Quality Account 2013–14
Our quality performance,
initiatives and priorities
Contents
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Who we are and what we do
Commendations
Part one: our priorities for quality
Joint statement from our Chief Executive and Chair of Trustees
Our vision and values
Our services map
Part two: our priorities for improvement
Our progress against our priorities for improvement 2013–14
Priority 1: Service user experience. To further develop tools to gain
feedback on how person-centred support is delivered in our services
Priority 2: Service user safety. To manage the risk of harm from medication
by piloting new ways of working with technology
Priority 3: Effectiveness. To further develop our activity programmes
Priority 4: Service user experience. To measure our culture for care delivery
and safety using a culture barometer
Priority 5: Service user experience. To ensure learning from complaints and
concerns and publish this information when it relates to upheld complaints
regarding care delivery
Priority 6: Service user experience. To measure the effectiveness of new
equipment for service user and staff safety following the introduction of
‘safer sharps’
Part three: our priorities for improvement 2014–15
Priority 1: Service user involvement. To embed the use of electronic
devices to gain real-time feedback from people who use our services
Priority 2: Service user safety. To manage the risk of harm from falls
Priority 3: Effectiveness. To continue to develop and then measure the
activity standard
Priority 4: Effectiveness. To develop our strategy for education and training
Priority 5: Effectiveness. To deliver an accredited development
programme for non-registered clinical staff
Priority 6: Effectiveness. To improve and measure the quality of our end of
life care
Part four: indicators
Part five: annexes
Annex 1: Legal requirement
Annex 2: Statement from Lead Clinical Commissioning Groups (CCGs)/
Commissioning Support Units, (CSUs) the Overview and Scrutiny
Committee (OSC) and Health & Wellbeing Boards
Cover image
Elizabeth, supported
receiving therapy
Who we are and what we do
Sue Ryder provides incredible care for people with life-changing illness.
Whether it’s bringing comfort to someone’s final days or enabling
them to make the most of their life, we are here for them and those
important to them.
We treat everyone in our care as an individual, taking the time to see
the person not the condition. We enable people to live the life they
want, and do everything we can to ensure their time with us is the
best it can be. We do this in our hospices, neurological care centres,
in the community and in people’s homes.
This document, the Sue Ryder Quality Account 2013–14,
demonstrates our continued commitment to improvement.
It outlines our improvement measures over the last year and
our priorities for the year ahead.
Commendations
“We are very pleased with the service, and the carers that come
in have all been excellent. We also have the assurance that if
there is anything different with Mum when they come they will
contact us immediately.”
Family of an individual we support in our homecare services
“Thank you, you made the last few days of her life an
experience that we shall remember with great thankfulness.
The loving care you gave to all of us meant so much.”
Family we supported at one of our hospices
“I like it here as everyone is like my family, very friendly”
A resident we support at one of our neurological care centres
Sue Ryder – Quality Account 2013–14
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Part one: our priorities for quality
Position and status on quality
Joint statement from our Chief Executive and the
Chairman of Trustees
Welcome to our annual Quality Account, a summary of our
performance against selected quality measures for 2013–14 and
our initiatives and measures for 2014–15. This is our fifth account
and each year we use the account to celebrate some of the year’s
achievements in healthcare.
Change in leadership
After seven years as Chief Executive Officer (CEO), Paul
Woodward retired at the end of last year. After a competitive
recruitment round, Heidi Travis was appointed the new CEO
and took over the operational day-to-day management from
Paul on 30th September 2013. Heidi joined Sue Ryder in
March 2010 as Director of Retail. Since then, she has
revolutionised our retail business which now delivers more
than £10.5 million profit a year.
We also said goodbye to our Director of Health and Social
Care, Steve Jenkin in the summer of 2013 and hello to Mike
Smeeton, who joined Sue Ryder in March 2014. Having
worked primarily at an executive level within the NHS, Mike
brings experience in commissioning, developing partnerships
and technology in a care environment to the charity.
Our aim for the coming year and beyond is to grow and
develop our range of services. We aim to achieve this by
utilising our experience in neurological and palliative care
services and by giving more ownership and control to our
care centres and hospices so they can maximise their local
opportunities. In the Health and Social Care Leadership Team
we have replaced the regional manager structure with
assistant directors for palliative, neurological and Scottish
services.
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Sue Ryder – Quality Account 2013–14
Better pay and developing staff behaviours
We believe our staff are our greatest ambassadors and
we committed to look at our pay rates for all of our clinical
staff last year. We also committed to put in place a skills
and development framework. In order to achieve this
we benchmarked pay against a range of providers in our
competitive market, including the NHS and other private
and charitable care providers. We developed a skills and
competency grid for all clinical roles. We piloted this initially
within one of our services and rolled out to the remaining
services throughout the year with the final implementation
in February 2014. Over the course of the coming year we
will continue to work closely with staff to monitor the
impact of this.
We have also developed an organisational framework of
11 behaviours to reflect what we will see if we are living our
values. ‘Doing the right thing’ might look different in other
areas of the organisation, but there are some common
behaviours we would expect to see, regardless of role. We are
currently exploring how we use the behaviours to form part
of our performance management process for 2014–15.
Part one: our priorities for quality
Working with the Department of Health
As a result of our response to and progress in implementing
the recommendations of the Francis Report there was an
exciting opportunity to work alongside the Department of
Health (DH). Since August 2013, we have enabled senior civil
servants from the DH to undertake placements in our
hospices. It’s a chance for them to shadow our frontline care
staff and see the excellent standards of care we provide. The
visits were part of the government’s ‘connecting’ initiative,
which was designed to help DH staff become more
connected to the real experiences of care. We were the first
hospice provider, and the first charity, to offer placements of
this kind to DH staff. In February 2014 we presented our
experiences of being part of the programme at a national
conference for the connecting programme.
Continuing to deliver quality services
Early in 2013 we received a grant of £1.2m from the DH to
improve facilities at three of our hospices. We have been busy
over the course of the year, completing the refurbishment of
our day care facilities at Leckhampton Court Hospice in
Cheltenham and Thorpe Hall Hospice1, Peterborough, as well
as improving inpatient facilities at Duchess of Kent Hospice.
We changed the name of our hospice in Reading from
Duchess of Kent House to Duchess of Kent Hospice in an
attempt to better reflect the services we provide there.
Sue Ryder took over the management of the services, which
includes two day therapy units and seven day a week specialist
palliative care nursing services, from the local NHS Trust back
in 2011. Over 2013-14 we have re-serviced the inpatient unit
and the day therapy unit at Duchess of Kent Hospice.
Some feedback:
“I cannot remember learning so much in a single day”.
Our Stirling Homecare service in Scotland received a glowing
report from the Care Inspectorate back in May 2013. The Care
“I was struck by the depth of knowledge about each individual Inspectorate, the independent regulator of social care
– their (medical) condition, treatments, personal
services in Scotland, grades services on six different areas
circumstances and wishes. The degree of compassion and
after an inspection. Stirling Homecare was awarded a Grade 6
consideration was exceptional”.
– the highest score, representing ‘excellent’ – in four of the six
areas. Grade 6 is not easily achieved and more or less unheard
We also worked with the DH strategic partnership programme of in a homecare setting.* The service was re-commissioned
to write some joint guidance for charities about what the
in 2014 and is now reaching more people across the local
Francis Report might mean for them and how they too can
area. The team delivered a workshop at the Social Services
improve their services.
Expo & Conference in March 2014, on achieving excellence in
homecare, sharing best practice with health and social care
Celebrating 60 years of incredible care
professionals.
In July 2013, staff and volunteers from across Sue Ryder
attended a reception at the House of Commons to celebrate Working in partnership
our 60th anniversary. Care centre managers were asked to
Partnership for Excellence in Palliative Support (PEPS)
nominate people who had made a special contribution to
The PEPS service was implemented as a pilot in December
providing incredible care.
2011. It aims are to improve the care experience for patients
in the last 12 months of life and to help co-ordinate health
Kris Hopkins MP, whose Keighley constituency is home to
and social care professionals to provide care in the place
Manorlands Hospice, hosted the reception. He shared his
where patients choose to be at the end of their lives. Liaison
experience of the care we provide, which included when
with the East of England Ambulance Service Trust (EEAST) has
his father was cared for at Manorlands Hospice during the
had a direct impact on reducing unnecessary conveyance to
last days of his life. We were also joined by Norman Lamb
hospital. This has been achieved by direct data input of all
MP, Health Minister, and Andy Burnham MP, Shadow
PEPS registered patients onto their EEAST computer system.
Health Secretary.
It is early days but in the first seven weeks of 2014,
ambulance services were called to the homes of 27 patients
who were on the PEPS register. By the ambulance services
directly contacting the PEPS services, 21 (78%) of patients
remained at home avoiding A&E attendances and probable
admission. We are extremely excited about the future impact
this could have on supporting more patients at home, where
this is their choice, and reducing emergency admissions.
1 The work at Thorpe Hall Hospice is part of our wider capital appeal
to raise funds to build a new hospice in Peterborough.
* The service was re-inspected in April 2014 and was awarded Grade 6
in all areas.
Sue Ryder – Quality Account 2013–14
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Part one: our priorities for quality
Extending our reach in Suffolk
Our dementia telephone helpline in Suffolk has been running
for year now, and has recently been extended to offer a 24hour service. During office hours we can offer practical
support and information about dementia, along with details
of other services in the local area that can help. At all other
times we offer a listening ear service. Our funding for the
helpline has been extended to September 2015. Sue Ryder is
part of the Suffolk Dementia Partnership, which also includes
Suffolk Family Carers, Age UK Suffolk and Alzheimer’s Society.
Furthermore, we are extending our support for individuals
with dementia for their carers in Suffolk through the rollout
of Synergy Cafés. A Synergy Café provides a relaxed and safe
environment where people with dementia and those that
support them at home can attend together and have access
to support, information and education about living with the
condition and signposting to other sources of help. The
service is grant funded and an extension of this grant has
meant we are able to operate not only from our care centre
The Chantry, but also from other external locations: Felixstowe,
Haverhill, Hadleigh and Shotley. A Synergy Café has also been
set up at our Thorpe Hall Hospice. We are also working in
partnership with Orbit Housing Association to provide cafés
in the Brandon and Newmarket area of Suffolk.
“Money cannot buy
what you get here.”
Our vision
We aspire to create a world where everyone has
access to personalised and compassionate care.
Our values
At Sue Ryder we’re passionate about giving
people the care they want, that’s why we
always aim to:
• do the right thing
• push the boundaries
• make the future together
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Sue Ryder – Quality Account 2013–14
Befriending in Scotland
Six months after of launching the Aberdeen Befriending
Service for older people in July 2013 (run in partnership with
four other charities) we won the Aberdeen Impact Award for
Change for Older People. Over 100 people have benefited
from the service to date. A recent survey showed that people
who have received visits from befrienders are feeling more
positive, more in control of their lives and more able to make
decisions about their daily life since the scheme started.
We continue to work in partnership across our services and
there are many more examples of how we are doing this. To
find out more, please get in touch.
We hope you find our Quality Account useful. We welcome
suggestions for future accounts. The Quality Account and the
information it contains is accurate at the time of print; it has
been reviewed via our internal governance structure and is
true to the best of our knowledge.
Heidi Travis
Chief Executive
Roger Paffard
Chairman of Trustees
Part one: our priorities for quality
Our service map
Head Office
1. Central Office, London
Registered Office
2. Sudbury Office, Sudbury
Extra Care
3. Sue Ryder – Heyeswood, Merseyside
Aberdeen
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22
11
17
4.
5.
6.
7.
8.
9.
10.
Palliative Care
Sue Ryder – Manorlands Hospice, West Yorkshire
Sue Ryder – Wheatfields Hospice, West Yorkshire
Sue Ryder – Thorpe Hall Hospice, Peterborough
Sue Ryder – St John’s Hospice, Bedfordshire
Sue Ryder – Nettlebed Hospice, Oxfordshire
Sue Ryder – Leckhampton Court Hospice, Cheltenham
Sue Ryder – Duchess of Kent Hospice, Reading
11.
12.
13.
14.
15.
Complex neurological care
Sue Ryder – Dee View Court, Aberdeen
Sue Ryder – Holme Hall, East Yorkshire
Sue Ryder – The Chantry, Suffolk
Sue Ryder – Stagenhoe, Hertfordshire
Sue Ryder – Cuerden Hall, Lancashire
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Elderly & dementia (residential care)
16. Sue Ryder – Birchley Hall, Lancashire
Homecare services (in Scotland)
17. Angus Homecare
18. Stirling Homecare
Supported living
19. Supported living unit, Suffolk
20. Supported living unit, Aberdeen
Leeds
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15
5
21.
22.
23.
24.
12
Liverpool
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3
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Other services
Befriending schemes (dementia & volunteer), Doncaster
Befriending Scheme for older people, Aberdeen
PEPS service, Bedfordshire
Dementia Helpline, Suffolk
Nottingham
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Birmingham
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7
9
14
Oxford
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2
13
24
London
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1
10
Sue Ryder – Quality Account 2013–14
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Part two: our priorities for improvement
At the Help the Hospices conference in October 2013, we
launched an end of life self-assessment tool entitled Progress
for Providers: End of Life. Sue Ryder, in partnership with Helen
Sanderson Associates, Hull City Council and St Ann’s Hospice,
developed the end of life self-assessment care tool. The tool
Over the course of the last year a number of projects have
shows what good end of life care should look like through a
culminated in improved information relating to user
series of comprehensive and evidence-based prompts and
experience, incidents, complaints and compliance with Sue
suggestions. Healthcare professionals can use the tool to
Ryder policies and procedures.
check that the care they are providing is tailored to their
patient’s individual needs and wishes in their anticipated last
Highlights of our activities
In 2013–14 we had our highest ever number of people taking year of life, as well as using it to see how they can develop,
improve and measure their current care provision. Each of
part in research. The Research Governance Group (RGG) has
our hospices has been working with the tool and we will
had a clear commitment to improving the processes around
evaluate their experiences looking at what personalisation
research. The research processes have been streamlined to
means in practice in the summer of 2014.
reduce study approval times. In view of this, eight research
studies have been approved. Recruitment to the majority of
In November 2013, we ran three workshops on end of x§life
these studies is not yet complete. One of the studies
care. These were open to the public and healthcare
recruited 270 patients in the West Berkshire area. This
professionals and were run on behalf of the Leadership
pharmaceutical study explored interactions between herbal
supplements and conventional medicines and was led by the Alliance for the Care of Dying People (LACDP). The LACDP
was established by NHS England in July 2013, to respond to
University of Reading Pharmaceutical Studies Department.
the recommendations of Baroness Neuberger’s independent
review of the Liverpool Care Pathway. Sue Ryder is a member
There has also been a focus on promoting research across
of the LACDP.
various centres. The RGG has been privileged to have the
Associate Director of Research and Development from the
For the past three years we have delivered, under licence,
local NHS research consortium in Gloucestershire who has
played an active role in providing external scrutiny to research the Royal College of Nursing (RCN) Clinical Leadership
programme. The service improvement projects from our
presented. More work has also been done to develop links
2013–14 cohort are included within this year’s account.
with the Sue Ryder Centre for the Study of Supportive,
Palliative and End of Life Care at Nottingham University,
Our priorities for going forward
We continue to improve service user and family experience in
We believe everyone should be able to choose the care that
they want at the end of their life, but inequalities in accessing our care, both on a local and national level. The priorities for
2013–14 and 2014–15 do not fully represent all that we are
co-ordinated, personalised and quality care at the end of life
still persist. ‘Dying isn’t Working’ is a campaign we launched in doing, but they give an indication of particular areas of focus.
2013; it re-examines the reasons behind these inequalities
Our quality strategy focuses on the same three overarching
and seeks to put the individual back at the heart of the end
key areas identified in previous Quality Accounts and these are:
of life care policy debate. We used our 60th anniversary
• service user experience
celebration at the House of Commons to launch the
• service user safety
campaign in parliament.
• effectiveness
Working with Demos, we’ve produced two research projects
exploring service journeys at the end of life. Ways and means
being the first. This is the first time this has been examined
from an individual’s perspective. The report identifies some of
the key drivers of poor service journeys and gives important
insight into the inequalities in end of life care. We followed this
report with ‘A time and a place’. The report identifies what
people want, and priority preferences at the end of life, how
they associate these with different places of death and how
perceptions of care differ. Our priorities for 2013–14 were influenced by service user
experience and involvement, national standards and learning
from enhanced quality performance data.
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Sue Ryder – Quality Account 2013–14
Part two: our priorities for improvement
Our progress against our priorities for improvement 2013–14
The priorities for 2013–14 were:
The priorities for 2014 –15 are summarised below:
Priority 1
Service user
experience
To further develop tools to gain
feedback on how person-centred
support is delivered in our services
Priority 1
Service user
experience
To embed the use of electronic devices
to gain real-time feedback from people
who use our services
Priority 2
Service user
safety
To manage the risk of harm from
medication by piloting new ways of
working with technology
Priority 2
Service user
safety
To manage the risk of harm from falls
Priority 3
Effectiveness
To further develop our activity
programmes
Priority 3
Effectiveness
To continue to develop and then
measure the activity standard
Priority 4
Service user
experience
To measure our culture for care
delivery and safety using a culture
barometer
Priority 4
Effectiveness
To develop our strategy for education
and training
Priority 5
Service user
experience
To share learning from complaints and
concerns, and publish this information
when it relates to upheld complaints
regarding care delivery
Priority 5
Effectiveness
To deliver of an accredited
development programme for
non-registered clinical staff
Priority 6
Service user
experience
To measure the effectiveness of new
equipment for service user and staff
safety following the introduction of
‘safer sharps’
Priority 6
Effectiveness
To improve and measure the quality
of our end of life care
Whilst we haven’t named medicines risk as a priority for
2014–15, it will continue to be a key risk area and remain on
our quality action group plan.
These priorities for 2014–15 have been approved by ACORNS
(our service user advisory group), the Health and Social Care
Governance Committee (HGC), the Executive Leadership
Team (ELT) and our Board of Trustees.
Sue Ryder – Quality Account 2013–14
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Part two: Our progress against our priorities for improvement 2013–14
Priority 1: Service user experience
To further develop tools to measure how personcentred support is delivered in our services
We said we would explore and embed the use of handheld devices in hospice settings to gain feedback in real-time.
Working closely with our information systems manager
(healthcare) we have been exploring the use of hand-held
devices and the possible providers we could work with. The
outcome was an options paper presented to our Executive
Leadership Team. Embedding the use of these devices will
feed into our approach in 2014–15.
We are asking our patients, carers, medical and nursing staff
for their opinions and input to ensure this application meets
the needs of the people we support. A series of meetings
were held to demonstrate the initial prototype and actively
engage this group in its development.
Feedback from Dynamic Health Systems has been that
through working in this way “things have been highlighted
[they] hadn’t considered” and the feedback received was
“like commercial gold dust”.
Dynamic Health Systems working with Sue Ryder were
successful in February 2014 in winning Department of Health
In addition to the use of hand-held devices, we are looking at funds to implement the ‘end of life’ personalisation internet
fixed devices in public places for capturing real-time feedback. application for use in the population served by three of our
hospices – Manorlands, St John’s and Wheatfields. We will
We said we would develop electronic tools for capturing report on progress in next year’s account.
feedback consistently across all hospices.
We said we would expand the skills and commitment
In 2013–14 we envisaged this work would focus on capturing of our volunteers by piloting a development programme to
feedback, but through looking more at this, it has evolved to
equip them to gain feedback from patients and carers outside
be more around patient involvement and input into their
of the professional workforce.
care plans.
We are exploring the training needs of volunteers who we
Sue Ryder is working with Dynamic Health Systems to look
hope in future will help with collecting feedback from patients
at how patient experience can be improved. Dynamic Health and carers. The majority of this work will take place in our
Systems have developed an internet application for devices
hospices. We have introduced a local volunteer orientation
such as personal PCs, smartphones and tablets. The
and mandatory induction workbook.
application enables individuals to record and change their
goals and aspirations, making these visible in real-time to
We said we would enhance links with volunteer
both the clinical team and chosen family members. We are
co-ordinators in each hospice to deliver local education
helping them test this to explore how it can improve
and support.
personalisation and the quality of care at the end of people’s
lives, putting the individual truly at the centre of care delivery. The volunteer co-ordinators will deliver ongoing education
and support for the volunteers collecting feedback when this
is implemented in 2014–15.
“I was asked what level of support I wanted,
right down to what sort of sheets I prefer
on the bed. They’re really accommodating.”
A relative said: “It really is a lovely place.
I don’t think we’d find anywhere better.
The care is fantastic; they treat my
[relative] brilliantly”
Comments from people we support. These comments were captured
by the Care Quality Commission as part of an inspection at one of our
neurological care centres.
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Sue Ryder – Quality Account 2013–14
Part two: Our progress against our priorities for improvement 2013–14
Mandy, Nikki
and Karolina
Improving communication between
shifts and teams
“…brilliant tool, we know
what’s going on even
after a week off.”
Feedback from staff
Sheeba, senior nurse, developed a tool to enable better
communication between shifts and teams within the
neurological centre in which she worked. Handovers
previously happened several times during one shift, an
example was given of internal (and on occasions external)
appointments missed as the handover information
followed no specific format.
Sheeba reviewed the handover process, gathered feedback
from colleagues and carried out observations by listening
to how handovers were taking place.
A handout prompt was developed which recorded relevant
information including service users’ appointments.
Evaluation has demonstrated how it has helped to improve
communication amongst nursing staff working different
shifts and saved time with having all the relevant information
in one place. At the Chantry, Sheba estimated that by working
in this way, it will have a cost saving of £6,796.
Sue Ryder – Quality Account 2013–14
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Part two: Our progress against our priorities for improvement 2013–14
Priority 1: Service user experience
Creating a home from home
With our client group getting younger and areas of the centre
not being utilised, Zoe-Anne, a unit lead from Stagenhoe, our
neurological centre in Hertfordshire, took on the task of
revamping an unused communal lounge.
The lounge was cold, unloved and very rarely used. Over time
it had become a storage area for unused wheelchairs, instead
of being an area used by our residents and their families.
Zoe-Anne consulted with management, residents and
families on how they would like to use the room in the short
and long term. This information was shared and a consensus
reached – not an easy task with so many to please, but the
experience of ensuring everyone was heard and opinion
valued was demonstrated throughout.
The room has been modernised; it no longer feels unloved or
cold, it’s now a commonly used area with a flat screen TV
added to one of the walls for residents and families to watch
films and play games or enjoy the extra space the lounge
provides with access to the gardens.
The project has brought the residents closer together by
having a common shared interest and it’s also created a real
buzz with the endless possibilities of what it could be shaped
into in the not-so-distant future. The new lounge will be
complete this summer.
Person-centred care
To help maintain regular interaction
with patients in our inpatient ward at
our hospice in Gloucestershire, we
introduced care rounding. The aim of
care rounding is to provide better than
expected care to patients. It is based on
the following six key elements of
nursing care:
1. continence
2. pain control
3. position and comfort
4. nutrition
5. safety
6. wellbeing check
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Sue Ryder – Quality Account 2013–14
Improved personal care was also
identified as a key area to address and
improve within the service’s quality
improvement plan.
Debbie, a ward manager with prior
experience of care rounding introduced
the new way of working with the
development of a template for nurses to
complete. Patient comfort is improving
through regular and positive interaction
between nursing staff, the patients
and their families.
Part two: Our progress against our priorities for improvement 2013–14
Priority 2: Service user safety
To manage the risk of harm from medication by
piloting new ways of working with technology
We said we would review current systems available
electronically in hospices for prescribing and administration.
We have reviewed our current prescribing and medications
management practices, the outcome of which is informing
research into appropriate electronic solutions that would
meet the specific needs of our hospices. Input has been
gained from numerous sectors, ranging from peer
organisations in the healthcare sector to the suppliers of
appropriate systems, with the aim of compiling a business
case for implementing an electronic solution within Sue
Ryder.
In addition to this, we have developed a new non-medical
prescribing policy, agreed in July 2013 at our Healthcare
Governance Committee (HGC) meeting. As a result of this we
now have non-medical prescribers in many of our hospices.
An information leaflet has been developed for each service
for patients and carers. By working in this way, we aim to:
• improve the timeliness and safety of prescribing medicines
• help improve the care and support our patients receive
from us by tailoring the care to meet their needs
• provide information about the medication patients
are taking, including risks and benefits
• work with patients to better monitor their treatment
We said we would review the medicines competencies
and ensure all education leads receive reports on incidents,
and include this information as standard in training.
During the course of 2013, four incident management
training days were delivered to managers who access the
online incident reporting system (including education leads
and practice educators). The learning outcomes of the day
were to:
• understand the importance of monitoring frontline reporting
• understand the duty of candour (reference Francis
Report, 2013)
• increase skills with regard to incident learning
• identify how incident reporting relates to managing risk
• recognise incident themes to enable reporting through
quality improvement groups
• ensure the full functionality of Datix (our on line incident
and adverse events reporting tool) is utilised
• briefly run through the process of reporting complaints
within Datix
• remind staff of RIDDOR* reporting process and identifying
a RIDDOR incident
We said we would continue the specialist review of all
medicines incidents.
With the help of our healthcare intelligence and information
analyst, a regular and more detailed incident report is now
produced quarterly for the HGC. We are looking at the trends
We said we would raise awareness about medicines risk in medicine incidents such as when they happen and the time
for all staff by including case studies in the two-yearly
of day. This is helping us to focus on day-to-day activities that
might impact on our medicines practice. The review stage of
competency review.
medicine errors (whether this is dispensing, storage,
In July 2013, we revised our nurse administration competency prescribing, administration, or disposal) has helped us to
understand at what stages the highest risks sit. Adjustments
framework. The revisions mean the nurse and assessor now
were made to the medicines policy in March 2014, to
jointly identify an area of practice, for example following a
standardise the process of follow up to prescribing errors in a
medicines administration incident, they would agree the
similar way to our current approach to administration errors.
learning outcomes. As part of this work, we have also
reviewed the medicines management audit tool and carried
out an audit against policy.
* RIDDOR – Reporting of Injuries, Diseases and Dangerous
Occurrences Regulations
Sue Ryder – Quality Account 2013–14
11
Part two: Our progress against our priorities for improvement 2013–14
Priority 2: Service user safety
Management of medicines
Our neurological centre in Suffolk, The Chantry, was having
problems with the supply of medication from their local
pharmacy and had captured the issues on Datix. In summary,
monthly deliveries were delayed, times were staggered or
items out of stock. As a consequence nursing staff were
spending a lot of time chasing up prescriptions and
reordering medicines.
Toni, a staff nurse on the RCN Clinical Leadership Programme
reviewed the current ways of working across the centre.
Working with the local GP practice, a service level agreement
with a new local pharmacy was set up.
The new pharmacy has taken responsibility for chasing up
repeat prescriptions, saving the centre time, and outstanding
prescriptions have significantly decreased. Nursing staff are
not as stressed looking for medications which have not been
delivered and report better medicines management.
They now have more time to deliver care and more
importantly it has increased resident satisfaction and
access to medicines.
Delivering intravenous therapy
Due to the increased need for intravenous therapy at
Thorpe Hall, our hospice in Peterborough, Rachel, a clinical
development nurse, took on a project to look at introducing
intravenous therapy (IV) within the hospice.
Newly developed procedures and care plans were
benchmarked with the local NHS trust. For a trial period
of three months these were tested and, following a review,
were implemented within the hospice.
Now these procedures have been put in place, patients
can have continuity of care by no longer needing to be
transferred to the local hospital for IV therapy. Feedback
from staff: “excellent checklist”, “user-friendly.”
12
Sue Ryder – Quality Account 2013–14
Part two: Our progress against our priorities for improvement 2013–14
My medicines – my way
Through observations of care at
Cuerden Hall, our neurological care
centre in Lancashire, Sue, the Head of
Care could see how time-consuming
medicines rounds were becoming. Daily
activities for residents tended to revolve
around nursing tasks, making them less
person-centred. Through enhancing
the services re-ablement programme
and exploring new ways of working, a
new process for medicines
management was introduced.
Care support workers were trained to
administer medicines, a role previously
only undertaken by a registered nurse,
increasing the access to timely
medicines and freeing up nurses’ time.
Sue Ryder – Quality Account 2013–14
Medication records and sheets were
produced for recording resident
medicines information. Staff training
which included distance learning,
in-house training and competency
assessments were carried out, as well
as risk assessments on the new way
of working.
By working differently we have
recognised and enhanced the skills
and abilities of our workers, providing
the people we support with greater
independence and improved personcentred care by a better use of staff
time. At Cuerden we are set to save
£2,275 per annum.
13
Part two: Our progress against our priorities for improvement 2013–14
Priority 3: Effectiveness
To further develop our activity programmes
We said we would review service user survey results for
activity groups that run at our neurological and palliative care
centres.
We have reviewed the results from service user surveys to
help focus the priority areas or for the activity standard. The
standard has been called ‘B-Active’ and covers the following
priority areas:
• planning
• involvement
• person-centred activity
• networking
• creativity
B – Acndtiardvsewith the aim
A series of sta
ingful activities
of producing mean
“There’s plenty of opportunity to go out to
town or to go on other trips out and there’s
always something going on here to keep
me busy.”
Person we support at one of our neurological centres
14
Sue Ryder – Quality Account 2013–14
We said we would work with service users to develop a
standard which reflects our approach to person-centred care
and support for meaningful activities and pursuits.
The idea of the standard initially came from our ACORNS
group as a result of reviewing experience reports from our
neurological care centres and from the success of the ‘Our
Mealtimes’ standard.
Activity leads from across our services came together on 16th
January to look at the role of activity provision in supporting
individuals, showcasing success and setting priorities for
activity provision and practice. The draft standards were
presented at ACORNS in April 2014. The group approved the
standard, and were pleased we were not taking a prescriptive
approach to allow for personalised activity programmes at a
service level. They felt the standard was clear, easy to read and
liked the illustrations.
ACORNS wanted to be sure that the work planned for 2014–
15 included a survey of the impact on the implementation
of the standard, and this has been added to the priorities
for 2014–15.
Part two: Our progress against our priorities for improvement 2013–14
We said we would ensure there is a launch of the
standard, bringing together staff and volunteers who facilitate
activities and pursuits.
Printed copies of the standard will be in centres by the end of
May, with a launch of the standard in the summer.
We said we would measure progress through existing
surveys, audits and the ACORNS group.
The results from our neurological care survey were collated in
December 2013, and presented to the HGC in January 2014.
Some of the results were disappointing and this helped us to
make the case for real-time feedback so that we can be more
responsive to issues raised. Questions about the activities
standard will be included in the next survey due to be sent out
in November 2014.
Our hospice in Leeds is working with Leeds University to look
at how an activity standard could be developed and used in a
palliative care setting. This will feed into embedding the
activity standard across services and will sit alongside the
standard with a specialist focus.
Supporting carers
We support carers differently in each of our care settings.
Last year, in West Yorkshire we set up a carer support
group. There was little to support carers in the local area
with many not knowing where to go for support. Clare, day
therapy team leader and Alison, ward sister, both
participants on the RCN Clinical Leadership Programme,
led the set up of the group. The group is open to anyone
caring for a patient known to our hospice.
The group provides an opportunity for carers to share
information, meet other carers and learn about local
services. They also have access to complementary therapy,
emotional and practical support and have the opportunity
to speak to healthcare professionals such as a specialist
nurse or our palliative care social worker.
The group takes place on the first and third Friday of the
month in a relaxed and supportive environment. Carers
attending the group have said they feel less stressed as
they now know where to go for support.
Sue Ryder – Quality Account 2013–14
15
Part two: Our progress against our priorities for improvement 2013–14
Priority 4: Service user experience
To measure our culture for care delivery and safety,
using a cultural barometer
We said we would report on the overview of safety
culture maturity to be presented at the HGC.
We said we would have a facilitated self-assessment
workshop and action plan for each centre, working with their
linked quality manager.
A paper outlining key themes from the ‘deep dive’ quality
visits and safety culture workshops was presented to the HGC
in April 2014.
During the course of the year the quality team have
developed and used a two-day ‘deep dive’ quality visit. Prior to
the visit an analysis of all information about the service (e.g.
training records, electronic incident reports, response to
safety alerts) informed the priority areas for the site visits by
two quality managers. The ‘deep dive’ visit is then focused on
talking in focus groups with staff, observing practice,
attending shift handovers, including out-of-hours shift
patterns, and talking with service users and those close to
them. This has helped us to better understand the safety
culture in each service and as a consequence we have
started to run safety culture workshops. To date we have run
these in four of our centres using the Manchester Patient
Safety Framework (2006). In one instance we have combined
this with a ‘winning team’ workshop*.
Below is an outline of some of the key points made within the
paper:
• the overwhelming view was that the service users and
their supporters e.g family members, were very
complementary of the services provided by staff in
all locations
• quality improvement group meetings and plans in
some locations need refreshing in line with the terms
of reference
• more work is needed in some locations to improve
the timeliness of learning from incident reports
• continue work on data quality incident reports is needed,
supported by incident management training
• continue to raise the profile of the ‘Our Mealtimes’
standard to ensure compliance and follow through
on recommendations from a food standards audit
• ensure the risk register is kept as a live document
• the HGC agreed we could continue with this model
of inspection
We said we would monitor service actions via local
quality improvement groups and assess through quality visits
and audits.
The quality improvement processes have formed a key part
of the ‘deep dive’ quality visit process.
* This is a workshop for a team to come together, explore best practice
and identify new ways of working.
16
Sue Ryder – Quality Account 2013–14
Part two: Our progress against our priorities for improvement 2013–14
Helena, Clint
and Valerie
Inducting our staff
“love it, the staff are
keen to complete it.”
Maria, ward sister from Thorpe Hall, our hospice in
Peterborough, revised our employee induction process as
her service development project.
“well laid out and
easier to follow.”
The induction process was lengthy, confusing, duplicated
and not fit for purpose. The aim was to have a clear
induction process for all staff, appropriate to their role.
Feedback from staff
Staff were asked for feedback on how the process could
be improved and what contents to cover. Maria met with
education leads across our centres and the People Team
to look at how this could be integrated within healthcare.
New staff now have an induction process that is fit for
their working environment, enabling them to be more
knowledgeable about their place of work and the people
they support.
Sue Ryder – Quality Account 2013–14
17
Part two: Our progress against our priorities for improvement 2013–14
Priority 5: Service user experience
To share learning from complaints and concerns and
publish this information when it relates to upheld
complaints regarding care delivery
We said we would revise the complaints policy and
associated templates (following national recommendations
from the Francis Report 2013).
Given the desire to be an organisation that is driven by the
views and experiences of people that use our services and by
recommendations in line with the Francis Report (2013), we
have made our openness to complaints more visible in the
following ways:
• we’ve updated the complaints policy to include clearer
definitions of concerns and complaints
• we’ve provided details on how Sue Ryder will demonstrate
publicly our response to learning from complaints with the
permission of complainants
• we’ve encouraged greater use of web-based complaints
reporting and reviewed the complaints page on our
website to make it more user friendly
• we’ve developed standard letter templates to assist our staff
in responding to complaints. They can be adapted locally
depending on the type and contents of the complaint
• we’ve added ‘duty of candour’ responsibility to all care role
job descriptions
• we’ve added ‘tell us what you think’ processes at each centre
cern
Process of raising a con
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We will come back to you
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If you are happy with our
we will
and recommendations,
close the complaint
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18
A new information leaflet has been developed following
service user feedback. The leaflet includes a flow chart to
make the process of making a complaint easier to understand.
The title of the leaflet has been changed to ‘How to raise a
concern or make a complaint’, recognising that not everyone
will want to make a complaint but may have something they
want to speak to management about.
A comment card for real-time feedback has been produced
and agreed at our quality action group for centre-wide rollout,
complete with suggestion boxes. The comments that are
submitted as a result of this initiative will be reviewed regularly
at local quality improvement group meetings and this
approach has already been trialed within some of our
services and is working well. We anticipate this will continue
even when we have real time feedback electronically.
We said we would provide multiple ways through which
concerns regarding care delivery can be raised and ensure
these are published widely in our centres and central offices.
In addition to the new information leaflet we also have
information on our website, with a direct web address. We
have developed a series of frequently asked questions that
feature in both the leaflet and on the web page and have
included information on regulatory councils.
The People Team have reviewed our social media policy and
we have started to deliver training to some of our leaders on
safe and effective use of social media.
charge
e speak to the person in
If you are unhappy, pleas
We will investigate your
We said we would revise the information for service
users on how to express a concern or make a complaint.
Sue Ryder – Quality Account 2013–14
Part two: Our progress against our priorities for improvement 2013–14
Improving patient communication
On admission to a hospice, a patient is told lots of
information and it can be hard remembering it all. Mari,
a team leader at Leckhampton Court, our hospice in
Cheltenham, developed a leaflet to help bridge this gap
as part of her service development project.
The contents of the leaflet were discussed in consultation
with staff, patients and relatives. The leaflet was developed
primarily for patients but it also acts as a useful source
of information for relatives. It’s also proven to be a good
communication tool for nurses, ensuring all patients
have access to the same information.
Shaping our services
The PEPS service in Bedfordshire has been running since
December 2012. It provides 24-hour co-ordinated care
for patients, families, carers and healthcare professionals.
The service occasionally gets feedback from callers about
the value the service provides, but there was no formal
process for collecting feedback. Tracy, lead nurse for the
service, as part of her service improvement project
explored how user feedback could be captured to
help improve the service and quality of care delivered.
A questionnaire was designed following discussions with
staff, patients and relatives, to identify any issues. It was
sent out to 60 patients on the PEPS system.
One improvement made following feedback was to call
ahead of someone visiting a patient at home, to inform
them of who was visiting and an estimated time of arrival.
A comment card was developed to capture feedback,
suggestions and general comments about the service
at regular intervals in between the questionnaire being
sent out. The idea of the comment card was for it to be
left in a patient’s home and completed as and when a
suggestion or comment came to mind, to get more
real-time feedback.
Sue Ryder – Quality Account 2013–14
Tracey and her
dog Ralphe
19
Part two: Our progress against our priorities for improvement 2013–14
Priority 6: Service user experience
To measure the effectiveness of new equipment for
service user and staff safety following the
introduction of ‘safer sharps’
We said we would monitor compliance against national
standards for availability of equipment and staff attendance at
our vaccinations programme.
We said we would conduct a specialist review of all
sharps injuries throughout the year.
A new occupational health contract was set up during 2013
to make available to ‘at risk’ staff a HepB immunisation
programme. This immunisation programme has been trialed
in a neurological care centre and hospice. The programme of
immunisation is currently being rolled out across all services.
Our aim was to implement the European Union directive
on safer sharps by May 2013. A paper was taken to HGC
on January 2014 to outline the progress to date regarding
introduction of safer sharps across services, and to review
needle-stick injuries across the course of the year. This paper
was one of two papers that was taken to the HGC during
2013–14 to review sharps incidents.
2012–13: There were 13 incidents, five of which related to the
failure to dispose of used sharps according to procedure.
Human error and patient unpredictability contributed to
remaining incidents.
Demonstration of the latest safer sharps equipment took
place at our professional forum (for heads of care) over the
course of three meetings to inform decision-making at a local
level. At the same meeting, decisions were made about how
training would be delivered to support the introduction of this
new equipment.
This programme of change has been led by our infection,
prevention and control lead nurse, who is a quality manager
in the clinical quality team.
A new safer sharps procedure was introduced and all
appropriate staff were trained. A marked improvement in
incident figures has been shown, with only four incidents in
2013–14. There has also been increased compliance with
post exposure procedures,disposal of sharps and full use of
safety-engineered equipment. “A huge thank you for all the care and love
you showed my mom. Her last few days
were very peaceful. Thank you for all the
support that you have given me also. When
mom heard she was going to Thorpe Hall
Hospice she was delighted and smiled for
the first time in weeks.”
Relative we supported at one of our hospices
20
Sue Ryder – Quality Account 2013–14
“Having the immunisation team come to our
centres, at times flexible for our staff, means
that all staff that wanted to be immunised
have had the option of a convenient time
and way. Its been well received, and means
our staff are actively supported and
encouraged to be immunised.”
Lead nurse
Part two: Our progress against our priorities for improvement 2013–14
Improving wound management
Following an internal audit of care plans at Holme Hall, our
neurological care centre in East Yorkshire, Tracy, the Head
of Care explored how better wound management and
documentation could enhance the current service provision.
Tracy collected staff and resident feedback, and set about
creating an easily located tissue viability resource box,*
helping staff with quick and easy access to items for wound
management. An easy-to-use booklet was created and sits
inside the box to act as a reminder to staff on the different
wound management plans relating to particular types of
wounds. New documentation was also created and all staff
were trained to ensure the correct use and completion
of documents.
Documentation is now completed as the wound appears and
is managed by planned interventions, which provides
continuity of care. We have received positive feedback from
our local tissue viability specialist service about the changes
we have made.
* A tissue viability resource box will include items such as different types
of dressing, assessment tools such as tape measures, wound maps
and documentation.
Sue Ryder – Quality Account 2013–14
21
Part three: our priorities for improvement 2014–15
Priority 1: Service user experience
Priority 2: Service user safety
To embed the use of electronic devices to gain realtime feedback from people who use our services
To manage the risk of harm from falls
In 2014–15 we will:
In 2014–15 we will:
• purchase, pilot and begin to use devices for real-time
feedback across all our services
• train volunteers to support service users to use
devices for feedback
• look at the use of real-time feedback for audits
• write a falls risk management strategy and
implementation plan
• deliver priority areas of the implementation plan
• evaluate the success of strategy through incident review
and a newly developed core audit
Executive Leadership Team (ELT) sponsor
Mike Smeeton, Director of Health and Social Care
Executive Leadership Team (ELT) sponsor
Mike Smeeton, Director of Health and Social Care
Implementation lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Implementation lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Programme manager
Angela Killip, Quality and Service User Experience Lead
Mark Woodfield, IT Systems Manager (Healthcare)
Programme manager
Helen Press, Quality and Risk Manager
22
Sue Ryder – Quality Account 2013–14
Part three: our priorities for improvement 2014–15
Priority 3: Effectiveness
Priority 4: Effectiveness
To continue to develop and then measure the
activity standard
To develop our strategy for education and training
In 2014–15 we will:
In 2014–15 we will:
• launch B-Active, our activity standard
• support activity co-ordinators to make service
improvements in line with the standard
• develop a themed survey to evaluate the success
and impact of the project based on recommendations
by ACORNS
• continue to consult with ACORNS on the delivery of
meaningful activities
• develop a three-year strategy for learning and
development across healthcare
• put in place an implementation plan for each of the strands
• agree a process for measuring and monitoring plans
and actions
Executive Leadership Team (ELT) sponsor
Mike Smeeton, Director of Health and Social Care
Executive Leadership Team (ELT) sponsor
Mike Smeeton, Director of Health and Social Care
Implementation lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Implementation lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Programme manager
Lesley Bates, Quality and Effectiveness Manager
Programme manager
Rudo Nyakuhwa, Quality and Learning Manager
Sue Ryder – Quality Account 2013–14
23
Part three: our priorities for improvement 2014–15
Priority 5: Effectiveness
Priority 6: Effectiveness
To deliver an accredited development programme
for non-registered clinical staff
To improve and measure the quality of our
end of life care
In 2014–15 we will:
In 2014–15 we will:
• develop a programme based on the six C’s* to be delivered
over the course of a year, recognising that leadership
happens at the point of care
• seek accreditation for the course
• start the recruitment process for the first cohort
• update our end of life care policy based on
recommendations from the Leadership Alliance for Care
of Dying People
• widen our use of the End of Life Care Quality Assessment
Tool (ELCQuA) from Public Health England
• continue to implement person-centred care plans across
our hospices
Executive Leadership Team (ELT) sponsor
Mike Smeeton, Director of Health and Social Care
Executive Leadership Team (ELT) sponsor
Mike Smeeton, Director of Health and Social Care
Implementation lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Implementation lead
Sue Hogston, Head of Clinical Quality and Nurse Lead
Programme managers
Rudo Nyakuhwa, Quality and Learning Manager
Jo Kerridge, Practice Educator – Berkshire West
Programme managers
Angela Killip, Quality and Service User Experience Lead
Helen Press, Quality and Risk Manager
* The six Cs are based on the chief nursing officers of England’s values
for nursing and care.
24
Sue Ryder – Quality Account 2013–14
Part four: indicators
1. Service user experience – all services
• Service user experience is measured within the annual service user surveys in the following ways:
• percentage of service users who rated overall care as ‘Good’ or ‘Excellent’
• percentage of service users who responded ‘Yes, completely’ or ‘Yes, mostly’ that overall they were treated with
respect and dignity
• percentage of service users who responded ‘Yes’ when asked if they would recommend the service to family
and friends (neuro and homecare services only)
• NHS Net Promoter Score which measures how likely service users are to recommend the service to family
and friends (hospices only)
Our overall hospice score for 2013–14 was 95
Neurological services
Palliative services
G 2012–13
G 2013–14
G 2012–13
G 2013–14
Rated overall care
Rated overall care
Treated with respect and dignity
Treated with respect and dignity
Recommend the service
Recommend the service
0
10
20
30
40
50
60
70
80
90
100 %
90
100 %
0
10
20
30
40
50
60
70
80
90
100 %
Community support and homecare services
G 2012–13
G 2013–14
Rated overall care
Treated with respect and dignity
Recommend the service
0
10
20
30
40
50
60
70
80
The response rate to our surveys is dependent upon those who are willing or able to complete the survey and therefore
does not necessarily represent the experience of all.
Sue Ryder – Quality Account 2013–14
25
Part four: indicators
1.1 Neurological care 2013–14
Survey
Centre
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
Percentage of service users
who responded ‘yes’ they would
recommend the service to
family and friends
100%
79%
92%
64% *
90%
78%
100%
86%
92%
71%
91%
68%
100%
77%
100%
86%
84%
82%
Birchley Hall
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
*
The care centre manager is working with service user group to understand why this score is low
compared to the percentage of service users that would recommend our service to others.
Many of the service users using neurological care services have varying capacity and therefore the numbers who are able to
take part are quite low. One of the initiatives for 2014–15 will help us to obtain real time information so that we can address
any dissatisfaction as it occurs.
1.2 Palliative care 2013–14
Survey
Hospice
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
*
96%
100%
100%
100%
98%
100%
100%
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
Those likely to
recommend the service
(Net Promoter Score)
96%
100%
100%
100%
97%
100%
100%
90
100
98
n/a*
91
92
91
St John’s did not include the net promoter score within the survey they sent out to patients. This will be included in 2014–15.
1.3 Community support and homecare services 2013–14
Survey
Service
Percentage of service users
who rated overall care as
‘Good’ or ‘Excellent’
Percentage of service users
who responded ‘Yes, completely’ or
‘Yes, mostly’ that overall they were
treated with respect and dignity
Percentage of service users
who responded ‘Yes’ they would
recommend the service to
family and friends
94%
88%
100%
88%
96%
100%
100%
99%
100%
Angus Homecare
Heyeswood
Stirling Homecare
26
Sue Ryder – Quality Account 2013–14
Part four: indicators
1.4 Formal complaints about care
We define a formal complaint as ‘an expression of discontent to which a response is required’. With reference to our
Complaints Policy, the complaint is considered formal when it is received orally, in writing or electronically and cannot be
resolved within 24-hours of receipt.
There were 19 formal complaints about care during 2013–2014. 50% (n=10) of our services had no complaints between April
2013 and March 2014. The target in the Complaints Policy for the initial holding response to complaints is three working days.
Where the complaint was initially received by a service, and where the complaint was by a named complainant 100% were
acknowledged within the timescale. The initial response time to a complaint within one service was not recorded, however this
service did meet the final response target.
The target in the Complaints Policy for the final written response to a complaint is 20 working days; however the policy does
acknowledge that in some instances this is not possible. This would usually be where the investigation is complex. In these
cases all services aim to maintain contact with the complainant, giving a report of progress and in all cases a holding reply was
sent within 20 working days. Of those complaints where the complainant requested a formal response, in 10 out of 19
instances the 20 working day target was met. Where the target time was not met the complainant was in all cases sent a
holding letter to explain the delay. All complaints were initially resolved locally however one complainant has since requested
the intervention of the Health Service Ombudsmen.
The complaints recorded in the tables below have been made about the delivery of care. In response to the Robert Francis
Report (2013) we have altered our Complaints Policy to acknowledge the importance of learning from complaints and have
committed to identify learning within the Quality Account. Having reviewed all complaints it was not possible to identify
common themes for learning. Listed below are some of the changes that we have made in individual locations as a result of
the complaints that have been made
We have:
• reviewed and further personalised individual care plans
• tested out a revised nutritional assessment
• developed a feedback card for meal times which is now being used in all locations
• reviewed the case loads of specialist nurses in one of our locations
• delivered training with regard to maintaining dignity when providing care
• reminded staff teams of the importance of providing written information in support of information given verbally
• applied a new system of ensuring regular nighttime checks of service users
• used our specialist end of life care knowledge to train care workers to deliver high quality end of life care in an
extracare* service
*
extracare is sometimes referred to as sheltered housing. This supports people with care needs who live in their own
home with on-site care workers.
Overall number
of complaints
24 in 2012–2013
19 in 2013–2014
Sue Ryder – Quality Account 2013–14
27
Part four: indicators
The tables below show formal complaints figures for all services for April 2013–March 2014:
Neurological care
Complaints about care
Centre
Number of formal
complaints in
2012–13
Number of formal
complaints
2013–14
Number of formal
Number of formal
complaints responded
to in writing within
20 working days
Upheld/
not upheld
Birchley Hall
The Chantry
0
1
0
3
3
2 out of 3 holding
reply sent where this
could not be achieved
1 upheld
1 partially upheld
1 not upheld
Cuerden Hall
2
1
1
1 holding reply sent
as this could not be
achieved
1 not upheld
Dee View Court
Holme Hall
Stagenhoe
0
0
0
0
0
0
Number of formal
complaints in
2012–13
Number of formal
complaints
2013–14
complaints aknowledged
Number of formal
Number of formal
complaints responded
to in writing within
20 working days
Upheld/
not upheld
Leckhampton Court
2
1
1
1 holding reply sent as
this could not be
achieved
Not upheld (with
Health Service
Ombudsman)
Manorlands
1
1
+
1 (CNS Service)
1
1 responded to
externally by CSU
Nettlebed
St John’s
Bedfordshire PEPS
Thorpe Hall
1
0
0
2
0
1
0
2
10
2
+
2 (CNS Service)
1
0
complaints aknowledged
within 3 working days
Palliative care
Complaints about care
Hospice
Duchess of Kent
(West Berkshire services)
Wheatfields
28
Sue Ryder – Quality Account 2013–14
within 3 working days
1 holding reply sent as
Upheld
this could not be Awaiting outcome
achieved
of external
investigation
1
1
Upheld
2
2
1 partially upheld
1 not upheld
3
1 not recorded
2
2 holding replies sent as
this could not be
achieved
3 partially upheld
1 upheld
Part four: indicators
Community support and homecare services
Complaints about care
Service
Number of formal
complaints in
2012–13
Number of formal
complaints
2013–14
complaints aknowledged
Angus Homecare
3
3
Fourways Suffolk
Heyeswood
0
0
0
1
Stirling Homecare
Doncaster Befriending Service
Doncaster Community Service
1
0
0
1
0
0
Sue Ryder – Quality Account 2013–14
Number of formal
Number of formal
complaints responded
to in writing within
20 working days
Upheld/
not upheld
3
2
1 holding reply sent
where this could not be
achieved
1 not upheld
2 upheld
N/A – complaint
received via
Commissioners
N/A
1 upheld
1
1
1 upheld
within 3 working days
29
Part four: indicators
2. Safety
2.1 Incidents
We commend our staff for ensuring that all accidents, incidents and near misses are appropriately reported so that we can
learn from such incidents and strive to improve our care in order to minimise patient safety issues. The National Patient Safety
Association recognises that high reporting is a mark of a ‘high reliability’ organisation. Research shows that providers with
significantly higher levels of incident reporting are more likely to demonstrate other features of a stronger safety culture.
2.2 Number of incidents affecting service users 2013–14
Indicator
Neurological care
2012–13 2013–14
Number of incidents resulting in death
Number of incidents resulting in permanent or long term harm
Number of service user slips, trips or falls resulting in hospital visit
Number of reports under RIDDOR
0
1
2
0
0
1
11
1
Palliative care
2012–13 2013–14
0
0
4
0
0
3
6
1
Homecare
2012–13 2013–14
0
0
6
0
0
0
4
0
The four incidents described as resulting in long term harm in palliative and neurological care were incidents involving a fall
resulting in a fracture and hospital admission.
Within our homecare services, slips, trips and falls have been reported by the service but have not occurred during active care
delivery. The increased reporting of the outcome of incidents within our on line incident reporting system could be attributed
to a number of incident management training sessions delivered to managers from each location.
Our health and safety team review all incidents reported by services. They have supported frontline staff to ensure guidance
regarding RIDDOR* reporting is understood.
There was one incident reported to RIDDOR where a bath chair appeared to collapse due to a design fault and this has been
reported to MHRA. A second incident was reported to RIDDOR where a hoist sling failed. No harm occurred to any service user
in either of these reported cases.
*
RIDDOR – Reporting of Injuries, Diseases and Dangerous Occurrences Regulations
2.3 Number of medicines incidents 2013–14
Neurological care
Centre
Birchley Hall
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Minimal harm, person required extra
observation or minor treatment
Moderate (short term harm – person
required further treatment)
3
10
5
2
1
4
0
0
0
0
0
0
The higher number of recorded medicines incident at the Chantry ‘resulting in extra observation or minor treatment’ is being
addressed by a change to a new pharmacy provider that is providing tighter systems and processes and additional training to staff.
30
Sue Ryder – Quality Account 2013–14
Part four: indicators
Palliative care
Hospice
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
Minimal harm, person required extra
observation or minor treatment
Moderate (short term harm – person
required further treatment)
4
9
1
7
10
1
11
0
1
0
0
0
0
1
The risk of medicines incidents occurring in our specialist palliative care settings is higher than our neurological care centres
because of the complex medicines regimes, high turnover of patients and frequent review of prescriptions. We will continue
with our specialist review of all medicines incidents to ensure trend analysis and learning.
Community support and homecare services
Service
Angus Homecare
Heyeswood
Stirling Homecare
Minimal harm, person required extra
observation or minor treatment
Moderate (short term harm – person
required further treatment)
0
2
0
0
1
0
Extensive management of medicines training, a review of local procedures and a review of medicines audit processes has
taken place over the last six months at Heyeswood. A recent review by the commissioners has demonstrated improvements
in practice.
Sue Ryder – Quality Account 2013–14
31
Part four: indicators
2.4 Regulatory inspection results
Neurological care
Centre
Birchley Hall *
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Date of last
check from CQC
Standards of
treating people
with respect and
involving them
in their care
Standards of
providing care,
treatment and
support which
meets people’s
needs
Standards of
caring for
people safely
and protecting
them from
harm
Standards of
staffing
Standards of
management
4 December 2013
9 August 2013
18 October 2013
**
3 January 2014
6 December 2013
*
We have taken steps to resolve the issues at Birchley Hall and have submitted our improvement plan. We are now awaiting
re- inspection and are confident that the non-compliance has been resolved. **
Dee View Court is inspected by the Care Inspectorate in Scotland.
Centre
Dee View court
Date of last
quality visit
Quality of care
and support
Quality of
environment
Quality of
staffing
Quality of
management
and leadership
15 May 2013
5 (Very Good)
5 (Very Good)
5 (Very Good)
6 (Excellent)
Palliative care
Hospice
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent
(West Berkshire services)
Wheatfields
32
Date of last
check from CQC
Standards of
treating people
with respect and
involving them
in their care
Standards of
providing care,
treatment and
support which
meets people’s
needs
Standards of
caring for
people safely
and protecting
them from
harm
Standards of
staffing
Standards of
management
11 Feburary 2014
September 2013
1 March 2014
21 November 2013
20 September 2013
17 Febuary 2014
31 January 2014
Sue Ryder – Quality Account 2013–14
Part four: indicators
Community support and homecare services
Service
Fourways Suffolk
Heyeswood
Date of last
check from CQC
Standards of
treating people
with respect and
involving them
in their care
Standards of
providing care,
treatment and
support which
meets people’s
needs
Standards of
caring for
people safely
and protecting
them from
harm
Standards of
staffing
Standards of
management
23 November 2013
19 June 2013
We have taken steps to resolve the issues at Heyeswood, submitted our improvement plan and are awaiting re-inspection.
We are confident that the non-compliance has been resolved.
Service
Angus Homecare
Striling Homecare
Supported Living
(House 7) Aberdeen*
*
Date of last
quality visit
Quality of care
and support,
13 March 14
28 April 14
22 November 2013
Quality of
environment
Quality of
staffing
Quality of
management
and leadership
5 (Very Good)
6 (Excellent)
5 (Very Good)
6 (Excellent)
5 (Very Good)
6 (Excellent)
4 (Good)
4 (Good)
4 (Good)
First inspection
For more information about our inspection results for our palliative, neurological and community support services in England,
please visit the Care Quality Commission website. For more information about our inspection results for our services in
Scotland, please visit the Care Inspectorate website.
Number of HCAI (2013–14)
Health Care Acquired Infections (2013–14)
G acquired within own service
G acquired external to service
Clostridium difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (infection)
ESBL (colonised)
Hepatitis (A, B or C)
Tuberculosis
Influenza
0
5
10
15
Sue Ryder – Quality Account 2013–14
20
25
new cases
33
Part four: indicators
3. Effectiveness
Health Care Acquired Infections (HCAI) and pressure ulcers
The number of infections and pressure ulcers across all neurological and palliative centres reflects the period between April
2013 and March 2014.
Cases are identified as those that were acquired by the service user whilst under our care, and those acquired prior to the
service user being admitted to one of our services.
Number of HCAI (2013–14)
Health Care Acquired
Infections
Clostridium difficile
Norovirus
MRSA (infection)
MRSA (colonised)
ESBL (infection)
ESBL (colonised)
Hepatitis (A, B or C)
Tuberculosis
Influenza
Total
34
Sue Ryder – Quality Account 2013–14
Neurological care
Palliative care
Acquired within
own service
Acquired external
to service
Acquired within Acquired external
own service
to service
0
18
0
0
0
0
0
0
0
18
0
1
1
0
0
0
0
0
0
2
2
0
0
0
0
0
0
0
0
2
10
2
5
4
0
0
2
1
0
24
Acquired within
own service
2
18
0
0
0
0
0
0
0
20
Part four: indicators
Number of HCAI by service (2013–14)
Neurological care
Centre
Constridium
Difficile
Norovirus
MRSA
(infection)
MRSA
(colonised)
ESBL
(infection)
ESBL
(colonised)
0
0
0
0
0
0
0
19*
0
0
0
0
0
19
0
0
0
0
1
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Constridium
Difficile
Norovirus
MRSA
(infection)
MRSA
(colonised)
ESBL
(infection)
ESBL
(colonised)
1
5
1
0
2
0
0
1
0
0
0
0
0
0
2
0
0
0
1
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
1
0
0
0
0
0
0
0
0
3
0
12
0
1
2
3
0
5
2
1
4
0
0
0
0
0
0
2
0
2
0
0
1
0
0
0
Birchley Hall
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Total
*
Hepatitis Tuberculosis
(A,B or C)
0
0
0
0
0
0
0
Influenza
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Hepatitis Tuberculosis
(A,B or C)
Influenza
We experienced one episode of norovirus.
Palliative care
Hospice
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent
(West Berkshire services)
Wheatfields
Total

3.1 Pressure ulcers 2013–14
The number of pressure damage reports has increased over 2013–14. This increase is reflected in both those admitted to our
services with pre-existing pressure damage and reports of pressure damage occurring whilst patients are within our hospice
services. At present our data collection methodology is being transformed within the Datix on line incident reporting system to
enable more information to be gathered centrally regarding the grade, site and origin of the pressure ulcer. This will enable us
to improve identification of trends and enable more effective management of risks. During 2013–14 we reviewed our
pressure ulcer prevention and treatment policy and our services are using local tissue viability nurse specialists to deliver
training to staff. All service users have an assessment of their skin integrity on admission and pressure relieving equipment is
available in all care settings. Patients admitted and treated within our hospices are generally at high risk of pressure ulcer
development because of poor nutritional status and deteriorating physical health.
In 2013–14 we had six incidents recorded as Grade 3 damage; three occurred within our neurological care centres. Two were
a deterioration of an existing pressure ulcer (one because of an underlying medical condition, the other because of varying
compliance with treatment). One developed shortly after a hospital admission and was a recurrence of a previous problem.
Three occurred within our hospice services and of these, one patient was near to end of life, one patient had cachexia and one
patient was non-compliant with treatment
In 2013–14 we had one incident recorded at a hospice where a Grade 3 pressure ulcer was present on admission and this
deteriorated to a Grade 4
Sue Ryder – Quality Account 2013–14
35
Part four: indicators
The information within our Datix on line system is not in line with our monthly monitoring figures. This will be resolved when
we apply the changes that we have developed within Datix. Where a pressure ulcer develops at Grade 3 or above we use a root
cause analysis approach (one of the recommended National Patient Safety Agency tools) to review and learn from such
incidents..
Pressure ulcers (2013–14)

G acquired within own service
G acquired external to service
Neurological care
Palliative care
0
50
100
150
200
250
300
new cases
Number of pressure ulcers by service 2012–13 compared to previous year
Neurological care
Centre
2012–13
Birchley Hall
The Chantry
Cuerden Hall
Dee View Court
Holme Hall
Stagenhoe
Total
2013–14
Acquired within
own service
Acquired external
to service
Acquired within
own service
Acquired external
to service
7
11
0
3
4
4
29
2
2
1
0
1
0
6
5M
3M
1L
2M
3M
2M
16 M
1
1
0
0
3
6
11
Palliative care
Hospice
2012–13
Leckhampton Court
Manorlands
Nettlebed
St John’s
Thorpe Hall
Duchess of Kent (West Berkshire services)
Wheatfields
Total
36
Sue Ryder – Quality Account 2013–14
2013–14
Acquired within
own service
Acquired external
to service
Acquired within
own service
Acquired external
to service
17
5
10
18
22
8
9
89
26
19
15
54
47
19
11
191
15 M
10 L
24 L
20 L
19 M
15 L
18 L
121 L
37
21
24
56
49
38
32
257
Part four: indicators
Number of pressure ulcers (compared to last year)
Pressure ulcers (acquired within Sue Ryder)
G 2012–13
G 2013–14
Pressure ulcers (acquired external to Sue Ryder)
G 2012–13
G 2013–14
Neurological care
Neurological care
Palliative care
Palliative care
0
50
100
150
200
250
new cases
0
50
100
150
200
250
Neurological care
Palliative care
Pressure ulcers (acquired within Sue Ryder)
G 2012–13
G 2013–14
Pressure ulcers (acquired within Sue Ryder)
G 2012–13
G 2013–14
Centre
Hospice
Birchley Hall
Duchess of Kent
The Chantry
Leckhampton
Cuerden Hall
Manorlands
Dee View Court
Nettlebed
Holme Hall
St John’s
Stagenhoe
Thorpe Hall
0
2
4
6
8
10
12
new cases
Wheatfields
0
Sue Ryder – Quality Account 2013–14
new cases
5
10
15
20
25
new cases
37
Part five: annexes
Annex 1
There is a legal requirement to report on this section
• During the period of this report, 1 April 2013 to 31 March
2014 Sue Ryder provided NHS funded community care
services in our hospices and some care centres and NHS
funded nursing care in most of our centres. Sue Ryder
had seven adult inpatient units within hospices, eight day
hospices, one hospice at home service, three community
nursing services, and five care homes with nursing. In
addition to these services we also delivered care within
one care home without nursing, two supported living
services and one extracare service.
• Sue Ryder has reviewed all the data available to it on the
quality of care in all of the above services.
• The percentage of NHS funding is variable depending on
the nature of the service and ranges from 35% to 90% of
the total cost of providing the service. The shortfall is met
from Sue Ryder charitable income.
• The income generated by the NHS services reviewed in
the period 1 April 2013 to 31 March 2014 represents
100% of the total income generated from the provision of
NHS services by Sue Ryder for the period 1 April 2013 to
31 March 2014.
• During the period from 1 April 2013 to 31 March 2014
there were no national clinical audits or national
confidential enquiries covering the NHS services that Sue
Ryder provides – Sue Ryder sets an annual core audit
programme that runs from April – March each year.
• The core audit programme is risk-driven, and for hospices
and neurological care centres includes record keeping,
medicines management, falls prevention, manual
handling, pressure ulcer assessment and management,
care at end of life (neurological centres), infection
prevention and control including environmental and hand
hygiene audit
– the monitoring, reporting and actions following these
audits ensure care delivery is safe and effective. Each
service reports audit findings into their local internal
Quality Improvement Group. The HGC for Sue Ryder
receives a twice-yearly overview of audit results and
actions taken in response. Learning from audits is
summarised and shared across health and social care
via learning for safety memos.
• From 1 April 2013 to 31 March 2014 Sue Ryder was not
eligible to participate in national clinical audits.
38
Sue Ryder – Quality Account 2013–14
• 270 patients were recruited for a research study from two
of our hospices in West Berkshire in a University of Reading
questionnaire study on interaction between herbal
supplements and conventional medicines. These patients
received NHS services provided by Sue Ryder from 1 April
2013 to March 2014. They were recruited during that
period to participate in research approved by a research
ethics committee. In addition the following number of
participants were recruited for the following trials:
– Acupressure (8)
– DASH (4)
– OIC (9)
– Sativex 0962 (6)
– Sativex 0999 (4)
Sue Ryder income in this reporting period for three
hospices was conditional on achieving quality
improvement and innovation goals through the
Commissioning for Quality and Innovation payment
agreed via local commissioning groups.
• Sue Ryder is required to register with the Care Quality
Commission. Conditions of registration include the
management by an individual who is registered as a
manager in respect of that activity at all locations and
maximum number of beds for its services in the following
regulated activities:
– accommodation for people who require nursing or
personal care
– diagnostic and screening procedures
– nursing care
– personal care
– transport services, triage and medical advice provided
remotely
– treatment of disease, disorder or injury.
• Sue Ryder has not participated in any special reviews or
investigations by the CQC during the reporting period.
• Sue Ryder was not required to submit records during the
period from 1 April 2013 to 31 March 2014 to the
secondary uses service for inclusion in the hospital
episode statistics.
• Sue Ryder is eligible to be scored for the period April 2013
to 31 March 2014 for information quality and records
management, assessed using the Information Governance
(IG) toolkit. The eligibility to be scored this year is due to a
change in our organisation type and amendments to the IG
toolkit. Previously the only option that was available to Sue
Ryder, when first taking NHS services, was as a 'Commercial
Third Party'. This did not focus on Information Quality and
Records Management. Last year a new organisation type
within the IG toolkit, ‘NHS Business Partner’, was introduced
and Sue Ryder submitted evidence based on selfassessment for attainment level one (amber).
Part five: annexes
• Sue Ryder was not subject to the Audit Commission’s
payment by results clinical coding audit during the period
1 April 2013 to 31 March 2014
• Sue Ryder will be taking appropriate actions to improve
data quality through:
– increased awareness in the importance of reporting
– training, including how to use our documentation
templates
– identifying trends through a balanced scorecard
reporting system
– ‘learning for safety’ memos for when systems and
processes change
• some of the people we support may be local authority
funded, depending on their needs.
• Sue Ryder has a Monitor licence to provide NHS-funded
services from 1 April 2014 onwards. None of Sue Ryder’s
services have been designated as commissioner
requested services.
Sue Ryder – Quality Account 2013–14
39
Part five: annexes
Annex 2
Statements from Lead Clinical Commissioning Groups
(CCG)/ Commissioning Support Units,(CSU) the
Overview and Scrutiny Committee (OSC) Health and
Wellbeing Boards
Feedback from the Leeds South and East Clinical
Commissioning Group
Thank you for the opportunity to review and provide a
response to your Quality Account for 2013/14. We have
sought views from a range of stakeholders and clinicians, and
our response is as follows:
Leeds South and East Clinical Commissioning Group (CCG)
welcomes the opportunity to comment on Sue Ryder quality
account for 2013/14. Leeds South & East Clinical
Commissioning Group is providing this narrative on behalf of
all three Leeds Commissioning Groups including Leeds West
CCG and Leeds North CCG.
We have reviewed the account and we believe that the
information published, that is also provided as part of the
contractual agreement, is accurate. We are supportive of the
priorities that have been proposed for the forthcoming year,
and pleased to note the specification of standards and
thresholds.
In November 2013 the Government published its response to
Sir Robert Francis’s report into the events at Mid-Staffordshire
hospital. This report, entitled ‘Hard Truths’, accepted the vast
majority of Sir Robert’s recommendations and confirmed the
need to focus on high quality health care. It is crucial that
commissioners and providers work together to ensure this.
We are therefore pleased to see that the organisations
priorities focus on the three main elements of quality, namely
clinical effectiveness, patient safety and patient experience. In
addition Sue Ryder continues to use the values adopted in
the NHS constitution.
We are pleased to note the work undertaken to better
understand the safety culture in each service and the two-day
‘deep dive’ quality visits. We are also pleased to note the use of
an established tool - the Manchester Patient Safety
framework - in support of the above.
It is pleasing to note the focus on the development of
education and training for the non-registered workforce, this
highlights the organisations commitment to high quality care
in line with the recent Francis recommendations.
40
Sue Ryder – Quality Account 2013–14
Sue Ryder continues to engage with service users and the
public and we commend the sharing of patient experience
stories and looking at ways to improve the complaints
process. As identified in our response last year, it would add
value if local providers or Sue Ryder as an appendix could
collate a summary page per provider to highlight local patient
experience and local quality initiatives
It is pleasing to see the Wheatfield’s commitment for 14/15
to ELQuA and falls, which fits well with local plans around
transformation and service developments this year.
We note the work that has been undertaken to improve
wound management, but it is concerning to note an increase
in both number of pressure ulcers reported/recorded and
medication incidents during 13/14 in Wheatfield’s. It would
be good to know what actions are planned to manage this
next year and how CCGs will be made aware of concerns,
themes and trends.
We continue to have a positive relationship with Wheatfield’s
and we look forward to working with them in 2014/15 with
the aim of delivering the highest standards of patient centred,
palliative care.
Ellie Monkhouse
Director of Nursing and Quality, Leeds North CCG
Director of Nursing and Quality, Leeds South and East CCG
Our response to the comments we received:
Sue Ryder welcomes this feedback. Next year’s quality
account will contain a local appendix pulling out this type of
information.
Part five: annexes
Feedback from the Airedale, Wharfedale and Craven
clinical commissioning group
Thank you for sending through the Sue Ryder 2013/14
Quality Accounts for review. Overall, the Sue Ryder Quality
Account provides a good and thorough account of the
initiatives over the last year and the priorities for the next
twelve months. It is clear a tremendous amount of hard work
has gone on over the last twelve months to achieve all the
things you have as an organisation.
I am particularly encouraged by the work Sue Ryder has
undertaken around staff behaviours and development. It is
great for the organisation to recognise the importance of its
staff and invest time and energy into their development and
behaviours. This is important as we know that motivated and
engaged staff provide higher quality care for patients.
I like the use of an easy read version for the public, however,
even the main document is written in such a way it is easy to
understand and flows well with great use of pictures and
diagrams to break up the text.
I particularly liked the sections where you have said what you
will do and then provided the evidence of how this has been
achieved. This makes it very clear to the reader what has
been done.
It is great to read of the new initiative around supporting carers
in our area and I feel this is a big benefit to the carers and I am
sure brings great job satisfaction for the staff involved as well.
In the section around patient feedback and complaints it is
fantastic to read about how highly service users praise
Manorlands and particularly around the areas of dignity and
respect and overall care where the scores were 100%. Staff
should be congratulated on this as clearly they show care,
commitment and respect to their patients which is firmly
embedded in the care and compassion document from the
chief nursing officer and the 6C’s.
The priorities for 2014/15 are clearly identified and are firmly
embedded in the three areas of quality; patient safety, clinical
effectiveness and patient experience.
Overall Sue Ryder appears to have had a great year and I feel
very assured that our patients using the services provided by
Sue Ryder clearly receive a very high standard of care. I look
forward to continuing to work closely with Sue Ryder and in
particular yourself and the staff at Manorlands over the
coming year.
Our response to the comments we received:
We welcome this feedback. We will be working on a local
summary with Manorlands to share with yourself and we look
forward to a working partnership over the coming year.
Feedback from NHS Cambridgeshire and Peterborough
Clinical Commissioning Group
– Priorities look to be in line with the general direction
of travel of healthcare services.
– Services look to be well received by patients
– You have delivered on most areas you said you would
in 13/14.
– Most areas have improved – I spotted only a couple
that had deteriorated.
Simon Pitts
Programme Manager, Borderline and Peterborough LCGs
NHS Cambridgeshire & Peterborough Clinical
Commissioning Group
Our response to the comments we received:
We will be working over the coming year to produce a local
summary. At Thorpe we will be working on improvements
for pressure ulcer prevention and protection. We note the
increase of patients with pressure damage but as a care team
we will addressing how we are managing this using a new tool
to identify ulcers present on admission and documentation of
their management.
The following organisations received our Quality Account for
2013–14 but were unable to provide comments or feedback
this year.
• Bedfordshire Clinical Commissioning Group
• Bradford NHS
• Camden Healthwatch
• Central Southern Commissioning Support Unit
• Suffolk County Council
ACORNS
The Quality Account priorities for 2014–15 were agreed by
ACORNS at their meeting in April 2014. The draft Quality
Account was then circulated for comment. A summary
version of the Quality Account will be developed for service
users, their families and for display within our centres, as this
has proved popular.
Steph Lawrence
Head of Clinical Quality and Governance/Executive Nurse
Sue Ryder – Quality Account 2013–14
41
Sue Ryder
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London
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For more information
call: 020 7554 5900
email: healthandsocialcare@sueryder.org
visit: www.sueryder.org
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incredible hospice
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Ref. No. 03359/0414/B/NP/H © Sue Ryder. May 2014.