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Page 1: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

The Huntercombe Group

Quality Account 2013/2014

Page 2: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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CONTENTS PAGE

Part 1 - Statement of Quality from the Board of Directors

Margaret Cudmore, Chief Executive, The Huntercombe Group 4

Paula Smyth, Head of Clinical Standards & Compliance, The Huntercombe Group

6

The Huntercombe Group – Visions and Values 7

Proud of what we do and Believing in our Values 7

Overview of Services Provided by The Huntercombe Group 8

Child and Adolescent Mental Health Services 8

Eating Disorders 8

Adult Mental Health and Learning Disabilities 8

Acquired Brain Injury & Neurological Services 8

Children and Adolescents with Specialist Needs 9

Addictions 9

NHS Services Provided by The Huntercombe Group 10

Part 2 - Priorities for Improvement and Statements of Assurance

from the Board

Priority One 12

Priority Two 12

Priority Three 12

Priority Four 12

Priority Five 12

Statements Relating to the Quality of NHS Services Provided 14

Review of Services 14

Participation in Clinical Audits 14

Participation in Clinical Research 15

Goals Agreed with Commissioners 15

What others say about The Huntercombe Group 16

Data Quality 16

NHS Number and General Medical Practice Code Validity 16

Clinical Coding 16

Page 3: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Contents Continued

Part 3 - How We Have Performed in 2013/2014

Celebrating Success 18

New Initiatives 19

Progress Against Our 2014/2014 Priorities 21

Priority One 21

Priority Two 22

Priority Three 22

Priority Four 23

Priority Five 23

Commissioning for Quality and Innovation (CQIN) Performance 24

Routine Performance Monitoring 26

Regulatory Compliance 26

Complaints 27

Incidents and Reporting 29

Lessons Learnt from Complaints and Incidents 30

Patient Experience and Listening to Others 31

Friends and Family Test Results 31

Patient Satisfaction 32

Carer Survey 35

Feedback from Referrers 38

Page 4: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Part 1 Statement on Quality from the Board of Directors

Page 5: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Margaret Cudmore,

Chief Executive, The Huntercombe Group

It gives me great pleasure to present the 5th Annual Quality Account for The Huntercombe

Group.

The Huntercombe Group is the Specialist Services Division of Four Seasons Health Care and

one of the leading providers of specialist healthcare working in partnership with the NHS and

Local Authorities throughout England and Scotland to provide high quality, safe and effective

care for its patients.

Specialising in Adult Mental Health, Specialist Brain Injury and Child and Adolescent Mental

Health (CAMHS) the Huntercombe Group has gained a reputation for innovation and

creating the right treatment solutions for patients with particularly challenging and complex

needs. We ensure that every individual admitted to our services has the potential to

enhance their prospects for a more fulfilling life.

Every patient at the Huntercombe Group is treated as an individual, with their own very

specific and often complex needs. It is their right to be valued and cared for in a safe,

therapeutic environment whilst receiving the professional, clinical care they require.

This has been another very exciting year for the Huntercombe Group and one that has seen the

group make good progress against last year’s priorities. There have been a number of

challenges in the past year including the implementation of new NHS commissioning

arrangements and increased regulatory scrutiny but working closely with our commissioners

and the CQC and this has helped us look at our systems and to drive forward improvements

with our care delivery. We also recognise it is the hard work and commitment of all our staff

that leads to these improvements in the quality of our services and we are proud of their skills

and dedication.

We are not however complacent and recognise that there are still improvements that can be

made and a number of these have been included in our priorities for 2014 and 2015.

Statement on Quality from the Board of Directors

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This quality account covers all of our services that provide NHS commissioned care across all

specialities. This Quality Account aims to:

Enhance our accountability to the people who use our services their carers and other

stakeholders of our quality improvement agenda

Enable us to demonstrate what improvements we have made and what we plan to make

Provide information about the quality of our services

Show how we involve and respond to feedback from our service users, carers and

others

Ensure we review our services, decide and demonstrate where we are doing well but

also where improvement is required

It comprises of three sections. Part one are statements from Huntercombe Group Board

Members. Part two outlines our priorities for improvement in the year ahead and mandatory

statements about various aspects of the quality of our services. The final part reviews our

progress against our quality account priorities for 2013/2014 and gives an overview of some of

our key performance indicator.

The report has been produced in accordance with guidance issued by the Department of Health

and will be published both on our website at www.huntercombe.com and also via the NHS

Choices website.

We hope you find this report both interesting and informative and we very much welcome your

feedback and suggestions regarding this quality account. If you would like to comment or if

you require any further information please email: Paula Smyth, Head of Clinical Standards and

Compliance at [email protected] Alternatively please write to Paula Smyth, Head

of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court,

Willie Snaith Road, Newmarket, Suffolk CB8 7FA

I will be standing down as Chief Executive during the summer of 2014 handing over to Valerie

Michie who replaces me. It has been a privileged for me to work with such a formidable team of

healthcare professionals for these last 9 years and I have no doubt that they will seek to

achieve even greater success in the years to come the patients best interests.

Margaret Cudmore

Chief Executive

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Paula Smyth

Head of Clinical Standards and Compliance

Welcome to the Annual Quality Account for The Huntercombe Group.

This quality account provides us with an opportunity to present to our patients, their carers,

commissioners and the wider public, the progress we have made against our quality priorities

set in 2012/2013, and overview of some of the many successes that we have achieved. The

report also highlights areas where we still need to do more and our priorities for 2014/1015.

At The Huntercombe Group we are committed to the provision of high quality care for all those who use our services and their families. We recognise that the delivery of good quality, safe services is dependent upon the commitment, motivation and engagement of all of our staff along with need to have robust systems and processes in place to continuously monitor and improve the services we deliver.

With the changing nature of health and social care regulation and individuals at Board level

being increasingly held to account for the quality of care, we continue to strive to demonstrate

what is being done to learn lessons when things go wrong and to ensure that there is a clear

line of sight ‘from Ward to Board’ in relation to our clinical governance processes.

We also recognise that high quality care can only be delivered in an environment where people

are listened to and where people’s views, concerns and complaints are welcomed and embraced

as a way to learn and improve.

We can already see that the year ahead is going to be every bit as challenging as the past year,

if not more, and we have set ourselves a number of ambitious priorities for 2014-15. We look

forward to reporting the outcome of these to you in our next quality account.

Paula Smyth

Head of Clinical Standards and Compliance

Statement on Quality from the Board of Directors

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The Huntercombe Group is a Specialist Services Division of Four Seasons Health Care, one of

the largest independent care providers in the UK. Specialising in Adult Mental Health, Specialist

Brain Injury and Child and Adolescent Mental Health Services (CAMHS). The organisation

gained a reputation for innovation and creating the right treatment solutions for patients with

particularly challenging and complex needs. With 55 hospitals and specialist centres across

England and Scotland, we work in partnership with NHS and Local Authorities to provide

innovative, high quality, person-centred health and social care services.

The Huntercombe Group (THG) aims to continuously improve and innovate in the services we

operate and we do this through various joint initiatives and partnerships with the NHS. Every

patient at THG is treated as an individual, with their own very specific and often complex needs.

It is their right to be valued and cared for in a safe, therapeutic environment whilst receiving

the professional, clinical care they require. We aim to ensure that every individual admitted to

our services has the potential to enhance their prospects for a more fulfilling life.

We are a specialist organisation delivering results though tailored inspirational care for adults

and young people with complex needs; through clinical excellence, quality environments and a

friendly ‘CAN DO’ approach.

We listen, we learn, we empathise, we respect and we care. Insight is fundamental to the way

we shape our services.

We are innovative, creative, dynamic and flexible in our service delivery, our research and

learning, and how we go about our business. Yet in everything we do, we take a measured

approach.

We put those in our care first; they are at the heart of everything we do. We also recognise

the commitment of our staff and stakeholders and the need to continually strengthen our

relationships with our external partners.

We strive for excellence across our whole service, through our clinical expertise and within our

care environments. Through good teamwork, we will always aim higher, are never complacent,

and lead by example.

We are reliable. Ours is a name to be trusted. We deliver results through transparent service

delivery and safety is paramount across all aspects of our business.

We offer accessible and tailored care pathways to meet geographical and specialist needs. We

aim to deliver the best possible value-based healthcare within our customers’ budgets.

Our strength is in our patient-centered focus, ‘CAN DO’ approach and flexibility. We believe in

making a difference to people’s lives through tailored solutions … not only to those in our care,

but to their families, commissioners and beyond.

The Huntercombe Group – Visions and Values

Proud of what we do and Believing in our Values

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Our CAMHS Tier 4 services are facilitated within our specialist hospitals situated in: Edinburgh,

Stafford, Maidenhead and Norwich, whilst our hospital in Cotswold Spa focuses on delivering a

specialist inpatient and outpatient programme of care for eating disorders. Our tailored

treatment packages for CAMHS are both innovative and flexible, delivered by a highly skilled

team of health care professionals.

At our specialist eating disorder hospitals, we provide assessment and treatment for

adolescents and young adults with severe and life threatening eating disorders such as anorexia

nervosa, bulimia nervosa and related disorders. Our hospitals are located in Edinburgh,

Maidenhead and Stafford. We also provide a shorter-stay eating disorder service based in the

Cotswolds for patients requiring less intensive treatment to that provided in our other hospitals.

Between our four hospitals we are able to offer treatment for eating disorders from the age of

11 upwards.

Our Hospitals and Centre’s throughout the UK provide a wide range of specialist treatment for

adults with a range of mental health disorders, learning disabilities and complex needs.

Specialist, patient centred care and treatment is delivered within a variety of settings and levels

of security, from medium/low secure Hospitals to step down services including Community

Hospitals and care homes with nursing and/or residential care. Continuum of care is vital for

patients stepping up or stepping down, and our uniform model of care supports patients

through a structured care pathway. Risk can also be managed efficiently around the patient’s

needs at any point in time.

We offer a broad range of specialist brain injury and neurological services from post-acute

intensive treatments for highly dependent patients through to supported living environments

that enable our clients to consider a return to independent living. Our award winning and

flexible person-centred neuro-rehabilitation services are delivered in centres across England and

Scotland.

Child and Adolescent Mental Health Services

Eating Disorders

Adult Mental Health and Learning Disabilities

Acquired Brain Injury & Neurological Services

Overview of Services Provided by The Huntercombe

Group

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We have two centres that specialise in the treatment and care of children and adolescents with

specialist needs. Our centre, Granville Lodge, in Hartlepool provides specialised care for children

with physical disabilities and delayed learning associated with their disabilities. Whilst our centre

in Stockton, cares for children with a moderate or severe learning disability with or without

associated challenging behaviours and can cater for those with more than one diagnosed

learning disability.

We provide detox and rehabilitation treatment in Sunderland, this service caters for both NHS

and private patients. The centre provides highly effective evidence-based interventions in the

treatment of drug and alcohol misuse. Our centre is able to cater for adults with complex needs

including poly-drug use, pregnant drug users, alcohol-related brain disease and mental health

co-morbidity.

Children and Adolescents with Specialist Needs

Addictions

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The table below outlines the NHS services provided by the group and the percentage of NHS

patients within each service. A majority of the remainder of the services provided by the

Huntercombe Group receive social care funding.

Service Name Service Type % of NHS

Patients

The Huntercombe Hospital Maidenhead Child & Adolescent Mental Health 100%

The Huntercombe Hospital Stafford Child & Adolescent Mental Health 100%

The Huntercombe Hospital Edinburgh Child & Adolescent Mental Health 100%

The Huntercombe Hospital Cotswold Spa Child & Adolescent Mental Health 100%

The Huntercombe Hospital Norwich Child & Adolescent Mental Health 100%

Blackheath Brain Injury Rehabilitation Unit Brain Injury & Neurodisability 100%

Frenchay Brain Injury Rehabilitation Unit Brain Injury & Neurodisability 100%

The Huntercombe Hospital Roehampton Adult Mental Health & Learning Disability 100%

The Huntercombe Hospital East Yorkshire Adult Mental Health & Learning Disability 100%

The Huntercombe Centre Sherwood Adult Mental Health & Learning Disability 100%

James House Adult Mental Health & Learning Disability 100%

Beech House Adult Mental Health & Learning Disability 100%

Murdostoun Brain Injury Rehabilitation Centre Brain Injury & Neurodisability 100%

Cedar House Adult Mental Health & Learning Disability 100%

Ashley House Adult Mental Health & Learning Disability 100%

The Huntercombe Centre Derby Adult Mental Health & Learning Disability 100%

Watcombe Hall Adult Mental Health & Learning Disability 100%

Stocksbridge Brain injury Rehabilitation Centre Brain Injury & Neurodisability 83%

The Huntercombe Centre Redbourne Adult Mental Health & Learning Disability 66%

The Huntercombe Centre Crewe Brain Injury & Neurodisability 60%

The Huntercombe Centre Sunderland Addictions 52%

Huntercombe Services Nottingham Brain Injury & Neurodisability 46%

Abbeymoor Neurodisability Centre Brain Injury & Neurodisability 44%

The Huntercombe Centre Cambridge Adult Mental Health & Learning Disability 38%

Murdostoun Neurodisability Centre Brain Injury & Neurodisability 29%

Hothfield Brian Injury Rehabilitation & Neurodisability Centre Brain Injury & Neurodisability 26%

Pathfields Lodge and Greenfields Adult Mental Health & Learning Disability 25%

The Huntercombe Centre Peterlee Adult Mental Health & Learning Disability 23%

The Huntercombe Centre Birmingham Adult Mental Health & Learning Disability 17%

Huntercombe Services Granville Lodge Children with Special Needs 17%

Stanhope Neurodisability Centre Brain Injury & Neurodisability 16%

Kings Delph Lodge Adult Mental Health & Learning Disability 14%

Meadowbrook Neurodisability Centre Brain Injury & Neurodisability 14%

Portland House Adult Mental Health & Learning Disability 13%

Huntercombe House Stockton Children with Special Needs 13%

South Quay Neurodisability Centre Brain Injury & Neurodisability 11%

Aspley Neurodisability Services Brain Injury & Neurodisability 8%

Beeton Grange Adult Mental Health & Learning Disability 5%

The Dell Adult Mental Health & Learning Disability 4%

The Royd Adult Mental Health & Learning Disability 4%

NHS Services Provided by The Huntercombe Group

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Part 2 Priorities for Improvement and Statements of Assurance from the Board

Page 13: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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The following priorities have been agreed, taking into account the views of staff, feedback that

we have received from those using our services through our service user surveys, audit reports

and commissioner requirements and priorities for 2014/2015.

The recruitment and retention of good staff remains a huge challenge for The Huntercombe

Group in ensuring that the Group continues to meet the needs of the individuals to whom we

provide care, the targets set by our commissioners and the modernisation agenda.

The Huntercombe Group needs to employ staff in certain areas and improve how we retain,

lead and support our workforce as well as ensure staffing levels continue to accommodate safe

and effective service delivery.

To achieve this we have identified a number of priorities for 2014/2015:

Focused recruitment activity and decreased reliance on agency staff

To review our Induction and Supervision Frameworks

Implement a bespoke leadership development programme for senior Nursing Staff in

conjunction with the Royal College of Nursing

Within the Huntercombe Group we recognise that the implementation of an effective risk

strategy and risk framework is key to the delivery of our key objectives and in the development

of a positive learning environment and risk aware culture.

In order to achieve this we will continue to:

Further develop our Framework for Risk Management Framework and Processes

Continue to embed and strengthen our electronic incident reporting across all Services

including new modules for the management of subject access requests and the

management of alerts

The Huntercombe Group vision of striving for excellence requires a determined and persistent

focus on the effectiveness of the care we provide for patients and the outcomes our services

achieve. Achieving best outcomes requires us to provide care that is safe and care that is

effective. In 2013/2014 we aim to:

Strengthen our clinical audit programme – focussing on priorities as informed by our risk

register.

Priorities for Improvement and Statements of Assurance from

the Board

Priority One

Priority Two

Priority Three

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Conduct an on-going programme of reviewing our policies and procedures ensuring

these are based on the best practice / research evidence and that they are fit for

purpose.

More effective use of outcome measures to inform us, our patients, the public and our

commissioners about our performance.

To sign up to the Learning Disability Provider Code.

To re-launch our Mindshare research programme for all employees of The Huntercombe

Group and to encourage take-up of academic and clinical research including the

introduction of the Mindshare Foundation Grant which is a modest initiative to

encourage research and alleviate some of the cost barriers associated with research

projects.

To provide welcoming, responsive services that listen and respond to those who use them and

their families and carers and to demonstrate respect, dignity, choice and involvement we will:

Continue to ensure a routine programme of satisfaction surveys across all services to

elicit feedback from those who use our services, the families and carers and those who

refer to us and to act upon their feedback to improve our services and the experiences

of those who use them.

Develop further information for people who use our services and their families based on

the feedback we have received from patients and residents in 2013/2014. This will

include the provision of leaflets, posters and feedback from key meetings across THG.

Information will be provided in a range of accessible formats and will be developed in

conjunction with those who use our services.

Pilot Patient Led Assessments of the Care Environment (PLACE) in a number of services

across THG. PLACE is a new NHS initiate that was launched in 2013 for assessing the

care environment. Place Assessments will provide clear messages for THG directly from

those who use our services about how the environment or services may be improved.

Following evaluation of the success of these pilots we will consider how these can be

rolled out further across the group.

To commence delivery and implementation of the Connect Tech Programme across THG.

Connect Tech is the programme associated with the implementation of the Coldharbour

software suite. Connect Tech comprises of six applications including Care Notes an electronic

patient record, e-compliance an integrated suite of compliance tools, Occupancy Management,

Time and attendance, Enquiry Management and Business Intelligence.

Priority Four

Priority Five

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During 2013/2014 the Huntercombe Group provided and / or subcontracted 40 NHS Services.

These have been described in Section 1.

The Huntercombe Group has reviewed all the data available to them on the quality of care in

100% of these NHS services.

The income generated by the NHS services reviewed in 2013/2014 represents 100% of the total

income generated from the provision of NHS services by the Huntercombe Group for

2013/2014.

During 2013/2014 five national clinical audits and one national confidential enquiries covered

NHS services that the Huntercombe Group provides.

During that period the Huntercombe Group participated in 0% national clinical audits and 100%

national confidential enquiries of the national clinical audits and national confidential enquiries

which it was eligible to participate in.

The national clinical audits and the national confidential enquiries that the Huntercombe Group

was eligible to participate in during 2013/2014 are as follows:

National Clinical Audits:

RCPH National Childhood Epilepsy Audit

National Adult Diabetes Audit

National Audit of Psychological Therapies

Prescribing in Mental Health Services (POMH)

National Audit of Schizophrenia

National Confidential Enquiries:

National Confidential Enquiry into suicide and homicide by people with mental illness

The national clinical audits and national confidential enquiries that the Huntercombe Group

participated in, and for which data collection was completed during 2013/2014, are listed below

alongside the number of cases submitted to each audit as a percentage of the number of

registered cases required by the terms of that audit or enquiry.

The National Confidential Enquiry into suicide and homicide for people with mental illness

100%.

The Huntercombe Group regularly receives and reviews local clinical audit reports at both unit,

divisional and group level. Each service has a programme of audits that are conducted

throughout the year. Findings of the audits are shared via out integrated governance

framework to ensure that the experience is shared, lessons learned and action plans monitored.

Statements Relating to the Quality of NHS Services

Provided

Review of Services

Participation in Clinical Audits

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The Huntercombe Group is committed to the improvement of their services and in sharing best

practice to disseminate learning’s throughout the public and independent healthcare sector,

which in turn contributes to patient improvements in the areas of health we work within.

A dedicated area on the Huntercombe website now features all past and current research

projects from across the group and we actively participate in a number of university student

placement schemes across England and Scotland.

We actively encourage the following:

Academic research ( in partnership with an academic institution or body ) Clinical research ( that is undertaken by a clinician or in partnership with another

institution, partner or body )

Best practice

By sharing original thinking, findings and best practice to better serve patients through the

promotion of self-development and advancement of clinical innovation across our specialist

fields. We do this through journal submissions and publications, our annual clinical conference,

workshops and educational forums with plans to utilise the Huntercombe iEVENTS network.

The number of patients receiving NHS Services provided or sub-contracted by the Huntercombe

Group in 2013/2014 that were recruited during that period to participate in research approved

by a research ethics committee was 0.

A proportion of The Huntercombe Group’s income in 2013/2014 was conditional on achieving

quality improvement and innovation goals agreed between the Huntercombe Group and any

person or body they entered into a contract, agreement or arrangement with for the provision

of NHS services, through the Commissioning for Quality and Innovation (CQUIN) payment

framework.

During 2013/2014 the Huntercombe Group met or exceeded all its Commissioning for Quality

and Innovation targets across all relevant service groups and has plans in place to ensure that

we continue to meet all of our CQUIN targets for 2014/2015.

Further details of the agreed goals for 2014/2015 and for the following 12 month period are

available on request by email to [email protected]

Goals Agreed with Commissioners

Participation in Clinical Research

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The Huntercombe Group is required to register with the Care Quality Commission and has full

registration under the Health & Social Care Act 2008. The group is currently registered in

respect of the following regulated activities:

Assessment of medical treatment for persons detained under the Mental Health Act

1983.

Treatment of disease disorder and or injury.

Diagnostic and screening procedures.

Accommodation for persons requiring nursing or personal care.

The Huntercombe Group has no conditions on its registration.

The Care Quality Commission has taken enforcement against two services the Huntercombe

Group during 2013/2014.

A Warning Notice was received in respect of Regulation 11 (Safeguarding) in one hospital in our

Adult Mental Health & Learning Disability Services and a Notice of Proposal was received by

another. This notice of proposal was challenged by The Huntercombe Group and after working

closely with Commissioners and re-inspection the service now has only minor non-compliance

against 3 outcomes and is awaiting further re-inspection by the CQC.

In its most recent Information Governance Assessment The Huntercombe Group achieved compliance at Level 2 and was graded Green.

The Huntercombe group was also successful in securing N3 connection to the NHS.

The Huntercombe Group did not submit records during 2013/2014 to the Secondary Uses

service for inclusion in the Hospital Episode Statistics which are included in the latest published

data.

The Huntercombe Group was not subject to the Payment by Results clinical coding audit during

2013/2014 by the Audit Commission.

What others say about The Huntercombe Group

Data Quality

NHS Number and General Medical Practice Code Validity

Clinical Coding

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Part 3 How We Have Performed in 2013/2014

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Specialist Care Awards During 2013/2014 the Huntercombe Group celebrated success through the achievement of a

number of coveted national awards and accreditation.

This year Campsie House was a finalist at this year’s Laing & Buisson Independent Specialist

Care Awards. Campsie House specialises in meeting the needs of adults with complex

neurological conditions who have high, medium or low nursing care needs as a result of a

neurological condition or brain injury.

The unit was recognised for its ability to tailor programmes specifically to meet the needs of

each individual to enable them to achieve their personal goals, reduce disability and improve

their quality of life. The judges were impressed that staff had developed a programme to firmly

establish the rights and responsibilities of each individual that depends on the centre’s services.

As a result,

The rights and responsibilities programme has added another layer to the service’s drive to

continue to develop participation and involvement through ‘co-production’. In turn this has

challenged staff and relatives perceptions on how the service should be delivered and has

raised overall awareness within Campsie House of people’s rights to equal opportunity and

citizenship no matter what barriers lay ahead.

Huntington’s Society Accreditation The Huntercombe Group Linlathen’ s Neurological Care Centre in Dundee allocated 12 beds for

the care and support of people with a diagnosis of Huntington’s disease and over a number of

years has acquired a substantial knowledge and expertise managing this challenging population.

Working closely with the Scottish Huntington’s Association (SHA) an opportunity presented itself

to formally submit a self-assessment of our service to the SHA for consideration as a fully

accredited care facility and specialist provider.

The self-assessment was a rigorous process divided into 4 main sections:

Management systems, staffing and organisation; regulatory compliance,

education/training and staff.

Health and personal care including; care planning, medication management, pain

management, cognitive changes, palliative care, nutrition and hydration, communication

difficulties.

Individual lifestyle; emotional support, independence, privacy and dignity, activities,

cultural and spiritual life, choices and decision making.

Health, safety and physical environment; fire, security and emergencies, housekeeping,

maintenance, infection control, catering.

How We Have Performed in 2013/2014

Celebrating Success

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An internal team approach was used to complete and submit the complex self-assessment

documentation for submission to the SHA.

A senior representative team from the SHA visited the centre spending a full day in the unit

observing, talking with the residents and examining/auditing evidence.

Following a full SHA Board meeting, Linlathen successfully met all the expected standards and

was subsequently awarded accreditation as the first such centre in Scotland. Demands for the

service have now increased with the addition of 4 extra beds and further capacity planned to

capture additional demand in the future.

Health Idol Programmes Health Idol applies a holistic approach, encouraging patients to take control of all aspects of

their life. The programme has been successful in other hospitals as patients achieve their

weight loss goals and see their self-esteem increase.

Health Idol has officially launched its 4 week programmes at the Huntercombe Hospital

Norwich, Stafford and Maidenhead. The courses cover all aspects of nutrition, lifestyle and

wellbeing for patients as part of their rehabilitation.

Health Idol has delivered comprehensive training to hospital staff and they have now completed

NVQ level 2 training in Fitness Instruction, and exercises and workshops in Nutrition and

Wellbeing. Staff can teach patients to lose weight safely and effectively whilst maintaining their

long term health and wellbeing.

CAMHS Services are also looking to set up Jamie Oliver’s cooking skills programme so that

patients can achieve a Level 1 BTEC in healthy cooking. In addition, Health Idol will continue to

work alongside the team to enhance the current hospital activity to include power walks,

outdoor activity and one-to-one fitness programming. An affiliation with a local college will

support the initiative as it helps to set up Jamie’s Cooking skills programme.

Driving Up Quality Code The Driving Up Quality Code is a code for providers and commissioners aimed at:

Driving up quality in services for people with learning disabilities that goes beyond

minimum standards.

Creating and building a passion in the learning disability sector to provide high quality,

values-led services

Providing a clear message to the sector and the wider population about what is and

what is not acceptable practice

Promoting a culture of openness and honesty in organisations

Promoting the celebration and sharing of the good work that is already out there.

Within our Adult Mental Health and Learning Disabilities Division we are committed to the code

and our intention to sign up during the first Quarter of 2014/2015.

New Initiatives

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In signing up to the Driving Up Quality Code the Adult Mental Health and Intellectual Disability Division will make a transparent public commitment that it is achieving or working towards the good practices which are outlined within the code. We have conducted reflective self assessments both as a division and across our services to identify where practices are in relation to the five key areas as outlined in the code, what evidence is in place to demonstrate this and to put in place plans for improvement. We have prepared corporate statements on behalf of the division in supporting our pledge. We will progress this work further over the year ahead.

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In this section of the report we outline our progress against our priorities for 2013/2014 and

our performance against a number of key quality indicators.

Whilst this report indicates that progress has been made in many areas, we are not complacent

and recognise that further work will need to be undertaken in the year ahead.

Last year in addition to seeking to strengthen our Quality Systems and increasing our regulatory

compliance we set ourselves a number of priorities within the following domains:

Safety

Effectiveness

Involvement

Clinical Leadership

Achievements

To Increase Regulatory

Compliance

Our regulatory compliance has increased significantly quarter by quarter

throughout the year. On the 31st March 2013 a total of 91% of all outcomes assessed by the CQC at the last inspection across all services were

complaint.

Strengthening our

Integrated Governance

Systems

We have continued to consolidate the implementation of our Integrated

Governance Framework at all levels across the group and improved the flow

of information from Ward to Board.

We have introduced “ Governance Hot Topics” to raise the awareness of all

staff of key governance issues affecting the group, to inform them on the

actions being undertaken, to ask their views and to outline their role in the

process. After each divisional governance meeting we highlight three “hot

topics” for each division and publish these on posters in every site. Where

appropriate feedback is then sought via local governance arrangements and

via surveys conducted via survey monkey.

We have strengthened our H&S arrangements through the introduction of a

cross divisional health and safety committee and have introduced monthly

Health & safety reporting on key indicators through to the Board.

We have restructured and strengthened our Clinical Standards and

Compliance Team with the introduction of Quality Manager roles for each of

our three divisions and through the appointment of a corporate governance

and risk manager. This will allow for a much closer alignment between the

team and operations and will increase the support available.

Progress Against Our 2013/2014 Priorities

Priority One: To continue to strengthen and embed our quality monitoring

systems and improve our regulatory compliance across the Group.

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Achievements

Strengthening our

Infection Control

Arrangements

We continue to strengthen our infection control arrangements and

monitoring of infection control practices within all our patient environments.

On 1st April 2013 we launched our revised infection control policy manual,

this policy manual provides a standardised approach to Infection Prevention

and Control across all sites within THG and we have also introduced a

standardised reporting framework. All areas have an identified Infection

Prevention and Control Lead through the development and implementation

of standardised audit tool. Our current compliance with our e-learning

compliance is currently 83% across the group and we recognise that further

work is required to ensure compliance with our own statutory and

mandatory standards and to ensure that sites have their own infection

prevention and control lead.

Implementation of DATIX

Risk Management System

We have introduced the DATIX Risk Management System across all services

to enable us to improve the management of all incidents and standardise

the reporting of incidents, complaints and compliments. Although this is

now in use across all services, some initial implantation difficulties have

been identified. We are currently working to address these and to ensure

that the system is used to its full potential.

Achievements

Promoting Evidence Based Practice

We have continued to promote evidence based practice, research and

innovation across the Huntercombe Group though arrange of initiatives

including an Annual Clinical Conference, Workshops and Educational Forums

Improving our Care

Documentation

In our Adult Mental Health and Learning Disability Services and our

Acquired Brain injury and neurological care services we have reviewed and

strengthened our care documentation and this is now in the process of

being rolled out across all services. In sites were implementation has

already taken place we are receiving favourable feedback from our

regulators and commissioners.

Priority Two: To continue to develop the way we measure and monitor

patient safety and take appropriate actions to ensure that the people who

use our services are not harmed.

Priority Three: Clinical Effectiveness is about doing the right thing at the

right time for the person using our services to achieve the right outcome. To

improve clinical effectiveness we will:

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Achievements

Objectives to Improve

Patient Involvement

At the beginning of the year each of our hospitals / units has set objectives

to improve the involvement of people who use their services. These have

been monitored via local and divisional governance meetings Initiatives

introduced include patient involvement in staff interviews, implementation

of rights and responsibilities programmes, patients presenting at relatives

open days, patients nominating a staff “Star of the week” for a staff

member who they feel has “made a difference” to them during the

preceding week, the development of local newsletters for patients and

improved mechanisms to feedback to patients actions taken in response to

their feedback and participation in Health Idol programmes.

The Development of

PEARL for Acquired Brain

Injury and Neurological

Services

We have also started to explore the potential to develop a PEARL

Accreditation Programme in our Acquired Brain Injury and Neurological

Services, based on a similar model to the award winning PEARL Dementia

programmes developed by Four Seasons Healthcare. Unfortunately due to

current demands on the PEARL team within this work has been slower than

originally expected but we will continue to explore this area of work over

the forthcoming year.

Responding to Feedback

and Improving Patient

Experience.

A routine programme of satisfaction surveys have been conducted across all

services to illicit feedback from those who use our services, the families and

carers and those who refer to us. An overview of the findings are included

later in this report.

Achievements

Development of a

communication and

information portal for our Registered Nurses

We are currently in the process of developing of a dedicated information

portal for our nurses within the Huntercombe Group. During the last six

months we have undertaken some brief research into how we could better

support nurses through an IT based support structure which provides;

better and faster access to information for nurses in enabling them to fulfil

their role, to provide mentorship and support for fellow nurses regardless of

geographical boundaries, to enable and empower our nursing teams to

share ideas and best practice in a secure and safe forum and to access the

latest nursing news and opportunities for personal development. It is

anticipated that this system will be available in August 2014.

Management Induction

Programmes

We have introduced a new Corporate Induction Programme for all new

managers joining the company; all existing Managers have also attended.

Priority Four: To provide welcoming, responsive services that listen and

respond to those who use them and their families and carers and to

demonstrate respect, dignity, choice and involvement.

Priority Five: To strengthen clinical leadership and further develop our

professional frameworks to ensure best practice.

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The Commissioning for Quality Improvement and Innovation (CQUIN) Payment

framework enables commissioners to reward excellence by linking a proportion of the

providers’ income to the achievement of local quality improvement goals.

This year commissioners set CQUIN targets for the following services:

Child and Adolescent Mental Health Services

Secure Services

Locked Rehabilitation Services

Brain Injury Recovery Units

The tables below indicate our performance against the targets set for each service.

CAMHS 2013 /14 CQUIN Performance

Q1

Q2

Q3

Q4

Clinical Dashboard

100% achieved

100% achieved

100% achieved

100% achieved

Optimising Pathways

100% achieved

100% achieved

100% achieved

100% achieved

Physical Healthcare

100% achieved

100% achieved

99% achieved

100% achieved

Care Programme Approach

100% achieved

100% achieved

100% achieved

100% achieved

Low Secure 2013 /14 CQUIN Performance

Q1

Q2

Q3

Q4

Clinical Dashboard

100% achieved

100% achieved

100% achieved

100% achieved

Optimising Pathways

100% achieved

100% achieved

100% achieved

100% achieved

Physical Healthcare

100% achieved

100% achieved

100% achieved

100% achieved

Care Programme Approach

100% achieved

100% achieved

100% achieved

100% achieved

Provision of literacy, numeracy,

IT and vocational skills training

100% achieved

100% achieved

100% achieved

100% achieved

Increase in use of communications technology

100% achieved

100% achieved

100% achieved

100% achieved

Commissioning for Quality and Innovation (CQUIN)

Performance

Page 26: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Locked Rehabilitation Services 2013 /14 CQUIN Performance

Q1

Q2

Q3

Q4

Best practice implementation

100% achieved

100% achieved

100% achieved

100% achieved

Further implementation of

Recovery Planning Tools

Integration with national secure

pathway

100% achieved

100% achieved

100% achieved

100% achieved

Excellence in Locked

Rehabilitation

100% achieved

100% achieved

100% achieved

100% achieved

Transparency for carers,

patients and public on outcomes

and involvement in

improvement

100% achieved

100% achieved

100% achieved

100% achieved

Blackheath BIRU 2013/14 CQUIN Performance

Q1

Q2

Q3

Q4

Friends and family test

100% achieved

100% achieved

100% achieved

100% achieved

Dementia

100% achieved

84% achieved

84% achieved

100% achieved

NHS Safety Thermometer

100% achieved

0% achieved

0% achieved

100% achieved

VTE Risk Assessment

100% achieved

100% achieved

100% achieved

100% achieved

10% improvement in patient

outcomes

100% achieved

100% achieved

100% achieved

100% achieved

Page 27: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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The Huntercombe Group services are regulated by the Care Quality Commission in England,

Health Improvement Scotland, the Care Inspectorate (Scotland) and Ofsted.

The quality of care and compliance with regulation is monitored within the Huntercombe Group

through the Quality Performance Management System.

Reports are reviewed at all local and divisional governance meetings and at every THG Board

Meeting.

At the 31st March 2014, based on the last inspection for each service – The Huntercombe Group

was

• 69 % fully compliant in all inspected outcomes

• 17 % of one or more minor concerns

• 13 % of one or more moderate concern

• 1 % of one or more major concerns.

The graph below outlines THG Performance against all outcomes assessed at the time of the

last inspection on a monthly basis from 1st April 2013 to 31st March 2013

Green Compliant – means that people who use services are experiencing the outcomes relating to the essential standard.

Yellow Minor concern – means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard

Amber Moderate concern – means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this.

Red Major concern – means that people who use services are not experiencing the outcomes relating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support.

0

50

100

150

200

250

300

Total Outcomes Assessed

Compliant

Minor Concern

Moderate Concern

Major Concern

Routine Performance Monitoring

Regulatory Compliance

Page 28: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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High quality care can only be delivered in an environment where people are listened to and

were people’s views, concerns and complaints are welcomed and embraced as a way to learn

and improve.

Within the Huntercombe Group we aim to ensure that all people who use our services have

access to guidance on the procedures for raising a concern or making a complaint.

All sites have access to complaints posters and leaflets and residents and their families are

encouraged to report comments, compliments and complaints on leaflets at each site. Since the

beginning of 2014 all complaints have been recorded on Datix, an online incident/risk

management system. This data is analysed by the Compliance and Clinical Standards Team and

distributed via governance processes.

A ‘benchmarking across services’ report and service individual report is completed to breakdown

all complaints across The Huntercombe Group each Quarter. These reports are shared within

services and provide opportunities for lesson learning and sharing of best practice and lead to

improvements in the complaints process for people who use our services. These are fed back to

patients in the forms of posters and lessons learnt and also fed through the local, regional and

divisional integrated governance processes.

During the last year a vast majority of our complaints were dealt with informally at the point at

which they were received to the satisfaction of the complainant. Where complaints are not able

to be resolved immediately to the satisfaction of the person making the complaint, they are

passed to the Hospital or Home Manager and are then fully investigated in accordance with our

formal complaints procedure. All complaints in writing or at the request of the complainant are

treated as a formal complaint.

The graphs below give details of the number of complaints received by The Huntercombe

Group in 2013 / 2014 and an overview of the nature of the complaint. These results show a

significant increase from reporting in the previous year. This is thought to be in part due to

improved reporting of complaints by staff and though promoting greater awareness of the

complaints procedure to our patients. The findings also demonstrate that a relatively small

number of all complaints are upheld.

During 2014/2015 we will be continuing to implement the feedback module on our Datix

System this will allow us to continue to focus on this key quality indicator and to have greater

visibility of the robustness of the investigation process.

Complaints

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Figure 1: Number of Formal Complaints and Overview of the Nature Received by

Division during 2013/2014

Adult Mental Health & Learning Disability Services

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Complaints Received 121 69 73 73

Complaints Upheld 28 18 18 18

Acquired Brain Injury & Neurological Services

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Complaints Received 14 10 15 3

Complaints Upheld 4 2 6 1

0

5

10

15

20

25

30

35

40

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Involvement and Information

Personalised Care and Treatment

Safeguarding and Safety

Quality of Staffing

Other

0

1

2

3

4

5

6

7

8

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Involvement and Information

Personalised Care and Treatment

Safeguarding and Safety

Quality of Staffing

Other

Page 30: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Child Adolescent and Mental Health Services

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Complaints Received 42 21 24 19

Complaints Upheld 4 3 3 1

Learning lessons from all incidents including Serious Incidents Requiring Investigation

(previously known as SUI’s) remains a priority for The Huntercombe Group.

We have made progress in maximising opportunities to ensure learning from incidents and

Serious Incidents and to ensure that this information is shared across all services.

In our governance meetings we have had presentation from root cause analysis investigations,

we have also shared learning through the use of our governance ‘Hot Topics’ and through

feedback to our Policy Review Group.

Figure 2: Number of Serious Incidents Requiring Investigation in 2012/2013 by

Division

0

10

20

30

40

50

60

Quarter 1 Quarter 2 Quarter 3 Quarter 4

ADMH&LD

BIND

CAMHS

0

5

10

15

20

25

Quarter 1 Quarter 2 Quarter 3 Quarter 4

Involvement and Information

Personalised Care and Treatment

Safeguarding and Safety

Quality of Staffing

Other

Incidents and Reporting

Page 31: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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The Huntercombe Group has processes to report, investigate, monitor and learn from

complaints and Incidents. One of the key aims of this process is to reduce the risk of repeat

both where the original incident or complaint occurred and elsewhere across the group. The

timely and appropriate dissemination of learning following a complaint or incident is core to

achieving this and to ensure that these lessons are embedded in practice.

Over the past 12 months in response to complaints and incidents within the Huntercombe

Group a sample of these are as follows. We have:

Reviewed a number of policies and procedures to make them more explicit this includes

our policies for seclusion, observation and cardiopulmonary resuscitation.

We have increased the provision of information for patients in the form of leaflets and

posters having first consulted them on what they see as the information they would like

to see and would find most helpful.

We have made a number of environment improvements in our hospitals and care

environment.

Staff in a number of units have received further training in medicines management.

Introduced a multi-professional peer review process for any patient who is being care

for in an individual care facility.

Introduced a bespoke Mental Health Act Administration system to provide more robust

monitoring of mental health act administration to reduce the risk of MHA errors and

centralised co-ordination, recruitment and support of our Mental Health Act Hospital

Managers.

Lessons Learnt from Complaints and Incidents

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It is clear that the patient experience is an essential part of quality healthcare provision. The

experience of care is important to patients alongside safety and effectiveness. Patients want to

feel informed, involved, listened to and supported so that they can participate and make

meaningful decisions and choices about their care and treatment.

Within the Huntercombe Group we have a number of different mechanisms for feedback from

those who use our services and their families. Patient Forums / Community Meetings are held

in all of our services and we have annual survey programmes in place in our Adult Mental

Health and Brain Injury and Neurological Services. Within our CAMHS services patient’s

questionnaires are completed shortly after admission and on discharge from the service.

This year we included within our Adult Mental Health and Learning Disability survey the friends

and family test question.

54% 23% 10% 9% 1% 4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

How likely are you to recommend this service to family or friends if they needed similar care or treatment ?

Patient Survey 2013 - Adult Mental Health & Learning Disability Services

Extremely likely Likely Neither likely or unlikely Unlikely Extremely unlikely Don't know

Patient Experience and Listening to Others

Friends and Family Test Results

Page 33: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Adult Mental Health & Learning Disability Services

In early 2014 we conducted our annual survey of patients and residents within our Adult Mental

Health and Learning Disability Services. In total 249 patients and residents out of a possible

417 agreed to participate in the survey. Giving a response rate of 60%.

The survey was based on the CUES questionnaire (Carers and Users Expectations of Services),

the NHS Service User Survey and the National Learning Disabilities Survey. The questions were

adapted where requires for adults with a learning disability often residing in secure

environments. The survey was facilitated by advocates from POWHER our contracted

independent advocacy. Where needed, advocates provided communication support to individual

patients to assist them in indicating their preferred responses to individual questions.

The graphs on the following page outlines the percentage of people who stated they were

happy or felt satisfaction in each of the areas covered within the survey. These scores give an

overall percentage for a number of individual questions in each section of the questionnaire.

The results are now being considered by the individual services and actions plans put in place

to address the findings.

54% 23% 10% 9% 1% 4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

How likely are you to recommend this service to family or friends if they needed similar care or treatment ?

Patient Survey 2013 - Specialist Brain Injury Services

Extremely likely Likely Neither likely or unlikely Unlikely Extremely unlikely Don't know

Patient Satisfaction

Page 34: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Figure 4: Patient Survey

*Support for Meaningful Life has only been part of the patient survey since 2014 therefore no

comparisons are available from previous years.

These results indicate an improvement in satisfaction across all areas with exception of

satisfaction with support provided from our staff and we will be reviewing the survey comments

and looking at this further to identify the reasons why and take steps to make improvements.

There was also a very small reduction in satisfaction with food.

Other highlights within the survey findings include:

87% consider the place where they live to be clean.

89% of patients / residents stated they knew who to contact if they wished to raise a

concern about their safety or to make a complaint.

83% of patients / residents felt that staff treated them with dignity and respect

90% of patients / residents felt that they were given prescribed medications when they

needed them (including pain relief).

We will continue to take actions to improve our patients and residents satisfaction in all areas

throughout the year ahead.

0%

20%

40%

60%

80%

100%

120%

2012

2013

2014

Page 35: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Child and Adolescent Mental Health Services

Within our CAHMS Services regular surveys of both Patient and Parent Satisfaction have been

undertaken on an on-going basis throughout the year both during treatment and upon

discharge.

Recent findings from the CAMHS satisfaction survey undertaken at Huntercombe Hospital

Maidenhead and Huntercombe Hospital Norwich identified the following:

Overall, 71% of patients across units felt that staff treated them with respect and

dignity (Maidenhead).

81% of patients reported that they have one consultant and one doctor in charge of

their care (Maidenhead).

65% of patients reported that they have an individual therapist (Maidenhead).

100% of patients who responded were happy with the input they received from

therapists (Norwich).

67% of patients who responded to the survey were very happy with their group therapy

(Norwich).

67% of patients said they were very happy with the help they received from the service

with regards to their education (keeping up with school work, taking exams) (Norwich).

Some patients at Norwich who responded to the survey were unhappy about how information

was given to them about the nature of their problems and what to expect in the future and a

number of patients at Maidenhead felt that the physical environment in which there were being

cared for could be improved. As a group we were aware of these issues and are committed to

addressing them.

Acquired Brain Injury & Neurological Services

During July 2013, surveys were distributed to all clients at every Huntercombe Group specialist

brain injury centre to obtain feedback about the service provided by our teams at each centre.

In previous years we combined the survey for clients and relatives, but this year, for the first

time, we issued separate surveys to each group. In light of these changes it makes

comparisons with the previous year’s results more difficult.

In total 392 questionnaires were given to clients for their completion. A total of 170

questionnaires were returned giving a response rate of 43%.

Outlined on the following page is a summary of the results.

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Service Provided by Acquired Brain Injury & Neurological Services in 2013 Survey

* In addition a further 48% stated that they could not recall if they had been offered on admission.

Brain Injury & Neurodisability Services

In March 2013 a new survey targeting our carers was developed by The Huntercombe Group,

this was sent by post to the next of kin/nearest relative for all patients within our Acquired

Brain Injury and Neurological Services survey.

In total 359 carers were invited to complete the survey, 79 surveys were returned giving a

response rate of 22%

Carers were asked how likely they would be to recommend The Huntercombe Group to

someone in a similar situation to their relative, and a selection of the key results was as follows:

0%10%20%30%40%50%60%70%80%90%

100%

43% 39% 4%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

How likely are you to recommend this centre to family or friends if they

needed similar care or treatment to your relative?

Extremely likely Likely Neither likely or unlikely

Carer Survey

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42% 48%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

How would you rate the quality of care your relative/friend has received so

far?

Excellent Good

91% 1%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Do you feel your relative is safe and well cared for?

Yes No

59% 38%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Do you feel your relative/ friend is treated with dignity and respect?

Totally Most of the time

Page 38: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

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Welcome and Support

Aspects of the Service That Impressed our Carers

The following are quotes taken from carers survey:

“Staff always find time to make our daughter smile and laugh.” – Elswick Hall

“The relationship between mum and carers is excellent, they interact with her really well and

make her feel part of a community.” – Crewe

“They detailed report received this year was by far the best we have ever had.” –

Hothfield

“The staff are always polite and helpful and the grounds always look nice.” – Murdostoun

“Care is brilliant and staff are very caring.” – Nottingham

“Staff are polite and always happy to answer any questions.” – Peter Gidney

“The centre manager is excellent.” – Frenchay

“I’m impressed with the one to one care provided during the early days of admission.” –

Frenchay

“The staff’s knowledge regarding Brain Injury and their extremely caring nature.” –

Nottingham

“The staff are helpful and nothing is too much trouble.” – Crewe

“Caring friendly staff, willingness to listen and act upon any changes we feel

necessary after discussion.” – Abbeymoor

“The existing centre manager and his approach to patient care.” – Campsie

“Support for family members, also staff retention is high this is of great benefit to

your patients.” – Stocksbridge.

94% 6%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Are you made to feel welcome by centre staff when you visit?

Totally Sometimes

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Child and Adolescent Mental Health Services

In June 2013 a relatives and carers survey was conducted at Huntercombe Hospital Norwich.

The findings of the survey were generally positive although a couple of areas for improvement

were noted and have been addressed.

Parents expressed difficulties around being able to get through to their relatives via the

main switchboard. In response to this, the switchboard answering message was

reviewed, direct dial numbers were facilitated on the wards and cordless phones placed

on the wards.

CPA’s – Although parents said they were able to input into their relatives CPA, they felt

the reports were distributed too late, leaving them insufficient time to read through the

paperwork prior to the meeting. New processes have been put in place internally to

address this.

Outlined below are some of the positive comments received from the parents of patients at

Norwich.

Reception staff are all excellent, polite and make you feel welcome.

As far as I know my relative receives fabulous care, always happy when she rings or I ring her. Only thing she says, “I’m unhappy as I’m too far away from my family which we all agree.

Very friendly and very professional, make it easy to bring up/talk about more difficult issues.

‘Staff I have had the chance to talk to have been great, can’t fault’ ‘Overall we are very pleased with the care our relative has received. Problems have

been addressed and acted upon.’

Skype is a great bonus for us as a family – thank you for providing the service’ ‘I would like to thank all the staff for the fantastic care they give X’

Adult Mental Health Services

Our Relatives and Carers survey for Adult Mental Health and Learning Disability Services is

currently underway and a report will be produced soon.

Each year The Huntercombe Group conducts surveys of its referrers. The aims of the surveys is

to gauge customer perception of The Huntercombe Group as a provider of specialised services,

to determine customer satisfaction across the Group, to better understand the key drivers for

referral and customers’ future needs and to identify strengths and weaknesses.

During 2013/20134 surveys have been undertaken in both our Child and Adolescent Mental

Health Services and our Brain Injury and Neurological Services divisions.

Referrers were asked to rate various aspects of our service. The following graphs show how

each service was scored out of ten against each criteria for both divisions.

Feedback from Referrers

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39

Figure 5: Aspects of our Service for Acquired Brain Injury and Neurological Services

Figure 5: Aspects of our Service for Child Adolescent and Mental Health Services

0 1 2 3 4 5 6 7 8 9 10

Overall quality of service your patients/clients have…

Overall clinical effectiveness of our MDT?

Clinical effectiveness of our consultants?

Clinical effectiveness of our therapists?

Clinical effectiveness of our nursing care staff?

Effectiveness of our administration and support staff?

Our ability to engage our patients/clients in all aspects…

Appearance of the centre and its facilities?

Range of activities available?

Quality and effectiveness of our communication?

Structure of our case review meetings?

How would you rate the following aspects of our service … (a score of 10 = "excellent")

2013

2012

0.00 1.00 2.00 3.00 4.00 5.00 6.00 7.00 8.00 9.00 10.00

Overall quality of service your patients have…

Overall clinical effectiveness of our MDT?

Clinical effectiveness of our consultants?

Clinical effectiveness of our therapists?

Clinical effectiveness of our nursing care staff?

Effectiveness of our administration and support…

Education Provision

Involvement in CPA process

Appearance of the hospital and its facilities?

Range of activities available?

Quality and effectiveness of our communication?

Structure of our case review meetings?

How would you rate the following aspects of our service … (a score of 10 = "excellent")

2013 2012

Page 41: The Huntercombe Group Quality Account 2013/2014 · of Clinical Standards and Compliance, The Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

40

The following comments were made by referrers:

Referrers were also asked to highlight aspects of the service they would like to see improved.

These are now being considered by The Huntercombe Group.

We very much welcome your feedback and suggestions regarding this quality account. If you

would like to comment or if you require any further information please email Paula Smyth, Head

of Clinical Standards and Compliance at [email protected]

Alternatively please write to Paula Smyth, Head of Clinical Standards and Compliance, The

Huntercombe Group, Tulip House, Craven Court, Willie Snaith Road, Newmarket, Suffolk CB8

7FA

The interdisciplinary model of

care and the communication

with professionals as well as

the patient and their family.

Regular written updates

are very helpful.

The effort and specialist skills

that is very evident in the team

and how they use those skills

to ensure the best outcomes

for the patient. The feedback on our patient

under your care was very

good and the staff were very

friendly.

Over a number of years an

effective partnership approach

including residents and their

families has been developed.

Easy access to any

member of the MDT for

up-to-date information.

Cotswold Spa have provided an

excellent service and I would

have ticked excellent in all of

the boxes about if my survey

just covered this unit.

Communication and work of

social work and education

staff. Very important bearing

in mind the geographical

location of the Edinburgh

service from the home areas.