Table of Contents
Page
1.
Statement from CEO
3
2.
Purpose and Values
5
3.
Governance
6
4.
Review of NHS Services
6
4.1
4.2
4.3
4.4
4.5
4.6
Participation in Clinical Audits
7
Research
Goals agreed with NHS Commissioners (CQUIN)
Regulation
Data Quality
Information Governance
8
8
8
9
9
5.
Key Achievements 2014/2015
9
6.
Regularly Reported Indicators
19
7.
Prescribed Information
19
8.
Priorities for 2015/2016
21
9.
Key Business Objectives for 2015/16
24
10. Conclusion
39
Schedule 1 CQUIN
Schedule 2 Clinical Audit List
40
41
Statements from External Bodies
42
Chief Executive’s statement
1. Statement from Chief Executive Officer
Welcome to the Quality Account for 2014/2015 for Fairfield
Independent Hospital. With difficult economic conditions that have
characterised the business environment the Charity has
nevertheless continued to provide high quality health care, invest
in its services, infrastructure and staff in pursuit of its overall
strategic objectives.
The difficult financial situation has served to emphasise the
importance of values and integrity. Our not-for-profit model is
particularly suited to health care as it enables us to remain
independent, to offer choice and puts the patient at the heart of
everything we do.
The Hospital has been delivering high quality health care to the
local community for 42 years. We are extremely proud of our
record of service as an independent health charity.
The Quality Report is designed to provide a transparent look at
our organisation and to give confidence to our patients, partners
and commissioners. We can improve our services by listening and
acting on what our patients tell us, ensuring that all patients
receive a personalised service.
“This is an
excellent
hospital; room,
facilities, staff,
food, visiting;
everything!
Definitely
recommend this
hospital .”
As an organisation we depend on our staff for their skills and
expertise. They can only do their jobs effectively if we listen to
them and learn from their experience and ideas. We continue to
have a stable, motivated workforce with low levels of staff
turnover.
Our staff team is committed to providing excellent
standards of care at all levels across the organisation. We also
value staff development and we have strong commitment to staff
training and skill improvement.
Quality matters to all of us working at Fairfield and we know that
it is key to the success of our organisation. Our reputation is
based on the provision of high quality, personalised care and our
core values as a charitable organisation means we stand out from
other private providers in the area.
We monitor the views of our patients and I am pleased to report
that we have maintained the very high levels of satisfaction that
they have experienced for yet another year.
We value the
feedback, comments and suggestions that our patients and
commissioners make about our services. Our services are open to
all via the insured, self-pay or NHS funding routes.
03
Fairfield Independent Hospital Quality Accounts 2014/2015
April 2014
Chief Executive’s statement
“How
can you
improve
something
that is already
a superb
service? ”
April 2014
Our core business is health and optimising outcomes for patients
and we have created an integrated governance framework for
delivering excellence and the best possible clinical results.
We
work in partnership with our consultants to ensure optimum care
for our patients.
During 2014/2015, we reinvested financial resources to enhance
the infrastructure of the Hospital and we have some exciting
developments planned for future years.
2014/2015 was challenging economically for us all, our finances
were very stretched.
However with improved cash flow we
continued, wherever possible, to invest in the infrastructure of our
organisation.
As always, any surplus generated is reinvested in
health care and better services in the following years.
The senior team at the Hospital and the Board have welcomed the
opportunity, through these Quality Accounts, to clearly state our
commitment to quality and make sure that we continue to improve.
It sets out facts and information about the quality of our services
which I hope you will find useful and easy to read and understand.
If you have any queries or comments on our quality account then
please let us know by emailing k.roche@fairfield.org.uk.
At Fairfield, we actively promote a culture of openness and
transparency, respecting complaints, learning lessons and being
open and honest about any mistakes we have made and seeking
to make improvements.
These opportunities have helped us
establish a positive culture enabling the provision of safe care
which permeates throughout the organisation.
The Quality Accounts have been compiled by members of the senior team and Board and have also drawn upon the feedback we
get from our patients. We are all working together to provide the
best possible care for our patients and we believe we have demonstrated this in our Quality Accounts. Therefore, I am able to state
to the best of my knowledge that the information contained in this
document is accurate at the time of publication.
Cheryl Nolan, Chief Executive
Fairfield Independent Hospital Quality Accounts 2014/2015
04
Purpose and Values
2. PURPOSE AND VALUES
Fairfield Independent Hospital’s charitable purpose is to relieve
sickness, injury and poor health and to promote and preserve good
physical and mental health.
Our vision, as the leading charitable hospital in the area, is
delivering the highest possible standards of safe and effective care
that is accessible and affordable to all, delivered by a highly
committed workforce.
This means that we are the hospital of
choice for many patients.
At all times we act with integrity and through the professional level
of service we provide, we create an atmosphere of warmth and
friendliness. Everyone who comes into the Hospital is treated with
dignity and respect and made to feel ‘special’. We pride ourselves
on the fact that throughout the Hospital we put the patient at the
heart of everything we do. We are a fair employer and supportive
of our staff.
The aims of our organisation are focused around quality and
putting patients at the heart of everything we do. We have the
following objectives:

continuous improvement of our services

evidencing outcomes within a robust governance framework
providing high quality value for money services that are
accessible to all

“An
excellent
Hospital and
staff. I cannot
think of any
negatives
about my stay,
only how well I
was treated .”
May 2014
providing a patient-focused service
ensuring we are the hospital of choice for patients and their
GPs


We monitor the views of our patients and are delighted at the
continued high levels of patient satisfaction with our services and
our facilities.
Our staff turnover is low and we have found that this aids continuity
of care for all our patients. Our focus on continuous improvement
is reflected in our commitment to clinical governance, audit and to
partnership working. Our consultants, many of whom are recognised
leaders in their field, are crucial to how the Hospital performs.
05
Fairfield Independent Hospital Quality Accounts 2014/2015
Patients First
3. GOVERNANCE
“Everything
was
perfect in all
aspects of
surgery and
care.”
May 2014
The Board sets the strategic direction of the organisation and
oversees the delivery of planned results by monitoring
performance against objectives.
Its role is also to ensure
effective stewardship and to ensure high standards of corporate
governance and personal behaviour. The Board is led by the
Chairman of the Trustees. It is important that the Hospital has
a highly effective and efficient Board that has the skills,
competence and business acumen to drive the strategic agenda.
As a registered charity and a company limited by guarantee
without share capital we have to balance the requirements of
running a not-for-profit business with the need to achieve our
charitable aims and objectives, to demonstrate public benefit;
adhere to the values of our charity; adopt best practices and
act with integrity at all times.
The Chief Executive is responsible for ensuring that effective
processes are in place so that the Hospital can discharge its
legal duty for all aspects of governance and quality, and for the
health and safety of patients, staff, visitors and contractors.
The Chief Nurse has executive responsibility for the effective
and safe delivery of clinical services. The Assistant Director of
Governance supports the Chief Nurse in her role and in
implementation of the clinical governance agenda. They work
with staff to ensure that systems and processes are in place to
enable improvements in the delivery of safe, effective patient
care.
4. REVIEW OF NHS SERVICES
During 2014/2015 Fairfield Independent Hospital provided advice
and treatment to 10,055 NHS patients referred from 304
different GP practices and 32 different CCG areas.
Fairfield Independent Hospital has reviewed all data available to
it on the quality of care for those services.
The income
generated by the NHS services in 2014/2015 represents 100
per cent of the total income generated for the provision of
NHS services by Fairfield Independent Hospital.
Fairfield Independent Hospital Quality Accounts 2014/2015
06
Patients First
Participation in clinical audits
4.1
During 2014/2015, two national clinical audits
services that Fairfield Independent Hospital provides.
covered
NHS
During that period Fairfield Independent Hospital participated in
6.2% national clinical audits and 0% confidential enquiries of the
national clinical audits and national confidential enquiries, which it
was eligible to participate in.
Fairfield Independent Hospital was eligible to participate in only one
National Comparative Enquiry into Patient Outcome and Death
(NCEPOD) audit. This was a Sepsis Study. However, during the
period of the study there were no patients admitted to Fairfield
Independent Hospital who became septic, thus making the audit
void.
The national clinical audits that Fairfield Independent Hospital were
eligible to participate in during 2014/2015 were as follows:
National elective surgery
- Patient reported outcome measures
(PROMS)
- Hip and knee replacements
- Hernia
- Varicose veins
“Very
happy
with treatment
and I felt I was
provided with
an excellent,
high level of
care.”
June 2014
National Joint registry (NJR) - hip, knee and shoulder replacements.
The reports of two national clinical audits were reviewed by the
Hospital in 2014/2015 and we intend to take the following actions
to improve the quality of health care provided:

Patient Reported Outcome Measures - we have improved our
results for PROMS data capture, however there is still work to
do. The fact that the sample size is small means our data
does not always show on the 6-monthly figures.

National joint registry for hip and knee replacements – we have
achieved 100% compliance for 2014/15.
Re-audits for the Quality Accounts for 2014/2015 audit categories
showed the following:
07
Fairfield Independent Hospital Quality Accounts 2014/2015
Patients first
“First
class
treatment
from every
person that I
saw;
excellent,
would never
want to go
anywhere
else .”
June 2014
Correct Surgical
Site marking
Changes to care pathways to include
surgical site marking documentation have
been implemented across all care pathways.
Record keeping
within pre-operative
assessment clinics
Final audit showed 100% compliance. To
ensure continued compliance a Key
Performance Indicator audit will be carried
out on a monthly basis this will include
record keeping and documentation across all
clinical areas.
Monitoring and
response to
patients’ oxygen
saturation levels
Audit showed 100% compliance with
procedures for monitoring oxygen saturation
levels to ensure safe care.
4.2 Research
The Hospital does not participate in clinical research.
4.3 Goals agreed with NHS Commissioners (CQUIN)
Use of Commissioning Quality and Innovation (CQUIN) framework
During 2014/2015 we entered into an agreement with the NHS to
provide services for the local population.
A percentage of the
Hospital’s NHS income was dependent on achievement of the CQUIN
targets agreed with the NHS commissioners. I am pleased to report
that the CQUIN targets were achieved.
Details of CQUIN targets and achievements are shown in Schedule 1.
4.4
Regulation
Fairfield Independent Hospital is regulated by the Care Quality
Commission to provide the activities detailed below in accordance
with Schedule 1 of the Health and Social Care Act 2008.
Regulated Activity - Diagnostic and screening procedures
Regulated Activity - Surgical procedures
Regulated Activity - Treatment of disease, disorder or injury
Regulated Activity - Accommodation for persons who require
nursing or personal care.
Fairfield Independent Hospital Quality Accounts 2014/2015
08
Patients first
Additional conditions that apply - the registered provider must only
accommodate a maximum of one service user at the Guy Pilkington
Memorial Home. (This activity is no longer applicable).
We had an unannounced visit from the Care Quality Commission in
December 2013. Whilst the final report was very positive there was
a minor non-compliance issue with regard to consent. In July 2014
we had a further inspection from CQC and I am delighted to report
that there were no areas of concern raised and the one area of
non-compliance had been resolved to the satisfaction of the
inspection team. A copy of the full report can be accessed via our
website www.fairfield.org.uk.
The Hospital has maintained its certified accreditation of ISO 9001
and ISO 27001.
4.5
Data Quality
Fairfield Independent Hospital submitted records during 2014/2015
to the Secondary Uses Service (SUS) for inclusion in Hospital
Episode Statistics which are included in the latest published data.
The percentage of records in the published data which included the
patient’s valid NHS number was:
100% for admitted patient care
100% for outpatient care
4.6
Information Governance
The Hospital is continually reviewing its information governance to
ensure that all information relating to and identifying individuals is
managed, handled, used and disclosed in accordance with the law
and best practice.
“From
arriving
to being
discharged all
the staff were
so friendly
and did their
upmost to
make me feel
at ease. They
are a credit to
the Hospital .”
July 2014
Fairfield Independent Hospital’s Information Governance Assessment
report score for the period stands at 91%. This is slightly down
on last year but demonstrates the continued rigour of how the
organisation deals with and manages its information.
5. KEY ACHIEVEMENTS 2014/15
Clinical Effectiveness
In our previous set of Quality Accounts we set out three key
development areas. Detailed below is what we achieved against the
specific areas identified. I am delighted to report that we met all
our key targets across all areas.
09
Fairfield Independent Hospital Quality Accounts 2014/2015
Key Achievements
Clinical Effectiveness (continued)
“Thanks to the
excellent care
by all staff,
I feel my
recovery was
speedy,
comfortable
and faultless.
Many thanks.”
Development Area
Outcome
To develop the pre-operative
assessment service further to
ensure that we can
co-ordinate multiple
appointments together, access
any necessary results in a
timely fashion and provide a
more efficient service for
patients.
Changes have been made to the preoperative assessment criteria to bring
in line with new evidenced based
studies. Private patients are now
MRSA screened as a routine. Elective
surgery patients are now triaged, a
telephone or face to face pre-op
assessment is arranged according to
patients’ medical status.
VTE risk assessment
compliance. To ensure we
benchmark our compliance
through the national
statistical website.
As part of the National Safety
Thermometer, the Hospital monitors
our patients by completing VTE risk
assessment, VTE prophylaxis and DVT/
PE rates. 1st Jan 2014 to 30th June
2014, 949 patients were eligible for
VTE assessment. 98.4% of the patients
were risk assessed and 99.4% of
patients had some form of preventive
VTE intervention. No patients suffered
a blood clot (VTE). VTE compliance
has improved to 99% of 956 patients
eligible for VTE assessment patients.
947 were risk assessed and 99% of
these had some form of preventative
VTE intervention. No patient suffered
either from a of blood clot, lung (PE)
or leg DVT).
Compliance with the World
Health Organisation Checklist.
The checklist will continue to
remain a priority at Fairfield
via audit. Any areas of non
compliance will be reported
to the Medical Advisory
Committee and Board.
The WHO check list has been
implemented into all care plans across
all specialities. An ongoing audit will
be continued on a monthly basis to
ensure compliance. The audit results
will be reported to the Medical
Advisory Committee bi-annually. In
the event of non-compliance the
findings will be discussed with the
individual in the first instance.
July 2014
Fairfield Independent Hospital Quality Accounts 2014/2015
10
Key Achievements
Development Area
Outcome
To maintain and develop the
skills of our workforce we will
ensure that we continue to
roll out job rotation for
clinical staff. We will provide
resources to enable staff to
undertake periods of training/
education away from the work
place.
Job rotation has commenced for
registered nurses and HCAs. Permanent
nursing night staff have been rotated
onto day shift to ensure skills are
updated. HCA theatre staff will be
rotated with HCAs from the ward and
outpatient department in 2015. New
guidance from the Association for
Perioperative Practice (AfPP) has been
issued regarding the role of 1st surgical
assistant. Training has been undertaken
by one of the theatre team who
successfully completed the training at
Edge Hill University in October 2014.
Other members of the theatre team will
now be identified and enrolled on the
course subject to their role specification.
Patient safety
We continue to practice in PROMS. The
final figures that are available show an
increase in participation rates for all
four areas based on the 12/13 rates.
However it must be noted that the data
is not timely with the full year ending
March 2014 being released in September
2014. PROMS was established to assess
overall health gain for patients undergoing certain procedures. The
unadjusted scores attributable to the
procedures carried out at Fairfield for
the period April 2014 to March 2015 are
as follows:
Hernia
38% (37%) patients had improved, 37%
(18%) stayed the same and 25% (45%)
reported their health had worsened.
Hip
86% (89%) saw improvement, 5% (6%) no
change and 7% (5%) worsened.
Knee
77% (81%) saw improvement, 12% (10%)
no change, 11% (9%) worsened.
Varicose veins
44% (51%) saw improvement, 56% (32%)
no change, 0% (16%) worsened.
To continue to participate in
PROMS and increase the
numbers of initial patient
responses in the four areas.
To review PROMs data to
examine poor practice if and
when it exists.
(Please note figures in brackets
are the average England figures).
11
“I would not
change
anything;
my whole
experience at
Fairfield was a
pleasant one.
All the staff are
lovely and very
professional
and made
my stay
comfortable
and welcoming.
I felt safe and
cared for during
the whole of my
stay.”
August 2014
Fairfield Independent Hospital Quality Accounts 2014/2015
Key Achievements
Patient Safety (continued)
Development Area identified
“No comments
on improvement
whatsoever.
I can’t praise
the staffing
team enough.
Everyone was
so friendly. I
would never be
frightened of
coming into
Fairfield again,
as my mind was
put at ease
straight away.”
August 2014
Outcome
To meet the requirements of ISO The Hospital has successfully passed
9001:2008 (Quality Management
both its external ISO 9001:2008 and
System) and ISO 27001:2005
ISO 27001:2005 audits during 2014.
(Information and Security
Management System).
To continue to participate in the
National Joint Register collection
of data and benchmark our
compliance.
The National Joint Register target is
95% patient to consent compliance.
Fairfield Independent Hospital consent
compliance is 98.3%. Part of this
process is to link the patient by a
number of factors. The national
target is 97% link ability. Fairfield
achieved 100% for 2014/2015. For
2014/15 all changes to the National
Joint Register minimum data set have
been implemented by the Hospital.
To ensure that all of our staff
receive the right level of training
with regarding to safeguarding
adults and children. Such training
is a mandatory requirement for
staff employed at the Hospital.
To ensure that staff and self
employed consultants and
clinicians have appropriate mental
capacity training. In order that we
discharge our duties with regard
to any patients who present to
our services who are vulnerable
or who lack capacity.
The organisation has invested heavily
in training in the last 12 months. All
staff have undertaken their mandatory
and statutory training undertaking and
30 staff have completed World Host
training, which is a high level of
customer service training. 25 staff
have undertaken ILM qualifications.
One member of staff has completed
their First Surgical Assistant
qualification.
All staff and Consultants are required
to have mental capacity training and
this has been completed and
evidenced.
Patient Experience
Roll out/phased expansion of
friends and family test (FFT) to
all NHS inpatients and
outpatients.
This has been rolled out to day cases
and outpatients as from 01/10/2014.
We are averaging 52% per month
response rate from the FFT and, of
those, 100% of patients are extremely
likely or likely to recommend our
Hospital.
Fairfield Independent Hospital Quality Accounts 2014/2015
12
Key Achievements
Patient Experience (continued)
Development Area
Outcome
Refurbishment of patient areas
We embarked on a programme of updating the patient areas in 2014. WiFi
is available across the hospital and
rooms have been modernised to include wet rooms and improved fixtures
and fittings. We have also been working on plans to improve the waiting
areas and also improve patient flow
throughout the Hospital.
Further improve communication
with patients
We ask every patient who comes to
the Hospital how they would like to be
communicated with - e-mail /text/
mobile/landline - and this is put on
the patient’s record. When we need
to contact them we look and
communicate using their preferred
method.
We text the patients or telephone
them with their procedure date (TCI)
and time offering them their first
choice, then if that is not suitable a
second choice. We text patients if appointments are being moved.
We now give the TCI pack out at
pre-op instead of posting it, allowing
the pre-op nurse to go through everything they need to know and allowing
questions to be asked by patients.
Sending texts has been very popular
with our patients.
“I was very
professionally
and
compassionately
treated in a
friendly way.
I have no idea
how you can
improve as it is
excellent at
Fairfield
Independent
Hospital.”
5.1 What else did we achieve during 2014/15?
Governance
We were successful in recruiting to the Assistant Director of
Governance post and the post holder commenced employment at
the beginning of October 2014. We will continue to develop a
range of policies and procedures that will further strengthen our
governance framework. The risk register continues to be populated
and reported to the Board identifying the top risks and the actions
that have been put in place to mitigate those risks.
13
Fairfield Independent Hospital Quality Accounts 2014/2015
September 2014
Key Achievements
“All areas of
care and
information
were met or
exceeded
expectation;
excellent. I am
very pleased
that friends
recommended
Fairfield for my
treatment.”
The audit programme for 2014/15 was agreed by the Board
the Medical Advisory Committee. The programme was linked
any incidents/adverse events that may have occurred and we
demonstrated the learning that took place as a result. The
has been regularly reported on to our NHS commissioners as
of the suite of reporting we need to do on a monthly basis.
and
into
also
plan
part
A further formal sub committee of the Board has been established
to oversee clinical governance and risk.
Leadership and training
The Executive Team headed by the CEO continue to access
Continuing Professional Development and other opportunities
relevant to their roles including membership of other charitable
boards.
The implications and recommendations of the Francis
and Berwick Reports and the new inspection regime of the Care
Quality Commission mean that the leadership of the organisation
forms an integral part of the regulatory assessment.
Student nurses continue on placement. A further two staff members have undertaken Mentorship training and as a result of
having more mentors, our partner Universities have asked us if we
would place two more students in our Outpatient Department for a
thirteen week placement, to which we have agreed. Placements at
the Hospital are favoured by the Universities because the student’s
experience is enhanced by the variety of specialities that the
student has access to here. The ward will continue to take two
students on a thirteen-week placement with some time spent in
the theatre and recovery ward environment. The links with the
universities and the education system remains strong and the
Hospital has attended education events at Edge Hill University.
During 2014/15 100% of staff have accessed training. There are
32 staff doing formal recognised qualifications with various outside
bodies including Institute of Learning and Management (ILM).
Nursing Strategy
The strategy has, as its core, the unique relationship that nurses
form with patients, family members and their carers, which often is
the measure of quality that people use most frequently in
describing their experience of the hospital and the service it
delivers. Dementia leads have been identified in all departments
to enable patients with a diagnosis of dementia to be cared for
holistically in a dementia friendly environment..
Fairfield Independent Hospital Quality Accounts 2014/2015
14
Key Achievements
A member of the theatre team has completed the First Surgical
Assistant Role, this will enable the team to work more effectively
with the Consultant to expedite surgery thus reducing the time
spent under anaesthetic for our patients, at the same time leaving
the Resident Medical Officer (RMO) free to continue with his duties
on the ward. A member of the ward team, has completed the
Non-Medical Prescribing course, this has reduced the amount of
time patients have waited to have medicines prescribed at
discharge.
Listening and acting on patients’ views/patient satisfaction
It is important that we continually audit and benchmark our
services. No organisation can stand still and we are continually
reviewing how we provide our services. Our managers routinely
audit how patients flow through the system by shadowing patients,
with their consent, and ‘walking in their shoes’.
We have updated our work with patients regarding their emotional
journey through theatre as we realise that this is a very anxious
time for all patients.
The results indicated that most patients
were Happy, Reassured, Comfortable and Informed at all stages
All patients in the recovery ward have their pain score
documented and analgesia is given if indicated via the scoring
system.
As part of our dementia care pathway we have introduced the
Abbey pain score tool to enable patients with dementia to
demonstrate their pain level, thus enabling staff to effectively
manage pain levels for our patients who also live with dementia.
All our internal patient questionnaire responses are reviewed by
the CEO on a daily basis which means our results are in real time
and any actions that are needed can be taken quickly. We are
delighted that patients rate our services highly.
The results for 2014 are as shown below:

99% of the patients rated the cleanliness of the Hospital as
very good or excellent.

99% of the patients rated the overall standard as very good
or excellent.

100% of patients would recommend the Hospital to a friend or
family member.
15
Fairfield Independent Hospital Quality Accounts 2014/2015
“In my opinion
the care and
cleanliness of
the Hospital is
excellent and I
am very satisfied
with my
treatment.”
October 2014
Key Achievements
Patient Questionnaire Analysis April 2014 - March 2015
100.00
October 2014
98.00
Pre- Admission
97.00
Percentage
“This is the
best Hospital I
have ever been
too. Everything
was perfect.
Thank you.”
99.00
Reception & Escort to
Room
Medical & Nursing
96.00
95.00
94.00
Hospital Services
93.00
Communication
92.00
Visiting
91.00
90.00
Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 Jan-15 Feb-15 Mar-15
From April 2014 to March 2015, the Hospital admitted 5,411
patients. The
number of questionnaires returned was 3,691, resulting in a 68% response rate.
Patient Complaints
In 2014/15 we had in total 20 complaints from 10,055 NHS
patient contacts. The complaints were all dealt with in accordance
with the Hospital’s complaints policy and as far as I am aware
none have proceeded to litigation.
There were no particular
themes running through the complaints that would give cause for
concern. They are monitored and reported to the Hospital’s Medical Advisory Committee, where a review takes place, and to the
Board on a regular basis. The Heads of Department meeting review all complaints on a monthly basis and all clinical complaints
are considered by the Integrated Governance Committee.
Stakeholder Engagement
We continue to seek out patients views in ‘real time’. As well as
our own internal questionnaire we also do ad hoc audits where
members of the team speak with patients, ask questions about
how their experience has been, if we are getting it right and if
there could be any improvements. Following the introduction of the
Friends and Family Test for NHS patients we are averaging a 50%
response rate with 100% of those responding saying they would
recommend the hospital to a friend or family member.
We obtain the views of our consultants and discuss areas of good
practice and concerns via the Medical Advisory Group (MAC). The
MAC has a direct line of accountability to the Board and the
Chairman of the Board of Directors meets regularly with the MAC
Fairfield Independent Hospital Quality Accounts 2014/2015
16
Key Achievements
Chair. The MAC Chair is also a Board member. The MAC provides
advice and guidance on how we take specific areas of the
business forward and they also advise on development opportunities for the Hospital and implementing new initiatives based on
best practice.
Quality
Our core values compliment the increased emphasis from all of
our commissioners on the need to evidence and demonstrate our
commitment to the provision of quality services.
We strongly
believe that the quality of the clinical and non clinical services
that we provide allows us to demonstrate this. Our patients tell
us about how they feel we have treated and cared for them and
the results of this ‘real time‘ feedback is excellent.
Infection Control
We are extremely proud of our infection rates and the fact that
we are maintaining such good rates is testament to how seriously
all our staff take the issue of making sure that our Hospital is
free from infection.
During 2014/15 we have continued to
maintain an average monthly infection rate of below one percent.
We continue to maintain zero rates for MRSA, MSSA, C-difficile
infection organisms. Our hand washing compliance audits show
100% compliance across the Hospital.
Refurbishments/Capital Programme 2014/15
The Hospital’s activity in 2014/15 has continued to grow and
capital programmes planned have been challenging to plan around
this increased activity coupled with the operational management
demands of those leading the capital projects.
During 2014/15 the Hospital has invested in upgrading and
improving
its
inventory
of
medical
diagnostic
scopes,
instrumentation and general medical equipment. Improvements have
been made to the patients bedrooms by refurbishing bathrooms,
installing sensor lighting in bathrooms, panel lights have replaced
diffuser light fittings in the most used rooms, improvements have
been made to the hospitals WiFi and general office areas including
the Boardroom.
The most significant capital investments for the year include:

17
installation of a new air handling unit into Theatre One
£180,000.
Fairfield Independent Hospital Quality Accounts 2014/2015
“ Everything is
perfect .”
November 2014
Key Achievements

“Fantastic
Hospital, no
faults what so
ever.”
November 2014



a new boiler plant installed into the old theatre plant room
£65,000.
a new C-arm scanner £46,000.
replacements/upgrading of mechanical/engineering plant
£32,600.
new servers for Version 3 of the CSC Patient Information
Manager system £16,000.
Productivity and Efficiency
During 2014/15 we have continued with the work on reducing
our cost base and making sure that we utilise our resources to
their maximum effect. We have further enhanced what we
identified as priority areas in 2012/13 with other elements, which
became a condition under our NHS contract terms.
Where there are further reductions in the prices paid to us from
our NHS commissioners in 2014 and 2015, we in turn have had
to reduce what we pay out. Working with an evidence based
approach, we are now in a far better position to determine
activity is generating losses and what is not. We will continue
with this approach as we do need to ensure that we remain
profitable and that all new services that are proposed for
introduction are assessed in terms of what they can bring to the
organisation.
During the year we have introduced a scheme whereby we ring
patients directly to agree a date and time of their inpatient
procedure. This cuts down on missed appointments, unnecessary
paperwork being produced and patients being able to make the
necessary arrangements to cover child care, work absences, etc.
well in advance of their procedure date.
We have introduced speciality specific Saturday minor procedure
clinics, which have proved very popular with patients; these clinics
will be developed further and will continue in 2015.
NHS Work
During 2014/15 we continued to participate in NHS Choices. The
NHS accounts for at least 70% of our work via NHS Choices.
The NHS work is bringing in valuable resources. albeit at tight
margins but we are extremely mindful of our reliance on the NHS
as a source of income.
Fairfield Independent Hospital Quality Accounts 2014/2015
18
Key Achievements
We do have a good relationship with the contracts and quality
team who we meet with on a regular basis. There is a good
understanding of each others perspectives.
We have also established, working in partnership with the local
CCG, some community ENT clinics. The clinics are run by a local
GP who as a special interest in ENT. The arrangement, at the
time of writing, is in a pilot phase which will last approximately
ten months and then be evaluated and possibly go out to tender.
We continue to meet all the waiting time standards for care and
treatment and during 2014/15 there have been no breaches of
the terms of our NHS contract.
“Excellent
Hospital and
the staff are
extremely
friendly and
polite.”
6. REGULARLY REPORTED INDICATORS
December 2014
Total numbers
in period
1 April 2014 to 31
March 2015
%
Inpatient mortality
0
0
Peri-operative mortality
0
0
Unplanned readmissions within 28 days
11
0.14
Unplanned returns to theatre
3
0.03
Unplanned transfers to another hospital
9
0.11
Mortality within 7 days of discharge
0
0
Pulmonary Embolism
0
0
Deep Vein Thrombosis
0
0
Surgical infection
0
0
MRSA blood cultures
0
0
MRSA positive blood cultures
0
0
Indicator
rate
7. PRESCRIBED INFORMATION
The indicators detailed below have been included by NHS England
as part of the suite of information that should be included in the
14/15 Quality Accounts.
Some of the information is not yet
routinely available for the independent sector, the source of the
data has therefore been identified in the results column.
19
Fairfield Independent Hospital Quality Accounts 2014/2015
Key Achievements
“Very pleased
with the care
received.”
NHS Outcomes Framework
Domain
Indicator
Results
1. Preventing people from
dying prematurely.
a) Summary hospitallevel mortality indicator
Nil (0) patients died in
the reporting
period.
b) The percentage of
patient deaths with
palliative care coded
Nil (0) palliative care
in N/A to patients
referred to FIH
Fairfield Independent
Hospital considers that
this data is as described.
December 2014
Helping People to recover
from episodes of ill health
or following injury.
1. Patient reported
outcome measures:




groin hernia surgery
varicose vein surgery
hip replacement surgery
knee replacement
surgery
Due to low numbers of
procedures the health
gain data for the period
has been suppressed on
the national release for
the period. The data
shown below is the
adjusted health gain
attributable to the 12/13
data set. Figures in
brackets are for England.
No data showing
No data showing
0.797 (0.436)
0.733 (0.323)
Fairfield Independent
Hospital considers that
this data is as described
The percentage of
11 Patients in total
(0.14%)
patients aged 15 and
over re-admitted to the
Fairfield Independent
Hospital within 28 days of Hospital considers that
being discharged.
this data is as described
Ensuring that people have
a positive experience of
care.
Personal needs data from
Health and Social Care
Information Centre.
The percentage of staff
employed in the reporting
period who recommend
the hospital as a provider
of care to their friends
and family.
National data not available. In-house questionnaire results detailed on
Page 14
97%
Fairfield Independent
Hospital considers that
this data is as described
Fairfield Independent Hospital Quality Accounts 2014/2015
20
Priorities for 2015/16
NHS Outcomes Framework
Domain
Indicator
Results
Treating and caring for
people in a safe
environment and protecting
them from avoidable harm.
Percentage of patients
100%
who were admitted to
hospital and who were
risk assessed for a
venous thrombo-embolism.
Case of C-difficile
reported
None
Rates of patient safety
incidents and the number
of such incidents that
resulted in severe harm
or death.
One patient safety
incident reported and
subject to RCA
investigation.
“Excellent
level of
patient care
and staff are
really helpful
and caring.”
Fairfield Independent
Hospital considers that
this data is as described
8. PRIORITIES FOR 2015/16
8.1 Key Development Areas
Development area
Outcome to be achieved
Clinical effectiveness
To reduce the Did Not Attend
(DNA) rate across the Hospital
A reduction of outpatient DNAs from 5%
to 4%
Post Surgical Patient Observations
Assess use of the National Early Warning
Score (NEWS) assessment tool following
surgery to ensure early detection of
patient deterioration is identified and
acted upon promptly.
Reduced Inpatient length of stay
Assess the patient experience and clinical
outcome achieved with a reduced length
of stay within two specialities and
benchmark our patients against national
treatment pathways to ensure the Hospital
is following recognised best practice.
Discharge Communication
Discharge communication process to be
evaluated to identify that a safe transfer
of patient care from hospital to
community is achieved.
Clinical Audit
For 2015/2016 we have a comprehensive
audit plan across all patient facing
departments, that will focus on driving the
quality of patient care whilst minimising
risk, waste and inefficiency.
21
Fairfield Independent Hospital Quality Accounts 2014/2015
January 2015
Priorities for 2015/16
Development area
“As Hospital
procedures
go, this was
an excellent
experience.
Very friendly
staff. Thank
you.”
Outcome to be achieved
Patient Safety
Patient Reported Outcome Measures
(PROMS)
To continue to participate in PROMS
and increase the numbers of initial
patient responses in the four areas.
To review PROMs data to examine
poor practice if and when it exists.
ISO 9001:2008 (Quality Management
System)
and ISO 27001:2013 (Information and
Security Management System).
3 year re-certification audit of ISO
9001:2008 to be passed.
Full rewrite and accreditation of the
new ISO 27001:2013 standard to be
met.
National Joint Register
To continue to participate in the NJR
collection of data and benchmark our
compliance.
(NJR
Safeguarding and Mental Health Act
capacity training.
To ensure that all of our staff
continue to receive the right level of
training with regarding to safeguarding
adults and children. Such training is a
mandatory requirement for staff
employed at the Hospital.
To ensure that staff and self employed
consultants and clinicians have
appropriate mental capacity training. In
order that we discharge our duties
with regard to any patients who
present to our services who are
vulnerable or who lack capacity.
Certain staff will also be trained in the
use of restraint.
Management/ Board Walk Rounds
During 2015/16 we will adopt a far
more structured approach to walk
rounds conducted by the senior
management team and or Board
members. Walk rounds will bring
together front-line staff with executive
leadership to highlight the priority of
patient safety.
They will consist of visits to clinical
and non-clinical areas where Executives
will be with staff from the dept and
will talk to patients, to gain a deeper
understanding about their care and
their experience at FIH but also about
individual areas and the challenges
faced by staff on a day-to-day basis.
January 2015
Fairfield Independent Hospital Quality Accounts 2014/2015
22
Priorities for 2015/16
Development Area Identified
Outcome to be Achieved
Patient Safety
Strengthen Organisational
Governance
Evidence FIH services are compliant with
new fundamental standards and the
CQC's key lines of enquiry (KLOE).
Further develop the data base for all
incidents. Work with staff to embed
reporting into the organisation to ensure
learning. Develop process for sharing of
incident and complaints outcomes, with
reports to all governance committees.
Monitor action plans for validity and
completion. Report on outcomes. Ensure
Policies continue to be updated.
Learn and evidence learning from
experience.
Patient Experience
Increase % of patients completing
patient questionnaire
Although the figure of 68% of compliance
is good we need to set ourselves a target
of at least 70% completion for 2015/16.
The ward clerks and the staff will
encourage patients to let us have some
feedback on the positive and negative
aspects of their treatment/stay.
Redesign of reception and
outpatient areas.
A scoping exercise was commenced in
March 2015 regarding a redesign of the
ground floor patient areas.
This is a substantial piece of work for the
organisation and we will involve our
patients, our staff and our consultants in
the plans.
Improving and streamlining the
patients journey
Review the current utilisation of Clinic
booking system in the Out Patient
Department. Review the systems in place
to ensure the patient journey is more
streamlined.
Responding to patients comments.
Ensure that we respond in a timely
fashion to both positive and negative
comments posted on various media websites including NHS Choices, Facebook
and Twitter.
Ensure that comments made on our
patient questionnaire are acknowledged
and where necessary investigated and
actions taken – making sure we advise
patients accordingly.
23
Fairfield Independent Hospital Quality Accounts 2014/2015
“Fairfield
is
an exemplar
of hospital
treatment
and care.”
February 2015
Priorities for 2015/16
“All
staff kind,
caring and
professional
at all times.”
February 2015
9. KEY BUSINESS AREAS FOR 2015/16
9.1
Governance
The Board will continue to set the strategic direction of the
organisation and have recently approved the strategic plan for the
next five years. Whilst the role of the board encompasses
overseeing the implementation all the organisation’s plans it also
has a major role in ensuring effective stewardship and to ensure
high standards of corporate governance and personal behaviour.
The Board is led by the Chairman of the Trustees. It is important
that the Hospital has a highly effective and efficient Board that
has the skills, competence and business acumen to drive the
strategic agenda.
As a registered charity and a company limited by guarantee
without share capital we have to balance the requirements of
running a not-for-profit business with the need to achieve our
charitable aims and objectives:
to demonstrate public benefit;
adhere to the values of our charity; adopt best practices and act
with integrity at all times.
The Chief Executive is responsible for ensuring that effective
processes are in place so that the Hospital can discharge its legal
duty for all aspects of governance and quality and for the health
and safety of patients, staff, visitors and contractors. The Chief
Nurse has executive responsibility for the effective and safe
delivery of clinical services. The Board has reviewed the current
organisational structure with regards to governance and has
increased the staffing establishment in this area and we have
appointed an Assistant Director of Governance.
9.2
Governance key development areas

With the appointment of an Assistant Director of Governance
in the establishment we will improve our methods of
monitoring our performance against the revised Care Quality
standards and
inspection regime.
We will update and
demonstrate evidence of our compliance.
If we identify
areas where we are not compliant, we will ensure that there
are clear action plans in place that enable us to move to
compliance quickly.
Fairfield Independent Hospital Quality Accounts 2014/2015
24
Priorities for 2015/16

We will establish a governance committee as a formal sub
committee of the Board.

We will review the Governance Framework to
arrangements for adverse events and incident reporting

We will continue to develop our governance framework by the
introduction of further policies and procedures through the ISO
framework.

Our audit programme for 2015/16 has been agreed by the
Board and the MAC. The programme includes clinical and nonclinical audits and is be linked into any incidents/adverse
events that may have occurred and also demonstrate the
learning that we would expect to see as a result.
Regular
audits will take place across the organisation. A 2015/16 audit
list is shown in Schedule 2.

We will undertake Root Cause Analysis scenarios with senior
staff at least twice yearly.
include

We will continue to build up our Risk Register, updating the
Board bi annually and reporting incidents bi monthly.

We will draw up a more robust induction programme for new
starters to ensure that any gaps in knowledge are identified at
an early stage and can be addressed.
9.3
Workforce
We have a dedicated and committed workforce here at Fairfield.
During 2015/16 we are not envisaging increasing our staffing
establishment and will consider replacing staff who have left
especially in vulnerable clinical areas. We will continue to ensure
that our nurse to patient staffing ratios exceed current guidelines.
During 2015/16 we, along with other private providers, will have to
start collecting workforce information and submitting it to the Health
and Social Care Information Centre. This is a big piece of work and
the data will need to be submitted monthly. We will also, during
the year. carry out our bi-annual staff survey.
There continues to be a shortage of appropriately qualified skilled
staff and this has been exacerbated by the fact that training places
at the colleges and universities have been cut over the last few
years so there are not as many suitably qualified staff coming
through. We need, wherever possible, to offer career opportunities
across the organisation allowing and promoting nursing specialisation
in fields where we have not done so before.
25
Fairfield Independent Hospital Quality Accounts 2014/2015
“You cannot
improve on
perfection, I so
enjoyed my
day with you,
so kind, all the
staff I met .”
March 2015
Priorities for 2015/16
“A
very good
service by all
staff and
extremely
satisfied with
stay. Many
thanks.”
March 2015
We have had some success in ‘growing our own’ in 2014 as we
supported, through university, our first Surgical First Assistant
(Enhanced role in Theatre).
We will look to see of we can
replicate this with other staff across the organisation enabling
them to become specialists in their field.
We will continue with staff rotation and shadowing across all
areas. Annual appraisals will continue and will be linked to the
business objectives.
The staff are our greatest asset and during 2015/16 we want to
continue to work with them in building and developing a
successful business in which they feel their work and the
contribution they make is valued.
When possible we will try to facilitate placements for clinical staff
into other clinical providers to broaden their experience and
develop new techniques. We will also ensure that we continue our
initiative of staff shadowing others in different departments to gain
a greater understanding of how the organisation works and
introducing a structured programme of coaching and mentoring.
As the two charts below demonstrate we do have a workforce
where 79% of employees are in the over 40 age group and 56%
are over 50.
While this provides an experienced and highly
competent workforce, it also has implications for training and
ensuring our clinical staff are competent in the latest medical
practice and continue to be professionally aware. It is highly
publicised that there is and will be a skills shortage in healthcare
staffing and, as part of our workforce planning, we may have to
consider looking beyond the UK to secure the right staff with the
right skills and competencies.
Sickness level across the Hospital has fluctuated over the year.
As at 31 March.2015 the level of sickness is 3.6%. Unfortunately
over the past 12 months there have been a number of staff who
have been quite poorly and are on long term sick leave from the
organisation. Managers need to ensure that they regularly monitor
sickness levels and that they continue to support staff who wish
to return to their duties following extended period of sickness. To
ensure that our staff are getting the best possible advice and care
we have contracted our occupational health service to a local
NHS Trust and are providing a range of services for staff including
physio, access to counselling and also agreeing initiatives to help
ease staff back into work following periods of sickness.
Fairfield Independent Hospital Quality Accounts 2014/2015
26
Priorities for 2015/16
Productivity of staff is of paramount importance and we will continue
the development of key indicators to provide evidence of
improvements in our productivity by a range of measures. These
measures could include changes to contracts, different ways of
working, job rotation and secondment opportunities.
9.4 Key workforce development areas - Clinical Workforce
(excl Consultants)
The age profile of the clinical workforce is shown below:
Age
Clinical
20-29 30-39
11
11
40-49
50-59
23
34
60-69 70-79
7
2
Grand
Total
88
Workforce Age Profile for Clinical Employees
September 2014
40
35
No of Employees
30
20-29
30-39
25
40-49
20
50-59
15
60-69
70-79
10
5
0
“Thank
you, I
have had an
extremely
positive
experience at
Fairfield
today. Your
staff are all
polite and
very
professional.
Thank you
very much.”
CLINICAL
Employee Type
9.5
Recruitment and Retention
The Outpatients department has now recruited staff to cover both
pre-operative assessment and clinic sessions. The future for the
outpatient staff will be to look to develop more nurse led clinics
and extend their skills within this field. We currently do not seem
to have a particular problem recruiting to nursing posts, it is the
more specialist area of theatre where there are problems. We will
need to undertake a review of roles and productivity in the theatre
environment during 2015. We have been successful in attracting
and recruiting some highly qualified staff for our theatre all be it on
a part time basis.
27
Fairfield Independent Hospital Quality Accounts 2014/2015
March 2015
Priorities for 2015/16
9.6
“This
is an
excellent
hospital; room,
facilities, staff,
food, visiting;
everything!
Definitely
recommend
this hospital.”
April 2014
Student placements
Both John Moores University and Edge Hill University continue to
place student nurses throughout the Hospital and feedback from
tutors and students alike is excellent. Edge Hill University are
looking to place operating department practitioner (ODP) students
within the theatres which is most welcome. The existing staff can
offer a wealth of experience and exposure to the students. This
will offer the Hospital the chance to “grow our own”, in that
students who are of a high standard with the attitude and aptitude
who look to further their career, could be offered the opportunity
to apply for a post within the Hospital on completion of their
course.
9.7
Nursing Revalidation
Staff are working towards the new revalidation scheme from the
Nursing and Midwifery Council (NMC).
A new Code of Conduct
published in December 2014 outlines the standards for registered
nurses. Revalidation has caused much debate within Nursing and
Midwifery.
However, now that the new Code is released the
process is clearer.
There are now a number of training sessions for senior nurses to
attend in order that revalidation is a sound structured process that
will evidence a nurse’s fitness to practice.
This will include
embedding professional values that can be evidenced within the
appraisal system, reflective practices such as clinical supervision
and continuing professional development. The senior nursing team
are then able to verify that the nursing staff within Fairfield
Independent Hospital are competent and are able to achieve
revalidation with the Nursing and Midwifery Council.
9.8
Nursing Strategy 2015/16
Our nursing strategy, which has been approved by the Board,
includes recommendations from Francis Report and Berwick Report
‘New Ways of Working’ on how professionals should develop in the
future.
Nurses will be encouraged to take advantage of new and enhanced
roles such as Assistant Practitioner and Non-Medical Prescriber, to
lead and develop services, thus improving the quality of care and
providing job enhancement and enrichment.
Fairfield Independent Hospital Quality Accounts 2014/2015
28
Priorities for 2015/16
9.9 Clinical Risk Assessment and Management
The Hospital has appointed a Clinical Governance lead at Assistant
Director level to lead this growing area of risk assessment and the
management of risk within healthcare.
The newly established
Integrated Governance Committee functions a sub committee of
the Board and deals with all aspects of clinical risk and
management.
9.10 Competencies for HCAs
The Health Care Assistants are about to complete a suite of
competencies and clinical skills training via Skills for Health and
Skills for Care. NHS England Education and Training are piloting a
competency package for HCAs in a few areas within the country.
This “Certificate in Care” is expected to be transferable within the
healthcare market unlike the previous NVQ training within health.
Staff are able to complete the certificate and move through
various healthcare placements offering assurance to patients and
employees of their competencies across a wide range of care
skills to an agreed standard.
9.11 Training and education
Ward staff have undertaken ALERT courses this year with seven
staff completing this training course. This course ensures staff are
able to intervene at an earlier stage to prevent a patient
deteriorating to a level that would require robust medical
interventions. A theatre staff member has completed their First
Surgical Assistant training course at Edge Hill University; this
allows the staff member to assist Consultants during surgery
should it be required. The Heads of Department are looking to
continue Coaching and Mentoring staff once their Institute of
Leadership and Management course has been completed.
A
number of clinical staff with management responsibilities are in the
process of completing their ILM management certificates.
9.12 Consultant Workforce
At the moment we do have a waiting list for consultants wishing
to practise at Fairfield.
29
Fairfield Independent Hospital Quality Accounts 2014/2015
“Everything
was perfect in
all aspects of
surgery and
care.”
May 2014
Priorities for 2015/16
“Very
happy
with treatment
and I felt I was
provided with
an excellent,
high level of
care.”
9.13 Key workforce development areas - Non-Clinical workforce
The age profile of the non-clinical workforce is shown below:
Age
NonClinical
20-29 30-39
6
9
40-49
50-59
18
37
60-69 70-79
20
Grand
Total
1
91
Workforce Age Profile For Non- Clinical Employees
September 2014
40
35
No of Employees
30
June 2014
20-29
25
30-39
40-49
20
50-59
15
60-69
70-79
10
5
0
NON CLINICAL
Employee Type
September 2014
The non-clinical workforce play a very important role in the
services provided by the Hospital. In order to develop existing
staff and attract new recruits we will:

continue to build on the success of the training programmes
that were put in place in 2014 to ensure that staff have up
to date skills and professional development.

continue to offer placements to apprentices from the local
colleges in order to support people either back into work or
those new to employment.

offer coaching and or mentoring to appropriate staff by the
ILM qualified team.

ensure that customer service training is undertaken for all
customer facing staff.

all our non - patient facing staff are undertaking Rescue
Training as recommended by the Resus Council (UK).
Fairfield Independent Hospital Quality Accounts 2014/2015
30
Priorities for 2015/16
9.13 Refurbishments/Capital Programme 2015/16
In 2014 work began to complete a full inventory register of all
medical and non medical equipment. From this work the following
capital programme has been developed based on a ten year
replacement programme. The programme for 2015/16 is set out
below by operational area.
Dept
Project
Amount
Hotel Services
Replace equipment
£1,600
OPD incl ENT
Replace equipment
£7,500
Quality and safety
Improve access controls
£1,500
Recovery
0
Decontamination
0
Theatre
Replace equipment
£307,000
Mechanical plant and
equipment
Replace plant and equipment
£144,000
Gas plant
class
treatment
from every
person that
I saw;
excellent,
would never
want to go
anywhere
else.”
0
X-ray
Replace equipment
£80,000
Physiotherapy
Replace equipment
£20,000
Ward and Day Ward
0
Bedroom/flooring
Refurbishment of bedrooms and flooring
£15,000
Building and Estates
Repairs to building
£45,000
Additional projects
Creation of a new Hospital Entrance
£350,000
Investment of lasers for a skin clinic
£120,000
Creation of a new car park and walkway
£70,000
Clearance of space next to Out Patients
for scanning van £45,000
Windows replaced in original part of the
house £30,000
£615,000
£1,236,600
31
“First
Fairfield Independent Hospital Quality Accounts 2014/2015
June 2014
Priorities for 2015/16
“Thanks
to
the excellent
care by all
staff I feel my
recovery was
speedy,
comfortable
and faultless.
Many
thanks.”
July 2014
The high capital investments shown in “Additional Projects”, if
approved by the Board, will be funded by bank loans and internal
finance.
The lower cost items will need to be funded via
individual departmental budgets. Each individual replacement will
be appraised and where applicable reviewed.
If not replaced
(without compromising patient and staff quality and safety) in 2015
due to lack of urgency, capital, and activity, etc, the replacement
date will be moved into another year of the 2015-2020
replacement strategy.
9.14 Electronic Patient
Records
It is anticipated that the project to scan in all case notes and
work of an electronic records management system will be
completed mid way through 2015/16. Training has been rolled
out to all consultants. Whilst there have been a number of small
issues they have been more to do with communication and timing.
There will be space freed up as a result of this project and it will
be considered as part of the overall ground floor redesign.
9.15 Environmental issues
The Hospital will continue to segregate the waste streams across
the Hospital. New suppliers will be sourced on the basis that they
have the recognised ISO 14001 Environmental Quality Management
standard.
The Hospital will look at producing a business case (which is
separate to the capital plan) to install solar panels onto the flat
roof area above day ward in order to reduce current and future
energy bills.
9.16
Financial Security
The Charity must consider how services are to be provided in the
future to reduce the overall cost of provision and obtain
sustainable long term financial stability. This will be done in a
staged way and will include a number of initiatives that will act as
enablers for cost reduction.
We will look to target specific groups of the population in order
to promote the Hospital and make people aware of the services
that we provide. For example a recent survey from Saga showed
that the 50+ age group are those that will see the PMI market as
Fairfield Independent Hospital Quality Accounts 2014/2015
32
Priorities for 2015/16
an attractive option as NHS waiting times rise and their need to
access services becomes greater.
The demand for our services from the NHS, self pay and the PMI
market may well go up and down in the coming year. However, it
is vital that we are flexible enough to respond to these changes.
Where the NHS is actually restricting access to certain services,
we will look to capitalise on these restrictions by working with our
consultants and offering competitively priced packages of
affordable care.
We will consider, by broadening the range of the services we can
offer, how we can make a contribution to improving health in the
area and consolidate our financial position in the local health
economy..
9.17 Financial Environment
On the demand side of the Hospital business, there is continual
pressure from all commissioners to reduce/hold prices and there
is still a lack of funds available to the general public for private
health care. Our NHS work through the Choose and Book system
continues to be very popular, although the restrictions on price
increase makes some services increasingly difficult to provide and
justify further investment.
There is therefore no underlying reason why we should not be
successful in 2015/16. However, increasing our surplus may prove
challenging with reduced tariffs for our services paid by the NHS
thus putting pressure on already tight margins. We will continue
to invest in the safety, quality and range of treatments we provide
at Fairfield and increasing our contribution to the health and well
being of the area and the
patients whom we serve.
9.18 Efficiency
We will continue to renegotiate contracts with our suppliers in
order to get best value and the best deal for the Hospital.
We will continue to participate in initiatives as required by our
commissioners who are all looking to adopt best value principles.
We will use the experience of our Consultants, who are based in
many NHS hospitals across the North West, to share their best
practice initiatives.
33
Fairfield Independent Hospital Quality Accounts 2014/2015
“From
arriving
to being
discharged all
the staff were
so friendly and
did their
utmost to
make me feel
at ease. They
are a credit to
the Hospital.”
July 2014
Priorities for 2015/16
9.19 Business Intelligence and Information Technology
“ I would not
change
anything; my
whole
experience at
Fairfield was a
pleasant one.
All the staff are
lovely and very
professional and
made my stay
comfortable and
welcoming.
I felt safe and
cared for during
the whole of my
stay .”
2015/16 will see the implementation of two main steps towards
the improved efficiency and resilience of the Hospital’s IT
environment. First, we will be using an updated version of the
patient software which will have an increased number of functions
and be easier to support by our main provider. Second we will
have a full on site secondary processing environment. This will
mean that if the Hospital’s main computer room is out of action
then the Hospital’s computing needs can be met from another
computer room in another part of the building.
There will be three main areas of development in 2015/16:

The Hospital’s current financial system does not provide the
kind of budget reporting and costing structure that a £12
million turnover business demands. The current system does
not facilitate departmental budgeting or activity costing. The
Hospital needs a system to support decision making and
reporting and this will be a key target for 2015/16.

Coding – Private Health Information Network
The private sector is looking to collect information on
treatments and performance across the private health sector
with the ability to compare performance between hospitals
and between the private and public health sector. This will
require some additional work but should provide a basis for
demonstrating the quality of the Hospital’s work.

August 2014
Finance system incorporating pharmacy and stores
Reporting/analytics patient tracking
The Hospital finds it difficult to provide detailed information
on what particular elements of treatment cost and, for
example, the cost of providing the histology service is
generated by particular specialities or by particular treatments.
However, this data is all held within our systems and a
challenge for 2015/16 is to make this kind of analysis
effective and useful.
9.20 Charitable objectives and Public Benefit
As a charity the Hospital will continue to deliver services which
are of public benefit. The organisation also recognises that this
Fairfield Independent Hospital Quality Accounts 2014/2015
34
Priorities for 2015/16
must be demonstrable.
The Hospital will review its Memorandum and Articles of
Association (Governing document) and the benefits that could flow
from aligning all its corporate activities under the single name of
Fairfield Independent Hospital.
9.21 Partnerships
We can help achieve our ambitions by working closely with our
partners nationally and locally. During the past few years we have
developed strong foundations with our key partners, and this year
we will be reviewing and refreshing these agreements, so that they
are focused on the right priorities going forward. We will also
broaden our partnerships, looking beyond traditional partners, to
take advantage of wider opportunities for driving change and
improvement and of course development. We are committed to
co-production with our partners, harnessing expertise and
experience from the whole system in the work that we do.
Whilst 2015/16 is highly unlikely to see radical changes, the
Executive Team will need to ensure that they are ‘connected’ to
what is happening both locally and nationally. This will involve
many different forms of communication both to and from GP
practices and to the public. We will continue to support the NHS
when it requests us to carry out work on a sub-contractual basis.
We will respond to ad hoc requests to carry out extra work when
we can but it will be:



at a cost that offers us a realistic margin
when it takes up any spare capacity we may have
not detrimental to the efficiency and high standards of the
Hospital.
We will continue to respond to tender opportunities and will work
with our partners wherever we can in producing joint submissions.
We are looking at some areas of diversification to include working
with other organisations on providing rehabilitation care and more
initiatives around health and well being. These initiatives are all in
the early stages.
We view all our Consultants as important partners in our business.
During 2015/16 we will continue to work with our consultant body
to develop ideas and plans to feed into the Hospital’s strategic
35
Fairfield Independent Hospital Quality Accounts 2014/2015
“I was very
professionally
and
compassionately
treated in a
friendly way.
I have no idea
how you can
improve as it is
excellent at
Fairfield
Independent
Hospital.”
September 2014
Priorities for 2015/16
direction. With the emphasis in nursing being specialisation,
consultant support is crucial in realising different models of care
than we have at present, in some areas.
“All areas of
care and
information
were met or
exceeded
expectation;
excellent. I am
very pleased
that friends
recommended
Fairfield for my
treatment.”
9.21 Marketing and Communication
With the appointment of a marketing manager 2014 has seen
important steps towards improving the Hospital’s marketing effort.
For example, the Hospital’s social media profiles are all branded
and effective in pushing visitors to the Hospital’s website.
We currently have more control of the website without the need of
external expertise. To improve our transparency we released our
prices and integrated best practice in terms of email marketing.
Using the latest analytical tools we can now monitor the Hospital’s
website performance and have a better understanding of any
opportunities and threats. We can also respond very quickly to
comments or questions raised via the social media sites or NHS
choices. This is really important to us as it shows our patients
that we really do care about what they say and that if there is a
problem we will do our utmost to resolve it and learn from it so it
does not happen again.
What do we want in 2015/16? We will continue to improve the
Website, in terms of visibility and usability.

Visibility refers to improving the performance on search engines.
 When a visitor is on our website, we will ensure they are
finding the information they require.
September 2014
In terms of public relations the Hospital needs to ensure that we
are building relationships with local communities and attending
various events in the region.
We will continue to monitor, adapt and deliver newsletter
communications to key stakeholders with the first quarter of 2015
witnessing the expansion of communications to people who have
signed up to our newsletter online.
9.22
Fundraising and alternatives
We have continued to target the Trust Fund applications that we
sent out in 13/14. The current balance in the Fairfield Future
account is £24,500.
We have not replaced the part time Fundraising Manager and can
see no real reason to do so at present. We are a trading charity
Fairfield Independent Hospital Quality Accounts 2014/2015
36
Priorities for 2015/16
and as such we are not perceived as needing to fundraise in the
ways that other Charities are seen. However, we can exploit our
status and history but we have to acknowledge that we are not
resourced or required to run fundraising campaigns. Staff, not
surprisingly, perceive us as a hospital and like most employees
would not expect to be involved in generating funds to operate a
Hospital with donated cash, goods or services. We most certainly
need to be more active on social media and also more
philanthropic in terms of what we do with others.
We realise that fundraising in the current economic climate is
difficult and we are competing with some very emotive charitable
causes so we need some fresh thinking on what we need to do to
find a role for fund raising.
9.23 External Environment
The Hospital continues to be very susceptible to market forces.
Like many ‘private’ hospitals we have and are heavily reliant on
NHS work to support us. Our NHS activity has overtaken our
private activity significantly.
The NHS environment remains very challenging. There are many
changes afoot with regard to how the Clinical Commissioning
Groups (CCG) want to commission activity in the future. There is
a push for integrated services across health and social care and
to enable this the 2014 Care Act now lays a duty on local
councils to promote such services.
CCGs are keen to move activity away from secondary care into
primary care as the health system as it currently works is
unaffordable.
However, rationalisation of the NHS estate will
enable clinical hubs to be established across the local area to
facilitate taking care closer to patients. We will ensure that we
stay engaged with the CCGs and participate in any initiatives that
are suitable and will:
be at a cost that offers a realistic margin
 take up any spare capacity or utilise our site more efficiently
 not be detrimental to the efficiency and high standards of
the Hospital
We continue to have regular requests form consultants to practice
here. When considering such applications we will continue to
assess for any gaps in provision, possible development
opportunities and areas of potential innovation that we can
capitalise on. We continue to get a great deal of advice and
support from our existing consultants who are very supportive of

37
Fairfield Independent Hospital Quality Accounts 2014/2015
“In
my opinion
the care and
cleanliness of
the Hospital is
excellent and
I am very
satisfied with
my treatment.”
October 2014
Priorities for 2015/16
“This
is the
best Hospital
I have ever
been too.
Everything
was perfect.
Thank you.”
October 2014
the staff in their daily work. The Medical Advisory Committee
(MAC) will continue to be part of the governance framework for
the organisation offering advice and support on incidents, risks
and also on the future development of services looking at new
products and techniques, new ways of working and development.
9.24
Quality and Risk
Infection Prevention and Control
Fairfield Hospital considers infection prevention and control to be
a core element of quality and patient safety. We will continue to
support and develop the role of the Infection Prevention and
Control Lead Nurse. This is to ensure that we have effective
systems and documentation in place to enable us to be proactive
in minimising the risks to patients, staff and visitors, from
acquiring an infection through treatment or during their stay within
the hospital. We will continue to work with our NHS colleagues to
ensure our practice is up to date and in line with national
guidance and best practice.
9.25
Other Risk Areas
The Charity is totally committed to minimising, managing and
preventing risk through a comprehensive, systematic system of
internal controls, whilst maintaining potential for flexibility,
innovation and best practice delivery.
As part of the Hospital’s assurance framework, the risk register
provides the Board with the detail of the high level risks within the
organisation and how those risks are to be effectively managed.
The risk register will be reviewed by the Board bi annually during
2015.
The Hospital will continue to produce annual Quality Accounts
which detail the quality of the services that we deliver.
The risk profile for the Charity includes:




Financial
Clinical
Workforce
Infrastructure risks
We will continue to do our utmost in 2015/16 to ensure that the
systems we have in place do not leave us open to criticism,
potential claims or put the organisation at risk. We will ensure
that all claims are fully investigated and, where procedures have
not been followed, that relevant action is taken. We would expect
Fairfield Independent Hospital Quality Accounts 2014/2015
38
Priorities for 2015/16
our clinical and non-clinical audits to structure assessment of
performance and provide mechanisms for incident reporting and
adverse events. All incidents will continue to be monitored by the
Executive and the Board and learning from incidents will be
cascaded throughout the organisation as part of our commitment
to continuous improvement.
9.26 Leadership and training
We have invested heavily during 2014 in training for all staff and
we will continue to invest in 2015/16. Wherever possible we will
utilise e-learning for staff and secure opportunities to visit other
organisations and do some internal programmes such as ‘walk in
my shoes’. We will also encourage other organisations to visit
Fairfield to look at how we do things, comment as necessary and
share best practice. Staff and Board members will continue to
receive training on the new COC inspection regime. Now they are
appropriately qualified departmental managers and will undertake
regular coaching and mentoring of staff so we can embed such
practices into the organisational culture.
10. CONCLUSIONS
The business of healthcare is both challenging and uncertain. The
Board and the staff at Fairfield are all aware that to remain a
viable organisation we have to continue to offer high quality care
in a safe and welcoming environment. However, the provision of
that care has to be affordable and offer us the opportunity to
make a surplus in order to reinvest in the organisation. Via our
business planning process we must ensure that we can build a
sustainable and viable future for the organisation. That may mean
doing something different than we do now, diversification, seeking
out niche markets etc. With developments in technology and
doing things differently, the trick for us in the next twelve months
will to be to start to develop different models of care and
provision with different partners where we may have to take
calculated risks whilst staying true to our core values.
39
Fairfield Independent Hospital Quality Accounts 2014/2015
Fantastic
Hospital, no
faults what so
ever.”
“
November 2015
Schedule 1 - Overview of NHS CQUIN (Quality)
Targets & Achievements 2014/2015
Quality Indicator
Outcome
Friends & family test
To continue with inpatients and rollout to day
cases and outpatients from 01/07/2014.
Achieved.
Increased or maintained response rate.
Achieved the response rate stands at 50%
for inpatient and day cases and at 43%
across all three patient areas.
NHS Safety Thermometer
Reduction in prevalence
of pressure ulcers
To collect data on the following three elements of
the NHS Safety Thermometer: pressure ulcers, falls
and urinary tract infection in patients with a
catheter.
Achieved
ulcers.
the organisation had 0 pressure
Achieved in all cases 0 for 2014/15.
Supporting Carers
Monthly audit of carers of people with dementia
to test whether they feel supported
We have been accredited with the Dementia
Action Alliance and provide appropriate
advice and support to carers.
Audit undertaken and results show that carers
of people with dementia did feel supported.
Results will be reported at May 2015 Board.
Clinical leadership - confirm named lead clinician
and planned training programme
Lead clinician identified and training
gramme at various levels underway.
pro-
Patient Experience
Surveying the views of patients regarding their
experiences.
Details reported quarterly to CCG.
results were as follows:
At Q4 the
 99% of patients reported they were given
the right amount of information on discharge.
 100% of patients reported that they were
involved as much as they wanted to be in
decisions about their care and treatment.
 100% patients who reported that when
leaving hospital they were given written or
printed information about what to do or
not do.
Fairfield Independent Hospital Quality Accounts 2014/2015
40
Schedule 2
2015 -2016 Clinical Audit List
No.
Dept.
Title
OPD/21
OPD
Pre-operative Assessment
Jul-15
Ongoing
OPD/22
OPD
Medicines Management
Aug-15
Oct-15
OPD/23
OPD
Wound Care Documentation
Apr-15
Jun-15
OPD/24
OPD
To establish which is the most cost-effective;
autoclaving instrument v disposable
Nov-15
Jan-16
Wa/27
Ward
Patient observations using the NEWS
May-15
Jun-15
Wa/28
Ward
Nurse led ward urology clinic
Apr-15
May-15
Wa/29
Ward
Utilisation of second stage recovery unit
Jun-15
Jul-15
Wa/30
Ward
Laser Vein Procedures
Sep-15
Oct-15
Adm/13
Admin
Scanned case notes v paper case notes
Oct-15
Adm/14
Admin
Scanned Case Notes
Aug-15
Adm/15
Admin
ISO Folder
Oct-15
Xray/3
Xray
The requirement of ultrasound doppler after joint
replacement surgery
Mar-15
Sep-15
Xray/4
Xray
Xray activity in theatre
Jan-15
Jul-15
Xray/5
Xray
Radiation dose audit Image Intensifier
Mar-15
May-15
Physio/2
Physio
To establish the benefit of hydro-distention
Feb-15
Dec-15
Physio/3
Physio
AQP Physiotherapy treatment to establish average
number of treatments and costs
1.03.15
31.03.15
Physio/4
Physio
A retrospective audit of 2014 CAB patients who
require physiotherapy
1.02.15
28.02.15
Gov/1
Exec
Discharge Process
Apr-15
Jun-15
Gov/2
Exec
Efficacy comparison between Clexane and
Apixaban
Apr-15
Dec-15
Th/25
Theatre
Monitoring patient temperatures pre, post and
per-operatively
Th/26
Theatre
Additional staffing expenditure due to
overrunning sessions
Th/27
41
Theatre
Date start Date End
Reduction of anxiety in patients undergoing
surgical procedures under local anaesthetic
Fairfield Independent Hospital Quality Accounts 2014/2015
Statements from external bodies
Fairfield Independent Hospital Quality Accounts 2014/2015
42
Statements from external bodies
Healthwatch St Helens had no comments to make.
43
Fairfield Independent Hospital Quality Accounts 2014/2015