2013/2014

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Quality Account 2013/2014
About Danshell Healthcare Group Limited ...........................................................................................3
Statement on Quality from the Chief Executive Officer .......................................................................3
Statement on Quality from the Director of Nursing, Quality and Governance ...................................4
Part 1: Governance
i. Governance Process ...................................................................................................................5
ii. Key Policy Dissemination ............................................................................................................5
Part 2: Quality Performance
i. Review of Services during 2013 .................................................................................................6
ii. Quality Objectives for 2013 and 2014..................................................................................... 6
iii. CQC Statements ........................................................................................................................7
iv. Data quality ................................................................................................................................7
Part 3: User Experience
i. Service User Involvement and Feedback ...................................................................................8
ii. Statements from Families and Carers .......................................................................................11
iii. Advocacy ..................................................................................................................................11
Part 4: Clinical Effectiveness an Overview .........................................................................................12
i. Key Audit Results CPA Checklist ..............................................................................................12
ii. Key Audit Results MDT Checklist .............................................................................................12
iii. Key Audit Results Medication Management ..........................................................................13
iv. Key Audit Results Anti-psychotic Medication ..........................................................................13
v. Key Audit Results Infection Control .........................................................................................13
vi. Key Audit Results MHA & MCA ..............................................................................................13
Part 5: Patient Safety
i. Key Indicators Patient Safety ...................................................................................................15
ii. Physical Restraints Index...........................................................................................................15
iii. Service User Accidents Index ...................................................................................................16
Part 6: The Danshell Workforce
i. Views of Services from a Staff Perspective ...................................................................................17
Part 7: Annex Statement from Danshell Purchaser ............................................................................17

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The Danshell Board is committed to delivering the highest standard of quality care.
At Danshell, we believe that we must be fully accountable to those we serve, their families and those who commission services on their behalf. We promote appreciative, committed and people focused care. Our unique company structure emphasizes clinical governance and quality. We employ some of the most experience and qualified consultant nurses in the country to support our nursing teams across the UK.
This year’s Quality Account is based around the framework for delivery of the implementation and interventions designed to respond to the priorities raised by the people who use our services, families, staff and other key stakeholders. This report concentrates on the areas where we have improved and on the steps taken to assure key stakeholders of reforms to the three key areas of clinical effectiveness, patient safety and patient experience.
We strive to ensure that at the heart of what we do there is a passion to make a difference to people and their families. I hope that this Quality Account will show our commitments and our milestones.
Danshell is publishing its Quality Account 2013/14 for our independent hospital services within England*.
Chief Executive Officer - Efi Hershkovitz
*excludes hospitals in the South East as we work towards merging the data across England from what were two separate companies.

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It is our primary goal to do our best for every individual in our care and to ensure that we do that in a way that is:
Safe person centred and rights based
Sound high quality and appreciative
Supportive empowering and transforming
Some of the people we work with have had a long history of failed placements or institutional care. It can be hard for them and their family to imagine that ‘getting a life’ may be possible. By this we mean to do the everyday things that most of us take for granted. To live in a place of our own, to spend time with our family and friends, to have something worthwhile to do during the day and to feel included in our own communities. We aim to ensure that ‘getting a life’ is the primary goal for everyone who we serve and that we never forget that everyone has dreams and wishes for themselves, their families and friends. We want everyone in our services to feel that they matter and every staff member in our services to feel that they can make a real difference to the lives of the people they serve. One way we can do this is to really listen to what they tell us and to act on what they say. This strategy is our response to our listening exercise with stakeholders and how we will act on what we have heard.
Group Director of Nursing,
Quality and Governance - Debra Moore

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The Group Director of Nursing, Quality and Governance is responsible for nursing, governance and training within the organisation. She leads a team that includes expertise in nursing, governance, compliance, policy, audit and risk management.
This includes a Head of Governance, Compliance and Risk, a Compliance Manager,
Audit and Governance Co-ordinators and Data Analysts. There are also Consultant
Nurses supporting every region.
The focus for the Governance Team is to provide assurance of patient safety, the delivery of high quality care and measurable positive outcomes through a number of key initiatives which include the implementation of the company’s Quality Strategy, the Annual Audit Plan and the Internal Quality Development Reviews. The Quality
Development Review (QDR) is a key vehicle for internal assurance undertaken regularly and comprises unannounced visits by a team of experts that include external and service user representation. This work is supported by the Consultant Nurses who also provide professional nursing leadership, clinical expertise and supervision. The whole team oversee and maintain a number of key processes including the development of company policies and procedures, risk registers and regulatory actions.
The Governance Team undertake monthly analysis across key proxy indicators of patient safety and outcomes for each service and region. This is examined and analysed by the Senior Management Team led by the Director of Nursing, Quality and Governance and discussed at the Internal Whistle-blowing and Safeguarding meeting and reported at Board level. This information is used to monitor and continually improve the quality of care provision and to support and inform the operational management of services via Individual Service Review (ISRs) meetings and at unit, regional and national governance meetings.
All new staff coming to work at Danshell undergo an induction training period.
This includes training on key polices such as: Whistleblowing, Safeguarding,
Health & Safety, Information and Data Protection and how we keep service users safe. We provide training and support on new policy rollout and the implementation of policies is monitored through supervision and audit.

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Danshell has a range of services which can support people’s individual needs. These include services which support people with learning disabilities and complex needs, those on the autistic spectrum and a specialist brain injury and neurological service.
The units continue to be visited and reviewed monthly by the Regional Operations
Directors and their teams. Internal Inspections - Quality Development Reviews are undertaken to ensure compliance with required regulatory standards. There is an
Annual Audit Plan which includes Antipsychotic audit, CPA, Infection Control and
MDT audits. In addition there are audits provided by external companies including medicines management and administration, fire safety and health and safety.
Progress has been made with commissioners in defining clearer service specifications for each service.
Work in partnership with the people who use our services and their families to ensure they have increasing choice and their voice is heard and acted on at all levels of the organisation.
Ensure that our services are consistently reflective of the individuality of our service users and uphold their right to a safe, respectful and dignified experience.
Encourage the people who use our services to be part of their local communities and to provide opportunities for them to contribute and participate in activities that promote their independence.
Maximise the health and wellbeing of the people who use our services.
Provide services that represent good value for money demonstrating effectiveness and clear outcomes for those we serve.
Support learning and personal development for all our staff.
Improve our systems of compliance and audit and ensure we embed quality and governance in all we do.
Also:
We will finalise and implement tools which can report on audit results across all hospital services including the South East of England.
We will be reporting on the following in our next Quality Account: Outcome
Star Tool Re-porting, Health Equality Framework, Positive Behaviour Support
(staff training compliance), HoNOS LD audit results, Service User and Staff One
Page Profile compliance, Staff Satisfaction Surveys (using survey monkey and standard NHS survey).
We are currently working on an antidepressant audit which we intend to publish in next year’s Quality Account.

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Danshell is required to register its 18 hospitals in
England and Scotland with the Care Quality Commission in England and Healthcare
Improvement Scotland.
We are very proud of the work done to achieve the standards we now have.
As of June 2014 all 16 adult hospitals within England
(including the adult services in the South East) are 100%
CQC compliant against the outcomes assessed.
All the services regulatory and corresponding action plans are available to view on the relevant websites, details of which can be found at: http://danshell.co.uk/ cqc-regulator-reports.aspx
LEARNING DISABILITIES
AND COMPLEX NEEDS
AUTISM SERVICES
INDEPENDENT HOSPITALS
1
INDEPENDENT
HOSPITALS
23
24
25
11
12
9
10
4
5
2
3
6
7
Carard Cottage
Fareham, Hampshire
Monroe House
Dundee, Angus
8
RESIDENTIAL SERVICE
WITH NURSING
26 Thornfi eld Grange
Co. Durham
BRAIN INJURY SERVICE
27
OAKVIEW CHILD AND
ADOLESCENT MENTAL
HEALTH SERVICES
IN-PATIENT SERVICES
28
29
17
18
15
16
19
RESIDENTIAL SERVICES
WITH NURSING
13
Bracken Lodge
Hartlepool
14
33
34
31
32
35
ELDERLY CARE HOMES
WITH NURSING
30
RESIDENTIAL SERVICES
WITHOUT NURSING
20 Redlands
21
22
15
32 31
34
33
18
7 14
30
2 8
26 13
11
22
5 20
24
16
25
19
23
27 3
17
6
Danshell has further developed its key governance data sets in line with the Serious
Case Review (SCR) and it is informed by NPSA, NICE and other relevant guidance and research.
Clinical Governance data is used to improve patient safety and the information is utilised for care planning, MDT and CPA reviews and is reported monthly to the Board.
28
1
29
9
21
10
4
12

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Service User Forums are held regularly on a local, regional and national level.
We have also launched our National Family Carer Forum and have begun the process of supporting this independent group to meet and communicate with the use of a secure chat room, newsletters and meeting venues. These will be run at both regional and national levels.
(Operational Directors)
(Governance, Managers, Meetings)
(Service Managers)
Development of Rules,
Chairs, Terms of Reference and Agenda

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At Danshell we are clear that our values and beliefs are the foundation on which our work is founded. If our foundations are strong our care and support will be strong.
We believe that we take a strength based approach to the people we serve and the staff that support them. To enable us to do this we have taken an appreciative approach to care delivery and organisational development. How we do this for individual service users and families is through a range of measures that include the following:
Involving the service user in the design, development and evaluation of our services using appreciative summit meetings.
Using person centred approaches in our assessment and care planning processes e.g. what makes a good day/bad day for the individual.
Employing person centred tools to capture what we like and admire about them, their strengths and talents and how best we can support them e.g. One Page
Profiles.
Listening to the individual and their families and using tools to capture their compelling vision for the future e.g. MY CPA, Person Centred Care Plans, Wonder
Files and Life Story Books.
My care programme approach
CPA meeting
Name ............................................................................. Our Quality Development Reviews, Integrated Audit
Programme, Peoples Parliament and Patient forums monitor that these values and beliefs are embedded within our practices.
Date of
CPA meeting ..................................................
Filled in by ..........
...........................................................
Date filled in ......................
...........................................
We work in partnership with Frank Proctor at The Challenging Behaviour Foundation and the SHIEC project and have developed a number of service user paid work placements at head office. The project has allowed people to take their first steps to gaining meaningful employment. The work placements encourage people who use our services to learn new skills, experience team working and introduce them to a working environment. People have the opportunity to develop their CV, create a photo diary and obtain a professional reference which reflects their experience with us. Individuals provide one page profiles which help the HO staff to support each service user.
After each work placement session, time is taken to sit down and discuss their experiences in order to ensure suitability and progression. For example “what worked” and
“what didn’t work”.

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Danshell undertakes regular Quality Development Reviews (QDRs). Service users have been trained by an external provider as “experts by experience” reviewers and are directly involved in our internal Quality Development Reviews. We also host a Service
User Involvement Forum where we share all of the service user involvement projects and initiatives across the organisation and co-ordinate roll-out of best practice areas.
This includes the implementation and extension of a number of projects including family carer involvement initiatives.
These visual minutes were taken by Creative Connections at our inaugural Family Carer Forum. They are specially trained artists who capture and visualise key ideas and themes emerging from meetings.
Danshell’s Care Plan Approach (CPA) programme evidences person-centred working at all levels. This involves the implementation of new key documents for CPAs including easy read documents.
Care prog ramme ap proach

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We strive to ensure links with family carers are robust and we have established methods for communicating including the family carer feedback surveys and meetings.
It is through these methods that we seek their views, wishes and hopes for their family member and the service they use. The following are quotes from recent family carer surveys which we would like to share:
“Highly confident in the way staff deal with our son and keep him safe.
We are kept informed of events and invited to participate in appointments”
Parents of a person at Newbus Grange,
February 2014
“The staff are welcoming and hospitable, very good with my relative”
Relative of a person at Trinity House,
February 2014
“Thanks again for looking after x so well, it is hard to be so far away from him, but we know he couldn’t be in better hands”
Family member of a person at Oaklands,
December 2013
“The first place that I have come across that staff appear to know how to care for my son and I have confidence that they understand and can meet his needs”
Family member of a person at Hollyhurst,
December 2013
Danshell have national contracts with independent advocacy services. Each service user has access to an independent advocate. Quarterly reports are provided from VoiceAbility to the Danshell Board.
“The care provided for my client strives to meet his needs.
His needs are continually under review and care is taken to ensure he is happy.”
Advocate, May 2014 .
We collect a number of quality indicators including compliments and complaints. This information is reviewed in the Complaints Committee and lessons learned are shared at
National Clinical Governance Forums.
The number of complaints in England
(excluding the South East region) have reduced during 2014.
Complaints Trend Analysis
Danshell Hospitals (England)
Jan 2014 - May 2014
Complaints Trend Line

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We have an integrated audit programme which includes unit led, corporate and external audits. This assists us to measure progress against implementation of new initiatives and embedding of good practices to support effective care for our service users. Where audit results do not meet company minimum requirements, action plans are developed and monitored through Internal Service Reviews (ISRs) and re-audited as required.
We aim to facilitate admissions to Danshell services for the shortest possible period of time to complete an assessment and treatment process. In order to do so, we jointly complete comprehensive assessment and agree treatment goals prior to admission and monitor these weekly for the first 12 weeks leading up to the initial Care Programme
Approach (CPA) review meeting via a planned series of MDT reviews.
Danshell use a CPA system which focuses on the service user, who takes a lead in preparation for these meetings using the easy read “My CPA” booklet. All clinical
CPA reports are outcome focused and concentrate on discharge needs from the point of admission. CPA reports are sent to attendees 2 weeks in advance and attendance proactively encouraged, meetings are arranged at a time and date to meet service user and family needs and not those of the units.
Active participation is encouraged and facilitated in the meeting and feedback of the meeting sought from service users, family members and commissioners of services.
Danshell has developed a CPA framework which has been audited.
2013 Key Audits & Results (excl. South East & Scotland Hospitals)
AUDIT TITLE
CPA Checklist - Care Programme Approach
Audit Results
%
82
The MDT meeting remains the regular weekly forum to monitor service user’s progress.
We continue to review treatment goals using a structured template which ensures all areas of physical and mental health are regularly reviewed. Danshell hospitals are supported by a clinical team of Psychiatrists, Psychologists, Occupational and Speech and Language Therapists, where service users have additional needs we actively involve external clinical experts. To maximise physical health care of people using our services we ensure that all receive an annual health check from their registered general practitioner. We undertake an annual audit on MDT.
2013 Key Audits & Results (excl. South East & Scotland Hospitals)
AUDIT TITLE
MDT
Audit Results
%
75

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Danshell continues to work with national pharmacy suppliers whose expertise provide training to clinical, nursing and support staff, and supported the revision of Danshell’s medication policy. We undertake an annual audit on medication management to ensure that staff are adhering to company policy and NMC standards for medicines management.
2013 Key Audits & Results (excl. South East & Scotland Hospitals)
AUDIT TITLE
Medication Management
Audit Results
%
96
Danshell undertakes an anti-psychotic medication audit annually to establish whether the Royal College of Psychiatrists Consensus Statement Standards for high dose antipsychotic use, NICE (CG82) guidance and BNF recommendations have been achieved.
2013 Key Audits & Results (excl. South East & Scotland Hospitals)
AUDIT TITLE
Anti-psychotic Medication
Audit Results
%
91
Danshell completes an infection prevention and control audit twice a year to monitor the effectiveness of measures to protect service users and staff against infections and cross infections.
2013 Key Audits & Results
(excl. South East & Scotland Hospitals)
AUDIT TITLE
Infection Control
Audit Results
%
97
Danshell undertakes annual MHA and Mental Capacity Act Audits to ensure that we comply with regulation and to safeguards our service users.
2013 Key Audits & Results (excl. South East & Scotland Hospitals)
AUDIT TITLE
ENGLAND - MHA Detained service users
ENGLAND - MCA 2005 (All service users)
Audit Results
%
99
95

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As part of the audit programme the people who use Danshell services completed a Safeguarding survey. 84% of them said that they felt they could speak to staff about anything.
Danshell has adopted the Life Star and Spectrum Star as outcome measures.
All nursing staff have received training in the use of this tool and its electronic recording system. HoNOS LD continues to be used in all services and we are soon to be launching the use of the Health Equality Framework (HEF) outcomes tool.
All service users continue to have an individualised programme of activities, facilitated by in-house Activity Co-ordinators based in each service. This includes a balance of educational and leisure activities and endeavours to promote maximum physical exercise and a healthy lifestyle. Activity Co-ordinators are supported by Occupational
Therapists and attend a regular national forum enabling the sharing of good practice across the range of services.
We have fully implemented the national Medical Revalidation process for all of our doctors. A Responsible Officer is in place and continues to revalidate Danshell doctors.
We have implemented a new supervision policy which provides a clinical supervision structure for all nursing staff. We have also implemented a new nursing risk assessment and care planning system.
We have recently commenced roll out of Personal PATHS ™ which is a model of care delivery that enhances the focus on positive outcomes for service users and measurable progress. Personal PATHS follows five key principles; Positive behaviour support, Appreciative enquiry, Therapeutic outcomes, Healthy lifestyles and Safe services.
Danshell is also currently rolling out The Health Equalities Framework (or HEF) is an evidence based outcomes framework that was developed by members of the UK
Consultant Learning Disability Nurse Network. We will use it to measure the impact of exposure to known determinants of health inequalities in order to demonstrate the effectiveness of our services in reducing inequalities and achieving better health outcomes for the people who use our services. The HEF will inform our health action planning processes and in addition from aggregated anonymised data we will better understand service user needs across broader populations.

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The Governance team continually focus and review processes at all services.
They are responsible for ensuring that effective audit processes, quality checks and compliance requirements are in place. The team includes service users and involves external, independent expertise. We collect and analyse data on a number of patient safety indicators which inform care planning, MDT Review, and CPAs.
Trend analysis and lessons learnt are reviewed at Internal Service Reviews,
Complaints and Compliments Committee, Health and Safety Committee,
Safeguarding and Whistle Blowing Committee, Clinical Governance Committee,
National Clinical Governance Forum and the Board.
Our systems enable us to take a proactive approach to patient safety. We have an electronic incident reporting system, which provides improved analysis of incidents which helps us to act quickly and understand the lessons learnt from incidents.
This enables close analysis of the use of restrictive physical interventions at unit level during the care provision reviewing process, as well as enabling scrutiny at regional and national level for reviewing practice and trends. Danshell employs MAYBO as their preferred provider of physical intervention training. MAYBO do not teach the use of prone restraint to Danshell employees. We are working with our clinicians to learn how to safely administer intramuscular injections without the use of physical restraint.
There has been a significant reduction (41%) in use of high level physical restraints.
Over the same period, there was nil face down (prone) restraint.
Physical Restraints Index
Danshell Hospitals (England)
June 2012 (Base = 100) - May 2014
Physical Restraints Index

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A full and comprehensive review of our physical intervention policies has been undertaken which includes improvement to our quality of training, and increasing staff skills to manage complex and high risk situations safely. Positive Behaviour
Support (PBS) training is being rolled out across all services.
There has been a significant reduction (22%) in service user accidents from June 2012 to May 2014. During the same period no service user accident has resulted in death or prolonged hospitalisation of service user.
Service User Accidents Index
Danshell Hospitals (England)
June 2012 (Base = 100) - May 2014
Service User Accidents Index
*This index summarises a collection of data for hospitals in England (excluding South
East region) in the use of physical restraints and service user accidents on a monthly basis since June 2012 (the base period is assigned a base value of 100 and all subsequent data is expressed in relation to it).
Each service user has access to an independent advocate. There is a full suite of literature available in easy read for all service users which amongst others covers the subjects of bullying, keeping safe and reporting abuse. All our service users are encouraged to talk about and report anything they are not happy about.
There is an externally sourced, independent whistleblowing helpline to which all staff have access. Staff are also encouraged to report concerns of any kind in confidence to senior staff. Any concerns are then collated and considered at the Whistleblowing and
Safeguarding Committee attended by Board members.

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Staff have access to forums throughout the services and staff surveys have been commissioned for 2014 in order to better engage with staff. There is regular attendance by senior management at our services to allow staff to contribute their views, concerns and ideas.
The use of the company intranet and the staff newsletter keep members of staff up to date with new policies, progress and improvements as we continue to improve upon patient safety and the quality of services we provide. Regular team briefings continue to cascade information to all our staff. Staff views are recorded and included within subsequent Board discussions.
NHS Central Eastern Commissioning Support Unit has kindly reviewed Danshell’s
Quality Account and in light of our commissioning experience, I can confirm that the
Quality Account is correct although, they have not been fully audited by NHS Central
Eastern Commissioning Support Unit.
Signed by
Jackie Bland -
MH/LD/CAMHS Placements Manager
NHS Central Eastern Commissioning Support Unit

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© Danshell