Nottingham Woodthorpe Hospital
2014/15
Quality Account
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2014/15 (looking back)
2.1.2 Clinical Priorities for 2015/16 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2014/15 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account Indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Nottingham Woodthorpe Hospital is part of the Ramsay Health
Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 32 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs and, Clinical
Commissioning Groups.
The provision of high quality patient care is and will always be the highest priority of Ramsay
Health Care UK. Of course our team of clinical staff and consultants are very much at the
forefront of achieving this but there is also very much an organisation wide commitment to ensure
that we continue to improve out outcomes every day, week, month and year.
Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot
be the responsibility of just a few, it takes all of us to be responsible and accountable for our
performance in the various roles we all play. Having an organisational culture that puts the patient
at the centre of everything we do is key to ensuring we enable everyone to perform at their peak
to attain great outcomes.
Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on
which excellence in clinical practice depends, we will continue to strive to get ever better.
I am very proud of our long standing and major provider of healthcare services across the world
and of our Ramsay very strong track record as a safe and responsible healthcare provider. It
gives us pleasure to share our results with you.
Mark Page
Chief Executive officer
Ramsay Health Care UK
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Introduction to our Quality Account
This Quality Account is Nottingham Woodthorpe’s annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Simon Milner, General Manager
Nottingham Woodthorpe Hospital
As General Manager of Nottingham Woodthorpe Hospital, I believe that this
hospital is clinically driven and our goal is to support our clinicians in delivering
the highest quality care to our patients.
Not only that, but we aim to produce evidence to this effect whether it be
qualitative or objective – we will be able to demonstrate our capabilities, and
clinical excellence.
Our Hospital Vision is that:“As a committed team of professional individuals we aim to consistently deliver
quality holistic Acute Inpatient and Day Care Services with exemplary customer
care. This we believe we are able to achieve by continually updating our staffs’
skills and competencies. We strive to further develop our knowledge in order to
deliver evidenced based clinical practice”.
This Quality Accounts document details our performance over the past year
indicating how we have improved on the high standards of clinical care the
actions that we have taken over the past year.
Quality extends not only to the service we deliver to our patients but to our other
customers – Consultants, GPs, Commissioners, other Trusts and by no means
last, the people who work for us. To understand how we deliver our services, and
the quality standards we reach is critical in our understanding of where we can
improve and how.
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Where appropriate, Nottingham Woodthorpe Hospital participates in local,
corporate and national systems of quality review that are sometimes mandatory,
sometimes voluntary, but at all times we are honest in our responses. It is to our
benefit that we benchmark honestly against our peers, and that we take the
opportunity to learn from those facilities and people delivering better outcomes, in
order to drive up our own standards.
To ensure that we deliver clinical excellence depends on everyone in our hospital
and we have a training and education plan which involves all members of our
administrative, operational and clinical teams. The emphasis on training and
education is high and strongly encouraged in order that we develop our people,
as well as deliver standards that we can be proud of.
Every individual member of staff is crucial to the success of our Hospital and they
value the contribution that they make in delivering great customer care.
In addition to our people contributing to the quality of services delivered, we work
closely with our consultant colleagues we pride ourselves in having consultants
with the highest standards in the area
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the hospital.
These committees have reviewed and commented on the details within these
Quality Accounts.
If you would like to comment or provide me with feedback then please email at
simon.milner@ramsayhealth.co.uk or contact me on 0115 920 9209
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Simon Milner
General Manager
Nottingham Woodthorpe Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Ramsay Healthcare UK regional Director: James Beech
Medical Advisory Committee (MAC) Chair: Dr Ndu Okonkwo
Clinical Governance Committee Chair – Matron Jenny Holmes
Nottingham City CCG – Arden & Greater East Midlands Commissioning Support
Unit- Contract Support Officer – Linda Clarke
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Welcome to Nottingham Woodthorpe Hospital
Nottingham Woodthorpe Hospital has provided healthcare to the people of
Nottingham since 1877 and is conveniently located towards the north of
Nottingham city centre.
Today, we are a modern well equipped hospital with 41 private bedrooms and a
two bedded Level 2 High Dependency Unit. We have two theatres with laminar air
flow and a Minor Procedures Theatre with Endoscopy Suite and 10 Consulting
Rooms.
The hospital provides NHS and private inpatient and outpatient facilities for: Orthopaedic surgery
 General surgery including gastrointestinal
 Gynaecology
 Colorectal surgery
 Cosmetic and Plastic surgery
 Dermatology
 Upper and lower diagnostic Endoscopy procedures
 Ophthalmic surgery
 Dental surgery
 Spinal surgery
 Vascular surgery
 Urological surgery
 Podiatric surgery
 Weight Loss surgery
 General medicine including social care referrals, rehabilitation and respite
care
 Physiotherapy, including shockwave therapy, Sports Medicine and
acupuncture
 Diagnostic imaging services including MRI and CT
We provide safe, convenient, effective and high quality treatment for adult
patients (excluding patients below the age of 18 years), whether privately insured,
self-pay, or from the NHS.
A high percentage of our patients have come from the NHS sector with patients
choosing to use our facility through “Choose and Book‟. Our services help to
ease the pressure on local NHS facilities and our Hospital Management Team
work closely with local CCGs and the local NHS hospitals to ensure improved
access for patients and relieve acute bed pressures within the local trust. In
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addition, Nottingham Woodthorpe Hospital has undertaken some work with the
CCGs outside the Standard Contract. In particular our new Medical ward opened
in April 2014 and has now established close working relationships with the
Nottingham University Hospital Trust to help relieve beds within the acute
hospitals. Where patients require longer term medical and nursing care,
rehabilitation or are waiting for accommodation adaptations we are able to
provide short term care until social care packages are established either within
the rehabilitation sector or in the community.
GP Communication
We have close links with GP surgeries, providing information, training and liaison
in order to monitor their needs and the requirement of the local population.
Nottingham Woodthorpe Hospital employs a GP Liaison Officer who maintains
and establishes relationships with GPs and the practice staff from Nottingham
and the surrounding areas. A GP visit schedule is maintained whereby surgeries
are contacted and visited on a regular basis. GPs are sent regular newsletters
and updates, and information packs containing details about the hospital and how
to refer are distributed.
Nottingham Woodthorpe Hospital delivers a programme of educational visits
during practice learning times whereby the GP Liaison Officer will visit GP
surgeries with a topic of interest for a “Lunch & Learn” session. GP Educational
evenings are also held at the hospital.
Outside activities which show an involvement in the community include hosting
public open evenings for various clinical specialities.
For the Year-to-date (April 2013 to April 2015) Nottingham Woodthorpe Hospital
has seen 4,530 admissions.
 Insured: 7.5% (339 patients)
 Self-Pay: 5.9% (266 patients)
 NHS:
86.6% (3,925 patients)
Nottingham Woodthorpe Hospital employs the following staff
Senior Management Team
 General Manager
 Matron
 Operations Manager
 Finance Manager
 Sales & Marketing Manager
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Clinical Departments
 Surgical Ward Manager
 Medical Ward Manager
 Theatre Manager
 Outpatient Manager
 Physiotherapy Manager
 Radiology Manager
 Pharmacy Manager
 Endoscopy Lead
 Decontamination Lead
 Quality Improvement Manager
Senior Staff Nurses working within the Ward and Theatres -7
Registered Nurses working within the Ward, Outpatients and Theatre - 16
Operating Department Practitioners - 2
Health Care Assistants working within all clinical departments - 15
Radiographers – 2 and Sonographers - 3
Senior Physiotherapist – 1 and Physiotherapists 4
Occupational Therapist for hand therapy - 1
Pharmacy technician - 1
Sterile Services Technicians - 4
Non-Clinical Departments
PA to General Manager – 1
Reception & Administration Team Leader - 1
Administration staff working in Business Office, Bookings, Medical Secretaries
and Medical Records - 25
GP Liaison Officer - 1
Hospital Services Advisor - 1
Supplies Manager - 1
Maintenance Manager – 1 and Assistant Maintenance Assistant -1
Theatre Porters - 2
Housekeeping Team Lead – 1 supported by 6 housekeeping staff
Catering Team Leader 1 supported by 7 Catering staff
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Part 2
2.1 Quality priorities for 2015/2016
Plan for 2015/16
On an annual cycle, Nottingham Woodthorpe Hospital develops an operational
plan to set objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services. To meet these aims, we have various initiatives on going at any one
time. The priorities are determined by the hospitals Senior Management Team
taking into account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2014/15
Clinical Effectiveness
Clinical effectiveness targets were chosen in order to evidence that Nottingham
Woodthorpe Hospital is striving to strengthen governance and encompassed the
following four key areas:
 Dementia care
 Improved incident reporting
 NHS Safety thermometer
 Patient reported Outcomes - PROM’s
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Dementia Care
Nottingham Woodthorpe Hospital is committed to improving dementia care. We
have successfully extended our dementia assessment to all patients in the
hospital. All patients who are admitted to the medical ward or who have elective
surgery are assessed. If they meet the criteria of; being over the age of 75 years
of age or are experiencing memory gaps they are then asked to take part in a
dementia screening assessment which is a cognitive test. This allows us to alert
the patients GP at an early stage so that appropriate diagnosis and support can
be provided. . We have continued to invest in training for dementia, safeguarding
and DOL’s for all staff and have established support links with the Nottingham
City Safeguarding Board. We have also established support links with the
Alzheimer’s Society and their literature related to dementia care; education and
support are available and are displayed in the hospital.
Improved incident reporting
Clinical incidents are all systematically reviewed to determine trends, actions or
further analysis. Incident and near-miss reporting is encouraged to ensure that
effective learning takes place in a no blame culture. The Quality Improvement
Manager reports and manages the elements of clinical risk in order to improve
outcomes. All clinical incidents are communicated through the hospitals Clinical
Governance framework and reported through the MAC, SMT, Heads of
Department and Department meetings. Feedback by all department managers
following incidents has ensured that staff understand any lessons learnt and can
plan their actions accordingly. The Quality Improvement Manager now delivers
Incident reporting within the staff induction programme and she has provided
training and support to all departments to improve the data quality within the
reporting system. We are seeing rewards in the quality of data reported from
Riskman which is now more timely, accurate and purposeful.
NHS Safety Thermometer Audit
In order to monitor and improve services at Nottingham Woodthorpe hospital we
have used and successfully submitted the Hospital Safety Thermometer report in
2014 – 2015. The analysis functions built in to the NHS Safety Thermometer are
used alongside other instruments and tools to measure, assess, learn and
improve the safety of the care we provide. As an independent provider of care to
the
NHS
our
results
are
visible
via
the
HSCIC
website
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http://www.hscic.gov.uk/thermometer this in turn has improved the transparency
to our Clinical Commissioning Groups, GPs and patients.
PROMS (Patient Reported Outcome Measure Studies)
In 2014 - 2015 Nottingham Woodthorpe Hospital issued the National PROMS
questionnaires to patients undergoing hip, knee and groin hernia surgery. We
changed the point of issue to pre-operative assessment so that patients could
take time to complete the form prior to surgery. To improve the post-operative
survey response we communicate to patients the importance of completing this
valuable measure of patient outcomes. We continue to monitor compliance for the
return rate and we will continue to concentrate our efforts on this initiative
throughout 2015.
2.1.2 Clinical Priorities for 2015/16
Patient Safety; Five steps to safer surgery – WHO checklist
The WHO Surgical safety Checklist training was rolled out throughout all Ramsay
Units in line with all national requirements. It remains our high priority as we know
that effective teamwork and communication lie at the heart of providing safe
surgical care. The WHO Surgical safety Checklist was introduced in 2008 by The
World Health Organisation. Through the five step approach to safer surgery;
briefing, three stages of the WHO Surgical Safety Checklist and debriefing we will
pay attention to the crucial human factors in perioperative practice. While our
clinical audit results show improvement in terms of staff compliance we need to
enforce a coordinated approach in carrying out the mandatory stages in the five
steps to safer surgery process.
Our aim is to give us significant improvements in outcomes for patients as well a
better and more efficient working environment for staff.
Our staff will be required to:


Ensure a clinical lead is identified in order to implement the surgical safety
checklist within the operating theatre.
Ensure the checklist is completed for every patient undergoing a surgical
procedure including local anaesthesia.
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
Ensure that the use of the checklist is entered in the clinical notes or
electronic record by a registered member of the team.
The WHO Surgical Safety Checklist audit will be reported quarterly through the
corporate Clinical Governance Template.
Clinical Effectiveness - JAG Accreditation
The Joint Advisory Group on Gastrointestinal Endoscopy (JAG) operates within
the Clinical Standards Department of the Royal College of Physicians. It was
established in 1994 under the auspices of the Academy of Medical Royal
Colleges [AMRC] specifically through the Royal College of Physicians, Royal
College of Surgeons, Royal College of Radiology and the Royal College of
General Practitioners. The JAG has a UK wide remit. To ensure the quality and
safety of patient care by defining and maintaining the standards by which
endoscopy is practiced. Nottingham Woodthorpe Hospital’s Endoscopy Unit will
undergo JAG accreditation in September 2015 which will;

Set standards for individual endoscopists

Set standards for training in endoscopy

Give quality assurance in the endoscopy unit

Give quality assurance in endoscopy training
Our aim is to give us significant improvements in outcomes for patients as well a
better and more efficient working environment for staff.
Lead by our newly appointed Ramsay Group Endoscopy Lead we have already
introduced some effective working practices to improve the quality in our
endoscopy service. We aim to introduce nurse lead outpatient gastro- intestinal
clinics, endoscopy staged admissions and same sex endoscopy lists to enhance
the services we offer in all endoscopic surgery.
Additional quality assurance – Comfort Score CQUIN
To deliver against the Commissioning for Quality & Innovation (CQUIN) 2015/16
indicator we have included the recording of the Gloucester Comfort Score for all
patients as a CQUIN for 2015/2016. This is for patients undergoing upper or
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lower endoscopic procedures. Recognised as a patient directed quality initiative
this will be recorded individually for all patients and will be measured and reported
on a monthly basis by the Endoscopy team. In turn the monthly indicator CQUIN
score will be reported to our CCG’s in the monthly NHS Quality Report.
Patient experience – Friends & Family Patient satisfaction survey
Nottingham Woodthorpe Hospital has always achieved a high level of patient
satisfaction.
A NHS-wide ‘Friends and Family’ test to improve patient care and identify the
best performing hospitals in England was announced in 2012 by the Prime
Minister. From April 2013 inpatients at Nottingham Woodthorpe Hospital were
invited to take part in this anonymous survey. By completing a simple
questionnaire they are asked whether they would recommend our hospital to their
family and friends. Scores are published on the NHS Choices Website
http://www.nhs.uk/Pages/HomePage.aspx
Nottingham Woodthorpe Hospital expanded the Friends & Family survey to all of
the hospital departments in September 2104 and now asks all patients to
complete the Friends and Family test survey. This has enabled us to collate all
patient opinion and act immediately upon any concerns for NHS, private and selfpay patients. At Nottingham Woodthorpe Hospital we have introduced weekly
Friends & Family staff updates from the Friends & Family responses and this has
been recognised by all the staff as one of the most effective measure of quality
within their departments.
Our aim is;
 To improve patient outcomes in all areas by listening and acting upon to
patients views.
 To increase the response rate in the Friends & Family survey in all
departments
Current response rates as at May 2015 are; OPD 10% - DC 62% - IP 65%
This means that every patient will be offered the chance to give quick feedback
on the quality of the care they receive. This will continue to give us a better
understanding of the needs of their patients and enable improvements.
The Ramsay-wide “We Value your Opinion” survey will still be available for all
patients to feedback on a number of key areas including clinical and non-clinical
factors as well as how their care was delivered.
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In our plans to achieve this improvement we have looked at the means by which
the survey is delivered and how it is initiated in the departments. We have plans
to change the format of the survey to a smaller postcard sized form.
Our plan to improve the response rates has involved assessing individual
department response rates and we are planning to give the departments
ownership for managing the delivery of the survey at the end of each of the
respective patient pathways.
Patient feedback has been key to this decision as patients told us that they were
sometimes asked to complete the survey more than once if they had attended
outpatients on more than one occasion.
The Friends and Family survey results will continue to be measured by the
number of eligible acute patients for all inpatients, day-case and outpatients; this
is done corporately and is received at site on a monthly basis. This will then be
reported on a monthly basis via the monthly NHS Quality Report and we will
continue to distribute our weekly Friends & Family updates to the individual
departments in the hospital.
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2014/15 the Nottingham Woodthorpe Hospital provided the following NHS
services.

















Orthopaedic surgery
General surgery
Gynaecology
Colorectal surgery
Dermatology
Upper and lower diagnostic Endoscopy procedures
Ophthalmic surgery
Dental surgery
Spinal surgery
Vascular surgery
Ear, nose & throat surgery
Hearing and balance testing
Urological surgery
Podiatric surgery
General Medicine including trust referred social waits & rehabilitation
Physiotherapy, including shockwave therapy, Sports Medicine and
acupuncture
Diagnostic imaging services including X-Ray, Ultrasound, MRI and CT
The Nottingham Woodthorpe Hospital has reviewed all the data available to them
on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed in 1 April 2014 to 31st
March 2015 represents 86.6% per cent of the total income generated from the
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provision of NHS services by the Nottingham Woodthorpe Hospital for 1 April
2014 to 31st March 2015
Ramsay uses a balanced scorecard approach to give an overview of all audit
results across the critical areas of patient care. The indicators on the Ramsay
scorecard are reviewed each year. The scorecard is reviewed each quarter by
the hospitals senior managers together with Regional and Corporate Senior
Managers and Directors. The balanced scorecard approach has been an
extremely successful tool in helping us benchmark against other hospitals and
identifying key areas for improvement.
Except where otherwise stated for the period for 2014/15, the indicators on the
scorecard which affect patient safety and quality are as follows;
Human Resources
Staff Cost % Net Revenue
24.9 %
HCA Hours as % of Total Nursing
39.6 % HCS to 60.4% RGN
Agency Cost as % of Total Staff Cost
10.2 % Total
5 % Direct
Ward Hours PPD
6.23
% Staff Turnover
21.2% Total
27.2% Clinical
12.1% Support services
% Sickness
3.67 %
% Lost Time
14.2 %
Appraisal %
97 %
Mandatory Training %
86.6 %
Staff Satisfaction Score
4.16 (Ramsay average: 4.6)
Number of Significant Staff Injuries
1 (RIDDOR reported)
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Patient
Formal Complaints per 1000 HPD's
2.5 (0.25%)
Patient Satisfaction Score
100% Friends & Family
91.6% Qa Research
Significant Clinical Events per 1000 Admissions 4 (0.04%)
Readmission per 1000 Admissions
5 (0.05 %)
Quality
Workplace Health & Safety Score
98 %
Our Clinical Audit programme is set and conducted via the Ramsay Clinical Audit
Programme audit shown in appendix 2; audit results that are outside of this
programme include;
MRSA - 0% reported in year
Clostridium difficile – 0% reported in year
Serious Untoward incidents – 0 cases reported in year
Delayed transfer of care cases – 0 cases reported in year
2.2.2 Participation in clinical audit
During 1 April 2014 to 31st March 2015 Nottingham Woodthorpe Hospital
participated in three national clinical audits and zero national confidential
enquiries. The national clinical audits and national confidential enquiries that
Nottingham Woodthorpe Hospital participated in, and for which data collection
was completed during 1 April 2014 to 31st March 2015, are listed below.
Participation
National Clinical Audit Programme
% cases
submitted
Yes/ No/ N/A
National Joint Registry (NJR)
National PROMs Programme
NHS Safety Thermometer
Yes
97%
Yes
85% Hips
76% Knees
Yes
100%
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The reports of the three national clinical audits from 1 April 2014 to 31st March 11
2015 were reviewed by the Clinical Governance Committee and Nottingham
Woodthorpe Hospital intends to take the following actions to improve the quality
of healthcare provided.
National Joint Registry – We have seen improved results through 2014 and
2015 for compliance in the completion of National Joint Registry for all patients
having joint replacement surgery. Current percentage scored for compliance is
97% and we will continue to monitor and act upon the results of our corporately
generated monthly NJR reports.
Patient reported outcomes (PROMs) – We will continue to monitor the
submission rates for PROMs surveys. We have changed the starting point of the
survey delivery and we will continue to monitor and act upon the results of our
corporately generated monthly PROMs submission reports.
NHS Safety Thermometer – We will continue to use the Safety Thermometer as
a point of care survey instrument. It will be used alongside our other patient
measures and risk assessments to provide a care environment free of harm for
our patients
Local Audits
The reports of 70 local clinical audits from 1 April 2014 to 31st March 2015 were
reviewed by the Clinical Governance Committee and Nottingham Woodthorpe
Hospital intends to take the following actions to improve the quality of healthcare
provided. The Clinical Audit Schedule can be found in Appendix 2. Actions
shown demonstrate our response where the audit results were found to be below
90%

Environmental Audit demonstrated that chairs had torn and frayed fabric
on the arms of chairs presenting an infection control risk.
Action: Soft furnishings in patient areas were reviewed and new furniture
purchased for outpatient waiting areas and bedrooms.

Blood transfusion audit showed that not all patients received an
information leaflet post transfusion and the consent for transfusion was not
always documented in the medical records.
Action: Staff are now required to audit all patients that receive a blood
transfusion. They now audit each transfusion against the national blood
transfusion standards and are prompted give a standard advice leaflet to
the patient giving post transfusion advice.
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
Nutrition and hydration audit identified lack of compliance.
Action: A new fluid balance and (EWS) chart has been implemented with
training for all staff provided. Our re-audit results showed improved
documentation of fluid balance records and a notable improvement in the
theatre documentation of all peri-operative fluids and the pre- ward transfer
calculations of all fluids.
2.2.3 Participation in Research
There were no patients recruited during 2014/15 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Nottingham Woodthorpe Hospital’s income in from 1 April 2014 to
31st March 2015 was conditional on achieving quality improvement and
innovation goals agreed with any person or body they entered into a contract,
agreement or arrangement with for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
Each commissioner agrees a number of different CQUIN’s at the beginning of the
financial year with each of their providers. These include quarterly reviews of the
milestones set as well as final outcome targets.
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2.2.5 Statements from the Care Quality Commission (CQC)
Nottingham Woodthorpe Hospital is required to register with the Care Quality
Commission and its current registration status on 31st March is registered without
conditions
The Care Quality Commission (CQC) attended Nottingham Woodthorpe Hospital
to undertake an unannounced inspection, reporting on 8th March 2014. Staff,
patients and clinical departments were visited, along with a thorough investigation
into our credentialing and training databases. The CQC was impressed with the
standard of care, and processes in place. Nottingham Woodthorpe Hospital was
found to have met all standards required in the areas inspected. The detailed
report can be found on the CQC website at http://www.cqc.org.uk/location/1127032975.
Nottingham Woodthorpe hospital has not participated in any special reviews or
investigations by the CQC during the reporting period.
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2.2.6 Data Quality
Nottingham Woodthorpe Hospital will be taking the following actions to improve
data quality. Weekly data quality reports are issued to highlight any errors or
omissions in the data. These are reviewed and actioned as required.

We complete regular audits of all medical records. We have opportunities
for improvement and have tasked our Consultants to improve their
documentation in particular with regard to consent and anesthetic
assessment documentation. Integrated Medical Records have now been
introduced and this provides a more complete and accurate record of
care.

Monthly exception reports are monitored to ensure that there are no
omissions in the data we are submitting to our commissioners through
Secondary Uses Service (SUS).

We have introduced our own additional data tracking in 2015 this was
instigated by the growing requirement for additional information by Clinical
Commissioning Groups, GP’s and consultants. Examples of the additional
data that is now tracked; variances to the patient pathway, number of
patients choosing to postpone or reschedule and rejection reasons of
choose and book referrals following clinical triage. It may be seen as
additional monitoring but we feel that the additional information shows
where we are able prove that we provide excellent care as well as value
for money. This additional data will improve both the quality and quantity of
the data we can provide to our CCG’s.

We have a corporately set clinical audit calendar set out as an annual audit
plan (Appendix 2). All audit results are discussed at the MAC, Clinical
Governance, and Health and Safety meetings, and results are compared
against previous year results. The departments are required to identify any
issues that are pertinent and plan the actions required to improve. We also
receive corporate clinical audit updates on a quarterly basis which provides
us with quantitative data and comparative results from other regions.
Quality Accounts 2014/15
Page 23 of 47
NHS Number and General Medical Practice Code Validity
Nottingham Woodthorpe Hospital submitted records during 2014/15 to the
Secondary Uses Service (SUS) for inclusion in the Hospital Episode Statistics
(HES) which are included in the latest published data. The percentage of records
in the published data which included:
The patient’s valid NHS number:


99.97% for admitted patient care
99.96 for outpatient care
The General Medical Practice Code:


100% for admitted patient care
100% for outpatient care
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall score
for 2014/15 was 75% and was graded satisfactory.
Clinical coding error rate
Nottingham Woodthorpe Hospital was not subject to the Payment by Results
clinical coding audit during 2014/15 by the Audit Commission. Ramsay did
conduct its own Internal Audit of clinical coding error rates in 2014 and our score
was an error rate of 1%.
Quality Accounts 2014/15
Page 24 of 47
2.2.7 Stakeholders views on 2014/15 Quality Account
Linda Clarke, Contract Support Officer, Collaborative Contracting,
Arden and Greater East Midlands Commissioning Support Unit (Arden&GEM CSU)
acting as Contract Support to the Nottingham Woodthorpe Hospital NHS Standard
Contract, on behalf of East Midlands Clinical Commissioning Groups (CCGs)
Arden&GEM CSU, Collaborative Contracting lead on behalf of Nottingham City CCG and
other East Midlands CCGs on the contract management for NHS referrals and treatment
sent to Nottingham Woodthorpe Hospital.
The Stakeholders congratulate the hospital on their continued commitment to
continuously improve patient experience, patient safety and effectiveness of treatments.
It is notable in the 2014’15 report that Nottingham Woodthorpe Hospital includes details
on priorities for improvement for 14’15 and clinical priorities for 15’16 which are based on
Patient Safety – Five steps to safer surgery, Clinical Effectiveness and Patient
Experience
Setting these clinical priorities around Patient Safety and Patient Experience will ensure
that the services provided continue to meet the national Quality Standards set out in the
NHS Standard Contract.
The Stakeholders congratulate the hospital on their continued achievement in relation to
management of:
Patient Experience feedback
Every patient is offered the chance to give feedback and the hospital now publishes
responses onto the NHS Choices website. Plans to improve response rates will help
support assurance about the quality of care and treatment provided at the hospital and
provides assurance that there is a real commitment from the staff to continually learn and
improve.
Patient Safety
There has been zero reported never events and no reported MRSA cases, infection rates
continue to be very low.
Effectiveness of Treatments
The Patient Reported Outcome Measures for Groin, Hip and Knee procedures provide
valuable information on the success rates at Nottingham Woodthorpe Hospital for these
procedures.
Linda Clarke
19.06.15
Quality Accounts 2014/15
Page 25 of 47
Part 3: Review of quality performance 2013/2014
Statements of quality delivery
Matron, Jenny Holmes
Review of quality performance 1st April 2014 - 31st March 2015
This publication marks the sixth successive year since the first edition of Ramsay Quality
Accounts. Through each year, month on month, we analyse our performance on many levels, we
reflect on the valuable feedback we receive from our patients about the outcomes of their
treatment and also reflect on professional opinion received from our doctors, our clinical staff,
regulators and commissioners. We listen where concerns or suggestions have been raised and, in
this account, we have set out our track record as well as our plan for more improvements in the
coming year. This is a discipline we vigorously support, always driving this cycle of continuous
improvement in our hospitals and addressing public concern about standards in healthcare, be
these about our commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe in being open
and honest where outcomes and experience fail to meet patient expectation so we take action,
learn, improve and implement the change and deliver great care and optimum experience for our
patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
Quality Accounts 2014/15
Page 26 of 47
Ramsay Health Care Clinical Governance Framework 2015
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc., are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2014/15
Page 27 of 47
Quality Accounts 2014/15
Page 28 of 47
3.1 The Core Quality Account indicators
Mortality
Related NHS Outcomes
Framework Domain
The data made available to the National
1: Preventing People from dying
Health Service trust or NHS foundation trust by prematurely
the Health and Social Care Information Centre 2: Enhancing quality of life for
with regard to—
people with long-term conditions
(a) the value and banding of the summary
hospital-level mortality indicator (“SHMI”) for
the trust for the reporting period; and
(b) The percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level for the trust for the reporting
period.
*The palliative care indicator is a contextual
indicator.
Prescribed Information
Mortality:
Period
Jan13-Dec13
Apr13-Mar14
Best
RKE
RKE
0.62
0.54
Worst
RXL
1.18
RBT
1.2
Average
Eng
1
Eng
1
Period
2013/14
2014/15
Nottingham
NVC40
0.01
NVC40
0
Nottingham Woodthorpe hospital considers that this data is as described
for the following reasons.
In addition to providing surgical care and treatment, The Nottingham Woodthorpe
hospital also provides care and treatment for medical patients under the care of
Physicians. The table above explains the number of expected deaths in the last
year.
Nottingham Woodthorpe hospital continues to implement the following
actions to improve and monitor this rate by;

Completion of Corporate audits, statutory notifications, incident investigation,
root cause analysis of care episodes and continuous evaluation of care.

Robust mandatory training programme compliance

Information sharing at Clinical Governance level locally, corporately and with
our commissioners. Governance is also shared at local Medical advisory
committee and risk management meetings.
Quality Accounts 2014/15
Page 29 of 47
PROMS (Patient Reported Outcome Measures)
The data made available to the National
3: Helping people to recover
Health Service trust or NHS foundation trust by from episodes of ill health or
the Health and Social Care Information Centre following injury
with regard to the trust’s patient reported
outcome measures scores for—
(i) groin hernia surgery,
(ii) hip replacement surgery, and
(iii) knee replacement surgery
during the reporting period.
Best
PROMS:
Period
Hernia Apr13 - Mar14
Apr14 - Sep14
NT415
RXR
PROMS:
Period
Hips
Apr13 - Mar14
Apr14 - Sep14
NT441
RCB
PROMS:
Period
Knees
Apr13 - Mar14
Apr14 - Sep14
NT404
RWP
0.139
0.125
Worst
NVC11
0.008
Several
0.009
Average
Eng
0.085
Eng
0.081
Period
Apr13 - Mar14
Apr14 - Sep14
Nottingham
NVC40
*
NVC40
*
24.444
25.418
Worst
RQX
17.634
RJD
18.357
Average
Eng
21.34
Eng
21.922
Period
Apr13 - Mar14
Apr14 - Sep 14
Nottingham
NVC40
20.813
NVC40
*
19.762
20.44
Worst
NV323
12.049
RXF
14.416
Average
Eng
16.248
Eng
16.702
Period
Apr13 - Mar14
Apr14 - Sep14
Nottingham
NVC40
16.645
NVC40
17.809
Best
Best
Nottingham Woodthorpe hospital considers that this data is as described
for the following reasons
Nottingham Woodthorpe Hospital participates in the Department of Health
PROM’s survey for hip, knee and groin hernia surgery for NHS & private patients.
The PROMS hip questionnaire is a “before and after” assessment of the health
gain that patients show following surgery. Unfortunately there are not enough
‘paired’ surveys on the HSCIC database for groin hernias to provide an adjusted
health gain score for this surgery.
Nottingham Woodthorpe hospital has taken the following actions to
improve this score so the quality of its services can be consistently
monitored.
 Monitoring completion compliance and return rate for all PROM’s reported
procedures and use the monthly corporate PROMS’s reports to check the
number of returned questionnaires for all eligible procedures.

Evaluation of the effectiveness of the PROM’s process through the medical
records audit of pre-operative assessment and the inpatient pathways.
Quality Accounts 2014/15
Page 30 of 47

Information sharing of PROM’s compliance percentage rate at ward level
raises staff awareness of the importance of compliance in the completion of
PROM’s questionnaires prior to surgery.

Documentation of any/all clinical variances in the patient pathway as directed
Readmissions
The data made available to the National
3: Helping people to recover
Health Service trust or NHS foundation trust by from episodes of ill health or
the Health and Social Care Information Centre following injury
with regard to the percentage of patients
aged—
(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital which forms part of
the trust within 28 days of being discharged
from a hospital which forms part of the trust
during the reporting period.
Readmissions:
Period
2010/11
2011/12
Best
Multiple
0.0
Multiple
0.0
Worst
5P5
22.76
5NL
41.65
Average
Eng
11.43
Eng
11.45
Period
2010/11
2011/12
Nottingham
NVC40
4.5
NVC40
6.01
Nottingham Woodthorpe hospital considers that this data is as described
for the following reasons
Monitoring rates of readmission to hospital is another valuable measure of clinical
effectiveness and outcomes. As evidenced in the template above Nottingham
Woodthorpe Hospital demonstrates readmission rates are well below the average
national rate compared to other sites. This in part is due to sound clinical practice
ensuring patients are not discharged home too early after treatment, are
independently mobile and that patients and carers are fully informed of individual
discharge information. Patients are advised on discharge that if they require
advice or support that they can telephone the hospital in the post-operative
period. This encourages the early communication of any potential clinical postoperative complications. The hospital staff can advise and support patients and if
necessary the patient can return to the outpatient department for a review by the
appropriate multi-disciplinary team member. Effective discharge communication
has in turn been reflected in our low readmission rates throughout 2014- 2015
Quality Accounts 2014/15
Page 31 of 47
Nottingham Woodthorpe hospital has taken the following actions to
improve this score so the quality of its services can be consistently
monitored;





Completion of clinical incident reports for all readmissions with incident
investigation and root cause analysis if required.
Completion of patient variance form for each patient readmission and
recording of variances in the monthly data tracker.
Reporting of all readmissions to CCG’s through the monthly Quality report
Quarterly contract meetings will also highlight any readmissions to Trusts
that are flagged for review.
Information sharing through our local Medical Advisory Committee and the
Clinical Governance meetings held locally and corporately.
Reinforcement of Standard Operating procedures for communication with
patients post discharge
Responsiveness to personal needs
The data made available to the National
4: Ensuring that people have a
Health Service trust or NHS foundation trust by positive experience of care
the Health and Social Care Information Centre
with regard to the trust’s responsiveness to
the personal needs of its patients during the
reporting period.
Responsiveness:
to personal
needs
Period
2012/13
2013/14
Best
RPC
RPY
Worst
88.2
87.0
RJ6
RJ6
68.0
67.1
Average
Eng
76.5
Eng
76.9
Period
2013/14
2014/15
Norttingham
NVC40
90.8
NVC40
90.5
Nottingham Woodthorpe Hospital considers that this data is as described
for the following reasons;

Feedback from patients regarding their experience at The Nottingham
Woodthorpe hospital is encouraged and is essential to inform our staff how
care can be enhanced or adjusted to meet individual patient satisfaction

A robust multi-disciplinary care process where the patient can discuss their
individual needs

Bed management and staff planning at all levels contribute to the improving
score of 90.5% which places Nottingham Woodthorpe above the best rated
hospitals.
Quality Accounts 2014/15
Page 32 of 47
Nottingham Woodthorpe Hospital has taken the following actions to
improve the quality of its services.








Patient satisfaction surveys
We value your opinion questionnaire leaflet
Direct verbal feedback to Ramsay staff.
Internal Ramsay audit /inspection processes.
CQC inspection feedback.
Written feedback via letters/emails/complaints
Annual PLACE patient audit
Advance bed & theatre management planning and daily staffing reviews
Venous thromboembolism (VTE)
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the percentage of patients who
were admitted to hospital and who were risk
assessed for venous thromboembolism
during the reporting period.
VTE Assessment:
Period
14/15 Q2
14/15 Q3
Best
Several
100%
Several
100%
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Worst
RNL
86.4%
NT322
85.1%
Average
Eng
96.2%
Eng
96.0%
Period
14/15 Q2
14/15 Q3
Norttingham
NVC40
99.7%
NVC40
98.1%
The Nottingham Woodthorpe Hospital considers that this data is as
described for the following reasons;
We have a robust patient assessment process coupled with the co-operation of
all of our consultants this has ensured we always aim to reach full compliance for
venous thromboembolism assessment thereby minimising the risk for all patients.
The VTE assessment documentation is now issued at pre-operative assessment
where the assessment is instigated by the nurse it is then completed by the
admitting consultant.
Quality Accounts 2014/15
Page 33 of 47
The Nottingham Woodthorpe Hospital has taken the following actions to
improve this percentage and so the quality of its services.



VTE assessment forms part of the Ramsay patient pathway and these are
completed on admission for all patients
The completed discharge medical record check for all patients forms an
additional system check for the documented VTE assessment this is then
marked accordingly within the patient’s cosmic record.
Monthly checks of corporate report for VTE assessments are completed
Clostridium Difficile Infection
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the rate per 100,000 bed days of
cases of C difficile infection reported within
the trust amongst patients aged 2 or over
during the reporting period.
C. Diff rate:
per 100,000
bed days





Period
2012/13
2013/14
Best
Several
Several
0
0
Worst
RVW
30.8
RMP
32.5
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Average
Eng
17.4
Eng
14.7
Period
2012/13
2013/14
Nottingham
NVC40
0.0
NVC40
11.9
Nottingham Woodthorpe Hospital considers that this data is as
described for the following reasons
Nottingham Woodthorpe shows lower than average rates of clostridium
difficile infection and that the latest reported period is 2013-2014. It should
be noted however that from April 2014 to May 2015 Nottingham
Woodthorpe Hospital has again achieved a zero rate of clostridium difficile
infections.
An annual strategy for Infection Prevention and Control (IPC) is developed
at a corporate level by the Group.
IPC and policies are revised and redeployed every two years. Infection and
Prevention programmes are designed to bring about improvements in
performance and practice.
A network of specialist nurses and infection control link nurses operate
across the Ramsay organisation to support good networking and best
clinical practice.
Quality Accounts 2014/15
Page 34 of 47

The Nottingham Woodthorpe hospital employs a Specialist Infection
Control Nurse and there are Infection Control link nurses in all clinical
areas ensuring that IP& C management remains a high priority throughout
the hospital.
Nottingham Woodthorpe Hospital has taken the following actions to
improve this score so the quality of its services can be consistently
monitored and its objective will be to maintain a zero rate of clostridium
difficile infections in the year;




Maintain high standards of Infection Prevention and Control practice to
minimise the risk of occurrence of clostridium difficile infections.
Implement the correct treatment and nursing intervention for any confirmed
or suspected clostridium difficile infections
Report any incidence of clostridium difficile infections to the appropriate
Public Health bodies, responsible microbiologist, consultants and clinical
commissioning groups.
Follow national and corporate guidance on Infection Prevention and Control
standards, audits and processes.
Incident rate and patient safety
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the number and, where
available, rate of patient safety incidents
reported within the trust during the reporting
period, and the number and percentage of
such patient safety incidents that resulted in
severe harm or death
SUIs:
Period
(Severity 1 only) Oct 13 - Mar 14
Apr - Sep 14
Best
RBD
Several
Worst
0
0
R1F
RBZ
3.72
1.09
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Average
Eng
0.43
Eng
0.17
Period
Oct13-Mar14
Apr-Sep14
Nottingham
NVC40
0.00
NVC40
0.22
Nottingham Woodthorpe Hospital considers that this data is as described
for the following reasons
 The senior management team ensure that incidents are investigated and
when lessons are learned from these events they are shared with staff
across the hospital so that we can prevent the same type of incidents
happening again.
Quality Accounts 2014/15
Page 35 of 47



All incidents are reviewed by the General Manager and Matron and an
investigation process, Root Cause Analysis and action plan implemented
where appropriate.
The RiskMan system reports incidents directly to the Corporate Risk
Management Team allowing the identification of trends at the Nottingham
Woodthorpe Hospital and throughout the Ramsay organisation.
All incidents are reported through the Clinical Governance Committees
structure. Our incident rates with a severity rate of 1 are still comparable to
the average rates however the opening of the medical unit may account for
a rise in the number of incidents reported from April 2014.
Nottingham Woodthorpe Hospital has taken the following actions to
improve the quality of its services.








Maintaining a robust staff induction and mandatory training programme
Promoting the use of comprehensive risk assessment tools that are
available to identify and minimise risk
Monthly Risk management and Clinical Governance meetings are held and
key performance indicators and incidents are discussed and disseminated
The Centralised Alert System (CAS) disseminates all alerts for NPSA/
MDE and FSN to all departments with required actions feedback.
A falls assessment tool has been implemented successfully throughout the
hospital and is used whenever any risk of falls is identified.
All patients on the medical ward complete a falls risk assessment on
admission and then on a weekly basis
Daily process for the assessment and evaluation of patient dependency
and accorded placement of nurse to patient ratios.
RiskMan training for all staff on staff induction training.
Friends and Family Test
Friends and Family Test – Patient. The data
made available by National Health Service
Trust or NHS Foundation Trust by the Health
and Social Care Information Centre for all
acute providers of adult NHS funded care,
covering services for inpatients and patients
discharged from Accident and Emergency
(types 1 and 2)
F&F Test:
Period
Jan-15
Feb-15
Best
Several
100%
Several
100%
Worst
RPA02
51.2%
RHU10
75%
4: Ensuring that people have a
positive experience of care
This indicator is not a statutory
requirement.
Average
Eng
94.0%
Eng
94.7%
Period
Jan-15
Feb-15
Nottingham
NVC40
98.5%
NVC40
100.0%
Quality Accounts 2014/15
Page 36 of 47
Nottingham Woodthorpe Hospital considers that this data is as described
for the following reasons
•
•
The NHS-wide ‘Friends and Family’ test to improve patient care and
identify the best performing hospitals in England was announced in 2012
by the Prime Minister. Since this date the Friends and Family survey has
been expanded year on year at the Nottingham Woodthorpe Hospital and
now incorporates all of our departments.
All patients at the Nottingham Woodthorpe hospital are now routinely
invited to take part in this anonymous survey asking simply whether they
would recommend our hospital to their family and friends. This is reflected
in our increasing response rates and current high score of 100% would
recommend us to their friends and family.
Nottingham Woodthorpe Hospital has taken the following actions to
improve the quality of its services by:




Use the Friends and family survey feedback to continuously monitor
patient feedback in all departments
Disseminating individual department feedback from the Family and Friends
survey on a weekly basis; this is via email as a weekly staff update.
Acting on patient feedback and complaints to improve quality in areas
where any issues may have been identified
Using corporately generated Friends and Family results to analyse and act
upon any trends, individual comments and suggestions for improvement.
Quality Accounts 2014/15
Page 37 of 47
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
Never Events
Never events are serious, largely preventable patient safety incidents that should
not occur if the available preventative measures have been implemented.
The core list of “never events” includes:
 Wrong site surgery
 Wrong implant/prosthesis
 Retained foreign object post procedure.
 Wrongly prepared high risk injectable medication
 Maladministration of a potassium containing solution.
 Wrong route administration of chemotherapy
 Wrong route administration of oral /enteral treatment
 Intravenous administration of epidural medication.
 Maladministration of insulin
 Overdose of midazolam during conscious sedation
 Opioid overdose of an opioid naive patient
 Inappropriate administration of daily oral methotrexate
 Transfusion of ABO incompatible blood components.
 Misplaced naso-gastric tubes.
 Wrong gas administration.
 Failure to monitor and respond to oxygen saturation.
 Air embolism.
 Misidentification of patients
There were zero never events at Nottingham Woodthorpe Hospital during the
reporting period April 2014 to March 2015.
Quality Accounts 2014/15
Page 38 of 47
3.2.1 Infection prevention and control
Nottingham Woodthorpe Hospital has a very low rate of hospital acquired
infection and has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed at corporate level and the Infection Prevention
and Control (IPC) Committee and group policy is revised and re-deployed every
two years. Our IPC programmes are designed to
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Nottingham Woodthorpe Hospital has introduced Infection Control Link roles in all
departments. This introduces a shared work initiative to help bring about
improvements in performance and in practice in all departments.
Programmes and activities within our hospital include:





We chair bi-monthly infection control meetings with links to Microbiologists
at Nottingham University Hospital NHS Trust. This is a proactive group
with representation from all departments to ensure that each part of the
patient’s pathway is safeguarded against the risks of infections.
Hand washing is high on our agenda and in addition to regular staff
training we are replacing all the hand washing gel units across the hospital
with non-touch units to minimise the risk of cross infection.
Our Infection Control Specialist Nurse has implemented a corporate
annual hand health survey for all staff and is actively promoting the ‘Bare
below the Elbows’ campaign in all departments. This is included in her IP &
C training session as part of our in-house staff annual mandatory training.
We report on a monthly basis on all aspects of infection control to our
Clinical Effectiveness Committees and quarterly to the Medical Advisory
Committee.
Infection Prevention and Control forms part of our monthly Clinical audit
Programme. The different elements of infection prevention and control are
selected and include sharps, environment, hand washing, surgical site
infection and catheter care.
Quality Accounts 2014/15
Page 39 of 47
As can be seen in the graph below our infection rate has decreased substantially
over the last year. This reflects that the proposed actions from the annual Quality
account 2013-2014 have been effective in reducing our minimal infection rates to
0.03% as a percentage of admissions.
Infection Rates
(percentage of Admissiosns)
0.25
Infection Rates
0.2
0.15
0.1
0.05
0
2012/13
2013/14
2014/15
Nottingham Woodthorpe Hospital
3.2.2 Cleanliness and hospital hygiene
Assessments of the healthcare environments also include Patient-Led
Assessments of the Care Environment (PLACE)
At Nottingham Woodthorpe Hospital we believe that good environments matter.
Every patient should be cared for with compassion and dignity in a clean, safe
environment. PLACE assessments provide an objective clear message, directly
from patients, about how the environment and services might be enhanced or
improved.
PLACE assessments occur annually at Nottingham Woodthorpe Hospital,
providing us with a patient’s eye view of the buildings, facilities and food we
offer. Our annual assessment took place in the two weeks commencing May
13th 2015. The results of this assessment will be available July 2015 and will be
posted on our hospital website at; http://www.nottinghamhospital.co.uk/
Quality Accounts 2014/15
Page 40 of 47
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff has high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager which
ensures we keep up to date with all safety issues.
3.3 Clinical effectiveness
Ramsay Healthcare has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure.
Every surgical intervention carries a risk of complication so some incidence of
returns to theatre is normal. The value of the measurement is to detect trends that
emerge in relation to a specific operation or specific surgical team. Ramsay’s rate
of return is very low consistent with our track record of successful clinical
outcomes.
As can be seen in the graph below our return to theatre rate has not increased
greatly but the very small rise may be attributed to a more complex case mix over
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the last year. In comparison to the national average it is 0.15 % as a percent of
admissions. The majority of returns to theatre did not present any issues of
ongoing concern.
Retrnn to Theatre
(Percentage of Admissiosns)
Return to Theatre Score
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2012/13
2013/14
2014/15
Nottingham Woodthorpe Hospital
3.4 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also given to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experience is communicated via the various methods below, and is a
statutory agenda items on all Local Governance Committees for discussion, trend
analysis and further action where necessary. Escalation and further reporting to
Ramsay Corporate and DH bodies occurs as required and according to Ramsay
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and DH policy. Feedback regarding the patient’s experience is encouraged in
various ways via:
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Web based survey invitation for patient satisfaction feedback
Hot alerts received within 48hrs of patient making a comment on their survey
Friends and family survey in all departments
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons, General
Manager or Head of Department
Patient views and opinions in PLACE assessments
Shared experiences and learning by our monthly interdepartmental Lessons
Learned Forum and membership of the Nottingham Joint Complaints
Committee.
3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently
of the hospital so we receive a true reflection of our patient’s views. Every patient
is asked their consent to receive an electronic survey or phone call after they
leave the hospital. The results from the questions asked are used to influence
the way the hospital seeks to improve its services. Any text comments made by
patients on their survey are sent as ‘hot alerts’ to the Hospital Manager.
As can be seen in the graph below our Patient Satisfaction rate has increased to
91.6% over the last year. It is higher than the national average and we continue to
strive to offer the highest quality healthcare services to all of our patients.
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
100
80
60
40
91.0
91.6
2013/14
2014/15
20
0
Nottingham Woodthorpe Hospital
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3.4 Nottingham Woodthorpe Hospital
Hospital Case Study
The case study summarises just one example of positive changes that were
implemented as a direct result of patient feedback and audit results.
Routinely patients undergoing minor surgery in the ambulatory care unit were
booked in by the consultants in one long list with one admission time for all.
On investigating some friends and family comments the trend identified was that
although most patients were happy with their care they often commented on ‘the
long wait’ between arrival and actual surgery. Clinical audit results also reflected
the apparent delay when times recorded in patient pathways showed that the last
few patients on the list had a long period of time with no hands on care delivery
actually taking place. Further audit of documentation of waiting times from
admission to surgery identified real time results where there were long periods of
time with no patient hands on care.
After discussions with the consultants and bookings staff a plan was put together
to introduce staged admissions for the ambulatory care patients. The consultants
completing the consent process in outpatients prior to booking the procedure
ensured that the bookings team could then group the compiled list into two or
three time bands for staged admission.
Feedback following the change in process was positive and has proved to be
valuable in terms of efficiency and effectiveness. We continue to evaluate the
service by monitoring the staged admissions lists, the feedback from patients has
only been positive.
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Appendix 1
Services covered by this quality account
The hospital provides NHS and private inpatient and outpatient facilities for:
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Orthopaedic surgery
General surgery including gastrointestinal
Gynaecology
Weight loss surgery
Colorectal surgery
Cosmetic and Plastic surgery
Dermatology
Upper and lower diagnostic Endoscopy procedures
Ophthalmic surgery
Dental surgery
Podiatric surgery
Spinal surgery
Vascular surgery
Urological surgery
General medicine including social care referrals, rehabilitation and respite
care
Physiotherapy, including shockwave therapy, Sports Medicine and
acupuncture
Diagnostic imaging services including MRI and CT
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Appendix 2 Ramsay Health Care UK - Clinical Governance Audit Programme 2014/15
Appendix 2
Quality Accounts 2014/15
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Nottingham Woodthorpe Hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
0115- 9209209
www.nottinghamhospital.co.uk
Quality Accounts 2014/15
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