Document 10805574

is a registered charity and expanding
organisation providing a seamless service of integrated health and social
care to help improve the health and wellbeing of people living in South
Norfolk and North Suffolk. The Trust constantly evolves and develops
existing services and introduces new ones.
There are few parts of the country where such an integrated service as that
provided from All Hallows is available: services ranging from daycare,
homecare, medical assessment, nursing homecare, palliative care,
occupational therapy and physiotherapy, rehabilitation, respite care
through to specialist long term care. Many communities wish to have what
we have got, but they do not have the benefit of a foundation like All
Hallows Healthcare Trust to provide it.
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where care counts….
Our Values
All Hallows Healthcare Trust is an independent charity, which aims to deliver quality and
compassionate healthcare using skilled and dedicated staff.
We value the unique contribution of each member of staff and aim to develop their full
potential through a commitment to training and education.
Our distinctive philosophy of care, based on Christian values, is reflecte d in our welcoming
environment, understanding patients’, clients’ and carers’ needs and beliefs and respect for
the dignity of each individual.
Our Mission
To promote the relief of persons of either gender without regard to race or creed, while
suffering from any terminal or life threatening illness, or from any disability or disease,
attributable to old age, or from any other physical or mental infirmity, disability or disease . We
place patients’ clients and carers at the centre of what we do and with their consent.
Our Aims
To provide a seamless service of integrated health and social care for the local population
within the ethos of All Hallows Healthcare Trust.
To provide facilities and services of the highest quality and best value for mone y.
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Part 1: Our Commitment to Quality
Statement of Assurance from the Chairman
Statement on Quality, a foreword from the Chief Executive
Statement from our Matrons
Statement from our Head of Therapies
Statement from our Head of Homecare
Introduction to All Hallows Healthcare Trust
Part 2: Our Priorities for Quality Improvement 2014-2015
Review of Services
Quality Overview
Priorities for achievement in 2015-2016
Statement of Assurance from the Board
Participation in Clinical Audits
Participation in Clinical Research
Goals agreed with Commissioners - use of the CQUIN Framework
What others say about All Hallows Healthcare Trust
Data Quality (Including Information Governance & Clinical Coding)
Part 3: Review of Quality Performance
Achievement of priorities for improvement 2014-2015
Reporting on our top 10
Clinical Governance at All Hallows Healthcare Trust
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Part 1: Our Commitment to Quality:
Our Assurance to you
1.1 Statement of Assurance from the Chairman
I firmly believe that this Account needs no long-winded introduction from me. The year has seen a
massive change in culture with the appointment of Howard Green as our new CEO in June 2014 and
the desire and willingness of the Trustees to work far more closely with those who deliver our
frontline services. All Hallows Healthcare Trust operates as a team from top to bottom.
This Account demonstrates that we have continued to maintain, improve and extend the scope of
our services to patients and clients, that we have made real progress in our ambition , expressed
last year, to work with CCG's and local GP's to further the development of more closely integrated
healthcare and social care services, and, with our plans for a new 40 bed dementia unit, that we are
willing and able to rise to the challenge of increasing and pressing healthcare needs in our local
It is a truism that all healthcare providers are being asked to provide more for less or, more
appropriately, to provide differently for the needs of their population. This Account demonstrates
that we have both the resources and management team to deliver on that requirement without
compromising on the provision of compassionate care for every individual .
John Chapman
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1.2 Statement on Quality, a foreword from the Chief Executive
I am pleased to present our annual Quality Account which demonstrates our continued
commitment to delivering high quality patient care. We continually strive to improve the quality
and practice of our services, to deliver high standards of care and to safeguard our patients/service
users. This report assures our patients/service users and purchasers of care that our services are
safe, appropriate and effective, but additionally highlights the excellent quality improvement
initiatives undertaken by staff which are monitored through Clinical Audits and monthly Key
Performance Indicators (KPIs)
Clinical Audit is a process to improve patient care through the regular review of care against clear
standards and the implementation of change. Monthly Key Performance Indicators (KPIs) are
undertaken to review / monitor clinical quality indicators, and all staff are involved in collecting
evidence, such as length of stay, clinical incidents, drug errors, infections, pressure areas,
complaints and compliments.
Internal and External Mechanisms for Achieving Quality
To the best of my knowledge, the information reported in this quality
account is accurate and a fair representation of the quality of
healthcare services provided by All Hallows Healthcare Trust.
Howard Green
Chief Executive
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1.3 Statement from our Matrons
As the Matron of the All Hallows Hospital, along with my dedicated team, we work to ensure
patients are given a high quality of care, adopting a holistic and person-centred approach and
ensure they are cared for in a safe environment.
The hospital continues to care for patients for rehabilitation, post-acute care including bariatric,
general, and palliative and end of life care funded by NHS Norfolk and Great Yarmouth and
Waveney. Patients are also admitted with long term complex care funded by continuing health
Quality is monitored continually through patient satisfaction questionnaires, audits, management
of incidents and complaints, risk assessments, reviews of key performance indicators, and formal
reports to the Commissioners and the Board.
Nursing assistants continue to complete QCF level 2&3 (Formally NVQ).
Policies and procedures are reviewed regularly.
An annual training plan continues and opportunities are available for staff
to undertake specific training relevant to their needs to enhance patient
care. Training needs are identified at staff appraisals and meetings, to
ensure we provide good quality, evidenced based care to our patients.
UEA students continue to undertake placements at All Hallows Hospital
with positive feedback.
Denise Hubbard
Matron, All Hallows Hospital
The Nursing Home continues to be upgraded and has been upgraded
since last year. We have had positive feedback from the patients who are
using the new Physiotherapy room. At the Nursing Home we constantly
review and monitor the clinical procedures through various methods,
monthly audits and the resident’s questionnaires to help us improve our
quality of care in areas where we feel is necessary or are highlighted in
Cristiana Predoi
Matron, All Hallows Nursing Home
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1.4 Statement from our Head of Therapies
The Therapy Services department consists of Occupational Therapist (OT), Physiotherapists (PT),
Physiotherapy Assistants (PTA) & Therapy Assistant (TA) working together in teams to provide a
high standard of care and service. The assistants support the team in the day-to-day running of the
department thereby ensuring the smooth running of the department.
The therapy service is very effectively provided in the outpatient & inpatient settings (both private
and NHS funded) at the Hospital and at the Nursing Home. We strive to offer comprehensive
individualised patient centred care that is evidenced based. We as a team again succeeded in
managing every patient with dignity, courtesy and with individualised case management and will
continue to do so. Patients are empowered to be more in control of their treatment. We efficiently
managed to make the service easily accessible to patients for treatment by extending the working
hours to six days a week.
This year’s new developments were establishing a ‘Triage Clinic’ for the better use of physiotherapy
service. This service helped us to identifying the patient group who may not benefit from a
musculoskeletal physiotherapy service and direct them in the right direction for their care by using
the right outcome tools.
The department also expanded the service by opening a “Private Gym Facility” for public and staff
for promoting a healthy living by regular exercises. To a certain extent, the service helped us to
clarify the myths of the public about different exercises and use of equipment.
This year we also managed to “integrate the physiotherapy service” with occupational therapy
which in turn helped us in the effective management and smooth discharge of the in patients in the
hospital and nursing home.
As part of the Clinical Effectiveness, every year we review the efficacy of treatment and gather
information about experience via audit, Patient Reported Outcome Measures and patient feedback.
Information received via Patient Reported Experience Measures, audit and Patient Stories indicate
that the patients are provided with a high level of care, at a place convenient to them, are treated
well, have their therapy well explained and feel engaged and involved in their care and they were
very well satisfied with the service. 95% of our patient group suggested that they would
recommend our service to their friends and family and 72% suggested that we helped them to
improve their quality of life.
As a team this is the greatest achievement and we would like to continue this
high standard of care to all our patients. Let me quote one of our patients
comment “High quality, caring attitude displayed, quite excellent!!!”
Shilu John
Head of Therapies
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1.5 Statement from our Homecare Manager
The Homecare team pride ourselves in delivering a top quality service, with support plans tailored
to every client’s individual needs. We aim to ensure that every client receives the highest standard
of care, without compromise, in the comfort of their own home.
Our dedicated team will provide support every step of the way, from the initial enquiry through to
the delivery of care. We also provide the much needed support for family carers and relatives,
testimony to this is the comments and compliments we regularly receive.
All new staff undergo an extensive in-house induction and training programme and all staff receive
annual updates, as well as a choice of specialized training throughout the year. A community
trainer provides further “on the job” training as well as carrying out
quality assurance visits to our care staff whilst they are on duty and we
have now introduced Team leaders who are able to support and
mentor staff in the community whilst working alongside them.
Quality standards are continually being reinforced by us throughout the
Helen Southern
Homecare Manager
1.6 Introduction to All Hallows Healthcare Trust
Our Objectives
To provide a seamless service of integrated health
and social care for the local population within the
ethos of All Hallows Healthcare Trust.
To provide facilities and services of the highest
quality and best value for money.
Our Services
We are an expanding organisation (Registered Charity No. 1124717) offering a wide range of quality
healthcare services with priority for residents of Norfolk & Suffolk. We have two main locations, All
Hallows Hospital situated in Ditchingham, South Norfolk, with the Daycare Centre, situated in its
grounds and All Hallows Nursing Home in Bungay Suffolk (about 2.5 miles from the Hospital). Both
locations are registered separately with CQC.
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Current Services provided by the Trust are:
Daycare (for adults)
Medical Assessment
Nursing Home
Palliative care
Physiotherapy / Occupational Therapy
Respite care
Specialised Care Home (for people with physical and sensory
The Trust provides, under contract, a number of bed based and therapeutic services for the
National Health Service and has a range of short to medium term, intermediate care and
preventative services that aid faster recovery from illness, prevent unnecessary acute hospital
admission and support timely discharge.
We concentrate on needs based care for people whatever their circumstance: offering people what
they need not what we think they need.
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A seamless care approach that works locally to support patients at home and in the
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A closer look at the full range of services available from All Hallows Healthcare
All Hallows Hospital
All Hallows is a focal point for healthcare in our locality, and the hospital has 30 inpatient beds.
Inpatient Services include:
 Post-acute, e.g. post-operative rehabilitation, orthopedic patients and stroke patients
 Palliative / End of life
 Long term care to individuals with a physical or sensory disability
 GP assessment
 Individuals with complex needs
 Private respite care
The unique setting of the hospital allows the team to provide ‘Beds with Care’ an integrated care
service. Essentially inpatients receive a package of care from the hospital with additional services
from Daycare, Homecare and the Therapy Department. Other specialist onsite facilities include a
sensory garden, gym and sensory room. The hospital provides a unique and valuable service for the
young and old who have rehabilitation and long term needs.
The nursing team, led by matron are trained to exceptionally high standards to ensure that all
patients are cared for in a warm, friendly and professional manner.
11 beds are commissioned with NHS South Norfolk CCG and NHS Great Yarmouth and Waveney
CCG, and 2 South Norfolk Health Improvement Partnership beds. The Hospital accepts patients
from James Paget University Hospital, Norfolk and Norwich University Hospital, GPs and other
health professionals within the area. If a patient wishes to be referred to All Hallows they can
express their choice to their doctor, consultant or nurse. Private beds are also available for patients
wishing to self-fund and beds are available through NHS Continuing Care arrangements. Currently
11 residents are funded through NHS Continuing Healthcare.
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All Hallows Nursing Home
All Hallows Nursing Home provides 24 hour Nursing Care for up to 51 residents who are physically
dependant; many needing full assistance with most activities of daily living, requiring nursing care
from qualified staff with the experience, knowledge and skills to meet their needs. The home
welcomes people for both long and short stays including respite and postoperative convalescent
care. It accepts residents from the private sector, Social Services and the National Health Service.
The nursing team provide high quality, individualised care in a safe, friendly environment where
privacy and personal dignity are of the highest importance. Residents relax and participate in the
life of the home. There are three large day rooms all of which offer planned activities and
entertainment, a large conservatory leading to an enclosed garden, a dining room and a multidenominational chapel. The home also offers a range of Daycare services to local people.
We Provide
 Warm friendly atmosphere
 A high standard of professional nursing care
 Long and short stays including respite and postoperative convalescent care
 Single rooms with en-suite facilities
 Freshly prepared home cooking
 Minibus for outings
 Activities and entertainment programmes
 Open visiting
 A multi-denominational chapel on-site
 Physiotherapy treatment room on-site
 CQC Registered
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Two beds are commissioned with NHS South Norfolk Clinical Commissioning Group (CCG) for
postoperative convalescent care (and additional beds are spot purchased). 9 beds are budgeted
for funding through NHS Continuing Healthcare and other beds are funded through Social
Services or the resident themselves.
All Hallows Therapy Department
The Physiotherapy department provides a comprehensive range of diagnostic and rehabilitative
physiotherapy in outpatients and inpatients and the Nursing Home. We address the physical,
psychological, emotional, and social well-being of patients.
We are strongly committed to patient focused care, addressing their individual needs. Through
health promotion, preventive healthcare, treatment, and rehabilitation we help people and their
families and carers to aid the individual to reach their full potential following injury, illness or
Our expert team adhere to the guidelines of the Health Care Professions Council and the Chartered
Society of Physiotherapy. We follow best practice in clinical governance and ensure that we keep
abreast of the latest evidence based practice. The team continuously monitor and improve the
quality of our services to safeguard a high standard of treatment. The service is run by 5 highly
skilled Physiotherapists who are State registered and members of the Chartered Society of
Physiotherapy and 4 Assistant Physiotherapists.
The Physiotherapists may use a combination of manual therapy (mobilisation & manipulation),
exercise therapy, electrotherapy (ultrasound, interferential, TENS), moist hot packs and cryotherapy
(ice application) for treatment in accordance with the patient’s needs. Acupuncture treatment can
also be provided for musculoskeletal conditions.
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The Musculoskeletal Physiotherapy Service aim to provide Outpatient care for patients with;
 Neck and shoulder pain including whiplash
 Back pain
 Upper and lower limb problems; shoulder, elbow, wrist, hand, pelvis, hip,
knee, ankle and foot
Post-surgical Rehabilitation, e.g. Joint Replacement, Arthroscopy and Revision
Traumatic injuries
Arthritis and other degenerative conditions
Sports injuries
Pre and postnatal problems ( Women’s Health)
The department also provide rehabilitation for Hospital, Nursing Home and palliative care patients
of the Trust for the following conditions:
 Respiratory conditions
 Complex pain syndromes
 Reduced exercise tolerance
 Musculoskeletal impairment
 Neurological impairment
 Lymphoedema
We strive to offer a comprehensive individualised patient focused care that is evidenced based.
Every patient is managed with dignity, courtesy, with individualised case management. Initial
Assessment appointments are 45 -60 minutes and the follow up appointments are 30 minutes.
We aim to ensure the service is easily accessible to patients by offering flexible time for their
appointments. During the working days we are open from 8:00am - 18:30 and on Saturday we are
open from 8:30am – 16:00pm.
The department services are commissioned by NHS Great Yarmouth & Waveney CCG. Patients can
be referred to us by their GP (we are on Choose & Book) or they can self-refer by completing our
self-referral form. Department also has private patients from other areas.
The MSK services have a structured audit cycle to review documentation, Health and Safety,
Infection Control and audit service outcome measure using condition specific and standardised
outcome measures i.e. Patient Reported Outcome Measures (PROMS). As a Department we also do
half yearly Patient Reported Experience Measures (PREMS) by sending questionnaire randomly to
discharged patients. Information received via PREMS, audit and Patient Stories indicate that the
patients are provided with a high level of care, at a place convenient to them, are treated well, have
their therapy well explained and feel engaged and involved in their care.
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Occupational Therapy
The Occupational Therapy department ensures that patients receive an appropriate level of
Occupational Therapy to maximise functional ability and independence and facilitate a safe, prompt
and effective discharge home.
When a patient is admitted to the hospital and is first seen by our GP, it will be decided whether
referral to Occupational Therapy is appropriate. If a referral is made the Occupational Therapist
(OT) will aim to carry out an initial assessment within 3 working days of admission, with the
patient’s consent.
Following this assessment, the OT or assistant may require to assess the patient’s home.
Arrangements will be made to either take the patient in the OT’s car to visit the home, or for the OT
to visit the home in the presence of a relative.
The OT will discuss the outcome of the assessment with the patient and a report will be sent to the
GP and if appropriate, the Social Worker. The OT will arrange provision of all necessary
equipment/adaptation as provided by social services free of charge. The OT can advise on any extra
equipment that the patient may wish to purchase independently.
The OT works closely with the other members of the hospital team; nurses, physiotherapist, doctor
and social worker, as well as services in the community, to devise a treatment programme to
increase functional ability and independence and maximise the potential of each patient.
The OT will determine that
the patient has reached
their optimum level of
rehabilitation with regard to
managing personal care,
independence in activities of
daily living and mobility and
whether the patient will
require a package of care.
The OT/OTA (Occupational
Therapy Assistant) will liaise
with the patient and their
relatives/carer concerning
the home situation. They
will consider the
preferences and quality of
life of each and try to
facilitate a plan for
discharge which is agreed by all concerned.
The OT aims to provide a holistic service to the patient which can involve liaising with family,
charities, local authorities etc. to obtain specialist equipment or adaptations for the home and to
support patient, family and carers in what is sometimes a stressful time in their lives.
The All Hallows Occupational Therapy team is currently only able to care for NHS Great Yarmouth
and Waveney inpatients. An external OT visits NHS Norfolk inpatients and provides a very similar
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Daycare provides a range of services designed to
deliver social stimulus and a broad base of care that
supports care in the community. Daycare helps to
improve people’s general well-being; it assists with
maintaining skills and independence, and provides an
opportunity for people to learn new skills and gives
mental and physical stimulation.
Essentially it is a great way to meet people, take part in
a wide range of activities and is very well equipped
with aids for less able and dependent individuals.
 Bathing facilities
 Tea & Coffee, 3 course lunches with a choice of
hot and cold dishes and special diets are
catered for
 A wide range of therapeutic activities to
encourage both physical and mental stimulation
 Palliative Daycare
 Daycare is equally beneficial to family members who provide care at home, enabling them
to enjoy a well-deserved break.
 Day opportunities as requested
 A Hairdresser visits the Centre regularly offering their expert services at a nominal charge
 Daycare will help individuals to remain living in their own homes with guidance and support
in finding appropriate help
 It has a purposely adapted minibus to transport local people to and from home (subject to
availability) and alternative transport can also be arranged if required.
A range of activities
along with good
company and home
cooked meals creates a
great experience for all.
This service does not
have any contracts with
the NHS and is funded
through Social Services
or the resident
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Homecare specialises in Needs Based Care for people living at home. The team aim to ensure that
each client receives the highest standard of care, and to assist them to live as independently as
possible, whilst recognising personal freedom of choice and promote dignity, self-respect,
independence and privacy.
They consider their clients’ needs and what they would like to achieve from their assistance and
then work to deliver the level of support that's right for them. If their needs change, the care
Deciding to have Homecare can help people to retain their independence in their own home and is
equally beneficial to family members who provide care at home, enabling them to enjoy a welldeserved break for the evening or a week. The Homecare Team is contactable 24 hours per day 365
days per year. Outside office hours all calls are diverted to our dedicated on call team, so you will
always be safe in the knowledge of a response whatever time of day.
Personal Care
 Full wash, shower, bath and shave
 Getting in and out of bed
 Dressing
 Day or night sitting
 Companionship, having someone to talk to
 Emergency assistance
Home Call Services
 Housework/domestic tasks
 Laundry and ironing
 Shopping with or without the client
 Meal preparation
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Meals on Wheels
This service is for people aged 18 and over, normally older people, who are unable to prepare and
cook one hot meal a day. This may be a permanent situation due to sight loss, a physical or learning
disability, illness or a temporary situation such as recovering after a stay in hospital or a partner has
to go to hospital or away visiting relatives and the meals can help to make the situation easier. The
service is available 7 days per week and people can choose to have the meals as little or as often as
they like. All produce is locally sourced, freshly prepared and cooked in the kitchens at All Hallows
Befriending Services
Befrienders offer friendship and company on a supportive basis. What they do depends on the
needs of the client; they provide the opportunity to have a cup of tea and a chat or play Scrabble
and do a crossword. They may join sports activities, such as taking someone out and playing a
round of golf. Go shopping, to a garden centre, or just sit and listen. The good thing about this
service is that we can provide exactly what the client needs. It is also ideal for family carers to give
them a break, either for a few hours in the evening or even a week. Everyone needs other people,
but not everyone has someone. For people who become isolated because of poor health, disability
or social disadvantage, a Befriender can fill a big gap.
Tailor made Homecare Service
If you require a service not listed it does not necessarily mean the team cannot help. Care packages
can be arranged on either a short term or long term basis, offering flexibility.
This service has a small number of NHS clients commissioned by NHS South Norfolk and NHS
Great Yarmouth and Waveney CCG. (A registered nurse based at the Hospital is involved with
these clients). Other clients are either self-funded or funded through Social Services.
"Thank you to All Hallows Homecare
for the care put in place and for
working together with District
Nurses and Multi-Disciplinary Team".
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Part 2: Our priorities for Quality Improvement (2015/2016)
2.1 Review of Services – Scope of NHS
During 2014-2015 All Hallows Healthcare Trust provided 4 principal NHS services on behalf of
commissioners: Inpatients beds at two locations, Continuing Healthcare in the community and
in/out patient Physiotherapy.
For the purposes of the Quality Account All Hallows has reviewed all the data available to them on
the quality of care in these NHS services.
The income generated by the NHS services reviewed in 2014-2015 represents 51.32 % of the total
income generated by All Hallows Healthcare Trust.
2.2 Quality Overview
In 2014/2015 All Hallows Healthcare Trust cared for 172 NHS patients and their families within All
Hallows Hospital (22 long stay, 72 Norfolk, 73 Gt Yarmouth & Waveney & 5 Suffolk).
In 2014/2015 All Hallows Healthcare Trust cared for 82 NHS patients and their families within All
Hallows Nursing Home, (29 long stay -continuing healthcare funded) 53 Norfolk & 0 Gt Yarmouth &
In 2014/2015 All Hallows Healthcare Trust cared for 53 NHS continuing care patients within their
own homes (1 Norfolk & 52 Gt Yarmouth & Waveney).
In 2014/2015 a total of 6144 NHS patient attendances were seen by the All Hallows Physiotherapy
Department. (The department saw an additional 2571 inpatients from All Hallows Hospital and All
Hallows Nursing Home).
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2.3 Our Priorities for Achievement in 2015-2016
The areas we have chosen as our quality improvement targets for 2015-2016 .
Patient Safety
Priority 1: To ensure that new NICE Guidance on falls in older people (March 2015) is incorporated
into our falls policy.
How was this priority decided: Following on from last year’s priority of recording and analysing
more information about patient / resident falls, we have reviewed our accident and incident
reporting procedure, leading to an increase in reported falls. As a team, we want to follow best
practice guidelines and manage the risks effectively, aiming to improve the structure, process and
outcomes of care.
How will the priority be achieved: Falls policy to be reviewed to include new NICE Guidance. This
will include implementing clear systems to ensure people who fall during a hospital stay are
checked for signs or symptoms of fracture and potential for spinal injury before they are moved;
people who fall during a hospital stay and have signs or symptoms of fracture or potential for spinal
injury are moved using safe manual handling methods; people who fall during a hospital stay have a
medical examination; completing a multifactorial falls risk assessment on admission; people who
are admitted to hospital after having a fall are offered a home hazard assessment and safety
How progress will be monitored and recorded: Review of falls policy and procedure, informing
staff of policy update via staff meetings and supervision, continued monthly monitoring and
Priority 2: Computerising clinical records in SystmOne
How was this priority decided: The benefits of using a computerised clinical record system include
increased accuracy and efficiency, improved communication between the multi-disciplinary team,
reduction in errors, improved reporting and audit systems which all contribute to improving patient
How will this priority be achieved: Having a robust governance framework to support the
implementation of computerised clinical records, including a multi-disciplinary working group to
establish goals, timelines and policies. Ensuring adequate preparation and planning, considering
multiple methods of training, including the most basic computer skills for novice users. Ensuring we
have highly trained peer users to provide live, in person, support during the immediate go-live
period. Encourage strong clinical leadership to address the fear of change. Anticipating
consequences and having a process to address them.
How will progress be monitored and recorded: A project manager will be allocated the task of
planning and implementation of this project, with support from a clinical lead and multi-disciplinary
working group. Progress will be monitored via regular service governance and Head of Department
Priority 3: To ensure that all departments are fully staffed with the right people for the roles.
How was this priory decided: Our staff are our most valuable asset, as an expanding organisation
we have an ongoing recruitment programme, however we face the challenge of a national shortage
of registered nurses.
How will this priority be achieved: We seek to project an increasingly positive image of ‘working at
All Hallows’ and support this by creating video and e-recruitment systems which can widen our
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target audience, presenting a professional image and allow for quicker channels for applicants to
apply and for us to respond. We aim to improve staff retention by developing our staff inductions
and training, maintaining staff morale, as well as encouraging and providing opportunities for
professional development by developing the full potential from staff, through a commitment to
training and education.
How will progress be monitored and recorded: Vacancies are continually monitored and discussed
at monthly Head of Department meetings. Regular supervision and annual appraisals provide
support and monitoring for staff’s performance and training and development needs. Our HR
department will develop a set of performance Key Performance Indicators to monitor ‘people’
performance within the Trust to evidence Trust’s aims and objectives of providing quality care and
the value of each individual’s contribution. This will provide substance to the numerous
performance management policies and practices coming into place over the next few months.
Patient Experience
Priority 1: To broaden the care we offer to patients with dementia and their carers by developing
community-based and respite services.
How was this priority decided: Improving diagnosis and care for people with dementia is identified
as a priority by the government, commissioners and the community themselves. In developing
these services we aim to reduce acute hospital re-admission, reduce numbers of patients in
community based beds, and reduce delayed transfers of care from beds to back home.
How will the priority be achieved: All staff will receive Dementia Awareness training to become
Dementia Friends. This training will also be offered to families and carers. By working closely with
the community and key partner organisations such as Age UK and The Alzheimer’s Society, we aim
to focus on improving inclusion and quality of life for people with dementia. Working with the local
community to set up a steering group on order to understand the needs of the local population and
how these can be met. This may include an easy access local drop in service offering activities,
social contact, guidance on how to access resources and carers support. We also aim to offer
respite care at the Hospital and Nursing Home for people with a diagnosis of dementia, if they have
primary physical health care needs and would not be disruptive to the care of other residents.
How will progress be monitored and recorded: By signing up to the National Dementia Declaration
and completing an action plan describing what we will do to meet the identified outcomes, we will
monitor our progress against the outcomes.
Priority 2: To improve on following up bereavement with families and carers.
How was this priority decided: Following a bereavement summit it November 2014, we identified
ways to improve support offered families and carers following the death of a loved one.
How will the priority be achieved: Bereavement packs, including a handwritten card, will be sent to
the next of kin about ten days after the death of their loved one. The pack will contain a covering
letter forewarning of an invitation to the memorial service and tea afterwards. Bereavement
memorial services are held twice a year both at the Hospital and Nursing Home, attendance is
offered to all families who have lost a loved one within the last six months. We are considering
offering a bereavement peer support group to relatives with support from the Community of All
Hallows. In addition to this, bereaved relatives could be offered an invitation to the facilities at the
convent. Improvements will be made to Rose Cottage where families may view the bodies of the
deceased. This will include new beds, shrouds and curtains, improved privacy and repainting of the
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room. Staff will be offered a full day training with a local Funeral Directors in order to gain a better
understanding of the process and to be well equipped to offer support and advice to families.
How progress will be monitored and recorded: As well as staff meetings, group discussions and
continually monitoring feedback from relatives and carers, a further Bereavement Summit is
planned for July where we will review progress on our plans.
Priority 3: To enable Hospital, Nursing Home and Daycare patients to receive increased community
visits and social stimulation as part of their care package.
How was this priory decided: This need was identified at Nursing Team meetings, the nursing team
feel this would promote independence, confidence, increase engagement with the local
community, give interaction with other people and enable recovery quicker than just sitting within
the ward environment alone.
How will the priority be achieved: Regular outings will be arranged to local facilities, specific
destinations will be discussed with patients and their carers to meet their requirements. Risk
assessments will be carried out and we will ensure there is the correct ratio of carers to patients,
giving consideration to the timings of the trips in relation to meal times, required medication and
other personal care needs. A leaflet will be produced to inform patients and their families about
this service and the range of activities that will be available to them.
How progress will be monitored and recorded: We will count the number of people who attend
Daycare as an inpatient as part of their treatment. Monitoring effective outcomes will be by
discussion with patients, patient satisfaction surveys and discharge times. This would be assessed
on an individual basis and would be optional.
Clinical Effectiveness of Care
Priority 1: To use our clinical audit programme as a driver for improvement across all services.
How was this priority decided: We identified the opportunity to make better use of our clinical
audits not only to meet our reporting requirements, but to be a driver for implementing evidence
based changes to clinical practice to ensure continuous development of services.
How will the priority be achieved: Ensure that any shortfalls identified through clinical audits are
addressed systematically and actions are followed through. This will support improvement that
reduces waste and improves cost-effectiveness. Focussing on the priorities as informed by our risk
register and contractual obligations, including key performance indicators and CQUIN targets,
thereby providing assurance on our performance where we are meeting the standards.
How will progress be monitored and recorded: By having a clear and robust audit schedule,
monitored by an identified lead (Head of Service Development and Integration), monitoring the
implementation of action plans at monthly Head of Department meetings, ensuring improvements
we make are maintained.
Priority 2: Ensure our practice is based on the best available evidence.
How was this priority decided: NICE quality standards and CQC standards of best practice set out
the way care should be provided, these will increasingly be used to hold organisations to account.
As a Trust, we follow best practice guidelines and want ensure we remain up to date with evidence
based practice.
How will the priority be achieved: The Trust will continue to compare its own practice to that set
out in NICE guidance and, unless there are evidence based exceptions, seek to address any
shortfalls. We will assess our performance against NICE guidance within 3 months of issue and
comply with NICE guidance within 6 months of issue unless exceptions are agreed at executive
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level. Ensure the workforce has the skills to access evidence required for their practice and the
resources to do so. Ensure that locally developed guidelines are fit for purpose. In supporting the
wider agenda of ‘getting evidence into practice’ it is vital our staff know how to access evidence and
have the appropriate resources to do so. Increasingly we will expect to use technology to support
staff and patients.
How will progress be monitored and recorded: Via our clinical audit programme. Identify a lead
practitioner to ensure any new or updated NICE guidance is identified and incorporated into
practice within the given timeframes.
Priority 3: Develop our Daycare and Homecare services to support reducing length of stay from
both acute hospitals and All Hallows inpatient beds.
How was this priority decided: This is a fundamental priority for out commissioners. Supporting
reduced length of stay and delayed transfers of care is one of our CQUIN indicators; we feel that
our services could be developed to support this outcome.
How will the priority be achieved: Liaison with acute hospitals and Social Services to offer Daycare
and Homecare to facilitate timely discharge. Working closely within All Hallows Healthcare Trust to
ensure that Daycare is an integral part of ‘Out of Hospital’ care, to provide variety and breadth of
service availability, ensuring rehabilitation, differing environments, maintaining independence and
lengthening the time that patients remain at home without recourse to hospital admission.
Ensuring representatives from Daycare and Homecare attend Multi Agency Case conferences as
part of the discharge planning process.
How will progress be monitored and recorded: We will further analyse current lengths of stay in a
hospital bed for those patients otherwise ‘medically fit’ to determine a ‘trim point’ beyond which
occupation of a bed is deleterious to patient well-being;
Understand the ‘pinch points’ inhibiting appropriate discharge;
Monitoring the incidence of use of ‘beds with associated care packages.
We plan to develop a 40 bed dementia unit within the grounds of
All Hallows Hospital.
The number of people living with dementia is expected to increase
significantly within the next 10 years. While we are keen to
develop community based services for patients and carers to
support people to remain living at home, we also recognise that all
types of dementia are progressive and there will be an increasing
demand for specialist inpatient services to meet the needs of our
local population.
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2.4 Statement of Assurance from the Board
For us, there continues to be nothing more important than patient safety and being assured that
quality and care are at the heart of every encounter between our staff and those they care for.
To do this we focus on the “Checking Standards Are Delivered” box in the image towards the front
of this report. We regularly receive a list of all the incidents and complaints that have occurred and
have access to the detailed reports on all aspects of quality as measured in audits, patient
satisfaction questionnaires, key performance indicators (KPIs) and Commissioning for Quality and
Innovation (CQUIN) payments. We meet with the three registered managers at the Board Meeting
on a quarterly basis where we receive a detailed report and are able to discuss any issues arising.
John Chapman, Chairman attends the monthly Head of Department meetings to maintain close
communication with senior staff. Trustees will be invited to attend the Clinical Governance Steering
Group to ensure they are fully involved in the Clinical Governance Framework of the Trust.
To strengthen the framework, we are currently concluding the review of all our policies and
procedures we mentioned last year and are revising the Terms of Reference of the Clinical
Governance committee to ensure that we can check on the working of the framework.
Board of Trustees
2.5 Participation in Clinical Audits
The Trust participated in the 2014/2015 NHS National Audit of Intermediate Care Survey (National
Bed Audit): there were no other national clinical audits and national confidential enquiries that All
Hallows Healthcare Trust was eligible to participate in during 2014/2015.
Local audits All Hallows Healthcare Trust did take part in during 2014/2015 are included below. We
also followed and completed the Blue Cross Audit, Information Governance Toolkit, have regular
medication audits, regular care plan audits and record keeping audits. The results of these audits
demonstrate that we maintain high standards; they also inform staff supervision where actions are
All Hallows Healthcare Trust will continue to take part in audits during 2015/2016 and will include
the following:
 Quality Improvement- care plans, medications, Gold Standard Framework, and nutrition
 Patient Safety- Out of hours calls, pressure areas, medication errors, near
misses/incidents/accidents, hand hygiene and annual infection control (external).
 Health & Safety Management-Staff accidents, sharps injuries and health and safety risk
 In order to ensure provision of high quality Physiotherapy Service, we will continue issuing a
patient satisfactory survey every 6 months, distributing questionnaires to a sample of 100
patients who have received treatment from the Trust.
 Patient feedback will be encouraged and questionnaires will continue to be issued, recorded
and acted upon.
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2.6 Participation in Clinical research
There were no patients receiving NHS services provided or subcontracted by All Hallows Healthcare
Trust in 2014-2015 recruited to participate in research approved by a research ethics committee.
There has not been any national research projects in which our patients or the Trust were asked to
2.7 Goals agreed with Commissioners, following commissioning for Quality and
Innovation (CQUIN) principles.
A proportion of All Hallows Healthcare Trust income in 2014-2015 was conditional on achieving
quality improvement and innovation goals agreed between All Hallows Healthcare Trust and the
local commissioning bodies for the provision of NHS services, through the Commissioning for
Quality and Innovation payment framework.
The CQUIN Scheme Indicators for 2014/2015 for both Great Yarmouth & Waveney CCG and South
Norfolk CCG (worth 2.5% of contract value) are listed below and are all under the quality domain
Patient Safety.
The agreed goals for NHS South Norfolk CCG for 2014/2015 are:
1. NHS Safety Thermometer – To reduce harm. The power of the NHS Safety Thermometer lies
in allowing frontline teams to measure how safe their services are and to deliver improvement
2. Pressure Ulcer Care – Reduce incidence of grade 2, 3 & 4 pressure ulcers.
The agreed goals for NHS Great Yarmouth and Waveney CCG for 2014/2015 are:
1. NHS Safety Thermometer – Reduction in the prevalence of pressure ulcers – 0.25%
2. Developing best practice admission and discharge processes to reduce delayed transfers of
care and excess bed days – 2%
3. Friends and Family Test – Improved performance on FFT for reducing or maintaining at zero
negative responses from inpatient services – 0.25%
2.8 What others say about All Hallows Healthcare Trust
Statements from the Care Quality Commission (CQC)
All Hallows Hospital is required to register with the Care Quality Commission and is regulated for
the following activities:
Hospital, Hospice, Rehabilitation (illness or injury)
Accommodation for persons who require nursing or personal care, diagnostic and/or screening
services, Eating disorders, Nursing care, Personal care, Physical disabilities, Sensory impairments,
Treatment of disease, disorder or injury, Caring for adults under 65 yrs, Caring for adults over 65
(This includes Physiotherapy and Continuing Healthcare.)
The Care Quality Commission did not have cause to take enforcement action against All Hallows
Healthcare Trust during the period April 2014-March 2015. On 7th March 2014 the CQC carried out
an unannounced inspection. The inspection included:
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Care and welfare of people who use services
Supporting workers
All Hallows Hospital was found to be compliant with both of the Outcomes.
Summary of their report:
“We carried out this inspection in response to concerns that were raised with us anonymously. We
were told that people were not cared for properly and that staff were not supported in their work.
We spoke with four people who used the service and one person’s relative. We observed how staff
worked with people and spoke with four members of staff, the acting matron, the operational
administrator and the interim chief executive. There had recently been changes to the senior staff
at the service after a period of uncertainty. The long term matron, who was also the registered
manager, resigned in August 2013 and since then there had been a number of matrons appointed
who had not remained in post. There were also disciplinary issues that resulted in staff leaving the
service. People told us that they received a good service. One person told us, “I have been cared
for well.” Another person told us that staff, “… always help me if I need it.” We saw that care and
treatment was delivered in a way that was intended to ensure people's safety and welfare. We
found that staff had not been supported properly through supervision since the changes to
management, but that since the appointment of the acting matron the staff we spoke with told us
that they felt that things were improving. One staff member said, “It has been a difficult time, but
things are getting better now.” All of the staff said that they received training essential for caring
for the people they supported.”
On 17th September 2013 the CQC carried out a review as part of their routine schedule of planned
reviews. The inspection included:
Care and welfare of people who use services
Safeguarding people who use services from abuse
Requirements relating to workers
Supporting workers
Assessing and monitoring the quality of service provision
All Hallows Hospital was found to be compliant with all of the Outcomes; they stated: Care Quality
Commission – good standards maintained.
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Summary of their report:
“This inspection was conducted in respect of the Homecare service run by the provider, All Hallows
Healthcare Trust. During this inspection, we spoke with five people who used the service, five
relatives of people who used the service, three staff members and the manager of the service. The
people we spoke with were happy with the care they received from the service. One person told
us, “They are great, I couldn’t manage without them, they provide you with anything you need.”
Another person said, “You just have to ask if you want any help and they will help.” A further
person said, “I am very thankful for the service.” One relative told us, “The staff have gone beyond
what we would expect.” A further relative told us, “I am jolly glad that they are there, nothing is
too much trouble.” We saw that people had received an assessment of their needs before they
started using the service. The care was planned and delivered in line with their individual care
record. People told us that they felt safe when staff were providing care within their homes. We
saw that the service had taken the appropriate steps to ensure that people who used the service
were protected from the risk of abuse. The required recruitments checks were being undertaken
by the service before staff commenced their employment. The staff told us that they felt well
supported and trained. We saw that a variety of training was available to the staff to ensure that
they had the necessary skills and experience to provide care safely. The service regularly assessed
the quality of the care they provided and responded to any complaints or concerns that were
All Hallows Nursing Home is required to register with the Care Quality Commission and is regulated
for the following activities:
Care home with nursing, Rehabilitation (illness or injury)
Accommodation for persons who require nursing or personal care, Diagnostic and/or screening
services, Physical disabilities, Sensory impairments, Treatment of disease, disorder or injury, Caring
for adults under 65 yrs, Caring for adults over 65 yrs
The Care Quality Commission did not have cause to take enforcement action against All Hallows
Nursing Home during the period April 2014-March 2015. On 22nd November 2013 the CQC carried
out a review as part of their routine schedule of planned reviews. The inspection included:
Care and welfare of people who use services
Cooperating with other providers
Requirements relating to workers
All Hallows Nursing Home was found to be compliant with all of the Outcomes; they stated:
Care Quality Commission – good standards maintained.
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Summary of latest Care Quality Commission report for All Hallows Nursing Home
“Care and treatment was planned and delivered in a way that was intended to ensure people's
safety and welfare. We spoke with four people and they were generally pleased with the service
they received. One person told us, “I’m well looked after. It is very nice and I like being here.”
Another person described the service as, “Very good, but no one’s got time to just chat so it’s
rather lonely.” People’s health, safety and welfare was protected when more than one provider
was involved in their care and treatment, or when they moved between different services. This
was because the provider worked in co-operation with others. People were cared for, and
supported by, suitably qualified, skilled and experienced staff. There were effective recruitment
and selection processes in place with appropriate checks undertaken before new staff took up
their appointments. People were protected from the risks of unsafe or inappropriate care and
treatment because accurate and appropriate records were maintained. However, insufficient
action had been taken to ensure that personal notes were securely held, posing a threat to
people's privacy. The service undertook to tackle this issue immediately. Records and checks
relating to the management of the service helped ensure that a safe environment was
We have two new minibuses that are mainly used to provide transport for clients using Daycare
services. All the Trust vehicles have been specially sign written to include services provided.
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What our physiotherapy patients say
The department patient questionnaire focus was over 4 distinct areas; Dignity & respect,
communication, care & treatment, administration & location. Overall the results were very
pleasing showing a minimum of 80% of patients either agree or strongly agree.
The number of Hospital inpatients seen by our service has increased by 8% compared to last year,
outpatients seen have increased by 0.3% and we have seen 30% more Nursing Home residents
compared to last year.
Other questions included were:
Quality of Life Improved
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Patient and Carer Comments
“Excellent experience, thanks!”
“Lovely, friendly Physiotherapist. My hip pain went away when I did the exercises regularly”
“I was really impressed with the Physiotherapist I saw. My best ever experience within the
NHS. She really listened and explained well. Thank you”
“We are extremely lucky to have this facility in our community, as previously when I lived
elsewhere, I had to wait 6 months for a physio appointment. Thank you All Hallows for all
your good work.”
“I am extremely grateful for the treatment and advice as it 99% solved my shoulder problem
and I am continuing with the exercises recommended.”
“A brilliant service, excellent care and consideration.”
“I have been very happy with everything at All Hallows every time I have been. Thank you.”
“I especially like the fact that the gym is now open for public use. I will be back in full force
ensuring my back stays strong!”
“Excellent service that fitted around my work hours.”
“Very convenient to have this facility locally. Hope it continues to be available.”
“Couldn’t have asked for a nicer physiotherapist, treatment and all round satisfaction.”
95% of the patients said, they would recommend our service to their friends and family.
Hospital Inpatients
“Thank you all from the bottom of our hearts for the love, care and attention you all gave to
our beloved Dad during the last few weeks of his eventful life. None of you could have done
more to make Dad any more comfortable than you did and for that we will be forever
“An excellent stay, would not find anywhere better.”
“All staff who contacted me during my stay were very helpful and cheerful and made it feel
like home. Thank you very much to you all.”
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Continuing Healthcare
“Our family would like to thank you. My mother’s wish was to spend her last days at home
and you made this not only possible but a positive experience for her. Not only were you
kind, compassionate and thoroughly professional, but she came to regard you as friends.
Thank you for making her last days as comfortable as possible.”
"Dear all Homecare who were involved with Mum. Thank you so much for your love and
care over the last 10 months and especially in the last few weeks stepping up the visits and
support. Without this we couldn't have cared for Mum at home how we did. So thank you
"On behalf of my sister, I just wanted to thank all the All Hallows Team for their wonderful
help given so cheerfully and so full of care over the last few years. The meals on wheels
team, the befriending team, and all the staff at All Hallows Hospital. Their care of my
mother and kindness to us over my mother's last days made those last few precious days
bearable and my sisters and I are so grateful for that. With many thanks."
Nursing Home
“We are extremely grateful for the care given to mother on her recent stay with you. We are
most impressed with the standard given to everyone the cooperation, coordination and
efficiently within your organisation are excellent. Our thanks to you all”
“Thank you to everybody who helped make mums last few months of life so comfortable nurses, carers, kitchen staff, cleaners and the maintenance team! When we visited mum it
was comforting to see that she was comfortable, warm, well fed and happy. Getting to
know so many of you made us feel more comfortable about her not living in her own home
anymore. Your caring for mum was so much appreciated and the care and devotion shown
to mum and the other residents did not go un-noticed. A particular thank you to all the staff
for the care and support given to my dear mum, my sister and I during mum's last few
"To everyone with grateful thanks for all you have done to help me back onto the road to
2.9 Data Quality
Data referencing at All Hallows Hospital includes inpatient services within the Hospital,
Physiotherapy and Continuing Healthcare.
Data referencing at All Hallows Nursing Home includes inpatient services within the home.
All Hallows Healthcare Trust did not submit records during 2014 -2015 to the Secondary Uses
Service (SUS) for inclusion in the Hospital Episode Statistics which are included in the latest
published data. We have not been required to submit data to this system: however, in negotiation
with our principal commissioners, we anticipate being part of the SUS during the next 12 months
and have everything in place so to do.
Information Governance
All Hallows Healthcare Trust Information Governance Assessment Report score for 2014-15 was
graded as Satisfactory, 100% evidenced attainment Level 2 or above on all requirements.
To sustain robust Information Governance (IG), the expectation nationally is that all NHS
organisations should achieve Level 2 attainment on all applicable requirements as detailed in
version 12 of the Information Governance Toolkit (IGT) by 31st March 2015. Each requirement has
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a number of elements and detailed scoring guidance. The scores (attainment levels) range from Not
Satisfactory (not evidenced Attainment Level 2 or above on all requirements) to Satisfactory
(evidenced Attainment Level 2 or above on all requirements).
Clinical Coding
All Hallows Healthcare Trust was not subject to the Payment by Results clinical coding audit during
2014-2015 by the Audit Commission.
Part 3: Review of Quality Performance
3.1 Achievement of Priorities for Improvement 2014-2015
What We Have Done
Patient Safety
Priority 1: To implement and follow a procedure for collectively looking at data on patients who
developed pressure sores in both the Hospital and Nursing home. To analyse which area of the
body sores developed, which mattress type is used, does turning the patient have any effect and
consider other factors such as age, diagnosis and morbidity.
Outcome: Data on pressure sores is collected for monthly reporting via the NHS Safety
Thermometer. We have maintained a similar level of both acquired and developed pressure sores,
which is comparatively low against the national average. We maintain close liaison with the tissue
viability nurse for assessment and advice, any pressure sores are continually monitored until they
have healed. Our policy and procedure has recently been reviewed and updated. All staff have
relevant pressure area training and the risk of pressure sores is regularly assessed using the
Waterlow and MUST assessments.
Priority 2: To record more information about patient / resident falls looking at the time, location,
staffing skills available at any particular time and diagnosis. To analyse the data to see if the amount
of falls can be reduced across the Trust.
Outcome: Our incident and accident reporting system has been reviewed and updated. We have
seen a significant increase in reporting of falls which is due to our improved recording systems. This
has allowed us to identify trends and put management plans in place for identified risks. All patients
have a falls risk assessment completed and where a risk is identified the care plan describes how
the risk is managed. This is supported by our Physiotherapist and Occupational Therapist. All
reported falls are discussed at the monthly Head of Department meeting.
Priority 3: To improve communication between All Hallows staff and St. Elizabeth Hospice specialist
palliative care team.
Outcome: Due to contractual and budget changes, we no longer provide St Elizabeth Hospice beds,
however we continue to offer Daycare to this patient group and accept referrals direct to All
Hallows as an alternative to St Elizabeth Hospice. We maintain good communication with the
specialist palliative care team and staff receive specialist palliative care training.
Patient Experience
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Priority 1: To help patients understand their condition and how to manage it.
Outcome: The therapy service started using Physio tec (Exercise software) which helped us to
create tailored exercise programme for each patient with diagrams, number of repetition and
written explanation of each exercises. This software also has the benefits to show the video clips of
the exercises which can be send to patients via email after the consensus of the patients. There
was a question added in the patient questionnaire “My exercises & Treatment were explained
thoroughly” which 90% of the patient group strongly agreed. We also use Department of Health
guided &Chartered Society of Physiotherapist (CSP) guided leaflet for all the musculoskeletal
conditions which provide further information to patients regarding their conditions and treatment.
Priority 2: To create two additional private Physiotherapy treatment rooms and a new waiting area.
Outcome: All of this this priority is been achieved. As per the plan to provide more privacy to
patients, the department has two new private cubicles and a separate waiting area. Considering
the feedback from the last year’s questionnaire, we also kept a drink machine in both clinical and
gym side of the department. The 2014 – 2015 Patient’s questionnaire showed the improvement in
evidence; 91% of the patient group said that the condition of the physiotherapy room was good
and 89% agreed the waiting area was comfortable.
Priority 3: To enable Hospital and Nursing Home rehabilitation patients to receive social stimulation
as part of their care package (by attending Daycare twice a week).
Outcome: There has been limited uptake of this initiative, more recently patients have not wished
to attend, often due to the complexity of care required, or the age range has been younger
therefore not suitable. Demands on current attendees of Daycare regularly have meant they have
been up to capacity and unable to take extra patients. We will continue to promote this and try to
identify solutions to the barriers we have faced. We have also identified a new priority to increase
social contact by offering more trips outside of the hospital environment.
Clinical Effectiveness of care
Priority 1: To create a ‘Physiotherapy Triage Clinic’ not via the telephone but by actually seeing
patients which in turn will effectively scrutinise the self-referral system for better management of
patient care.
Outcome: This priority has been implemented in the last financial year. Which helped the
department positively and to a certain extent this had a negative impact as well.
We as a team managed to scrutinise the self-referral system and also managed to control the
recurrent referrals from same patients for the same problem for at least twice a year. The negative
impact was some patient’s had difficulty to accept the overall new structure of an outpatient
physiotherapy service and they had difficulty in breaking the mythical misconception of
physiotherapy service purely for massage and ultra sound therapy. Over all the total number of
repeated referrals has been reduced to 50% compared to previous years. The priority is progressing
and within the next few years we would progress further in achieving this task.
Priorty 2: To ensure a constant and equitable high standard of care is received across the Trust we
will review and align our policies and procedures. Reshaping our contract bid team across the Trust
to ensure corporately sound and clinically robust tender responses are prepared for submission to
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Outcome: Major long term review of policies and procedures is currently under way ensuring Trust
wide consistency and rationalisation of existing documentation. Contracting team based upon
relevant tender requirements. Our contract bidding responses are continually monitored and
discussed at monthly Head of Department meetings. All outcomes are fed back to the Trustees.
Priority 3: Review length of stay for patients in our care (including case conferences where
appropriate) and developing a discharge co-ordinator nurse post to facilitate movement of patients
through the health and social care system.
Outcome: We are closely monitoring length of stay and reasons for extended stay. Norfolk patients
are reviewed by the Community Liaison Team on a weekly basis. We have a case conference system
in place for complex patients from Suffolk. Our clinical leads ensure that discharge planning is
started at the point of admission.
NHS Choices review for All Hallows Hospital: My mum has been in All Hallows for the last
fortnight for respite care and the staff have been friendly, patient and understanding.
She was upset that she was being 'sent' to hospital in the first place and told me she wasn't
going to like it and then by the time she left she didn't want to come home.
Well done everyone! First class care.
3.2 Reporting on our top 10
1: Patient Feedback
We are very keen to know what our patients, residents, clients and their families think about us to
ensure that we provide high quality, individualised care in a safe, friendly environment where
privacy and personal dignity are of the highest importance. Handbooks are given to all patients,
residents and clients when they join us (except in Physiotherapy and a questionnaire is given) we
also have an Information for Visitors leaflet available in each reception all detailing how to complain
and how to leave a compliment. They also list a step by step guide of how to leave a comment on
three different websites: CQC, NHS choices and All Hallows Healthcare Trust.
Completion and return of patients’ questionnaires
Questionnaires are given out to all patients as part of their discharge pack. Nursing Home residents
and Homecare clients are asked to complete a questionnaire every 6 months. Poor results /
comments are acted upon and investigated as required.
Feedback from patients/public surveys are reported and will continue to be so.
We continued to:
Undertake in April and October (6 monthly)
Reply to poor performances as questionnaires received/returned
Aim to achieve response rate of 80% across both sites
In 2014/2015 22% of inpatient questionnaires where completed and returned in All Hallows
In 2014/2015 78% of inpatient questionnaires where completed and returned in All Hallows Nursing
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A single person has been allocated for recording and monitoring
the return of patient questionnaires in order to look at how we
can increase the amount of questionnaires returned to us.
There were 4 complaints during 2014/2015, compared with 7 complaints during 2013/2014 and 3
complaints during 2012/2013 for All Hallows Hospital.
There were no complaints during 2014/2015 compared with 2 complaints during 2013/2014 and 1
complaint during 2012/2013 for All Hallows Nursing Home.
All complaints were acted upon and resolved in line with our policies and procedures. All
complaints are acknowledged in writing and a full and proportionate investigation undertaken with
a conclusion and any learning outcomes identified.
Compliments continue to be received from patients and relatives; 60 were recorded during
2014/2015, 60 were recorded during 2013/2014 compared with 65 during 2012/2013 for All
Hallows Hospital
Compliments continue to be received from patients and relatives, 58 were recorded during
2014/2015, 42 were recorded during 2013/2014 compared with 63 during 2012/2013 for All
Hallows Nursing Home.
2: Needle stick related injuries, together with correct reporting, documentation, presentation
and reflection
In 2014/2015 there were no needle stick injuries in All Hallows Hospital.
In 2014/2015 there were no needle stick injuries in All Hallows Nursing Home.
We continue to:
Maintain our zero record of needle stick injuries at the Hospital and Nursing Home
by providing sharps training for all departments as mandatory training and staff to
be aware of policies and procedures.
Ongoing risk assessment and management plans
Adequate sharps bins available
Introduce self-retractable needles
Continue monthly audits on KPIs
Continue to report in our annual clinical governance report
Continue working with Occupational Health services
3: Infection control audits are carried out to ascertain that correct infection control procedures
were being adhered to. The results are as follows:
2014/2015 for All Hallows Hospital, by NHS Gt Yarmouth & Waveney – an excellent report received.
High standards are maintained in infection control with staff uniforms continuing to be laundered
on-site and no staff travelling in uniforms. Also, All Hallows Hospital infection control link nurse
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2014/2015 (August 2014) for All Hallows Nursing Home by NHS Norfolk infection, prevention and
control team – an excellent report received, noting the new kitchen fittings and decoration which
was completed with funds from the Friends of All Hallows.
High standards are maintained in infection control. Also, All Hallows Nursing Home infection control
link nurse maintained.
Both link nurses attend regular meetings and training sessions to ensure they are continually up to
date with infection control.
We have a new physiotherapy room at the Nursing Home. 30% more patients at the Nursing Home
have been seen by our Physiotherapists and this has reduced the need for patients to travel for
In All Hallows Hospital during 2014/2015 there was 1 case admitted and no cases developed of
MRSA bacteraemia.
In All Hallows Nursing Home during 2014/2015 there were no cases admitted and no cases
developed of MRSA bacteraemia.
Clostridium Difficile
In All Hallows Hospital during 2014/2015 there were no cases admitted and no cases developed of
Clostridium Difficile.
In All Hallows Nursing Home during 2014/2015 there was 1 case admitted and no cases developed
of Clostridium Difficile.
Urinary Tract Infections
The following figures are number of patients with urinary tract infections during the 12 month
In All Hallows Hospital during 2014/2015 there were no patients with catheters and 1 from NHS Gt
Yarmouth & Waveney without a catheter.
In All Hallows Nursing Home during 2014/2015 there were 20 patients from NHS Norfolk, and 16
NHS continuing care funded patients, 14 with catheters and 22 without catheters.
4: Monitoring and reducing the incidence of pressure sores (NHS Safety Thermometer)
Monitoring of pressure ulcers, where admitted from, treatment given and outcome, together with
grading, will benefit patient-centred care and the use of appropriate pressure relieving equipment
e.g. electric mattresses, relating to patient’s individual Waterlow scores, together with evaluation.
We continued to:
Monitor grades using European Pressure Ulcer Advisory Panel (EPUAP) grading and
Waterlow scores
Monitor all patients admitted with and developed at All Hallows Hospital & All
Hallows Nursing Home
Measure performance against the Essence of Care benchmark
Monitor outcomes, treatment, equipment used
Monitor monthly KPIs
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Be aware of National Institute of Clinical Excellence (NICE) guidelines
Continue monthly audits and report in annual clinical governance report
Wound care guideline procedure adhered to
Procedure AHH/NUR/29, Skin care/pressure ulcer risk assessment and prevention
2014/2015 In All Hallows Hospital no people were admitted with pressure sores; 1 grade 1 was
developed, 1 grade 2 was developed, 1 grade 3 was developed, no grade 4 were developed. Our
actions and reporting is monitored through CQUINS (see page 24-25)
2014/2015 In All Hallows Nursing Home 10 people were admitted with pressure sores (7 NHS, 2
continuing healthcare, 1 specialist palliative care); 6 grade 1 were developed, 10 grade 2 were
developed and 1 grade 3 was developed. Our actions and reporting is monitored through CQUINS
(see page 24-25)
5: Follow up bereavement with family
We continued to:
 Telephone next of kin of RIP patients for feedback (after funeral)
 Undertake After Death Analysis (ADA) with All Hallows Healthcare Trust medical team
 Commence GSF community hospitals for accreditation when released
 EOL questionnaires to be developed and undertaken
 Ensure relevant clinical and medical organisations are informed
6: Risk Management
Incident summaries and trend analysis for the Trust’s significant risks were maintained. This
includes risk assessment overview and staff/patient accident reports.
Clinical risk assessments are also carried out on all our patients, which include manual handling,
pressure ulcers, falls, use of bed rails, MUST screening (nutritional assessment) and self-medication.
The Hospital and Nursing Home has undertaken risk assessments for its clinical activities. It is our
policy to manage those risks to a level that is as low as can reasonably be expected. We cannot
eliminate all risks and when incidents occur they are reported, investigated and actions taken to
prevent the incident from recurring. Recognising and sharing lessons learnt when things have gone
wrong is critical to ensuring the highest standards of clinical and housekeeping services for patients
and staff.
The Trust has submitted its annual Organisational Crime Profile to NHS Protect.
7: Staff & Patient Accidents
The aim is to continue correct reporting of accidents, monitoring and reflection to prevent
All Hallows Hospital:
5 accidents, no needle stick injuries
31 accidents – 100% due to falls
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All Hallows Nursing Home:
6 accidents, no needle stick injuries
60 accidents – 93.33% due to falls
The increase in patient accidents can be accounted for by improved reporting procedures.
Following a review of the incident recording policy and procedure a new system has been
implemented in order to capture all staff and patient incidents and accidents.
All patients have a fall risk assessment and individual care plan, and manual handling assessment.
Our falls reduction service has been implemented internally to reduce incidents and will be closely
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (1995) require we
report certain incidents to the Healthcare Commission. These include accidents that result in death
or major injury, including the requirement to stay in hospital for more than 24 hours or absence
from work for more than 3 days.
During 2014/2015 there were 2 occurrences at the Nursing Home involving a patient who fell and
fractured their hip and a patient who fell and fractured their leg: these form part of our falls review
and monitored through the falls reduction programme.
9: Our Medical Advisors
Medical Care at All Hallows Hospital is provided by Dr A Self, Dr M Elisson and Dr H Amarawickrama
as Medical Advisors through our subcontracted arrangements with doctors at Bungay Medical
Centre. Out of hours medical cover is provided by IC24 Ltd & the East Anglian Ambulance Service.
16 hours a week is contracted for medical cover at the hospital site. This consists of:
daily rounds
extended time provided on Mondays
weekly case conference on Wednesdays
emergency care and cover as necessary
Medical Care at All Hallows Nursing Home is provided by Dr A Emerson and also by the doctors at
Bungay Medical Centre. Out of hours medical cover is provided by IC24 Ltd & the East Anglian
Ambulance Service.
6 hours a week is contracted for medical cover at the nursing home site. This composes of:
i) 2 weekly rounds every Monday and Thursday morning
ii) Emergency care and cover as necessary
Responsibilities include covering all aspects of inpatient care, clerking, assessment and discharge
plans. Decisions are also made regarding cardio pulmonary resuscitation/do not resuscitate status
achieved for all patients.
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10: How we support our staff:
The Human Resources and Training Department plays a vital role in organisational design and an
organisations success through the management of employee relations processes and practices,
ensuring compliance to employment law, corporate social responsibility and supports the operation
of all departments through the people.
The HR and Training team work together and align strategy with the overall Trust business plan in
the management of matters relating to the employees, such as recruitment and retention of
clinical and non-clinical staff, staff inductions, maintaining staff morale, staff training, employee
relations such as complex disciplinary and grievances, as well as encouraging and providing
opportunities for professional development by developing the full potential from staff, through a
commitment to training and education.
We have annual appraisals for all staff and encourage them to enhance their Qualifications through
Diplomas/Apprenticeships. Currently, 71% of staff has had an appraisal within the past 12 months.
We aim to achieve 100% within the next 12 months. All staff has regular supervisions and
opportunities to discuss their performance throughout the year.
The HR & Training Strategy provides a framework for improvement and assurance of best practice
in line with the Trust’s overarching objectives. Through discussions and feedback involving Heads
of Departments, the Chief Executive, and employees at all levels, a range of issues have been
identified and these will help shape the strategy and the development of key improvement
Training & Development
We systematically manage the training of 300 staff, in sometimes a high-risk environment where
exacting and standards are expected of them by our patients, our funders, and the public.
A training plan is produced for each department at the beginning of the financial year to enable us
to budget for staff requiring non-mandatory training.
Literature from study days is disseminated with other staff through a structured leaving programme
and reported back to clinical supervision meetings and staff meetings.
The department will seek to expand training services to external businesses as both a marketing
tool and to generate revenue. There may be a requirement for a part time administrator to support
the Training Officer in managing this and existing internal training delivery.
The HR & Training Strategy provides a framework for providing ‘excellence and innovation’ in all
that we do, focusing on high quality provisions which will enable us to consolidate our position in
the changing health and social care ‘market place’. It includes:
How training and development will support the organisation
Expectations of line management
Expectations of our employees
Training provided in line with Care Quality Commission standards
The structure of training
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Our HR development for 2015/2016 will include:
The HR Administrator will be trained and educated to achieve the post of HR Advisor providing a
much needed day-to-day advice point for generalist HR queries to Heads of Department and
The HR Apprentice, upon successful completion of the apprenticeship, shall take the post of HR
This change in role and responsibility will allow for better process management and assurance of
HR best practice and compliance. This change will also allow for more strategic planning and
support to all service and functional departments.
In the event that new business in generated through the service areas i.e. Homecare, an increase in
staffing would be required. For an increase of up to 70 new employees, 1 full time HR Advisor will
be required in the long term. For the recruitment campaign of the new employees, a fixed term
contract for a HR or Recruitment Coordinator can be offered for the short term recruitment needs
leading up to the development of new business being in place.
The department will develop a set of performance KPI’s to monitor ‘people’ performance within the
Trust to evidence Trust’s aims and objectives of providing quality care and the value of each
individual’s contribution. This will provide substance to the numerous performance management
policies and practices coming into place over the next few months.
Provide all Heads of Department a full Training List of Mandatory training, identifying which
trainer is responsible for specific topics
Ensure that all new starters undertake an Induction on day one of employment, or as close as
Provide all new starters with an Employee Handbook upon Induction, signed by the employee
as ownership of responsibility and understanding
Ensure that all new starters, clinical and non-clinical, receive mandatory training outlined
within the Care Certificate, within 12 weeks of employment.
Provide department relevant training i.e. Infection Control, PEG, PASMA, Customer Service.
Update Heads of Department as and when QCF funding becomes available for Health and
Social Care among additional options, e.g. End of Life, Infection Control.
Develop monitoring tools to ensure that all records of completed QCF qualifications are up to
Assist Heads of Department in ensuring staff are qualified to the level at which they are
Maintain an 85% QCF level across the Trust
3.3 Clinical Governance at All Hallows Healthcare Trust
Clinical governance is the process we use to maintain and improve effectiveness, and practice of
what we do through clinical audits, complaints management, clinical leadership and development,
continuing education and professional development, clinical supervision and clinical risk
management. It is a framework which helps all clinicians to continuously improve quality and
safeguards standards of care and monitor the kind of care we deliver.
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Clinical governance procedures are used to review progress against all aspects of improving patient
care and act as learning points for the future.
Aims: To ensure safety and quality of care to patients.
To ensure staff continually strive to improve their practice and delivery of high quality care.
To ensure systems are in place to support accurate and timely reporting of Key Performance
Indicators and other quality indicators to commissioners.
We have appointed a new Head of Service Integration and Development to provide the Trust with
quality assurance of best clinical practice across all its services and clinical leadership in the
development of new dementia services.
Roles and Responsibilities: Matron (Hospital) is the named responsible person for: i) overseeing
clinical governance across All Hallows Healthcare Trust for delivering, reporting, monitoring and
evaluating the policy and producing an annual report, which is widely available for staff, patients
and other stakeholders; ii) ensuring that the principle of clinical governance underpins the work of
our service and is monitored in our annual business plan and quality account; iii) overseeing clinical
risk management and that clinical risk assessments are undertaken for each patient to include
manual handling, pressure area care, nutrition using ‘MUST’, fall and use of bed rails, incident /
near misses, medication.
Through Clinical Audit the process of improving patient care through the regular review of care
against clear standards and the implementation of change is maintained. Changes in practice can be
introduced as a result of findings from clinical audits.
Evidence Based Practice: Clinical practice and effectiveness upon which care is planned is delivered
through staff having access to up-to-date information by access to internet, health journals, NICE
guidance. This information is disseminated throughout the organisation through Heads of
Department meetings, staff meetings, feedback from training days, a comprehensive learning and
training programme, and other specialists from multi-disciplinary teams as well as from clinical
guidance and care pathways such as the Gold Standard Framework for end of life care, infection
control guidelines and other professional bodies including Care Quality Commission, Royal College
of Nursing, Nursing & Midwifery Council, General Social Care Council, and commissioner clinical
governance teams. All Hallows Healthcare Trust uses the Royal Marsden Manual 7 th Edition
guidelines on routine clinical procedures.
“Quality is the focal point of our service”
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Statement from the Cath Gorman, Director
of Quality and Safety, Great Yarmouth and
Waveney Clinical Commissioning Group
Great Yarmouth & Waveney Clinical Commissioning Group as a commissioning organisation for All
Hallows Healthcare Trust supports the organisation in its publication of a Quality Account for
2014/15. We are satisfied that the Quality Account incorporates the mandated elements required
based on available data. The information contained within the Quality Account is reflective of the
challenges and achievements within the Trust over the previous 12 month period.
In our review, we have taken account and support the clinical quality improvement priorities
identified for 2015/16 and support the identified improvement objectives in the quality and safety of
care provided to Great Yarmouth & Waveney residents. The Trust will do this by:
Improving patient experience by improving the care offered to patients with dementia and
their carers.
The Trust will also improve the follow-up and support following bereavement building on feedback
from a summit held last year which will be repeated again in July 2015.
We also note that to promote independence, confidence and quicker recovery the Trust plan to
enable hospital, nursing home and day care patients to receive increased community support visits
and social stimulation as part of their care package.
Improving patient safety by ensuring that the new NICE guidance on falls in older people is
incorporated into the management of patients
The CCG are also pleased to note that Trust are progressing the implementation of a computerised
clinical records system to improve safety and multi-professional communication. In addition both
recruitment and retention of staff are being focused upon to ensure departments are fully staffed
with the right people for the roles.
Improving clinical outcomes and effectiveness by utilising clinical audit as a driver for
improvement across all services and by ensuring that clinical practice is based on the best
available evidence.
The Trust is also planning to support patients in having a reduction in length of stay in hospital
through the development of day care and homecare services.
Great Yarmouth and Waveney CCG also notes the improvement in the quality priorities which were
identified for 2014/15 including pressure ulcer prevention, use of individually tailored exercise
programmes for physiotherapy patients and the on-going development of a physiotherapy triage
We note the comprehensive section within the report about the Care Quality Commission and are
pleased to note the full compliance with regulatory requirements. We are also pleased to see the
inclusion of direct feedback from patients about the services they have received.
The Great Yarmouth & Waveney Clinical Commissioning Group looks forward to working with All
Hallows Healthcare Trust during 2015/16.
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Statement from Healthwatch Norfolk
Healthwatch Norfolk is pleased to have the opportunity to comment on the Quality Account.
Overall the layout and content of the document makes it very user friendly to the reader. The use of
photographs makes the document more interesting to view and there is a clear description of what
services are offered.
We are pleased to note the improvements to the services offered during the last year including:
Extending the therapy service to 6 days a week
Establishing a triage clinic
Opening a private gym facility for public and staff
New physiotherapy room
The inclusion of details as to how each priority was decided for 2015-16 is welcomed and the
examples of feedback directly from patients provides reassurance from a service user perspective.
We note several references throughout the document to the training provided to staff which helps
to demonstrate how the Trust are working to recruit and retain staff at a time when many Trusts are
struggling with workforce issues.
It would have been useful to have details as to how the Trust performed in the clinical audits
mentioned on page 24. There is reference to a case conference system in place for complex patients
from Suffolk but we could find no reference to a similar system for patients from Norfolk.
In view of the increased number of patient accidents relating to falls, (albeit the report state the
increase is due to improved reporting) we endorse one of the aims for 2015-16 being to ensure that
the new NICE Guidance on falls in older people is incorporated into the falls policy (and
As part of the HR development for 2015-16 we suggest that figures are produced as to the
percentage of annual appraisals undertaken to ensure that this important aspect of staff support
and performance is robustly monitored.
Finally Healthwatch Norfolk confirms that we will continue to ensure that any feedback we receive
from patients, carers and their families is fed back to All Hallows Healthcare Trust as part of our
developing relationship with all health and social care providers in Norfolk.
Alex Stewart
Chief Executive
Station Road, Ditchingham, Bungay, Suffolk. NR35 2QL
T: 01986 8927278
Daycare I Homecare I Hospital I Nursing Home I Occupational Therapy &
Physiotherapy I Specialist Care Home
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