Safe | Sound | Supportive
Quality Strategy
2016
A more compassionate mind, more sense
of a concern for other’s well-being,
is a source of happiness
- Dalai Lama
Contents
Introduction.......................................................................................................................... 3
Drivers for Quality................................................................................................................. 4
Board of Directors Responsibility....................................................................................... 6-7
Mission and Values .............................................................................................................. 8
Developing the Quality Strategy.......................................................................................... 9
Priorities for Improvement .............................................................................................. 9-15
Personal PATHS© Model Of Care ................................................................................. 16-18
Positive Behaviour Support............................................................................................. 16
Appreciative Inquiry Methodology ................................................................................ 17
Therapeutic Outcomes................................................................................................... 17
Healthy Lifestyles ........................................................................................................... 18
Safe Services.................................................................................................................... 18
Our Commitment To Clinical Governance ................................................................... 19-21
Embedding the strategy..................................................................................................... 21
Conclusion.......................................................................................................................... 21
Where are we now?..................................................................................................... 22-23
2
danshell.co.uk
Introduction
Welcome to Danshell’s second Quality Strategy
This Quality Strategy has been developed to articulate our continuing commitment to
the delivery of high quality services for the people we serve and to build on achievements
delivered by our staff through the delivery of our original Quality Strategy.
This Quality Strategy will support Danshell in continuing to meet the expectations within Transforming Care:
A National Response to Winterbourne View Hospital.
Danshell provides hospital and residential care services throughout England and Scotland for people living
with a learning disability with complex needs and behaviours that are perceived as being challenging. We also
provide services for people with Autistic Spectrum Disorder. Danshell ensures that high quality care and support
is the foundation stone for all of its services.
This Quality Strategy re-affirms our standards, our mission and a framework for improving the quality of service
delivery across the organisation and for enhancing the service user experience. This is the blueprint to ensure
that the quality of the day to day delivery of care is high. We will continue to have in place robust appraisal and
supervision methods that will ensure that every member of staff is clear about their personal contribution to
achieving this goal.
“How wonderful it is that nobody need wait a single
moment before starting to improve the world.
Anne Frank
3
Drivers for quality
In addition to our organisation’s own mission and strategic objectives,
the Quality Strategy needs be cognisant of the national and local
drivers that steer our service provision and the wider health and
social care system. To ensure we have a Quality Strategy that is fit
for purpose we need to take into account the legislation, policy,
guidance, regulation and research, pertinent to our services.
In both England and Scotland, most of our services are commissioned
by the NHS or Local Authorities who have a clear sense of what the
dimensions of quality and priorities for action are. These are centred
on improving the experience of service users and ensuring care and
support is:
Safe
Person centred
Effective and efficient
Equitable
Timely
We have to address the standards and regulatory frameworks
published by the Care Quality Commission for England, Healthcare
Improvement Scotland and the Social Care and Social Work
Improvement Scotland (SCSWIS/Care Inspectorate) for Scotland, as
well as key legislation, policy, guidance and research. These include:
Transforming Care for People with Learning Disabilities: Next Steps
The Keys to Life
Valuing People & Valuing People Now
Mansell Report
Challenging Behaviour: a unified approach
No Health Without Mental Health
Commissioning Specialist Learning Disability Health Services
We have taken care to ensure our Quality Strategy attends to
the findings and recommendations of relevant local and national
reviews* , inquiries** and guidance***
*Serious case review of 2011 ** The Francis Report 2013 *** Winterbourne View Response 2013
4
Over the next three years our aims
continue to be to:
Work in partnership with the people who use our
services and their families to ensure they have increasing
choice and their voice is heard and acted on at all levels
of the organisation.
Ensure that our services are consistently reflective of the
individuality of our service users and uphold their right
to a safe, respectful and dignified experience.
Encourage the people who use our services to be part
of their local communities and to provide opportunities
for them to contribute and participate in activities that
promote their independence.
Maximise the health and wellbeing of the people
who use our services.
Provide services that represent good value for money
and demonstrate effectiveness and clear outcomes for
those we serve.
Support learning and personal development for
all our staff.
Improve our systems of compliance and audit and
ensure we embed quality and governance in all we do.
danshell.co.uk
Life is so much brighter when we
focus on what truly matters
5
Board of Directors Responsibility
“Danshell is committed as its first priority, to the delivery of safe, high quality, person centred care”.
It is the Chief Executive’s responsibility to ensure that there are structures and processes within the company
so we can achieve compliance with regulatory and legislative standards.
Executive responsibility for clinical governance and quality assurance is vested in the Director of Nursing and Governance.
Director of Nursing and Governance –
Marie Greenberry
Chairman Efi Hershkovitz
It’s Danshell’s vision that every individual accessing our services has
a truly person centred experience that meets their needs, wants and
wishes in a way that is:
Quality is in our hearts and minds and it is what we
stand for at Danshell. It is embedded in our approach to
delivering care for our service users, to supporting their
families, to educating and leading our staff and to
working in partnership with all stakeholders.
Safe - person centred and rights based
Sound - high quality and appreciative
Supportive - empowering and transforming
Danshell supports people who experience challenges in their life.
We provide compassionate and skilled support to encourage and
promote the individual’s quality of life, to enable them to live it in
the way they choose. We support people to have valuable contact
with their family & friends, to participate in a range of activities that
are meaningful to them and to be involved in their local community.
In other words, to live the life that they choose, with the support
required to achieve this.
The most valuable resource for achieving this aim is the staff and
the skilled support that they provide to the service users. Therefore,
we are committed to developing our staff to acquire the skills and
knowledge required to provide the best support that they can.
We provide a sound governance framework supported by a
range of systems and resources that underpins the delivery
of high quality services.
Together, service users and their relatives, staff and the supporting
governance infrastructure, achieve Safe, Sound and Supportive
services that enable service users to live a life that is of their
choosing and involves their family and friends.
This strategy is developed to articulate our continuing commitment
to delivering high quality, person-centred services and identifies
the interventions that we will implement to achieve this.
Director of Nursing, and Governance Marie Greenberry
6
It has been a few years since we launched our first Quality
Strategy. This strategy was the blue print for ensuring
Danshell supports people to do the things most of us
take for granted such as independence, spending
time with family and friends and being able to access
and feel included in the local community. We are proud
to share with you some of the implemented processes
and achievements from the previous version of
the Quality Strategy on pages 22 & 23.
We are very pleased to bring you our refreshed quality
strategy, where we set out our intention for the next three
years to ensure we continue to place a firm focus on high
quality, person centred care. This document provides us
with a stable foundation to move forward and continue
to transform our values and ethos into practice. Together,
we will work to implement this strategy. The Board of
Directors and myself are sending this clear message;
making sure the vision of what you all said good
care looks like becomes a reality.
Chairman - Efi Hershkovitz
danshell.co.uk
Chief Executive Officer Andrew Murray
This document provides all stakeholders with an assurance
that our written mission, values and objectives are acted
upon. As the services which Danshell provide have increased
so too have the people who use our services, our staff,
the commissioners and importantly the families and carers
of those we support.
The Danshell Quality Strategy provides us all with the blueprint
to ensure that the quality of the day to day delivery of care is
high. We will continue to have in place robust appraisal and
supervision methods which will ensure that every member
of staff is clear about their personal contribution.
We have and always will, work closely with the people who
use our services, their families, commissioners and regulators
and we will be accountable and responsible for our the
decisions we make and the services we deliver.
Chief Executive Officer - Andrew Murray
Making a difference
To make a difference in
someone’s life, you don’t have
to be brilliant, rich, beautiful,
or perfect. You just have to
care enough and be there.
7
Danshell’s Mission and Values
From the work we undertook with our stakeholders in developing this quality strategy we were able to clarify our intent as an
organisation in terms of our mission and our values.
OUR MISSION is to make a positive difference to people and their families by
delivering personalised health and social care that helps them to achieve the
things they want out of life.
O u r va lu e s
Safe
Sound
Supportive
Person Centred
High Quality
Empowering
We will put the person and their
family at the centre of all our
work and listen and act on
what they tell us.
We will provide care and
support that is safe, evidence
based and outcome focused.
We will support people in a
manner that is progressive and
enables them to exercise
choice and control
Rights based
We will respect and promote the
human, legal and civil rights of
the individuals who use our
services within our organisation
and wider society.
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Appreciative
We will work with people in
a manner that is hopeful and
encouraging, using positive and
strength based approaches.
Transforming
We will work with our partners
to create pathways that enable
people to grow and achieve
their goals.
danshell.co.uk
Developing the Quality Strategy
To enable us to develop the Quality Strategy we listened to what service users told us they wanted.
In the main they told us that services should be:
Be person centred, respectful and individualised.
Facilitate choice.
Promote service user and family involvement.
Enable community access and participation.
Have multi-professional teams that work well, were well trained and in sufficient numbers to deliver
appropriate care and support.
Be delivered within environments that were safe for service users and staff.
Similarly, clear themes emerged around what the outcomes of the services would look like namely:
People achieving their potential and moving on from services.
Increased autonomy, independence, choice and control.
Improved support for families.
We have taken these into consideration when developing our priorities for improvement for the next 3 years.
Priorities for Improvement
To enable Danshell to achieve its Mission and deliver services that are underpinned by our Values we will
implement the following:
1. All service users have a person centred file that includes a range of person centred care plans and related documents
such as a communication passport, which promotes the delivery of person centred support.
2. We continue to ensure that all training delivered supports person centred thinking by staff in their everyday practice
and the way they provide support to service users.
3. We continue to work with families to ensure that we are able to clearly hear their voice and firmly value their role,
knowledge and expertise. This will include:
a. Supporting their contribution at service user/family carer forums and workshops at all levels within the organisation;
b.The regular publication of a newsletter for people who use our services and their families; and
c. Continued funding of independent advocacy services.
4. We continue to support families to keep in touch with their relative, to participate in clinical meetings and to contribute
to assessment/care planning processes. We will provide appropriate visiting facilities and information technology such
as email and Skype to enable family contact to be maintained
5. We allocate Named Nurses and Key Workers to support service users, taking into consideration shared interests,
personal skills, experience and attributes to meet individual need. All service users and staff will be supported to
develop a ‘one page profile’ to support this allocation process.
9
6. We continue our work to develop a suite of accessible materials in different formats to facilitate the participation
and choice of service users and their families. In particular, we will focus on ensuring information is available to
support involvement within the care planning and CPA process. Individual bespoke materials will be developed
to meet the unique needs of individual service users when required.
7. We ensure that the organisational training strategy supports the development of the skills and competencies
required to meet the needs of service users, that includes:
a.The delivery of training to support Positive Behavioural Support.
b.A robust and comprehensive training strategy that meets the needs of new starters and existing staff.
c.A comprehensive and supportive Preceptorship Programme for newly qualified nurses.
d.National Vocational Development opportunities for support staff.
e. Quarterly Regional Community of Practice, (COP) facilitated by Consultant Nurses to facilitate the sharing
and dissemination of knowledge and information.
8. We involve service users and/or family carers in recruitment process and provide training for those who wish
to participate in these processes.
9. We continue to undertake a programme of work within our residential services to encourage more inclusive
ways of working and increase opportunities for service users in education and employment.
10.We continuously review the membership, structure and outcomes of governance meetings and activities at local,
regional and national level to increase effectiveness and the contribution of people who use our services.
11.We are committed to a programme of training and support to enable people and families to participate as
‘Quality Checkers’ in the implementation of Quality Development Reviews.
12.We continue to audit and monitor our performance against a range of indicators that support and promote high
standards in relation of the safety and experience of service users and the clinical effectiveness of our interventions.
13.We provide training in and implement tools to support the monitoring of outcomes for service users. Specifically,
we will train staff to use the relevant Outcomes Star and the Health Equality Framework (HEF). All service users’
progress and outcomes will be monitored using an appropriate Outcome Star
and the HEF, and any additional outcome measures as required.
14.We will continue to review all services to regularly ensure that they meet
the national agenda related to Transforming Care to support the aim of
people with challenging behaviour only going into hospital if hospital
care is genuinely the best option, and only staying in hospital for as long
as it remains the best option.
Evstaertrys wiaccompl
i
s
hment
th the decision to try
10
danshell.co.uk
Priorities for Improvement
1
2
3
All service users have a person
centred file that includes a range of
person centred care plans and related
documents such as a communication
passport, Health Action Plan, Health/
Hospital Passports, which promotes the
delivery of person centred support.
Outcome Targets
The Clinical and Residential Record Keeping
Policies revised and include an extended index
for the Person Centred Files by target date.
Executive Sponsor
Director of Nursing
and Governance
100% of current Service User’s Person Centred
Director of Nursing
and Governance &
Files reviewed and revised to include full index
Chief Executive
contents as identified within the revised Clinical
and Residential Record Keeping Policies by target
date and new Service Users within 6 weeks
of admission.
Clinical/Residential Records Audit is undertaken
to ascertain level of compliance with Person
Centred files (following updated policy) and
identify recommendations for actions required
to achieve full compliance in Q4/2016.
Director of Nursing
and Governance
We continue to ensure that all training
delivered supports person centred
thinking by staff in their everyday
practice and the way they provide
support to service users.
100% of training reinforce reinforces and
supports person centred thinking and
approaches.
Director of HR &
Organisational
Development
We continue to work with families to
ensure that we are able to clearly hear
their voice and firmly value their role,
knowledge and expertise. This will
include:
100% of services undertake a survey to
Director of Nursing
ascertain the preference related to family/friends and Governance
involvement initiates within their service.
a) Supporting their contribution at
service user/family carer forums and
workshops at all levels within the
organisation;
100% of services implement the preferred
family/friends involvement method as identified
in the above survey and inform Governance
Administrator of their method, so this can be
monitored centrally.
Director of Nursing
and Governance
b) The regular publication of a
newsletter for people who use our
services and their families; and
A minimum of one companywide Family &
Service User Forum is held in 2016.
Director of Nursing
and Governance
& Chief Executive
Officer
c) Continued funding of independent
advocacy services.
Newsletters are developed and disseminated for
service users bi-annually and for family quarterly
during 2016.
Director of Nursing
and Governance
& Chief Executive
Officer
Advocacy contracts are in place that offer
100% of service users with individual advocacy
support.
Chief Executive
Officer
The Training Manager reviews and quality checks Director of HR &
100% of training resources to ensure they
Organisational
support person centred thinking and approaches Development
prior to them being approved for delivery.
11
Priorities for Improvement
4
We continue to support families to
keep in touch with their relative, to
participate in clinical meetings and to
contribute to assessment/care planning
processes. We will provide appropriate
visiting facilities and information
technology such as email and Skype to
enable family contact to be maintained.
Outcome Targets
Executive Sponsor
Names Nurses and Key Workers support
100% of service users to maintain contact with
family and maintain a record of this contact
in accordance with the Company Family
Involvement Policy.
Chief Executive
Officer
Family/Friends are invited and supported to be
involved in 100% of CPA and other significant
clinical meetings (not routine MDT meetings) if
service user agree to this, and are encouraging
to complete and return CPA feedback forms.
Chief Executive
Officer
100% of CPA feedback forms returned to the
Governance Administrator are entered on a
register that records good practice, areas of
improvements and actions implemented in
response to feedback received.
Director of Nursing
and Governance
Chief Executive
If agreed with service users, 100% of
Officer
assessments and care plans are shared with
family/friends to keep them informed of the care
provision and documents are signed by family/
friends to evidence this.
5
6
12
We allocate Named Nurses and Key
Workers to support service users,
taking into consideration shared
interests, personal skills, experience
and attributes to meet individual need.
All service users and staff will be
supported to develop a ‘one page
profile’ to support this allocation
process.
We continue our work to develop a
suite of accessible materials in different
formats to facilitate the participation
and choice of service users and their
families. In particular, we will focus on
ensuring information is available to
support involvement within the care
planning and CPA process. Individual
bespoke materials will be developed
to meet the unique needs of individual
service users when required.
There is a one page profile in place and
refreshed at least annually for 100% of existing
service users & staff, and one is developed for
new service users & staff users within 6 weeks
of admission/start of employment.
Chief Executive
Officer
100% of existing service users and within 2
week of admission for new service users, have a
Named Nurse and Key worker(s) allocated in a
way that (a) support the service users choice
and (b) has considered shared interests,
personal skills, experience and attributes to
meet individual need.
Chief Executive
Officer
A Named Nursing/Support Team Policy and
individual role clarity leaflets for team roles are
in place and leaflets are distributed to 1005 of
existing staff and included in the starter pack
for new staff by target date.
Director of Nursing
and Governance
A full range of easy read accessible materials are
available for and used by 100% of service users
and additional bespoke accessible resources are
provided as required.
Chief Executive
Officer
Accessible materials are readily available within
services and service users are supported by staff
to access them as/when required.
Chief Executive
Officer
Bespoke accessible materials are requested and
provided as/when required in the most suitable
format for an individual service user.
Chief Executive
Officer
danshell.co.uk
Priorities for Improvement
7
We ensure that the organisational
training strategy supports the
development of the skills and
competencies required to meet the
needs of service users, that includes:
Outcome Targets
Executive Sponsor
Positive Behavioural Support training is provided
to Masters level for identified senior clinicians,
at diploma level for nurse leads within services
and at a practice based level for all other staff
throughout 2016.
Director of HR &
Organisational
Development
b) Comprehensive regional training
plans that meets the needs of new
starters and existing staff.
A Training programme is developed and
delivered for each region that is underpinned
by the clinical needs of service users by the
target date.
Director of HR &
Organisational
Development
c) A comprehensive and supportive
Preceptorship Programme for newly
qualified nurses.
A comprehensive and supportive preceptorship
programme is delivered to 100% of newly
registered nurses to enable them to consolidate
their learning into practice and confidently
take on the role and responsibilities of a
registered nurse.
Director of HR &
Organisational
Development
&
Director of Nursing
and Governance
d) National Vocational Development
opportunities for support staff.
The Preceptorship Programme is reviewed and
revised to ensure that it meets the needs of
newly registered nurses by target date.
Director of HR &
Organisational
Development
&
Director of Nursing
and Governance
e) Quarterly Regional Community
of Practice, (COP) facilitated by
Consultant Nurses to facilitate
the sharing and dissemination
of knowledge and information.
Completion of Preceptorship Programme
for Newly registered nurses is identified as a
mandatory training need and its completion
is recorded on the individual nurse’s training
record, they receive a certificate on completion
and an incremental pay rise by target date.
Director of HR &
Organisational
Development
&
Director of Nursing
and Governance
At least 70% of support are staff complete a
National Vocational Qualification at Level 2
or above.
Director of HR &
Organisational
Development
&
Director of Nursing
and Governance
A Community of Practice Meeting is held
in each region each quarter in 2016.
Director of Nursing
and Governance
a) The delivery of training to support
positive behavioural support.
8
We involve service users and/or
family carers in recruitment process
and provide training for those who
wish to participate in these processes.
Service users and/or family representatives are
Chief Executive
involved in the recruitment of staff within service Officer
teams throughout 2016.
Service users and/or family representatives
for each service are provided with training in
recruitment of staff as required throughout
2016.
Director of HR &
Organisational
Development
13
Priorities for Improvement
9
Executive Sponsor
We continue to undertake a
programme of work within our
residential services to encourage more
inclusive ways of working and increase
opportunities for service users in
community based activities, education
and employment.
100% of service users are provided with
activities, work and employment opportunities
as appropriate to their personal needs.
Chief Executive
Officer
The role of the Activity Coordinator is revised
to ensure that it supports service users’
participation in a range of activities that meet
individual needs.
Director of Nursing
and Governance
10
We continuously review the
membership, structure and outcomes
of governance meetings and activities
at local, regional and national level
to increase effectiveness and the
contribution of people who use
our services.
There is a service user representative member
for 100% of Unit Led Clinical Governance
Committee.
Chief Executive
Officer &
Director of Nursing
and Governance
11
We are committed to a programme of
training and support to enable people
and families to participate as ‘Quality
Checkers’ in the implementation of
Quality Development Reviews.
Quality Checker training is provider for service
users and/or family representative, aiming to
have two trained quality checkers per service.
Director of Nursing
and Governance
Cross Team Quality Checkers are involved in
100% of Quality Development Review (QDR)
Inspections.
Director of Nursing
and Governance
A register is maintained of all trained Quality
Checkers by target date.
Director of Nursing
and Governance
The Integrated Audit Programme 2016 is
100% implemented and outcomes support
improvements in practice and service
user experience.
Director of HR &
Organisational
Development
&
Chief Executive
Officer
12
14
Outcome Targets
We continue to audit and monitor
our performance against a range of
indicators that support and promote
high standards in relation of the
safety and experience of service users
and the clinical effectiveness of our
interventions.
danshell.co.uk
Priorities for Improvement
13
14
Outcome Targets
Executive Sponsor
We provide training in and implement
tools to support the monitoring of
outcomes for service users. Specifically,
we will train staff to use the relevant
Outcomes Star and the Health
Equality Framework (HEF). All service
users’ progress and outcomes will
be monitored using an appropriate
Outcome Star and the HEF and
any additional outcome measures
as required.
100% of Senior Support Workers and Nurses
in all services are trained in the implementation
of the Outcome Staff.
Chief Executive
Officer
100% of Nurses are trained in HEF and 100%
of service have a HEF Lead Nurse.
Chief Executive
Officer
100% service users have the appropriate
Outcome Star and HEF completed and this
is updated every 3 months.
Chief Executive
Officer
We will continue to review all services
to regularly ensure that they meet
the national agenda related to
Transforming Care to support the aim
of people with challenging behaviour
only going into hospital if hospital care
is genuinely the best option, and only
staying in hospital for as long as it
remains the best option.
Services are reviewed on an ongoing basis,
and when deemed appropriate their registration
status is revised to meet the needs the service
users and ensure compliance with national
guidance throughout 2016.
Chief Executive
Officer
I have seen and been part of so many huge changes
since those early years of first becoming a nurse.
I like to know I can be a part of making a difference
to someone’s life but my reward remains seeing a service
user smile when they are taking control of their own life.
- Hazel Southern
Service Manager at Danshell
15
PERSONAL PATHS MODEL OF CARE
Personal PATHS Model of Care, continues to be our unique way of supporting people with complex needs
in health and social care and based on research and best practice. It draws together, contemporary thinking and
practice, and importantly, reflects what people and families tell us is important to them.
At Danshell we believe that we must be fully accountable to those we serve, their families and
to those who commission services on their behalf. In order to do this we have described what
we do in a straightforward and transparent manner based on 5 key principles.
Personal PATHS
©
The 5 key principles that form the foundation
stones of our model of care are:
Name
.........................................................................................................................
Name of service
.........................................................................................................................
coming to
Danshell
Service User Satisfaction
1. Positive Behaviour Support
Supported to complete by:
.........................................................................................................................
Was this a:
Date filled in
Talking Mats Score Sheet
or a Questionnaire
.........................................................................................................................
New Service Users
(This section of the questionnaire should be completed only for Service Users who are within
their first 3 months of placement.)
Open question: e.g. How happy are you with/what do you think about...?
2. Appreciative Inquiry Methodology
comments
Happy+4
Unsure 0
Unhappy -4
(no response/not relevant/
additional remarks from
service users)
STEP
welcome from staff
3. Therapeutic Outcomes
4. Healthy Lifestyles
ONE
welcome from
service users
help and support
Your CPA
What is the Care Programme Approach?
information
5. Safe Services
danshell.co.uk
17
Positive Behaviour Support
Many of the people we serve have behaviours that are perceived to challenge services. We believe that we have
to make a long term commitment to providing the right support for each individual to improve their quality of life.
This does not mean that people need to remain in the same place but rather we continue to support them in a person
centred way along their care pathway and ensure that what we learn about the person and the best way to work with
them, is respected, applied and built on. Importantly, our way of working supports people to be included in their own
communities and promotes choice and control, and develops skills and alternative strategies for coping with
challenging situations.
To enable this to happen we implement a range of interventions including:
16
Functional Assessment of Behaviour
Personal Positive Behavioural Support Plans
Individualised activity and skill acquisition programmes
Education and employment opportunities
Specialist assessments of need and risk i.e. HCR-20
danshell.co.uk
Appreciative Inquiry Methodology
At Danshell we remain clear that our values and beliefs are the foundation on which our work is founded. If our
foundations are strong our care and support will be strong. We believe that we take a strength based approach to the
people we serve and the staff that support them. To enable us to do this we use an appreciative methodology to care
delivery and organisational development.
How we do this for individual service users and families is through involving service users at all levels, including:
Individually regarding the delivery of their own care and support
At service level through user forums, involvement in recruitment and the day to day running of the service
At Regional level through involvement in regional forums and events
At National level through national forums and events
Our appreciative inquiry methodology involves using person centred approaches in our assessment and care planning
processes, and employing person centred tools to capture what we like and admire about people, their strengths and
talents and how best we can support them e.g. One Page Profiles. Listening to the individual and their families and using
tools to capture their compelling vision for the future e.g. MY CPA, Person Centred Care Plans and Life Story books.
We employ an appreciative inquiry methodology to energise people in our organisation to move in the direction of
what they most desire by utilising their existing core capacities, strengths and successes to envision their desired
future, through collaborative working.
This valuable methodology is used by service users and staff to achieve positive outcomes for all.
Therapeutic Outcomes
A core belief of our organisation is that we are accountable for everything we do with the service user, their family and
those who commission on their behalf. To do this we must demonstrate good outcomes and measure them in ways that
are valid and inclusive.
At Danshell we use a range of clinical and risk assessments depending on need. The following list represents our standard
range of assessments for a new admissions into hospital settings.
Psychology
1CORE
2Review of neuropsychological testing and ABAS-3
3Functional analysis
Psychiatry
1Full review of medication and possible side effects
2Assessment of capacity and where appropriate
application of the relevant Mental Health Act
3 Monitoring of Physical Wellbeing
Occupational Therapy
1The Model of Human Occupation Screening Tool
(MOHOST)
Speech and Language Therapy
1Pragmatic Profile of Functional Communication
2 Screening Checklist for Eating and Drinking Difficulties.
An important part of the Therapeutic Outcomes
methodology is the use of comprehensive
outcome tools, these are:
The Outcomes Star™
The Health Equality Framework (HEF)
Clinical Outcome measures such as HoNOS LD,
These tools place the person and their family central to the
process and enable us to support and measure
change with each individual.
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Healthy Lifestyles
We know there is a solid body of evidence about the positive effects that diet and exercise can have on mental
and physical wellbeing, and that people with learning disabilities and Autistic Spectrum Disorder are more likely to
experience ill-health and premature death.
At Danshell we want to ensure that the people we serve have the best chance of living a healthy life and that
we do all we can to enable this by providing:
Robust individualised activity programmes for everyone
Health Action Plans and Hospital Passports
Healthy lifestyles groups and health improvement interventions such as smoking cessation,
relaxation classes, anger management, weight reduction programmes etc.
Implementation of the Health Equality Framework (HEF)
Access to national initiatives to promote sport and exercise e.g. Special Olympics
Safe Services
We serve many vulnerable adults who need to feel and experience care that is safe, sound and supportive. We take this
need very seriously and have developed a quality assurance and governance system that provides us with the measures
and tools to ensure we can monitor, improve and check our services robustly.
By setting targets and working directly with service users and families we are clear about ‘what good care and support
looks like’ and strive to deliver to their expectations. We check and support this goal by:
Applying a robust Quality Assurance System (Quality Development Reviews) and a comprehensive
annual audit programme
Training and working with service users and families to check the quality of our services
Measuring and monitoring different aspects of clinical care e.g. reducing the use of restrictive physical
interventions, monitoring incidents and accidents,
Providing an extensive library of accessible information for service users
Service user and family carer feedback systems
The Health Equalities Framework (HEF) is an evidence based outcomes
framework that was developed by members of the UK Consultant
Learning Disability Nurse Network. It can be used to measure the impact
of exposure to known determinants of health inequalities in order to
demonstrate the effectiveness of services in reducing inequalities and
achieving better health outcomes for people with learning disabilities.
The HEF informs health action planning processes and allows
anonymised data to be aggregated in order to understand
needs across broader populations.
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danshell.co.uk
OUR COMMITMENT TO CLINICAL GOVERNANCE
The systems and structures now in place within Danshell provide us with a sound approach to securing service
user safety.
Executive responsibility for service user safety within Danshell lies with the Director of Nursing and Governance
who leads a team that includes expertise in compliance, audit, data analysis, research and the design and collection
of clinical outcome measures and other relevant metrics. The team provides, on a monthly basis, detailed data to
inform every level of the organisation from each service through to the Board of the progress we are making towards
improving service user safety and care delivery in our organisation.
We remain sincere in our commitment to high quality, safe and person centred care. Set out below are is the
architecture of our Clinical Governance system, “how we do what we do” to ensure we can act on and
demonstrate this commitment.
The architecture of this approach was designed to ensure that the feedback and views of people who use our
services and their families is central. By collecting information and using qualitative and quantitative methodology
we are able to measure each service in our organisation and its progress towards improved care and outcomes.
Information/
feedback from
service users and
families and outcome
measures
Information/
feedback from internal
and external assurance
processes reports
and research
This diagram illustrates the 3 key
sources of information we routinely
collect, analyse and report and act on.
Information/
feedback from proxy
indicators of quality
and safety, RCA’s and
investigations
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Information and Feedback from those who use our Services and their Families & Outcome Measures
We make sure that the voices of those we serve and their families are heard. Getting their feedback is crucial and
listening and acting on what they tell us is critical. We do this in a number of ways as briefly described below:
Service user forums at service, regional and national level
The Family Carer Forums
Family, User and Commissioner CPA feedback
Exit interviews and annual surveys
Family Carer Questionnaires
At Danshell we recognise the importance good outcomes for people and this means, to be accountable, we need a way
to measure progress. To do this we are committed to employing a range of assessments and measures, including two key
outcome tools: the Outcomes Star and the Health Equality Framework (HEF)
Information and Feedback from Proxy Indicators of Quality and Safety, RCA’s, Investigations and Reports
The foundation of our work to assure quality and safety continues to be our monitoring of performance of every service
against a set of proxy indicators relating to service user safety. These indicators were drawn from research, reports and
inquiries that relate to the care of people with learning disabilities and mental health problems. They include:
Incidents, graded by severity
Accidents by patients and staff
Use of restrictive physical interventions (categorised by type)
Unexpected Hospital Admissions
Allegations of abuse
Absconding
Police attendance
Complaints
Compliments
We have a rigorous system of undertaking investigations using a Root Cause
Analysis (RCA) methodology into Serious Incidents, Allegations and Complaints to
enable us to ensure transparency, sharing of lessons learned and improving practice.
We hold meetings regularly throughout the year to enable us to use this data and information
and assess our progress.
Information/Feedback from Internal and External Assurance Process, Reports and Research
At Danshell we employ a range of internal strategies for monitoring the quality of our service provision
that provide feedback on the services we provide, including:
20
Individual Service Reviews
Clinical Governance and Risk Management Committees at Group, Regional and service level
Quality Development Reviews
Annual Integrated Audit Programme
danshell.co.uk
We employ a range of strategies related to different stakeholders, which provides us with valuable feedback, including:
For Service Users: CPA Questionnaires, Annual Service User Feedback, Exit Questionnaires, Advocacy, MDT,
Complaints and Compliments and Regional and National User Forums.
For Family Carers: Family Carer Annual Feedback, Family Carer CPA Feedback, Complaints, Compliments, Regional and
National user forums and Family Carer Forums.
For Purchasers: Purchaser CPA Feedback, Complaints, Compliments, Regional Relationship Managers and Contract
Monitoring meetings.
For Staff: Clinical Supervision, Managerial Supervision, Appraisal, Staff Meetings, Training, Staff Questionnaires,
Grievances, Whistleblowing, Incident reporting, Team briefs and involvement in RCA investigations.
Embedding the strategy
To fully embed this strategy within the organisation and for it to truly add value to the quality of the service provision we need
to make sure that it is properly communicated throughout our organisation and at every level. We will do this by utilising existing
mechanisms such as team meetings and governance meetings at local, regional and national level. The strategy will be referred
to in all training delivered to our staff, the Quality Strategy Document will be shared with all stakeholders and it will be available
on our website.
There will be an Easy Read version of the Quality Strategy to support the people who use our service to understand it and
contribute to its delivery.
We will formally monitor and report on the progress we make against the 14 interventions and targets which will become
personal actions for Directors who will be responsible for delivery of these.
Conclusion
Whilst we recognise the importance of implementing a sound governance infrastructure, we acknowledged that this alone
cannot assure high quality, person centred care. We recognise that the most significant contributory factor of assuring high
quality, person centred care is the staff who provide the support to service users, in whatever capacity that may be. Each
and every one of us employed by Danshell has a part to play in ensuring that our organisation delivers care that is safe,
sound and supportive. Together to can achieve the Mission and Vision of this Quality Strategy.
Quality is not an act it’s a habit
- Aristotle
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Where are we now?
All training delivered reinforces
and supports person centred
thinking and approaches
95%
of service users have up
to date one page profiles
Hi i’m
Anne
100%
of service users are allocated
Named Nurse and Key Worker(s)
Danshell provide service
user involvement forums
at service, regional and
national levels
Data correct as of February 2016.
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All new staff are
trained on Positive
Behaviour Support
(PBS) in their
corporate induction
Hi i’m
Mark
danshell.co.uk
97%
of service users
have an
Outcome Star
93%
of service
user have
HEF outcomes
reviewed at
regular intervals
Families are actively
involved in the care
of their loved ones
(if they choose to)
Nursing Community
of Practice Forums
are held quarterly
Easy read
materials are
available and
accessible to all
service users
85%
of
all care support staff
have completed or
are working towards
a National Vocational
Qualification at
level 2 or above
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Safe | Sound | Supportive
One Manchester Square
London
W1U 3AB
Tel: 020 7487 0060
Danshell Group Central Support Office
Gateway 1
Holgate Park Drive
York
YO26 4GL
Tel: 0844 998 0880
Email: [email protected]
© Danshell
danshell.co.uk