Blakelands Hospital
Quality Account
2014/15
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2014 / to 2015(looking back)
2.1.2 Clinical Priorities for 2015/16 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2014/15 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Blakelands Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs, Clinical Commissioning
Group.
“The provision of high quality patient care is and will always be the highest priority of Ramsay
Health Care UK. Of course our team of clinical staff and consultants are very much at the
forefront of achieving this but there is also very much an organisation wide commitment to ensure
that we continue to improve out outcomes every day, week, month and year.
Delivering clinical excellence depends on everyone in the organisation. Clinical excellence cannot
be the responsibility of just a few, it takes all of us to be responsible and accountable for our
performance in the various roles we all play. Having an organisational culture that puts the patient
at the centre of everything we do is key to ensuring we enable everyone to perform at their peak
to attain great outcomes.
Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism on
which excellence in clinical practice depends, we will continue to strive to get ever better.
I am very proud of our long standing and major provider of healthcare services across the world
and of our Ramsay very strong track record as a safe and responsible healthcare provider. It
gives us pleasure to share our results with you.”
Mark Page
Chief Executive officer
Ramsay Health Care UK
Quality Accounts 2014/15
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Introduction to our Quality Account
This Quality Account is Blakelands Hospitals annual report to the public and other
stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patient’s treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within the Ramsay Health Care UK. It was recognised that this didn’t
provide enough in depth information for the public and commissioners about the
quality of services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the General
Manager
Julie Fraser, General Manager
Blakelands Hospital
As the General Manager of the Blakelands Hospital I am passionate about
ensuring that we deliver consistently high standards of care to all of our patients.
Our Hospital Vision is that;“As a committed team of professional individuals we aim to consistently deliver
quality holistic Acute Day Case Services with exemplary customer care. This we
believe we are able to achieve by continually updating our staffs skills and
competencies. We strive to further develop our knowledge in order to deliver
evidenced based clinical practice”.
Our Quality Account details the actions that we have taken over the past year in
order to ensure that our high standards in delivering patient care are maintained
and for those areas where we have identified as requiring improvements, these
have been actioned. We have implemented changes to our processes in order to
deliver high standards of care some changes include updated patient discharge
information, updating letters sent to patient for out-patient appointments to include
more information about what to expect, implementing Friends and Family for outpatients and Physiotherapy patients and standardising dressing regimes.
Our hospital has a strong track record of safety and high standards of care, which
we share with our local CCG.
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Our Quality Account has been produced to provide accurate information about
how we monitor and evaluate the quality of the services that we deliver
throughout our Hospital. We hope to be able to share with the reader our
progressive achievements that have taken place over the past year. Blakelands
Hospital has a very strong track record as a safe and responsible provider of Day
Case services and we are proud to share our results.
To ensure that we continue to deliver clinical excellence involves everyone in our
Hospital. Every individual member of staff is crucial to the success of our Hospital
and they value the contribution that they make in delivering great customer care
we have a training and education plan which involves all members of our
administrative and clinical teams.
Our Quality Accounts have been developed with the involvement of our staff who
have been very much engaged with developing a systems approach to risk
management which focuses on making every effort to reduce the likelihood and
consequence of an adverse event or outcome associated with treatment of a
patient.
To ensure a coordinated approach to the delivery of care for patients and to
monitor the adherence to professional standards and legislative requirements the
Clinical Governance Committee and Medical Advisory Committee meet on a
quarterly basis to review the clinical and safety performance of the Hospital.
These committees have reviewed and commented on the details within this
Quality Account.
If you would like to comment or provide me with feedback then please do contact
me on julie.fraser@ramsayhealth.co.uk. Or contact me on 01908 334200.
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Julie Fraser
General Manager
Blakelands Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr. Cyril. Marek
Mr James Beech
Medical Advisory Committee Chair( MAC )
Midland regional Director
Milton Keynes Clinical Commissioning Group
Health watch Milton Keynes
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Welcome to Blakelands hospital
Blakelands Hospital is a purpose built day case unit which was opened in 2006.
It was designed to combine an exceptional standard of patient day case facilities
with the technical equipment that modern medicine demands.
The Centre provides NHS and private day care facilities for:
General Surgery
Ophthalmic Surgery including YAG Laser
Orthopaedic Surgery
Upper and lower diagnostic Endoscopy procedures, including direct referrals
Podiatric Surgery
Physiotherapy including Shockwave Therapy.
Acupuncture
We provide safe, convenient, effective and high quality treatment for adult
patients (excluding children below the age of 18 years), whether privately insured,
self-pay, or from the NHS. A high percentage of our patients are referred from
the NHS sector, patients choosing to use our facility through ‘Choose and Book’.
Our services help to ease the pressure on Milton Keynes General Hospital and
NHS facilities and we have worked closely with the Hospital Management Team
and the Clinical Commissions Group (CCG) to ensure improved access for
patients requiring day case surgery, diagnostics and physiotherapy. We are one
of the approved providers for Acupuncture for local people referred from the Pain
Clinic at Milton Keynes General Hospital.
We have close links with GP surgeries, providing information, training and liaison
in order to monitor their needs and the requirement of the local population. We
have carried out over 2,319 procedures in the past 12 months of which 97% are
for NHS Patients.
We currently employ the following staff at the Blakelands Hospital;
Consultant Orthopaedic Surgeon, a Consultant Anaesthetist and a
Consultant Endoscopist. We also have consultants who work on a regular
basis and these include Consultant Ophthalmologist, Consultant General
Surgeons and Consultant Radiologist, and Consultant Podiatrists.
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






1 Matron, 7 Registered Nurses and an Operating Department Practitioner
and 1 Health Care Assistant
1 Radiologist and 1 Physiotherapist
6 Administrators, 1 PA/HR Coordinator
1 Supplies Co-coordinator and a Maintenance Assistant
Sales and Marketing/GPL coordinator
6 Sterile Services Technicians
2 House Keeping Staff
Blakelands Hospital employs a GP Liaison Officer (GPL) who maintains and
establishes relationships with GP’s and the practice staff from Milton Keynes
Surgeries and the surrounding areas. A GP visit schedule is maintained whereby
surgeries are contacted and visited every month. GP’s are sent regular
newsletters and updates via email and hard copies are also delivered.
Information packs containing information, about the Hospital and how to refer are
distributed via mail or during the visits held at the surgeries. Educational visits are
set up during practice learning times whereby the consultant and GP Liaison
Officer will visit GP’s with a topic of interest for a “Lunch & Learn” session. GP
Educational evenings are also held at the Hospital.
GP’s, Practice Managers and Medical Secretaries are invited and attend regular
Choose and Book workshops at the Hospital.
The following table lists all of the surgeries in Milton Keynes. Each surgery has
been visited and has received an informationl pack of information about the
Hospital.
BROUGHTON GATE HC
CMK MC
COBBS GARDEN
SURGERY
DRAYTON ROAD SYRGERY
-
FISHERMEAD MC
GROVE SURGERY
HILLTOPS MC
KINGFISHER SURGERY -
MK VILLAGE SURGERY -
NEALTH HILL HC
NEWPORT PAGNELL MC -
PARKSIDE
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PURBECK HC
RED HOUSE SURGERY -
SOVEREIGN MC
STANTONBURY HC
STONEDEAN PRACTICE -
STONY STRATFORD HC
-
WALNUT TREE HC
WATER EATON HC
WATLING VALE MC
WESTCROFT HC -
WESTFIELD ROAD
SURGERY -
WHADDON MEDICAL
CENTRE
WILLEN VILLAGE
SURGERY -
WOLVERTON HC
ASHFIELD MC
BEDFORD STREET
SURGERY

Outside activities include hosting Patient Participation Group meetings,
meeting with group members and discussing services provided at the
hospital. Meeting with members from Healthwatch Milton Keynes and
involving them in the Patient Led Assessment of the Care environment
(PLACE) audits and presenting patient experiences at Milton Keynes CCG
Board meeting.

The Hospital also promotes its services to the community via advertising in
local publications such as the GP magazines, MK live and local radio.
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Part 2
2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, Blakelands Hospital develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us, result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospitals Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of clinical priorities 2014/15 (looking back)

Changes to Ramsay’s National Audit Programme ensure that patients who
are at risk of their condition deteriorating receive the very best care by
means of an ‘early warning score’. This specific auditing of the medical
records of this group of patients has now been implemented. This ensures
that all aspects of the service delivery can be reviewed and changes
implemented so that the best and most safe outcomes are achieved. One
Clinical Priority for 2104 was to increase the number of staff trained on the
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Advanced Life Support training, to recognise deteriorating patients and
manage medical emergencies and maintain patient safety. There are
several staff trained on the ALS and all clinical staff are trained on the ILS,
Intermediate Clinical Support at Blakelands Hospital. We are also
encouraging all Consultants who work at the Hospital to undertake the
ILS course. Staff also attend the Acute Illness Management course to help
recognise the deteriorating patient.

Staff Survey 2013
The results of the staff survey for 2013 was excellent, Blakelands Hospital
come top of several aspects with the Ramsay region and third highest
hospital score overall. The Staff engagement group has been formed to
review the results and identify areas of improvement for staff, this is
working well and ensures staff are listened to and suggestions
considered.

Pain management
Through the patient survey we will gather information on how well patient
pain was controlled and that they thought staff did everything they could to
help control their pain. Quarterly audits have taken place and results have
shown that overall patients have been satisfied with their pain
management. Staff have attended pain management courses to enhance
their knowledge and update their skills.

Discharge information
Through the patient survey we will gather information that patients were
given written information about what they should or should not do following
their procedure. Quarterly audits have taken place and results have shown
that overall patients have been satisfied with their discharge information
Some patient information leaflets have been updated
2.1.2 Clinical Priorities for 2015/16 (looking forward)
Patient safety
One of the dimensions of quality is that we do no harm to patients, this means
ensuring the environment is safe, clean and reducing unavoidable harm.
Venous thromboembolism
We follow NICE guidelines to ensure patients are assessed and given the
appropriate prophylaxis to avoid VTE’s. This is a requirement of the national and local
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Commissioning for Quality and Innovation (CQUIN). Through robust audit and reports
we will ensure we are 100% Compliant.
Surgical Safety Checklist
Safer surgery is a priority at the hospital. The surgical safety checklist is a tool
devised by the World Health Organisation to ensure theatre checks are carried
out through the patient’s theatre journey.
Through our robust clinical governance audit program, we will continue to ensure
every patient undergoing surgical procedure (including Local anaesthesia) has
the WHO checklist completed and entered in clinical notes by a registered
member of the team.
Clinical Effectiveness
Consent process
One of the local CQUINS for the coming year is to ensure patients receive the
correct information prior to giving consent for surgery and an opportunity to ask
questions.
Through patient surveys we will gather information to ensure a process for
healthcare intervention will ensure the patient has been given all information in
terms of what the treatment involves, including benefits and risks.
Hand Hygiene
Infection and prevention control is a priority, all staff receive training and updates
on hand hygiene. We will continue to perform monthly and quarterly audits and
participate in national hand hygiene awareness events.
Friends & Family
At Blakelands hospital we place feedback from our patients at the very heart of
our service. Friends and Family is one of the national CQUINS and Blakelands
Hospital has achieved 100% compliant collecting data to ensure patients
feedback is collected and communicated to staff.
Our friends and family questionnaires and external audits gives us the feedback
required to improve and review our services.
We operate a complaints process that responds, flexibly, open and honesty to the
patient’s concerns or complaints, which enables us to support complaints
effectively and promote public confidence in our service.
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2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2014/15 the Hospital provided and/or subcontracted 6 NHS services.
Blakelands Hospital has reviewed all the data available to them on the quality of
care in 6 of these NHS services.
The income generated by the NHS services reviewed in 1 April 2014 to 31st
March 2015 represents 99.9% per cent of the total income generated from the
provision of NHS services by the Blakelands Hospital hospital/centre for 1 April
2014 to 31st March 2015
Ramsay uses a balanced scorecard approach to give an overview of audit results
across the critical areas of patient care. The indicators on the Ramsay scorecard
are reviewed each year. The scorecard is reviewed each quarter by the hospitals
senior managers together with Regional and Corporate Senior Managers and
Directors. The balanced scorecard approach has been an extremely successful
tool in helping us benchmark against other hospitals and identifying key areas for
improvement.
In the period for 2014/15, the indicators on the scorecard which affect patient
safety and quality were:
Human Resources
Staff Cost % Net Revenue
24.28%
HCA Hours as % of Total Nursing
15.80%
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Agency Cost as % of Total Staff Cost
21.18%
Ward Hours PPD
0
% Staff Turnover
23.3
% Sickness
1.90%
% Lost Time
16.02%
Appraisal %
100%
Mandatory Training %
83%
Staff Satisfaction Score
4.86
Number of Significant Staff Injuries
3
Patient
Formal Complaints per 1000 HPD's
2.24
Patient Satisfaction Score
94.9%
Significant Clinical Events per 1000 Admissions
5.75
Readmission per 1000 Admissions
0.64
Quality
Workplace Health & Safety Score
98%
Infection Control Audit Score
100%
2.2.2 Participation in clinical audit
During 1 April 2014 to 31st March 2015 Blakelands Hospital didn’t participate in
national clinical audits as we either didn’t undertake the procedures or have
enough patient activity to warrant participation.
Local Audits
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The reports of 70 local clinical audits from 1 April 2014 to 31st March 2015 were
reviewed by the Clinical Governance Committee and Blakelands Hospital intends
to take the following actions to improve the quality of healthcare provided. The
clinical audit schedule can be found in Appendix 2.



Pharmacist visit to educate staff on Controlled Drugs requisition
documentation
Care pathway review undertaken
Provision of Hand Hygiene leaflets and displayed in all clinical areas
2.2.3 Participation in Research
There were no patients recruited during 2014/15 to participate in research
approved by a research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Blakelands Hospital income in from 1 April 2014 to 31st March
2015 was conditional on achieving quality improvement and innovation goals
agreed Blakelands Hospital and any person or body are entered into a contract,
agreement or arrangement for the provision of NHS services, through the
Commissioning for Quality and Innovation payment framework.
Further details of the agreed goals for 2014/15 and for the following 12
month period are available on request.
2.2.5 Statements from the Care Quality Commission (CQC)
Blakelands Hospital is required to register with the Care Quality Commission and
its current registration status on 31st March is registered without
conditions/registered with conditions.
Blakelands Hospital has not participated in any special reviews or investigations
by the CQC during the reporting period.
A positive unannounced inspection was carried out by the CQC in February 2014;
all areas reviewed in the inspection conclude full compliance.
2.2.6 Data Quality
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Statement on relevance of Data Quality and your actions to improve your
Data Quality
The hospital successfully passed the ISO 20071 external audit in March 2015.
Blakelands Hospital will be taking the following actions to improve data quality.


Archiving of information to a secure off site storage.
All offsite storage has been logged and boxed to ensure we have
access as required.
NHS Number and General Medical Practice Code Validity
Information Governance toolkit levels
2.2.6 Data Quality Statements
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2014/15 to the Secondary Users Service for
inclusion in the Hospital Episode Statistics which are included in the latest published
data. The percentage of records in the published data included:
The patient’s valid NHS number:
 99.97% for admitted patient care;
 99.96% for outpatient care; and
 Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
The General Medical Practice Code:
 100% for admitted patient care;
 100% for outpatient care; and
 Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall for 2014/5 was
75% and was graded ‘green’ (satisfactory).
This information is publicly available on the DH Information Governance Toolkit website
at:
https://www.igt.hscic.gov.uk
Ramsay Group Information Governance Assessment Report score overall
score for 2014/15 was 96% and was graded ‘green’ (satisfactory).
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Clinical coding error rate
Blakelands Hospital was not subject to the Payment by Results clinical coding
audit during 2014/15 by the Audit Commission.
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2.2.7 Stakeholders views on 2014/15 Quality Account
Comments from Health Watch Milton Keynes
‘Thank you for forwarding the Quality Account which we found to be very
informative. The data collected clearly shows that your internal arrangements
are working well, with high levels of care and positive outcomes for your
patients including those who are receiving treatment though your NHS
contracts - 95% of the total numbers.’
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Part 3: Review of quality performance 2014/2015
Statements of quality delivery
Matron, Janet Brackley
Review of quality performance 1st April 2014 - 31st March 2015
Introduction“
This publication marks the sixth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our
performance on many levels, we reflect on the valuable feedback we receive from
our patients about the outcomes of their treatment and also reflect on
professional opinion received from our doctors, our clinical staff, regulators and
commissioners. We listen where concerns or suggestions have been raised and,
in this account, we have set out our track record as well as our plan for more
improvements in the coming year. This is a discipline we vigorously support,
always driving this cycle of continuous improvement in our hospitals and
addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe
in being open and honest where outcomes and experience fail to meet patient
expectation so we take action, learn, improve and implement the change and
deliver great care and optimum experience for our patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
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Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc, are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
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Ramsay Health Care Clinical Governance Framework
National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
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3.1 The Core Quality Account indicators:Mortality
Related NHS Outcomes
Framework Domain
The data made available to the National
1: Preventing People from dying
Health Service trust or NHS foundation trust by prematurely
the Health and Social Care Information Centre 2: Enhancing quality of life for
with regard to—
people with long-term conditions
(a) the value and banding of the summary
hospital-level mortality indicator (“SHMI”) for
the trust for the reporting period; and
(b) The percentage of patient deaths with
palliative care coded at either diagnosis or
specialty level for the trust for the reporting
period.
*The palliative care indicator is a contextual
indicator.
Prescribed Information
Period
Best
Worst
Average
Period
Blakelands
Jan13-Dec13
RKE
0.62
RXL
1.18
Eng
1
2013/14
NVC31
0
Apr13-Mar14
RKE
0.54
RBT
1.20
Eng
1
2014/15
NVC31
0
The Blakelands hospital considers that this data is as described for the following
reasons:
We have not had any reported deaths since facility opened in 2007
Patient Reported Outcomes Measures (PROMS)
The data made available to the National
3: Helping people to recover
Health Service trust or NHS foundation trust by from episodes of ill health or
the Health and Social Care Information Centre following injury
with regard to the trust’s patient reported
outcome measures scores for—
(i) groin hernia surgery,
(ii) varicose vein surgery,
(iii) hip replacement surgery, and
(iv) knee replacement surgery,
during the reporting period.
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Hernia
Period
Best
Apr13 Mar14
NT41
5
Apr14 - Sep14
RXR
Worst
0.13
9
0.12
5
0.00
8
0.00
9
NVC11
Severa
l
Average
En
g
En
g
0.08
5
0.08
1
Period
Blakeland
s
Apr13 Mar14
NVC31
*
Apr14 - Sep14
NVC31
*
Veins
Period
Best
Worst
Apr13 Mar14
RT
H
11.29
2
NT35
0
Apr14 - Sep14
RYJ
-4.567
RWA
16.849
16.762
Average
En
g
En
g
8.698
9.479
Period
Blakeland
s
Apr13 Mar14
NVC31
Apr14 - Sep14
NVC31
Hips
Period
Best
Apr13 Mar14
NT44
1
Apr14 - Sep14
RCB
24.44
4
25.41
8
Worst
RQ
X
RJD
17.63
4
18.35
7
Average
En
g
En
g
21.34
21.92
2
Period
Apr13 Mar14
Apr14 - Sep
14
Blakeland
s
NVC31
NVC31
Knees
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
NT40
4
19.76
2
NV32
3
RWP
20.44
RXF
12.04
9
14.41
6
Average
En
g
En
g
16.24
8
16.70
2
Period
Apr13 Mar14
Apr14 Sep14
Blakeland
s
NVC31
NVC31
The Blakelands Hospital considers that this data is as described for the following
reasons:
Out of the above procedures, only groin Hernia repairs are performed at
this hospital with insufficient quantities to produce a PROMS (Patient
reported Outcome measures) score. Patients are however encouraged
to participate in the study.
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Readmissions
The data made available to the National
3: Helping people to recover
Health Service trust or NHS foundation trust by from episodes of ill health or
the Health and Social Care Information Centre following injury
with regard to the percentage of patients
aged—
(i) 0 to 14; and
(ii) 15 or over,
Readmitted to a hospital which forms part of
the trust within 28 days of being discharged
from a hospital which forms part of the trust
during the reporting period.
Readmissions per 1000 HPDs
0.70
0.60
0.50
0.40
Series1
0.30
0.20
0.10
0.00
2009/10
2010/11
2011/12
2012/13
2013/14
2014/15
The Blakelands hospital considers that this data is as described for the following
reasons –
Readmsissions per HPD’s ( Hospital patient days)

As a day unit we are made aware of any readmission via the postoperative follow up call and the out of hour’s helpline.
There has been 2 patients readmission to hospital in the last year which has been
reported on our Riskman incident reporting tool and reviewed at clinical
governance meetings.
Quality Accounts 2014/15
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Responsiveness to people’s needs
The data made available to the National
4: Ensuring that people have a
Health Service trust or NHS foundation trust by positive experience of care
the Health and Social Care Information Centre
with regard to the trust’s responsiveness to
the personal needs of its patients during the
reporting period.
Period
2012/13
2013/14
Best
RPC
RPY
Worst
RJ6
68.0
RJ6
67.1
88.2
87.0
Average
Eng
76.5
Eng
76.9
Period
2013/14
2014/15
Renacres
NVC16
93.2
NVC16
94.4
The Blakelands hospital considers that this data is as described for the following
reasons
 As a day unit facility we do not qualify for this survey, however we do
participate in an external research survey and score highly
VTE assessments (Venous thromboembolism)
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the percentage of patients who
were admitted to hospital and who were risk
assessed for venous thromboembolism
during the reporting period.
Period
Best
14/15 Q2 Several 100%
Worst
RNL
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Average
Period
Blakelands
86.4% Eng 96.2%
14/15 Q2 NVC31 100.0%
14/15 Q3 Several 100% NT322 85.1% Eng 96.0%
14/15 Q3 NVC31 100.0%
The Blakelands hospital considers that this data is as described for the following
reasons:-
Quality Accounts 2014/15
Page 27 of 38
The scores are higher than the national average in compliance with VTE
assessment.
Nurses participate in VTE assessment
Clinicians are encouraged to complete VTE assessment and update on the postoperative notes
C difficile rate :- per 100,000 bed days
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the rate per 100,000 bed days of
cases of C difficile infection reported within
the trust amongst patients aged 2 or over
during the reporting period.
Period
Best
Worst
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Average
Period
Blakelands
2012/13
Several
0
RVW
30.8
Eng
17.4
2012/13
NVC31
0.0
2013/14
Several
0
RMP
32.5
Eng
14.7
2013/14
NVC31
0.0
The Blakelands hospital considers that this data is as described for the following
reasons: Good infection control and prevention measures in practice
 No incidents of C-Diff
Serious Incidents level 1 only
The data made available to the National
Health Service trust or NHS foundation trust by
the Health and Social Care Information Centre
with regard to the number and, where
available, rate of patient safety incidents
reported within the trust during the reporting
period, and the number and percentage of
such patient safety incidents that resulted in
severe harm or death
Period
Best
Worst
5: Treating and caring for people
in a safe environment and
protecting them from avoidable
harm
Average
Period
Blakelands
Oct 13 - Mar 14
RBD
0
R1F
3.72
Eng
0.43
Oct13-Mar14
NVC31
0.00
Apr - Sep 14
Several
0
RBZ
1.09
Eng
0.17
Apr-Sep14
NVC31
0.00
The Blakelands hospital considers that this data is as described for the following
reasons
Quality Accounts 2014/15
Page 28 of 38

No reported Seriious incidents severity 1.
F&F Test
Friends and Family Test – Patient. The data
made available by National Health Service
Trust or NHS Foundation Trust by the Health
and Social Care Information Centre for all
acute providers of adult NHS funded care,
covering services for inpatients and patients
discharged from Accident and Emergency
(types 1 and 2)
Period
Jan-15
Feb-15
Best
Several 100%
Several 100%
Worst
RPA02 51.2%
RHU10
75%
4: Ensuring that people have a
positive experience of care
This indicator is not a statutory
requirement.
Average
Eng
94.0%
Eng
94.7%
Period
Jan-15
Feb-15
Renacres
NVC16 100.0%
NVC16 100.0%
The Blakelands hospital considers that this data is as described for the following
reasons:
Blakelands consistently score ‘extremely likely’ to friends and family

The score reflects the response rate which has declined due to patients
being asked the question several times during their hospital experience
on the inpatient and out-patient visits.
The Blakelands hospital will continue to invite patients to participate in the survey
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every
year and in all performance respects, and certainly in regards to our track record
for patient safety.
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Risks to patient safety come to light through a number of routes including routine
audit, complaints, litigation, adverse incident reporting and raising concerns but
more routinely from tracking trends in performance indicators.
3.2.1 Infection prevention and control
Blakelands hospital has a very low rate of hospital acquired infection and
has had no reported MRSA Bacteraemia in the past 3 years.
We comply with mandatory reporting of all Alert organisms including
MSSA/MRSA Bacteraemia and Clostridium Difficile infections with a programme
to reduce incidents year on year.
Ramsay participates in mandatory surveillance of surgical site infections for
orthopaedic joint surgery and these are also monitored.
Infection Prevention and Control management is very active within our hospital.
An annual strategy is developed by a Corporate level Infection Prevention and
Control (IPC) Committee and group policy is revised and re-deployed every two
years. Our IPC programmes are designed to bring about improvements in
performance and in practice year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
At Blakelands hospital we have a dedicated infection control nurse who is
involved in the yearly infection control surveillance, hand hygiene, surgical site
infection and environmental audits. A network of link nurses meet regularly to
improve clinical practice.
Our (IPC) Committee meet regularly. Group policy is revised and re-deployed
every two years. The local infection control committee produce an annual plan in
line with the corporate IPPC recommendations.
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Infection Rates
(percentage of Admissiosns)
Infection Rates
0.2
0.18
0.16
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
2012/13
2013/14
2014/15
Blakelands Hospital

We have a small increase in infections this year through raising awareness
and a more robust reporting system. Through Root cause analysis
investigation, we have no trends identified, actions required have been
implemented.

Infection control is a priority for the hospital any signs of infection are
reported on the riskman incident reporting tool.
3.2.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient-Led
Assessments of the Care Environment (PLACE)
PLACE assessments occur annually at Blakelands Hospital, providing us with a
patient’s eye view of the buildings, facilities and food we offer, giving us a clear
picture of how the people who use our hospital see it and how it can be
improved.
The main purpose of a PLACE assessment is to get the patient view.
Results of Patient Led Assessment of the Care Environment audit 2014
Quality Accounts 2014/15
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In 2014 a representative from Healthwatch Milton Keynes and an ex patient
formed part of the assessment team. Our results are as below:-
Cleanliness
100%
Higher Than the national average score.
Food
66.67%
We do not have catering facilities at Blakelands hospital, therefore reflected in the
score
Privacy & Dignity
87.73%
Some of the measurements assessed do not apply to a day unit facility. As we do
not provide individuals with TV, radio and internet access, this is reflected in our
scores.
Condition, appearance and maintenance
98.72%
Higher than the national average score. Some blinds required attendance. We do
have a robust maintenance programme in place.
3.2.3 Safety in the workplace
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been a foundation for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Our record in workplace safety as illustrated by Accidents per 1000
Admissions demonstrates the results of safety training and local safety initiatives.
Effective and ongoing communication of key safety messages is important in
healthcare. Multiple updates relating to drugs and equipment are received every
month and these are sent in a timely way via an electronic system called the
Ramsay Central Alert System (CAS). Safety alerts, medicine / device recalls and
new and revised policies are cascaded in this way to our General Manager which
ensures we keep up to date with all safety issues.
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Safety alerts on equipment, products and medicines are cascaded and
communicated throughout the hospital.
Health and safety and the’ safer sharps’ has progressed with products, in house
training and staff awareness.
The WHO checklist is integral to daily practice in theatre. Training, education and
audits ensure compliance.
3.3 Clinical effectiveness
Blakelands hospital has a Clinical Governance team and committee that meet
regularly through the year to monitor quality and effectiveness of care. Clinical
incidents, patient and staff feedback are systematically reviewed to determine any
trend that requires further analysis or investigation. More importantly,
recommendations for action and improvement are presented to hospital
management and medical advisory committees to ensure results are visible and
tied into actions required by the organisation as a whole.
3.3.1 Return to theatre –
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.14
0.12
0.1
0.08
0.06
0.04
0.02
0
2012/13
2013/14
2014/15
Blakelands Hospital
Ramsay is treating significantly higher numbers of patients every year as our
services grow. The majority of our patients undergo planned surgical procedures
and so monitoring numbers of patients that require a return to theatre for
supplementary treatment is an important measure. Every surgical intervention
carries a risk of complication so some incidence of returns to theatre is normal.
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The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. Ramsay’s rate of return is very low
consistent with our track record of successful clinical outcomes.

In the last 12months one patient was transferred to theatre at the local
NHS trust following a surgical complication.
3.4 Patient experience
All feedback from patients regarding their experiences with Ramsay Health Care
are welcomed and inform service development in various ways dependent on the
type of experience (both positive and negative) and action required to address
them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and
notice boards. Managers ensure that positive feedback from patients is
recognised and any individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are also fedback to the
relevant staff using direct feedback. All staff are aware of our complaints
procedures should our patients be unhappy with any aspect of their care.
Patient experiences are fedback via the various methods below, and are regular
agenda items on Local Governance Committees for discussion, trend analysis
and further action where necessary. Escalation and further reporting to Ramsay
Corporate and DH bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:










Continuous patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web
survey
Yearly CQC patient surveys
Friends and family questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff - including Consultants, Matrons/General
Managers whilst visiting patients and Provider/CQC visit feedback.
Written feedback via letters/emails
Patient focus groups
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan
of care
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3.3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently
of the hospital so we receive a true reflection of our patient’s views.
Every patient (inpatient or outpatient) is asked their consent to receive an
electronic survey or phone call after they leave the hospital. The results from the
questions asked are used to influence the way the hospital seeks to improve its
services. Any text comments made by patients on their survey are sent as ‘hot
alerts’ to the Hospital Manager within 48hrs of receiving them so that a response
can be made to the patient as soon as possible.
Patient Satisfaction
120.0%
100.0%
80.0%
60.0%
Patient Satisfaction
40.0%
20.0%
0.0%
2009/10
2011/12
2013/14
Quality Accounts 2014/15
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Appendix 1
Services covered by this quality account
All Day case patient, out-patients, Radiology and Physiotherapy
General Surgery
Ophthalmic Surgery including YAG Laser
Orthopaedic Surgery
Upper and lower diagnostic Endoscopy procedures, including direct referrals
Podiatric Surgery
Physiotherapy including Shockwave Therapy.
Acupuncture
Quality Accounts 2014/15
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Appendix 2 – Clinical Audit Programme 2013/14. Each arrow links to the audit to be completed in
each month.
Quality Accounts 2014/15
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Blakelands hospital
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Hospital 01908 334 200
www.blakelandshospital.co.uk
Quality Accounts 2014/15
Page 38 of 38