity of their
challenging behaviours.
Katherine Allen Unit provides care and treatment for women with a diagnosis of a
functional or organic disorder. They present with behaviours which cannot be
managed either in the community or outside a hospital setting.
Allis Unit provides care and treatment for men and women with a background of long
term mental illness. They have complex mental health needs but have some
independent living skills.
The Cottage is a rehabilitation unit for men who need additional time to develop
emotional and practical skills before moving into independent or supported living in the
community.
9
The Retreat Strensall is a specialist mental health rehabilitation unit in the community
for men and women. It provides care and treatment for adults with long term mental
health needs, providing slower stream rehabilitation for people working towards
increased independence.
Community Psychological Therapies
The Tuke Centre continues to provide high quality counselling, psychotherapy,
psychiatric and psychological services for individuals, groups, couples and families in
the community. The specialist services for trauma, personality disorders and eating
disorders utilising our own Dialectical Behaviour Therapy and Cognitive Behavioural
Therapy teams are growing and proving to be effective.
Our new Family Therapy Service is guided by our resident family therapist in
conjunction with the rest of the Tuke Centre team. The exciting prospect of delivering a
family service, which can include individual interventions at a single point of delivery, is
one The Retreat is looking forward to.
The Tuke Centre also provides employee assistance programmes for organisations
along with specialist support and consultancy for employers and managers. This area
of work is now developing a training programme to support health care professionals in
the community as a result of our continuing good working relationships with local GPs.
New Developments for Older Adult Services completed in 2011/12
In 2011/12 The Retreat completed a major piece of work to develop pathways for its
older adults, as follows:

Long-term Care Pathway - for high need patients to enable them to reach their
potential. The key focus was on environment and non-pharmacological
management.

Dementia Care Pathway - for people with dementia or cognitive impairment
requiring long-term hospital treatment.

Rehabilitation and Recovery Pathway - primarily for people with partially treated
functional disorders. The aim was to move people on to some form of
independent living or community placement.
As a result of this work in 2011/12 more people in our older adult services were able to
move out of hospital care to more appropriate settings.
The Retreat Haxby was relocated to a new site in Strensall to become The Retreat
Strensall. The updated accommodation, including independent living bungalows, has
provided an improved environment and extended the range of the pathways available.
We opened a new service, The Cottage, which is a rehabilitation unit for men and is
situated in the grounds of The Retreat with access to all its facilities.
10
Participation in clinical audits
Information on participation in clinical audits
The Retreat undertakes an annual Audit Programme which is included as part of the
overall Clinical Audit Strategy. Each audit is undertaken in accordance with the stages
of the Audit Cycle. Results are reported bi-monthly to the Audit Group and in the
quarterly Governance Report to the Board. The results of 14 clinical audits were
reviewed in 2011/12 and the organisation has taken action as a result of these findings
to improve the quality of care and treatment it provides. The Clinical Audit Strategy
including Audit Programme for 2012/13 can be provided upon request.
Local clinical audits completed in 2011/12
Compliance
Against
Standards
25 hr Weekly Activity
Carers Strategy
Care Plans/Patient Records
November
December
January
February
March
Forms T2/T3 Consent to Treatment
High Dose Antipsychotic Prescribing
HoNOS Scores
Missing Persons Procedure
Patient Engagement & Maintenance of Personal Safety (Pilot)
Section 17 Leave Forms
Section 18 AWOL
Key
Minor level of changes to practice identified as a result of the audit
Moderate level of changes to practice identified as a result of the audit
Significant level of changes to practice identified as a result of the
audit
11
National clinical audit
During 2011/12 there were four national clinical audits applicable to the services
provided by The Retreat. These were as follows:

Psychological Therapies

Suicide and Homicide in Mental Health

Prescribing Observatory for Mental Health (POMH-UK)

Schizophrenia (National Schizophrenia Audit)
The Retreat reviewed these audits but was not eligible to participate in any of them due
to having insufficient patient numbers. The POMH-UK audit template will be included in
the Audit Programme as a local audit. There were no national confidential enquiries
applicable to the organisation during this period.
The Retreat took part in the Community of Communities audit in 2011/12. The results
and recommendations will be incorporated into the Acorn Programme’s Quality
Improvement Plan for 2012/13.
Participation in clinical research
No patients receiving NHS funded treatment participated in research reviewed by our
Research Group during 2011/12. One proposed research project was reviewed and the
changes recommended by our research governance process required a re-submission
to the NHS Research Ethics committee. Consequently this research project has yet to
begin.
Commitment to research as a driver for improving the quality of care and patient
experience:
Ongoing research projects during 2011/12 included an occupational therapy clinical
supervision pilot study, a qualitative evaluation of an art therapy group and our
participation in a multicentre project to develop UK normative data for the Occupational
Card Sort assessment.
During 2011/12 resources were directed to increasing service evaluation to ensure all
services assess clinical effectiveness and in turn integrate this into patient clinical
reviews and service area annual reports.
The Retreat recognises the importance and potential value of clinical research and is
considering a proposal to increase research activity.
The Retreat’s enquiring and collaborative stance, together with a combination of
quantitative and qualitative approaches, help facilitate continued exploration of the key
factors in mental health recovery. Our aim is to maximise the contribution The
Retreat’s services provide to this stage of an individual’s pathway.
12
Use of the CQUIN (Commissioning for Quality and Innovation) payment
framework
A proportion of The Retreat’s income in 2011/12 was conditional on achieving quality
improvement and innovation goals agreed between The Retreat and NHS North
Lancashire with whom they entered into a contract for the provision of NHS services,
through the Commissioning for Quality and Innovation payment framework.
The Retreat was successful in achieving the CQUIN target for 2010/11.
Statements from the CQC (Care Quality Commission)
The Retreat is required to register with the Care Quality Commission and its current
registration status is in respect of:

Assessment or medical treatment for persons detained under the Mental Health
Act 1983.

Diagnostic and screening procedures.

Treatment of disease, disorder or injury.
The Care Quality Commission has not taken enforcement action against The Retreat
during 2011/12.
The Retreat has participated in a special review by the Care Quality Commission
during the 2011/12. This was regarding a Safeguarding alert raised by the CQC in
response to an anonymous alerter sent to the CQC. The Retreat held an investigation
which fully satisfied the concerns reported by the CQC and the alert was closed.
Data Quality
The Retreat did not submit records during 2011/12 to the Secondary Uses service for
inclusion in the Hospital Episode Statistics. Work has been undertaken over the past
year to develop a more robust process for the managing of corporate and clinical
records with the implementation of an organisational Information Lifecycle (Records
Management) Policy including a Records Retention Schedule.
The organisation is working towards compliance with the NHS Information Governance
Toolkit and has implemented action plans for areas of non compliance.
The Retreat was not subject to the Payment by Results Clinical Coding Audit during
2011/12 by the Audit Commission.
Review of our data quality
The Retreat will be taking the following actions to improve data quality.
In 2011/12 The Retreat reviewed the Care Quality Commission Essential Standards of
Quality and Safety. Our self assessment identified a number of areas that needed
improvement including Outcome 21 Records. This has resulted in the implementation
of a programme of staff training and development for clinical documentation to ensure
13
staff have the necessary knowledge and skills to be able to provide the best possible
care and treatment. The importance of this work has led us to identify this as a priority
for the coming year.
Our performance metrics are reported and monitored through our Governance
Committee and its reports to the Board.
The Information Governance Toolkit
There is a mandatory requirement as part of The Retreat’s contracts with NHS
commissioners of our services to complete an annual Information Governance Toolkit
return to NHS Connecting for Health. Compliance is measured across the following
Information Governance areas:




Information Governance Management
Confidentiality and Data Protection Assurance
Information Security Assurance
Clinical Information Assurance
The organisation completes a self-assessment against standards in each of these
areas at one of four levels of compliance; 0 being the lowest level and 3 the highest.
Achievement against requirements
The Audit and Information Manager, with the support of the Information Management
Group, has assessed the organisation’s level of compliance against each standard
including supporting evidence. Detailed action plans have been implemented for each
standard assessed as non-compliant and assigned to a Lead Officer to complete. The
Retreat’s current level of compliance at March 2012 is Level 1. NHS contracts require
our organisation to achieve Level 1 compliance by March 2012 and Level 2 compliance
by March 2013 across all standards.
Compliance
Against Standards
2011/2012
Level 2
Information Governance Management
Confidentiality & Data Protection Assurance
Level 1
Information Security Assurance
Level 1
Clinical Information Assurance
Level 2
Key
Level 0
Level 1 (required by March 2012)
Level 2 (required by March 2013)
Level 3
14
PART THREE
Review of quality performance in 2011/12
Update on Priority 1 - To improve the way in which we manage and support
individuals who experience verbal or physical conflict when in our care. We will
introduce a range of measures to reduce incidents and improve our management
of incidents that occur.
During the last 12 months several initiatives have taken place to improve the
management and handling of patient conflict incidents.
Zonal observations were introduced across all Older Adult units and our policy was
changed to reflect this.
A new complaints process was introduced which included a complaints leaflet, patient
information sessions carried out by our involvement workers and all staff being
informed of the new system.
Even with the introduction of new methods of working our incident reporting data
highlighted that some months showed an increase in this type of incident. After an
investigation into the reasons why this was happening it became apparent that higher
than normal levels of staff sickness and the vacancies that some units were carrying
resulted in an increase in the use of bank staff which led to some patients becoming
unsettled on their unit. A reduction in sickness absence and the filling of vacancies
resulting in less use of bank staff has seen the number of incidents decrease.
Regular audits are now carried out on the use of zonal observations. Zonal
observations were introduced to allow patients who are known to upset each other to
be nursed in quieter surroundings away from communal spaces such as lounges.
Update on Priority 2 – To improve the use of the Health of the Nation Outcome
Scale (HoNOS). To achieve this we will extend its use to those patients for whom
we are not currently contractually obliged to provide the data. We will also
ensure that regular HoNOS scores produced are analysed and passed to the
clinical teams to monitor and inform the recovery process.
In 2011/12 we have extended the use of the HoNOS to produce a regular quarterly
HoNOS score for each patient. HoNOS scores are fed back into the Clinical Teams on
a monthly basis and via the quarterly Governance Report to the Board.
In addition to training on completing electronic assessments which produce HoNOS
scores, our ongoing commitment in 2011/12 has been demonstrated by:

Implementation of the HoNOS data tool used to extract quarterly scores from our
Electronic Patient Records System (FACE).
15

Development of a database by the Quality, Compliance and Business Unit to log
all HoNOS scores with an automatic reporting system to aid improved feedback
and interpretation of scores by Clinical Teams.

Monitoring of HoNOS scores via the quarterly Governance Report.

Continued compliance to NHS contractual requirements in relation to HoNOS (as
demonstrated by recent positive audits).
Update on Priority 3 – To improve the involvement of people using our services
by the introduction of advanced statements, designed and written by the people
who use our services.
Over the past year the Involvement Team have undertaken a project to develop an
advanced statement in three parts.
Part one – Development of the statement
A project team was convened to include people that use the services, the Mental
Health Act Law Advisor and the Involvement Team. The team developed a workshop
that is pertinent to the diverse range of units at The Retreat.
Part two – Workshops and consultation
Workshops and individual interviewing were carried out on each unit, by the
Involvement Team, to develop the statement. The project team was re-convened to
add final designs to the statement. The name ‘Respect My Wishes’ was chosen by the
project team.
Part Three – Training for staff on advanced statements
Training for all staff members on each individual unit, facilitated by the Involvement
Development Worker and Mental Health Act Law Advisor, took place.
Compliance
All of the units have received training on advanced statements. On every induction the
involvement awareness training includes the advanced statement.
Each unit has had input from the Involvement Team to support people to fill in ‘Respect
My Wishes’. This has been successful on most units and is ongoing.
Update on Priority 4 - To further enhance the patient experience in the area
of Spirituality.
Rationale
Valuing and enhancing the spiritual life of all individuals and the community is central to
the work and culture of The Retreat. While this work has always featured in care for
people here, we are keen to look at it more closely in order to ensure that needs are
being met across The Retreat.
16
Report on action against plan

The ‘S’ Group worked with people who use our services to develop a definition of
Spirituality as “what uplifts us, what makes us whole and what connects us.”

In line with our plans, the ‘S’ Group has researched and recorded a wide range of
spiritual activity during the year. This includes:
o Memorial Service on 2 November for anyone who has been recently bereaved.
People wrote messages on a memory tree and everyone took away a spring of
‘rosemary for remembrance’ (Hamlet).
o Tree planting event that took place in December, where patients planted trees
in memory of loved ones, or to symbolically mark their own recovery.
o Community arts project: sense of pride and achievement in the display boxes
created, meaningful engagement across units and a sense of being part of
something significant.
o Pat dog appreciated on older adult units
o Each day of Hannukah marked with an older adult
o Ongoing attendance at a range of local churches and hymn singing with Holy
Communion in our Quiet Space. Regular Quaker worship available each week,
two patients have attended recently.
o Monday music group for older adults now has a monthly live music input from
an external musician – positive responses
o Carol service well attended and 50 people hung a star on the Christmas tree to
make a Christmas wish or prayer
o Mindfulness regularly takes place on several units. There is a mindfulness
forum for all who are interested in developing this work at The Retreat.

With significant input from our involvement team through a questionnaire, the
Group has worked with the people who use our services to find out how best to
meet their needs. The strongest theme that came out of the questionnaire in
terms of spirituality was relationships with others.

We are in the process of finalising two leaflets about supporting spiritual health:
one for the staff and one for the people who use our services.
17
Complaints Report
A total of nine complaints were received during 2011/12.
The table below shows the reasons for the complaints:
Reason for the Complaint
Number
Number
Attitude of staff
3
2 Upheld
1 x Withdrawn
All aspects of clinical treatment
4
3 Upheld
1 x Withdrawn
Other – Behaviour of a patient towards another patient
1
Upheld
Other - Failure to follow agreed procedures
1
Upheld
(Complaint Categories are as defined by the Department of Health)
Complaints Dealt with within 25 Working Days
9 complaints received were dealt with within 25 working days.
Learning from the Complaints:

A review of security arrangements brought about changes to security
arrangements at night.

Regular meetings were introduced with a patient’s relative to discuss various
aspects of the patient’s care and treatment.

Unit staff were reminded of the observation policy and how it is implemented
locally.
Compliments Report
In 2011/12 we introduced a Compliments Policy and each clinical unit now keeps a log
of all compliments which it forwards monthly to the Audit and Information Manager.
Compliments reports are submitted to NHS commissioners of our services and a
summary of this information is reviewed at the Governance Committee on a quarterly
basis. We have received 19 compliments in total in the period 2011/12.
18
The following metrics have been chosen to measure our performance
against internal Retreat Standards:
Safety
Indicators
1
Number of incidents reported to the CQC as Serious Untoward
Incidents (SUIs).
0.1
(per 100 patients)
2
Safeguarding - number of incidents that resulted in patient to patient
conflict.
10.9
(per 100 patients
3
Mental Health Activity – number of incidents reported that resulted in
a breach of Section 18 of the Mental Health Act.
3.6
(per 100 patients)
4
Medicines Management Incidents – number of incidents that related
to the administration, management and handling of medicines.
16
(per 100 patients)
5
Use of Seclusion - Number of occasions where seclusion was used.
0
(per 100 patients)
6
Incidents reported to the CQC - Number of incidents that we reported
to the CQC.
8.4
(per 100 patients)
Patient Experience
Indicators
1
Number of Health of the Nation Outcome Scale (HoNOS) reports
produced.
2
Recovery orientated patient satisfaction measure.
3
Complaints - number of complaints received.
10.8
(per 100 patients)
4
Use of MOVA (Physical Restraint) – number of times restraint was
used.
41.9
(per 100 patients)
5
REAT Inspections – Annual inspection results (Number of actions)
following environmental inspections on clinical units.
100%
(No of actions
completed)
6
25 hour week activity
586
(per 100 patients)
Not collated in
2011/12
76%
Clinical Effectiveness
Indicators
14
(Audits completed)
1
Key Audit findings and actions.
2
Sickness Absence Levels.
3
Staff off sick with stress.
4
Use of Bank/Agency staff – number of shifts used.
5
Staff vacancies.
6
Appraisals completed.
99%
7
Training completed – Average figure for mandatory staff training.
76%
4.15%
1.9
(per 100 Staff)
> 6% of total shifts
13.6%
Key
Reached required standard
Actions identified to reach required
standard
19
Significant actions required
Information on the National Patient Survey
The Retreat openly encourages the people who use our services to give their feedback
on all aspects of their care and treatment. This ensures that we can constantly improve
the services that we offer. In order to gather these views formally, we utilise the
National NHS Patient Survey which enables us to benchmark ourselves against NHS
Trusts. The Retreat undertakes the Patient Survey as part of our annual programme of
Patient Experience Surveys. During the 2011/12 period the Patient Survey was
conducted twice across the organisation in April 2011 and October 2011. In the most
recent survey patients were asked:
‘Overall how would you rate the care you receive at The Retreat?’
Responses given were as follows:
Excellent (19%) Very Good (28%) Good (29%) Fair (10%) Poor (5%)
‘Overall, do you feel you are treated with respect and dignity while at The Retreat?’
Responses given were as follows:
Yes, always (73%) Yes, sometimes (18%) No (9%)
All results were reported to the Audit Group and included in the summary report to the
Governance Committee. Action plans were developed to improve the overall ‘patient
experience’.
2011/12 Patient Surveys Completed
Compliance
Against Standards
Patient Survey (April 2011)
Patient Survey (October 2011)
Outpatients Survey (April 2011)
Outpatients Survey (October 2011)
Key
Minor level of changes to practice identified as a result of the audit
Moderate level of changes to practice identified as a result of the audit
Significant level of changes to practice identified as a result of the
audit
Further information on results of the Patient Surveys can be provided upon request.
20
Comments taken from the Patient Surveys (April & October 2011)

Overall the care is excellent and very caring at The Retreat.

Support and understanding from particular members of staff.

Staff treat you better, trust you more and are very knowledgeable.

More flowers.

I think the food menu could have more variation of choice

The Retreat looks after the whole person, not the illness. It is the best care I have
received.
Information on the Staff Survey
The Retreat undertakes an annual Staff Survey using questions similar to the NHS
Staff Survey. This was conducted in December 2011 and 105 surveys were returned by
staff. Data collected is used to assist in improving working conditions and practice for
Retreat staff. The results of the survey were reported to the Governance Committee,
Senior Management Team and to all staff through the Team Brief. A range of measures
have been implemented to address any areas in which improvement was indicated.
21
Statements from PCTs and LINk
A draft copy of The Retreat’s Quality Account was sent to colleagues at NHS North
Yorkshire and York, NHS North Lancashire and York LINk. Please see below
statements from these organisations.
NHS North Yorkshire and York
The Retreat is commissioned to deliver care to vulnerable and complex mental health
patients by NHS North Yorkshire and York.
We have enjoyed a good long standing working relationship with The Retreat which
continues to deliver good quality care, year after year.
The Retreat is one of our key partners in the overall delivery of mental health services
and they have continued to be responsive to both the changing presentation and needs
of the local population and in supporting us to deliver local and national mental health
policy.
We also welcome improvements in quality performance from other independent
providers who are commissioned by NHS North Yorkshire and York to provide
services.
NHS North Lancashire
The Retreat offers a very high quality service to individuals within a therapeutic/caring
environment which is conducive to their optimum recovery. The Retreat continues to
offer the individual the opportunity to maximise their recovery by ensuring a high calibre
of staff, and ensuring a multidisciplinary approach to individualised care.
York LINk
Thank you for giving York LINk the opportunity to comment on your Quality Account for
2011/12.
Some members of the LINk Steering Group have been able to read the account and we
would like to congratulate you for producing a very open and honest report.
The LINk is concerned that the CQC did find issues which needed attention, but
reassured that you are addressing this as one of your priorities for 2012/3.
During the coming year, if there is any way you feel that the LINk could be of
assistance to you in improving or enhancing your patients’ experience, please don’t
hesitate to get in touch.
22
Glossary
CQC
Care Quality Commission
The independent regulator of health and social care in England. It
regulates health and adult social care services, whether provided by
the NHS, local authorities, private companies or voluntary
organisations.
CQUIN
Commissioning for Quality and Innovation
Measures which determine whether we achieve quality goals or an
element of the quality goal. These achievements are on the basis of
which CQUIN payments are made.
FACE
Functional Analysis of Care Environments
Electronic Patient Record System used by The Retreat
HoNOS
Health of the Nation Outcome Scale
A widely used routine clinical outcome measure used by English
mental health services.
LINk
Local Involvement Network
A network of local people and community groups who want to improve
social care and healthcare in the local area. Their job is to find out
what the public like and dislike about local health and social care. They
will then work with the people who plan and run these services to
improve them.
MDT
Multidisciplinary Team
A group of different types of clinicians who work together as a team.
PCT
Primary Care Trust
A Primary Care Trust is an NHS organisation responsible for improving
the health of local people, developing services provided by local GPs
and their teams and making sure that other appropriate health services
are in place to meet local people’s needs.
SHA
Strategic Health Authority
Manages the NHS locally and provides an important link between the
Department of Health and the NHS.
23
If you would like to make any comments regarding the
content of this report, or make any suggestions for
future reports please contact our Marketing Manager
at the address below.
Electronic copies of this Quality Account can be
obtained from our website (www.theretreatyork.org.uk)
and the NHS Choices website (www.nhs.uk)
Printed copies can be obtained by contacting the
Marketing Department.
If you require this report in another language please
contact the Marketing Department.
Marketing Department
The Retreat
Heslington Road
York
YO10 5BN
t: 01904 412551
e: marketing@theretreatyork.org.uk
Heslington Road York YO10 5BN t: 01904 412551 f: 01904 430828
e: info@theretreatyork.org.uk f: www.theretreatyork.org.uk
Registered office: The Retreat York Heslington Road York YO10 5BN
Registered in England and Wales No 4325622 A Registered Charity No 1089826