Quality Accounts
2013/14
Quality Accounts 2013/14
Contents
About Alpha Hospitals
3
Section 3
Our locations and services
4
Review of performance in 2013 – 2014
Our vision, mission & our values
5
Section 1
Statement from the Chief Executive Officer
6
Safety indicators
18
Effectiveness indicators
19
Patient experience indicators
19
Priority 1 – Optimising care pathways
20
Priority 2 – Physical wellbeing
20
Priority 3 – Skills for life
21
Section 2
Priority 4 – Enabling environments
21
Looking forward to 2014 – 2015:
Priority 5 – Culture
22
Priority 6 – Staff training
22
Priority 7 – Audit
23
our priorities for improvement
1. Improving governance processes
8
2. Improving carer liaison
8
3. Improving the service user experience
8
4. Improving incident reporting
9
5. Improving patient records
9
6. CQC compliance
9
Treating and caring for people in a
7. Implementation of specialist training
9
safe environment and protecting
Department of Health mandatory indicators:
Ensuring that people have a positive
experience of care: staff survey
25
them from avoidable harm
26
Statement of Assurance from the Board
Statement relating to the quality
of NHS services provided
11
Participation in national clinical audits
11
National confidential enquiry into suicide
11
Research
15
Use of the CQUIN framework
15
Regulation with the Care Quality Commission
16
Data quality
17
Statement of support
28
How to provide feedback
30
P2
Quality Accounts 2013/14
About Alpha Hospitals
Alpha Hospitals is one of the UK’s leading providers of
specialist mental health services for adolescents and
adults. The company was established in 2002, with
purpose built, state of the art hospitals in Bury in Greater
Manchester, Sheffield in South Yorkshire and Woking
in Surrey. The group provides an extensive range of
psychiatric care for people with complex mental health
conditions within rehabilitation, general, psychiatric
intensive care, low secure and medium secure settings.
Alpha Hospitals works in partnership with the NHS
and is committed to providing outstanding levels of
service to patients and partners, that is flexible and
needs led based on the individual’s requirements.
P3
Quality Accounts 2013/14
Our Services
Alpha Hospital Bury
Services for Adolescents
Tier 4 CAMHS
Services for Adult Men
Low Secure Services for Men
Low Secure Services for
Men who are Deaf
Medium Secure Services for Men
(Mental Illness)
(Personality Disorders)
Medium Secure Services
for Men who are Deaf
Services for Adult Women
Locked Rehabilitation
Services for Women
Low Secure Services for Women
Low Secure Services for
Women who are Deaf
Medium Secure Services for Women
(Mental Illness)
(Personality Disorders)
Medium Secure Services for
Women who are Deaf
Alpha Hospital Sheffield
Alpha Hospital Woking
Services for Adult Women
Services for Adolescents
Locked Rehabilitation
Services for Women
Tier 4 CAMHS
Low Secure Services for Women
Services for Adult Women
Services for Adolescents
Locked Rehabilitation Services for
Women (opening end of 2014)
Tier 4 CAMHS
Low Secure Services for Women
Services for Adult Men
Locked Rehabilitation Services for Men
Low Secure Services for Men
P4
Quality Accounts 2013/14
Our vision, mission & our values
Vision
Working in
partnership with
the NHS, we will
make a positive
and lasting
difference to
people with mental
health problems.
Mission
To deliver the
highest standard
of patient care,
respecting dignity,
privacy and
individuality in an
outstanding clinical
environment.
Objective
We believe that everyone
in our care can recover
and live a meaningful
life. Our objective is
to help patients take
the best care pathway
for them as easily and
quickly as possible.
Our
values
Transparency
Professional
Complete transparency at every
level of business and clinical
practice means our people,
patients and partners can have
complete confidence in us.
A professional attitude across
our organisation ensures we
meet best practice standards and
put the patient at the heart of
everything that we do.
Supportive
Innovation
Specialist
Inclusiveness and team
work are everything. We
support our staff and
patients at all times.
We embrace innovation
and welcome positive
change in the treatment of
those we care for.
Our services are wholly
clinically led and shaped
by experts in the field.
P5
Quality Accounts 2013/14
1
Statement from the Chief Executive Officer
Patricia Hodgkinson
Chief Executive Officer
I am delighted to report on the
quality and standard of care
provided within the Alpha Hospitals
group. The aim of this document is
to illustrate how important quality
is to our organisation and how it
underpins all of our work. It outlines
our quality achievements during
2013/14 and sets out our objectives
to further enhance the quality
of our services for the benefit of
service users during 2014/15. In
compiling this report we have
liaised closely with our Board, our
clinicians, service users and carers,
our staff and NHS Commissioners
and other key stakeholders.
Working within mental health will
always be challenging. This last
year was no exception. The bar was
raised in terms of the standard
and quality of services provided
through more rigorous inspection
processes by the regulator and NHS
England. This has made providers
stronger. In our own organisation
we have gone on to strengthen
our governance structure. Working
with Niche Patient Safety Ltd
and NHS England we now have a
Corporate Governance framework
which is truly fit for the healthcare
environment of today.
During the year we have been
inspected by NHS England, the
Care Quality Commission and
the Quality Network. As an
organisation we ensure that we
learn from our current practice,
embrace change, innovation, new
ways of working and embed these
in our practice and planning.
Our priorities for the last year were
heavily influenced by the targets
set for Commissioning for Quality
and Innovation (CQUIN) as well
as critical issues from the Francis
Report and Winterbourne View
Enquiry. This report shares how we
have performed in these areas.
P6
Quality Accounts 2013/14
Our priorities from 2013/14
1. Optimising the care pathway
2. Physical wellbeing
3. Skills for life
4. Enabling environments
5. Culture
6. Staff training
7. Audit
Whilst we are proud of what we have achieved
in the last year we have also reflected on areas
where we needed to make further improvement.
These mainly related to the systems required
to evidence our care. The learning from this and
further improvements we intend to make are
captured in our priorities for the coming year.
As a nurse, and a leader, nothing gives me greater
pleasure than spending time on the wards talking
to the staff and the patients. This year, I have
been fortunate to spend many days and weekends
on the wards and it is always extremely rewarding
to hear feedback on how we can continue to
develop and grow and make Alpha a great place to
work and recover. We will continue to put our staff
and our patients at the heart of everything we do.
As the Chief Executive of Alpha Hospitals
I can confirm that, to the best of my
knowledge, the information contained
in this document is accurate.
This Quality Account was approved
by the Board in June 2014.
Patricia Hodgkinson
Chief Executive Officer
P7
Quality Accounts 2013/14
2
Looking forward to 2014 – 2015:
our priorities for improvement
We have consulted extensively with key stakeholders to agree our priorities for improvement for 2014
– 2015. We have looked at areas we wish to improve following helpful feedback from our service users,
NHS England and our regulator, the Care Quality Commission. We have set seven key priorities.
Key Priority 1
Patient
Safety
P
Improving governance processes
We will achieve our goal through:
Patient
Experience
P
P
Monitoring Tool
CQUIN Goal Action Plan
n The review of processes at Group and hospital level
Measure
Overall improvements in quality
of patient care reported via audit
and inspection.
n The implementation of new systems to ensure
improvement in the care of patients
Key Priority 2
Clinical
Effectiveness
Patient
Safety
Clinical
Effectiveness
Patient
Experience
P
Improved carer liaison
We will achieve our goal through:
Monitoring Tool
CQUIN Goal Action Plan
n Mapping every contact we have with carers and highlighting
opportunities for increased contact
Carer Satisfaction Survey
n Ensuring service users are supported to identify key and meaningful
family members who can be involved in CPAs and other aspects of their care
Measure
Number of carers who report
improved communication,
involvement and support.
n Greater use of IT to promote good communication and feedback
Key Priority 3
Patient
Safety
Clinical
Effectiveness
Patient
Experience
P
Improved patient experience
We will achieve our goal through:
Monitoring Tool
Action plan
n Action plans connected with the patient experience service provided by a
clinical psychologist
Patient Satisfaction Survey
n Service strategies contributed to by staff and patients
Measure
Improved service user satisfaction
n Implementation of the Friends and Family Test
P8
Quality Accounts 2013/14
Key Priority 4
Patient
Safety
P
Improved incident reporting
We will achieve our goal through:
n The mapping of incidents and the shared learning in real time
n Improved systems for sharing learning group wide
Patient
Safety
P
Improved patient records
We will achieve our goal through:
n Mock inspections
Patient
Safety
P
n Mock inspections
Patient
Experience
P
Clinical
Effectiveness
Patient
Experience
P
P
Measure
Improvements in audit performance and
inspection compliance.
n Enhanced robust audit calendar
Specialist training
Clinical
Effectiveness
Monitoring Tool
Action Plan
We will achieve our goal through:
Key Priority 6
Measure
Improvements in data quality and
increased sharing of lessons learnt
and good practice.
Measure
Improvements in data quality
and audit performance inspection
compliance.
n The audit of notes
CQC compliance
P
Monitoring Tool
Action Plan
n The investment in and implementation of electronic records
Key Priority 6
Patient
Experience
Monitoring Tool
Action Plan
n Investment in an electronic incident reporting system
Key Priority 5
Clinical
Effectiveness
Patient
Safety
P
We will achieve our goal through:
n Providing further specialist training for each speciality service
n Investing in more practice development nurses for each hospital
to improve practice
Clinical
Effectiveness
Patient
Experience
P
P
Monitoring Tool
Training action plan
Measure
Increased staff attendance in
specialist training.
P9
Quality Accounts 2013/14
Our key stakeholders - whose input and vision help Alpha Hospitals shape the services and outcomes focus
Service
Users
Staff
Family members
and carers
Board
Quality
Network
Groups
Local Area
Teams
Audit
Committee
Clinical
Commissioning
Groups
Senior
Management
Team
NHS
England
Group
Governance
Board
CQC
Advocacy
Lead Clinicians
and Managers
Governance
Committees
“I would like to take this opportunity to pass on our thanks for the
way in which the team have worked with this particularly complex
young person. She is without doubt a challenge to services and has
had numerous admissions over the past couple of years.” (Commissioner)
P 10
Quality Accounts 2013/14
Statement of assurance from the board
Statement relating to quality of NHS services provided
Information required under the National Health Service (Quality Accounts) Regulations 2010
During the year ending 31 March 2014 Alpha Hospitals provided nine types of services on behalf of the NHS.
Alpha Hospitals have reviewed all the data available to us on the quality of care in all nine of these NHS services.
The income generated by the NHS services reviewed in the year ending 31 March 2014 represents 100 per cent of the
total income generated from the provision of NHS services by Alpha Hospitals for the year ending 31st March 2014.
Participation in National Clinical Audits
During the year ended 31 March 2014 two national
The national clinical audits we were eligible to participate
clinical audits and one national confidential inquiry
in for the year ended 31st March 2014 were:
covered NHS services that Alpha Hospitals provides.
Alpha Hospitals participated in the Prescribing
Observatory for Mental Health (POMH’s-UK) and
n
National Audit of Schizophrenia
n
Prescribing Observatory for Mental Health (POMH-UK)
submitted an audit to the Prescribing Observatory
Alpha Hospitals has begun the process of registering
for Mental Health during 2013-2014.
with the Prescribing Observatory for Mental Health
In addition, we undertook a programme of local
audit of clinical performance which is reported to
the Governance Committee on each hospital site.
(POMH’s-UK) and will be involved in the submission
of audits to Prescribing Observatory for Mental
Health for the reportable year 2013-2014.
National Confidential Enquiry into Suicide
We report to The National Confidential Inquiry into Suicide
and Homicide by People with Mental Illness to identify
individuals on the data sheets for whom we hold medical
records to ensure all cases of patient suicide and homicide
are included in the research undertaken by this group.
We are involved in the following quality improvement
programmes which were underway in the year ending 31
“You all work so
hard and help us so
much even when
we don’t want it”
March 2014; The Quality Network for In-Patient Child and
Adolescent Mental Health Services (QNIC) and the Quality
Network for Forensic Mental Health Services (QNFMHS).
P 11
Quality Accounts 2013/14
Clinical audit
The audit team
We have a clinical audit department with dedicated
We recognised that there was a need to increase our
staff who co-ordinate the clinical audit programme
investment in clinical audit. In order to achieve this
for each hospital within the group. The clinical audit
we recruited a Group Audit Team. We also appointed
programme is designed to meet the audit requirements
an independent company, Niche Patient Safety Ltd,
of government initiatives and demonstrates the
to ensure that audit systems continue to work.
achievement of group objectives, standardised approaches
The reports of 84 local clinical audits were reviewed
to care and treatment, outcome measures, and selfregulation of patient centred care and clinical practice.
A clinical audit committee is established and includes
by Alpha Hospitals in the year ended 31 March
2014 and we identified the following key actions
to improve the quality of healthcare provided:
members of the multidisciplinary team who are involved
in carrying out audits within their own clinical speciality.
n
Continue to provide debriefs for patients and
incident records and incident related records of
restraint to ensure patients feel safe and to
seclusion, restraint and medication administration.
Ensure clear and thorough documentation of incidents
and actions taken and post incident reviews.
n
Ongoing work to ensure that risk is managed
in the least restrictive manner and patients
n
Further training for staff in consent to treatment.
n
Increased medical scrutiny of prescription
cards and consent to treatment.
n
Additional training for staff to ensure their
n
n
n
Improved communication to Mental Health Act
department when Section 62 urgent treatment utilised.
so they may better support patients to
enable them to exercise their rights.
Enhanced procedures for patients being offered
a replacement meal should they miss a meal.
full understanding of patients’ rights under
the Mental Health Act 1983 (amended 2007)
Achieve greater consistency and standardisation
in patient file record keeping templates.
are truly involved in their care.
n
Ward staff to conduct more in-practice audits of
for staff following episodes of seclusion and
allow staff to reflect and improve practice.
n
n
n
To ensure that when a patient has declined
Further work required to re-advertise
to sign to evidence involvement in their care
carers’ forums to increase the involvement
planning the offer and refusal is recorded.
of carers in service development.
n
Audit identified the need for an A&E pack for use
in the event of a patient being admitted to A&E.
n
Audit of PRN indicated the need for more frequent
monitoring of PRN to identify trends and take
relevant actions where there are concerns. This
practice is now established and will continue.
P 12
Quality Accounts 2013/14
Patient satisfaction survey
We carried out patient satisfaction surveys with all service users across our group. Below is a snapshot of some of the results.
Question
Bury
Sheffield
Woking
Percentage of participants
76%
58%
69%
Do you understand why you are here?
95%
100%
100%
Do you understand what section you are on?
96%
91%
100%
Do you understand your rights under that section?
91%
100%
93%
Do you feel safe at Alpha?
83%
82%
86%
Do you feel involved in your care?
79%
64%
79%
“Alpha have some incredible staff and patient
care is always their number one priority”
P 13
Quality Accounts 2013/14
CASE STUDY
Patient experience
Service user experience report from the Group Quality
and Culture Lead
Within the past year, the hospital group has
physical activity opportunities also led to the
focussed on understanding and enhancing the
implementation of a project to provide outdoor
patient experience across the Alpha Hospital
exercise facilities which the patients have been
sites. This has involved investment into a post
involved in designing from the outset.
to focus on understanding and developing
the ‘Alpha Culture’ from the perspectives of
the patients and young people accessing the
services. “Service users identified that they wanted more
involvement in the decoration and refurbishment
of their wards. Over the past year there has been
extensive refurbishment of some areas within the
Every ward across the hospital group was visited
hospitals and service users have led the way by
by the Group Quality and Culture Lead. Extended
selecting the colours, furniture, fabrics etc. used
periods of time were spent with patients in order
throughout their living spaces.” to understand their experience of day to day living
on their wards. Further consideration was given to
what was positive about their experience and how
this may be further enhanced. A project has also been initiated exploring the
ward community/governance meetings to ensure
that these remain responsive to the needs of the
people using our services and are patient/young
Reports were completed following each visit.
person led. The direct involvement of patients/
These were shared with senior managers across
young people in service development has meant
the group and same day feedback was given to
that they are at the centre of everything we do
the Responsible Clinician, Senior Nurse and Clinical
and are also able to help in shaping and moulding
Team Leader. This has enabled steps to be taken
services that meet their needs; thus enhancing
to respond to the comments made by the people
their experience of being in hospital and ultimately
using our services and subsequently improve the
supporting their pathway into less secure and
patient experience.
community services. In addition, a service where
“We identified that patients wanted better access
to the gym facilities across our sites. We trained
more staff to facilitate gym sessions, we enhanced
patients feel listened to and valued further
enhances the relationships that those accessing
the service have with staff and managers.
the equipment within the gyms, improved the
Neil Gredecki
environment and the overall experience.”
Group Quality and Culture Lead
Discussions with patients about outdoor
P 14
Quality Accounts 2013/14
Research
During the year ending 31 March 2014 no patients receiving
n
NHS services provided or sub-contracted by Alpha
Section 17 leave for patients in locked rehabilitation
prior to and during admission up to discharge.
Hospitals were recruited during that period to participate
in research approved by a research ethic committee.
n
Empowering Deaf patients to chair CPAs.
n
Student career choice in psychiatry:
A core group of professionals with an interest in research
Findings from 18 medical schools.
and development attends regular Research Governance
n
DBT for Deaf Women.
relation to developments in social, psychological practice,
n
Case study on fire setting.
research and clinical guidelines.
n
Deafness and schema therapy.
We are committed to improving the quality of care we
n
Managing violence and aggression in inpatient
meetings and reports to the Governance Committee in
offer and in contributing to wider healthcare quality
forensic settings.
improvement which is demonstrated through our
n
involvement in clinical networks and research and
forensic units.
presentation programmes which include:n
Metabolic syndrome and vitamin D levels in
Communication in Tribunals and the quality of
standards and accessibility of information for
interpreters within the Deaf Service.
n
North West Consultant’s Forum.
n
Care Programme Approach Association.
n
Quality Network.
Use of the CQUIN payment framework
A proportion of Alpha Hospitals’ income in the year ending 31st March 2014 was conditional on achieving quality
improvement and innovation goals agreed between Alpha Hospitals 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
payment framework.
Over the course of the year we participated in the CQUIN programme and produced four Quarterly Service Quality Reports.
Our outcomes for CQUIN targets are detailed below.
QUARTER 1
QUARTER 2
QUARTER 3
QUARTER 4
SUCCESS RATE
P
P
P
P
100%
ADULT CQUINS 2013 / 14
Optimising pathways
Physical healthcare
Adult education
CPA
Video conferencing
Alpha Hospital
Bury
Alpha Hospital
Sheffield
Alpha Hospital
Woking
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P
P 15
Quality Accounts 2013/14
ADOLESCENT CQUINS 2013 / 14
Alpha Hospital
Bury
Alpha Hospital
Sheffield
Alpha Hospital
Woking
P
P
P
P
P
P
P
P
P
Care pathway
Physical healthcare
CPA
Regulation with the Care Quality Commission
Alpha Hospitals is required to register with the Care
and both hospitals have subsequently been re-
Quality Commission and its current registration status
inspected and have been found to be fully compliant.
is detailed below. Alpha Hospitals has no conditions
The Care Quality Commission inspected Alpha
on its registration at the time of this report. It has
Hospital Sheffield in November 2013 and an action
action plans in place in one hospital in relation to non-
plan was implemented in relation to assessing and
compliance with one standard with minor impact.
monitoring quality where the hospital was found
The Care Quality Commission issued warning notices
to have a minor non-compliance. All actions in
to Alpha Hospital Bury and Alpha Hospital Woking
relation to this outcome have been completed.
during the year ending 31st March 2014. The warning
Feedback from the CQC influenced our strategic
notices for both hospitals related to concerns about
safeguarding, management of medicines, care and welfare,
records, staffing and assessing and monitoring quality.
implementation of enhanced governance
arrangements throughout the Group.
Immediate detailed action plans were implemented
HOSPITAL
priorities during year and has driven the
Registration Category
Registration Category
Registration Category
Registration Category
Treatment of
disease, disorder or
injury
Assessment of medical
treatment for persons
detained under the
Mental Health Act
Diagnosis and
screening
Accomodation for
persons requiring
nursing or personal
care
Alpha Hospital
Bury
P
P
P
P
Alpha Hospital
Sheffield
P
P
P
P
Alpha Hospital
Woking
P
P
P
NA
P 16
Quality Accounts 2013/14
Data quality
Alpha Hospitals did not submit records during the year
Alpha Hospitals was not subject to the Payment by Results
ended 31 March 2014 to the Secondary Uses Service for
clinical coding audit during the year ending 31st March
inclusion in the Hospital Episode Statistics which are
2014 by the Audit Commission.
included in the latest published data.
Records Management assessed using the Information
Governance Toolkit was Level 2.
Actions taken during 2013/14 to improve data quality and
information governance in general include:
n
Appointment of the Group Information Governance
Alpha Hospitals Information Governance Assessment
Lead who will ensure our systems comply with
Report score overall score for the year ending 31st March
national standards.
2013 was Level 2.
Our Information Management Strategy was reviewed
and approved by the Board providing assurance that the
n
Introduction of a Board Assurance Framework.
n
Development of dashboards to give meaningful
clinical data.
organisation has commitment and support to ongoing
improvement of data quality at the highest level. Alpha
n
Implementation of electronic patient records system.
Hospitals’ score for the year ended 31 March 2014 for
n
Investment in an electronic incident reporting system.
Information Quality and Records Management was 70%.
“The Alpha
community has a real
‘can do’ attitude”
“Good opportunities for
people to grow and learn”
“Superb working environment, great team,
excellent supervision, great support and training “
P 17
Quality Accounts 2013/14
3
Review of quality performance
Safety indicators
Ensuring patient safety is of paramount importance
serious incidents which have taken place on a quarterly
to us in the delivery of our services. We have robust
basis and describe the actions we have taken. This
systems in place to ensure we are aware of and adhere
information is shared across the group and with the NHS.
to new service user safety announcements and guidance.
This demonstrates our commitment to learning from
All safety notices are processed in line with national
experience and improving practice. We review all incidents
guidance and feedback is gained from the clinical areas
and accidents on an individual basis and service basis in
as directed. A patient safety report is discussed at
the following forums: Multidisciplinary Team Partnership
the Clinical Governance Committee each month and
Forums, Health and Safety meetings and Clinical
actions taken are cascaded via the meeting minutes.
Governance. We use the information available to measure
There have been no breaches of Nationally Specified
Events during year ending 31 March 2014. We report
Indicator
reduction of risk in individual patients and safety on the
wards and we have identified trends through analysis of
data and we produce action plans to improve practice.
Target
Result
Report serious and untoward incidents to NHS Secure
Commissioners within one working day
At least 95% reports
Target met
Achieve compliance with requirements set out in the Best
Practice Guidance: specification for adult medium secure
services and National Minimum Standards for General Adult
Services in Low Secure Psychiatric Intensive Care Units (PICU)
or for Adolescents and Low Secure Environments including
draft low secure guidance
At least 90% compliance
Target met
Compliance with infection prevention and control guidance
At least 90% compliance
Target met
Compliance with Standards for Medium Secure Forensic
Services – QNFMHS
At least 90%
Target met
Compliance with NPSA safety alerts.
100% compliance
Target met
P 18
Quality Accounts 2013/14
Effectiveness indicators
An effective service can be defined as one that puts people who use services at the heart of what it does using ‘No
decision about me without me’ as the governing principle. This section describes some of the indicators we have in
place to measure the effectiveness of our services in providing the right service, to the right person at the right time.
Indicator
Target
Result
All patients will have the opportunity to complete a recovery plan using an
approved recovery tool
All services
Target met
Physical health checks for all patients on admission and annually including
adhering to best practice for chronic disease management
All patients
Target met
Robust and comparable data on ethnicity of service users collated and reported
All patients
Target met
Implementation of service user defined CPA standards
All patients
Target met
Patient experience indicators
We are committed to seeking patient and carer feedback and input to service delivery to support continual improvement
in the patient experience ensuring care is personalised to reflect individual needs, access to information and support
to exercise choice and receive care and treatment in accordance with clinical guidance and which can be measured.
Indicator
Target
Result
Ensure all patients on CPA have a named care co-ordinator to support the
patient’s (eventual) discharge
All services
Target met
Undertake an annual patient satisfaction survey and ensure actions are
taken following the feedback to further enhance the patient experience
All patients
Target met
Undertake regular surveys of the ward atmosphere taking into account
how safe patients feel, how engaged in treatment they feel and the level of
support they have from care staff and other patients they live with
All patients
Target met
All patients have a CPA within 3 months of admission
All patients
Target met
All patients have an initial care plan within 24 hours of admission
Target met
All patients have a detailed care plan within 3 months of admission
Target met
All patients are offered a copy of their care plan
Target met
Complaints are responded to within 2 days and are resolved
within 25 days or an agreed extended period
Target met
P 19
Quality Accounts 2013/14
Review of our performance against
priorities for 2013/14
Priority 1
Optimising the care pathway
Our goal was to implement a recovery and outcomes based approach to the care pathway which demonstrated recovery
orientated practice in identifying, planning and achieving joint goals and outcomes with service users and which gave
service users more choice and opportunities to drive their own outcomes.
Priority 2
Physical wellbeing
Improving the physical wellbeing of patients with mental
n
illness was a CQUIN for 2013/14. In order to fulfil the
CQUIN requirements Alpha Hospitals developed a unique
database to capture all the elements which required
indicated by a symbol.
n
n
n
n
Inviting our catering staff to attend community
n
1:1 sessions with dieticians were provided.
meetings to advise on diet and nutrition.
n
Well woman and man clinics held regularly
and screening offered in line with national guidance.
Catering staff meet patients on a 1:1 basis to
discuss specific dietary preferences.
n
Gym instructors are available to all patients and
access to on and off site gyms are facilitated.
Other initiatives included:
n
Patients are encouraged to attend external
groups for fitness/weight management.
health care requirements and indicators for each and
every service users.
Health promotion material is displayed
on each ward.
monitoring. The bespoke database is directly linked to RiO
and it ensures that staff have live access to all physical
Daily menus have the healthier choices
Catering staff led programmes which focussed
n
National events such as Sport Relief
incorporated into ward events.
on budgeting, buying and cooking a balanced meal.
“I’ve received outstanding care and treatment; the team really make time for
you and meet your needs. They are very focused on your recovery”
P 20
Quality Accounts 2013/14
Priority 3
Skills for life
Our skills for life programme improved the opportunity for
patients to access education and skills development. There
was a specific focus on literacy, information technology,
n
Some of the initiatives implemented included:
n
Patients now have secure email addresses
that they can use for correspondence with colleges
numeracy and vocational skills.
At the start of the year, the uptake of education and
for their training.
n
Alpha courses have received NOCN Accreditation.
By the end of the year, the number of patients accessing
n
Patient led libraries.
education and skills development courses had increased
n
New IT Suites provided.
skills development was 58% across the adult population.
to 76.5% with a 300% increase in the number of education
and skills based hours being offered.
Priority 4
Enabling environments
Over the course of the year Alpha Hospitals carried out
Design concepts and mood boards were presented to
environmental works across the group. This ensured that
the service users and their advice fed directly into the
the wards truly met the needs of the patient group. In
final specification. Visitors to the service have highly
addition to this there has been increased emphasis on
commended both the design of the building and the soft
service user involvement in refurbishment and decoration
furnishing which create a calm, homely atmosphere.
with service users able to select colour palettes and unique
artwork for the wards.
All adult services participated in peer reviews. The
peer review process is an extremely helpful review and
Alpha Hospitals commissioned a new locked rehabilitation
feeds into a direct action plan to further improve the
service during the year. The patients made a major
environment and the provision of services.
contribution to the internal soft furnishing specifications.
Quality Network results for adult services
Hospital
Score
Alpha Hospital Bury Medium Secure Services
98%
Alpha Hospital Bury Low Secure Services
96%
Alpha Hospital Sheffield Low Secure Services
98%
Alpha Hospital Woking Low Secure Services
86%
P 21
Quality Accounts 2013/14
Priority 5
Physical wellbeing
The Francis Inquiry called for a real change in culture across the NHS. Alpha Hospitals have focused on embedding the
culture of the organisation. Here are just a few of the initiatives we have implemented:
n
The publication of our mission, vision and values which
n
are shared with all staff upon induction.
n
The introduction of a new staff feedback website which
enables staff to communicate confidentially and
directly with the Chief Executive Officer.
The development and publication of a Manifesto by the
Chief Executive Officer which clearly states the values
n
of the company and the objectives for everyone who is
The appointment of a Group Quality and Culture Lead
to monitor patients and staff experience.
part of the company.
Priority 6
Staff training
Over the course of the year, in addition to statutory and mandatory
training we have delivered the following training to our staff:
n
Team leader training
n
Least restrictive practice training
n
Culture and values training
n
Patient rights training
n
Introduction to leadership
n
My shared pathway training
n
Substance awareness
and management
n
CAMHS training
n
Smoking cessation
Management skills training
n
Governance training
n
DBT skills
n
MAPA trainer updates
n
Life minus violence
n
Clinical tool training (CANFor,
n
Working with and
n
(modules 1-4)
n
n
Interview skills
Managing conflict and
n
health support workers
understanding people who
HCR20, STAR, HoNOS, START,
difficult situations
sexually offend
SAPROF, RSVP)
n
Managing attendance
n
BSL
n
Complaints training
n
Diabetes and insulin
n
Appraisal training
n
Performance management
n
Customer care
n
Investigation skills
Clinical skills for mental
n
Fire setting interventions and
programme awareness
management
n
Gym training
Clozapine treatment
n
Boundaries
and management
n
Root cause analysis training
n
Safer medicines administration
n
ASD training
n
Lithium awareness training
n
P 22
Quality Accounts 2013/14
Priority 7
Audit
Over the course of 2013/14 Alpha Hospitals significantly strengthened the audit systems across the group. This started
with the development of the Quality Department which has grown to provide a comprehensive system of quality
management and governance.
Corporate Governance
New governance arrangements
Alpha Hospitals is committed to achieving the highest
n
Providing support to the Hospital Director as their
standards of integrity, ethics, professionalism and
line manager in the delivery of safe, effective care and
business practice throughout its operations. It recognises
treatment and the day to day management of clinical/
that it is crucial to ensure the structure and resources for
professional issues in designated clinical areas.
corporate governance are subject to ongoing review and
development if good governance is to continue to support
achievement of the organisation’s quality objectives.
A decision was taken in early 2013 to review and
strengthen the Group’s structure and corporate
governance arrangements. A detailed review of the
Group’s quality governance framework, with the goal of
n
Providing leadership, direction, support and supervision
for the nursing team to achieve compliance with both
professional and regulatory standards in accordance
with any operational and strategic objectives.
New performance management arrangements are in place
led by the Chief Executive via the management team.
supporting further improvement in the quality of patient
We have established a new Governance Directorate
care, was undertaken. The review focused on the Group
which is led by the Director of Governance and includes
governance structure and function but also took account
senior clinical managers and audit staff. The aim of the
of changes being made to the overall management
Directorate is to support services to maintain statutory
structures to support improved clinical engagement.
(regulatory) and best practice requirements and to
In order to ensure accountability, we have invested in
nursing management resources, such that every ward in
the group is now managed by a dedicated Senior Nurse
provide assurance to the Board on the efficacy of controls
and assurances to manage risks faced by the Group in
achieving its corporate objectives.
or Clinical Lead who is supernumerary to the core ward
staffing team. Job descriptions have been reviewed and
updated and it has been made explicit that the Senior
Nurse or Clinical Lead for each ward is responsible and
accountable for:
P 23
Quality Accounts 2013/14
The governance review led to more comprehensive, coordinated, organisational-wide governance structures and
processes being put in place. Clinical governance structures
are now more closely linked to the organisation’s corporate
governance framework (i.e. integrated governance). The
new framework places strong focus on patient safety,
patient experience, clinical audit and effectiveness and
staffing. We are proud of the enhanced systems of
governance we now have in place.
The Group has developed a two year Quality Assurance
Strategy that is designed to obtain accurate and
appropriate information for the decision-makers regarding
quality of care and delivery of services 2105 which
underpins our plans to ensure the quality of our services
from the ‘ward’ to the Board. The Quality Assurance
Strategy describes in detail how the Group intends to
deliver, maintain and improve high quality care for all its
patients.
“All the staff are
very supportive
and you are
made to feel part
of the team”
We have a Group Assurance Framework in place which:
n
n
covers all of the Group’s main activities
identifies the objectives and targets the Group
is striving to achieve
n
identifies the risks to the achievement of these
objectives and targets
n
identifies and examines the system of internal
control in place to manage the risks
n
identifies and examines the review and assurance
mechanisms which relate to the effectiveness of the
system of internal control.
The Group’s Assurance Framework makes it possible
for the Chief Executive and the Board of Directors to
demonstrate that the Board has been properly informed
about the totality of risk.
P 24
Quality Accounts 2013/14
Department of Health mandatory quality indicators
The NHS (Quality Accounts) Amendment Regulations 2012 set out a core set of quality indicators, which we are
required to report against in our Quality Accounts from 2012/13 onwards. We have reviewed these indicators and are
pleased to provide our position against all indicators relevant to our services for the last year.
Ensuring that people have a positive experience of care: staff survey
Alpha Hospitals carried out the Friends and Family Test with staff.
Results
58%
of staff would recommend Alpha Hospitals to
friends and family as a place to work
59%
of staff would recommend Alpha Hospitals to
friends and family if they needed care or treatment
To note: Staff survey results are based on a sample of our workforce not all staff employed by, or under contract to, us.
We have taken and will continue to take the following actions to further improve this percentage:
n
Discuss feedback from the survey with key staff
n
representatives and develop local action plans.
n
Chief Executive Officer via a confidential website
and continuing to regular feedback to staff
Continue to conduct an annual staff survey for all of
on the actions taken in response to that feedback.
our staff and more frequent localised staff surveys to
ensure we continue to be aware of any areas
requiring improvement.
Continuing to encourage staff feedback to the
n
Providing corporate feedback to all staff from
the Chief Executive about staff survey results
and associated actions.
“Thanks for not giving up on me
when I had given up on myself”
P 25
Quality Accounts 2013/14
Treating and caring for people in a safe environment and
protecting them from avoidable harm: patient safety incidents
The number and, where available, rate of patient safety incidents reported and the number and percentage of such patient safety
incidents that resulted in severe harm or death.
The total number of patient safety incidents recorded in 2013/14 is set out below.
None of our patient safety incidents resulted in death:
Total no of incidents
2013/14
Total no of patient safety
incidents 2013/14
Alpha Hospital Bury
6,968
4,259
Alpha Hospital Sheffield
1,039
719
Alpha Hospital Woking
2,519
1,561
All three hospitals recorded a reduction in the number of incidents.
We have taken and will continue to take the following actions to improve this:
n
Improving incident reporting
All staff will continue to receive training in incident reporting to encourage complete, accurate and
timely reporting of patient safety incidents. Our plans to implement electronic patient records during the
forthcoming year will further enhance current reporting systems.
n
Continuing to learn from incidents
As part of our safety strategy we will continue to learn from safety incidents and to make improvements in
practice. All incidents and related trends will continue to be reviewed and action plans devised to identify
root causes, remaining risks and actions to address required improvements. Follow up meetings will be held
to formally review action plan progress. Incidents will be reviewed monthly at Governance meetings.
P 26
Quality Accounts 2013/14
Patient Poem
Just wanted to say a massive thank you
For all the good things that you do
You’re caring, supporting, nurturing and kind
And staff like you are hard to find
I like how you see a change in me
And how positive I am that you see
I’m glad you were here when I got back
Because now you know me differently now I’m on track
You’re a laugh to be around you make me smile
And make me feel like life’s worthwhile
I want to say you are good at what you do
You help poorly people get better
and see their illness through
What more can I really say
You do your best every day
P 27
Quality Accounts 2013/14
Statements of support
NHS England has been working productively with Alpha Hospital Woking during 13/14.
We have experienced excellent engagement and leadership from the senior team
to continually improve the care and treatment of the patients in their care. During
the course of the year we have engaged with patients and front line staff who have
commented on significant and positive changes to the quality of care.
We look forward to continuing to work with the team at Alpha during 14/15.
Amanda Fadero
Julia Dutchman-Bailey
Area Director, Surrey & Sussex
Director of Quality and Nursing, Surrey & Sussex
NHS England
NHS England
NHS England have continued to work with Alpha Hospitals as an organisation and more
closely with Alpha Hospital Bury.
This year has seen many improvements and NHS England have been impressed with the
commitment and collaboration shown by Alpha Hospitals to drive through change and
improve their services.
We look forward to continuing to work together in the future to ensure the provision of
high quality care for service users.
Alison Tonge
Tina Long
AT Director
Director of Commissioning
P 28
Quality Accounts 2013/14
Quality Network Feedback
“It was observed that there is strong MDT working across the service with full involvement
of all involved in a patients care. Staff reported that they felt supported by the service,
both with their peer group and clinically supported in their roles. It was observed that
the staff group are highly motivated and engaged with the patients they work with.”
Quality Network Review 2013
“The programme of activity was praised, particularly the development
of vocational opportunities. The development of the patient library, in
particular, was highlighted as an achievement as the whole project is
patient driven including the development of the lending database.”
Quality Network Review 2013
“The peer-review team were pleased to receive extremely positive feedback from
patients in relation to their care and involvement at the service. In particular,
patients are involved in each step of their CPA process; patients are able to add
to, or write their CPA reports, are present in the meeting from the beginning
and can invite their own guests. Similarly, patients reported that they are
involved in writing their care plans and are read their rights regularly.”
Quality Network Review 2014
P 29
How to provide feedback
We welcome feedback on our Quality Accounts for 2012 / 2013.
To share your feedback please contact us using the details below:
Zsara Thomas
Commercial Director
Alpha Hospitals Ltd
1 Vincent Square
London
SW1P2PN
Tel: 07956 536 259
Email: zsara.thomas@alphahospitals.co.uk