Quality Account 2013/14
01
Contents
Part One
Statement on Quality from the Chief Executive
03
Part Two
Priorities for improvement 2014/15
08
Statement of Assurance from the Board
13
Review of services
14
Participation in clinical audits
14
Part Three
Review of quality performance in 2013/14
29
Statements from local CCG and Healthwatch
38
Glossary
40
Part One
Statement on Quality from the Chief Executive
03
03
Statement on Quality from the Chief Executive
I am pleased to introduce The Retreat’s Quality
Account for 2013/14.
This Quality Account is our annual report to
the public and to people who use our services
about the quality of care we deliver. It includes
examples of improvements we have already
made to the quality of the services we provide
and our plans to improve further the quality
of our services. It also describes some of the
systems we have in place to measure quality.
The Retreat is a not-for-profit provider of
specialist mental health services. We work
closely with the NHS to provide services
for people with complex and challenging
needs. The Retreat was established over 200
years ago by Quakers and was the first place
where people with mental health problems
were treated humanely and with dignity and
respect. Long before today’s focus on recoveryorientated, inclusive services The Retreat was
providing care based on the belief that, given
the right environment and if treated as equals,
people using our services could be empowered
to take responsibility for their own recovery.
We are very proud of our long-standing
reputation for excellence and for providing
care of the highest quality. We are committed
to working with those who use our services to
improve the quality of the services we deliver
and to being able to evidence that quality
improvement.
Looking back over 2013/14, I am pleased to
report that we made solid progress with the
priorities we identified in last year’s Quality
Account. You can read more about these items
on pages 29-31.
Last year there were a number of concerns
expressed about the quality of the catering
service in the Patient Satisfaction Survey,
following the contracting out of the service to
Wilson Vale in the summer of 2012. I am pleased
to see that, following a lot of hard work on the
part of our dietitians and Wilson Vale, those
concerns have largely been addressed.
Our aim is that all our
services receive external
accreditation
Our aim is that all our services receive external
accreditation and I am pleased to report that
the Acorn Programme has been re-accredited
by the Community of Communities and that
Katherine Allen Unit has been accredited by
AIMS-OP (Accreditation for Inpatient Mental
Health Services Older People). In addition to
this, in November 2013 our Naomi team won the
Psychiatric Team of the Year Award for working
age adults, awarded by the Royal College of
Psychiatrists. Such recognition is well deserved
and much appreciated by our staff teams.
Our Clinical Governance systems continue to
develop and 2013/14 saw some major changes
following the arrival of a new Associate Director
of Governance and Change who carried
out a review of our governance processes.
Information Management is an increasingly
critical part of the organisation and we continue
to explore ways in which we can use information
technology to assist us. We are currently looking
for a replacement Electronic Patient Records
System and are developing an IT strategy.
We are particularly
interested in finding out
what happens to people
post discharge
All services have been routinely collecting
outcome data and producing an annual clinical
review for some years. In the last twelve months
we have moved to the quarterly reporting
of outcome measures. We are particularly
interested in finding out what happens to people
post discharge and are thinking about how we
might obtain regular and systematic information
on this. We want to assist people to achieve
a Recovery that is sustainable. All services
produce an annual Quality Improvement Plan
and we recently held our first Clinical Outcomes
Conference, where all units shared their
outcomes for the previous year.
04
05
We recognise that highly trained, committed
and valued staff teams are pre-requisites of
any quality service. In December 2013 we
were pleased to be re-accredited by Investors
in People. Whilst the results of this year’s Staff
Survey were better than previous years there
were still concerns raised about communication,
consultation and levels of pay. We have been
able to go some way towards addressing the
latter in relation to our lowest paid staff and
have made a commitment to implementing
the “Living Wage” for all staff as soon as we
are able. This year the highest paid staff went
without their pay rise so that this amount could
be distributed amongst the lowest paid staff.
We will be working with the Staff Consultative
Committee to address issues of concern raised
in the Staff Survey.
In 2013 we conducted the third round of
appraisals under the new system, having further
modified this following feedback from staff. The
appraisal includes a grading for all staff and,
whilst this remains unpopular, we believe this
is an important part of any appraisal and are
keen to retain it. Following the appraisal round
we conducted a survey of staff to obtain their
feedback and will be making further changes
to the system in response to this. We continue
to carry out our quarterly face-to-face team
briefings and these are well received.
I am pleased to report that we were found to be
fully compliant by the Care Quality Commission
when they inspected our services.
I remain confident that The Retreat will rise to the
challenges ahead
This past year has been every bit as challenging
as we predicted and the coming years will
be even more so. I remain confident that The
Retreat will rise to the challenges ahead and
continue to provide high quality services that
represent value for money.
On behalf of The Retreat, I affirm my
commitment to providing high quality services
and confirm that, to the best of my knowledge,
the information contained in this report is
accurate.
Jenny McAleese
Chief Executive
22/05/2014
Part Two
Priorities for improvement 2014/15
08
Statement of Assurance from the Board
13
Review of services
14
Participation in clinical audits
14
07
“Very thorough,
intelligent and
supportive
programme”
08
Priorities for improvement 2014/15
The Retreat is embarking on a programme
of transformational change to ensure we are
working efficiently, safely and continuing to
provide the highest quality care for our patients.
implementing new ways of working that will
ensure more robust identification, mitigation and
management of both strategic and operational
risk.
The governance structures and processes
across the organisation have been reviewed
in 2013/14 and we are in the process of
Key elements of this change programme are
identified as our priorities for 2014/15 and are
listed below:
Patient Safety
Objective
Rationale
2014/15 Activities
Indicators for success
Lead, monitoring
and reporting
Ensure the
organisation has
IT systems which
are fit for purpose
and enable the
efficiencies available
from IT systems to
be gained.
Efficient and effective
use of IT is essential
in the delivery of
healthcare,
Conduct a review of
the underlying network
structure and make
any changes which are
necessary to ensure the
system is robust and fit for
purpose.
Actions stemming from
the review will have been
completed.
SMT Lead Director of Finance
and Facilities.
Implement wireless
capability across the main
site.
Wireless capability
implemented.
Evaluate options for a
new EPR system and
recommend a selected
supplier to the Board.
Report to the Board with
a recommended EPR
system detailing capital
investment required.
Implement new EPR
system.
New system
implemented across all
services.
Progress reports
given to the SMT
and the Board.
09
Patient Safety
Objective
Further develop
and embed robust
risk management
systems and
processes across
the organisation.
Rationale
In order to ensure the
safety of both staff and
patients it is important
that robust systems and
processes, designed
to identify and mitigate
risks, are embedded
across the organisation.
2014/15 Activities
Conduct Board
Development Days
to further develop the
Board’s awareness and
confidence in using
the Board Assurance
Framework (BAF).
Ensure the Risk Register
is maintained in a timely
and accurate manner.
Ensure that Action Plans
are developed and
implemented in a timely
manner.
Extend the number of
staff able to add risks to
the Risk Register.
Indicators for success
Both the BAF and
the Risk Register are
maintained as dynamic
documents and give
an accurate overview
of strategic and
operational risk across
the organisation at any
given point in time.
Lead, monitoring
and reporting
SMT Lead –
Associate Director
of Governance and
Change.
The BAF will
be monitored
at Governance
Committee and
reported to the
Board.
The Risk Register
will be monitored
at the Risk
Management Group
and reported to
the Governance
Committee.
“I have found the holistic approach to caring on the unit in general and my family member in particular warming and reassuring.”
Clinical Effectiveness
Objective
Conduct and
implement a review
of the nursing
workforce.
Rationale
The organisation has
in place a strategy
which supports
the professional
development and
advanced opportunities
for nurses that will
enhance clinical
practice and outcomes.
Supporting staff in
developing their range
of clinical skills is seen
as important for staff
personal development,
career progression and
overall patient care.
Indicators for success
Lead, monitoring
and reporting
To support nurses to
become independent
prescribers.
A register of
appropriately qualified
staff will be available.
SMT Lead –
Director of
Operations.
Expand the number
of staff trained in
phlebotomy and
performing an ECG.
This will include:
HR Manager and
Learning and
Development
Manager to monitor
activity.
2014/15 Activities
•
Non-medical
prescribers.
Annual rolling programme • Increased number
of qualified and
for pre-registration
students, to support
support staff trained
in phlebotomy and
unqualified staff to
able to perform
progress towards a
professional nurse
ECG.
qualification.
Two pre-registration
students join the
programme each year.
Evidence of
increased clinical
effectiveness
through audit.
“I have never witnessed or experienced anything but consideration to visitors and patients alike.”
10
11
Patient Experience
Objective
Ensure all patients
have full access to
physical healthcare
assessments
and screening
programmes.
Rationale
The impact of physical
healthcare problems
on mental health is well
recognised. To support,
and encourage patients
to acknowledge their
physical healthcare
needs in a proactive and
thoughtful way.
To ensure access to
primary healthcare
services is available
and improve access
to screening for early
detection of longer
term physical health
conditions.
2014/15 Activities
Indicators for success
Physical Healthcare
Assessments
All patients are
offered a physical
healthcare assessment
on admission. This
assessment is repeated
as a standard, dependent
on length of stay.
SMT Lead –
Director of
Operations.
All patients will have
received a physical
assessment on
admission and an
annual physical review,
appropriate to length of
stay.
Personal Care Strategy
In collaboration with
the person, individual
strategies are developed
and reviewed as part of
the CPA process. This
will, as appropriate,
indicate dental,
ophthalmic and podiatry
needs.
Lead, monitoring
and reporting
Evidence of assessment
of personal care
needs and appropriate
treatment plans
completed.
Practice
Development
Nurse and
Advanced Nurse
Practitioner will
complete
bi-annual audit.
Evidence through
audit provided
by the Smoking
Cessation Advisor
Lead.
Monitor through the
CPA Group.
Smoking Cessation
•
On admission each
patient will be given
a ‘smoking cessation’
pack and referral to
a Smoking Cessation
Advisor.
An increased number
of patients who have
attempted to, and
successfully stopped
smoking.
•
Increase the
number of Smoking
Cessation Advisors.
An increased number
of Smoking Cessation
Advisors are available.
•
Enable and support
An increased number
staff to stop smoking. of staff who have
successfully stopped
smoking.
Patient Experience
Objective
Rationale
Establish a Recovery To promote recovery
College, open to
through education and
everybody in York.
learning.
To build individual
resilience leading
to reduced hospital
admissions.
2014/15 Activities
Consultation with all
stakeholders.
Identify and redeploy
resources.
Establish Outcomes and
Evaluation Framework.
To offer a pathway out of Market and promote the
services.
Recovery College.
Indicators for success
Recovery College York
is launched, with a
curriculum of at least 12
different courses.
Within the first year 45
students will access
the college with 60%
satisfactorily completing
their courses.
Lead, monitoring
and reporting
SMT Lead –
Director of
Development.
Monitor through
Steering Group
which feeds
into Business
Development
Group.
75% of students who
complete their courses
will demonstrate
improvements in their
health and wellbeing.
Roll out the Family
and Friends Test
(FFT) across the
organisation aiming
to achieve an 80%
response rate for all
patients discharged.
We want to make sure
that patients have
the best possible
experience of care,
and that they can easily
make known their views
on the quality of this
care.
We are introducing the
FFT because we want to
obtain regular and timely
feedback from patients
about their care and
treatment.
Implementation of staff
FFT as per guidance,
according to the national
timetable.
We will benchmark the
return rates of the FFT
against other providers.
Full delivery of FFT
across all services
delivered as outlined in
guidance.
We will ensure that we
have achieved an 80%
return rate from all
discharged patients.
We will follow up
with focus groups to
understand the results
we receive through The
Retreat Involvement
Forum.
We will review all
feedback from the action
plans and The Retreat
Involvement Forum in
the Patient Safety and
Experience Group.
SMT Lead –
Director of
Operations.
Monitor through
Patient Safety and
Experience Group.
12
13
Statement relating to quality of NHS services
provided
Statement of Directors’ responsibilities in
respect of the Quality Account
The Directors are required under the Health Act
2009, National Health Service (Quality Accounts)
Regulations 2010 and National Health Service
(Quality Account) Amendment Regulation 2011
to prepare Quality Accounts for each financial
year. The Department of Health has issued
guidance on the form and content of annual
Quality Accounts (which incorporate the above
legal requirements).
In preparing the Quality Account, Directors are
required to take steps to satisfy themselves that:
• The Quality Account presents a balanced
picture of the organisation’s performance
over the period covered;
• The data underpinning the measures of
performance reported in the Quality Account
is robust and reliable, conforms to specified
data quality standards and prescribed
definitions, is subject to appropriate scrutiny
and review; and
• The Quality Account has been prepared
in accordance with Department of Health
guidance.
The Directors confirm to the best of their
knowledge and belief they have complied with
the above requirements in preparing the Quality
Account.
By order of the Board
• The performance information reported in the
Quality Account is reliable and accurate;
• There are proper internal controls over the
collection and reporting of the measures of
performance included in the Quality Account,
and these controls are subject to review to
confirm that they are working effectively in
practice;
Stuart Humby
Chair of Directors
22/05/2014
14
Review of services
During 2013/14 The Retreat provided eight NHS
services in three service areas.
an annual clinical report which was presented to
the Board for review.
The Retreat has reviewed all the data available
to them on the quality of care in eight of these
services. In addition to clinical audits and
clinical research, each named service produced
The income generated by the NHS services
reviewed in 2013/14 represents 100% of the
total income generated from the provision of
NHS services by The Retreat for 2013/14.
Participation in Clinical Audits
The Retreat undertakes an annual programme
of Clinical Audit which is included within our
overall three-year Clinical Audit Strategy. We
reviewed the list of national clinical audits and
enquiries for inclusion in Quality Accounts
2013/14.
There are three National Clinical Audits
applicable to the services provided by The
Retreat, but due to insufficient patient numbers
The Retreat did not participate in them. These
were:
•
National Audit of Dementia
•
National Audit of Schizophrenia
•
Prescribing Observatory for Mental
Health (POMH-UK) (Prescribing in mental
health services)
The results of 28 Local Clinical Audits were
reviewed in 2013/14 and the organisation has
taken action as a result of these findings to
improve the quality of care and treatment it
provides.
“Very caring staff, everyone is treated with respect and dignity. ”
15
Local Clinical Audits Conducted
Audit
25hr Weekly Activity
Quality improvement actions
•
•
•
Bank Staff Record Keeping
•
•
Recovery Plans and Record
Keeping*
•
•
•
•
•
•
•
Clinical Supervision
•
•
•
•
•
•
Capacity Assessment Forms/
Consent to Treatment
•
•
DBS Induction Programme
•
•
•
•
•
*12 Audits carried out in 2013/14
Development and implementation of a database to ensure all units can produce
individual reports for patients to support identification of areas for improvement.
Training provided to the Clinical Team Managers on use of the database.
Development of a performance report as part of the Quarterly Report to
Governance Committee.
Bank Staff to ensure they follow guidelines on the signing of entries on the
Electronic Patient Record system (FACE).
Incorporate into FACE training as part of induction sessions.
All patients have a clearly structured Recovery Plan in place that is reviewed and
updated within agreed timeframes.
The importance of discharge planning (and documentation thereof) is emphasised
as early as possible in a patient’s stay.
A new tab introduced on FACE to record consent to treatment.
Ensure that all patients have the opportunity to develop Advance Statements.
Ensure that repeat Risk Assessments and other relevant assessments are
completed within the agreed timeframe.
Personal Improvement Plans are put in place by Clinical Team Managers for staff
not achieving the required target at re-audit stage.
Six month review of the effectiveness of the Audit Tool and process.
Management team structures used to demonstrate and promote the need for
Clinical Supervision.
Ensure that each member of clinical staff has a supervisor identified and an
understanding of what Clinical Supervision entails.
Supervisors to review supervision every six months.
Communicate to staff the minimum frequency/duration for Clinical Supervision.
Remind staff of their professional recommendations to engage in Clinical
Supervision.
Each clinician to maintain a record of attendance that is signed by themselves and
their supervisor.
Implement new section on the EPR system (FACE) for documenting Consent to
Treatment and Capacity Assessments.
Include new standards within the Recovery Plan Audit to monitor compliance.
New induction programme introduced.
All staff have a DBS before commencing employment.
Reviewed existing Induction programme to ensure it can respond to operational
needs.
Welcome day introduced.
Local inductions and extension of e-learning training programme.
Local Clinical Audits Conducted
Audit
Blood Monitoring for Medication/
NICE Clinical Guideline 38 Bi­
polar Disorder
Quality improvement actions
•
•
•
•
NICE Clinical Guideline 136:
Service User Experience in Adult
Mental Health
•
•
•
Hand Hygiene
•
•
•
Health of the Nation Outcome
Scale (HoNOS)
•
•
•
High Dose Anti-Psychotic Use
•
•
Physical Healthcare**
•
•
•
•
**3 Audits carried out in 2013/14
Improved number of ECGs undertaken
Use Blood Monitoring Form (BMF) to record and prompt investigations. Each
patient has BMF with drug card detailing when last test was done and when next
test due.
Improved documentation. Record when blood monitoring done/offered but refused
by patient on FACE under Physical Health tab. Created form for staff to fill in when
ringing York Hospital for blood results.
Collaborative working in the MDT. Pharmacist to access results and report back to
MDT and responsible for ensuring each patient has a BMF.
Review of verbal and written information given to patients regarding hospital care
and treatment.
Review length of time of group and 1:1 staff/patient sessions with regard to NICE
standards.
Advanced Statements to be included within Crisis Plans.
Unit based hand hygiene training carried out by Infection Control representatives
for all staff including use of an ultra violet machine.
Improve hospital wide signage for use of hand gels as best practice.
Introduction of new hand-dryers in all public areas.
Development of a database to ensure all units can produce individual reports for
patients.
Introduce reporting systems to facilitate completion of HoNOS section as part of
Minimum Data Set.
Development of a Performance Report as part of the Quarterly report to
Governance Committee.
Remind Psychiatrists of the need for documenting rationale for use of high dose
anti-psychotic medication.
The rationale for the use of combination anti-psychotic must be recorded by the
prescribing doctor in the case notes.
Annual and physical examinations on admission are recorded on the agreed
assessment sheet.
Influenza vaccinations documentation. Accessibility of a record of a discussion of
administration of influenza vaccinations to patients. Add to physical assessment
sheet.
GPs to record Retreat patients’ consultation on FACE.
Implement method of alerting clinical staff when physical assessments and annual
Practice Nurse Reviews are due via CPA Database.
16
17
Local Clinical Audits Conducted
Audit
Subject Access Requests
Quality improvement actions
•
•
•
•
•
Sessional Therapists
•
•
•
•
•
•
•
Zoplicone Drugs
•
•
•
•
Addition to our Information Governance Risk Register. 81% compliance against
the standard achieved. The Data Protection Act 1998 requires all requests to be
completed within 40 days.
Central Subject Access Requests Log to ensure requests are dealt with efficiently.
Amend on Access to Health Records Policy to include a procedure for dealing with
follow-on Subject Access Requests that are made after an initial request has been
completed.
Access to Health Records (AHR) Application Forms. Review current suitability
of AHR forms as part of the Access to Health Records Policy. Amalgamate three
current forms into one.
Increase knowledge of NHS Medical Records Systems and Procedures.
Review Sessional Therapists Policy. Include timescale for how often Sessional
Therapists should undergo a DBS check and the need for this to be included in
their HR file. Nominate CTM to be named policy author.
Devise database for Sessional Therapists HR records.
DBS Checks. Ensure all current Sessional Therapists have a documented DBS
check logged in their HR file.
Clarify those Sessional Therapists that are categorised as Category 1 therapists in
relation to HPC registration.
HR Department to log current HPC registration documents in HR files for Category
1 Sessional Therapists.
Carry out performance review twice a year.
Review appropriateness of Performance Review Form.
Pharmacists to review medication with patients who have been prescribed regular
Z-drugs.
Use of patient decision aid from NPC to guide therapy.
Better liaison with Psychologists for non-drug methods to aid sleep e.g. mindfulness
and CBT.
Medication information for clinical team and patients on usage of z-drugs.
External Acceditation
The Royal College of Psychiatrists Centre for Quality Improvement (CCQI) aims to raise the standard of care that people with emotional
or mental health needs receive by helping
providers, users and commissioners of services
assess and increase the quality of care they
provide.
During 2013/14 Katherine Allen unit achieved
Accreditation for In-patient Mental Health
Services for Older People (AIMS-OP).
Units’ continued accreditation:
• The Acorn Programme - Community of
Communities
• Naomi unit - Quality Network for Eating
Disorders
Other units are actively preparing to join
accreditation processes run by CCQI.
“I get first class care and all the staff are very caring and friendly.”
18
19
Participation in Clinical Research
The number of patients receiving NHS funded
treatments that were recruited during 2013/14 to
participate in research approved by a Research
Ethics Committee was zero. Four service
evaluation projects have been initiated during
this year:
• The well-being of staff working with older
adults with dementia: Rising to existential
challenges.
• Introducing the Cognitive Analytic Therapy
model into a specialist mental health service
for older adults: a staff training programme.
• Staff perception of recovery in older adults.
• Attached and Secure? Exploring the patients
attachment experience within an inpatient
psychiatric unit.
Commitment to research as a driver for
improving the quality of care and patient
experience:
During 2013 we established a jointly funded
post of Research Facilitator with the Institute
of Mental Health (IMH) at the University of
Nottingham. The Retreat recognises the
importance and potential value of Clinical
Research and our aim is to develop an effective
research culture that further improves clinical
care and treatment.
This represents a significant development of
new collaborative research relationships with
the University of Nottingham. This complements
The Retreat’s existing relationship with the
York St John University as one of the founding
partners of the Research Centre for Occupation
and Mental Health (RCOMH), and our shared
research interests with the Universities of York
and Sheffield.
The Retreat’s enquiring and collaborative
stance, together with a combination of
quantitative and qualitative approaches, help
facilitate continued exploration of the key
factors in mental health recovery. Our aim is to
maximise the contribution The Retreat’s services
provide to this stage of an individual’s pathway.
20
Use of the Commissioning for Quality and Improvement (CQUIN) payment framework
A proportion of The Retreat’s income in
2013/14 was conditional on achieving quality
improvement and innovation goals agreed
between The Retreat and NHS England - South
Yorkshire and Bassetlaw Area Team with whom
we entered into a contract for the provision of
Specialised Eating Disorder Services (Adult),
through the Commissioning for Quality and
Innovation payment framework.
CQUIN
The Retreat was successful in achieving the
CQUIN target for 2013/14.
Further details of the agreed goals for 2013/14
and for the following 12 months period are
available electronically by emailing info@
theretreatyork.org.uk
QTR1
QTR2
QTR3
QTR4
1 (D) Optimising Pathways (Eating Disorders)
100%
100%
100%
100%
2 (B) Physical Healthcare (Eating Disorders)
100%
100%
100%
100%
3 Care Programme Approach
100%
100%
100%
100%
6 Safety, Clinical Effectiveness Innovation
100%
100%
100%
100%
“Staff are always very welcoming and always make the effort to spend time talking to us.”
21
Statements from the Care Quality Commission
The Retreat is required to register with the Care
Quality Commission and its current registration
status is in respect of:
•
Assessment or medical treatment for persons
detained under the Mental Health Act 1983.
•
•
Diagnostic and screening procedures.
Treatment of disease, disorder or injury.
The Care Quality Commission has not taken
enforcement action against The Retreat during
2013/14.
The Retreat York - 22 October 2013
Outcome
Judgement
Outcome 2 (Regulation 18)
Consent to care and treatment
Outcome 4 (Regulation 4)
Care and welfare of people who use services
Outcome 9 (Regulation 13)
Management of medicines
Outcome 14 (Regulation 23)
Supporting workers
Outcome 17 (Regulation 19)
Complaints
“During our visit we had the opportunity to speak with seven people who use the service. People were very
positive about the care and treatment they had received. Comments included, “They have really supported
me here and now I am so much better” and “Staff are lovely. They listen to you. Unlike some places I’ve been
before.” We looked at the records and talked to the staff working in the hospital. We confirmed that people
were supported to give their consent to care and treatment. People also told us they felt involved and included
in decision making within the service. We confirmed that care records were person centred and reflected
individual choices in their rehabilitation. We talked with the staff and they confirmed they felt well supported
and confident in their role with good training and development plans in place. We saw that there were good
systems in place to listen to people’s concerns and everyone was supported to access advocacy services and
other help networks. We also saw there were effective systems in place to monitor complaints. People who use
the service told us that if they wanted to make a complaint they would know how to. We saw that the hospital
recorded all complaints and resolved them where they could to the complainants’ satisfaction.”
Quote from CQC inspection report
The Retreat Strensall - 18 November 2013
Outcome
Judgement
Outcome 2 (Regulation 18)
Consent to care and treatment
Outcome 4 (Regulation 4)
Care and welfare of people who use service
Outcome 9 (Regulation 13)
Management of medicines
Outcome 14 (Regulation 23)
Supporting workers
Outcome 17 (Regulation 19)
Complaints
“During our visit we had the opportunity to speak with several people who use the service. People told us
that they felt the staff were ‘helpful’ and ‘friendly’ and supported them to have a varied and inclusive life at
Strensall. Comments included, “The staff are alright here, they are really supportive and talk to you.’’ We
looked at the records and talked with some of the staff. We confirmed that people were supported to give
their consent to care and treatment. People also told us they were offered copies of their care programme
and felt involved and included in decision making within the service. We confirmed that care records
were person centred and that they included people’s individual choices and aspirations. We looked at the
medication systems in the unit and confirmed that medication was stored, administered and managed safely.
This was important to make sure people’s health needs were safely met. We talked with the staff and they
confirmed they felt well supported and confident in their role. They also said that there were good training
and development plans in place. We confirmed that there were good systems in place to listen to people’s
concerns and everyone was supported to access advocacy services and other help networks. We also saw
there were effective systems in place to monitor the quality of the service complaints.”
Quote from CQC inspection report
“Caring staff, good facilities, innovative therapy.”
22
23
Information Governance and Data Quality
Data Quality
The Retreat did not submit records during
2013/14 to the Secondary Uses service for
inclusion in the Hospital Episode Statistics which
are included in the latest published data.
such as the Information Governance Toolkit
and the Care Quality Commission Essential
Standards of Quality and Safety.
Statement on relevance of Information Quality
and actions to improve Information Quality
• Implemented a more robust Data Protection
and Confidentiality policy.
The Department of Health (DoH) requires
hospitals to ensure they hold accurate, reliable
and complete information. Clear processes
and procedures need to be in place to give
assurance that information is of the highest
quality.
• Re-mapped our Confidential Information
Flows to and from the organisation and
introduced a Staff Guidance Booklet to
improve understanding and information
sharing both internally and externally.
High quality information is important for the
following reasons:
• It helps staff provide the best possible care
and treatment on the basis of accurate and
up-to-date information.
• It ensures efficient service delivery,
performance management and the planning
of future services.
In 2013/14 we have continued our work to
improve the quality of information across the
organisation. The Information Management
Group is responsible for ensuring the
organisation’s data collection systems operate in
line with the requirements of national standards
In particular over the last year we have:
• Developed an Information Governance Risk
Register.
• Reviewed the effectiveness of our Electronic
Patient Records system (FACE) and agreed
to implement a new system in 2014/15
to improve the efficient management of
information.
• Reviewed and implemented a new audit
tool and process, in addition to training for
Recovery Planning across the organisation,
to ensure staff have the necessary skills and
knowledge to be able to provide the best
possible care and treatment through the
accurate and complete documentation of
patient information.
The Information Governance Toolkit
• Introduced a number of new database
initiatives for Human Resources, the
Care Programme Approach (CPA) and
Safeguarding to ensure information quality
is of the highest standard and available to
those who need it.
• Improved internal data recording systems in
order to more efficiently produce information
to satisfy datasets as part of our NHS
contracts’ compliance.
This programme of work will continue into
2014/15 with a focus on raising the profile of
information quality through staff awareness,
training and monitoring. Our performance
metrics will continue to be reported and
monitored through our Information Management
Group and the Governance Committee reporting
to the Board of Directors.
“The staff and care team are an excellent support.”
The Information Governance (IG) Toolkit is an
annual self-assessment audit that The Retreat
is required to complete and submit to the
Department of Health (DoH) to ensure that the
necessary safeguards are in place for managing
patient and personal information.
A scoring system ranks an organisation from
Level 0 to 3, with 0 being the lowest score.
The Retreat is required to achieve a minimum
standard of Level 2 against all 17 standards
as part of the contracts we have with NHS
Commissioners.
Initiatives included within the measured areas
include:
• Information Governance Management.
• Confidentiality and Data Protection
Assurance.
• Information Security Assurance.
• Clinical Information Assurance.
The IG Toolkit is self-assessed by the
organisation and in 2013/14 The Retreat
increased the submission score by 2%
and submitted an additional factor at Level
3 compliance (the highest level). This
demonstrates to our patients that The Retreat
has robust controls in place to ensure the
security of patient and staff information.
24
25
IG Toolkit Final Ratings
Asessment
Lvl 0
Lvl 1
Lvl 2
Lvl 3
Req’ts
Score
Grade
Version 11
(2013-2014)
0
0
16
1
17
68%
Satisfactory
Version 10
(2012-2013)
0
0
17
0
17
66%
Satisfactory
Version 9
(2011-2012)
0
6
11
0
17
54%
Not
Satisfactory
Grade
Satisfactory
Achieved Attainment Level 2 or above on all requirements
Not Satisfactory
Not achieved Attainment Level 2 or above on all requirements
In accordance with national guidance,
Information Governance awareness and
mandatory training procedures must be in place
to ensure that staff are appropriately trained.
The Retreat achieved its target of 100% in the
training of staff whose role was identified as
requiring to complete the ‘Beginners Guide to
Information Governance’.
The Retreat achieved 93% in the training of
staff whose role was identified as requiring
to complete the ‘Introduction to Information
Governance’ or ‘Information Governance The Refresher Module’ which was below The
Retreat’s 100% target.
As a result of this the organisation is further
developing training mechanisms to deliver role
based IG training to all staff in 2014/15 in order
to achieve the 100% target.
“I am involved in every step.”
26
Clinical Coding Error
The Retreat was not subject to the Payment by
Results Clinical Coding Audit during 2013/14 by
the Audit Commission.
National Core Indicators of Quality
The National Quality Board has recommended
a national core set of quality indicators to be
included in the Quality Account 2013/14. This
comparative information is intended to set
performance in context and to explain whether
that performance is strong or weak.
Reporting against these indicators is not
mandatory for independent providers with the
exception of the staff element of the Friends
and Family Test. The Retreat considers it good
practice to report against those that apply to the
care we provide.
In the Staff Survey, conducted in March 2014,
84% of respondents were satisfied with the
quality of care given to patients.
84%
“I get first class care and all the staff are very caring and friendly”
27
“The Retreat offers extremely high
standards of care in all areas and seems to be constantly looking
to improve services.
I cannot speak
highly enough of the
organisation and staff.”
Part Three
Review of quality performance in 2013/14
29
Statements from local CCG and Healthwatch
38
29
Review of quality performance in 2013/14
This section provides a summary of the progress we have made towards achieving our 2013/14
priorities.
Patient Safety
Objective
To review the
Electronic Patient
Records (EPR)
System.
Actions taken
Outcome
Reviewed functionality
of our current EPR
system – FACE.
A number of concerns were identified with both
FACE systems which were formally reported to the
Governance Committee and Senior Management
Team. The Governance Committee acted on these
concerns and requested a full system presentation
by the FACE EPR provider including their proposed
developments and upgrades. Following this
presentation it was felt that we did not have the
required level of assurance that the FACE system
would satisfactorily meet the current and future needs
of The Retreat.
Trial of a new webbased FACE system.
Assessment of
the functionality
of alternative EPR
systems that were
available.
Achieved
A decision was made by the Board of Directors
that the organisation would therefore source and
implement an alternative EPR system across the
organisation in 2014/15.
“The extra mile that staff go to keep
myself as a carer, with the Power of
Attorney, informed not just of bad
episodes but also good ones is most
helpful and appreciated.”
Clinical Effectiveness
Objective
All qualified nursing
staff would receive
individual clinical
supervision on
a regular basis
(minimum of nine
sessions a year).
Actions taken
Facilitate clinical
supervision training.
Four training courses
facilitated a further
course planned for
later this year.
A survey of nurses’
experience of clinical
supervision using the
Manchester Clinical
Supervision Scale.
Outcome
Increased access to and quality of clinical supervision
for nursing staff to comply with Nursing and Midwifery
Council recommendations and meet Continuing
Professional Development (CPD) requirements.
Increase in reflective practice.
A survey was carried out in January 2014. It clearly
demonstrated how important and valuable nurses
find clinical supervision. However it does not provide
sufficient evidence for the organisation of compliance
on the number of individual supervision sessions. A
new way of auditing this is to be agreed at the Clinical
Supervision Steering Group.
We also need to further develop the strategy over
the next year to ensure all support workers receive
individual clinical supervision.
To ensure that patients
are able to maximise
their physical
wellbeing.
Dedicated Nurse
Practitioner time for all
units.
Increased documentary evidence of compliance.
Practice Nurses
facilitated monthly
clinics for chronic
disease management.
Specialist monitoring and treatment for our patients.
Smoking cessation
service identified
through The Retreat
Pharmacy Services.
Increased access to smoking cessation services for
our patients.
Regular audits of
standards of physical
healthcare.
Identification of areas we can continue to improve our
services.
Achieved
30
31
Patient Experience
Objective
Encourage further
development of
Vocational Pathways.
To ensure that patients
have the opportunity
to give feedback on
the quality of food and
the catering service
provided.
Actions taken
Outcome
Develop a variety
of volunteering
opportunities.
A variety of voluntary opportunities means that there
are more options for engagement on the pathways. In
turn this has developed a more robust service.
Awareness raising of
Vocational Pathway.
Increased community activity and staff awareness
means better engagement on the pathway helping
people get back into community activities.
Developed passport
for Vocational Pathway
so progress can be
tracked and fed into
the clinical teams.
This means that work that takes place on the pathway is
fed back into the clinical teams. The individual can also
keep track of their progress and be more involved in
their care.
Identify future
developments of the
Pathway.
A consultation into the development of the Vocational
Pathway with our patients, has led to the initiation of the
Recovery College York.
Focus group to
determine what
was important to
patients with regards
to the whole dining
experience.
The dining survey is meaningful as it captures the
questions that are important to the patients and
therefore the feedback and subsequent actions are
authentic. The feedback will be used to create a set
of Service User Defined Standards, which will be
surveyed annually to ensure an improvement in service
provision.
Quarterly ‘Meet the
Chef’ event to invite
real time feedback on
the quality of food and
the catering service.
There are checks in place that allow a diverse range
of individuals to be engaged to ensure that the quality
of the catering provision is appraised. This event
enables relationship building and allows catering staff
to understand the nutritional needs of individuals within
The Retreat, but also for the patients to appreciate
some of the catering staffs’ limitations.
Monthly catering
forum, where both
staff and patients
are invited to give
feedback on the
quality of food and
catering service over
the previous month to
the Catering Manager
and Dietitians.
This ensures a robust communication loop between
patients and the catering team. The patients are
invited to give their feedback, supported by staff,
and the catering team agree how they will action the
suggestions. This is then monitored and reported back
on at the next meeting.
Achieved
32
Complaints Report
A total of 12 complaints were received during
2013/14.
Learning from the complaints:
• The communication process between staff
and patients has been changed to keep
patients informed of decisions that relate to
their outpatient appointment.
The table below shows the reasons for the
complaints:
• Staff are adopting various techniques to
reduce the problems some patients are
experiencing with other patients on the unit.
Reason for the Complaint
Number
Number Upheld
Attitude of staff
1
Upheld
All aspects of clinical treatment
3
2 Upheld
Communication/Information to Patients (Written or Oral)
2
2 Upheld
Other – Behaviour of a patient towards another patient
5
5 Upheld
Other - Environment
1
Upheld
12 complaints received were dealt with within 25 working days
(Complaint Categories are as defined by the Department of Health)
“More therapy in the community as
I am now struggling to get out [enough] near to discharge.”
33
Compliments
In 2013/14 we introduced a new Compliments
Policy across the organisation with the aim of
providing clear information on how individual
compliments are reported and logged in
addition to the ways in which they will be used.
Each clinical unit keeps a log of all compliments
which is forwarded monthly to the Quality and
Compliance unit. Compliments reports are
collated and submitted to NHS Commissioners
on a monthly basis as part of our National
Minimum Dataset submissions.
In total we received 29 compliments in 2013/14,
an improvement on 23 received in 2012/13.
A key theme emerging from the compliments
received this year was the quality of care and
treatment received by the patients.
“The care for [X]
has been much better at The Retreat than at the previous hospital.
Both myself and
my sister feel
much happier that
[X] is being cared
for.”
“My mental illness is very complex and challenging and without [The Retreat’s] support I would struggle even more than I do now.”
34
Performance Measures
Patient Experience
The Retreat openly encourages patients and
carers to give their feedback on all aspects
of care and treatment. This ensures that we
can constantly improve the services we offer.
In order to gather these views formally, we
implemented an annual programme of Patient
Experience Surveys as part of our Clinical Audit
Strategy.
These surveys ensure that patients’ voices
are heard and are used to help deliver better
care and treatment, provide evidence to
commissioners of the quality of our services
and ensure we can drive service improvements
in relation to CQC Outcome 16: Assessing and
Monitoring the Quality of Service Provision.
The Retreat Involvement Forum and the Friends,
Family and Carers Forum, offer an arena for the
people who use our services and their carers, to
be fully involved in service delivery, development
and provision. These forums meet quarterly and
ensure that we hear first hand, the things that
are important to people and what is working
well. We also facilitate Involvement meetings
on the units to ensure that we capture as many
people’s opinion as possible.
“The staff are the best I have ever met, they listen and care.”
“Would recommend to friends and family,
our mother is extremely well
looked after by
good people who
care about her.”
35
For 2013/14 this programme and the quality improvement actions agreed following the survey results
included the following:
Survey
Quality improved actions
Inpatient Survey
•
•
•
•
•
Out Patient Survey
•
•
•
Carers’ Survey
•
•
•
•
•
Dining Survey
•
•
•
•
Raise patient awareness regarding the complaints procedure including a review of the visual
information provided at unit level.
All patients to have a lockable storage facility in their rooms.
Senior Management Team to review the Catering Service to ensure it remains fit for purpose.
Increase the frequency and range of external outings available to all patients.
Measure organisation compliance against the standards outlined in NICE Clinical Guideline 136:
Service User Experience in Adult Mental Health. Implement improvements to best practice as
required.
Improve parking provision for patients by requesting staff to avoid parking at The Tuke Centre
during busy times and to utilise the main Retreat car park.
Increase signage to make patients aware of the cycling provision available.
Admin staff and clinicians to respond to individuals’ needs for provision of hot drinks as required.
Update the Carers’ Guide and ensure it is available on all units.
Raise the profile of the Carers’ Forums and their role in service development among staff by
attending more Clinical Team Manager days and facilitating Clinical Development Groups.
Create and promote more carers’ skills groups alongside carers to allow for unit-based skills and
knowledge to carry over to the transition between The Retreat and home.
Disseminate more widely information on appropriate local and national services that carers could
turn to for support.
Create an Involvement Section on The Retreat website which will raise the profile of local and
national organisations including direct links to their websites.
Patient involvement in choosing menu options.
‘Meet the chefs’ event.
Review of the Dining Experience on each unit with specific actions for improvement.
Improved variety of vegetarian meals.
36
Friends and Family Test
The Friends and Family Test (FFT) aims to
provide a simple headline metric which, when
combined with follow-up questions, can drive
a culture change of continuous recognition of
good practice and potential improvements in the
quality of care received by patients.
During 2013/14 a pilot of the FFT questions
were included within our inpatient surveys. As a
result of this trial from 1 March 2014 it has been
agreed that the organisation will adopt the FFT
and this will be asked of all patients as part of
routine discharge procedures.
Results will be used to benchmark The Retreat
against similar organisations nationally and to
identify and drive improvements to our practices
at a local level.
How likely are you to recommend The Retreat to Friends
and Family if they needed similiar care of treatment?
100%
Extremely Likely
80%
Likely
60%
Neutral
Unlikely
40%
Extremely Unlikely
20%
0%
November (n=43)
37
Staff Survey
Every year The Retreat conducts a
comprehensive survey of its employees in
order to establish their satisfaction with their
employment and to seek feedback on areas
that might be developed or improved. This is
only one tool that we use in order to talk to
our workforce. In 2013/14 we also undertook
a successful Investors in People review and
carried out a range of different briefings,
surveys and feedback sessions throughout the
year.
This reporting year, the design and distribution
of the staff survey was undertaken by a
group of employees nominated by the Staff
Consultative Committee. This approach has
enabled us to draw on wider experience for
the design of the survey and offers a visible
demonstration that The Retreat wants to
genuinely engage all of its employees in its
ambition to become an employer of choice.
In March 2014 we had a 52% response rate
which is a good improvement on the previous
year. The headline indicators from the staff
survey show that:
• 86% of staff thought The Retreat was a good
place to work.
• 76% of staff believed that The Retreat’s top
priority was patient care.
• 86% of staff were satisfied with the quality of
care given to patients.
A number of themes were identified within the
survey for further action. These included:
• Reviewing some terms and conditions of
employment.
• Internal communications providing a clear
understanding for the future.
• Further developing the team spirit.
• Ensuring equality between clinical and non­
clinical staff.
These issues will be explored over the coming
months, with solutions being developed through
consultation with the staff team, before being
taken forward for further consideration.
“The Retreat is a lovely place
to work, and patient care is
paramount.”
Statement from the local CCG and Healthwatch
Partnership Commissioning Unit
Healthwatch
“The Retreat is commissioned to deliver care to
vulnerable and complex mental health patients
by The Partnership Commissioning Unit (PCU)
on behalf of Scarborough & Ryedale CCG,
Harrogate & Rural District CCG, and Hambleton,
Richmondshire & Whitby CCG & Vale of York
CCG.
Thank you for offering us the opportunity to
review and comment on your Quality Account
report. We feel that it is a well set out document,
easy to read text with data nicely formatted into
tables.
The existing and developing services at The
Retreat demonstrate flexibility and a keenness
to work with commissioners to ensure locally
commissioned services are a priority. Year
on Year we are confident in the standard of
specialist services The Retreat provides.
During recent changes to the commissioning
of NHS services The Retreat has shown and
demonstrated a willingness to be engaged with
commissioning processes and we consider them
a valuable contributor in driving forward health
initiatives.
As with all our independent health providers the
PCU looks forward to working together in the
year ahead at commissioning effective mental
health services”.
We’d like to congratulate you on your
commitments to staff development, patient
experience and improving IT systems. It’s clear
to see that goals are being set, worked towards
and reviewed across the board, and that
marked improvements are being made in many
areas. This is well documented by both selfassessment and external inspections, resulting
in some well deserved accreditation.
We particularly appreciate the effort being made
to ensure that patients, staff and carers are able
to feed their opinions into service provision. It’s
encouraging to see a management style that is
actively responsive.
It’s important to note work done by The
Retreat in the community and with academic
institutions, and we’re excited to see the ongoing
development of the Recovery College, briefly
mentioned in this report.
We look forward to further opportunities to work
together in the coming year.
38
Glossary
40
Glossary
CCG
FACE
Clinical Commissioning Group
Is a statutory NHS organisation, representing
groupings of GP Practices, that are responsible
for designing local health services In England.
They will do this by commissioning (or buying)
healthcare services. There are 211 CCGs in
England.
Functional Analysis of Care
Environments
Electronic Patient Record System used by The
Retreat.
HoNOS
Health of the Nation Outcome Scale
CQC
Care Quality Commission
The independent regulator of health and social
care in England. It regulates health and adult
social care services, whether provided by the
NHS, local authorities, private companies or
voluntary organisations.
A widely used routine clinical outcome measure
used by English mental health services.
MDT
Multidisciplinary Team
A group of different types of clinicians who
work together as a team.
CQUIN
Commissioning for Quality and
Innovation
Measures which determine whether we achieve
quality goals or an element of the quality goal.
These achievements are on the basis of which
CQUIN payments are made.
01904 412551 01904 430828
Heslington Road York YO10 5BN
info@theretreatyork.org.uk
www.theretreatyork.org.uk
If you would like to make any comments regarding the content of this report, or make any suggestions for future reports, please
contact our Communications and Engagement Officer at the address below.
Electronic copies of this Quality Account can be obtained from our website (www.theretreatyork.org.uk) and the NHS Choices
website (www.nhs.uk).
Printed copies can be obtained by contacting the Marketing Department.
If you require this report in another language please contact the Marketing Department.
Marketing Department
The Retreat
Heslington Road
York
YO10 5BN
t: 01904 412551
e: marketing@theretreatyork.org.uk