2014/15

Introduction page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART ONE – STATEMENT ON QUALITY
1.1 Statement from the General Manager
1.2 Hospital accountability statement
PART TWO
2.1 Priorities for improvement
2.1.1 Review of clinical priorities 2014/15 (looking back)
2.1.2 Clinical priorities for 2015/16 (looking forward)
2.2
Mandatory statements relating to the quality of NHS services provided
2.2.1 Review of services
2.2.2 Participation in clinical audit
2.2.3 Participation in research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on data quality
2.2.7 Stakeholders views on 2014/15 Quality Accounts
PART THREE – REVIEW OF QUALITY PERFORMANCE
3.1 The Core Quality Account indicators
3.2 Patient safety
3.3 Clinical effectiveness
3.4 Case study
3.5 Patient feedback
Appendix 1
– Services covered by this Quality Account
Appendix 2 – Clinical audits

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 1,000 ’s of
NHS patient episodes of care each month, working seamlessly with other healthcare providers in the locality including GPs and the 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 our 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 even better.
I am very proud of our long standing reputation and being a major provider of healthcare services across the world, particularly of our 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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This Quality Account is
Euxton Hall Hospital’s annual report to the public and other stakeholders about the quality of the services we provide. It reports on the period between 1st April 2014 to 31st March 2015 and presents our achievements in terms of clinical excellence, effectiveness, safety and patient experience. It also demonstrates that our managers, clinicians and staff are all committed to providing continuous, evidence based, quality care to those people we treat. We aim to demonstrate how 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 already good at and where we need to improve.
Our first Quality Account in 2010 was developed by our Corporate Office, which summarised and reviewed quality activities across every hospital and treatment centre within Ramsay Health Care UK. It was recognised that this did not 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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“Ramsay Health Care UK is committed to establishing an organisational culture that puts the patient at the centre of everything we do. As General Manager of Euxton
Hall Hospital I am passionate about ensuring that high quality patient care is our number one priority. This relies not only on excellent medical and clinical delivery, but also upon continued commitment to driving improvement in clinical outcomes.
Ramsay Health Care UK has a structured clinical governance framework that enables continual review of performance, which allows us to drive improvements for the benefit of all patients.
This Quality Account not only accurately documents through collated data our achievements in delivering excellent services, but also highlights the areas that we need to improve upon.
Our Quality Account is information for our patients and Commissioners to assure them that we are committed to sharing our progressive achievements year on year.”
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To the best of my knowledge, as requested by the regulations governing the publication of this document, the information in this report is accurate.
David Winters
General Manager, Euxton Hall Hospital, Ramsay Health Care UK
Dr Ian Drake
Consultant Gastroenterologist, Chairman of Euxton Hall Medical Advisory Committee
(MAC)
Mrs Helen White
Northern Regional Director, Ramsay Health Care UK
Healthwatch
A copy of the Quality Accounts has been sent to Healthwatch
Jan Ledward
Chief Officer, NHS Chorley and South Ribble Clinical Commissioning Group.
Quality Accounts 2014/15
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CCG feedback for Euxton Hall Quality Accounts 2014/15
Ramsay Health Care Quality Accounts 2014/15
NHS Greater Preston CCG welcomes the opportunity to comment on the Ramsay Health Care annual quality accounts for 2014/15. The accounts have been discussed with the CCG Quality and
Performance committee and forwarded to the relevant associate commissioners in order to formulate this response.
Throughout the year a clearly defined, professional relationship has been evident between the CCG and the provider. This has ensured and open and honest culture of reporting to he CCG. The CCG review the quality of the providers’ service in terms of safety, effectiveness and patient experience utilising a variety of methods. These include formal monitoring process, partnership discussions and a programme of quality visits.
It has been clear to see the hospital’s commitment to providing a quality service for all patients. This is supported by the introduction of a ‘Quality Improvement Manager’ at Fulwood Hall Hospital. In addition to this, the utilisation of the Ramsay Health Care Clinical Governance Framework’ emphasises the importance that the organisation places upon providing and environment and culture that will assure the quality of patient care.
Ramsay Health Care have demonstrated consistently high score across the core quality account indicators, although PROMS data remains difficult to measure due to the small volumes of appropriate cases. Fulwood Hall, Euxton Hall and Renacres Hospital have also demonstrated a consistently high level of performance against the applicable national performance standard.
The CCG is pleased to confirm that the provider has achieved the defined requirements of two national CQUIN’s:

Friends and Family Test

NHS Safety Thermometer
Ramsay Health Care has also achieved the main components of the local CQUIN’s which have delivered improvements in patient care:

Equality and Diversity

Advanced Quality

PROMS
Two never events have been recorded by Ramsay Health Care during 2014/15, both of which were classified as surgical errors. Duty of candour was undertaken in both cases along with a rigorous root cause analysis of both incidents. The CCG undertook a theatre assurance visit, along with quality visits at Fulwood Hall, Euxton Hall and Renacres Hospital in response to this. Assurance was obtained at these visits in relation to dissemination of lessons learned and the subsequent changes in practice.
Although Ramsay Health Care are treating significantly higher numbers of NHS patients each year it is reassuring to note the continued reduction in the numbers of patients that required a return to theatre for supplementary treatment. Information received from the NHS Safety Thermometer database also demonstrates the delivery of 100% harm free care. The continued commitment of key
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personnel to the safe guarding agenda ensures that the hospitals demonstrate a proactive approach to safeguarding local patients’ whilst in their care. There have been no reported cases of MRSA or
Clostridium Difficile during 2014/15. The CCG is also pleased to note the continued improvement in post surgery infection rates across the three hospital sites. Furthermore, Patient Led Assessment of the Care Environment have identified favourable results.
Ramsay Health Care has participated in national audits where these are applicable. Additionally, the group participate in local audits, which are reported in line with their audit schedule. Improvements to services as a result of these audits have been evidenced within the accounts for both Renacres and
Euxton Hall Hospitals. The CCG would like to see further evidence of these improvements throughout 2015/16.
The CCG would like to acknowledge the commitment to improving data quality at Ramsay Health
Care, but would also like to see the impact that the identified improvement actions have made in practice.
Ramsay Health Care display a serious commitment to ensuring that patient feedback is obtained using various methods. Throughout 2014/15 they have experienced a continuously high level of performance from the Friends and Family Test results. March 2015 data indicates 100% of patients would recommend the care they received which is a very commendable achievement. Ramsay
Health Care also ensure a personalised, individual response to any complaints that are submitted, furthermore ensuring that the CCG is aware of any potential or identified issues with patient care.
The CCG look forward to receiving additional feedback from the patient forum once this has been established in 2015.
It is very clear that the clinical priorities for the year ahead maintain a strong focus upon patient safety, clinical effectiveness and patient experience. As Ramsay Health Care predominantly provide elective surgery procedures, it is also pleasing to note that 100% compliance with the World Health
Organisation ‘Surgical Safety Checklist’ has been published as one of these priorities.
CQUIN targets for 2015/16 have retained a strong patient focus. The CCG look forward to the potential improvements to patient care that will be identified from participation in the following:

Advancing Quality

Sepsis

Reducing Health Inequalities

Patient Experience Phone Calls
In conclusion the information reviewed portrays a very positive service experience with a clear emphasis upon continuous quality improvement. The CCG value the collaborative working relationship that is in place with Ramsay Health Care and look forward to working together in
2015/16.
Yours sincerely
Jan Ledward
Chief Officer
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Euxton Hall Hospital is one of Lancashire’s leading private hospitals situated on the outskirts of Chorley, close to Preston and Wigan.
The facility offers 32 beds all with ensuite facilities to ensure complete privacy. Each room includes a digital television and telephone. Our private patients are automatically allocated a Premium Care single room with ensuite facility, they are also provided with Molton Brown toiletries, a newspaper of their choice and an à la carte menu.
The hospital boasts two fully equipped ultra clean air theatres, a JAG accredited endoscopy suite, small treatment room and by investing in advanced medical technology offers a wide range of treatments and services.
Euxton Hall Hospital specialises in Orthopaedic surgery offering procedures such as arthroscopy, hip and knee replacement surgery, upper limb surgery and offers rapid access to breast care services supported by the X-ray and radiology facilities on site.
Euxton Hall Hospital offers the latest physiotherapy support in a purpose built sports injury centre. The hospital has the latest Cybex Isokinetic equipment and offers electrotherapy, continence clinic, back pain clinic, personal training, aromatherapy, reflexology and acupuncture.
Other services offered at Euxton Hall Hospital:

Cardiology

Cosmetic Surgery

Dermatology

Diagnostics

ENT

Gastroenterology

General Surgery

Gynaecology

Neurology

Pain Management

Physiotherapy

Speech Therapy

Urology
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With 105 registered Consultants, a workforce of approximately 125 contracted staff and a 24 hour Resident Medical Officer, Euxton Hall Hospital provides fast, convenient, effective and high quality treatment for patients (subject to certain exclusion criteria), whether medically insured, self-pay or from the NHS.
In addition, Euxton Hall Hospital has established a successful Outreach clinic.
The Gathurst Consulting rooms offer Gynaecological and General Surgery services to the people of Wigan without the need to travel. The hospital is currently investigating the possibility of opening further Outreach clinics in Leigh,
Bolton and East Lancs.
Euxton Hall Hospital is part of the Central Lancashire Critical Care Network and has a Service Level Agreement in place for emergency transfer of critically ill patients.
Each year Euxton Hall Hospital chooses one charity to support for the year, however after the success of supporting Hand on Heart in 2013 it was decided that the hospital would continue to support this charity for an additional year, in an attempt to provide as many local schools as possible with lifesaving defibrillators and training. Euxton Hall Hospital is extremely proud that in addition to the four local primary schools that were supplied with defibrillators in 2013, in 2014 a further seven schools benefitted from the hospital ’s fundraising. The complete list of schools is below:

Buckshaw Primary
 Eccleston St Mary’s

St Georges C of E Primary

St Josephs Catholic Primary

Withnell Fold

Mayfield School

Balshaw Lane Community Primary School

Euxton CE Primary School

Euxton Primrose Hill Primary

Euxton St Marys Catholic Primary

Westholme School

On an annual cycle Euxton Hall 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 audits 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.
PLACE is a patient led audit undertaken by an assessment team that consists of at least fifty per cent patient representation. The audit includes all internal and external areas of the hospital. The scoring matrix employs a system whereby areas are given a ‘Pass’, ‘Fail’ or ‘Qualified Pass’.
Euxton Hall Hospital’s PLACE audit took place on 16th May 2014 and the following is an overview of the scores achieved:

Cleanliness
– 100%

Food
– 98.50%

Privacy
– 87.80%

Condition – 98.98%
Public bodies including the Care Quality Commission, the NHS Commissioning
Board, and the Department of Health use information from PLACE assessments to ensure that all patients are given a high quality service.
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JAG Accreditation
– In January 2015 the hospital’s Endoscopy Unit underwent the JAG Accreditation visit and achieved a pass.
Clinical documentation audits – This remained a priority in all areas with a corporate Ramsay focus in 2014/15 on out-patient processes and practice, and theatre safety checks. The team achieved full completion of the Ramsay corporate audit programme.
Local CQUINS

Equality Deliver System Self-Assessment

Advancing Quality
– Hip and Knee Replacement

Patient Reported Outcome Measures (PROMs)
Euxton Hall Hospital had one Never Event in the reporting period - a left sided femoral component implanted into a right knee during a total knee replacement in
August 2014. Following investigation the Standard Policy being implemented relating to ‘Checking of Prosthesis and Implants’ Policy No. TH11 was amended.
These lessons have been shared by clinical leads across the Ramsay group.
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Patient Safety
Safety Thermometer - The Safety Thermometer focuses on the reduction of patient harm. The power of the NHS Safety Thermometer lies in allowing frontline teams to measure how safe their services are and to deliver improvement locally.
The data can also be aggregated to measure improvement at a regional and national level.
The Safety Thermometer is a national CQUIN indicator, and in 2014/15 Euxton
Hall Hospital achieved its CQUIN target.
Surgical Safety Checklist – ‘Never Events’ are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented as standard practice. Monthly audits will continue to be undertaken with an expectation of 100% compliance. Where this is not achieved, actions plans will be developed and responsibilities communicated to the teams. Briefing and debriefing sessions after all operating sessions continue and give opportunity for shared learning, recommendations for future practice and aim to encourage autonomy for all members of the team.
Compliance will be monitored by regu lar audit and reviewed by the hospital’s
Clinical Governance and Medical Advisory Committees.
VTE assessment - A VTE risk assessment is completed for patients according to
CM 001 VTE policy, and requires Consultants to review and complete the assessment prior to procedure. This remains a focus at Euxton Hall Hospital with quarterly audits completed to maintain standards. Results are reviewed and actions determined at the hospital’s Clinical Governance and Medical Advisory
Committees.
Clinical effectiveness
Sepsis - A new local CQUIN has been introduced relating to sepsis. The aim is to ensure that staff at Ramsay are aware of the early signs of Sepsis and to implement the Sepsis 6 pathway. The CQUIN also aims to ensure that patients and carers are made aware of the early signs of Sepsis and the correct action to take.
Patient Experience
Friends and Family Test The Friends and Family test aims to improve the experience of patients in line with Domain 4 of the NHS Outcomes Framework.
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The Friends and Family test will provide timely, granular feedback from patients about their experience. In the first six months of use, the Friends and Family test gathered almost one million responses; by contrast, in the 2012 inpatient survey,
64,500 patients were asked for feedback. Commissioners should be assured that
NHS providers have plans in place to reduce the proportion of people reporting a poor experience of care in line with the locally set level of ambition.
In 2015/16 the friends and family test will continue to include in-patients, day cases and out-patients as a national CQUIN .
Patient Satisfaction Survey - We will continue to encourage patients to provide feedback using our web based satisfaction survey. ‘Hot alerts’ received following completion of the survey will be reviewed by the General Manger and Clinical
Lead, and action taken if there are areas identified for improvement. All comments, positive and negative, are shared with the whole team along with a monthly patient satisfaction dashboard. Compliments and complaints are reviewed at the hospital’s Clinical Governance and Medical Advisory Committees, and lessons learnt shared with the nursing teams. We will continue to monitor posts on NHS Choices and remain committed to retaining our 4.5 star recommendations. We have added to our current patient feedback mechanisms by inviting patients to our endoscopy user group and including patients in hospital
PLACE audits.
Advancing Quality - This initiative is aimed at improving the quality of care and patient experience. It is a local CQUIN where Euxton Hall Hospital submits data regarding DVT and antibiotic prophylaxis. Compliance with completion of data is expected at 95%, achievement of 95% ACS, and 80% compliance on external audit.
Reducing Health Inequalities - Elaborating on last year’s local CQUIN “Equality
Delivery Systems”, the Reducing Health Inequalities focuses on two key areas:

Better Health Outcomes . By auditing patient outcomes total health gain will be reviewed for elective procedures, specifically for those individuals who identify with a protected characteristic. Following analysis, actions will be implemented with changes made to services including any reasonable adjustments that have improved health outcomes for patients, specifically those with protected characteristics.

Improved patient access and experience . The purpose of this local
CQUIN indicator is to monitor that patients, carers and communities can readily access services and that they are not be denied access on unreasonable grounds and are involved with decisions about their care.
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Patient Enquiry Phone Calls - The aim of this local CQUIN is to reduce the number of phone calls and to utilise the tacit knowledge within frontline staff to improve patient care.
Patient Reported Outcome Measures Studies (PROMS) - We will continue to monitor patient response rates for those patients who have undergone hip and knee joint replacement surgery, and inguinal hernia repairs.
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The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
During 2014/15 Euxton Hall Hospital provided NHS services across eight surgical specialties.
Euxton Hall Hospital has reviewed all the data available to them on the quality of care in all of these NHS services.
The income generated by the NHS services reviewed from 1st April 2014 to 31st
March 2015 represents 89.1% per cent of the total income generated from the provision of NHS services by Euxton Hall Hospital for 1st 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

HCA hours as % of total nursing

Agency cost as % of total staff cost

Ward hours PPD

% Staff turnover

% Sickness

% Lost time

Appraisal %

Mandatory training %

Staff satisfaction score

Number of significant staff injuries
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Patient

Formal complaints per 1000 HPD's

Patient satisfaction score

Significant clinical events per 1000 admissions

Readmission per 1000 admissions
Quality

Workplace health & safety score

Infection Control audit score
During 1 st
April 2014 to 31 st
March 2015 Euxton Hall Hospital participated in two national clinical audits.
The national clinical audits that Euxton Hall Hospital participated in, and for which data collection was completed during 1 st
April 2014 to 31 st
March 2015, are listed below as the number of cases submitted to each audit as a percentage of the number of registered cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome
Review Programme
% cases submitted
100
National Joint Registry (NJR)
88.85
Elective surgery (National PROMs Programme)
The reports of these national clinical audits were reviewed by the hospital’s
Clinical Governance Committee.
The reports of 79 local clinical audits from 1 st
April 2014 to 31 st
March 2015 were reviewed by the Clinical Governance Committee and Euxton Hall Hospital.

Nutrition and Hydration Audit . Issues relating to full completion of fluid balance chart was identified and training arranged accordingly. In addition there has been an increased focus on ensuring the nursing staff document that patients have been offered fluids if the time to theatre is greater than two hours.
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
VTE Audit. This audit identified that although the VTE assessment process was robust and well embedded; the forms were not always dated and timed. This has been addressed through the Local Clinical
Governance Committee and the Medical Advisory Committee (MAC). The issue continues to be monitored.
The clinical audit schedule can be found in Appendix 2
There were no patients recruited during 2014/15 to participate in research approved by a research ethics committee.
A proportion of Euxton Hall Hospital’s income is from 1 st
April 2014 to 31 st
March
2015, was conditional based on achieving quality improvement and innovation goals through the Commissioning for Quality and Innovation payment framework.
Euxton Hall Hospital is required to register with the Care Quality Commission and its current registration status on 31 st
March 2015 is registered without conditions.
Euxton Hall Hospital has not participated in any special reviews or investigations by the CQC during the reporting period.
Euxton Hall Hospital submitted records during 2014/15 to the Secondary
Use r s Service (SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the latest published data. The percentage of records in the published data which included:
The patient’s valid NHS number:

99.97% for admitted patient care;

99.96% for outpatient care; and

Accident and emergency care not applicable (as not undertaken at Ramsay hospitals).
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The General Medical Practice Code:

100% for admitted patient care;

100% for outpatient care; and

0% for accident and emergency care (not undertaken at our hospital).
The 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
Euxton Hall Hospital was subject to the payment by results clinical coding audit during 2014/15 by the National Audit Commission the result of which is shown below.
Hospital Site Audit
Date
Next Audit
Date
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
Euxton Hall June 14 96.6% 98.9% 98.3% 92.3%
The hospital continues to take the following actions to improve data quality:

Regular training to ensure staff understand the importance of accurate data input and have sufficient technical competence.

Employment of a clinical coder to improve accuracy of recording.

Supporting national projects to ensure data accuracy.
Healthwatch:
A copy of the Quality Accounts has been sent to Healthwatch
Chorley and South Ribble Clinical Commissioning Group
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st
st
Statement from Vivienne Heckford
“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
The aim of Clinical Governance is to ensure that Ramsay develops 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,
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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 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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National Mortality Rates:
Period
Jan13-Dec13
Apr13-Mar14
RKE
RKE
Best
0.62
0.54
Euxton Hall Hospital
RXL
Worst
1.18
RBT 1.20
Average
Eng
Eng
1
1
Period
2013/14
2014/15
Euxton
NVC05
NVC05
0
0
Euxton Hall Hospital has taken action to improve the returns rate of PROMs questionnaires and so the quality of its services, by actively involving Consultants in the PROMs process in encouraging patient participation.
Hernia repair
National PROMs:
Period Best Worst
Apr13 - Mar14 NT415 0.139 NVC11 0.008 Eng
Average
0.085
Apr14 - Sep14 RXR 0.125 Several 0.009 Eng 0.081
Euxton Hall Hospital PROMs:
Period
Apr13 -
Mar14
Apr14 -
Sep14
Euxton
NVC05 0.031
NVC05 0.089
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Varicose Veins
National PROMs:
Period
Apr13 -
Mar14
Apr14 -
Sep14
RTH
Best Worst
11.292 NT350 -16.849 Eng
Average
-8.698
RYJ -4.567
Euxton Hall Hospital PROMs:
RWA -16.762 Eng -9.479
Period
Apr13 -
Mar14
Apr14 -
Sep14
Euxton
NVC05
NVC05
*
*
*Varicose vein surgery is currently no longer offered at Euxton Hall Hospital
Hip Replacement
National PROMs:
Period
Apr13 -
Mar14
Apr14 -
Sep14
Best Worst
NT441 24.444 RQX 17.634 Eng
Average
21.34
RCB 25.418 RJD
Euxton Hall Hospital PROMs:
18.357 Eng 21.922
Period
Apr13 -
Mar14
Apr14 - Sep
14
Euxton
NVC05 22.457
NVC05 *
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Knee replacement
National PROMs:
Period
Apr13 -
Mar14
Apr14 -
Sep14
Best Worst
NT404 19.762 NV323 12.049 Eng
Average
16.248
RWP
Euxton Hall Hospital
20.44 RXF 14.416 Eng 16.702
Period
Apr13 -
Mar14
Apr14 -
Sep14
Euxton
NVC05 17.787
NVC05 *
* Volumes were too low to be reported
Readmissions
National Readmissions:
Period
2010/11
2011/12
Best
Multiple
Multiple
0.0 5P5
Worst
22.76
0.0 5NL 41.65
Euxton Hall Hospital Readmissions:
Eng
Average
11.43
Eng 11.45
Period
2010/11
2011/12
Euxton
NVC05 4.63
NVC05 2.44
VTE assessment
National VTE assessment:
Period
14/15 Q2
14/15 Q3
Best
Several 100% RNL
Worst
86.4% Eng
Several 100% NT322 85.1% Eng
Average
96.2%
96.0%
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Euxton Hall Hospital:
Period
14/15 Q2
14/15 Q3
Euxton
NVC05 99.8%
NVC05 99.8%
Euxton Hall Hospital considers that this data is as described; we monitor compliance monthly and agree an action plan if completion rates drop below 95% maintaining a target above the national average. Euxton Hall Hospital will continue to audit to maintain the quality of its services.
C Difficile rate
National C Difficile rate:
Period
2012/13
2013/14
Best
Several
Several
Euxton Hall Hospital:
Worst
0 RVW
0 RMP
30.8
32.5
Eng
Eng
Average
17.4
14.7
Period
2012/13
2013/14
Euxton
NVC05
NVC05
0.0
0.0
Euxton Hall Hospital considers that this data is as described as there have been no reported cases of C Difficile. Euxton Hall Hospital intends to maintain this rate by ensuring robust infection control measures are in place.
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SUI
’s Severity level 1
N ational SUI’s Severity level 1
Period
Oct 13 - Mar
14
Apr - Sep 14
Best
RBD
Several
Euxton Hall Hospital
0 R1F
Worst
3.72
0 RBZ 1.09
Eng
Average
0.43
Eng 0.17
Period
Oct13-
Mar14
Apr-Sep14
Euxton
NVC05
NVC05
0.00
0.27
Euxton Hall Hospital considers that this data is as described. We have a low level of incidents and an open culture which encourages reporting to ensure incidents are investigated and lessons are learned. Euxton Hall Hospital ensures a safe environment is maintained with all staff undertaking training and competency assessments and a robust audit system. All incidents and accidents are reviewed at the Clinical Governance meeting, Health and Safety meeting and the Hospital
Medical Advisory Committee, and any action plans developed and lessons learnt are shared.
Friends and Family Test
National:
Period
Jan-15
Feb-15
Euxton Hall
Best Worst
Several 100% RPA02 51.2% Eng
Several 100% RHU10 75% Eng
Average
94.0%
94.7%
Period
Jan-15
Feb-15
Euxton
NVC05 100.0%
NVC05 100.0%
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Responsiveness to Personal Needs
National:
Period
2012/13
2013/14
Euxton Hall
Period
2012/13
2013/14
RPC
RPY
Best
88.2
87.0
Euxton
NVC05 93.9
NVC05 94.1
RJ6
Worst
68.0
RJ6 67.1
Eng
Average
76.5
Eng 76.9
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We are a progressive hospital and focussed on stretching our performance every year and in all performance respects, and certainly in regards to our track record for patient safety.
Risks to patient safety come to light through a number of routes including routine audit, complaints, litigation, adverse incident reporting and raising concerns but more routinely from tracking trends in performance indicators.
Our focus on patient safety has resulted in a marked improvement in a number of key indicators as illustrated in the graphs below.
Euxton Hall 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:
The dedicated infection control link nurse provides mandatory training in hand hygiene to all staff and completes a hand hygiene training session during the staff induction day for all new staff.
Hand hygiene awareness days are led by the infection control link nurse involving staff, patients and visitors and information in waiting areas.
The infection control nurse reviews and completes a root cause analysis of confirmed infections to determine any possible trends with results being presented at our quarterly infection control committee meetings. We continue to
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have a robust process in identifying and reporting of all infections with a dedicated infection control nurse in post. As can be seen in the graph below our infection rate has decreased over the last year and rates remain below the national average.
1.4
1.2
1
0.8
0.6
0.4
0.2
0
2012/13 2013/14
Euxton Hall Hospital
2014/15
Assessments of safe healthcare environments also include P atientL ed
A ssessments of the C are E nvironment ( PLACE )
PLACE assessments occur annually at Euxton Hall 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.
2014 PLACE results:

Cleanliness – 100%

Food – 98.50%

Privacy – 87.80%

Condition
– 98.98%
An action plan was compiled in conjunction with a refurbishment/future development plan to rectify some of the low scores. An active maintenance programme was introduced to ensure the condition and maintenance of the
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facilities is maintained to a high standard. Incorrect data entry has resulted in an incorrect percentage score. Privacy & Dignity actual score achieved should have been circa 96%.
The unit has since been audited on 16 th
April 2015 and the scheduled publication date for the 2015 National results is 11th August.
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.
Euxton Hall Hospital 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 Hospital Medical Advisory committee to ensure results are visible and tied into actions required by the organisation as a whole.
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
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supplementary treatment is an important measure. Every surgical intervention carries a risk of complication so some incidence of returns to theatre is normal.
The value of the measurement is to detect trends that emerge in relation to a specific opera tion or specific surgical team. Ramsay’s rate of return is very low consistent with our track record of successful clinical outcomes
0.5
0.45
0.4
0.35
0.3
0.25
0.2
0.15
0.1
0.05
0
2012/13 2013/14
Euxton Hall Hospital
2014/15
Euxton Hall Hospital continues to have a very low return to theatre rate as a percentage of overall admissions.
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 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 feedback 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.
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Patient experiences are feedback via the various methods below, and are standard agenda items on the Hospital Management meeting under Customer
Service, Local Governance Committee for discussion around lessons learnt, and department team meetings to review feedback, discuss trend analysis and implement 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

PROMs surveys
 Care pathways – patient are encouraged to read and participate in their plan of care
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of the hospital so we receive a true reflection of our patient’s views.
Every patient is asked if they consent to receive an electronic survey or phone call to take part in this survey. 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 48 hours of receiving them so that a response can be made to the patient as soon as possible.
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NHS/Private Patients
100
80
60
40
20
0
95.0 93.5
2013/14 2014/15
Euxton Hall Hospital
During the latter part of 2014 a working group was established to look into how
Euxton Hall Hospital
’s private service could be improved. As an outcome from this group it was decided that to evolve and improve the service a designated regional enquiry service would be piloted to offer a complete call handling service
Monday to Friday, 8am to 6pm, to our patients.
This regional service would be responsible for coordinating all aspects of a patient enquiry, from initial contact through to inpatient booking.
The service encompassed five hospitals from the Northern region and was based at Euxton Hall. The pilot ran for 6 months the feedback from patients was extremely positive as they felt they had contact throughout their decision making process. As well as this positive feedback, a number of process lessons were learnt from the pilot including, what information is given to patients, how well we manage appointments and expectations of patients prior to admission. These lessons from the pilot have been fed into the national review so we can inform service improvements prior to implementation.
This is a service that will be developed into a permanent service within Ramsay in
2015.
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“Friendly, approachable staff. Clean and welcoming environment.”
“A good combination of efficiency, expertise and friendliness. I actually enjoyed the whole procedure! Thank you
.”
“All staff have been very helpful and caring, whilst being competent and professional .”
“Appointment on time, very kind and helpful staff, happy with everything during my stay .”
“Everyone was very friendly and approachable; I was well informed and did not feel rushed. I would recommend Euxton Hall to anyone .”
“Excellent care from all staff, who have kept me informed every step of the way.”
“First class venue, all the team are friendly and caring, what an enjoyable experience. It was a pleasure, I wanted to stay longer. Thank you
.”
“Treated with dignity and respect. An excellent patient experience with superb staff throughout from OPD, ward, theatre and catering.
”
“I have received lovely care, was kept fully informed about my procedure and had excellent aftercare. I would advise anyone to come here.
”
“Lovely hospital and wonderful staff, I feel safe and well cared for.”
“Excellent care from all staff, all the way through, comfy and immaculate rooms.”
“Clean, efficient, friendly staff”
“1st class service”
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Services Provided Peoples Needs Met for:
Treatment of
Disease,
Disorder
Or injury
Surgical
Procedures
General medicine, Orthopaedic medicine,
Physiotherapy, Psychology, Rheumatology, Sports
Medicine
All adults and children 3 yrs and above
Diagnostic and screening
Family
Planning
Services
Colorectal, Cosmetic, Dermatological, Ear, Nose and
Throat (ENT), Gastrointestinal, General surgery,
Gynaecological, Maxilo-facial/oral surgery, Ophthalmic,
Orthopaedic, Urological, Sports medicine and cardiology,
Ambulatory, Day and Inpatient Surgery
All adults and children 16 yrs and above excluding:

Patients with blood disorders (haemophilia, sickle cell, thalassaemia)

Patients on renal dialysis

Patients with history of malignant hyperpyrexia

Planned surgery patients with positive MRSA screen are deferred until negative

Patients who are likely to need ventilatory support post operatively

Patients who are above a stable ASA 3.

Any patient who will require planned admission to
ITU post surgery

Dyspnoea grade 3/4 (marked dyspnoea on mild exertion e.g. from kitchen to bathroom or dyspnoea at rest)

Poorly controlled asthma (needing oral steroids or has had frequent hospital admissions within last 3 months)

MI in last 6 months

Angina classification 3/4 (limitations on normal activity e.g. 1 flight of stairs or angina at rest)

CVA in last 6 months
GI physiology, Imaging services, Phlebotomy, Urinary
Screening and Specimen collection.
However, all patients will be individually assessed and we will only exclude patients if we are unable to provide an appropriate and safe clinical environment.
All adults and children 3 yrs and above
Gynaecology patient pathway, insertion and removal of inter uterine devices for medical as well as contraception purposes
All adults 18 years and over as clinically indicated
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