Quality Account
2012/2013
Contents Page
Part 1: Statement on quality from the Chief Operating Officer
Part 2: Governance, Patient Safety and, Service User Feedback and Involvement
Governance Process
Service User Involvement and Feedback
Statements from Families and Carers
Patient Safety
Views of Services from a Staff Perspective
Advocacy
Key Policy Dissemination
Review of Services during 2013
CQC Statements
Data quality
Part 3: Clinical Effectiveness
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Annex Statement from Castlebeck Purchaser
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PART 1: Statement on quality from the Chief Operating
Officer
Castlebeck provides hospital and residential care services for people with learning disabilities,
people with autism and people with acquired brain injury. Each year Castlebeck publishes a Quality
Account for our independent hospital services.
Castlebeck’s approach focuses on care pathways, outcomes and discharge planning from the point
of admission onwards. We will continue to be transparent and answerable in all we do.
This year’s Quality Account is based around the framework for delivery of the implementation and
interventions designed to respond to the priorities raised by the people who use our services,
families, staff and other key stakeholders. This report concentrates on the areas where we have
improved and on the steps taken to assure key stakeholders of reforms to the three key areas of
Clinical Effectiveness, Patient Safety and Patient Experience.
We strive to ensure that at the heart of what we do there is a passion to make a difference to people
and their families by delivering personalised health and social care that helps them achieve what
they want out of life.
To quote “Whenever you do a thing, act as if all the world were watching” Thomas Jefferson
Simon Harrison
Chief Operation Officer
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PART 2: Governance, Patient Safety and, Service User Feedback
and Involvement 2012/2013
Governance Process
The Group Director of Nursing and Patient Safety oversees a team that includes Head of
Governance, Compliance and Risk, regional nurses, the audit and governance coordinators,
compliance manager and governance staff team. The focus for the team is to provide assurance of
patient safety through a number of key initiatives which include the implementation of the
company’s Quality Strategy, the Annual Audit Plan and the Annual Internal Quality Development
Reviews.
The Governance Team produce monthly analysis across key indicators for each service. This
information is used to monitor and continually improve care provision and care planning and is used
in discussion with the management team at service review meetings and at the internal
whistleblowing, safeguarding and board meetings.
Service User Involvement and Feedback
Service User Involvement Forums are regularly held across the organisation and the remit is to have
sight of all service user involvement projects/initiatives across the organisation and co-ordinate rollout of best practice areas. This includes the implementation and extension of a number of projects
including relative/carer involvement initiatives.
Example of service user project:
We work in partnership with Frank Proctor at The Challenging Behaviour Foundation and the SHIEC
project and have developed a number of service user work placements at head office. The project
has allowed people to take their first steps to gaining meaningful employment. The work
placements encourage people who use our services to learn new skills experience team working and
introduce them to a working environment. Each service user leaves their placement with a CV, photo
diary and reference which reflects their work experience with us. Individuals provide one page
profiles which help the HO staff to support each service user. After each work placement session,
time is taken to sit down and discuss their experiences in order to ensure suitability and progression.
Castlebeck undertakes regular quality development reviews (QDRs). Service users have been
trained by an external provider as “experts by experience” reviewers and are directly involved in our
internal quality development reviews. We also host a Service User Involvement Forum where we
share all of the service user involvement projects and initiatives across the organisation and coordinate roll-out of best practice areas. This includes the implementation and extension of a number
of projects including relative/carer involvement initiatives.
Castlebeck’s Care Plan Approach (CPA) programme evidences person-centred working at all levels.
This involves the implementation of new key documents for CPAs including easy read documents.
Statements from families and carers
We strive to ensure links with family carers are robust and we have established methods for
communicating including the family carer feedback surveys and meetings. It is through these
methods that we seek their views, wishes and hopes for their family member and the service they
use. The following are quotes from recent surveys which we would like to share:
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“I am treated as a friend when I visit my brother and am confident in the care and attention he
receives.” sibling of service user
“This is the best place he’s been. There is a member of staff whose patience, ability and
understanding to support service users with complex needs is astounding.” parent of service user
“The progress in the 4 years our son has been here can be summed up in one word “REMARKABLE”
parent of service user
“To leave your son so far away from home in someone else’s care is a hard thing to do. Knowing he
is here gives me peace of mind when I am not there, I know my son is happy and looked after”
parent of service user
Patient Safety
The Governance teams continually focus and review processes at all services. They are responsible
for ensuring that effective audit processes and quality checks and compliance requirements are in
place. The team includes service users and involves external, independent expertise.
A full and comprehensive review of our physical intervention policies has been undertaken which
includes improvement to our quality of training, and increasing staff skills to manage complex and
high risk situations safely. Positive Behaviour Support (PBS) has been rolled out across all services.
Each service user has access to an independent advocate. There is a full suite of literature available
in easy read for all service users which amongst others covers the subjects of bullying, keeping safe
and reporting abuse. All our service users are encouraged to talk about and report anything they are
not happy about.
Our systems enable us to take a proactive approach to patient safety. We have an electronic incident
reporting system, which provides improved analysis of incidents which helps us to act quickly and
understand the lessons learnt from incidents. This enables close analysis of the use of restrictive
physical interventions at unit level during the care provision reviewing process, as well as enabling
scrutiny at regional and national level for reviewing practice and trends. Castlebeck do not use ‘face
down restraint’ within its services.
There is an externally sourced, independent whistleblowing procedure to which all staff have access
to. Staff are also encouraged to report concerns of any kind in confidence. Any concerns are then
collated and considered at the Whistleblowing and Safeguarding Committee attended by Board
members.
Views of services from a staff perspective
Staff have access to forums throughout the services and staff surveys have been commissioned and
consultations have been undertaken in order to better engage with staff. There is regular
attendance by senior management at our services to allow staff to contribute their views, concerns
and ideas.
The use of the company intranet and the staff newsletters keeps all members of staff up to date with
new policies, progress and improvements as we continue to improve upon patient safety and the
quality of services we provide. Regular team briefings continue to cascade information to all our
staff. Staff views are recorded and included within subsequent Board discussions.
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Some comments from Castlebeck staff we would like to share with you.
“In 5 years’ time I would like to see myself still working within the organisation. I feel that the
organisation has supported me and given me the opportunity to develop my skills. I would like to
pass on the knowledge that I have and hopefully if there are any new managers coming in then I can
provide the support to them like I had.”
“It’s like having stepping stones in the unit. Every person in the building has a contribution to make.
We are part of one big team.”
“We all play our part which at the end of the day all contributes to the welfare of the service user.”
Advocacy
Castlebeck have national contracts in England and Scotland with independent advocacy services.
Each service user has access to an independent advocate. Quarterly reports are provided from these
third party companies to the Castlebeck Board.
Key Policy Dissemination
All new staff coming to work at Castlebeck undergo an induction training period. This includes
training on key polices such as: Whistleblowing, Safeguarding, Health & Safety, Information and Data
Protection and Restrictive Physical Intervention. We provide training, support on new policy rollout
and implementation of policies is monitored through supervision and audit.
Review of Services during 2013
Castlebeck has a range of services which can support people’s individual needs. These include
services which support people with learning disabilities and complex needs, those on the autistic
spectrum and a specialist brain injury hospital.
units continue to be visited and reviewed monthly by the Regional Operations Directors and their
teams. Internal Inspections - Quality Development Reviews are undertaken to ensure compliance
with required regulatory standards. There is an Annual Audit Plan which includes Antipsychotic
audit, CPA, Infection Control and MDT audits. In addition there are audits provided by external
company including medicines management and administration, health and safety and
environmental, housekeeping and catering audits. Progress has been made with commissioners in
defining clearer service specifications for each service.
CQC Statements
Castlebeck is required to register its 20 hospitals and homes in England and Scotland with the Care
Quality Commission in England, Care Inspectorate and Healthcare Improvement Scotland.
All the services regulatory and corresponding action plans are available to view on the relevant
websites or at http://www.castlebeck.com/professionals/governance/cqc-and-regulator-reports/
Data quality
Castlebeck has further developed its key governance data sets in line with the SCR
Clinical Governance data is used to improve patient safety and the information is utilised for care
planning, MDT and CPA reviews and is reported monthly to the Board.
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PART 3: Clinical Effectiveness
The following is a summary for the above area:
Clinical Effectiveness
Effect
We aim to facilitate admissions to Castlebeck services for the shortest possible period of time to
complete an assessment and treatment process. In order to do so we jointly complete
comprehensive assessment and agree treatment goals prior to admission and monitor these weekly
for the first 12 weeks leading up to the initial CPA review meeting via a planned series of MDT
reviews.
Castlebeck have implemented a new CPA system into all hospital services. The new process focuses
on the service user who takes a lead in preparation for these meetings using the easy read “My CPA”
booklet. All clinical CPA reports are outcome focused and concentrate on discharge needs from the
point of admission. CPA reports are sent to attendees 2 weeks in advance and attendance
proactively encouraged, meetings are arranged at a time and date to meet service user and family
needs and not those of the units.
Active participation is encouraged and facilitated in the meeting and feedback of the meeting sought
from service users, family members and commissioners of service. A companywide audit for the
CPA process is planned for 2013.
The MDT meeting remains the regular weekly forum to monitor service user’s progress, we continue
to review treatment goals using a structured template which ensures all areas of physical and
mental health are regularly reviewed. Castlebeck hospitals are supported by a clinical team of
Psychiatrists, Psychologists, Occupational and Speech and Language Therapists, where service users
have additional needs we actively involve external clinical experts. To maximise physical health care
of people using our services we ensure that all receive an annual health check from their registered
general practitioner. A repeat audit of the MDT process is due to be completed in 2013.
Castlebeck has adopted the Life Star and Spectrum Star as outcome measures. All nursing staff have
received training in the use of this tool and its electronic recording system. HoNOS LD continues to
be used in all services.
A structured programme of psychological group work has been piloted and completed 12 week
cycles within 2 regions. The Therapeutic Support Programme is run jointly by Psychology and
nursing staff and targets and focuses on;
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Development of Social Skills
Emotional Management
Relationship Management
Development of Self-Esteem
All service users continue to have an individualised programme of activities, facilitated by in house
activity co-ordinators based in each service, this includes a balance of educational and leisure
activities and endeavours to promote maximum physical exercise and a healthy lifestyle. Activity coordinators are supported by occupational therapists and attend a regular national forum enabling
the sharing of good practice across the range of services.
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Castlebeck have worked with a national pharmacy supplier, taking over as sole supplier of
medication to all English services. This external expertise has provided training to clinical, nursing
and support staff, completed external medication audits of all services and supported the revision of
Castlebeck’s medication policy.
We have fully implemented the national Medical Revalidation process for all of our doctors. A
Responsible Officer is in place and has been revalidated in 2013, all other doctors have an identified
designated body and revalidation date. We have implemented a new supervision policy which
provides a clinical supervision structure for all nursing staff. We have also implemented a new
nursing risk assessment and care planning system.
Annex statement from a Castlebeck purchaser
Newark and Sherwood CCG on behalf of the five CCGs across Nottinghamshire County has reviewed
Castlebeck’s quality accounts and in light of our commissioning experience I can confirm that the
Quality accounts are correct although they have not been fully audited by Newark and Sherwood
CCG.
Signed by
Charlotte Wilkinson
Commissioning Officer
NHS Newark and Sherwood CCG
For and on behalf or
Karon Glynn
Assistant Director Mental Health and Learning Disabilities
NHS Newark and Sherwood Clinical Commissioning Group
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