Quality Account
2022 | 2023
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Contents
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About Elysium Healthcare
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Our acquisitions
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Our developments
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Our divisions
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Our values
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Our locations
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Board statement on quality
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Provider Collaboratives
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Elysium Healthcare in Wales
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Review of performance
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Creating a culture of improvement
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Clinical specifications
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Improving our services through peer review
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Evaluating care
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Ensuring people have a positive experience of care
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Corporate Experts by Experience
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Service User Advisory Group
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Service user involvement
50
Real work opportunities for service users
50
Mission Fit
51 52
Driving improvements through the sharing of good practice
18
Quality Improvement
19
Our objectives
20
Sustainability
22
Statement of assurance from the Board
24
Participation in National Clinical Audits (NCAs)
25
Participation in contractual audits
25
Research
26
Mortality surveillance and prevention
29
Care Programme Approach (CPA) Patient Related Outcome Measures (PROMs)
Use of CQUIN
30
Family, friends and carers
53
Regulator statement
30
Diversity Equity and Inclusion
54
Data quality
30
Investment in our workforce
55
Data security and protection toolkit
30
Global Graduate Programme
59
Clinical coding error rate
30
Health and wellbeing
60
Governance
31
Revalidation for Nurses
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Our quality framework
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Revalidation for Doctors
61
Freedom to Speak Up
34
Regulation and inspection
62
Treating and caring for people in a safeenvironment and protecting them from avoidable harm
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Patient safety incident statistics
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Complaints
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Department of Health core quality account mandatory indicators
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External reviews
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About Elysium Healthcare We are an independent sector provider of specialist health and care services which are commissioned by the NHS and Local Government authorities across England and Wales.
Our acquisitions
Our hospitals and care homes provide a range of
Ramsay opened their first site in 1964 which
Hillview Hospital
services to enable people with complex and often
was a psychiatric clinic in Sydney, Australia. Their
long-term conditions to access the expert care
business has since grown to include more than 70
they need. We work as a true partner with our
mental health facilities and community services in
colleagues in the health and social care sector to
Australia, France, and Sweden. Elysium provides
identify needs and deliver local services to local
the specialist care provision in the UK.
people through the newly formed Integrated Care
The Ramsay Health Care motto “People Caring
Boards. Our partnership working provides specialist and niche services for both adults and young people. In addition, we provide beds to support the NHS’s acute mental health and Psychiatric Intensive Care Unit national capacity.
for People” was developed over 25 years ago and has become synonymous with Ramsay Health Care
Barnet Lane Clinic Gardens and Jacobs Neurological Centres The Dean Neurological Centre
Our developments
and the way it operates its business. Ramsay’s values are closely aligned with our own and are a critical part of the way we must go about our
Elysium is owned by Ramsay Health Care, a global
daily operations to meet the expectations
healthcare operator employing more than 89,000
of all our stakeholders.
Brook House Moorlands Neurological Centre The Woodmill
people at more than 500 sites across Australia, Asia, Europe, and the UK.
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About Elysium Healthcare, our divisions
Our divisions
Mental Health and Wellbeing
Learning Disabilities and Autism
Neurological Services
Children and Education
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Mental Health & Wellbeing
Our Mental Health & Wellbeing division has a strategic network of hospitals and community houses across England and Wales. Each service is unique with a well-defined clinical service specification giving staff, service users1 and our partners total clarity on the provision, how we deliver care and how we measure outcomes and improvements. Service users play a very active role in shaping services which is supported by our group wide Service User Network.
Services Acute services for men and women Psychiatric intensive care services (PICU) for men and women Specialist rehabilitation services for men and women
Our key qualities Established co-production Pathway choices and models Maximising potential for all our service users in the workforce Positive risk taking Expert clinical teams Accessible Board RRN/BILD (ACT) Certification status Member of the Royal College of Psychiatrists Quality Network Member of International Association of Forensic Mental Health Services (IAFMHS)
Secure services for men and women Services for men and women who are Deaf Community houses for men and women
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Our divisions
Learning Disability & Autism
Elysium offers a range of specialist hospitals,
Our key qualities
complex care services, community, and individual apartments for people with a learning disability or autism and additional complex needs. We are
Partnership based community living services
truly passionate about the Transforming Care
Established co-production
Agenda and ensuring people have the choice to lead independent, meaningful lives as active
Maximising potential for all our service users in the workforce
members of the community. We have focused
Positive risk taking
our service development and our investment
Expert clinical teams
on community-based models of care which grow from a true partnership of working with stakeholders from the earliest point.
Accessible Board RRN/BILD (ACT) Certification status Strongly established community links
Services Community based living services Single apartment services
Using digital innovation to enable service users Group wide neurodevelopmental expert forum
Hospitals transitioning people to the community
1. Clients, patients, residents, and young people are usually collectively referred
Complex care services
services choose the terminology they wish to use along with those in our care.
to as service users throughout to simplify the reading of this report. Each of our
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Children & Education
We have made additional investment into
Services
our quality monitoring systems and our sites so that we can continue to develop
Schools
and grow the services we provide. Our
CAMHS Tier 4 (Low Secure, Eating Disorders, Transitional)
clinicians are renowned experts in their
Eating disorder services
field and in a time of scarce resources in this speciality we are proud of the teams
Day patient service (Eating Disorders)
we have. We strive to give those in our care the right help at the right time in
Our key qualities
the right place and prevent children and young people from entering retracted
Specialist CAMHS trained workforce
adult mental health services. We want
CAMHS Consultants and Psychologists
those in our care to be healthy, confident,
CAMHS Quality Nurse Specialists
and happy in their community lives.
Specialist education teams Established co-production Accessible Board Services co-designed by young people
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Our divisions
Neurological (Hospitals and Specialist Care Homes)
Elysium provides a broad range of
Services
specialised neurological services for men and women across several locations in
Neurorehabilitation
the UK. We work with adults who have
Neurobehavioural rehabilitation
a brain injury or other neurological
Neuroprogressive conditions
conditions requiring a multidisciplinary service. We care for people who come to us directly from acute services for
Complex Dementias Complex Physical Care
active rehabilitation. We also provide continuing healthcare packages of
Our key qualities
rehabilitation, discharge-to-assess, behaviour management, respite stays
iCare electronic records to monitor care quality
and palliative care. We offer a range
Renowned clinical experts in the field
of care and rehabilitation pathways designed to meet the individual needs of
Nationally recognised services of excellence
those accessing our specialised services:
Accessible Board
longer-term care and treatment,
Established family integration into services Pathways across England
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Our values Our values were created in partnership with those we support, their families, and our people. We all voted and decided together which values we hold most dear and which ones unite us all. Our values are standards which we will uphold each and every day.
Kindness in everything we say and do
Integrity being honest and doing the right thing
Teamwork working together to deliver great care and outcomes
Excellence being outstanding at what we do
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Our values, our locations
Our locations 1 Lichfield Lane
Braeburn House
Hope House
The Chimneys Clinic
13 Alexandra Gardens
Brighton and Hove Clinic
Hurstfield
The Copse
185 Arabella Drive
Bromley Road
Jubilee House
The Cottage
187 Nursery Road
Brook House
Martham House
The Dean
1a Upper Brighton Road
Cefn Carnau
Moorlands Neurological Centre
The Farndon Unit
21b Upper Brighton Road
Chadwick Lodge & Eaglestone View
Ormesby House
The Limes
39 Castle Road
Chesterfield House
Pathfields Lodge
The Spinney
78 Park Road
Clipstone House
Pinhoe View
The Woodlands
89 Ewell Road
Cotswold Spa Hospital
Potters Bar CAMHS Service
The Woodmill
Aberbeeg
Crossley Place
Potters Bar Clinic
Thornford Park
Adderley Green
Dane House
Ranworth House
Three Valleys Hospital
Aderyn
Fairmead House
Reene Court
Tottle Brook House
All Saints Hospital
Farmfield
Rhodes Wood Hospital
Ty Grosvenor
Ann House
Felbrigg House
Rosebank House
Tydfil House
Arbury Court
Field House
School House
Ty Gwyn Hall
Asher House
Gardens and Jacobs
Spring House
Victoria Gardens
Badby Park
Gateway Recovery Centre
Spring Wood Lodge
Walcott House
Ballington House
Ghyllside
St Mary’s Hospital
Wellesley
Barnet Lane Clinic
Greenhill
St Neots Neurological Centre
Beech Grove
Gregory House
Stanley House & Bowley Court
Bere Clinic
Gresham House
Sturt House
Bradfield House
Healthlinc Apartments
The Aster and Darcy Wards
Bradley Apartments
Hillview Hospital
The Avalon Centre
Bradley Complex Care
Holkham House
The Bridge
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Board statement on quality 2022|2023 Our Quality Account for 2022/2023 demonstrates our continued drive and commitment to provide compassionate, safe and evidence-based care. We also continue to further develop our pathway of services so that people can access the right care, at the right time, in the right place. The quality of the care we deliver is based on the strength and openness of our leadership and the skill and commitment of our people. We are proud of our workforce and remain dedicated to caring for their health and wellbeing and investing in them as individuals, so they stay with us for their entire career. As we close our Quality Account statement, we would like to express our continued commitment to the delivery of safe, effective, and well-led care. We believe that everyone
Joy Chamberlain
Dr. Quazi Haque
has the right to be treated with respect and dignity. Compassionate care is central to
Chief Executive Officer
Executive Medical Director
everything we do. The Board is satisfied that the data presented here is of a high quality and that it evidences our sixth full year of operation.
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Board statement on quality, provider collaboratives, Elysium Healthcare in Wales
Provider Collaboratives
Elysium Healthcare in Wales
We continue working with Provider Collaboratives, for all our specialised services and welcome
Elysium works in partnership with clinicians,
NHS England’s current extension of collaboratives until March 2026.
commissioners, and regulators in Wales.
The future development of collaboratives and the developing system changes with the growing
The regulators for Elysium’s Welsh services are
role of Integrated Care Systems, will be part of the work we will support with our Provider
Healthcare Inspectorate Wales (HIW) and Care
Collaborative colleagues as this change to the collaboratives develops over the next few years.
Inspectorate Wales (CIW).
Provider Collaboratives have enabled our services to provide care as part of the whole NHS
We have developed adult care pathways which range
system and meet the needs of service users. They offer assurance that the whole system quality
from acute, medium, and low secure services, locked
of care, the integration of the clinical pathway and access to local services is supported by our
and open rehabilitation services, 24 hour supervised
partnership colleagues. The collaborative model has been a success.
step-down placements and residential care. Medium secure beds are commissioned by the Welsh
Provider Collaboratives we work with: South West Secure Provider Collaborative
Lancashire Provider Collaborative South East KSS Secure Collaborative
ForMe – Secure Provider collaborative South East KS CAMHS Collaborative IMPACT Provider Collaborative South Coast CAMHS Collaborative Prospect Provider Collaborative Surrey and Borders Partnership NHS Foundation Trust
West Midlands Adult Eating Disorders Collaborative West Midlands CAMHS Collaborative
Greater Manchester Provider Collaboration
East of England Provider Collaborative
Health Specialised Services Committee (WHSSC) and other beds by the seven local health boards in Wales. Elysium Welsh services are all on the NHS Wales Quality Framework for Mental Health Services which is organised through the National Collaborative Commissioning Unit (NCCU) – NHS Wales and each have obtained three Qs from latest inspections. Elysium use the electronic patient record software Carenotes, which is fully compatible with the Welsh measure. We have Care Treatment Plans (CTPs) for each patient and care planning is based on the eight life domains in Wales which differs from the English system of Care Programme Approaches (CPAs) and care plans based on “My Shared Pathway”. Elysium are a member of the Independent Healthcare Provider Network (IHPN) in Wales.
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Driving improvements through the sharing of good practice The Good Practice Hub is a platform to support learning and sharing across the organisation. It offers the following: Library of resources, housing good practice guidance, audit findings and practical information to support service improvements Good practice video library, including short informative videos and webinars Good practice quick links (external sites) Elysium quick links (internal sister sites e.g., research, quality improvement, governance, and safeguarding, policy consultation etc.) Ideas and suggestions, to ensure the site is meeting the needs of all users
At the time of reporting, we have published eight editions of the Good Practice Bulletin. This bulletin covers governance updates for the whole organisation and includes contributions from sites to showcase good practice in relation to each edition's theme. It has been designed to drive improvements by sharing news, knowledge, and learning. Themes have included: well-led, effective, experience, teamwork, safety, physical health, quality improvement, compassionate leadership and trauma-informed care.
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Driving improvements, Quality Improvement
Quality Improvement Empowering staff, service users and carers to solve complex problems through a process of testing and learning Throughout 2022, we have been further developing our organisational strategy for driving change using Quality Improvement (QI) methods and tools. QI is a systematic and applied approach to solving a complex issue. It requires testing, learning, measuring, collaboration, and user involvement. To date, we have made achievements in the following areas: Building an infrastructure for change: We have been focused on delivering the organisation's vision and commitment to develop and embed a culture of quality improvement and learning. From a corporate QI Committee to regional QI hubs, we have developed robust governance structures to ensure appropriate oversight and support of QI activity, as well as the learning and sharing of best practice. We have also invested in Life QI, a web-based platform, to manage all QI activity across the company. Leadership: The corporate QI team have either achieved or are in the process of achieving qualifications from the Institute of Healthcare Improvement (IHI), leaders in the field of improvement science. This expertise and knowledge has given Elysium Healthcare an excellent foundation for leading and coaching QI activity. Senior leaders across the company have received awareness sessions in QI
to ensure each service is supported and encouraged to engage in QI initiatives.
over 35 projects across the company focusing on making improvements in a variety of areas,
Skills and knowledge: We are well on our way to building a community of quality improvers. Each week more and more staff members are completing QI training, either through Elysium's e-learning package or through face-to-face workshops and events. We are in the process of designing a development pathway to establish QI as an opportunity for career progression.
including reducing restrictive interventions and healthy living.
Engagement: Local teams have access to coaching from the corporate QI team to support with the planning and delivery of QI projects. A dedicated micro-site, ElysiumQI, has been created on the intranet to give staff members access to everything they need to know about QI, including approval processes, guidance and templates. Staff members can also access a monthly coffee and QI drop-in session for informal project support. We currently have
External engagement: We have collaborated with key partners, such as the IHI, NHS England, provider collaboratives and medical colleges, to learn and share QI knowledge and support wider system improvements. Service user and carer involvement: We have championed coproduction and involvement at all levels of our QI programme and provided dedicated guidance and resources on ElysiumQI to support teams in doing this. Ongoing review and development: We continue to review our QI strategy and programme, involving people at all levels in the process, to ensure it develops in the most effective and useful way for our teams.
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Our objectives Our strategic priorities for 2023 – 2028 are laid out in the Elysium Strategy and supported by corporate and local operational implementation plans. They will be reviewed annually to ensure they are still relevant and a priority.
Best CARE 1
To improve service user safety, including: Deploying temporary staff safely and effectively Improving connections between services and the local health system Effective safeguarding practice Effective use of safe and supportive observations Development of PSIRF (Patient Safety Incident Response Framework)
2
To ensure that service users have a voice: to speak up to work in partnership across the organisation ensuring decision making and service design take account of the needs and views of the people using services and their families
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3
To enhance personalisation (individualisation) of care for our service users.
4
To celebrate diversity, to improve inclusion and to ensure equity in all that we do for the people we care for.
5
To collaborate with our stakeholders so that we contribute towards the whole pathway of care providing integrated services which meet the needs of the population.
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Our objectives
Best PEOPLE 1
2
In order to recruit and retain our people we will provide exceptional induction, training, and development so they can excel in their role, progress, and maximise their potential whilst delivering outstanding care. To celebrate diversity, to improve inclusion and to ensure equity in all that we do as we are better together – We Are Elysium.
3
To ensure that our people have a voice and are confident to speak up.
4
To enhance the wellbeing of our people so that they want to stay with us for the long term.
5
To ensure that people understand the corporate, regional, and local structures, including their role, the accountability they hold, and the competencies expected of them to deliver the best care.
Best PLACE 1. To deliver partnership services in the right place, in community settings, which are aligned with the commissioning intentions of the Integrated Care Boards and the local population needs. 2. To improve the personalisation of environments to meet the needs of the people we care for. 3. To ensure our environments are well maintained, clean and fit for purpose. 4. To future proof facilities so they can flex to meet emerging population needs whilst supporting best practice environmentally. 5. To achieve net zero by 2040 in line with our Ramsay Health Care strategy and in line with Greener NHS – Delivering a net zero NHS (sustainability).
Measuring our success In setting our strategic priorities we have a responsibility to ensure that we act on them and measure our achievements. All implementation plans are reviewed on a quarterly basis by the Board.
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Sustainability As part of Ramsay Health Care, Elysium shares the global commitment to near-term and long-term targets to achieve Net Zero emissions across the Ramsay value chain by 2040. Each business in the Ramsay Health Care group is responsible for implementing our approach and improving our environmental and sustainability performance. The Group Sustainability Officer and Global Sustainability Committee, including regional Sustainability Leads, provide support and guidance to the Global Executive and Global Risk Management Committee on our approach and monitoring progress towards our goals. During this reporting period Elysium have undertaken baseline and climate vulnerability assessments on our sites. We are in the process of identifying appropriate facilities where solar electricity panels, also known as photovoltaics (PV) panels will make a demonstrable difference and will in 2023/24 look to begin installation. We are introducing electric vehicle chargers across several services to support the change to electric vehicles. Over 90% of our services participated in the Queens Green Canopy project, a unique tree planting initiative created to mark Her Majesty's Platinum Jubilee in 2022.
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Sustainability
Elysium actions include:
Launch of an Elysium Cares Team
Identify ways to save energy and reduce waste
NET
Communicate to colleagues, service users, carers, and suppliers about supporting our Net Zero emissions goal Encouraging all our people to be recycling champions
Promote sustainable commuting
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Statement of assurance from the Board During the year ending 31 March 2023 Elysium provided services on behalf of the NHS. Elysium has reviewed all the data available to us on the quality of care in all these NHS services. The income generated by the NHS services reviewed in the year ending 31 March 2023 represents 100 per cent of the total income generated from the provision of NHS services by Elysium for the year ending 31 March 2023.
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Statement of assurance, participation in audits
Participation in National Clinical Audits (NCAs) During the year ending 31 March 2023, we participated in the following Prescribing
Additional contractual audits we participated in, include:
Observatory for Mental Health (POMH-UK) audits: Topic 1h&3e: Prescribing high dose and combined antipsychotics
Audit
Topic 21a
The use of melatonin
Infection, Prevention & Control Audit
Topic 20b
Valproate prescribing in adult mental health services
Infection, Prevention & Control Self-Audit Self-Assessment Quality Monitoring Tool Safeguarding Audit
Participation in contractual audits
Data & Security Protection Toolkit
Elysium participated in the following contractual audits:
Care Home Care Plan Audit & Quality Schedule Workforce, Race Equality Standard Audit
Audit
Frequency
Patient Related Outcome Measures
Quarterly
Health & Safety
Workforce Race Equality Audit
Annual
DOLS/ MCA Audit
CAMHS Experience Surveys (on admission, mid treatment and discharge
As they occur
Care Home Statement of Compliance
Carer Experience Survey
Annual
Service User Survey (on admission, My Care and Treatment (annual), and Discharge
As they occur. My Care and Treatment (annual)
Observation Findings Audit
Friends & Family Test (as per discharge survey)
At the point of discharge
Ligature Audit
NHS England DCF Portal (Data Collection Framework): Annual SelfDeclaration (service specification)
Annual
NHS England DCF Portal (Data Collection Framework): QSIS SelfDeclaration for CAMHS and restrictive practice data collection
Quarterly
NHS England DCF Portal (Data Collection Framework): QCRS SSQD data collections
Quarterly
Medicine Management Audit Weekly Ward Compliance Audit
Elysium is compliant with all mandatory requirements of Mental Health Services Data Set, increasing the number of data sets that it provides in 2022 - 2023 and will increase these further in 2023 - 2024.
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Research Elysium are part of Ramsay Health Care who encourage a positive culture of research that can explore ideas, communicate best practice, and contribute to outstanding healthcare around the world. The Ramsay Global Community of Practice for research leaders and experts enables them to share knowledge, experience, tools, and approaches across our network of facilities and services. At Elysium staff members across the organisation actively participate in research to stay at the forefront of innovative healthcare delivery. Our research outputs inform the way we work and actively flow through to care delivery. All research involving service users receiving care within Elysium is subject to approval, as described in the Conducting, Hosting or Collaborating in Research policy. The policy provides details on ethical approval and data security.
CAMHS Title Giombini, L. (2022) Evaluation of Group Emotion Skills Training and Individual Cognitive Remediation Therapy in a specialist inpatient eating disorder service for children and adolescents (Doctoral Thesis). Available at: https://kclpure.kcl. ac.uk/portal/en/theses/evaluation-of-group-emotion-skills-training-and-individualcognitive-remediation-therapy-in-a-specialist-inpatient-eating-disorder-service-forchildren-and-adolescents(0a5d97bc-515c-400c-9bfe-3078560dd9fa).html Giombini, L., Nesbitt, S., Leppanen, J., Cox, H., Foxall, A., Easter, A., and Tchanturia, K. (2019) ‘Emotions in play: young people’s and clinicians’ experience of ‘Thinking about Emotions’ group’, Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, https://doi.org/10.1007/s40519-019-00646-3 Giombini, L., Moynihan, J., Turco, M., Nesbitt, S. (2017) ‘Evaluation of individual cognitive remediation therapy (CRT) for the treatment of young people with anorexia nervosa’, Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity, DOI: 10.1007/s40519-016-0322-4 Giombini, L., Turton, R., Turco, M., Nesbitt, S., and Lask, B. (2016) ‘The use of cognitive remediation therapy on a child adolescent eating disorder unit: Patients and therapist perspectives’, Clinical Child Psychology and Psychiatry, https://doi. org/10.1177%2F1359104516657859 Giombini, L., Nesbitt, S., Waples, L., Finazzi, E., Easter, A., & Tchanturia, K. (2018) ‘Young people's experience of individual cognitive remediation therapy (CRT) in an inpatient eating disorder service: a qualitative study’, Eating and weight disorders, 23(4), 499–505. https://doi.org/10.1007/s40519-017-0369-x
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Research
CAMHS Title Giombini, L., Nesbitt, S., Cox, H., Foxall, A., Sharia, T., Easter, A., and Tchanturia, K. (2018) ‘Cognitive remediation therapy (CRT) in a specialist inpatient eating disorder service for children and adolescents: CAN-CRT study protocol for a pilot randomised controlled trial’, European Eating Disorders Review, 26(5), https://doi.org/10.1002/erv.2592 Giombini, L., Nesbitt, S., Kusosa, R. et al. (2021) ‘Adapted emotion skills training group for young people with anorexia nervosa’, Neuropsychiatrie, 35, 76–83. https://doi.org/10.1007/s40211-020-00347-9 Nesbitt, S. and Giombini, L. (2021) Emotion Regulation for Young People with Eating Disorders: A Guide for Professionals, Routledge. Emotion Regulation for Young People with Eating Disorders: A Guide for (routledge.com) Tchanturia, K., Giombini, L., Leppanen, J., and Kinnaird, E. (2017) ‘Evidence for Cognitive Remediation Therapy in Young People with Anorexia Nervosa: Systematic Review and Meta-analysis of the Literature’, European Eating Disorders Review, 25(4) https://doi.org/10.1002/erv.2522 Waples, L. Giombini, L., Wiseman, M. et al. (2021) ‘Psychological changes in young people with anorexia nervosa during an inpatient treatment: exploration of optimal length of stay predictors’, Neuropsychiatrie, https://doi.org/10.1007/s40211-021-00390-0
Conference papers and workshops Title Ali, S., and Ogan, T. (2022) The Psychiatric Intensive Care of a Violent Mentally Ill Pregnant Woman; Antenatally, Through Childbirth, and Beyond, International Association of Women's Mental Health Annual Conference 2022 [Poster]. Bains, H. (2023) Evolution of neurodevelopmental services across the age spectrum in the UK, Annual Indian Psychiatry Conference [Presentation]. Broadhurst, S., and Swindell, K. (2021) Screening for ADHD in male medium secure psychiatric services, RCPsych Congress 2021 [Poster]. Coombes, P. (2021) Trauma and compassion – the blocks to effective CBT [Poster]. Haque, Q., Sen, P., Georgiou, M. et al (2022) Long COVID symptoms and patterns of vaccination in forensic patients, IAFMHS Annual Conference 2022 [Presentation] Kakkllaya, S. et al (2022) Effectiveness of behavioural reinforcement approach in female patients with EUPD and mild LD, RCPsych Intellectual Disability Spring Conference [Poster] Sen, P. (2021) Biological Predictors of Risk and Outcome in Forensic Mental Health Patients, IAFMHS Annual Conference 2021 [Presentation]. Sen, P. (2021) Developments in Mental Healthcare for Asylum Seekers and Refugees in Western Countries –The Science And The Politics: A UK Perspective, RCPsych Congress 2021 [Presentation]. Sen, P., Georgiou, M. et al (2022) Evaluating cultural competence of staff members at a secure service, IAFMHS Annual Conference 2022 [Presentation] Wilson, J., Huckle, A., Thomas, A. (2022) Open nursing stations on medium secure wards: An evaluation of safety and patient experience, IAFMHS Annual Conference 2022 [Poster]
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Learning disabilities and autism Title
Neurological services Title
Bains, H. (2023) ‘A specialist secure service for people with autistic spectrum disorders’, IAFMHS Newsletter (Winter, 2023). Available here: 2023 Winter Newsletter -v6 (wildapricot.org) Craven, R., and Shelton, L. (2020) ‘Assessing the effectiveness of the “I Can Feel Good” programme mindfulness module for a group of detained intellectually disabled patients’, Advances in Mental Health and Intellectual Disabilities, DOI 10.1108/AMHID-06-2020-0013 Craven, R., and Shelton, L. (2020) ‘Emotional problems and intellectual disability: comparing groups with and without forensic involvement’, Journal of Intellectual Disabilities and Offending Behaviour, DOI 10.1108/JIDOB-05-2020-0010 Collins, J., Halder, N., & Chaudhry, N. (2012). ‘Use of ECT in patients with an intellectual disability: Review’. The Psychiatrist, 36(2), 55-60. doi:10.1192/pb.bp.110.033811
Alderman, N. (2011) ‘Effectiveness of Neurobehavioural Rehabilitation for Young People and Adults with Traumatic Brain Injury and Challenging Behaviour’, Advances in Clinical Neuroscience and Rehabilitation, 11: 26-27. Alderman, N., Williams, C. and Wood, R.Ll. (2017) ‘Measuring neurobehavioural disability using the SASNOS: applications and new developments’, Advances in Clinical Neuroscience and Rehabilitation, 16 (3), 24-25. SASNOS-PDF-6.pdf (acnr.co.uk) Alderman, N., Williams, C., and Llewellyn Wood, R. (2021) ‘Using the St Andrew’s – Swansea Neurobehavioural Outcome Scale (SASNOS) to determine prevalence and predictors of neurobehavioural disability amongst survivors with traumatic brain injury in the community’, Neuropsychological Rehabilitation, DOI: 10.1080/09602011.2021.1946092 Williams, C., Llewellyn Wood, R., Alderman, N., Worthington, A., (2020) ‘The Psychosocial Impact of Neurobehavioral Disability’, Frontiers in Neurology, https://doi.org/10.3389/fneur.2020.00119
Psychiatry recruitment Title Halder, N., and Mulliez, Z. (2020) ‘Encouraging recruitment into psychiatry: practical initiatives’, BJPsych Bulletin, doi:10.1192/bjb.2020.53
Psychology Title Lazzari, C., Nusair, A., and Rabottini,M. (2021) Comorbidity and Similarities between Factitious Disorder and Borderline Personality Disorder: Theory, Psychological Assessment, and Management, Advances in Psychology Research. Volume 146. Lucock, M. et al. (2021) Using implementation intentions to prevent relapse after remission from psychological treatment for depression: The SMArT intervention, Psychotherapy Research, https://doi.org/10.1080/10503307.2021.1959079
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Research, mortality surveillance and prevention
Research practice Title Halder, N., Ramsay, R., Tyrer, P., and Casey, P. (2011) ‘Peer reviewing made easy’ Advances in psychiatric treatment, doi: 10.1192/apt.bp.109.007294 Halder, N., Tyrer, P., and Casey, P. (2020) ‘Peer reviewing made easier: your questions answered’ BJPsych Advances, 27(4), 255-262. doi:10.1192/bja.2020.62
Mortality surveillance and prevention Elysium operates according to best practice standards identified by the CQC, National Quality Board and NHS Improvement (Learning from Deaths in the NHS, 2017). Our Mortality Surveillance and Prevention Group chaired by the Executive Medical Director ensures that there is a robust approach toward the investigation of all deaths. In the vast majority, deaths relate to known, managed, longterm physical healthcare conditions associated with shortened life expectancy. Throughout the year we have further embedded the following initiatives across services to minimise the likelihood of
Secure services
avoidable deaths: NEWS (National Early Warning Scores) to support early
Title
detection of physical healthcare problems
Chadwick, E. (2021) ‘Beauty and the Beast: Trauma-informed dramatherapy with a male patient in a forensic setting’, in (eds) Hastilow, S. and Liebman, M., Arts Therapies and Sexual Offending, Jessica Kingsley Publishers. Arts Therapies and Sexual Offending – Jessica Kingsley Publishers - UK (jkp.com)
COVID primary vaccine and booster campaigns for staff
Sen, P., Forrester, A., Georgiou, M., Haque, Q., Ismail, N., and Neville, P. (2022) Mental health in the criminal justice system: austerity must now be reversed, BMJ, 376:o727 https://doi.org/10.1136/bmj.o727
Comprehensive IPC response to the COVID pandemic including
and service users Winter influenza vaccine campaigns for staff and service users supporting shielding of those identified as most at risk. Continued robust monitoring of physical health vital signs and
Tripp, E. and Halder, N. (2021) A systematic review of the content and modality of hallucinations in prelingually deaf people with schizophrenia, International Journal on Mental Health and Deafness, 5(1), http://www.ijmhd.org/index.php/ijmhd/article/view/59
metabolic indicators for services treated with emergency or
Webster, C., Eaves, D., Eaves-Thalken, J., Haque, Q. (2019) Risk Rules: A Practical Guide to Structured Professional Judgment and Violence Prevention, Pavilion Publishing. Risk Rules - A Guide to SPJ and Violence Prevention, Pavilion Publishing (pavpub.com)
and young people alongside responsive access to primary and
continuing psychotropic medication Maintain comprehensive physical healthcare screening for adults specialist secondary care Targeted campaigns to address underlying risk factors associated with physical health morbidity (Smoking cessation, Mission Fit, Reducing Falls and Deep Vein Thrombosis)
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Use of CQUIN
Data quality
(Commissioning for Quality & Innovation)
Elysium was not required to submit records during 2022/2023 to the
The CQUIN framework aims to support operational improvements in
Secondary Uses Service for inclusion in the Hospital Episode Statistics
the quality of services commissioned by NHS England. Both CQUINs
which are included in the latest published data.
were for our CAMHS services and these were Needs Formulation and Supporting Quality Improvement in Restrictive Practice.
Data security and protection toolkit Elysium has provided all mandatory evidence for assessment and has been deemed to have met the required data security and protection
Regulator statement
toolkit standards.
All our services in England are registered with the Care Quality
Clinical coding error rate
Commission and our services in Wales are registered with either Healthcare Inspectorate Wales (hospitals) or Care Inspectorate Wales
Elysium was not subject to the Payments by Results clinical coding audit during 2022/2023 by the Audit Commission.
(care homes). Each of the schools within our Children and Education division are Ofsted registered. During this reporting period Elysium had a well-led review by the CQC, an Action Plan was developed and monitored, with progress well underway. Two services, The Copse in Somerset, and Bradley Apartments in Lincolnshire were participating in ongoing investigations during this reporting period.
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Quality Account 2022 | 2023
PA R T 2
CQUIN, Regulator statement, data quality/security, Governance
Governance Elysium’s Clinical Governance (CG) is supported by accurate, effective, and timely communications which enables ward to board reporting. This allows us to focus on achieving good clinical care and is an essential part of a well-led organisation. The aim of CG ensures that Clinical Directors (CDs), clinical leaders, Lead Clinicians (LCs) and Operation Directors (ODs) lead regional governance feedback from agreed proforma, sharing planning and local and regional actions. The Corporate Clinical Governance Meeting (CCG) also receives reports from standing subgroups, and key safety and compliance performance reports that are part of the core CCG function to ensure oversight and effectiveness of quality and safety assurance as part of the overarching clinical governance function. Quality Governance combines evidence-based care, professionalism, effective compliance and assurance to ensure that service users receive high quality care. This is achieved in partnership with service users, their friends and family, regulators, commissioners, and experts by experience. Everybody has a part to play in quality governance. Our Quality Governance Guide for staff clearly outlines our expectations from staff and from the company in supporting staff.
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Clinical Governance Subgroups Quality across Elysium relies on the expertise across our workforce, working in partnership with our services users and their families. We have the following sub-groups in place with multidisciplinary representation across our portfolio: Physical Healthcare and Wellbeing Committee Policy and Procedure Committee Quality Improvement (QI) Committee Reducing Restrictive Interventions Group Research Network Security Group Clinical Ethics Committee Health and Safety Committee Infection Prevention Control Group Mortality Surveillance and Prevention Group Neurodevelopment Group
Ways in which we monitor our services: Audits
Our Quality Framework
Policy and procedure
The Elysium Quality Governance Framework
Proven clinical treatments Incident management process including reporting and investigating serious incidents
enables us to deliver transparent, effective, and responsive care and clarity of reporting throughout our services. The Corporate Clinical Governance and Corporate
Safeguarding reports
Management Committees meet monthly and
Executive team visits to sites
are chaired by Dr Quazi Haque, Executive
Attendance at community meetings
Medical Director and Joy Chamberlain, Chief
by executives
Executive Officer respectively. The meetings
Service to Board/Board to Service reports Internal and external inspections
are attended by the Operations Directors and the operational and clinical leads of all our service lines. At the meetings, monthly
Risk registers
quality reporting information from each site
Complaints and whistleblowing
or service is reviewed.
Listening and responding to feedback Continuous learning and development Ward quality monitoring by staff
Patient Safety Incident Response Framework
and service users
(PSIRF) Development Project Group
Staff appraisals Staff forums Service User Network forums Service user/staff community meetings Patient Experience Lead visits Expert by Experience visits
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Quality Account 2022 | 2023
PA R T 2
Governance, our quality framework
Elysium Board
Clinical Governance (CG)
COVID Governance
Operational Meetings (info only if needed)
n Standing Governance items (every meeting) Standing Reports
n Sub Group reports (timetabled)
Sub Groups
n Output of CG via comms
Policy & Regulation – Report and Policy for ratifying
Learning and Development – Update and future plan
Clinical Director (CD/LC) / Operations Director (OD) Reports – (every meeting)
Safeguarding – Reports
n Templates for regional governance (RG) reports (reporting last RG)
QI – Update and future plan
Clinical Effectiveness – Report
n RG meeting to occur week after CG – to allow planning time for reports at next CG
Security – Update and future plan
SUI – Report
n Thematic CD/LC/OD reports on set subjects over a planned year
Physical Health – Report
n All Data submitted to CG is validated Ethics – Report
Service User and Carer – Report
Medical-Legal - Report
Medicines – Report
OD/CD/LC Led Governance Reporting IM – Report on system wide issues
R&D – Report
Regional Governance – Proforma /agenda
Ad Hoc & T&F – TOR
Identified Participants and Leads
Hospital and Care Home Governance – Proforma /agenda
BAU Line for data
Validated Information Flow - Primary flow to Hospital, Care Home and Regional Governance
Hospital and Care Homes Information QA Data
Performance Data
n Information Flow Contractual Data
n Participation
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Freedom to Speak Up We want staff to carry out their roles to the best of their ability and ensure that those we care for receive the best possible care. Service user and staff safety, and wellbeing is at the heart of everything we do. It is very important to us that any concerns relating to the safety or wellbeing of staff or service users are raised. There are six different ways people can raise concerns, each offering a different route depending on what is most comfortable for the person raising the concern.
At Elysium staff must speak up by raising a concern with any of the following: 1
their Line Manager
2
their Registered Manager
3
their Operational Director
4
the Elysium Board (direct access to the Board by email)
5
the nominated company Speak Up Guardian
6
our Staff Concern Line which is operated by an independent company
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Quality Account 2022 | 2023
PA R T 2
Speak Up
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Quality Account 2022 | 2023
PA R T
3
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Quality Account 2022 | 2023
PA R T 3
Review of performance
Review of performance Our objective is to provide the best care, delivered by the best people in the best place. We will achieve this through the implementation of our strategic priorities which have been developed with input from our people, those we care for, their families and carers, Experts by Experience, and many of our partners. We have taken into account key learnings from a number of recent events which include;
COVID-19, keeping people safe from infection
Edenfield, Greater Manchester, keeping people safe from harm and supporting people to speak up
Recommendations from the National Mental Health Director in relation to Edenfield
Recommendations from the 2022 CQC Well-led review
Patient Safety Incident Response Framework
Our priorities are completely aligned throughout the organisation, with every site and support function championing their development. This is underpinned by an overarching corporate implementation plan.
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Creating a culture of improvement Elysium has formed a Quality Forum for Regional Quality Leads to support sharing and learning between different parts of the organisation. Each member provides an update on topics in their region and any good practice they wish to share. It is an
Case study
opportunity to identify arising key themes, discuss common issues, and consider potential solutions.
Quality initiative for learning disability and autism services
2022|2023 Health Education Group for people with a learning disability
An inclusive project to improve the physical health and wellbeing of men with a learning disability at The Spinney was launched to help fight a range of health conditions such as high cholesterol, obesity and diabetes and improve mental wellbeing. This group of men required additional support to understand their health conditions, what makes a healthy lifestyle and the importance of making healthy choices. The team adopted a culture change surrounding physical health and wellbeing, which included staff and the people being supported. They provided accessible, relevant, health education in an informal and interactive way. A 12-week educational group was introduced, and each session had a different topic, such as healthy meals, sugar intake, exercise, personal hygiene, oral hygiene and a final session with a quiz and awards. The service users decided to call the group “The Feel-Good Club”. The sessions have been designed to be accessible, taking into account people’s complex communication difficulties and concentration levels with each session starting with a re-cap of the previous week’s subject. The sessions are presented using accessible formats, interactive activities, and group work. Practical
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activities are introduced such as trying healthy alternatives, doing a workout routine, or setting a challenge relevant to the topic to achieve by the next session. Everyone has their own file to record their progress in a format including visual prompts, which is meaningful to them. Outcome measures include the monitoring of participant’s weight and BMI along with the completion of the Patient Health Questionnaire 9 (PHQ9) which looks at patient mood and mental state. These are repeated at the end of the 12-week programme and progress recorded. Engagement has been very positive, and feedback suggests that individuals have found the sessions fun and interactive. We have seen remarkable changes to several people’s approaches to their health and wellbeing with some patients actively choosing healthier food and drink options and engaging in more physical activity. “I have been coming to the group and getting information. It has been very good, and the staff are giving us good advice. I am making healthier choices.” Service user, The Spinney
Quality Account 2022 | 2023
Case study
PA R T 3
Review of performance
Quality initiative for CAMHS and speciality services 2022|2023 Reducing nasogastric (NG) feeds under restraint in an adolescent eating disorder inpatient unit Nasogastric (NG) tube feeding under restraint can be a lifesaving intervention in the treatment of certain eating disorders. Although sometimes essential, it is an extremely restrictive intervention which can be traumatic for patients, staff and families who’s loved ones are being fed in this way. During a Multidisciplinary Team (MDT) reflective practice session, the nursing team at the Brighton and Hove Clinic raised concerns about the number of NG feeds they were delivering. They were concerned about the impact on the young person involved, their peers, staff, staff patient relationships and the unit culture. The team were prompted to review their working practices and address the culture around NG feeding on the unit. The aim of this work was to achieve a 50% decrease in restraints for NG feeding within one month. The introduction of personalised
care plans for NG feeding lowered the cases of NG feeding under restraint by 83% in the first week, compared to the previous week, and 74% in the first month compared to the previous month. The team used Plan, Do, Study, Act (PDSA) and Quality Improvement (QI) cycles and ran a focus group with staff to brainstorm ways in which to improve practice. This led to two phases of change. In the first QI cycle, the team switched from routine delivery of NG feeding under restraint to an MDT care planned decision. This single change led to an 98% reduction in NG feeds delivered under restraint when comparing the first six months. In the second PDSA cycle, the team worked with the National Patient Safety Improvement Programmes, specifically the Reducing Restrictive Practice Programme (RRP).
By creating and implementing personalised care plans for NG feeding, the team reduced the instances of NG feeding under restraint and improved communication inside the team, as well as between the patients and the staff members. Through this work there is an overall reduction in the use of restrictive practice and there is a positive atmosphere and sense of community for the young people, families, and staff members. The RRP programme completed in March 2023, and data submitted to the NHS monthly. The project has been added to the Elysium Quality Improvement (QI) system. The team were invited to share their project at the Mental Health Collaborative in February 2023. “There’s been a big improvement in terms of reducing distress around feeds for the young people. It’s been more intensive for staff, but made them much more aware of the implications of the intervention” Registered Manager, Brighton & Hove Clinic
We have learnt that simple solutions, followed thoroughly and consistently can bring spectacular results. In fact, the nursing team has noticed an instant improvement, presenting in patients walking into the treatment room.
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Case study
Quality initiative for mental health & wellbeing services 2022|23 Dysphagia and Mental Health – a tough pill to swallow Dysphagia (difficulty or discomfort in swallowing) can affect people at any stage of their lives and many mental health conditions have dysphagia associated with them, either as an intrinsic part of the disorder or as a side effect of medication. Staff working within mental health services require experience, skills, and competence in dysphagia to enable them to support people effectively. This includes areas such as signs and symptoms of dysphagia, safe eating and drinking strategies and International Dysphagia Diet Standardisation Initiative (IDDSI) descriptors. As part of this it is important to ensure that staff have access to effective training. A lack of understanding of dysphagia has the potential to lead to increased risk of non-compliance of care plans and possible increased risk of aspiration and choking in patients with dysphagia.
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At St Mary’s hospital in Warrington, an evaluation of the current training appeared to show some gaps around staff understanding and a generalisation of learning to patient specific situations. Reflecting on this a full review of the content and method of delivery of the training package was completed. The service adopted the three-tier competence-based training model from LaVigna et al (1994) to design a more effective, interactive training package. Bespoke training was designed to be delivered at ward level and targeted the specific needs of the patients with dysphagia on the ward. The training included functional activities, group work, problem solving activities, role play and interactive activities. Staff reported that they preferred the interactive training as it gave them opportunities to embed their skills and ask questions specifically relating to the patients they support, creating a more meaningful training session.
Following this review and putting in to place the new style of training, St Mary’s provided a more effective learning experience. Creating and delivering an innovative and interactive training programme appeared to significantly improve staff’s understanding of dysphagia ultimately improving patient care and reducing the risk of harm.
Quality Account 2022 | 2023
PA R T 3
Review of performance
Case study
Quality initiative for neurological services 2022|23 Implementing a physical health strategy within a specialised Neurorehabilitation setting Working in Neurorehabilitation, psychological interventions are at the core of our service. However, it is well established that Acquired Brain Injury (ABI) patients often present with a complex mix of cognitive, behavioural/ psychosocial, and physical needs. Understanding those needs and evolving interventions that address all of them simultaneously is essential to progress. Evidence clearly shows how a good level of overall physical health can improve emotional wellbeing, this in turn will allow cognitive and behavioural interventions to have more impact. At Avalon Neurological Centre, the service has employed a Nursing Assistant Practitioner for Physical Health (NAP) to improve physical health care delivery, communication, strategy, implementation, and to promote patient engagement. The NAP’s role and primary focus is to help patients achieve improved physical health, through supporting interventions, educating and promoting good healthy life choices and routines.
Through systematically organising and coordinating care delivery into manageable chunks, barriers to effective physical health interventions have been identified. Interventions include: n Weekly physical health therapeutic group sessions patients n NAP and RGNs also see patients 1:1 in line with ICR to support discuss concerns privately
and effective where actions are logged and follow ups recorded appropriately. All physical health results are also provided during GP rounds and added to care notes. Avalon has their own wheelchair vehicle to support external healthcare appointments. Within the service there is inclusive and accessible equipment such as wheelchair scales to reduce the risk to staff during routine physical health checks.
n Induction and refresher staff training to highlight the importance of monitoring physical health n RGN and NAP as named points of contact for physical health queries and appointments n NAP arranges service to be brought in where a patient is unable to leave the ward, enabling physical health interventions for the most vulnerable patients n NAP is named contact for physical health, coordinating ward rounds, medical appointments and recording and documentation of care delivery Having one named person to oversee physical health delivery has enabled more robust recording and sharing of information within the team. The ward rounds are more structured
Thank you for the help you provide each week in support of the GP visit to Avalon. Since starting in this role, the handovers have been efficient and concise covering the physical wellbeing of each patient. It is useful to have you as the liaison between the GP surgery and the staff at Avalon, encouraging real team working between the many disciplines present in the unit and at the GP service. Current GP, Avalon Neurological Centre
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Clinical specifications
Our Guiding Principles Our model of care is guided by the following principles in striving to achieve these standards:
We have challenged ourselves to develop models of care which are co-produced, recovery-oriented, and evidence-based which place the people we support at the centre of all that we do. Clinicians from all professional backgrounds have worked together
Collaboration
with Experts by Experience to produce models of care and service
We co-ordinate with the referring community team and other relevant agencies around the treatment plan, including discharge arrangements, ensuring continuity of care.
specifications for each of our service directorates. These documents set out principles of treatment, specific treatment protocols, clearly defined purpose of admission, identified risk management protocols and tools, evidence-based best practice according to research and clinical diagnostic tools and practices. Elysium use a range of tools to measure and monitor services and treatment. These tools also evidence our outcomes. Our shared goal is to make our services, centres of excellence that are trauma-informed, humane, culturally responsive,
Compassionate services Our staff treat people with compassion, dignity and respect.
Equitable services
Evidence based
The care that we provide does not vary in quality because of a person’s characteristics.
We provide our services based on evidence.
collaborative, and effective in addressing mental health, learning disabilities and autism and complex social care needs. We are
Safe and effective
Timely and responsive
committed to ensuring our services celebrate diversity, remove
We provide services that avoid harm to patients, both physically and psychologically. Least restrictive options are employed in the treatment plan.
Our services are responsive to people’s needs and choices, and arrange for appropriate care as soon as is possible.
inequitable care and the models of care we use are regularly re-evaluated in partnership with all stakeholders, especially those with lived experience. We endeavour to improve knowledge and awareness of learning disabilities and autism and make necessary adaptations to care
Co-production
and risk management to optimise the safety and day-to-day
Co-production of the treatment plan occurs with the individual, their family and the referrer.
functioning of these individuals and to promote equitable access to high quality health and care services that meet their needs.
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Quality Account 2022 | 2023
PA R T 3
Review of performance
In addition to the tools used to measure individual progress and
keep up to date with professional competencies through annual Basic
monitor the quality of our services and outcomes, we fully engage
Life Support (BLS) or Immediate Life Support (ILS) training and regular
with external professionals, community services, families, carers, and
emergency medical simulations. All services use National Early Warning
services users. This is through informal engagement, developing a
Score (NEWS2) parameters to monitor health.
collaborative and holistic approach to care and through the formal
Elysium is committed to suicide prevention and our suicide prevention
infrastructure of Care Programme Approach (CPA) and Care (Education) and Treatment Reviews (CETRs).
strategy is underpinned by national policies and frameworks and guided by the organisation’s suicide prevention group. Our objectives are
Elysium continually monitors and reviews key areas of service provision
aligned to the National Suicide Prevention Strategy for England (NSPS).
for opportunities for learning and improvement, at service, regional
Our models of care support a positive and therapeutic culture
and corporate level. This includes monitoring activity such as length of stay, responsiveness to referrals, monitoring and reducing the use of
across the whole organisation.
restrictive interventions and robust review of all incidents in line with Patient Safety Incident Response Framework (PSIRF) arrangements. Across all services a programme is in place to improve physical health outcomes by reducing rates of obesity and diabetes, improving fitness
"It is positive that even through a difficult time
and health screening and access to primary healthcare services. There
(bereavement) we can see good positive risk taking with
is a corporate physical healthcare group to promote best practice and
the swimming sessions. There is a true PBS approach with
monitor outcomes, informed by National Institute for Health and Care
discharge in progress and a timeline. Communication has
Excellence (NICE) guidance. We review and agree quality activities in consultation with our NHS-led provider collaboratives. We support and observe the STOMP principles (stopping over medication of people with a learning disability, autism, or both, with
been positive with weekly updates and 1:1 records being sent to show improvement, things like that have been positive." ICB Case Manager, Essex, January 2023 - The Chimneys
psychotropic medicines). We ensure our medical and nursing staff
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Improving our services through peer review
Service
Date of last review
Outcome
Service
QNFMHS
Our services participate in peer review All Saints
February 2023
Awaiting report
Arbury Court
March 2022
% standards met: 84% MSU 69% LSU
Quality Network for Forensic Mental Health Services (QNFMHS) Quality Network for Psychiatric Intensive Care Units (QNPICU)
Chadwick Lodge
October 2022
Awaiting report
April 2022
% standards met: 65% MSU 69% LSU
Quality Network for Inpatient CAMHS (QNIC)
Farmfield
Quality Network for Working Age Services (QNWA)
The Farndon Unit
September 2022
% standards met: 64% LSU
Gateway Recovery Centre
May 2022
% standards met: 75% LSU
St Mary’s Hospital
March 2022
% standards met: 68% MSU 57% LSU
The Spinney
March 2022
% standards met: 78% MSU 75% LSU
Thornford Park
April 2023
Awaiting report
Wellesley
April 2022
% standards met: 66% MSU 71% LSU
Prescribing Observatory for Mental Health (POMH) Not all membership options provide a rating of overall performance, but a review summary. The following table details the date of last review and the outcome of the review process for each participating service.
46
Outcome
QNPICU
networks organised by the Royal College of Psychiatrists, including:
Date of last review
Hulton Ward
November 2022
% standards met: 54%
QNIC Brighton and Hove Clinic
April 2022
Focused review only
Cotswold Spa Hospital
May 2022
Focused review only
Rainbow Ward, Rhodes
April 2022
Focused review only
Wood Hospital
May 2022
Focused review only
QNWA Participating, no report available at this time
Kenn Ward
POMH
Elysium Healthcare
December 2022
Received benchmarking report on prescribing of antipsychotic medication in adult mental health services, including high dose, combined and PRN
Quality Account 2022 | 2023
PA R T 3
Review of performance
Evaluating care One of the most important measures in evaluating care is the feedback from service users. Here is the main feedback from our surveys:
Service User Satisfaction Surveys 2022
Adult
CAMHS Key strengths
Areas for us to develop
Key strengths
Areas for us to develop
People are able and do attend regular ward community meetings
Improve people accessing and participating in activities in the local community
Were made to feel welcome on admission and were shown round the unit
Review how services offer and schedule Primary Nurse sessions so that they are happening on a weekly basis
Understand their rights regarding consent to treatment
Increase the time people we support have with staff to improve communications, feedback, and the relaying of important information in a polite and timely way.
Said they knew who their Care Coordinator and their Primary Nurse were
Ensure young people are given patient information before or on admission
Access to education and their education needs were being met
Decrease agency staff at nights and weekend who, through lack of training, sometimes say unhelpful things
They understood their diagnosis and felt appropriate decisions were made about their care
Improve the communication between staff, patients, and MDT members
Know how to access the advocate and how they can help People feel supported and encouraged by staff members to progress in their recovery
Know how to make a complaint
Improvement to healthy food choices Improve staff training and avoid frequent staffing changes
Felt they could manage their difficulties more effectively now and have increased knowledge and understanding
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Evaluating care
Service User Satisfaction Surveys 2022
Learning Disability & Autism
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Key strengths
Areas for us to develop
Neurological Key strengths
Areas for us to develop
People are asked what they would like to do and given choice
Improve the choice and variety of food to include healthier options and encourage selfcatering
People were supported well to keep in touch with their family and friends
Increase participation in activities in the local community
Those we support felt safe and looked after in their service
Involve the people we support in decisions about how to make their service better
Service users felt safe in their service
To consider individual preferences when planning activities
People felt that staff talked to them, and they were listened to
Support people we care for to be more involved in discussions around their care
People can access the right technology to help them stay in touch with their family and friends
Increase permanent staff base and reduce agency
Good support was given for people to stay in touch with their family and friends
More choice in activities which are offered
People understood their rights regarding consent to care and treatment
Improve catering to provide more choice for dietary and cultural needs
Quality Account 2022 | 2023
PA R T 3
Review of performance
Ensuring that people have a positive experience of care
Corporate Experts by Experience Elysium employs Corporate Experts by Experience who are integral to improving service users experience of our services. Each Expert by Experience has personal experience of services or has cared for an individual who has used services. These
Service user survey
members of our staff team bring with them a wealth of
the percentage of service users across all hospitals rated their stay with us as good or very good
70%
knowledge to ensure the people we support are heard and in turn, will help us shape our services and the support we offer. These professionals have oversight of the work we do which incorporates coproduction and involvement.
Service User Survey (Adult MH & Neuro) 2022
Service User Advisory Group Elysium has a Service User Advisory Group which its members and the contributions of the people we support impacts our
Staff survey
70%
87%
the percentage of our workforce who would recommend Elysium to family and friends if they needed care or treatment the percentage of our workforce that get satisfaction from the work they do
Staff Survey 2022
how we create meaningful change. The Service User Advisory
69%
the percentage of our workforce that would recommend Elysium as a good place to work
Group meet quarterly and have been asked how they would like the group to progress and what they feel the meetings should look like. The initial aims of the group include: Review of policies Review of post CPA feedback guidelines
78%
the percentage of our workforce who say Elysium has a positive culture
Review of implementation of new corporate strategies Diversity, equity and inclusion are a key part of all collaboration and coproduction, with every effort made to ensure inclusivity. Service users are also involved in our coproduced Quality Improvement (QI) projects at both local and national levels.
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Service User
Involvement example
Real work opportunities for service users Providing meaningful work opportunities for service users is an integral part of the rehabilitation experience at Elysium and include: Elysium-wide awareness of the therapeutic use of work Consistent payment protocols
Service users at Field House in Derbyshire are integral to the monthly patient audit on quality walk-rounds of the service and report their findings back to the Registered Manager for actions. This is driven by the NHS England (NHSE) and NHS Improvement (NHSI) request that service users be involved in quality standards. Field House also has service user representatives who ensure that the people who are supported there have their voices heard. Individuals at Field House are meaningfully involved in the recruitment and interview processes for new staff, with volunteer service users attending and supporting recruitment days.
for service users Local action plans to support work opportunities Service users at Field House are encouraged and supported to deliver walk round tours of the service for new staff, host Integrated Care Boards (ICBs), Care Quality Commission (CQC), families and other visitors. “Having the individuals, we support at recruitment open days with us really is great. Not only does it help us to engage with people thinking about working at Field House, but it also helps builds the social skills people need to move on to more community facing living.”
Annual reviews to reflect on achievements Designated local Work Opportunity Champions Expert by Experience roles Guidance and support packs for service users
Vicky Gibson, Registered Manager, Field House
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Quality Account 2022 | 2023
PA R T 3
Review of performance
Mission Fit Mission Fit is a 13-week modular programme that uses physical exercise to support education on the NHS Eat Well Guide, improve social skills, build confidence, and offer service users access to the community which benefits their rehabilitation. The range of activities on offer means there is a good choice of activities for
Mission Fit initiatives 2022 | 2023
individuals wanting low impact exercise and for those who want
Community weekly gym sessions
to push themselves further. Offsite activities offer people the
Golf course and driving
opportunity to experience new settings, increase their confidence out in the community and to volunteer at the gyms.
range sessions Ward based exercise classes
FIT
mıssıon
Green gym spaces for outdoor exercise classes Outdoor circuit training Walking groups Cycling Community Football Sheep walking sessions
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Care Programme Approach (CPA) Patient Related Outcome Measure (PROM)
"Just wanted to thank you and
During this reporting period we used the quality measure identified by services users which would be meaningful from their perspective. This was the Care Programme Approach.
all your staff for their hard work with the complex and probably difficult cases we have placed with you, and the way
How it works:
the service runs from an admin
The service user receives a printed postcard which enables them to grade their CPA meeting between one and five.
point of view. We obviously
How helpful was your CPA meeting? Unsupported and didn't understand the meeting
1
2
3
4
5
Supportive and clearly understood the meeting
have different experiences
(Please circle one number above to rate your CPA meeting)
in different hospitals and my
If you chose a score less than 5, please let us know what could have been better: (Tick where appropriate - you can choose more than one)
They can use a tick box to indicate where the
Attendance by a key staff member
main areas of concern are and write free text.
Additional personal preparation time needed
Further comments
Any problems with the venue?
colleagues all speak highly
If we've missed anything let us know!
of you and the quality of the
Increased support from your Care Coordinator More involvement from your family preferred
The data from the postcards is entered in our
Reports could have been made clearer
service."
Decisions at the meeting could have been clearer
electronic records and discussed with the
Were you happy with the outcome?
Commissioner, West Yorkshire ICB, December 2022 - Three Valleys
clinical team to see what we can learn from the feedback and improve future CPAs. The service user keeps the postcard in their portfolio so they have a record of each
CPA Feedback Card
meeting and can track how satisfied they are. This method is an opportunity for service users to
Your opinion matters to us We want to know how you feel about your recent CPA meeting and if it can be improved. It would be great if you could provide us with your feedback - it won't take long!
express their feelings about their CPA. It is also an opportunity for clinical teams to review each
Name:
Hospital:
Date:
If you need help completing this please speak to a member of staff.
CPA taking in to account the feedback provided by the service user.
52
Quality Account 2022 | 2023
PA R T 3
Review of performance
Family, friends and carers
Role of families and carers
A total of 294 ‘Experience survey: Family, friends and carer’ surveys
Families and carers along with the people we care for are
were returned from 51 services, up from 44 services the previous
supported to have active participation in all aspects of care and
year. Responses ranged from one survey completed for a site, to 25
treatment planning and decision-making. We promote family
surveys which reflects the different types and sizes of our services.
and community connections, acknowledging their experiences
From the survey the following highlights have emerged.
and skills to support learning and improvement. This ethos of involvement is proactively promoted, and it features at all levels of the organisation, from corporate Experts by Experience,
Key strengths
Areas for us to develop
85% of all carers stated ‘agree’ or ‘strongly agree’ that they were welcomed by the service and treated with respect
Involving carers in service developments and asking carers for their views on service changes and improvements
83% of all respondents stated they could easily make contact with their loved one, and 80% stated visiting arrangements were easily explained
Signposting carers to alternative forms of support
78% of carers stated they could have a conversation with their loved one with privacy
Providing carers with written information on consent and confidentiality, and how to comment on the service or make a complaint
71% of carers stated ‘agree’ or strongly agree’ that there loved one was receiving high quality care tailored to their needs, and 70% of carers stated they felt listened to by staff.
Providing carers with carer engagement opportunities
service user advisory groups, representation on groups core to local service design and delivery.
Elysium have developed a Carers Charter and Family, Friends and Carers handbook to align with the standards as laid out in the NHS 'Carer support and involvement in secure mental health services: A Toolkit'
Audit period April 2022 to March 2023.
53
Diversity, Equity & Inclusion We are committed to providing services that are accessible, inclusive, and non-discriminatory by promoting equity and leveraging the skills, experience, and knowledge of our diverse workforce. Our aim is that Diversity, Equity and Inclusion (DEI) is an essential part of daily working, and our entire workforce can thrive and achieve their full potential in a culture that is respectful and inclusive. In August 2022 Elysium launched the We are Elysium initiative along with a DEI Steering Group with representation across the organisation. Elysium’s Head of Diversity was recruited to focus on DEI to accelerate our progress in building a culture which celebrates diversity. Employee Resource Groups (ERGs) have been launched which bring together employees with a shared interest in a DE&I topic, whether as a member of a diverse community, or as an ally or supporter. The aim is to provide a network for support, be a collective voice, raise awareness, and develop initiatives that will lead to greater inclusion for all our staff. The five ERGs that were elected by the workforce are: Women, Disability, Working Families and Caregivers, Race & Ethnicity and LGBTQ+.
Mandatory DEI e-learning has been implemented as well as a session at staff induction. Other training available includes Introduction to LGBTQ, Transgender Awareness, Unconscious Bias, and Banter in the Workplace. Inclusive leadership sessions have been run at senior leadership level with further training planned. Monthly communication and reporting on DEI initiatives and progress has been implemented together with an internal DEI intranet site. A three-year DEI Strategy has been developed which builds on the work already started, addresses the recommendations from the Benchmark and Audit conducted previously and provides the DEI strategic direction for Elysium which is aligned to the corporate strategy and objectives.
54
Quality Account 2022 | 2023
PA R T 3
Review of performance
Investment in our workforce Our people are our greatest asset, their training, health, and wellbeing are very important to us. The settings in which our teams work are highly specialist and we have developed our training matrix to support this. We have also invested in our induction programme to help better prepare new staff for their roles in the care sector.
2.0
Elysium Employer Brand Guidelines Our values - what unites us, drives us, inspires us and guides us
Values
Our shared values
Whenever you create an experience, ask yourself whether you exhibited any or all of the below. Whether you did it the Elysium way.
In March 2017 we consulted with our patients, residents, staff, management team and our Board on our values. These are the behaviours that unify us and set the standard for how we manage our decisions and our actions as a company. Opposite is what the people of Elysium stand for and what you can expect from interacting with us, working with us or receiving care from us.
Our values are also inherent throughout all of our communications.
Anything done by the business or its employees, that doesn’t live up to these values, is unacceptable.
They’re in our tone of voice. They’re in our website. Our advertising. And our environment.
Remember, standing for something is more than mere words – it’s actions.
They are the backbone of our culture, how we are to each other, and we have to live up to that.
So ask yourself this, if we’re not in the room, will people judge us correctly and say we acted in line with our values?
Protect it.
We certainly hope so.
Elysium Employer Brand Guidelines
Elysium Employer Brand Guidelines
Our Employer Value Proposition - Why great people want to join and stay with us
We’re all about clarity, understanding and the individual
EVP Deliver an individualised experience. Creative Expression
The lasting thought we leave with candidates and employees.
Employer Brand Guidelines 2019 5
3.0
All employees: Nurses Clinicians Doctors Cleaners Receptionists Porters Patients and family Etc...
Every organisation has a reason for people wanted to join and stay, this is called an Employer Value Proposition. Effectively, for us, it helps us communicate our strengths to both employees and candidates, meaning our employment experience is consistent, transparent and relevant. The expression of our EVP is what we want to leave in the minds of our audience – it sums up the ‘what’s in for me?’ factor as well as providing us with a brand idea that can be used across all our collateral, website and social media channels, and much, much more.
We arrived at the opposite findings (which you have to read bottom to top, by the way) by arranging interviews with colleagues and looking at our competitors, to determine what the conventions of our market are – you’ll be surprised how alike we all are.
Long-hand EVP The deal.
By going through this exercise, not only did we unearth our value proposition, we now also have insights that can propel us above our 6 competitors and make us even more relevant to those we need to attract and retain – the people who make Elysium a great place to work and a great place to recieve care.
EVP Pillars
The truths that support our proposition.
9.0
Bring out the emotive benefits Challenge the market A rallying call for quality Defining the employment experience United sense of purpose
What delivering great healthcare should feel like.
We ensure our staff have the right environment and support to flourish and we empower them to deliver the necessary care to patients. With four services provided, there is diversity not only in what you want to do now but where you might want to grow into.
Cared for
Room to grow
Prepared
Supported Well-being Valued Recognised Respected People
Variety of roles and pathways to progress
Environment Development Investment
Part of something bigger, national
Let’s not be vague, let’s talk directly to our employees and our candidates. Let’s involve them, converse with them and share with them. It’s a human thing.
Regular contact, simple language and interesting thoughts. That’s how we develop the best working relationships.
Empowered
Let’s see the individual and their ambitions, motivations and suggestions.
Values
The behaviours that underpin the employment experience.
7
19
Innovation | Empowerment | Collaboration | Compassion | Integrity
8
Let’s show just as much care here than we do to our patients.
20
Employer Brand Guidelines
55
Preceptorship Programme and Preceptorship Academy Elysium is committed to the development of newly registered Nurses and supports this with a fully structured and researched Preceptorship Programme, completed
Preceptorship Nurses through Preceptorship Academy
75
within the services of the organisation. In addition to the Preceptorship Programme, Elysium also provide a Preceptorship Academy for all newly qualified Nurses to gain extra support and training over a 12-month period.
Apprenticeships n Assistant Practitioner Apprenticeship The Assistant Practitioner apprenticeship prepares the Healthcare Workers
Apprenticeship figures April 2022 – March 2023 Shortened Nursing Degree Apprentices in training
1
Nursing degree apprentices qualified between 31st March 2022 & 1st April 2023
0
Nursing Associate Apprentices in training
6
Assistant Practitioner Apprentices in training
20
Assistant Practitioner apprentices who completed their training between 31st March 2022 & 1st April 2023
0
Assistant Practitioner Apprentice applications for next cohort
6
to become Assistant Practitioners and they qualify with a Level 5 Foundation degree (or diploma). The Assistant Practitioner is a highly trained Senior Support Worker who takes on extra responsibility in the care of the service user group and they gain many new skills including those associated with physical health. n Nursing Associate Apprenticeship The Nursing Associate apprenticeship is a Level 5 Foundation degree, which prepares the trainee to become a Registered Nursing Associate. The Nursing Associate role is registered with the Nursing & Midwifery Council (NMC). n Shortened Nursing degree apprenticeship This apprenticeship allows people who have completed their Assistant Practitioner or Nursing Associate apprenticeship to go on and train to become a Registered Nurse by joining the nursing degree programme in the 2nd year.
56
Quality Account 2022 | 2023
PA R T 3
Review of performance
Skills Development Programme (SDP) for Healthcare Workers
Registered Nurse Masterclasses/Seminars
Elysium Leadership Journey
The Senior Healthcare Worker Skills Development
Short seminars on topics that may not be
two-day course after which participants
Programme (SDP) aims to develop reflexivity, sharing
routinely delivered. The sessions aim to be
have the option of completing a Leadership
of good practice and encouraging the HCSW to
interactive and therefore numbers attending
Apprenticeship. During the pandemic this
develop and improve practice areas within their own
are usually kept to a maximum of 25 delegates.
course was moved from Face2Face to virtual.
sphere. The programme is generic in nature as brings
Delivered virtually to ensure easy access for all
The programme enables Team Leaders
together people from across all service types.
RNs from across the company.
and Managers to:
The workshops are not just knowledge based but also about exploring and sharing good practice ideas with
The Elysium Leadership Journey (ELJ) is a
Identify how to maximise strengths;
Figures April 2021 – March 2022
manage development areas and inspire
each other and then asking the question – ‘how can I take this learning back to site and develop my own
Climate Change & Healthcare x 2
30
Supporting International Nurses x 2
50
An Introduction to Dialectical Behaviour Therapy x 2
39
RCN Accountability & Delegation seminar x 2
56
practice and that of others?’.
personal change Assess and establish own professional accountability
The idea is to move the cohort of learners through the programme in preparation for the final three months which is the RCN Introduction to Leadership Programme (ILP). The RCN ILP asks delegates to consider a practice improvement project and their own leadership and development journey..
Build a team culture to inspire others to take responsibility and ownership of their role Assess and improve team motivation and communication skills Evaluate performance and give timely and constructive feedback
Figures April 2022 – March 2023 Completed programme Sept 2021 – July 2022
Achieve tasks and goals, through enabling effective team and project work 8
Develop own “Leadership proposition” to deliver results
Commenced Programme Sept 2022
18
Between April 2022 – March 2023 a total of 111 participants completed the Elysium Leadership Journey course.
57
International Nurses As part of the ongoing recruitment of International Nurses we welcomed 166 in this twelve-month period. Following a three-week induction programme at our training centre, Ty Solomon in Welshpool all the Nurses successfully passed their Objective Structured Clinical Examination (OSCE). This is a modern assessment method based on a student’s performance designed to test clinical ability, performance, and competence in skills such as communication, nursing procedures and recording of accurate documentation. Once they have passed their OSCE they all received their UK NMC pin and are registered on the NMC register to practice as a Nurse in the UK. In January 2023, Elysium launched their International Support Worker recruitment initiative which we will be reporting on more fully in the next Quality Account.
58
Quality Account 2022 | 2023
PA R T 3
Review of performance
Global Graduate Programme As part of Ramsay Health Care’s Global Graduate Programme, Elysium has been able to offer unique opportunities for graduates to start and build their careers in healthcare. With a long and strong history in clinical Graduate Programmes, Ramsay has supported many thousands to start and build their careers in health care. The 24-month programme is made up of three, eight-month rotations that include both a corporate and operational placement as well as an international rotation in one of Ramsay’s global locations. Elysium have supported four graduates across Human Resources, Contracting, Legal and Commercial departments, each with an executive sponsor and buddy to support them on their structured learning programme. After completion of the Graduate Programme most of our graduates stay with us and are supported for continuing growth and development.
59
rewards and benefits which can mean cost savings from buying a car through to concert tickets and flights. Each site has a Wellbeing Champion and sites are given a wellbeing budget to spend on initiatives which will benefit their staff team.
60
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ia
nd
ini
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t
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m sites
ing
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el
d c an
s
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ng
e
W
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o
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H o l is t i
es K n nal campa i gn s tio ow s ns ta f f n e w s l e t te r AN NUA L STAFF SURVEY
resources from fitness and diet to a comprehensive list of
y days and BBQs
ar T d n n le Wellbeing ca u g h I ugg Signpost
he
The Elysium wellbeing platform hosts a selection of
art n s, p
ne -care t ips f n fi tne ss serv at i ce s
critical incident, resilience, legal and financial issues.
d e:
In h o
365 days a year for support with mental health, trauma,
om
p
tiv
ti e ti
d ay s a
Programme (EAP), 24 hours a day, seven days a week,
ng
M o n t h ly w DS ell el C Christmas vouch er s l arr a Fun
All staff have free access to our Employee Assistance
LONG SERVICE AW AR
The wellbeing of the people who work for Elysium is recognised as being essential to the delivery of safe, effective, caring, timely, and well-led interventions for those we support. Taking the wellbeing of our employees seriously demonstrates our values of Kindness, Integrity, Teamwork and Excellence (KITE).
i be
ti a in i
nclu es i
AwSTA ar R ds
Health and wellbeing of our people
ro rs c o m m u n i c a t e d t h ub fo il h Central wellbeing ema
Quality Account 2022 | 2023
PA R T 3
Review of performance
Revalidation for Nurses
Revalidation for Doctors
Introduced by the Nursing & Midwifery Council
Revalidation for Doctors is a requirement of the General Medical
(NMC) in April 2016, revalidation is the process that
Council. It supports Doctors to develop their practice, drives
all Nurses and Midwives in the UK need to follow to
improvements in clinical governance and gives service users
maintain their registration with the NMC. It helps
confidence Doctors are up to date with practice. The following
our Nurses demonstrate their practice is safe and
measures are in place to support this process:
effective. It encourages Nurses to reflect on the role of the NMC Code of Practice (The Code) in their own clinical practice. All Nurses need to revalidate every three years to maintain their NMC registration in addition to paying an annual registration fee. The
Implementation of national policy and reporting requirements Adherence to the annual appraisal system Nominated Responsible Person Oversight of Clinical Governance Completion of revalidation recommendation submissions
documentation for revalidation can be found on the
A culture of support for Doctors with their
Elysium learning platform and professional support
personal development and appraisal needs
is offered on an individual or service level by Lead Nurses and the Group Director of Nursing. The HR department run annual checks to ensure all Nurses are up to date with their registration and therefore have an active PIN to allow them to practice.
"Having already placed a young woman at Victoria Gardens the Care Coordinator said how well she is doing and how pleased she is with the staff team being consistent. She liked the flats and is looking at two further placements as she liked the pathway the flats at Victoria Gardens offered." Care Coordinator, St Helens, February 2023 - Victoria Gardens
61
Regulation and inspection We welcome regulatory inspection from the Care Quality Commission (CQC), Healthcare Inspectorate Wales, Care Inspectorate Wales and OFSTED. In addition to inspection by these bodies many of our services undergo external peer reviews. We also report to the NHS and the General Medical Council with respect to the revalidation of all our doctors and to the NMC in respect of our Nurses.
Outstanding services 1a Upper Brighton Road
Elysium Care Partnerships
21b Upper Brighton Road
Elysium Care Partnerships
Alexandra Gardens
Elysium Care Partnerships
medical health organisations.
Ewell Road
Elysium Care Partnerships
Care Quality Commission Inspections
Gresham House
Elysium Care Partnerships
At the end of this reporting period Elysium had 78 services registered with
Holkham House
Elysium Care Partnerships
Martham House
Elysium Care Partnerships
School House
Elysium Care Partnerships
Ranworth House
Elysium Care Partnerships
Our Hospital Directors, Managers, Care Centre Directors, and clinical teams also work closely at local level to liaise with safeguarding teams, community teams, police, and
the Care Quality Commission. 22 services were inspected during the year.
CQC Ratings - overall
1%
22%
12%
Outstanding Good
65%
Requires Improvement Inadequate
62
Quality Account 2022 | 2023
PA R T 3
Review of performance
Healthcare Inspectorate Wales and Care Inspectorate Wales Elysium has six services registered with Healthcare
Autism Accreditation
Inspectorate Wales, two of which were inspected during
Eight of Elysium Care Partnerships community homes
the reporting year. There are two services registered
for people with a learning disability or those who have
with Care Inspectorate Wales, one of which was
autism have achieved Advanced Autism Accreditation.
inspected during the reporting year.
The programme is the UK’s only autism specific quality
Although there is no comparable rating system all our
assurance programme of support and development for
services deliver good care and there are no issues with
all those providing services to people who have autism.
any registration. We also work very closely with the
Achieving accreditation proves that an organisation is
Local Health Boards to ensure that we meet quality
committed to understanding autism and setting the
standards on the core framework agreements.
standard for autism practice.
NAS Autism Accreditation Advanced - services: School House
Elysium Care Partnerships
Park Road
Elysium Care Partnerships
Arabella Drive
Elysium Care Partnerships
Ewell Road
Elysium Care Partnerships
21b Upper Brighton Road
Elysium Care Partnerships
1a Upper Brighton Road
Elysium Care Partnerships
Alexandra Gardens
Elysium Care Partnerships
Nursery Road
Elysium Care Partnerships
63
Treating and caring for people in a safe environment and protecting them from avoidable harm
Service user incidents within Elysium are
Patient safety incidents, the number and where available,
the majority of incidents are either no, or low
rate of patient safety incidents reported and the number and percentage of such patient safety incidents that resulted in severe harm or death.
reported based on the level of harm ranging from level 1 – no harm, through to level 5 – severe harm. It is expected and evidenced that harm as illustrated by the table below which shows that 96.2% of incidents reported are low harm or lower.
Per 1000 bed days
%
Level 1 - No harm
65.51
66.0%
Level 2 - Low harm
27.27
29.9%
Level 3 - Moderate harm
3.18
3.6%
Level 4 - High harm
0.44
0.5%
Level 5 - Severe harm
0.04
0.1%
Unit
through directly into the electronic patient record system
to the Elysium portfolio. Complaints are monitored monthly through Clinical Governance frameworks. We promoted our staff, service users and our
Key facts for 2022/2023 include:
93% of complaints were acknowledged in writing within two working days of receipt
Over the year we acquired new sites which diversified our service streams adding neurological services, mental health and wellbeing and young people’s services. We focused on establishing our culture of ‘openness and transparency’ and actively encourage staff to report all incidents through IRIS. Our overall results for the Quality Account detail service looked at in isolation due to the nature of the services and the point at which they aligned with the IRIS system. 96.45 91.15
87% of complaints were resolved within 25 working days 42% of complaints has an element upheld or partially upheld 47% of complaints came from directly from current service users
user incidents for the entire group and should not be
Patient safety incidents per 1000 days
services, as services have been acquired and added
512 complaints were received
incidents which is invaluable for clinical teams.
Total incidents for Group per 1000 days
of complaint management systems and policies across
raise concerns or complaints with us at any time.
Elysium has an inhouse Incident Recording System (IRS),
and into live dashboards giving real time information into
Elysium healthcare has continued its harmonisation
stakeholders feeling confident and comfortable to
Patient safety incident statistics Incident Recording & Informatic System (IRIS) which feeds
Complaints
Self-harm represents the highest number of reported service user incidents representing 27% of all service user related incidents, followed by physical aggression with 26% and then verbal aggression with 13%, combined, these account
Elysium’s complaints policy changed to responding within 20 days mid-year. For reporting purposes and consistency, we are measuring against 25 days. The change to policy and reporting will be reflected in the next Quality Account.
for 66% of all service user incidents recorded.
Extract from incident reporting
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Quality Account 2022 | 2023
PA R T 3
Review of performance
Department of Health core quality account mandatory indicators The NHS (Quality Accounts) Amendment Regulations 2012 set out a core set of quality indicators, which we are required to report against in our Quality Account. We have reviewed the indicators and are pleased to provide our status against them. Providers are only required to report on indicators that are relevant to the services that they provide or sub-contract in the reporting period.
Domain and indicator
Applicable / not applicable to Elysium
Domain 1 Preventing people from dying prematurely n Summary Hospital-level Mortality Indicator (SHMI) n Patients on Care Programme Approach (CPA) followed up within 7 days of discharge from psychiatric inpatient stay n Category A telephone calls (Red 1 and Red 2 calls); emergency response within 8 minutes n Category A telephone calls; ambulance response within 19 minutes n Patients with suspected ST elevation myocardial infarction who received an appropriate care bundle (Domain 1 and 3) n Patients with suspected stroke assessed face to face who received an appropriate care bundle
Domain 2 Enhancing quality of life for people with long-term conditions n Admissions to acute wards where the Crisis Resolution Home Treatment Team were gate keepers
Domain 3 Helping people to recover from episodes of ill health or following injury n PROMS; patient reported outcome measures n Patients readmitted to a hospital within 28 days of being discharged
Domain 4 Ensuring people have a positive experience of care n Responsiveness to the personal needs of patients n Staff who would recommend the trust to their family or friends n Patients who would recommend the trust to their family or friends n Patient experience of community mental health services
Domain 5 Treating and caring for people in a safe environment and protecting them from avoidable harm n Patients admitted to hospital who were risk assessed for venous thromboembolism n Rate of C.difficile infection n Patient safety incidents and the percentage that resulted in severe harm or death
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External reviews NHS England (NHSE) holds accountability
Throughout 2022/2023 Elysium has
Elysium Healthcare continue to work closely with
for the specialised services within the
demonstrated a flexible and responsive
NHS Wales’ National Collaborative Commissioning
Elysium estate. Low and Medium Secure
ability to react to rapidly changing market
Unit to ensure that all Services, that are part of
services for Mental Health, Learning
needs, and deliver unique, individualised
the National Framework Agreements, maintain
Disability and Autism, Tier 4 CAMHS
services for individuals who struggle to
the highest quality rating available (3Q). Most
inpatient services, and CAMHS and Adult
have their needs met through mainstream
settings that provide services under the National
Eating Disorder services are delegated
services. They have also responded quickly
Frameworks currently have a 3Q rating.
through Provider Collaboratives (PCs)
to the newly emerging commissioning
across the NHSE regions according to the
environment of Provider Collaboratives
PC footprint that the services fall into.
whilst maintaining a national perspective.
Smaller Nationally accessed Specialised
This has included a joint bespoke project
Services, Low and Medium Secure Deaf
to provide inpatient care to vulnerable
Services, and Low and Medium Secure
CAMHS patients in Surrey. NHSE will
Acquired Brain Injury Services, are
continue to work with Elysium in
Commissioned directly through the NHSE
2023/2024 to ensure care is in place for
Southeast Region. Contract performance
the most uniquely vulnerable patients.
is monitored through Quarterly Contract review meetings and quarterly and monthly data returns.
66
Adrian Clarke RN(MH)MSc Dirprwy Gyfarwyddwr a Pennaeth Nyrsio Deputy Director & Head of Nursing Uned Gomisiynu Cydweithredol Cenedlaethol National Collaborative Commissioning Unit
Kevin Brenton Senior Contract Manager NHS England
Quality Account 2022 | 2023
PA R T 3
Review of performance
"Throughout 2022/2023 Elysium has demonstrated a flexible and responsive ability to react to rapidly changing market needs, and deliver unique, individualised services for individuals who struggle to have their needs met through mainstream services."
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Get in touch Elysium Healthcare 2 Imperial Place Maxwell Road Borehamwood Hertfordshire
t
020 8327 1800
e
info@elysiumhealthcare.co.uk
w
elysiumhealthcare.co.uk
WD6 1JN
1609/0623