quality account 2014/15 - nhs...of clinical audit which is included within our overall three-year...

Quality Account 201415

01 Contents

Part One Statement on Quality from the Chief Executive 03

Part Two

Priorities for improvement 201516 08

Statement of Assurance from the Board 11

Review of services 12

Participation in clinical audits 12

Part Three

Review of quality performance in 201415 27

Complaints and compliments report 32

Friends and Family Tests 35

Statements from local CCG and Healthwatch 39

Glossary 42


03 Statement on Quality from the Chief Executive

I am pleased to introduce The Retreatrsquos Quality Account for 201415

This Quality Account is our annual report to the public and to people who use our services about the quality of the care we deliver It includes examples of improvements we have already made to the quality of the services we provide and our plans to make further improvements It also describes some of the systems we have in place to measure quality

The Retreat is a not-for-profit provider of specialist mental health services We work closely with the NHS to provide services for people with complex and challenging needs The Retreat was established over 200 years ago by Quakers and was the first place where people with mental health problems were treated humanely with dignity and respect Long before todayrsquos focus on recovery-orientated inclusive services The Retreat was providing care based on the belief that given the right environment and if treated as equals people using our services can be empowered to take responsibility for their own recovery

We are proud of our long-standing reputation for

excellence and for providing care of the highest quality

We are very proud of our long-standing reputation for excellence and for providing care of the highest quality We are committed to working with those who use our services to improve the quality of the services we deliver and enable us to evidence that quality improvement

04 Looking back over 201415 I am pleased to report that we made solid progress with the priorities we identified in last yearrsquos Quality Account Where we have not progressed as far as we would have liked such as with the electronic patient record system there are good reasons for this You can read more about these items on pages 27-31 Another pleasing feature of 201415 was the progress we made with implementing our new governance structures These alongside the introduction of the Board Assurance Framework ensure our Board focuses on the important areas of quality safety and risk

I am particularly pleased with the feedback we have received from the people who use our services and you can read some of their comments throughout the report In the main it is extremely positive and we are committed to addressing those areas of concern

Our aim is that all our services receive external accreditation and three of them have already done so You can read more about this on page 16 Other services continue to work towards accreditation and this is an area where we may need to push harder to accelerate progress

All services have been routinely collecting outcome data and producing an annual clinical review for some years In the last twelve months we have moved to six monthly reporting of outcome measures We are particularly interested in finding out what happens to people post discharge and are thinking about how we

might obtain regular and systematic information on this We want to assist people to achieve a recovery that is sustainable

Particularly encouraging in 201415 is the increase in research activity driven by a comprehensive strategy We continue to develop links with a range of universities and to take students from a number of clinical disciplines on placements We are really looking forward to taking on our first medical student in the summer of 2015

We recognise that highly trained committed and valued staff teams are pre-requisites of any

quality service

We recognise that highly trained committed and valued staff teams are pre-requisites of any quality service We work hard to support listen to and value our staff and it was disappointing that the results of the recently conducted Staff Survey were not as good as last yearrsquos Equally the results of the Staff Friends and Family Test were disheartening as only 51 of staff would recommend The Retreat as a place to work and 24 would not recommend it We know that staff are dissatisfied with the level of pay they

05 receive particularly when compared with that offered by the NHS and we have taken steps to address this for nursing staff our largest staff group Our staff also complain about poor communication from the Leadership Team so we are embarking on a project to look at how we can improve this and thereby raise levels of staff engagement and satisfaction

In 201415 we conducted the annual round of appraisals having further modified this following feedback from staff The appraisal includes a grading for all staff and whilst this remains unpopular we believe this is an important part of any appraisal and are keen to retain it We continue to carry out our quarterly face-to-face team briefings and these are well received

We were not inspected by the Care Quality Commission in 201415 but were found to be fully compliant when they inspected our services in 201314 We are working hard to familiarise ourselves with the new system of inspection and have implemented a programme of internal inspections using the Key Lines of Enquiry

I remain confident that The Retreat will rise to the

challenges ahead

This past year has been every bit as challenging as we predicted and the coming years will be even more so I remain confident that The Retreat will rise to the challenges ahead and continue to provide high quality services which represent value for money

On behalf of The Retreat I affirm my commitment to providing high quality services and confirm that to the best of my knowledge the information contained in this report is accurate

Jenny McAleese Chief Executive 04062015

Part Two Priorities for improvement 201516 08




07 ldquoThe staff almost always find time for you if you need it The staff are approachable and

kindrdquo

Priorities for improvement 201516

Having spent 201415 improving the governance systems and processes across the organisation the priorities for 201516 mark a year of consolidation and change for the organisation

The management and monitoring of risk will be further developed to incorporate strategic risks The investment we have made in developing outcome measures and supporting staff who wish to undertake research will be embedded

Change will be focused on developing links with the local community and seeking opportunities to work with partners The exciting Cafeacute+ initiative will incorporate both these aspirations

A new pilot nursing structure will be implemented in May 2015 and this offers great opportunity to not only develop the potential of nurses across The Retreat but also think about introducing new roles and ways of working across multi-disciplinary teams

Patient Safety

Objective Rationale 201516 Activities Indicators for success Lead monitoring

and reporting

Continue to further develop and embed robust risk management systems and processes across the organisation

The organisation needs to identify and manage all risks

Increase the scope of the Risk Register to include strategic risks

Increase the number of staff that can add risks to the Risk Register

The Risk Register will include strategic risks signed off by the Board

All clinical staff will have been trained in entering risks on the Risk Register and will be doing so as appropriate

Associate Director of Governance and Change

08

09 Clinical Effectiveness


and reporting

Develop and implement evidence based outcome measures to demonstrate the effectiveness of our interventions

Ensure we are able to demonstrate the positive impact of our interventions for patients

Drive ongoing improvement in clinical practice

Provide evidence to commissioners that our interventions are effective

The Research and Clinical Outcomes Strategy will be implemented across The Retreat

Outcomes will be reported on at six monthly intervals in a format that can be shared with commissioners

A robust approach to supporting research and developing meaningful outcome measures is embedded across The Retreat

Medical Director

ldquoHave been made very welcome and involved from day one - very impressed by the calm and efficient manner of

everyone that works thererdquo

Patient Experience


and reporting

Develop a new community recovery facility in partnership with local organisations

To create a sanctuary a place that offers respect safety and similar people to meet It will offer a range of activities that can promote recovery

Working in partnership we aim to develop the idea of establishing a cafeacute type safe space which allows service users and others to relax and socialise

Funding is identified to support the establishment of a safe space for service users and others to utilise

Tuke Centre Manager

ldquoNothing is too much trouble and support given to the families of their

patients is also very goodrdquo

10

11 Statement Relating to Quality of NHS Services Provided

Statement of Directorsrsquo responsibilities in respect of the Quality Account

The Directors are required under the Health Act 2009 National Health Service (Quality Accounts) Regulations 2010 and National Health Service (Quality Account) Amendment Regulation 2011 to prepare Quality Accounts for each financial year The Department of Health has issued guidance on the form and content of annual Quality Accounts (which incorporate the above legal requirements)

In preparing the Quality Account Directors are required to take steps to satisfy themselves that

bull The Quality Account presents a balanced picture of the organisationrsquos performance over the period covered

bull The performance information reported in the Quality Account is reliable and accurate

bull There are proper internal controls over the collection and reporting of the measures of performance included in the Quality Account and these controls are subject to review to confirm that they are working effectively in practice

bull The data underpinning the measures of performance reported in the Quality Account is robust and reliable conforms to specified data quality standards and prescribed definitions is subject to appropriate scrutiny and review and

bull The Quality Account has been prepared in accordance with Department of Health guidance

The Directors confirm to the best of their knowledge and belief they have complied with the above requirements in preparing the Quality Account

By order of the Board

David Peryer Chair of Directors 04062015

12 Review of Services

During 201415 The Retreat provided eight NHS services in three service areas

The Retreat has reviewed all the data available to them on the quality of care in eight of these services

The income generated by the NHS services reviewed in 201415 represents 100 of the total income generated from the provision of NHS services by The Retreat for 201415

Participation in Clinical Audits The Retreat undertakes an annual programme of Clinical Audit which is included within our overall three-year Clinical Audit Strategy We reviewed the list of National Clinical Audits and enquiries for inclusion in the Quality Account 201415 There are three National Clinical Audits applicable to the services provided by The Retreat but due to insufficient patient numbers The Retreat did not participate in them

The three audits which are contained in the Prescribing Observatory for Mental Health (POMH-UK) framework were bull Prescribing for substance misuse Alcohol

detoxification bull Prescribing for bipolar disorder (use of

sodium valproate) bull Prescribing for ADHD in children adults and

adolescents

The results of 24 Local Clinical Audits were reviewed in 201415 and the organisation has taken action as a result of these findings to improve the quality of care and treatment it provides

ldquoThe Retreat does a fantastic job of

caring for all their patients rdquo

13 Local Clinical Audits Conducted Audit Key quality improvement actions

NICE Quality Standard 1 Dementia

bull Improve recording of Carersrsquo assessments being offered as part of the CPA documentation Nursing staff to record when such an assessment is offered and document evidence of liasion with our social work team Dissemination within the unit teams

bull Greater use of assessment tools to monitor improvement in a target symptom when behaviours challenge Psychology staff to investigate and implement an appropriate tool to capture this information

bull Greater use of cognitive tools to monitor changes in cognition when pharmacological methods are used to manage behaviours that challenge Psychology staff to investigate and implement an appropriate tool to capture this information

Bank Staff Record Keeping bull Bank staff (both RMNs and Support Workers) to ensure they follow correct guidelines on documentation ensuring they sign their entries on the Electronic Patient Record System (FACE)

bull Maintain the FACE training session in the new starters Induction Programme and continue with unit based training schedule

Recovery Plans and Record Keeping

bull Ensure that all patients have a clearly structured Recovery Plan in place that is reviewed and updated within agreed timeframes

bull Named Nurses to address the areas for improvement in their own documentation following each bi-monthly audit

bull Ensure that all patients have the opportunity to develop Advance Statements bull Ensure that repeat Risk Assessments and other relevant assessments are

completed within the agreed time frame of one month

NICE Clinical Guideline 136 Service User Experience In Adult Mental Health

bull Crisis Plans - for people who may be at risk of crisis a crisis plan should be developed by the patient and their care coordinator The crisis plan should include specified areas as per NICE guidance

bull Use of Advanced Statements to be increased Increase use of the Respect My Wishes document on those units showing a lack of uptake Re-audit use of Respect My Wishes documents to get a benchmark across the organisation

bull Recovery Plan to include social care and crisis plan This will ensure care planning supports effective collaboration with social care and other care providers during endings and transitions and includes details of how to access services in times of crisis

CPA Reports (10 day target) bull Implementation of a new electronic CPA recording system bull Unit Administrators standards awareness training

7 Audits carried out in 201415

Local Clinical Audits Conducted Audit Key quality improvement actions

Mental Capacity ActConsent To Treatment

bull Improved documentation of Consent to Treatment Advanced Decisions and Lasting Power of Attorney on the FACE EPR System Completion of Capacity Assessment Forms If a patient lacks capacity to consent to the care plan a Capacity Assessment should be recorded

bull Mental Capacity Act Training Ensure all staff have received training appropriate to their roles

Risk Profile Assessments bull Ensure Naomi unit staff are aware of need for Risk Profiles to be reviewed every three months as part of NHS England contract

Physical Healthcare bull Annual and physical examinations on admission are recorded on the agreed assessment sheet

bull Influenza vaccinations documentation Accessibility of a record of a discussion of administration of influenza vaccinations to patients Add to physical assessment sheet

bull GPs to record Retreat patientsrsquo consultation on FACE

Hand HygieneInfection Control bull Introduce new audit tool and process to be carried out across all units bull Unit based hand hygiene training carried out by Infection Control representatives

for all staff including use of an ultra violet machine bull Improve hospital wide signage for use of hand gels as best practice

Health of the Nation Outcome Scale (HoNOS)

bull Quarterly report for Patient Safety and Experience Group

Respect My Wishes bull Ensure all patients have a Repect My Wishes document bull Agree and implement a standard for review of Respect My Wishes

Subject Access Requests bull Remove from Risk Register bull Central Subject Access Requests Log to ensure requests are dealt with efficiently bull Amend Access To Health Records Policy to include Access to Health Records

(AHR) Application Forms Review current suitability of AHR forms as part of the Access to Health Records policy

T2T3 Forms (Mental Health Act) bull Only the current T2 form should be in the patientrsquos notes Issue guidance to unit clinical staff

bull Route of medication to be indicated on T3 forms

Nursing amp Midwifery Council bull Develop guidance on writing defensible patient records highlighting in particular Record Keeping Standards (Tuke the key areas of improvement noted Centre) bull Develop a checklist for clinicians to use based on the Audit tool

bull Purchase of an Electronic Patient Record System

14



ldquoEveryone I have met either therapist or admin staff have been extremely supportive efficient and welcomingrdquo

15

16 External Acceditation The Royal College of Psychiatrists Centre for Quality Improvement (CCQI) aims to raise the standard of care that people with emotional or mental health needs receive by helping providers users and commissioners of services assess and increase the quality of care they provide

Unitsrsquo continued accreditation

bull The Acorn Programme - Community of Communities

bull Naomi unit - Quality Network for Eating Disorders

bull Katherine Allen unit - In-patient Mental Health Services for Older People (AIMS-OP)

Looking forward during 201516 Hannah Mills Allis and Strensall units are working toward accreditation through The Royal College of Psychiatrists Enabling Environments Award

In October 2014 The Acorn Programme was awarded the 2014 Independent Healthcare Apex Specialist Provider of the Year award

ldquoTheyrsquore great Very professional Always seem to know what theyrsquore doing which makes me calmerrdquo

17 Participation in Clinical Research The number of patients receiving NHS funded treatments that were recruited during 201415 to participate in research approved by a Research Ethics Committee was zero

Four projects have been initiated and approved by The Retreat Virtual Research Group during this year across the range of our services

bull Talking about shame without talking about shame - a thematic analysis of interviews with carers of individuals with an Eating Disorder

bull What does The Retreat do Intersubjective workplace goals of The Retreat Strensall

bull Where is the emotion in dementia bull An evaluation of the use of The Retreat

labyrinth

A staff survey of all research-related activity generated a list of additional ongoing projectsshybull A long-term follow-up evaluation of the Acorn

Programme bull The impact of introducing Compassion

Focused Therapy into DBT (Dialectical Behaviour Therapy)

bull Integrated Care Pathways in an inpatient unit for women with eating disorders

bull Medical risk study of Naomi Pathways to Recovery

bull Focus group project on running psychotherapy groups in the older adult service

bull Development of the Dementia Card Sort assessment

bull What it means to recover service usersrsquo perspectives on recovery within an inpatient unit

bull Evaluating the service user experience of a Compassion Focused Therapy group

Research has been disseminated internally through The Retreatrsquos Clinical Development Group and externally via national conference and scientific journal publication

18 Commitment to Research as a Driver for Improving the Quality of Care and Patient Experience The Retreat has continued to develop research links with a number of Universities including the University of Nottingham Bangor University University of York York St John University University of Sheffield and the University of Leeds

There is current involvement with research networks within the Institute of Mental Health and the Centre for Social Futures (University of Nottingham) the College of Occupational Therapy the Research Centre for Occupation and Mental Health (York St John University) and the Physiotherapy with Eating Disorders network

Retreat staff members have had involvement in clinical training at Hull University University of Leeds University of York Leeds Metropolitan University and Hull York Medical School

Developing research-derived clinical innovation clinical outcomes and our training of others are to be key aspects of our organisational strategy for the coming years

The Retreatrsquos enquiring and collaborative stance together with a combination of quantitative and qualitative approaches help facilitate continued exploration of the key factors in mental health recovery Our aim is to maximise the contribution The Retreatrsquos services provide to this stage of an individualrsquos pathway

19 Use of the Commissioning for Quality and Improvement (CQUIN) payment framework A proportion of The Retreatrsquos income in 201415 was conditional on achieving quality improvement and innovation goals agreed between The Retreat and NHS England North of England Specialised Commissioning Team Yorkshire and Humber with whom we entered into a contract for the provision of Specialised Eating Disorder Services (Adult) through the Commissioning for Quality and Innovation payment framework

The Retreat was successful in achieving the CQUIN target for 201415

CQUIN QTR1 QTR2 QTR3 QTR4

Friends and Family Test 100 100 100 TBA

Improving Physical Healthcare to Reduce Premature Mortality in People with Severe Mental Health Illness

100 100 100 TBA

MH8 Outcome Measures 100 100 100 TBA

MH9 Optimising Resource Use in the Specialised Adult Eating Disorder Services

100 100 100 TBA

MH22 Quality Dashboard 100 100 100 TBA

ldquoPatients seem to be involved in all elements of their care packagerdquo

During 201415 The Retreat also entered into a contract with NHS Cumbria CCG for the provision of residential rehabilitation through the CQUIN framework


Friends and Family Test 100 100 100 100


100 100 100 100

Capturing Patient Outcomes 100 100 100 100

Improved Effectiveness 100 100 100 100

ldquoI think the staff [at The Retreat] work extremely hard to help me with my recovery They are very

dedicated and hard working peoplerdquo

20

21 Statements from the Care Quality Commission The Retreat is required to register with the Care The Retreat has not been inspected by the CQC Quality Commission and its current registration during the 201415 period status is in respect of

The Care Quality Commission has not taken bull Assessment or medical treatment for persons enforcement action against The Retreat during

detained under the Mental Health Act 1983 201415 bull Diagnostic and screening procedures bull Treatment of disease disorder or injury

The Retreat York - 22 October 2013 Outcome Judgement

Outcome 2 (Regulation 18) Consent to care and treatment

Outcome 4 (Regulation 4) Care and welfare of people who use services

Outcome 9 (Regulation 13) Management of medicines

Outcome 14 (Regulation 23) Supporting workers

Outcome 17 (Regulation 19) Complaints

ldquoDuring our visit we had the opportunity to speak with seven people who use the service People were very positive about the care and treatment they had received Comments included ldquoThey have really supported me here and now I am so much betterrdquo and ldquoStaff are lovely They listen to you Unlike some places Irsquove been beforerdquo We looked at the records and talked to the staff working in the hospital We confirmed that people were supported to give their consent to care and treatment People also told us they felt involved and included in decision making within the service We confirmed that care records were person centred and reflected individual choices in their rehabilitation We talked with the staff and they confirmed they felt well supported and confident in their role with good training and development plans in place We saw that there were good systems in place to listen to peoplersquos concerns and everyone was supported to access advocacy services and other help networks We also saw there were effective systems in place to monitor complaints People who use the service told us that if they wanted to make a complaint they would know how to We saw that the hospital recorded all complaints and resolved them where they could to the complainantsrsquo satisfactionrdquo

Quote from CQC inspection report

22 The Retreat Strensall - 18 November 2013 Outcome Judgement


Outcome 4 (Regulation 4) Care and welfare of people who use service




ldquoDuring our visit we had the opportunity to speak with several people who use the service People told us that they felt the staff were lsquohelpfulrsquo and lsquofriendlyrsquo and supported them to have a varied and inclusive life at Strensall Comments included ldquoThe staff are alright here they are really supportive and talk to yoursquorsquo We looked at the records and talked with some of the staff We confirmed that people were supported to give their consent to care and treatment People also told us they were offered copies of their care programme and felt involved and included in decision making within the service We confirmed that care records were person centred and that they included peoplersquos individual choices and aspirations We looked at the medication systems in the unit and confirmed that medication was stored administered and managed safely This was important to make sure peoplersquos health needs were safely met We talked with the staff and they confirmed they felt well supported and confident in their role They also said that there were good training and development plans in place We confirmed that there were good systems in place to listen to peoplersquos concerns and everyone was supported to access advocacy services and other help networks We also saw there were effective systems in place to monitor the quality of the service complaintsrdquo


ldquoI feel very privileged to have got a place on this program It has saved my

life in more ways than onerdquo

23 Information Governance and Data Quality Data Quality The Retreat did not submit records during 201415 to the Secondary Uses service for inclusion in the Hospital Episode Statistics which are included in the latest published data

Statement on relevance of Information Quality and actions to improve Information Quality The Department of Health (DoH) requires hospitals to ensure they hold accurate reliable and complete information Clear processes and procedures need to be in place to give assurance that information is of the highest quality

High quality information is important for the following reasons

bull It helps staff provide the best possible care and treatment on the basis of accurate and up-to-date information

bull It ensures efficient service delivery performance management and the planning of future services

In 201415 we have continued our work to improve the quality of information across the organisation The Information Governance Steering Group and the IT amp Systems Group are responsible for ensuring that the organisationrsquos data collection systems operate in line with the requirements of national standards such as the

Information Governance Toolkit and the Care Quality Commissionrsquos EssentialFundamental Standards In particular over the last year we have

bull Implemented a more robust Information Governance policy framework

bull Improved our Information Governance Information Technology Risk Register

bull Reviewed the effectiveness of our Electronic Patient Records System (FACE) and agreed to implement a new system in 201516 to improve the efficient management of information

bull Implemented a three year Clinical Audit Strategy and annual Clinical Audit Programme

bull Developed an electronic recording and monitoring system for dealing with Subject Access Requests

bull Implemented a new Clinical Audit Action Plan template giving a Risk Rating to all actions as well as recording the learning from each audit undertaken and associated outcomes

bull Developed the Ulysees Electronic Incident Reporting System to assist our internal performance reporting and the implementation of additional modules including one for Safeguarding Alerts

bull Developed a new Governance Performance Management reporting framework

bull Improved internal data recording systems in

24 order to more efficiently produce information to satisfy datasets as part of our NHS contractsrsquo compliance

This programme of work will continue into 201516 with a focus on raising the profile of information quality through staff awareness training and monitoring Our performance metrics will continue to be reported and monitored through the Governance Committee and its associated sub-groups and reporting to the Board of Directors

The Information Governance Toolkit The Information Governance (IG) Toolkit is an annual self-assessment audit that The Retreat is required to complete and submit to the Department of Health (DoH) via the Health and Social Care Information Centre (HSCIC) to ensure that the necessary safeguards are in place for managing patient and staff information

The levels of compliance against each of the 17 requirements range from Level 0 to Level 3 with Level 3 being the highest level of compliance and Level 2 being the minimum target level of compliance set by our NHS contracts

Initiatives included within the IG Toolkit

bull Information Governance Management bull Confidentiality and Data Protection

Assurance bull Information Security Assurance bull Clinical Information Assurance

In our 201415 self-assessment The Retreat maintained Level 2 compliance against each of the toolkit requirements This demonstrates to the people who use our services and our commissioners that The Retreat has robust controls in place to ensure the security of patient and staff information

In accordance with national guidance and recognised good practice Information Governance must be in place as part of mandatory training programmes to ensure that staff are appropriately trained The Retreat achieved its target of 100 in the training of staff whose role was identified as requiring them to complete the lsquoBeginners Guide to Information Governancersquo

As of May 2015 The Retreat has achieved 92 in the training of staff whose role was identified as requiring to complete the lsquoIntroduction to Information Governancersquo or lsquoInformation Governance - The Refresher Modulersquo This was below the 95 target set by the IG Toolkit As a result of this the organisation is addressing Information Governance training as a priority action to ensure this target is met

25 Clinical Coding Error The Retreat was not subject to the Payment by Results Clinical Coding Audit during 201415 by the Audit Commission

National Core Indicators of Quality The National Quality Board has recommended In the Staff Survey conducted in February 2015 a national core set of quality indicators be 84 of respondents were satisfied with the included in the Quality Account for 201415 quality of care given to patients This comparative information is intended to set performance in context and to explain whether that performance is strong or weak

Reporting against these indicators is not mandatory for independent providers with the exception of the staff element of the Friends 84and Family Test The Retreat considers it good practice to report against those that apply to the care and treatment we provide

ldquoStaff are excellent they go so out of their way to help anyone with anything

and never fail to help rdquo

Part Three Review of quality performance in 201415 27




27 Review of quality performance in 201415 This section provides a summary of the progress we have made towards achieving on our 201415 priorities

Patient Safety Objective Actions taken Outcome Achieved

Ensure the Conduct a review Discussions with external suppliers completed and organisation has IT of the underlying IT steps are being implemented systems which are network structure and fit for purpose and make any changes enable the which are efficiencies available necessary to ensure from IT systems to be the system is robust gained and fit for purpose

Implement wireless Wireless capability implemented throughout the capability across the buildings main site

Evaluate options for Work completed and decision take to trial a web a new EPRS and based version of our current system recommend a selected supplier to the Board

Implement new EPRS Expected to be implemented in early 201516

ldquoEveryone is always friendly and helpful when we visit or ring We are grateful for

the excellent care that Dad receivesrdquo

28 Patient Safety Objective Actions taken Outcome Achieved

Further develop and embed robust risk management systems and processes across the organisation

Conduct Board Development Days to further develop the Boardrsquos awareness and confidence in using the Board Assurance Framework (BAF)

Ensure the Risk Register is maintained in a timely and accurate manner

Ensure that Action Plans are developed and implemented in a timely manner

Extend the number of staff able to add risks to the Risk Register

Board Development Days have been conducted throughout the 201415 year They have addressed the management of risk and an awareness raising session about the new CQC regulatory system Further Development Days are planned in the coming year The BAF has been used throughout the year and revised to ensure it continues to be fit for purpose

The Risk Register is being used across the organisation and is routinely reviewed by the Risk Management Group

An integrated action plan was developed and used to plot progress against key workstreams

Training has taken place and continues to take place to ensure all clinical staff can add risks to the Risk Register

29 Patient Experience Objective Actions taken Outcome Achieved

Establish a Recovery College open to everybody in York

Launch a Recovery College with a curriculum of at least 12 different courses

Deliver courses to 45 students and have 60 satisfactorily completing their course

Monitor the improvements in students health and wellbeing and have 75 of students demonstrate improvements

The Recovery College was launched in April 2014 with 35 different courses available

The Recovery College welcomed 63 students onto its courses with 91 completing the course

The Recovery College had an outcomes framework in place However these outcome measures were not routinely collected and we therefore cannot demonstrate an improvement in students health and wellbeing

In December 2014 we took the decision to change our strategy for the future development of the Recovery College The decision was prompted by two key issues bull Uptake of courses was much lower than predicted bull Potential partners saw the Recovery College

as competition rather than an opportunity for collaboration


Roll out the Family Implementation of and Friends Test staff FFT as per (FFT) across the guidance according organisation aiming to the national to achieve an 80 timetable response rate for all patients discharged Full delivery of FFT

across all services delivered as outlined in guidance

We will follow up with focus groups to understand the results we receive through The Retreat Involvement Forum

Clinical Effectiveness Objective Actions taken

Conduct and To support nurses to implement a review of become Independent the nursing workforce Prescribers

Expand the number of staff trained in phlebotomy and performing an ECG

Annual rolling programme for preshyregistration students to support unqualified staff to progress towards a professional nurse qualification

Staff FFT was implemented as per the national guidance

We have failed to meet this target The target is high and should be regarded as aspirational Our results reached an average return rate of 43 over the year

Feedback from action plans are reviewed through the bindashannual Involvement Forum

Outcome

Register of Independent Prescribers in place Two Nurses are currently on the register One nurse is in training and one has been accepted onto the next available course We also have a Pharmacist Prescriber

Phlebotomy ndash In addition to staff trained in previous years11 staff have completed training in 201415

Electrocardiogram (ECG) ndash Eight qualified and Support Workers are on this register We are awaiting training dates for 201516

Pre-registration Nurse Practitioner ndash Three accepted in 201415 Another Support Worker is awaiting interview for the 201516 programme

Achieved

31 Clinical Effectiveness Objective Actions taken Outcome Achieved

Ensure all patients have full access to physical healthcare assessments and screening programmes

Physical Healthcare Assessments All patients are offered a physical healthcare assessment on admission

This assessment is repeated as a standard dependent on length of stay

Personal Care Strategy In collaboration with the person individual strategies are developed and reviewed as part of the CPA process This will as appropriate indicate dental ophthalmic and podiatry needs

Smoking Cessation On admission each patient will be given bull A lsquosmoking

cessationrsquo pack and referral to a Smoking Cessation Advisor

bull Increase the number of Smoking Cessation Advisors

bull Enable and support staff to stop smoking

100 patients received a physical healthcare assessment after admission

69 of patients were offered an annual physical review

Assessment documents have been changed to include Podiatry Dental and Ophthalmic care as necessary

Three patients have successfully stopped smoking this year All Pharmacy Technicians are trained to provide Smoking Cessation Advice Four members of staff have successfully stopped smoking The hospital site became totally non-smoking for staff on 11 March 2015

Complaints Report The Retreat is carrying out ongoing work to make it easier to raise a complaint or concern As part of this work The Retreat has already added an online complaints comments and compliments form to its website

A total of 13 complaints were received during 201415

The table below shows the reasons for the complaints

Learning from the complaints

bull The communication process between staff and ex-patients has been changed to ensure that any correspondence is sent to current addresses and that ex-patients have given their consent to receive any correspondence

bull Unit staff are now providing better information about the groups that are available to newly admitted patients

Reason for the Complaint Number Number Upheld

All aspects of clinical treatment 6 6 Upheld

CommunicationInformation to Patients (Written or Oral) 2 2 Upheld

Other ndash Behaviour of a patient towards another patient 5 5 Upheld

13 complaints received were dealt with within 25 working days

(Complaint Categories are as defined by the Department of Health)

ldquoI am not happy with the way in which I feel your staff speak to me or treat me

when I callrdquo (Patientrsquos mother)

32

33 Compliments

The Retreatrsquos Compliments Policy works across the organisation with the aim of providing clear information on how individual compliments are reported and logged in addition to the ways in which they will be used

Each clinical unit keeps a log of all compliments which is forwarded monthly to the Contracts and Policies Officer Compliments reports are collated and submitted to NHS Commissioners on a regular basis in line with contractual reporting requirements In total we received 39 compliments in 201415 an improvement on the 29 received in 201314 Key themes emerging from the compliments received this year were satisfaction with the quality of care and treatment received by the patients as well as praise for the quality of the environment of The Retreat

ldquoI think the level of care offered

by all the staff onGeorge Jepsonis absolutely

superb All treatmy relative

excellently andwith considerable

dignityrdquo

ldquoI am now looking forward to going out there and living my life when I first came in I didnrsquot think that would be

possiblerdquo

Performance Measures

Patient Experience The Retreat openly encourages patients and carers to give their feedback on all aspects of their care and treatment This ensures that we can constantly improve the services we offer In order to gather these views more formally we have implemented an annual programme of Patient and Carer Experience Surveys as part of our annual Clinical Audit Programme

These surveys ensure that patientsrsquo and carersrsquo voices are heard and are used to help deliver better care and treatment provide evidence to commissioners of the quality of our services and ensure we can drive service improvements in relation to CQC standards

For 201415 the recommendations agreed following each surveyrsquos results were as follows

Survey Quality improved actions Inpatient Survey bull

bull bull bull bull bull

Increase response rate to the survey from Hannah Mills Allis and Katherine Allen units Lockable personal storage facility for Naomi and Acorn patients Choice of Named Nurse for Naomi patients Review the effectiveness of the survey tool and its questions Dissemination of survey results and action plan to relevant patient and staff groups Ensure patients are aware of the complaints procedure and improve visual information across the units

Out Patient Survey bull Methods of increasing participation in the survey (Tuke Centre) bull


Car Parking Waiting room reception area and welcome Information given to patients about our services their problems and our procedures Communication with patients Privacy and Confidentiality Affordability

Carersrsquo Survey bull

bull

bull

bull

Improve carersrsquo understanding of who they can talk to in order to pass comment on any aspect of the service Review how carers are supported at the point of discharge and in particular if discharge is early or unexpected Disseminate more widely information on appropriate local and national services that carers could turn to for support Review the friendliness and helpfulness of staff when carers visit as to how this could be improved

34

35 Patient Friends and Family Test

The Patient Friends and Family Test (PFFT) aims to provide a simple measure which when combined with follow-up questions can drive a culture change of continuous recognition of good practice and potential improvements in the quality of care received by patients The PFFT is given to all patients as part of the discharge process and uses a six point response scale as follows (1) Extremely Likely (2) Likely (3) Neither likely nor unlikely (4) Unlikely (5) Extremely unlikely or (6) Donrsquot know

Important Change - NHS England Brief (Oct 2014) lsquoA review of the PFFT was published in July 2014 and made a number of recommendations The PFFT Review suggested that the presentation of the data should move away from using the Net Promoter Score (NPS) as a headline score and use an alternative measure In line with this recommendation the NHS England statistical publication will move to using the percentage of respondents that would recommendwouldnrsquot recommend the service in place of the NPSrsquo

This change took place from 1 October 2014 and this was reflected within our subsequent two Quartersrsquo performance reports on the PFFT Therefore the first two quartersrsquo reports show the PFFT as a numerical score and the last two quarters as the percentage recommendnot recommend

We aimed to give the PFFT to all patients discharged from our services in 201415 and set an internal target of achieving a minimum 80 return rate We did not achieve this target in any of the quarters over the last year although we did show improvement quarter on quarter with the return rates as follows

Quarter Return Rate

1st Quarter (Apr-Jun 2014) 47

2nd Quarter (Jul-Sept 2014) 47

3rd Quarter (Oct-Dec 2014) 51

4th Quarter (Jan-Mar 2015) 67

The scores we achieved for the PFFT are shown in the table below These generally show a high level of patient satisfaction with the care and treatment offered by The Retreat The information generated from the PFFT has also been used to benchmark against other organisations each quarter

Quarter PFFT Score



Recommend Not

Recommend

3rd Quarter (Oct-Dec 2014) 93 0

4th Quarter (Jan-Mar 2015) 60 3

Staff Friends and Family Test

From the 1 July 2014 The Retreat has been required to carry out the Staff Friends and Family Test (SFFT) on a quarterly basis as part of our NHS England contract The SFFT is a tool which allows staff to give feedback on The Retreatrsquos services based on their recent experience

Staff are asked to respond to two questions

The lsquoCarersquo question asks how likely staff are to recommend the services they work in to friends and family if they needed similar care or treatment to that offered by The Retreat

The lsquoWorkrsquo question asks how likely staff would be to recommend the service they work in to friends and family as a place to work Staff are given a six point response scale for each question as follows (1) Extremely Likely (2) Likely (3) Neither likely nor unlikely (4) Unlikely (5) Extremely unlikely or (6) Donrsquot know

Scores are produced relating to feedback as a place for lsquoCarersquo and as a place to lsquoWorkrsquo

Results for the SFFT over 201415 were as follows

The Retreat (Jul - Sep) Quarter 2

The Retreat (Oct - Dec) Quarter 3

The Retreat (Jan - Mar) Quarter 4

Total number of responses to the SFFT 58 45

44 - Care Question 45 - Work Question

of staff who would recommend their organisation to friends and family in need of caretreatment (the lsquoCarersquo question)

83 91 84

of staff who would not recommend their organisation to friends and family in need of caretreatment (the lsquoCarersquo question)

5 0 5

of staff who would recommend their organisation to friends and family as a place to work (the lsquoWorkrsquo question)

66 49 51

of staff who would not recommend their organisation to friends and family as a place to work (the lsquoWorkrsquo question)

10 24 24

36

37 Staff Friends and Family Test With regard to the feedback received for the lsquoCarersquo question over the three quarters the response from staff has been favourable in terms of whether they would recommend The Retreatrsquos clinical services to friends and family

With regard to the lsquoWorkrsquo question however this has shown unfavourable feedback from staff in terms of whether they would recommend the organisation as a place to work most notably in the last two quarters

Staff made a number of comments against their responses for the lsquoCarersquo and lsquoWorkrsquo questions and these are sent to the Senior Management Team each quarter for review as part of the SFFT action plan and in order to determine any particular trends arising and any changes to practice required

ldquoAs a patient Ifeel respectedlistened to and very involved inmy own care and

recoveryrdquo

Staff Survey 38 Every year The Retreat conducts a comprehensive survey of its employees in order to establish their satisfaction with their employment and to seek feedback on areas that might be developed or improved This is only one tool that we use in order to talk to our workforce We also carried out a range of different briefings surveys and feedback sessions throughout the year

Once again the design and distribution of the Staff Survey was undertaken by a group of employees nominated by the Staff Consultative Committee This approach enables us to draw on wider experience for the design of the survey and offers a visible demonstration that The Retreat wants to genuinely engage all of its employees in its ambition to become an employer of choice

Following the survey in 2014 a number of changes were introduced including bull Occupational sick pay re-introduced for

employees with six to twelve months service bull An engaging Change Management

Programme started to communicate changes within the organisation

bull New Employee Assistance Programme introduced along with various salary sacrifice schemes and Well-being initiatives

bull Reward Statements issued for all employees bull New and improved internal newsletters

launched

In March 2015 we had a 45 response rate to the survey which is a drop of 7 on the previous year although only five fewer individuals filled out the survey The headline indicators from the staff survey show that bull 83 of staff said they were enthusiastic

about their role bull 73 of staff said they were happy to work at

The Retreat bull 73 of staff believed that The Retreatrsquos top

priority was patient care bull 84 of staff were satisfied with the quality of

care given to patients

A number of themes were identified within the survey for further action These included bull Internal communications being more open

and giving all staff an understanding of the future of the organisation

bull Communicating the value of the work in terms other than financial

bull Reviewing pay scales across the organisation

These issues will be explored over the coming months with solutions being developed through consultation with the staff team before being taken forward for further consideration

39 Statement from the local CCG and Healthwatch Partnership Commissioning Unit

ldquoThe Partnership Commissioning Unit on behalf of the North Yorkshire CCGs have a solid commissioning history of working closely and effectively with The Retreat in commissioning services for a vulnerable patient group The transparency of the services provided demonstrate a high quality of care delivery this is consistently assured year on year

Throughout 201415 we have continued to witness positive outcomes for our patients moving through in-patient services to positive discharge

As in previous years we have maintained effective relationships to explore and discuss service developments that meet the needs of the North Yorkshire population that complement existing NHS commissioned services

We look forward to continuing our support to The Retreat through 1516rdquo

Healthwatch

ldquoThank you for giving us the opportunity to review and comment on your Quality Account 201415 We feel it is an open and honest report We welcome the inclusion of a glossary which is very helpful in helping make the document more readable for members of the public

Among the priorities for 201516 we particularly welcome the focus on developing links with the local community and seeking opportunities to work with partners We look forward to seeing the development of the Cafe+ initiative

It is good to see that feedback from patients and carers is encouraged and used to improve the quality of services Using quotes of positive feedback received from people who have used the services provides a reminder of the personal stories behind the figures and statistics

We welcome the ongoing work to make it easier for people to raise a complaint or concern and are pleased to see that complaints are used as a learning opportunity

Healthwatch York looks forward to working with The Retreat in the coming year We very much appreciated being invited to the first lsquoRetreat Open To Allrsquo event in May and hope there will be other opportunitiesrdquo

ldquoEverything is done with you in mind and you have a say in your care which is

incredibly empoweringrdquo

40

Glossary

Glossary

CCG Clinical Commissioning Group

Is a statutory NHS organisation representing groupings of GP Practices that are responsible for designing local health services In England They will do this by commissioning (or buying) healthcare services

CPA Care Programme Approach

A framework used by all units to monitor patient progress and set new outcomes and goals

CQC Care Quality Commission

The independent regulator of health and social care in England It regulates health and adult social care services whether provided by the NHS local authorities private companies or voluntary organisations

CQUIN Commissioning for Quality and Innovation

Measures which determine whether we achieve quality goals or an element of the quality goal These achievements are on the basis of which CQUIN payments are made

42 EPRS

Electronic Patient Record System

A digital patient record stored in an online database

DBT Dialectical Behavior Therapy

A talking therapy designed to help people change patterns of behavior that are not helpful

FACE Functional Analysis of Care Environments

Electronic Patient Record System used by The Retreat

HoNOS Health of the Nation Outcome Scale

A widely used routine clinical outcome measure used by English mental health services

MDT Multidisciplinary Team

A group of different types of clinicians who work together as a team

Heslington Road York YO10 5BN 01904 412551 01904 430828 wwwtheretreatyorkorguk infotheretreatyorkorguk

If you would like to make any comments regarding the content of this report or make any suggestions for future reports please contact our Marketing Department at the address below

Electronic copies of this Quality Account can be obtained from our website (wwwtheretreatyorkorguk) and the NHS Choices website (wwwnhsuk)

Printed copies can be obtained by contacting the Marketing Department

If you require this report in another language please contact the Marketing Department

Marketing Department The Retreat Heslington Road York YO10 5BN

t 01904 412551 e marketingtheretreatyorkorguk

01 Contents


Part Two

Priorities for improvement 201516 08




Part Three

Review of quality performance in 201415 27




Glossary 42
















quality service






challenges ahead









kindrdquo






Patient Safety


and reporting








08



and reporting








Medical Director



Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS

































quality service






challenges ahead









kindrdquo






Patient Safety


and reporting








08



and reporting








Medical Director



Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS






















challenges ahead









kindrdquo






Patient Safety


and reporting








08



and reporting








Medical Director



Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS























kindrdquo






Patient Safety


and reporting








08



and reporting








Medical Director



Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS























Patient Safety


and reporting








08



and reporting








Medical Director



Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS




















and reporting








Medical Director



Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS


















Patient Experience


and reporting





Tuke Centre Manager



10





















adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS






































adolescents









































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS























































14




15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS



















15














labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS































labyrinth





















100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS




























100 100 100 TBA



100 100 100 TBA







100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS






















100 100 100 100





20
































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS

















































































































Outcome





Achieved




























32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS













































32

33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS


















33 Compliments







dignityrdquo


possiblerdquo












bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS





























bull

bull

bull


34






Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS























Quarter Return Rate






Quarter PFFT Score



Recommend Not

Recommend
















83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS































83 91 84


5 0 5


66 49 51


10 24 24

36





recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS






















recoveryrdquo








launched
















Healthwatch








40

Glossary

Glossary









42 EPRS

























launched
















Healthwatch








40

Glossary

Glossary









42 EPRS























Healthwatch








40

Glossary

Glossary









42 EPRS




















40

Glossary

Glossary









42 EPRS


















Glossary

Glossary









42 EPRS


















Glossary









42 EPRS


















quality account 2014/15 - nhs...of clinical audit which is included within our overall three-year...

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