The Huntercombe Group Quality
Account
2012 /2013
Contents
Page
Section One - Statement on quality from the Board of Directors
Dr Peter Calveley, Chief Executive, Four Seasons Healthcare
3
Margaret Cudmore, Managing Director, The Huntercombe Group
5
The Huntercombe Group – Vision and Values
6
Overview of Services provided by the Huntercombe Group
7
NHS Services Provided
9
Section Two – Priorities for Improvements and Statements of
Assurance from the Board
Our Priorities for 2013 / 2014
11
Priority 1 – Quality Framework & Systems
11
Priority 2 – Patient Safety
11
Priority 3 – Clinical Effectiveness
12
Priority 4 – Patient Experience
12
Statements Relating to the Quality of NHS Services Provided
13
Section Three - How we have performed in 2012/ 2013
Celebrating Success
17
Progress Against our 2012 / 2013 Priorities
18
Commissions for Quality & innovation (CQUIN) Performance
23
Routine Performance Monitoring
26
Complaints
26
Serious Incidents Requiring Investigation
28
Skin Integrity
29
Patient Satisfaction
30
2
Statement on Quality from Board of Directors
Dr Peter Calveley
Chief Executive, Four Seasons Healthcare
It gives me great pleasure to present the Huntercombe Group Annual Quality Account for
2012/2013.
The Huntercombe Group operates as the specialist provider arm of Four Seasons Healthcare
and is a leading specialist provider of health and social care services, working in partnership
with the NHS and Local Authorities throughout England and Scotland to provide effective
healthcare solutions for its patients. A significant number of our services are commissioned
by the NHS.
We currently offer a portfolio of specialist services enabling us to develop effective care
pathways and flexible approaches to meet the needs of individual patients in the following
specialities:
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Adult Mental Health
Learning Disability
Child and Adolescent Mental Health
Alcohol and Substance Misuse
Eating Disorders
Neurodisability
Acquired Brain Injury
Children with Specialist Needs
Our goal is to deliver safe and effective care in a welcoming environment that meets the
needs and expectations of those using our services. We highly regard the views and opinions
of those who use our services and are committed to continuous quality improvement.
This Quality Account aims to:
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Enhance our accountability to the people who use our services their carers and other
stakeholders of our quality improvement agenda
3
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Enable us to demonstrate what improvements we have made and what we plan to
make
Provide information about the quality of our services
Show how we involve and respond to feedback from our service users, carers and
others
Ensure we review our services, decide and demonstrate where we are doing well but
also where improvement is required
This has been a another very exciting year for the Huntercombe Group and one that has seen
the group make good progress against last year‟s priorities. We are not however complacent
and recognise that there are still improvements that can be made and a number of these have
been included in our priorities for 2013 and 2014.
This quality account covers all of our services that provide NHS commissioned care across all
specialities. It has been produced in accordance with guidance issued by the Department of
Health and will be published both on our website at www.huntercombe.com and also via the
NHS Choices website.
We very much welcome your feedback and suggestions regarding this quality account. If you
would like to comment or if you require any further information please email: Paula Smyth,
Head of Clinical Standards and Compliance at paula.smyth@huntercombe.com Alternatively
please write to Paula Smyth, Head of Clinical Standards and Compliance, The Huntercombe
Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8 7FA
Dr Peter Calveley
Chief Executive
4
Section One
Statement on Quality from the Board of Directors
Margaret Cudmore,
Managing Director, The Huntercombe Group
Welcome to the 4th Annual Quality Account for The Huntercombe Group.
At The Huntercombe Group we are committed to the provision of high quality care for all
those who use our services and their families. We strive to learn from this feedback and that
of other stakeholders. We recognise that true assurance of this will come from our ability to
demonstrate high levels of patient satisfaction, through the provision of safe services and
through exemplar clinical outcomes.
Since our last report was published we have seen considerable changes in the NHS. We have
seen new structures evolve and now face a new commissioning landscape with the
introduction of the new Commissioning Board (NHS England) and Clinical Commissioning
Groups. These changes have brought about new challenges for The Huntercombe Group.
We have also seen the publication of the reports from Winterbourne View and the Francis
inquiry, both of which have challenged us to look critically at the services we provide, and we
continue to face robust scrutiny from our regulators.
Throughout the past 12 months we have continued to work to consolidate the expansion in
our services that we reported last year and to embed our governance framework and
processes. There have been challenges along the way but there has also been a huge
amount of success as we have worked together to share our experience, knowledge and skills
and strive to deliver the highest quality services. In this report we have highlighted some of
our achievements and successes during the past year and identified areas where we still have
further work to do to achieve our aspirations. We have incorporated these areas into our
priorities for 2013/2014.
I am confident that the Huntercombe Group will continue rise to the challenge again in the
year ahead and will continue to provide high quality, flexible, innovative and responsive
services for our patients and residents.
Margaret Cudmore
Managing Director
5
Section One
The Huntercombe Group - Our Vision and Values
Proud of … what we do
We are a specialist organisation delivering results though tailored inspirational care for adults
and young people with complex needs; through clinical excellence, quality environments and a
friendly „CAN DO‟ approach.
Believing in … our values
Understanding
We listen, we learn, we empathise, we respect and we care.
Insight is fundamental to the way we shape our services.
Innovative
We are creative, dynamic and flexible in our service delivery, our
research and learning, and how we go about our business. Yet
in everything we do, we take a measured approach.
People First
We put those in our care first; they are at the heart of
everything we do. We also recognise the commitment of our
staff and stakeholders and the need to continually strengthen
our relationships with our external partners.
Towards Excellence
We strive for excellence across our whole service, through our
clinical expertise and within our care environments. Through
good teamwork, we will always aim higher, are never
complacent, and lead by example.
Reliable
Ours is a name to be trusted. We deliver results through
transparent service delivery and safety is paramount across all
aspects of our business.
Accessible
We offer accessible and tailored care pathways to meet
geographical and specialist needs. We aim to deliver the best
possible value-based healthcare within our customers‟ budgets.
Our strength is in our patient-centered focus, „CAN DO‟ approach and flexibility. We believe in
making a difference to people‟s lives through tailored solutions … not only to those in our
care, but to their families, commissioners and beyond.
6
Overview of Services Provided by the Huntercombe Group
Child and Adolescent Mental Health Services
Our CAMHS Tier 4 services are facilitated within our specialist hospitals situated in: Edinburgh,
Stafford, Maidenhead and Norwich, whilst our hospital in Cotswold Spa focuses on delivering a
specialist inpatient and outpatient programme of care for eating disorders. Our tailored
treatment packages for CAMHS are both innovative and flexible, delivered by a highly skilled
team of health care professionals.
Eating Disorders
At our specialist eating disorder hospitals, we provide assessment and treatment for
adolescents and young adults with severe and life threatening eating disorders such as
anorexia nervosa, bulimia nervosa and related disorders. Our hospitals are located in
Edinburgh, Maidenhead and Stafford. We also provide a shorter-stay eating disorder service
based in Broadway for patients requiring less intensive treatment to that provided in our other
hospitals. Between our four hospitals we are able to offer treatment for eating disorders from
the age of 11 upwards.
Adult Mental Health and Learning Disabilities
Our Hospitals and Centre‟s throughout the UK provide a wide range of specialist treatment for
adults with a range of mental health disorders, learning disabilities and complex needs.
Specialist, patient centred care and treatment is delivered within a variety of settings and
levels of security, from medium/low secure Hospitals to step down services including
Community Hospitals and care homes with nursing and/or residential care. Continuum of care
is vital for patients stepping up or stepping down, and our uniform model of care supports
patients through a structured care pathway. Risk can also be managed efficiently around the
patient‟s needs at any point in time.
Brain Injury and Neuro-Disability Services
We offer a broad range of specialist brain injury services from post-acute intensive treatments
for highly dependent patients through to supported living environments that enable our clients
to consider a return to independent living. Our award winning and flexible person-centred
neuro-rehabilitation services are delivered in centres across England and Scotland
Children and Adolescents with Specialist Needs
We have two centres that specialise in the treatment and care of children and adolescents
with specialist needs. Our centre, Granville Lodge, in Hartlepool provides specialised care for
children with physical disabilities and delayed learning associated with their disabilities. Whilst
our centre in Stockton, cares for children with a moderate or severe learning disability with or
without associated challenging behaviours and can cater for those with more than one
diagnosed learning disability.
7
Addictions
We provide detox and rehabilitation treatment for addictions in two locations in the UK:
Sunderland in the North East and Murdostoun, near Glasgow. Our centres cater for both NHS
and private patients.
At both centres we provide highly effective evidence-based interventions in the treatment of
drug and alcohol misuse. Our centres are able to cater for adults with complex needs
including poly-drug use, pregnant drug users, alcohol-related brain disease and mental health
co-morbidity.
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Section One
NHS Services Provided by the Huntercombe Group
The table below outlines the NHS services provided by the group and the percentage of NHS
patients within each service. A majority of the remainder of the services provided by the
Huntercombe Group receive social care funding.
Service Name
Service Type
% of NHS
Patients
The Huntercombe Hospital Maidenhead
Child & Adolescent Mental Health
100%
The Huntercombe Hospital Stafford
Child & Adolescent Mental Health
100%
The Huntercombe Hospital Edinburgh
Child & Adolescent Mental Health
100%
The Huntercombe Hospital Cotswold Spa
Child & Adolescent Mental Health
100%
Blackheath Brain Injury Rehabilitation Unit
Brain Injury & Neurodisability
100%
Frenchay Brain Injury Rehabilitation Unit
Brain Injury & Neurodisability
100%
The Huntercombe Hospital Roehampton
Adult Mental Health & Learning Disability
100%
The Huntercombe Hospital East Yorkshire
Adult Mental Health & Learning Disability
100%
The Huntercombe Centre Sherwood
Adult Mental Health & Learning Disability
100%
James House
Adult Mental Health & Learning Disability
100%
Beech House
Murdostoun Brain Injury Rehabilitation
Centre
Adult Mental Health & Learning Disability
100%
Brain Injury & Neurodisability
100%
Cedar House
100%
The Huntercombe Hospital Norwich
Adult Mental Health & Learning Disability
Child & Adolescent Mental Health and
Adult Mental Health & Learning Disability
Ashley House
Adult Mental Health & Learning Disability
100%
The Huntercombe Centre Derby
Stocksbridge Brain injury Rehabilitation
Centre
Adult Mental Health & Learning Disability
86%
Brain Injury & Neurodisability
83%
Watcombe Hall
Adult Mental Health & Learning Disability
75%
The Huntercombe Centre Redbourne
Adult Mental Health & Learning Disability
66%
The Huntercombe Centre Crewe
Brain Injury & Neurodisability
60%
The Huntercombe Centre Sunderland
Addictions
52%
Huntercombe Services Nottingham
Brain Injury & Neurodisability
46%
Abbeymoor Neurodisability Centre
Brain Injury & Neurodisability
44%
The Huntercombe Centre Cambridge
Adult Mental Health & Learning Disability
38%
St Germans
Adult Mental Health & Learning Disability
33%
Murdostoun Neurodisability Centre
Hothfield Brian Injury Rehabilitation &
Neurodisability Centre
Brain Injury & Neurodisability
29%
Brain Injury & Neurodisability
26%
Pathfields Lodge and Greenfields
Adult Mental Health & Learning Disability
25%
Murdostoun Castle
Addictions
25%
The Huntercombe Centre Peterlee
Adult Mental Health & Learning Disability
23%
The Huntercombe Centre Birmingham
Adult Mental Health & Learning Disability
17%
100%
9
Service Name
Service Type
% of NHS
Patients
Huntercombe Services Granville Lodge
Children with Special Needs
17%
Stanhope Neurodisability Centre
Brain Injury & Neurodisability
16%
Kings Delph Lodge
Adult Mental Health & Learning Disability
14%
Meadowbrook Neurodisability Centre
Brain Injury & Neurodisability
14%
Portland House
Adult Mental Health & Learning Disability
13%
Huntercombe House Stockton
Children with Special Needs
13%
South Quay Neurodisability Centre
Brain Injury & Neurodisability
11%
Aspley Neurodisability Services
Brain Injury & Neurodisability
8%
Beeton Grange
Adult Mental Health & Learning Disability
5%
The Dell
Adult Mental Health & Learning Disability
4%
The Royd
Adult Mental Health & Learning Disability
4%
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Section Two
Priorities for Improvement and Statements of Assurance from
the Board
Our Priorities for 2013 / 2014
The following priorities have been agreed, taking into account the views of staff, feedback
that we have received from those using our services through our service user surveys, audit
reports and commissioner requirements and priorities for 2012/2013.
The priorities are set out in accordance within the following domains:
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Safety
Effectiveness
Involvement
Clinical Leadership
We also aim to strengthen our Quality Systems and to continue to improve our regulatory
compliance.
Priority One
To continue to strengthen and embed our quality monitoring systems and
improve our regulatory compliance across the Group.

To consolidate the implementation of our Integrated Governance Framework at all
levels across the group and improve the flow of information.

To strengthen our H&S arrangements and reporting framework at local, divisional and
group level.
Priority Two
To continue to develop the way we measure and monitor patient safety and
take appropriate actions to ensure that the people who use our services are
not harmed.

To strengthen our infection control arrangements and monitoring of infection control
practices within all our patient environments through the development and
implementation of standardised audit tools and increasing compliance with mandatory
training.

To implement the DATIX Risk Management System across the group to enable us to
improve the management of all incidents and standardise the reporting of incidents
complaints and alerts.
11
Priority 3
Clinical Effectiveness is about doing the right thing at the right time for the
person using our services to achieve the right outcome. To improve clinical
effectiveness we will:

To review our care documentation within each or our three divisions and improve
standards of record keeping.

To continue to promote evidence based practice, research and innovation across the
Huntercombe Group though arrange of initiatives including an Annual Clinical
Conference, Workshops and Educational Forums.

Improve outcomes and outcomes monitoring across all three divisions, through the
exploration of appropriate IT solutions.
Priority 4
To provide welcoming, responsive services that listen and respond to those
who use them and their families and carers and to demonstrate respect,
dignity, choice and involvement.

To develop clear frameworks and standards for patient involvement within each of our
divisions.
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To explore the potential to develop a PEARL Accreditation Programme in our
Neurodisability services. This would be based on a similar model to the award winning
PEARL Dementia programmes developed by Four Seasons Healthcare.

To ensure a routine programme of satisfaction surveys across all services to illicit
feedback from those who use our services, the families and carers and those who refer
to us.
Priority 5
To strengthen clinical leadership and further develop our professional
frameworks to ensure best practice.
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To develop a new professional nursing strategy for the group.
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To explore opportunities for clinical leadership development across all services.
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Section Two
Statements Relating to the Quality of NHS Services Provided
Review of Services
During 2012/2013 the Huntercombe Group provided and / or subcontracted 42 NHS Services.
These have been described in Section 1.
The Huntercombe Group has reviewed all the data available to them on the quality of care in
100% of these NHS services.
The income generated by the NHS services reviewed in 2012/2013 represents 100% of the
total income generated from the provision of NHS services by the Huntercombe Group for
2011/2012.
Participation in Clinical Audits
During 2012/2013 five national clinical audits and one national confidential enquiries covered
NHS services that the Huntercombe Group provides.
During that period the Huntercombe Group participated in 0% national clinical audits and
100% national confidential enquiries of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and the national confidential enquiries that the Huntercombe
Group was eligible to participate in during 2012/2013 are as follows:
National Clinical Audits:
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RCPH National Childhood Epilepsy Audit
National Adult Diabetes Audit
National Audit of Psychological Therapies
Prescribing in Mental Health Services (POMH)
National Audit of Schizophrenia
National Confidential Enquiries:

National Confidential Enquiry into suicide and homicide by people with mental illness
The national clinical audits and national confidential enquiries that the Huntercombe Group
participated in, and for which data collection was completed during 2012/2013, are listed
below alongside the number of cases submitted to each audit as a percentage of the number
of registered cases required by the terms of that audit or enquiry.
The National Confidential Enquiry into suicide and homicide for people with mental illness
100%.
13
The Huntercombe Group regularly receives and reviews local clinical audit reports at both unit,
divisional and group level. Each service has a programme of audits that are conducted
throughout the year. Findings of the audits are shared via out integrated governance
framework to ensure that the experience is shared, lessons learned and action plans
monitored.
Participation in Clinical Research
The number of patients receiving NHS services provided or sub-contracted by the
Huntercombe Group in 2012/2013 that were recruited during that period to participate in
research approved by a research ethics committee was 20.
These patients participated in the following research projects:

A multicentre Ravello profile research project, which is studying the neuro-cognitive
functioning of people with anorexia nervosa (Huntercombe Hospital Maidenhead and
Huntercombe Hospital Stafford).

Rehabilitation of Memory following Traumatic Brain Injury – Phase III Randomised
Control Trial (The Huntercombe Centre Nottingham)

Do sleep difficulties exacerbate cognitive defects following head injury in an inpatient
rehabilitation population? (Murdostoun BIRC)

Prevalence and types of sleep problems in head injury patients during the
rehabilitation period (Murdostoun BIRC)

Unawareness of memory defects following brain damage (Blackheath BIRC)
Goals agreed with Commissioners
A proportion of The Huntercombe Group‟s income in 2012/2013 was conditional on achieving
quality improvement and innovation goals agreed between the Huntercombe Group and any
person or body they entered into a contract, agreement or arrangement with for the provision
of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment
framework.
During 2012/2013 the Huntercombe Group met or exceeded all it‟s Commissioning for Quality
and Innovation targets across all relevant service groups and has plans in place to ensure that
we continue to meet all of our CQUIN targets for 2013/2014.
Further details of the agreed goals for 2012/2013 and for the following 12 month period are
available on request by email to brett.cowell@huntercombe.com
14
What others say about The Huntercombe Group
The Huntercombe Group is required to register with the Care Quality Commission and has full
registration under the Health & Social Care Act 2008. The group is currently registered in
respect of the following regulated activities:

Assessment of medical treatment for persons detained under the Mental Health Act
1983.

Treatment of disease disorder and or injury.

Diagnostic and screening procedures.

Accommodation for persons requiring nursing or personal care.
The Huntercombe Group has no conditions on its registration.
The Care Quality Commission has taken enforcement action against the Huntercombe Group
on three occasions during 2012/2013.
Warning notes were received by three of our services:
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Huntercombe Hospital East Yorkshire
Ashley House Hospital
Crewe Neurodisability Centre
In each of the services, robust action plans were developed to address the inspection
findings; these were closely monitored by the Huntercombe Senior Management Team. In all
three services significant progress was made and when re-assessed by the CQC were found to
be fully compliant again.
The Huntercombe Group has participated in the Care Quality Commission Thematic Probe into
restricted practices.
The Huntercombe Group intends to take the following action to address the conclusions or
requirements reported by the CQC:

Detailed action plans have been put in place to address the findings related to
individual services that were reviewed as part of the process.

Regular progress reports are being submitted to the CQC.

The Mental Health & Learning Disability Division Senior Management Team and
Integrated Governance Committee are reviewing the CQC review reports as they are
received.
The provider is continuing to make progress in the implementation of these action plans and
where the CQC had noted concerns most services have been re-inspected by the CQC and all
have demonstrated significant improvements and increased levels of compliance with the
Essential Standards of Quality and Safety.
15
Data Quality
The Huntercombe Group is working towards compliance with the NHS Information
Governance Toolkit and is implementing action plans to address areas of non-compliance.
NHS Number and General Medical Practice Code Validity
The Huntercombe Group did not submit records during 2012/2013 to the Secondary Uses
service for inclusion in the Hospital Episode Statistics which are included in the latest
published data.
Clinical Coding
The Huntercombe Group was not subject to the Payment by Results clinical coding audit
during 2012/2013 by the Audit Commission.
16
Section Three
How we have performed in 2012 / 2013
Celebrating Success
During 2012/2013 the Huntercombe Group celebrated success through the achievement of a
number of coveted national awards and accreditation.
Adult Mental Health Services
Within our Adult Mental Health and Learning Disability our service at Moorpark Place achieved
National Autistic Society (NAS) Autism Accreditation for its specialist knowledge of autism and
good practice in the treatment and high standards of care and support for adults on the
autistic spectrum including Aspergers Syndrome and or displaying autistic traits.
Brain Injury & Neurodisability Services
Within our Brain Injury and Neurodisability Services, Frenchay Brain BIRU won a prestigious
specialist care award for excellence in the provision of brain injury rehabilitation. Frenchay is
a Level 1 specialist neuro-rehabilitation hospital in Bristol which provides assessment and
treatment for people who have suffered a brain injury. The award recognises excellence and
effectiveness and the unit was able to demonstrate this through initiatives including new
treatment programmes to support people with eating and drinking and an upper limb pathway
that uses mirror therapy as a treatment in aiding recovery and movement in the arm after a
brain injury.
Business Management
The Huntercombe Group also achieved an Award for its use of the internet. The Digital
Entrepreneur Awards celebrate internet entrepreneurialism and The Huntercombe Group‟s
success in re-developing its website articulates our commitment to accessibility standards and
the development and introduction of a new clinical portal that will improve interactions with
clinicians and commissioning groups.
17
Progress against our 2012/2013 Priorities
In this section of the report we outline our progress against our priorities for 2012/2013 and
our performance against a number of key quality indicators.
Priority One
To harmonise and strengthen our quality monitoring systems and improve our
regulatory compliance across the Group.
Integrated Governance
We now have established Integrated Governance frameworks in place across all our services
from individual service level to board level. These are becoming integral to our service
provision and we are working hard to harness the commitment and involvement of all our
staff.
We have reporting mechanisms and systems in place that enable us to identify what is going
well within our services, to share this information and build upon best practice. It also
enables us to identify where improvements need to be made, agree how these improvements
will be achieved, monitor progress and to share learning.
Our Integrated Governance Committees now receive regular reports from each service area
together with compliance tracker information on internal and external inspections, health and
safety reports, infection control, CQUIN reports and key quality indicators reports on
Complaints, Serious Incidents, Safeguarding, Medication Incidents and pressure ulcers. Our
intention is to further develop our quality dashboard over the year head and to incorporate
our new contractual quality reporting requirements.
Our Quality Performance Monitoring System (QPM)
Early in 2012 we launched our phased implementation of our new Quality Performance
Monitoring System (QPM) within the Group. The Quality & Performance Monitoring System
(QPM) is an internally designed / built database which tracks and reports on compliance with
the Health and Social Care Act 2008.
The Care Quality Commission regulates our services against the Essential Standards of Quality
and Safety, in particular against the sixteen „key outcomes‟ using the Judgement Framework.
Any inspections against the outcomes carried out by the CQC are logged in the QPM and
Registered Managers then input any remedial actions required to address areas of
improvement required in the report. The benefit of logging all inspection reports in the QPM is
that we are now more able to compare results of inspections across The Huntercombe Group,
analyse any trends, address corporate issues where needed, identify potential training need
and review our policies and procedures where necessary. Importantly it also allows us to
identify and share best practice across our services. Reports are reviewed at regular intervals
by members of the senior management team.
18
In addition to logging external inspection reports, the QPM system also allows the
Huntercombe Group to:

Track self-assessments against the standards; this is achieved through Registered
Managers being able to input data regularly on their level of compliance based on
audit results, patient feedback etc.

Internal inspections carried out by the compliance team are logged in order to
centrally track recommendations made to sites to ensure constant service review and
improvement in addition to the celebration of good practices.
Any areas of non-compliance are then highlighted and remedial actions agreed and entered
along with a lead accountable person and deadline for completion, the system can generate
reminders to the lead person when deadlines are approaching. Much work has recently been
undertaken to improve the QPM system to allow for easier use and more robust reporting
We are now launching the trial of the system for use in Scotland, once completed further
work will be undertaken to include MHA inspections and OFSTED reports in order to support a
full compliance review for all units within The Huntercombe Group.
Policies and Procedures
On 1st April 2013, Four Seasons Healthcare and The Huntercombe Group launched a new suite
of Care and Clinical and Health & Safety Policies and Procedures.
This launch follows a major project which involved bringing together policies and procedures
relating to the Four Seasons Healthcare, The Huntercombe Group, the former Care Principles
and Southern Cross Services and harmonising these into an initial single suite of corporate
policies for use across the organisation.
From the end of January 2013, when the policies were ratified, to the launch date on 1st April
2013 work has been undertaken to familiarise staff with the process and that new
documentation and to establish new mechanisms for on-going reviews.
Despite the huge amount of work that has been undertaken to date the Company recognises
that it will take more time for staff to become fully conversant with the new policies and for
them to be embedded in practice. In developing a common set of policies, the Company is
aware that there will need to be further improvements and adjustments made to
accommodate regional and service specific variations in practice. The Company is committed
to making these adjustments in response to feedback over the forthcoming weeks and
months to ensure that we establish a new set of policies that are fit for purpose and
embedded into practice.
Feedback mechanisms have been created to ensure all staff a means of giving feedback on
the policies this includes the use of feedback forms and a dedicated policy questions and
feedback email address. We will be reviewing this feedback on a regular basis and updating
the policies in accordance with identified needs.
19
Priority Two
To continue to develop the way we measure and monitor patient safety and take
appropriate actions to ensure that the people who use our services are not
harmed.
Infection Control Practices
We continue to strive to improve infection control practices within all our patient environments
and to continue to reduce the incidence of pressure sores and MRSA.
After seeing a significant reduction in the incidence of MRSA across the group in the last two
years we set ourselves a target to achieve zero incidence of MRSA across the Group in
2012/2013.
Unfortunately we saw a slight increase in the incidence of MRSA with the number of cases
reported increasing from 2 to 5 reported cases across the group. Of these 3 cases were
acquired by patients prior to admission to one of our Brain Injury and Neurodisability Services.
We are planning to continue our focus on improving our infection control practices and
strengthening the provision of education for our infection control leads during the year ahead.
Datix Risk Management System
In the first half of the year the Datix Manager post was recruited to, and an in-depth analysis
of the strengths and weaknesses of the existing system carried out. As a result of usability
and data quality issues highlighted by this report, the development of a new system
implementing the latest version of the software was recommended. Work to develop more
streamlined selection and analysis options was carried out through the re-formed Datix Project
Group, via consultation with specialist advisors, and following visits to a number of sites. A
separate group was convened to deal specifically with implementation of the system in those
sites not yet using Datix.
Complaints, concerns and compliments can be managed in the new version of Datix, including
the automatic production of acknowledgement letters from standard templates to ensure a
consistent response across the division. Once the Incidents and Complaints modules have
been implemented, it is anticipated that development of the Safety Alerts module will
commence.
Support for the new system is provided via a number of routes, including face-to-face training
sessions across the country, and the introduction of an innovative new e-learning system. This
simulates Datix in a safe environment and thus allows staff to familiarise themselves with the
various options, but without the possibility of adversely affecting the system.
The implementation of the revised Datix system is scheduled for 1st August 2013 in those sites
already using the software (later than anticipated due to delays in receiving the latest version
of the software). Sites not currently using Datix will receive dedicated training from
September 2013, and will begin using the system from 1st January 2014.
20
Priority 3
Clinical Effectiveness is about doing the right thing at the right time for the person
using our services to achieve the right outcome.
My Shared Pathway Implementation
During 2012/201 My Shared Pathway (MSP) has been implemented cross all Learning
Disability Adult Mental Health & Learning Disability secure services. My Shared Pathway is a
process to help service users manage their stay in secure services by encouraging
responsibility and control over their own recovery. By working with staff they are encouraged
to set goals or outcomes that can be achieved to help them move through the secure service
more quickly and on to a less restrictive environment. Service users are encouraged to reflect
on how they came to be in a secure service and maintain or improve their existing skills
during their stay.
Prior to the 2012 / 2013 the Huntercombe Group had undertaken significant work towards
restructuring the CPA process towards a recovery orientated approach which echoed the
values raised with in My Shared Pathway. Training for MSP was delivered through July 2012August 2012 for all of our secure sites, followed by select community services that were
working to achieve a rehabilitation services CQUIN.
Evidencing recovery orientated practice through the use of a recognised recovery tool is
essential in completion of MSP. Within the Huntercombe Group we have selected the
Outcomes Star as the tool of choice and the first phase of roll out of the Outcomes Stars (life,
Mental Health Recovery and spectrum) is now complete. From August 2012 to June 2013, the
full licence of 200 outcome star assessors will have been trained.
During the past year we have met and on occasions exceeded our targets for implementation.
In Quarter 1 our objective was to establish joint recovery and outcomes groups. This was
achieved and all sites have a group that meets regularly on site and they also attend the
Regional groups led by the National team.
In Quarter 2 the target was to have completed the training programme for all secure sites.
Our Compliance team embarked on site training ahead of the target and the majority of sites
had received joint training (staff and patients) for the recovery and outcomes group by early
August. These groups then proceeded to train the staff and patients at site, with the aim of
completing 100% by September 2012. This was again achieved.
The objective for Quarter 3 was for 50% of patients to have completed a shared
understanding booklet and baseline outcomes scores for my outcomes plans and progress
evidencing the use of a recovery tool and the 4 pathway step process. Individual sites met
and/or exceeded this. We also developed a questionnaire for all patients to gain an objective
measure of who had completed the training, level of understanding of the process and % who
had commenced the pathway. 64% of patients completed the questionnaire, 11% declined.
The corporate average for having received training was 43%, understanding of the process
51% and having commenced the paperwork 41%. This survey evidenced that THG
21
demonstrated proactive approach to implementing MSP and were ahead of the CQUIN targets
laid down for the year. This pre-empted the National drive that later developed their own
measure to assess patient involvement and understanding.
By Quarter 4, all patients were to have outcome plans and progress completed evidencing the
four pathway steps and the use of a recovery tool. In line with this, by the end of Q4 all
secure sites reported that all patients had a 4 step pathway outcome plan in place which is
evidenced through the CPA documentation.
In recognition of the innovative and proactive work undertaken in relation implementing MSP,
The Huntercombe Group was shortlisted as a finalist in the Specialist Healthcare awards,
presented as a keynote speaker at the National conference and secured a role within the East
of England Regional lead group.
Clinical Conference and Workshops / Educational Forums
To continue to promote evidence based practice, research and innovation across the
Huntercombe Group has arranged of number of initiatives including a very successful Annual
Clinical Conference, together with service specific Workshops and Educational Forums.
To improve outcomes and outcomes monitoring across all three divisions, we have developed
a Huntercombe Group Clinical Portal. This is an innovative digital platform due to be launched
in 2013 that will enable healthcare professionals and commissioners to share best practice,
outcomes, research, skills, training and industry news within an encrypted network hosted by
The Huntercombe Group.
Priority 4
To provide welcoming, responsive services that listen and respond to those
who use them and their families and carers and to demonstrate respect,
dignity, choice and involvement.
Provision of Structured Activities (CAMHS)
To promote a balanced and structured day for people using our CAMHS services, our aim was
for them to be fully involved in a minimum of 20 hours meaningful activity each week which
was linked to an agreed care plan which aims to promote and aid recovery. This was one of
our CQUIN Targets and was monitored on a quarterly basis and reports submitted to our
commissioners. Throughout 2012/20013 our services successfully achieved this target each
quarter.
PEARL Accreditation
The award winning PEARL (Positively Enriching and Enhancing Residents Lives) Accreditation
Programme has been implemented in Four Seasons Healthcare since 2008. The programme
was introduced to recognise dementia care units that are providing excellent care for their
residents and to support the units to become leaders in their field.
22
In 2012 / 2013 it was agreed that the Huntercombe Group would explore the development
and possible introduction in a specialist PEARL programme within Group‟s Brain Injury and
Neurodisability Services. This initiative was met with significant enthusiasm by staff within
our brain injury services and following an initial workshop with managers the decision was
made to conduct a baseline assessment in our Neuro-disability Centre in Crewe to assess its
suitability for PEARL and to test the PEARL Criteria with this patient group. As a result of this
assessment and an adaptation of the PEARL criteria plans are being put in place for initial roll
out. This work will be undertaken during the forthcoming year and is one of our Quality
Objectives for 2013/2014.
Patient Surveys & Feedback
We have continued to ensure a routine programme of satisfaction surveys across all services
to obtain feedback from those who use our services, the families and carers and those who
refer to us and ensure that actions are taken in response to the findings. Results from a
sample of surveys are included in this Quality Account.
23
Commissioning for Quality and Innovation (CQUIN) Performance
CAMHS 2012/13 CQUIN Performance
Q1
Q2
Q3
Q4
Clinical Dashboard
100% achieved
100% achieved
100% achieved
100% achieved
Provision of education, training
and meaningful activity
100% achieved
100% achieved
100% achieved
100% achieved
Patient involvement in
recruitment
100% achieved
100% achieved
100% achieved
100% achieved
Patient flow
100% achieved
100% achieved
100% achieved
100% achieved
Junior MARSIPAN
100% achieved
100% achieved
100% achieved
100% achieved
Low Secure 2012/13 CQUIN Performance
Q1
Q2
Q3
Q4
Shared Pathway - recovery and
outcomes
100% achieved
100% achieved
100% achieved
100% achieved
Implementing a standard secure
pathway
100% achieved
100% achieved
100% achieved
100% achieved
Feasibility project - “PbR”
100% achieved
100% achieved
100% achieved
100% achieved
Clinical dashboard
100% achieved
100% achieved
100% achieved
100% achieved
Access to specialised mental
health services
100% achieved
100% achieved
100% achieved
100% achieved
Optimising length of stay
100% achieved
100% achieved
100% achieved
100% achieved
20 User defined CPA standards
100% achieved
100% achieved
100% achieved
100% achieved
24
Locked Rehab 2012/13 CQUIN Performance
Q1
Q2
Q3
Q4
Best practice implementation
(25 hours activity)
100% achieved
100% achieved
100% achieved
100% achieved
Further implementation of
Recovery Planning Tools
100% achieved
100% achieved
100% achieved
100% achieved
Integration with National Secure
Pathway
100% achieved
100% achieved
100% achieved
100% achieved
Ensure length of stay for Acute
Mental Health inpatients in the
care of MHTs are kept to a
minimum
100% achieved
100% achieved
100% achieved
100% achieved
Transparency for carers and
public on outcomes and
involvement in improvement
100% achieved
100% achieved
100% achieved
100% achieved
Frenchay BIRU 2012/13 CQUIN Performance
Q1
Q2
Q3
Q4
VTE assessment on admission
100% achieved
100% achieved
100% achieved
100% achieved
Carers experience
100% achieved
100% achieved
100% achieved
100% achieved
NHS Safety Thermometer
100% achieved
100% achieved
100% achieved
100% achieved
Contingency planning for
Frenchay
100% achieved
100% achieved
100% achieved
100% achieved
redevelopment
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Routine Performance Monitoring
Complaints
Within The Huntercombe Group we take all complaints and concerns about our services
seriously and deal with them all in accordance with our agreed Complaints Policy and
Procedure.
We recognise that there will be occasions when people who use our services or their family
and carers are dissatisfied with aspects of the care and services we provide and we are
committed to dealing with any such problems that may arise as effectively as possible. We
also wish to address any issue raised at the earliest possible opportunity and most local level.
By dealing immediately with any concern or complaint we reduce the risk of escalation and
increases the possibility of finding a satisfactory resolution to the problem.
We aim to ensure that all our staff are trained in dealing with concerns and complaints and to
ensure that all people who use our services have access to guidance on the procedures for
raising a concern or making a complaint. We are also committed to ensuring that lessons
learned from concerns and complaints are used as a means of improving standards of care
and the quality of our services.
During 2012 / 2013 a vast majority of our complaints were dealt with informally at the point
at which they were received to the satisfaction of the complainant. Where complaints are not
able to be resolved immediately to the satisfaction of the person making the complaint, they
are passed to the Hospital or Home Manager and are then fully investigated in accordance
with our formal complaints procedure. All complaints in writing or at the request of the
complainant are treated as a formal complaint.
The graphs below give details of the number of all formal complaints received by The
Huntercombe Group in 2012 / 2013 and an overview of the nature of the complaint.
Figure 1: Number of Formal Complaints and Overview of the Nature Received by
Division during 2012/ 2013
Adult Mental Health & Learning Disability Services
Complaints Received
Complaints Upheld
Quarter 1
Quarter 2
Quarter 3
Quarter 4
20
8
37
5
41
16
77
31
26
Brain Injury & Neurodisability Services
Complaints Received
Complaints Upheld
Quarter 1
Quarter 2
Quarter 3
Quarter 4
5
2
11
1
6
2
13
4
Child Adolescent and Mental Health Services
Complaints Received
Complaints Upheld
Quarter 1
Quarter 2
Quarter 3
Quarter 4
17
3
10
0
10
2
16
0
Huntercombe Hospital Norwich transferred to the CAMHS Division in Quarter 3. The figures in the chart reflect all
complaints received from Quarter 1 by Huntercombe Hospital Norwich (previously Rowan).
27
Incident and Accident Reporting
We continue to monitor all accidents and incidents across the Huntercombe Group but as a
result of the expansion in our services over the past year, further work is still required to
harmonise accident and incident policies and procedures across each of the three divisions.
The accidents and incidents reported during 2012 / 2013 identified a number of key themes:



There appears to be a positive reporting culture across the group for incidents,
accidents and safeguarding concerns
There were no “never events” reported during 2012 / 2013
Levels of incidents within or MH/LD and CAMHS services were higher than other parts
of the group – as would be expected with the types of services provided
We currently report serious untoward incidents in accordance with our commissioner‟s
requirements. New definitions of Serious Incidents and reporting requirements have been
agreed as part of our contract. The figures below relate to the number of serious untoward
incidents reported by each division in accordance with their own specific definitions/needs.
Figure 2: Number of Serious Incidents Requiring Investigation in 2012/2013 by
Division
16
14
12
ADMH&LD
10
8
CAMHS
6
BIND
4
2
0
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Huntercombe Hospital Norwich transferred to the CAMHS Division in Quarter 3. The figures in the chart reflect all
complaints received from Quarter 1 by Huntercombe Hospital Norwich (previously known as Rowan House).
28
Skin Integrity
We have continued to see a significant reduction in pressure ulcers within our neuro-disability
and neuro-rehabilitation services. In 2010/2011 there were a total of 39 pressure ulcers
reported within NHS commissioned services in England and in 2011/2012 there were 22
pressure ulcers reported. This year the number is 27, with many of these arising prior to
admission to our services. This is a small increase in the number reported last year but is
reflective of the increasingly complex and dependant patients being admitted within our brain
injury and Neurodisability services.
The graph below shows the incidence of pressure ulcers by grade for 2012 / 2013 and
includes both those that have formed whilst in our care and those that were acquired prior to
admission.
Figure 3: Incidence of Pressure Ulcers by Grade
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Grade 1
Grade 2
Grade 3
Grade 4
0
0
0
3
3
3
5
7
1
0
1
3
4
3
6
14
Grade 1
Non blanchable erythema (redness) of intact skin.
Grade 2
Partial thickness skin loss. Presents as abrasion or blister.
Grade 3
Full thickness skin loss. No exposure of bone/tendon/Muscle.
Grade 4
Full thickness skin loss. Bone, tendon or muscle exposure.
During the year ahead we will take steps to maintain and continue to improve our assessment
and management of skin integrity by ensuring appropriate assessment of skin integrity for
those people who use our services, deliberate prevention of functional decline in skin integrity
and through appropriate wound management including wound assessments.
Patient Satisfaction
In early 2013 we conducted our annual survey of patients and residents within our Adult
Mental Health and Learning Disability Services. In total 250 patients and residents out of a
possible 419 agreed to participate in the survey. Giving a response rate of 60%.
The survey was based on the CUES questionnaire (Carers and Users Expectations of Services),
the NHS Service User Survey and the National Learning Disabilities Survey. The questions
were adapted where requires for adults with a learning disability often residing in secure
environments. Where needed, communication support was provided allowing patients to
indicate their preferred responses to individual questions.
29
The graphs below outline the percentage of people who stated they were happy or felt
satisfaction in each of the areas covered within the survey. These scores give an overall
percentage for a number of individual questions in each section of the questionnaire.
The results are now being considered by the individual services and actions plans put in place
to address the findings.
Figure 4: Patient Survey
120%
100%
80%
60%
40%
2012
2013
20%
0%
These results indicate an improvement in satisfaction across all areas with exception of
satisfaction with support provided by outside professionals. This year the questions in this
section of the questionnaire were extended to include non-medical professionals such as
chiropody services and the provision of information, which may explain the slight drop in
levels of satisfaction in this area.
Other highlights within the survey findings include:

Over 90% of patients /residents like there room and 85% consider the place where
they live to be clean.

89% of patients / residents stated they knew who to contact if they wished to raise a
concern about their safety.

91% of patients / residents stated they knew how to complain and who to complain to
if they wished to.

82% of patients / residents felt that nursing or care staff gave them the support they
needed when they asked for help.
30
Areas where we will continue to take actions to improve our patients and residents
satisfaction:

Only 60% of patients / residents felt they had enough to do to keep themselves busy
in the evenings and at weekends.

Only 49% of patients / residents reported that they do not get to see reports written
about them prior to review meetings.

Only 63% of patients / residents feel they are given the opportunity to meet their
cultural needs.
A further survey will be undertaken in 2014.
Child and Adolescent Mental Health Services
Within our CAHMS Services regular surveys of both Patient and Parent Satisfaction have been
undertaken on an on-going basis throughout the year both during treatment and upon
discharge.
Recent findings from the CAMHS satisfaction survey undertaken at Huntercombe Hospital
Maidenhead identified the following:

Overall, there were no significant differences between responses from patients on
different units.

Patients across the hospital reported feeling increasingly better and an improvement in
their ability to get on with their day-to-day life since their admission into the hospital.

Patients across the hospital would like staff members to be more available to talk to
about their worries and things they do not understand.

Patients report a clear understanding of unit guidelines and expectations, and their
rights under the Mental Health Act.

The majority of patients report staff making are working hard to involve them in their
treatment.

Patients from all units stated that they understood why they were taking the
medication prescribed to them; patients on Kennet would like clarification regarding
side effects of prescribed medication.

The majority of patients express having an involvement in their CPAs and patients on
Kennet found CPAs to be useful.

Patients across the hospital would like to see their key workers more often.

Patients on Kennet report being involved in making their care plans; patients on other
units would like more involvement.
An action plan has been put in place to address these findings and will be monitored by the
local integrated governance committee.
31
Brain Injury and Neurodisability Services
The annual survey of patients within our Brain Injury and Neuro-disability Services is currently
underway. The results from this survey along with the actions taken in response will be
included in our next annual quality account.
Referrers Surveys
Each year The Huntercombe Group conducts surveys of all its referrers. The aims of the
surveys is to gauge customer perception of The Huntercombe Group as a provider of
specialised services, to determine customer satisfaction across the Group, to better
understand the key drivers for referral and customers‟ future needs and to identify strengths
and weaknesses.
During 2012/2013 surveys have been undertaken for four of our five service streams. The
survey for adult mental health and learning disabilities is currently underway.
Referrers were asked to rate various aspects of our service. The following graphs show how
each service was scored out of ten against each criteria. Some criteria were not relevant for
some services, for example, education provision for brain injury services. Where this is the
case, no score is shown for the service.
Individual services and our Business Development Team are now working to ensure that these
levels of satisfaction are maintained or improved during the year ahead.
Figure 5: Aspects of our Service
32
Figure 5: Aspects of our Service Continued
The following comments were made by referrers:

Very impressed by the level of commitment in working with challenging behaviours and
able to be flexible with service users in meeting their needs”. (Abbeymoor Neurodisability
Centre)

“I believe the services provided are very professional and there is good communication
and liaison with the staff”. (Blackheath Brain Injury Rehabilitation Centre and
Neurodisability Service)

"Huntercombe Edinburgh- excellent management of very difficult cases, very good support
post- discharge". (The Huntercombe Hospital – Edinburgh)

The standard of care received in respite is high(Granville Lodge) "Good quality of service
from eating disorder unit in Maidenhead (The Huntercombe Hospital-Maidenhead)

“Overall I have been very impressed with the unit. There is always plenty of staff and
everyone has a professional manner. There is no doubt that the patients get excellent
care. Well done!” (Frenchay Brain Injury Rehabilitation Centre)
33