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Quality Account 2009/10Quality performance, initiatives and priorities

Living through life’s challenges

Sue Ryder – Quality Account 2009/102

ContentsWho we are and what we do 2Statement by Paul Woodward, Sue Ryder Chief Executive 3Part 1: Our priorities for quality 4Part 2: Our priorities for improvement 5– Our four priorities 5– Priority 1: Service user experience 6– Priority 2: Effectiveness, safety and service user experience 8– Priority 3: Service user safety – reporting 10– Priority 4: Service user safety – falls 11Part 3: Our indicators 12– 1. Service user experience 12– 2. Safety 12– 3. Effectiveness 13Part 4: Annexes 14– Annex 1: Legal requirement 14– Annex 2: Statement from commissioning 15

Primary Care Trust (PCT), OCS and LiN

Who we are and what we do

Sue Ryder provides compassionate health and socialcare for people living with life-threatening and long-term conditions. We are a national charity that deliversservices to local communities through day care, respitecare, homecare, hospices and hospice at home, long-term residential care, sheltered housing andcommunity integration.

Sue Ryder Quality Account lays out our continuedpriority to quality.

Sue Ryder – Quality Account 2009/10 3

Quality issues – a continued priorityStatement by Sue Ryder Chief Executive

Welcome to our first annual Quality Account, a summary of ourperformance against selected quality measures for 2009/10and our initiatives and priorities for 2010/11.

In addition to embedding new quality initiatives throughout theorganisation we also seek to embed a culture of Clinical QualityImprovement within each of our services. Each service has theirown Quality Improvement Plan that reflects both local andnational priorities, identifying quality improvement initiativesthat enhance the safety, experience and outcomes for all ourservice users.

We will continue to work closely with our staff to makeaddressing quality issues a continued priority.

I am very pleased to have the opportunity to publish this QualityAccount and to confirm my personal commitment to it.

Paul Woodward Chief Executive, Sue Ryder


Part 1Our priorities for quality Position and status on quality

Sue Ryder is a national health and social care charity which providesspecialist palliative care, neurological and homecare to people livingwith conditions such as cancer, dementia, Parkinson’s disease,Huntington’s disease and other complex conditions. The past year2009/10 has been a positive year for the Sue Ryder Health and SocialCare directorate in which we have made significant improvements inthe quality of our services and key quality measures. The primarypurpose of this quality account is to inform our service users, theirfamilies, our staff, supporters, the public and our Council of Trusteesabout the progress towards our annual key targets.

To the best of my knowledge the information held within this qualityaccount is accurate

Paul Woodward Chief Executive, Sue Ryder


Part 2 Our priorities for improvement

Priority 1: To achieve an overall service user experience rating of good or excellent on the service user survey

Priority 3: To introduce an electronic incident reporting system

Priority 2: To improve our quality rating at inspections

Priority 4: To reduce the harm from falls

These priorities have been approved by the Executive Management Team and our Board of Trustees. In selecting thepriorities for 2010/11 we have consulted our Service User Advisory Group to ensure we focus on issues which arehigh priority for the people who use our services.

Throughout 2009/10 we also identified and developed ourpriorities for the year 2010/11. In selecting our priorities wehave been mindful of national and local policy as well as thoseissues which are of concern to our service users, our workforce,our partners and our Trustees. In setting our priorities we haveattempted to set stretching and challenging targets which willmake a real difference to the people who use our services.

Our quality strategy focuses on three key areas:

• Effectiveness

• Service user safety

• Service user experience

Our four prioritiesFollowing our assessment the top priorities for 2009/10 will be:


Priority 1 Service user experience

To achieve an overall service user experience rating as'good' or 'excellent' on the service user survey.

We aim to provide the best possible experience for our serviceusers by providing high quality and responsive services thatclosely meet people’s needs and preferences. We strive toprovide services which are caring, supportive and in whichpeople can have confidence. Feedback from our service usersis crucial in order that we focus on what matters to people andwe seek feedback through a number of different routes.However, to measure progress we will use the overallexperience rating in our national service user survey. This is acomposite measure and is therefore a good general measureof service user experience.

A key part of current NHS and social care reforms are thatpeople are given more choice and a much stronger voice.These requirements are reflected in our strategy for involvingpeople in our care that aims to deliver:

• an organisational culture that values the views of serviceusers and remains consistently receptive to their views

• high quality services tailored to what service users say thatthey need

• the development of services through proactiveinvolvement of service users who represent the diverserange of people in our care

• a practical structure that encourages and enables theinvolvement of service users at all levels of the organisation

Measuring progress We will measure our success by how well service users rate uson key aspects of our care:

• Percentage of service users who rate the care as good orexcellent – standard measure of service user experience

• Percentage of service users who overall feel treated withdignity and respect – key measure of service userexperience

• Percentage of service users who would recommend ourservice to friends or relatives – more demanding measurethan just satisfaction

• Total number of formal complaints

The table below demonstrates how our service users ratedour services in the service user survey, this data has beencollected over 2009/10.

Indicator

Service users who rated overall care as good or excellentService users who felt that overall they were treated withrespect and dignityService users who would recommend the service tofamily and friendsNumber of formal complaints % of formal complaints acknowledged within target of 2 days% of formal complaints responded to in writing withintarget of 20 days

Neurological Care

86%87%

91%

1080%

80%

Palliative Care

99%100%

100%

1080%

70%

Homecare

86%97%

Data available 2010/11

Data available 2010/11Data available 2010/11


Service user experience


New initiatives in 2009/10

• We are providing new information about our services thathelps service users make informed choices about theirfuture care. The charity is accredited under the Departmentof Health Information Standard (IS). The first year has seenthe development of core information about Homecare,Specialist Palliative Care and Neurological Care Centres.

• We have established a new Service User Advisory Group,representing the diverse range of our service usersthroughout England and Scotland, to advise the Board ofTrustees and ensure focus on service users.

• We are improving how we use feedback to help shape ourservices. In 2009 a new service user survey programmewas introduced. The views gathered from this and othersources of service user feedback are being regularly collatedso we know what is most important to service users, wherewe are doing well, and areas for improvement.

• We have a Service User Involvement Policy in place and aStrategy for people in our care to be involved in all aspectsof our service delivery, evaluation and ongoingimprovements.

• We have reviewed our Complaints procedure and haveupdated our policy. We are starting to deliver training to allour staff on this new procedure.

New initiatives for 2010-11These include, improving how we manage complaints, byrecording and learning from issues and trends raised throughcomplaints.

Also, working with the Service User Advisory Group to promotethe importance of every person being treated as an individual,and what this means for people using our service.

Executive Management Team sponsorSteve Jenkin, Director of Health and Social Care

Implementation LeadPam McClinton, Head of Clinical Quality and Risk

Programme ManagerSarah Mudd, Service User Involvement Lead


Priority 2Effectiveness, safety and service user experience

To improve our quality ratings at inspections.

Sue Ryder services are inspected by two regulatory bodies:

• Care Quality Commission (England) • Care Commission (Scotland)

The different services are currently inspected against a set ofNational Minimum Standards (England) and Care Standards(Scotland) and these standards vary dependent on the serviceand its registration. From October 2010 the Health and SocialCare Services in England will be inspected against the new

Guidance on Compliance. During 2009 Sue Ryder adapted its quality monitoring processes in order to be ready for thischange.

We aim to improve our inspection ratings to be rated good orabove. The following table demonstrates an improvement ormaintenance of inspection rating. In the majority of cases itoffers a summary of CQC quality ratings for our services after2 years. Hospices have not been included within this table asthey are not graded.

Date of inspection

August 2009November 2009March 2010June 2009August 2007

January 2010

Feburary 2010

December 2009March 2010

January 2010January 2010

July 2009

April 2009

February 2009

August 2008

Feburary 2010

Service

Holme HallCuerdenStagenhoeThe ChantryHickleton

Dee View

Birchley

Wigan (St Helen’s)Lincoln

MacclesfieldWolverhampton

Leek (Staffordshire)

Sale (Trafford)

Doncaster(Mexborough)Bixley Rd Ipswich(Independent Living)

Arbroath

Current rating (at March 2010)

Good – 2 starsGood – 2 starsExcellent – 3 starsExcellent – 3 starsGood – 2 stars

Excellent/Very Good

Excellent – 3 stars(annual servicereview)

Good – 2 starsExcellent – 3 stars(annual servicereview)Good – 2 starsGood – 2 stars(annual servicereview)Adequate – 1 star

Adequate – 1 star

Good – 2 stars

Good – 2 stars

Primarily Good andAdequate

Previous rating

Good – 2 stars (Aug 07)Adequate – 1 star (Sept 08)Excellent – 3 stars (April 07)Excellent – 3 stars (June 07)Good – 2 stars (Aug 06)

Excellent/Very Good (June 09)

Excellent (Dec 07)

Good (Dec 07)Excellent (Dec 08)

Adequate (Dec 08)Good (Nov 08)

Good (July 06)

Adequate (April 08)

Good – 2 stars (March 07)

August 08 was the firstinspection

Primarily adequate (March 09)

Direction of travel since last inspection

Standards maintainedImprovementStandards maintainedStandards maintainedStandards maintained

Standards maintained

Standards maintained

Standards maintainedStandards maintained

ImprovementStandards maintained

Rating has gone down.Inspected 29/3/2010 –awaiting reportStandards maintained.Inspected on 11/4/10 –awaiting reportStandards maintained

NA

Improvement

Adult care – England

Adult care – Scotland

Care of older people – England

Domiciliary Care – England

Domiciliary Care – Scotland


The six Sue Ryder Hospices are inspected by the Care QualityCommission and do not receive an overall rating. Four ofthese Hospices have received an inspection during the2009/2010 year. The two other Hospices received aninspection towards the end of the 2008/2009 year. All fourHospices inspected during this year met the majority ofstandards based on either their self assessment or thestandards that were assessed on the day. Where standardswere not met or were partially met, the service then puttogether an action plan to address any requirements andrecommendations. These were progressed throughmonitoring at quarterly quality visits by a member of theClinical Quality Team.

Examples of two areas identified for improvements haverelated to the update of Human Resource Policies andProcedures and the implementation of a Risk Register. SueRyder has learnt from this, and a new Written Controls Processhas been introduced. A plan to introduce risk registers atcorporate level and at service level was already identifiedwithin the Risk Strategy and this is now being implementedacross all services influenced by a corporate Health and SocialCare Risk Register.

New initiatives for 2010

These have included:

• Further review of the quality visit process for Hospices andNeurological Care Centres based on regulatoryrequirements

• Introduction of a revised quality visit process withinDomiciliary Care Services

• Continued quarterly reporting of inspection findings to theHealthcare Governance Committee and IntegratedGovernance Committee, with actions taken in response toinspection and organisational learning

• Increased operational support to Care Managers inHomecare to support quality improvement initiatives




To introduce an electronic incident reporting system

The way in which an organisation manages risk is a keyindicator of its competence. Managing risk, the identificationand effective treatment of risk, and learning from adverseevents protects those who receive care, staff and assets,improves performance and reputation, and helps to reducefinancial loss. Sue Ryder set out its proposal to introduce amore reliable system of monitoring incidents in its RiskManagement Strategy for 2008-2011.

The purpose of this strategy was to further develop anintegrated approach to risk management across Healthcare.The strategic objectives were organised under the headings inthe NPSA Seven Steps to Patient Safety (2004) and theintroduction of a web based electronic incident reporting toolwas a key objective within the ‘promoting reporting’ step.

The Charity agreed to promote reporting of incidents usingnew technology with the aim of providing managementinformation at all levels. It purchased an electronic riskmanagement tool (Datix) that is compatible with the currentSue Ryder computer system and that meets therequirements of health and safety reporting and datacollection, service user safety reporting and the monitoring ofcomplaints.

During 2009 a designated project group (includingrepresentatives from the Health and Safety Team, ClinicalQuality Team and IS&T Services):

1. Set out a detailed project plan for implementation and useof the tool across all Health and Social Care Services byMarch 2010

2. Configured the tool to meet the requirements of theCharity (Datix has primarily been used within the NHS)

3. Piloted the tool within three sites representing all Healthand Social Care Services

4. Reviewed the tool based on feedback from the pilot5. Designed training materials to support use of the tool6. Revised the Incident and Near Miss Policy in line with

procedural change

Between January 2010 and April 2010 the project group:

1. Arranged and delivered training to front line staff andmanagers

2. Arranged ‘go live’ dates for each service3. Developed a reporting process to the Healthcare

Governance Committee


1. To further refine the tool based on feedback from servicesand learning from the process of producing reports

2. To use the latest version of Datix which has greaterfunctionality but does not change the process of reportingfor front line staff

3. Build a portfolio of reports to inform the Head ofOperations and Head of Clinical Governance and Quality

4. Inform further development of the Health and Social CareRisk Register

5. Use of the Complaints Module within Datix with the aim ofimproving the monitoring and learning from complaints



Programme Manager Helen Press, Quality and Risk Manager

Priority 3 Service user safety – reporting


To reduce the harm from falls

Falls are known to be the most reported safety incidentreported nationally, many of which result in harm to theperson who is receiving care. There will always be a risk of fallswithin health and social care services given the nature of thepeople we care for. However, there is much that can be doneto reduce the risk of falls and to minimise harm, whilst at thesame time enabling service users to be independent and asmobile as possible.

During 2009 the Clinical Quality Team in conjunction with theHealth and Safety Team launched a major initiative to reducethe risk of falls with the aim of reducing harm from falls. Thereason for this was based on the fact that incident figuresindicated that the risk of falls was and is a key area of riskwithin the Charity. Whilst many falls do no result in harm tothe person receiving care, in some cases injury occurs withthe potential for serious injury resulting in distress to theperson receiving care and possible admission to hospital.

The prime aim of the project was to manage this risk from fallsas far as possible without impeding a service user’s right toindependence and choice. A small project group was formedand had representation from Health and Social Care Servicesin addition to a member of the Clinical Quality Team andHealth and Safety Team.

Achieved during 2009:

1. Development of a Falls Risk Management Policy andProcedure (incorporating strategies to reduce the risk offalls)

2. Development of a ‘falls toolkit’ incorporating:• a validated falls risk assessment • falls risk assessment guidelines• decision making tool (with regard to the use of bed rails)• prompt for care planning• guidance for detailed falls incident reporting• environmental assessment tool

3. Revision of the bed rails risk assessment tool andguidelines

4. Provision of a training pack to support implementation ofthe policy


1. Completion of a Falls Prevention Leaflet (for people inreceipt of care and their families)

2. In conjunction with the introduction of electronic incidentreporting, closer monitoring of the number of falls and thefactors associated with falls

3. Falls risk management training incorporated intoinduction and annual priority training

4. Audit of compliance with policy across services



Programme Manager Helen Press, Quality and Risk Manager

Priority 4 Service user safety – falls


Part 3 Our indicators

There are two key risk areas that have been identified within SueRyder services and these are medicines management and falls.

In response to the incidents relating to falls Sue Ryder hasintroduced a new Falls Risk Management Policy and toolkit(refer to Priority 4). As a result of this new policy and theaccompanying training a falls risk assessment is completed atadmission and is repeated if a service user falls so that new riskmanagement measures can be considered and incorporatedinto the care plan.

Following a medicines incident a ‘drug risk matrix’ is used topromote a fair approach to the management of staff who areinvolved in an incident. Retraining and competencyassessment is often used in response and the MedicinesManagement Policy has been reviewed at least annually basedon the learning from incidents or to action national safety alertsthat relate to medicines management.

1. Four Hospices were inspected during 2009/2010. The percentage in the table is based on the results of inspection for three Hospices as the final report isawaited for a Hospice Inspection that took place December 2009. The percentage calculation is based on an assumption that standards that were not inspectedwere found to have been met within the annual self assessment.

2. The environment score is a composite indicator which measures compliance with a number of safety standards within the care centres and hospices. Audits areundertaken on the communal areas and service users’ own rooms to ensure that a safe and clean environment is maintained.

Indicator

Service users who rated overall care as good or excellentService users who felt that overall they were treated withrespect and dignityService users who would recommend the service tofamily and friendsNumber of formal complaints % of formal complaints acknowledged within target of 2 days% of formal complaints responded to in writing withintarget of 20 days

Neurological Care

86%87%

91%

1080%

80%

Palliative Care

99%100%

100%

1080%

70%

Homecare

86%97%


Data available 2010/11Data available 2010/11


Neurological

See section on Priority 2 above for details

443110

14243 (82%)

See section below

Indicator

Regulatory body inspection rating (Neurological and Homecare only)Percentage of care standards met or exceeded by those Hospices inspected1Number of incidents resulting in serious injury per yearNumber of medicines administration incidents per yearNumber of medicines prescription incidents per yearNumber of slips trips and falls resulting in serious injuryper yearNumber of reports under RIDDOREnvironment score and percentage compliance withstandards2Number of Healthcare Acquired Infections and pressureulcers acquired within our own service or acquiredexternally

Palliative

92% (3 services)

253171

1264 (89%)

Homecare

Data available 2010/11Data available 2010/11Data available 2010/11Data available 2010/11


1. Service user experience

2. Safety


3. Effectiveness

HCAI and pressure ulcersThe number of infections and pressure ulcers across allneurological and palliative centres reflects the period betweenJuly 2009 and March 2010. Cases are identified as those whichwere acquired by the service user whilst under the care of SueRyder and those acquired prior to the service user beingadmitted to a Sue Ryder service.

Number of HCAI (July 2009 – March 2010) ● Acquired within own service● Acquired external to service

30

25

20

15

10

5

0

Num

ber o

f new

cas

es

Clostridium Difficile

Novirus MRSA Infection

MRSAColonised

Hepatitis(A, B or C)

Influenza

Number of pressure ulcers (July 2009 – March 2010) ● Acquired within own service● Acquired external to service

Num

ber o

f new

cas

es

Neurological Centres Palliative Care

140

120

100

80

60

40

20

0

Neurological

Health Care Acquired

Infections (HCAI)

Clostridium DifficileNorovirusMRSA infectionMRSA colonisedHepatitis (A, B or C)InfluenzaPressure UlcersPressure ulcers

Neurological

Acquired in Sue Ryder

1

30

AcquiredExternal to Sue Ryder

2313

21

Palliative


1

40

AcquiredExternal to Sue Ryder 6124

1

119

Total


2

70

AcquiredExternal to Sue Ryder 61227131

140


Part 4 Annexes

Annex 1

There is a legal requirement to report on this section:

• During the period of this report, 1 April 09 to 31 March 2010Sue Ryder provided NHS-funded community healthservices through its 6 Adult Hospices, 5 Day Hospices, 1Hospice at Home service, 2 Community Nursing Servicesand 6 Care Homes with Nursing .

• The percentage of NHS funding is variable depending onthe nature of the service ranges from 35 per cent to 90 percent of the total cost of providing the service. The shortfallis met from Sue Ryder charitable income.

• Sue Ryder has reviewed all the data available to it on thequality of care in all of the services detailed in the precedingsection

• The income generated by the NHS services reviewed in theperiod 1 April 2009 to 31 March 2010 represents 100 percent of the total income generated from the provision ofNHS services by Sue Ryder for the period 1 April 2009 to 31March 2010.

• During the period from 1 April 2009 to 31 March 2010 therewere no national clinical audits covering the NHS servicesthat Sue Ryder provides.

• Clinical audits have taken place within Sue Ryder; theseform part of the annual audit calendar programmeimplemented for services July 09 – March 10. Themonitoring, reporting and actions following these auditsensure care delivery is safe and effective. The clinical auditcalendar included Documentation, MedicinesManagement, Falls Prevention, pressure Ulcer assessmentand Management, Documentation, Care at death Audits,environmental and hand hygiene audit.

• Key learning apart from the results of the audits themselvesincluded the fitness for purpose of the tools used and theway in which this data can be captured.

• Where indicated changes are implemented at an individual,team or service level and further monitoring is used toconfirm improvement in healthcare delivery.

• During that period from 1 April 2009 to 31 March 2010 SueRyder was not eligible to participate in national clinicalaudits.

• The number of patients receiving NHS services provided orsub-contracted by Sue Ryder from 1 April 2009-March 2010that were recruited during that period to participate inresearch approved by a research ethics committee was nine.

• Sue Ryder income in this reporting period was notconditional on achieving quality improvement andinnovation goals through the Commissioning for Qualityand Innovation payment framework because theseschemes had not yet been implemented by localcommissioners.

• Sue Ryder is required to re-register with the Care QualityCommission by 30 September 2010. Until re-registrationSue Ryder will not know if it has any conditions on itsregistration.

• The Care Quality Commission has not taken enforcementaction against Sue Ryder during the period 1 April 09 to 31March 2010.

• Sue Ryder is not re-registered with the Care QualityCommission. It will not know until 1 October 2010 whetherit will be subject to periodic reviews by the Care QualityCommission and, if so, what form these will take.

• Sue Ryder has not participated in any special reviews orinvestigations by the CQC during the reporting period.

• Sue Ryder did not submit records during the period from 1April 2009 to 31 March 2010 to the Secondary Uses servicefor inclusion in the Hospital Episode Statistics which areincluded in the latest published data.

• Sue Ryder was not eligible to be scored for the period 1 April2009 to 31 March 2010 for Information Quality and RecordsManagement, assessed using the Information GovernanceToolkit.

• Sue Ryder was not subject to the Payment by Resultsclinical coding audit during the period 1 April 2009 to 31March 2010 by the Audit Commission.


Annex 2

Statement from commissioning PCT, OSC and LiN’s

NHS Leeds was approached for comment on the national SueRyder Quality Account 2009/10, following guidance from theDepartment of Health that advice should be sought from theorganisation’s largest value NHS commissioner.

We approached NHS Leeds which commissions services fromone of our hospices. NHS Leeds notes the areas we haveidentified for improvement during 2010/11. These are:

Priority 1: To achieve an overall service user experience ratingof good or excellent on the service user survey

Priority 2: To improve our quality rating at inspectionsPrioirty 3: To introduce an electronic incident reporting systemPriority 4: To reduce the harm from falls

As outlined in this document, associated progress measuresand related new initiatives make a significant contribution tothe delivery of safe, high quality services which reduce healthinequalities and improve outcomes for service users and carers.

NHS Leeds commends Sue Ryder for the publication of itsQuality Account 2009/10 at a time that community providersdo not have to publish until 2010/11.

These comments are qualified by an inability to endorse theaccuracy of the information presented.

Sue Ryder114 –118 Southampton RowLondonWC1B 5AA

Sue Ryder Care is a charity registeredin England and Wales (1052076)and in Scotland (SC039578).

Ref No.0329.p/B/P/H© Sue Ryder Care. June 2010.

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