Quality Account
2012/13
Contents
Page
PART ONE
Statement on Quality from the Chief Executive
2-3
PART TWO
Priorities for improvement 2013/14
4-8
Statement of Assurance from the Board
9
Review of services
10-11
Participation in clinical audits
12-16
PART THREE
Review of quality performance in 2012/13
17-23
Statements from local CCG and Healthwatch
24
Glossary
25
1
PART ONE
Statement on Quality from the Chief Executive
I am pleased to introduce The Retreat’s Quality Account for
2012/13.
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 further the quality of our services. It also
describes some of the systems we have in place to measure
quality.
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 2012/13, 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 16 and 17.
I am pleased to report that we successfully opened a new GP Consulting Room and
Pharmacy on our site, both of which represent a significant improvement to the quality of
service we provide to the people who use our services. In August 2012 we contracted out
the catering service to Wilson Vale with the aim of improving quality. Given this and the
increased investment we have made in this area, it was disappointing to read in the Patient
Satisfaction Survey that our patients are not happy with this. We need to understand this
as it does not tie in with the regular feedback we have received at the monthly catering
meeting that the quality of catering is improving after some initial teething problems.
Our Clinical Governance systems continue to develop and in 2012/13 the Quality,
Compliance and Business Unit continued to refine our Quarterly Governance Report, the
cornerstone of our clinical governance systems. Information Management is an
increasingly critical part of the organisation and we continue to explore ways in which we
can use information technology to assist us. The successful implementation of the Ulysses
system for incident reporting was a very good example of this.
2
All services have been routinely collecting outcome data and producing an annual clinical
review for some years. We are particularly interested in finding out what happens to
people post discharge and are thinking about how we might obtain regular and systematic
information on this. We want to assist people to achieve a recovery that is sustainable. 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 previous
years’, there were still concerns raised about communication, consultation, valuing staff
and levels of pay. We have been able to go some way towards addressing the latter in
relation to our lowest paid staff and have made a commitment to implementing the “Living
Wage” for all staff as soon as we are able. We will be working with the Staff Consultative
Committee to address issues of concern raised in the Staff Survey.
In 2012 we conducted the second round of appraisals under the new system, having
modified this following feedback from staff. The appraisal includes a grading for all staff
and, whilst this remains unpopular, we believe this is an important part of any appraisal and
are keen to retain it. Following the appraisal round we conducted a survey of staff to obtain
their feedback and will be making further changes to the system in response to this. We
continue to carry out our quarterly face-to-face team briefings and these are well received.
The Care Quality Commission was happy with the progress we had made with improving
the quality of our record keeping in terms of recording the high level of patient involvement
in care and care planning.
I am pleased to report three units received external recognition for the quality of the
services they provide. In May 2012 two units (George Jepson and Katherine Allen) were
presented with ‘Full Monty’ Star Wards award by Marion Janner, OBE. Run by the charity
Bright, Star Wards is a project devised by Marion consisting of 75 ideas to make life for
mental health inpatients more active, interesting and therapeutic. Wards which implement
all of the ideas are awarded a ‘Full Monty’ award.
In January 2013 the Naomi unit was 'accredited as excellent' to the Quality Network in
Eating Disorders Adult Inpatient Standards (QED) following their peer review last autumn.
Naomi unit is one of five national eating disorder services to achieve the highest level of
accreditation, and one of two independent providers who were accredited.
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 2013/14
PATIENT SAFETY
Priority 1 – To review the Electronic Patient Records (EPR) System.
Rationale
Reporting
The FACE Electronic Patient Record
System is currently utilised across the
organisation. This is scheduled to be
upgraded to a web-based system in
May 2013. A review will be undertaken
to ensure that the functionality
continues to meet the organisation’s
requirements. Alternative EPR systems
will be assessed as part of the review.
Reporting with be through the
Governance Committee and Senior
Management Team via the Director of
Operations.
Project Lead: Project Review Team
(Director of Operations, Audit &
Information Manager, Clinical Team
Manager, Practice Development Nurse,
Senior (II) Occupational Therapist,
Senior Staff Nurse)
Plan

Establish Project Review Team and
Project Lead.

Review the effectiveness of the
current FACE EPR system and trial
upgraded web-based system.

Assess functionality of alternative
EPR systems available.

Produce report of recommendations
for Senior Management Team
following system reviews.

Proceed with updated FACE webbased EPR system or contract with
a different provider for an alternative
system.
Senior Management Lead: Director of
Operations
Monitoring
The monitoring of the actions resulting
from the review will be carried out by
the Director of Operations.
4
CLINICAL EFFECTIVENESS
Priority 2 - To improve the standards of clinical supervision for our nursing staff.
Rationale
Monitoring
Our goal is to ensure people using our
services receive an excellent standard
of nursing care. Clinical Supervision is
an integral part of professional practice
and the NMC guidance is that all nurses
engage in clinical supervision. The
ability to reflect on clinical practice is a
core nursing competency.
The organisation will monitor progress
via audit, appraisal and use of the
Manchester Supervision Scale
Plan
Project Lead: Practice Development
Nurse

Reporting
Progress will be reported through the
Governance Committee.
Increase the number of
appropriately qualified Clinical
Supervisors.

Obtain feedback on the Clinical
Supervisors’ training using an
electronic survey.

Ensure there is an easily accessible
and contemporaneous Clinical
Supervisors’ register.

Establish a bi-annual Clinical
Supervisors’ Forum.

Audit the frequency and quality of
Clinical Supervision.
Senior Management Lead: Director of
Operations
5
CLINICAL EFFECTIVENESS
Priority 3 - To ensure that the people who use our services have access to good
physical healthcare and increase their level of physical wellbeing.
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
via audit and patient evaluation.
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 Chronic Disease
Management Clinics.

Increase smoking cessation
promotion and support by
accessing smoking cessation
services provided by pharmacy staff
trained in smoking cessation.

Ensure all people who use our
services continue to receive a
physical assessment on admission
and an annual physical review.
Project Lead: Practice Development
Nurse
Senior Management Lead: Director of
Operations
6
PATIENT EXPERIENCE
Priority 4 - Encourage further development of Vocational Pathways.
Rationale
Monitoring
Everyone who experiences mental
health problems has the right to
individually tailored support to obtain
employment that matches their
preferences, their strengths and their
needs.
The Social Enterprise Committee (SEC)
will review the progress of the
Vocational Pathway. Goals will be set
for the pathway and will be monitored
by the SEC during its monthly meetings.
Plan
Progress reporting will be to the
Governance Committee through the
Involvement Report and to the Senior
Management Team.

Develop a service that is
underpinned by the philosophies
of recovery and social inclusion.

The services will work in
partnership with external agencies
and groups in the locality to create
vocational opportunities for the
people who use our services.

Enable people who use the
services to be central to the
service design and development
through a localised involvement
structure.

Challenge the low expectations
about and raise awareness of the
employability of people who use
our services, through supported
and independent vocational work.

Develop opportunities in the
community for work experience
and training options.

Act as a link between the people
who use the services and
community services who offer
training opportunities.

Develop social enterprises with the
people who use our services.
Reporting
Project Lead: Involvement
Development Worker
Senior Management Lead: Director of
Operations
7
PATIENT EXPERIENCE
Priority 5 - To ensure that the people who use our services have the opportunity to
give feedback on the quality of the food and the catering service provided.
Rationale
Monitoring
The Care Quality Commission
acknowledge how important it is for
service users to have their views and
experiences taken into account in the
way a service is provided and delivered.
In order to ensure that the people who
use our services enjoy their food intake,
and that the new catering service and
menus meet their nutritional needs, we
will seek their feedback directly.
The organisation will monitor catering
feedback from people who use our
services at the quarterly nutrition forum
meetings. This meeting has service
user representation through the
attendance of the Involvement
Development Worker.
Reporting
Progress reporting will be to the
Governance Committee through the
Nutrition Forum Report and to the
Senior Management Team.
Plan



Continue to carry out an annual
service user satisfaction survey on
the catering service and the quality
of food provided.
Project Lead: Professional Lead for
Dietetics
Ask for specific feedback from the
service users six weeks after the
introduction of any new menu.
Senior Management Lead: Director of
Operations
Continue to invite the people who
use our services to the monthly
catering meetings to provide their
feedback.
8
Statements relating to quality of NHS services provided
Statement of Assurance from the Board
The Retreat’s 11 Directors have a positive and active
involvement in sustaining and developing The Retreat’s
quality standards. They do so in collaboration with the
organisation’s Senior Management Team.
The Board exercises its involvement in a number of
ways:

Through membership of The Retreat’s Governance
Committee which reports to the Board. Two
Directors serve on the committee with one serving
as its Chair. The Governance Committee gathers
and monitors a wide range of quality data.

By receiving and considering a detailed quarterly
report on quality measures, standards and
incidents, together with a mechanism for highlighting key issues The reports are
prepared by the Governance Committee

By individual Directors playing an important role in projects and gaining insights
into operational matters. Their work embraces research, visits to units, staffing
matters and The Retreat’s commitment to providing patients with a spiritual
environment.
Five key priorities are set out in this Quality Account. The successful execution of
these and other projects are vital to the high standards of care that The Retreat has
always aspired to. Be assured that the Board will deliver its responsibilities.
Stuart Humby
Chair of Directors
9
Review of services
During 2012/13 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 2012/13 represents 100% of
the total income generated from the provision of NHS services by The Retreat for
2012/13.
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.
10
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.
The Bungalows are rehabilitation units for women who need additional time to develop
emotional and practical skills before moving into independent or supported living in the
community.
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.
The addition of a Family Therapy Service during the year, guided by our resident family
therapist in conjunction with the rest of the Tuke Centre team, has fulfilled the
expectations of delivering a family service, which includes individual interventions at a
single point of delivery.
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.
11
Participation in clinical audits
Information on participation in clinical audits
The Retreat undertakes an annual Audit Programme which is included as part of our
overall Clinical Audit Strategy. Results are reported at quarterly Audit Group meetings
and in the Quarterly Report of the Governance Committee. The results of 20 clinical
audits were reviewed in 2012/13 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 2013/14 can be provided upon request.
Local clinical audits completed in 2012/13
Compliance
Against
Standards
25 hr Weekly Activity
April
May
June
July
August
Care Plans/Patient Records
September
October
November
January
February
March
Data Protection & Confidentiality
Forms T2/T3 Consent To Treatment
High Dose Antipsychotic Prescribing
HoNOS Scores
Physical Healthcare
Patient Engagement & Observation
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
12
National clinical audit
The organisation has reviewed the list of national clinical audits and enquiries for
inclusion in Quality Accounts 2012/13. There are three National Clinical Audits and one
Clinical Outcome Review Programme applicable to the services provided by The
Retreat. These are as follows:
National Clinical Audits

National Audit of Dementia

National Audit of Schizophrenia

Prescribing Observatory for Mental Health (POMH-UK)
Clinical Outcome Review Programmes
Mental Health Programme: National Confidential Inquiry into Suicide and Homicide for
people with Mental Illness (NCISH)
The Retreat is not eligible to participate in any of these identified due to having
insufficient patient numbers.
The Royal College of Psychiatrists Centre for Quality Improvement (CCQI) offers a
range of audits and inquiries to services as part of their Quality Improvement work.
Our services participate in quality improvement projects available at the CCQI:

The Acorn Programme has for the third time participated in the Community of
Communities appraisal process, and has been accredited.

Naomi unit was one of the pilot services for the Quality Network for Eating
Disorders (QED) and was accredited with Excellence.

Katherine Allen is now participating in the Accreditation for In-patient Mental
Health Services for Older People (AIMS-OP)

Other units are actively preparing to join accreditation processes run by CCQI.
Participation in clinical research
The number of patients receiving NHS funded treatments that were recruited during
2012/13 to participate in research approved by a research ethics committee was ten.
These patients all participated in one approved multicentre project (ref 12/EM/0311)
entitled “Therapeutic Transformations of Self; social interaction in the lives of
therapeutic community client members”. The research is ongoing.
Commitment to research as a driver for improving the quality of care and patient
experience:
This research, together with a further case note review project, represents a significant
development of new collaborative research relationships with the University of
Nottingham, and with the Universities of York and Sheffield. This complements The
13
Retreat’s existing relationship with the York St John University as one of the founding
partners of the Research Centre for Occupation and Mental Health (RCOMH).
Ongoing research and service evaluation projects during 2012/13 included an
examination of case note information and patterns of self-harm and treatment outcome
and an examination of the effect of eating disorders on occupational identity.
The Retreat recognises the importance and potential value of clinical research and has
agreed the funding of a research manager/ facilitator for an initial five year period. The
aim is to develop an effective research culture at The Retreat that further improves
clinical care and treatment. This is intended to be a joint post with a successful
university mental health research unit.
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.
Use of the CQUIN (Commissioning for Quality and Innovation) payment
framework
A proportion of The Retreat’s income in 2012/13 was conditional on achieving quality
improvement and innovation goals agreed between The Retreat and NHS North of
England Specialised Commissioning Group - Yorkshire and The Humber office with
whom they entered into a contract for the provision of NHS Tier 4 Eating Disorders
services, through the Commissioning for Quality and Innovation payment framework.
The Retreat was successful in achieving the CQUIN target for 2012/13.
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 2012/13.
Data Quality
The Retreat did not submit records during 2012/13 to the Secondary Uses service for
inclusion in the Hospital Episode Statistics. A robust process for the managing of
corporate and clinical records is now in place as outlined in the organisation’s
Information Lifecycle (Records Management) Policy which includes a Records
Retention Schedule.
14
The organisation has achieved Level 2 compliance with the NHS Information
Governance Toolkit and has implemented ongoing actions to ensure continued
adherence to standards.
The Retreat was not subject to the Payment by Results Clinical Coding Audit during
2012/13 by the Audit Commission.
Review of our data quality
The Information Management Group is responsible for ensuring the organisation’s data
collection systems operate in line with the requirements of the Information Governance
Toolkit and the Care Quality Commission Essential Standards of Quality and Safety. As
part of our ongoing actions to ensure compliance with Outcome 21 Records, a
programme of staff training and development for care planning and documentation has
been established to ensure 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 Information
Management Group, 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 and assigned to a Lead Officer. The Retreat’s current level of compliance at
the time of its March 2013 submission is Level 2. This is in line with NHS contracts
which require our organisation to maintain Level 2 compliance.
Compliance
Against Standards 2012/13
Level 2
Level 2
Information Governance Management
Confidentiality & Data Protection Assurance
15
Information Security Assurance
Clinical Information Assurance
Level 2
Level 2
Key
Level 0
Level 1
Level 2 (required as part of NHS Contracts)
Level 3
16
PART THREE
Review of quality performance in 2012/13
Update on Priority 1 - To improve our current process for annual environmental
assessments on units to reflect the NHS Patient Environment Action Team
(PEAT) tool.
A new environmental assessment tool was developed based on the NHS PEAT. This
tool not only looked at the general condition of our environment but took into account
areas such as Infection Control arrangements, Nutrition and Cleanliness. The tool was
used successfully during the 2012/13 period of assessment and allowed The Retreat to
benchmark against NHS organisations as we were now looking at comparable areas.
The assessment process allowed a more comprehensive environment report to be
produced for our Governance Committee which was updated throughout the year as
actions were completed.
Update on Priority 2 – To improve our current process for incident
reporting across the hospital.
Research was carried out into various electronic incident reporting software systems
and a decision was made to purchase the web-based incident reporting module of the
Ulysses Safeguard Risk Management System. A unit was chosen to pilot the new
software and staff received training on the use of the new system. Very few problems
were encountered during the pilot and the software was then rolled out across all other
units and departments within four weeks.
The change from a paper-based system to using a web form for reporting did not show
any significant change in the level of reporting which was due to the fact that staff found
the new system easy to operate. Having used the new system for six months, the
quality of the data being reported has improved which has led to a more accurate
analysis of incidents. One aspect of the new system now being developed is the
automatic provision of up-to-date reports for MDT meetings.
Update on Priority 3 – To ensure that the people who use our services
have access to good physical healthcare.
During 2012/13 we have sought to raise the profile of the importance of physical well
being and health care for the people who use our services. A dedicated consulting
room has been opened on site for the GPs and Advanced Nurse Practitioner to see
people who use our services away from their unit.
We have increased the sessions facilitated by the Nurse Practitioner and Practice
Nurses. This has led to the development of Chronic Disease Management Clinics and
the promotion of smoking cessation. An additional Dietitian’s post has also been
created.
17
Physical and leisure activities are promoted for all in a variety of ways as follows:
Jabadao and dance, swimming, badminton, yoga, Powerplate sessions, chair-based
exercises groups, balance and core exercise groups.
We will continue to monitor progress using Clinical Audit in May 2013 and Patient
survey feedback in August 2013.
Update on Priority 4 - To ensure that people who use our services have the
opportunity to be involved in all aspects of their care.
The Retreat is committed to developing ways of involving the people who use our
services in their care, with particular emphasis on collaborative care planning. In order
to ascertain what people’s experience of care planning is and in order to develop the
quality of care planning within The Retreat, the following was carried out:

A semi-structured interview that is able to be used on both Specialist Adult and
Specialist Older Adult Services was developed.

Two interviews per month took place with the people who use the services across
the year.

An alternative care plan was designed with the people who use the services to
ensure that it is conducive to collaborative working as a result of the feedback
from the interviews.

Awareness raising sessions and training to management teams and staff on
involving patients in care planning and recording this involvement have been
carried out across the organisation.

Monthly audits are carried out across the organisation to measure the quality of
the care plans, with a steady increase in the overall outcome. Where staff are
identified as not reaching required standards, a training programme has been
implemented for them.
18
Complaints Report
A total of nine complaints were received during 2012/13.
The table below shows the reasons for the complaints:
Reason for the Complaint
Number
Number
Attitude of staff
1
Upheld
All aspects of clinical treatment
5
4 Upheld
Communication/Information to Patients (Written or Oral)
2
2 Upheld
Other – Behaviour of a patient towards another patient
1
Upheld
Other - Environment
1
Upheld
(Complaint Categories are as defined by the Department of Health)
Complaints Dealt with within 25 Working Days
10 complaints received were dealt with within 25 working days.
Learning from the Complaints:

A review of assessment procedures brought about changes to eliminate patient
data being observed by other patients.

The manner in which personal care was being carried out was reviewed and
changed for a patient.
Compliments Report
In 2011/12 we introduced a Compliments Policy with each clinical unit keeping a log of
all compliments which it forwards monthly to the Quality, Compliance and Business
Unit. Compliments reports are submitted to NHS commissioners of our services. We
have received 23 compliments in total in 2012/13.
19
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 Incidents (SIs).
2.3
(per 100 patients)
2
Safeguarding - number of reports that relate to The Retreat services
37.8
(per 100 patients
3
Mental Health Activity – number of incidents reported that resulted in
a breach of Section 18 of the Mental Health Act.
16.52
(per 100 patients)
4
Medicines Management Incidents – number of incidents that were
reported as a Serious Incident
1.1
(per 100 patients)
5
Use of Seclusion - Number of occasions where seclusion was used.
0
(per 100 patients)
6
Incidents reported to the CQC that required a level 2 investigation
0
(per 100 patients)
Patient Experience
Indicators
1
Number of Health of the Nation Outcome Scale (HoNOS) reports
produced.
445
(per 100 patients)
2
Complaints - number of complaints received.
10.8
(per 100 patients)
3
Use of MOVA (Physical Restraint) – number of times restraint was
used to put a patient on the floor.
1.1
(per 100 patients)
4
REAT Inspections – Annual inspection results (Number of actions)
following environmental inspections on clinical units.
100%
(No of actions
completed)
5
25 hour week activity
95%
Clinical Effectiveness
Indicators
20
(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.
87%
3.1%
1.8
(per 100 Staff)
7% of total shifts
16.5%
Key
Reached required standard
Actions identified to reach required
standard
Significant actions required
20
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 In-Patient Survey which enables us to benchmark ourselves against
NHS Trusts. The Retreat undertakes this survey as part of our annual programme of
Patient Experience Surveys. This survey was conducted in March 2013 and the
questions patients were asked included the following:
‘Overall how would you rate the care you receive at The Retreat?’
Responses given were as follows:
Excellent (42%) Very Good (37%) Good (10.5%) Fair (10.5%) Poor (0%)
‘How likely are you to recommend The Retreat to friends and family if they needed
similar care or treatment?’
Responses given were as follows:
Extremely Likely (70%)
Extremely Unlikely (3%)
Likely (17%)
Neutral (3%)
Unlikely (7%)
For the first time this year we have carried out a Carers’ Survey. This has been led by
our Involvement Team who is responsible for completing the survey action plan. The
Carers’ Survey will now be conducted on an annual basis.
Results of all surveys 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’.
2012/13 Patient Surveys Completed
Compliance
Against Standards
Outpatients Survey (November 2012)
Patient Survey (March 2013)
Carers’ Survey (March 2013)
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.
21
Comments taken from The Retreat Patient Survey (March 2013)
Is there anything particularly good about your care?

Staff being available when I am distressed.

A lot of variety with groups.

Very good staff team for interventions.

The staff and the care team are an excellent support

Staff are very hardworking, feel I get a say in my care.

I am involved in every step.

The dedication of the members of staff. Having therapy once a week. Being able
to have interventions with staff when I need it.

Staff seem friendly.

My Named Nurse/Keyworker who is very caring and outstanding at her job. My
mental illness is very complex and challenging and without her support I would
struggle even more than I do now.

The Hannah Mills unit has some of the kindest, caring most professional staff I
have ever come across.

How all units help each other when there’s a crisis eg. MOVA team.
Is there anything that could be improved?

Food – always cold and lack of flavour. A lot of it isn’t made correctly and doesn’t
look appetising.

The food!!.

The quality of the food could be improved and more trips off the Unit.

The food.

Staff take more responsibility for decision that affect patients.

The temperature of the meals. Staff to do long days to maintain continuity of care.
More cultural unit trips.

Organisation in groups and 1:1’s.

Maybe another patient on Detox at the same time would have been helpful.

Far more trips out of the unit.

Patients to have a Plan B in place in case it doesn’t work at The Retreat.
22
Information on the Staff Survey
The Retreat undertakes an annual Staff Survey using questions similar to the NHS
Staff Survey. This was conducted in March 2013 and 122 surveys, representing 45% of
our staff, 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, Directors and to all staff. We will
be working with the Staff Consultative Committee to address any areas of concern
where improvements are necessary.
Further information on results of the Staff Survey can be provided upon request.
23
Statements from local Clinical Commissioning Group and
Healthwatch
A draft copy of The Retreat’s Quality Account was sent to colleagues at Vulnerable
Adults’ and Children’s Commissioning Unit (VACCU), hosted by - NHS Scarborough
and Ryedale CCG on behalf of North Yorkshire CCGs, and Healthwatch in York.
Please see below statements from these organisations.
Vulnerable Adults’ and Children’s Commissioning Unit (VACCU)
Hosted by - NHS Scarborough and Ryedale CCG on behalf of North
Yorkshire CCGs
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 the improvements in quality performance from other independent
providers who are commissioned to provide services.
Healthwatch York
Thank you for giving Healthwatch York the opportunity to comment on your Quality
Account for 2012/3. The report is easy to read and understand and is well presented.
The inclusion of a glossary is very helpful to enable lay people understand some of the
jargon and acronyms used.
The updates on the priorities identified in the 2012/13 Quality Account are particularly
interesting. It is pleasing to see that such tangible progress has been made.
The complaints report showing details, not just the number of complaints received,
demonstrates a very open approach. It was also good to see the learning points from
the complaints.
The comments from the Patient Survey are very interesting – both the good comments
and the comments about what could be improved.
Healthwatch York looks forward to working with The Retreat during the coming year.
24
Glossary
CCG
Clinical Commissioning Group
Is a statutory NHS organisation, representing groupings of GP
Practices, that are, from April 2013, responsible for designing local
health services In England. They will do this by commissioning (or
buying) healthcare services. There are 211 CCGs in England.
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.
MDT
Multidisciplinary Team
A group of different types of clinicians who work together as a team.
25
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 safehaven fax: 01904 430906
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