Horton Treatment Centre
Quality Account
2014/15
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2013/14 (looking back)
2.1.2 Clinical Priorities for 2014/15 (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 2013/14 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Clinical Audits
Welcome to Ramsay Health Care UK
Horton NHS Treatment Centre is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to
become a global hospital group operating over 100 hospitals and day surgery
facilities across Australia, the United Kingdom, Indonesia and France. Within the
UK, Ramsay Health Care is one of the leading providers of independent hospital
services in England, with a network of 31 acute hospitals.
We are also the largest private provider of surgical and diagnostics services to
the NHS in the UK. Through a variety of national and local contracts we deliver
1,000s of NHS patient episodes of care each month working seamlessly with
other healthcare providers in the locality including GPs and Clinical
Commissioning Groups
Chief Executive Officer Statement
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 believe that across Ramsay we nurture the teamwork and
professionalism on which excellence in clinical practice depends, we will continue
to strive to get ever better.
I am very proud of our long standing as a major provider of healthcare services
across the world and of our Ramsay very strong track record as a safe and
responsible healthcare provider. It gives us pleasure to share our results with you.
Mark Page
Chief Executive officer
Ramsay Health Care UK
Quality Accounts 2014/15
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Introduction to our Quality Account
This Quality Account is Horton Treatment Centre’s annual report to the public and
other stakeholders about the quality of the services we provide. It presents our
achievements in terms of clinical excellence, effectiveness, safety and patient
experience and demonstrates that our managers, clinicians and staff are all
committed to providing continuous, evidence based, quality care to those people
we treat. It will also show that we regularly scrutinise every service we provide
with a view to improving it and ensuring that our patients’ treatment outcomes are
the best they can be. It will give a balanced view of what we are good at and what
we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment
centre within Ramsay Health Care UK. It was recognised that this didn’t provide
enough in depth information for the public and commissioners about the quality of
services within each individual hospital and how this relates to the local
community it serves. Therefore, each site within the Ramsay Group now
develops its own Quality Account, which includes some Group wide initiatives, but
also describes the many excellent local achievements and quality plans that we
would like to share.
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Part 1
1.1 Statement on quality from the General Manager
Gill Faure General Manager
Horton NHS Treatment Centre
As General Manager at Horton NHS Treatment Centre I am committed to
delivering consistently high standards of care to all of our patients. Delivering
clinical excellence depends on everyone in the organisation being responsible
and accountable for their performance in the roles they play. Our Quality Account
has been developed with the involvement of our staff to provide information about
the quality of the service we provide. We have reported on our performance
across the past year detailing both our results and the actions we have taken to
improve the quality of the service. To demonstrate our commitment to continuous
improvement we have shared our quality priorities for the coming year. The report
explains our governance framework and how we work within this to continually
monitor and evaluate the quality of the services that we deliver.
I am extremely proud but not complacent about the quality results achieved by
the team at Horton Treatment Centre. By placing the patient at the centre of
everything we do we have consistently delivered good patient experiences and
quality outcomes which are reflected in our excellent patient feedback. The
results have been accomplished through the hard work, commitment and focused
attitude of the team to continually improve quality and patient care.
Our governance framework is robust and our approach to risk management
focuses on doing everything within our power to reduce the likelihood and
consequence of an adverse event or outcome.
Last year we invested significant resources to strengthen further our governance
framework. We engaged our Consultants and staff at all levels through education,
training, continuous development and appraisal.
Our framework incorporates a range of committees who meet on a regular basis
to review quality. The meetings are open, collaborative and action orientated. Our
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Medical Advisory Committee (MAC) in which our Consultants are empowered to
work alongside the General Manager and Matron to positively influence quality is
held quarterly. Our Clinical Governance and Clinical Effectiveness meetings are
held quarterly and attended by clinical staff across the unit. Our Health & Safety
Committee is bi-monthly and attended by staff of all levels. Quality is a key
agenda item for our monthly Senior Management, Head of Department and Team
Meetings. Infection control, blood transfusion, resuscitation leads have input into
these committees and are supported centrally from Ramsay’s corporate clinical
team.
We have a comprehensive audit programme in place which measures our teams’
adherence to professional standards and legislative requirements. We complete
internal review of audit findings and implement corrective action plans where
improvement is required, subsequent review is undertaken to ensure timely
completion of actions.
In the event of a clinical incident or complaint we complete a thorough root cause
analysis to identify the cause and a detailed action plan is then implemented to
reduce the risk of re-occurrence. Risk registers are proactively managed through
the governance framework. Local risks are recorded electronically on a central
database which allows us to identify trend and enables further review by
Ramsay’s corporate clinical team.
We hold weekly clinical audit meetings where Consultant Surgeons, Radiologists,
Clinical Heads of Department and Radiographers meet to review surgical
outcomes for patients undergoing implant surgery. In addition to performing an
audit function the multi-disciplinary meetings encourage peer review and sharing
of expertise and best practice.
When inspected by the Care Quality Commission (CQC) in January 2014 our
governance framework was examined in detail and findings confirmed that we
had an effective system to regularly assess and monitor the quality of service that
patients received. Full details of the inspection report can be found on the CQC
website at http://www.cqc.org.uk/location/1-128732838.
We share detailed quality information with our lead commissioner Oxfordshire
Clinical Commissioning Group (OCCG) through monthly reporting and discussion
at regular contract review meetings. We extend invitation to OCCG colleagues to
visit the Treatment Centre unannounced, informally or in a formal capacity to
attend internal quality meetings.
We have a very healthy open relationship with our commissioners and been
grateful for all the support and feedback we receive and hope to continue to
develop this relationship going forward.
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In addition to engaging with our commissioners, we have worked hard to develop
stronger relationships with our Consultants, General Practitioners (GPs) and
Musculoskeletal Triage Service Providers through a collaborative approach. We
have been provided with the opportunity to make recommendations on services
that impact on patients before they are referred into our service and have worked
diligently to improve patient choice and the quality of the entire patient pathway.
We are supportive of innovation and have participated in service redesign
initiatives to ensure our patients are provided with a high quality, effective service.
We have worked with several neighbouring NHS Trusts to support them to
achieve 6 week diagnostic and 18 week referral to treatment (RTT) targets.
We actively seek feedback from our patients and service users. On the few
occasions where we get things wrong we are not defensive. We act promptly and
openly to ensure that areas of dissatisfaction are addressed. Lessons learned are
shared openly throughout our governance framework to Consultants, Managers,
and Commissioners and most importantly to the staff caring for our patients every
day.
We measure and celebrate success with our team through the many positive
questionnaires and handwritten, personalised patient compliment letters we
consistently receive.
If you would like to contact me with feedback or queries please do not hesitate to
do so on gill.faure@ramsayhealth.co.uk or 01295 755000.
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1.2 Hospital Accountability Statement
To the best of my knowledge, as requested by the regulations governing the
publication of this document, the information in this report is accurate.
Gill Faure
General Manager
Horton NHS Treatment Centre
Ramsay Health Care UK
This report has been reviewed and approved by:
Medical Advisory Committee (MAC) Chair: Mr Bijan Shafighian
Clinical Governance Committee Chair: Mr Bijan Shafighian
Clinical Governance Committee Deputy Chair: Mr Dusan Repel
Ramsay Health Care UK Regional Director: Mr James Beech
Oxfordshire Clinical Commissioning Group (OCCG)
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Welcome to HORTON NHS TREATMENT CENTRE
Horton NHS Treatment Centre in Banbury is a modern 40 bedded hospital. It was
purpose built in 2006 as a specialist Orthopaedic Treatment Centre and was
designed to provide an excellent standard of care for impatient and daycase
patients through modern facilities and the technical equipment that modern
medicine demands.
Ramsay Health Care is registered as a provider with the Care Quality
Commission (CQC) under the Health & Social Care Act 2008.
Horton NHS Treatment Centre is registered as a location for the following
regulated services:
 Treatment of disease, disorder or injury.
 Surgical procedures.
 Diagnostic and screening procedures.
The Services we provide include:
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Outpatient Consultation and Pre-Operative Assessment within a modern
Outpatient Department of 9 Consulting Rooms.
Dedicated Radiology Department providing X-ray, Ultrasound, and MRI
scanning.
Mobile Dexa Scanning service for direct GP referral.
Surgical Operations undertaken in a modern theatre suite composed of 3
well equipped theatres all with laminar flow air change.
Inpatient and day care utilising 40 inpatient beds with ensuite facilities and
an ambulatory day care unit.
Physiotherapy treatments delivered to both inpatients and outpatients from
a dedicated department equipped with a large in-house gymnasium.
Provision of freshly cooked meals, with a relaxing restaurant for visitors
and staff.
Onsite decontamination services.
Outreach Clinics at Bicester Health Centre, Windrush Medical Practice in
Witney and Blakelands Hospital in Milton Keynes.
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We provide safe, convenient, effective and high quality treatment for adult and
adolescent patients (excluding children below the age of 16years) whether
privately insured, self-pay, or NHS funded.
The majority of our patients choose the Horton NHS Treatment Centre for
Orthopaedic Surgery. We specialise in hip and knee replacement and revision,
sporting injuries, shoulder, hand and wrist and foot surgery.
A high percentage of our patients come from the NHS sector where patients have
chosen to use our facility through ‘Choose and Book’.
Our services help to ease the pressures on NHS Trust facilities within
Oxfordshire, Northamptonshire, Warwickshire, Buckinghamshire and surrounding
counties.
We work closely with neighbouring county NHS Trusts to support Trusts to treat
patients within 18 weeks and achieve national referrals to treatment targets
(RTT). In addition we provide diagnostic support assisting NHS Trusts to achieve
6 week diagnostic treatment targets. Within this reporting period we have worked
in association with Buckinghamshire NHS Trust, South Warwickshire NHS
Foundation Trust, Northampton General Hospital NHS Trust and Oxford
University Hospitals NHS Trust.
We have worked with Oxfordshire Clinical Commissioning Group (OCCG) and
General Practitioner practices to ensure patients have improved access to our
services by providing information, training and liaison to clinical and
administrative staff.
The introduction of outreach clinics has been welcomed by OCCG, Associate
Commissioners, GPs and patients as this allows patients, where clinically
appropriate, to be treated closer to home. We have expanded the geographical
coverage and frequency of our outreach clinics to meet the increasing needs of
our patients.
In the last 12 months we have performed 2701 procedures. 98.7% of these
procedures were performed for NHS patients who chose to have their surgery
with us. The remaining patients chose to self-fund their healthcare or used private
medical insurance policies.
To support the delivery of excellent clinical care, all of our services are led by
Consultant Specialists, Consultant Anaesthetists and Consultant Radiologists.
We have a Resident Medical Officer who remains on site 24 hours a day, 7 days
per week.
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In addition to Orthopaedic Surgery we offer the following specialties for
patients who have private medical insurance or choose to self-fund their
treatment:
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Spinal Surgery
Cosmetic Surgery
Pain Management
General Surgery
Oral Maxillofacial Surgery
Dermatology
Clinical Psychology
Allergy Management
Horton NHS Treatment Centre Team:
We currently engage the following Clinical Specialists:
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Consultant Orthopaedic Surgeons
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Consultant General Surgeons
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Consultant Pain Specialists
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Consultant Cosmetic Surgeons
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Consultant Oral Maxillofacial Surgeons
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Consultant Spinal Surgeons
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Consultant Anaesthetists
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Consultant Radiologists
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Clinical Psychologist
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Consultant Dermatologists
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Audiologist
The General Manager is supported by a senior management team comprising:
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Matron
Operations Manager
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Finance Manager
Sales & Marketing Manager
All departments have a Manager or Lead and dedicated teams to ensure that our
services run smoothly and efficiently.
Clinical Departments:
Quality Improvement
Horton NHS Treatment Centre has recognised the importance of quality
assurance and to enhance this further a Quality Improvement Lead was recruited
in 2014. This experienced senior nurse works alongside Matron and the clinical
teams to further enhance the quality of service delivery and care to patients.
Outpatient Department
Managed by an experienced Outpatient Manager and supported by 5 Registered
Nurses and 3 Health Care Assistants.
Physiotherapy Department
Managed by an experienced Senior Physiotherapist and supported by a team of 5
qualified Physiotherapists. The department also contribute to the training of
student physiotherapists.
Inpatient Ward & Day Care Unit
Managed by an experienced Ward Manager and supported by a Deputy Ward
Manager and a team of 10 Registered Nurses and 6 Health Care Assistants and
a ward clerk.
Theatre Department
Managed by an experienced Theatre Manager and supported by a Deputy
Theatre Manager and a team of 8 Registered Theatre Nurses and Operating
Department Practitioners and 4 Health Care Assistants.
Non Clinical Teams comprise:
• 4 Decontamination Technicians
• 15 Administration Staff
• 4 Receptionists
• 6 Housekeepers
• 3 Chefs and 1 Catering Assistant
• 1 Supplies Coordinator
• 1 Engineer
• 3 Porters
• 1 GP Liaison
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Primary Care:
To ensure that our patients experience the smoothest of patient pathways we
invest a significant amount of time building on the strong relationships we have
with GPs working in Primary Care and providers of Musculoskeletal Triage
Services. The GP Liaison staff member makes regular visits to surgeries in the
local area to engage with staff and both provide information and respond to
queries. We welcome feedback from our colleagues in primary care as this allows
us to respond to issues arising in a timely fashion.
Due to our location in the northern tip of Oxfordshire, we represent a convenient
choice of location for patients from several counties, including Oxfordshire,
Warwickshire, Buckinghamshire, Northamptonshire, Gloucestershire, Berkshire
and Milton Keynes.
We receive patient referrals from GPs in more than 250 practices which
represents decisions from over 1000 GPs. In the last year we have received
patient referrals from 70 new GP practices demonstrating an increase in our
popularity with patients.
We work extremely hard to provide GP surgeries and Musculoskeletal Triage
service teams with up to date information on the services offered at the Treatment
Centre. We constantly revise the information we supply to include more detailed
quality data, admission criteria and appointment waiting times; all of these
initiatives have been positively received. Within the last year we have developed
improved relationships with triage service teams and together we have improved
our patient journey and experience.
Our Consultant Surgeons proactively support the continued professional
development of GPs by presenting educational seminars or informal question &
answer sessions both on site at the Horton NHS Treatment Centre and within GP
practices. Topics are agreed with GPs and ensure an exchange of information
which supports the ongoing relationships and clinical practice.
In addition we have provided workshops for Medical Secretaries working within
primary care on topics including Customer Service excellence and use of the
Choose & Book system.
To support Practices Managers we provided educational workshops and
delivered Basic Life Support (BLS) training to practices.
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Patient Participation Group
We encourage people to join our Patient Participation Group with the aim of
seeking feedback from patients on where improvements to our services can be
made. We endeavour to recruit representatives through phone calls, cards placed
around the Treatment Centre and an advert on our website. We are continuing to
seek additional patients to join the group to broaden representation.
Community Engagement
Our aim is to engage more broadly with the general public to grow awareness of
their right to choose the hospital in which they are treated in accordance with the
NHS Constitution. During the year we have been working closely with local GP
surgeries to provide the general public with information about the Government’s
‘Choice Programme’. We work in partnership with various local organisations to
support them in their work.
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Part 2
2.1 Quality priorities for 2014/2015
Plan for 2014/15
On an annual cycle, Horton Treatment Centre develops an operational plan to set
objectives for the year ahead.
We have a clear commitment to our private patients as well as working in
partnership with the NHS ensuring that those services commissioned to us result
in safe, quality treatment for all NHS patients whilst they are in our care. We
constantly strive to improve clinical safety and standards by a systematic process
of governance including audit and feedback from all those experiencing our
services.
To meet these aims, we have various initiatives on going at any one time. The
priorities are determined by the hospital’s Senior Management Team taking into
account patient feedback, audit results, national guidance, and the
recommendations from various hospital committees which represent all
professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical
effectiveness and improve the experience of all people visiting our hospital.
Priorities for improvement
2.1.1 A review of the clinical priorities of 2013/14
1. Dementia Care.
Horton NHS Treatment Centre highlighted Dementia Care as a priority for
2013/14. This was supported by Oxfordshire Clinical Commissioning Group and
formed part of the CQUIN (Commissioning for Quality Innovation) framework. The
CQUIN payment framework enables commissioners to reward excellence and
quality improvement. Horton NHS Treatment Centre achieved 100% in all CQUIN
measures within this reporting period.
Horton NHS Treatment Centre has been committed to improving the care
provided to patients and detecting the early signs of dementia in patients who are
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using our services. The outpatient clinical staff have been providing support to
patients and their families by measuring memory loss and communicating with
the patient‘s GP to ensure that ongoing support is provided. Many families have
welcomed this interaction with their loved ones as a way of identifying reasons for
lapses in memory of the patient and starting the process of diagnosis. The staff at
Horton NHS Treatment Centre will continue to offer this support.
2. PROMS (Patient Reported Outcome Measures) Hip and Knee
PROMs measures health gain in patients undergoing hip and knee replacement,
varicose vein and groin hernia surgery in England, based on responses to
questionnaires before and after surgery. At Horton NHS Treatment Centre we
report on the hip and knee joint replacement scores. We provide the preoperative questionnaire and support the patients to complete this; however the
post-operative questionnaire is sent from a Government central point outside of
the Treatment Centre.
The information gained from completed pre and post-operative questionnaire
results helps the hospital to improve the quality of care for future patients.
The low number of completed post-operative questionnaires has prevented us
from knowing whether or not there was real improvement following surgery.
Whilst we have submitted paired questionnaires, low figures are not published
due to data confidentiality.
Last year the Treatment Centre made the decision to implement a ‘reminder’
letter to patients which we hoped would encourage them to complete both
surveys and add to the information received at the Health & Social Care
Information Centre.
Unfortunately this reminder letter has not had the desired effect and again this
year the number of post-operative questionnaires being completed is too low to
be included. We will continue to encourage patients to complete their
questionnaires.
Improvement in recording the patient’s fluid level status
It is important to maintain good fluid levels in order to aid patient recovery. An
audit was undertaken and the results of the audit indicated that although patients
were having fluids appropriately, their ‘fluid charts’ did not always indicate the
volume and were not completed extensively. This audit scored an ‘amber’ alert
(scores range from 80-89%) at ward level and as a consequence was an area for
improvement.
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An improved process to monitor fluid levels was introduced. In addition the fluid
charts were reviewed and improvements made to the care plan. These changes
allowed us to remind the nurses of the importance of accurate recoding of fluid
levels. The results of the audit have shown a great improvement with audit results
regularly showing a score range of 90-96%. We will continue to monitor the
performance in this area to ensure the best standard in this aspect of care.
2.1.2 Clinical Priorities for 2015/16
Clinical priorities have been chosen to improve our performance across the
following domains:
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Patient Experience
Clinical Effectiveness
Patient Safety
Priorities include:
1. Training Compliance
2. Improved Pain Relief
3. Promoting a Culture of Safety
1. Training Compliance.
There is clear evidence that highly trained staff are more efficient, effective and
safer. In 2014 Horton NHS Treatment Centre introduced a new role of Quality
Improvement Lead. This additional resource was intended to enhance the focus
on compliance for training across the Treatment Centre.
Staff complete mandatory E-learning and face to face practical training across a
range of subject areas, all impacting positively on patient safety. The Quality
Improvement Lead also increases the awareness of staff of their responsibility in
relation to training
Horton NHS Treatment Centre has improved training compliance to 95% and will
continue to monitor and increase compliance.
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2. Improved Pain Relief
The Horton NHS Treatment Centre monitors all patients who are readmitted for
whatever reason. In the last year a number of patients have been readmitted
because of the pain they experienced after discharge. A review was undertaken
of the patients readmitted during this period and the team felt that we could
improve on the experience for patient’s pain control after discharge. For that
reason we are implementing changes to our processes as follows;
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Training from a pain specialist nurse to relevant staff to improve the
knowledge base of nursing team.
A full review of the discharge process for each registered nurse at ward
level by the Ward Manager.
Greater involvement in the discharge process for the patient.
Introduction of alternative drugs for pain relief.
The success of these changes will be monitored throughout the next year and by
the context of a patient’s readmission.
3. Promoting a Culture of safety
The Manchester Patient Safety Framework (MaPSaF) is a tool to help healthcare
organisations and healthcare teams assess their progress in developing a safety
culture.
MaPSaF helps teams understand how effective their systems are at treating
people safely. It looks at such things as how well patient safety incidents are
investigated, how well staff are supported in their professional development
education and training.
MaPSaF can be used in many ways, for example:
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To facilitate reflection on patient safety culture.
To stimulate discussion about the strengths and weaknesses of the
patient safety culture.
To reveal any differences in perception between staff groups.
To help understand how a more mature safety culture might look.
To help evaluate any specific intervention needed to change the patient
safety culture.
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Horton NHS Treatment Centre has agreed with Oxford Clinical Commissioning
Group (OCCG) to implement this tool and further promote the excellent safety
culture throughout the Treatment Centre.
2. Mandatory Statements
The following section contains the mandatory statements common to all Quality
Accounts as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2014/15 Horton NHS Treatment Centre provided elective Orthopaedic
services for young persons from the age of 16 and adult patients.
The Horton NHS Treatment Centre has reviewed the data available relating to
the quality of care of these NHS services.
The income generated by the NHS services reviewed in the period 1st April 2014
to 31st March 2015 represents 98.7% per cent of the total income generated from
the provision of services by the Horton NHS Treatment Centre
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:
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Human Resources:
Staff Cost % Net Revenue
19.14%
HCA Hours as % of Total Nursing
33.0%
Agency Cost as % of Total Staff Cost
11.46%
Ward Hours PPD
4.45%
% Staff Turnover
26.0%
% Sickness
2.90%
% Lost Time
13.0%
Appraisal %
79.0%
Mandatory Training %
80.0%
Staff Satisfaction Score
4.80
Number of Significant Staff Injuries
0%
Patients
Formal Complaints totalled 15 (0.56%) this shows improvement through a
reduction from complaints received in the prior year.
Patient Satisfaction Score using the question ‘Overall, how would you rate the
care you received?’ scored 94.4% this is significantly higher than the national
average.
Number/Rate of Patient Readmissions totalled 14 (0.52%) this shows
improvement through a reduction compared to prior year.
Number/Rate of Patient Returns to Theatre totalled 4 (0.14%) this shows a slight
increase from previous year but remains a very low incidence.
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Quality
The yearly audit programme uses a ‘traffic light’ score in that completed audits
scores receive a red, amber and green rating.
Green
100%
Cool
Amber
90 - 99%
Amber
80 - 89%
Hot
Amber
70 - 79%
Red
69% and under
Summary of Audits Scores:
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Hand Hygiene
Consent
Urinary Catheter Care Bundle CCB
SSI
Blood Transfusion
Prescribing
Theatre
MRSA
Cleaning Standards
Medicine Management
Controlled Drugs
Anaesthetic Standards
100%
100%
96%
95%
100%
97%
100%
Nil Positive
98%
97%
99%
100%
Infection Control Audit Score
The rolling audit schedule (appendix 2) ensures all aspects of infection prevention
and control are audited and reviewed for trends and used to identify where
improvements can be implemented. The Infection Prevention and Control
Committee meets bi-monthly to discuss the outcomes of audits and agrees and
implements actions to be taken.
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Results from the audits during this reporting period are as listed:
Infection Control Environmental Audit
98-99%
Minor issues were identified around the disposal of waste. Extended training for
staff was implemented.
Hand Hygiene Audit
99-100%.
These scores are consistently high with non-compliance centering on the wearing
of staff jewelry.
2.2.2 Participation in Clinical Audit
During 1st April 2014 to 31st March 2015 the Horton NHS Treatment Centre
participated in 2 national clinical audits in which it was eligible to participate.
The national clinical audits and national confidential enquiries that Horton NHS
Treatment Centre participated in, and for which data collection was completed
during 1st April 2014 to 31st March 2015, are National Joint Registry (NJR) and
Patient Reported Outcome Measured (PROMS, discussed previously).
% cases
submitted
Name of audit / Clinical Outcome
Review Programme
98%
National Joint Registry (NJR)
Hips 45.9%
Elective surgery (National PROMs Programme) for Hips and Knees
Knees
54.0%
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The reports of the 2 national clinical audits from 1st April 2014 to 31st March 2015
were reviewed by the Clinical Governance Committee, and Horton NHS
Treatment Centre intends to take the following actions to improve the quality of
healthcare provided.
We have already improved our compliance of collection and electronic input of
NJR data by identifying those patients eligible for NJR on the basis of their
episode data on Cosmic, our patient system. In 2014 we achieved 100%
compliance and 98% has been achieved to date in 2015.
To improve the percentage of PROMS questionnaires being completed a member
of staff has been identified to take on the role of ‘champion’ for this task .This staff
member will oversee the process to ensure that the pre-operative questionnaire is
completed and sent to the National PROMS team.
Local Audits
The reports of 79 local clinical audits from 1st April 2014 to 31st March 2015 were
reviewed by the Clinical Governance Committee and Horton NHS Treatment
Centre and actions plans formulated to improve the quality of healthcare
provided. Examples are shown below.


The Decontamination Audit identified that staff shoes needed to be stored
more appropriately.
Action: A shoe rack was purchased to store staff shoes. Action completed.
Environmental Audit demonstrated that several mattresses were showing
signs of wear and tear and needed replacing.
Quality Accounts 2014/15
Page 23 of 48



Action: Mattresses renewed and a checking system implemented to review
going forward. Action completed.
Blood transfusion audit showed that some patients were not receiving an
information leaflet post transfusion.
Action: Nursing staff required to document that they talked to the patient
about the post-operative transfusion, alternatives of the transfusion, and
patient given the leaflets. Action completed.
Disposal of waste into the appropriate bins was not always compliant.
Action: A review and re-placing of the bins to ensure the most practical
access for staff. This is monitored throughout the year.
Completion of Fluid Chart Audit
Action: training for all staff/ re-audit to improve compliance. Action
completed.
2.2.3 Participation in Research
There were no patients recruited during 2014/15 to participate in research
approved by a research ethics committee.
Quality Accounts 2014/15
Page 24 of 48
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Horton NHS Treatment Centre income from 1st April 2014 to 31st
March 2015 was conditional on achieving quality improvement and innovation
goals. This was agreed between Horton NHS Treatment Centre and any person
or body they entered into a contract, agreement or arrangement with for the
provision of NHS services, through the Commissioning for Quality and Innovation
payment framework.
Unit Name: Horton
CQUIN
Indicator weighting
Friends and Family Test - Early
Implementation
Friends and Family Test Increased or maintained
Response Rate
Friends and Family Test Increased Response Rate in
acute inpatient services
Management of Deteriorating
Patient through EWS s ys tem
Management of a patients
fluid balance
Dementia - Find, Assess,
Investigate & Refer
Completion and submission of
NHS Safety Thermometer tool
Estimated value of CQUIN £
based on annual activity plan
Number of patients > 75 years
Further implementation at
admitted as an elective
Ward Level of Early Warning
admis s ion undergoing a face
Scoring s ys tem (EWS) to
Further implementation at
to face pre-as s es s ment, the
incorporate national guidance
Ward level of fluid
proportion of thes e identified
to allow s taff to identify
management chart to maintain
as potentially having dementia
patient deterioration in timely patient hydration levels and
who are appropriately
manner and take appropriate
promote recovery
as s es s ed, and the number
action and in turn reduce
referred on to s pecialis t
clinical ris k
s ervices
Continued completion and
s ubmis s ion of Safety
Thermometer tool with RCA
inves tigation of any relevent
incidents
Description of indicator
Early implementation
Increas ed or maintained
res pons e rate
Increas ed or maintained
res pons e rate
Frequency of reporting to
commissioner
Final indicator period/date (on
which payment is based).
One off activity
Monthly return
Monthly return
Quarterly
Quarterly
Quarterly
One day per month <to agree
locally which dates >
Achieving October 2014 early
implementation
Q4 in 2014/15
Q4 in 2014/15
Q4 2014/2015
Q4 2014/2015
Q4 2014/2015
April 2014-March 2015
Improvement on Q1 res ult
2014/15
Improvement on Q1 res ult
2014/15
Improvement on Q1 res ult
2014/15
90% completion
Provider achieving an increas e
or maintaining a good
res pons e rate average for A&E A res pons e rate for Quarter 4 of
in Q4 (of at leas t 20%) and for
40% (or more)
inpatient s ervices for Q4 (of at
leas t 30%)
Final indicator value (payment
threshold).
Full delivery of FFT acros s all
s ervices delivered by the
provider as outlined in
guidance
Rules for calculation of
payment due at final indicator
period/date
Provider to demons trate to
commis s ioner that miles tone
has been met
N/a
N/a
Submis s ion of Audit
Submis s ion of Audit
Submis s ion of Audit
Completion of NHS Safety
Thermometer Tool
Are there rules for partial
achievement of the indicator at
the final indicator
date/period?
N/a
If the target for Q1 is mis s ed,
but the provider achieves the
target for Q4, 50 per cent of this
portion of the FFT CQUIN will
be payable
N/a
N/a
N/a
N/a
N/a
Final indicator reporting date
Oct-14
Q4 in 2014/15
Q4 in 2014/15
1s t April 2015
1s t April 2015
1s t April 2015
1s t April 2015
Quarter 1
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
Quarter 2
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
Quarter 3
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
Quarter 4
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
100.00%
PERFORMANCE
Quality Accounts 2014/15
Page 25 of 48
2.2.5 Statements from the Care Quality Commission (CQC)
Horton NHS Treatment Centre is registered with the Care Quality
Commission (CQC) however has not been inspected in the last 12 months.
Previously the CQC quality inspection took place on 27 January 2014.
Three clinical inspectors visited the ward, outpatient and theatre departments,
interviewed patients and staff, reviewed documentation and considered the
processes and systems in place within the Treatment Centre.
The Care Quality Commission inspected the following standards as part of a
routine inspection. This is what was found:
Consent to care and treatment
 this standard was met
Care and welfare of people who use services
 this standard was met
Management of medicines
 this standard was met
Supporting workers
 this standard was met
Assessing and monitoring the
Quality of the service provision
 this standard was met
ISO 27001 Accreditation
In March 2015 Horton NHS Treatment Centre was externally audited against ISO
27001 standards and successfully achieved full accreditation.
The Treatment Centre is extremely proud of this achievement as it demonstrates
that the team takes information security exceptionally seriously. All staff teams
are aware of their responsibilities around maintaining patient confidentiality and
data protection requirements.
Service users can have full confidence that their information is managed and
protected in line with the guidelines.
Quality Accounts 2014/15
Page 26 of 48
2.2.6 Data Quality Statements
Horton NHS Treatment Centre has taken the following actions to improve data
quality:




Weekly Data Quality reports are issued to highlight errors or omissions in
data; these are reviewed and actioned appropriately.
Periodic internal audits of our clinical coding are completed to ensure
accuracy of the data submitted.
We complete regular audits of our medical records and we develop and
implement action plans to resolve any areas of concern.
Monthly exception reports are monitored to ensure that there are no
omissions in the data we are submitting to our commissioners through
Secondary User Service (SUS).
NHS Number and General Medical Practice Code Validity
The Ramsay Group submitted records during 2014/15 to the Secondary Users
Service for inclusion in the Hospital Episode Statistics which are included in the
latest published data. The percentage of records in the published data included:
The patient’s valid NHS number:



99.97% for admitted patient care
99.96% for outpatient care
Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
The General Medical Practice Code:



100% for admitted patient care
100% for outpatient care
Accident and emergency care N/A (as not undertaken at Ramsay hospitals).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report score overall for
2014/5 was 75% and was graded ‘green’ (satisfactory).
This information is publicly available on the DH Information Governance Toolkit website at:
https://www.igt.hscic.gov.uk.
Quality Accounts 2014/15
Page 27 of 48
Clinical Coding Error Rate
Hospital Site
Audit
Date
Next Audit
Date
Primary
Diagnosis
Secondary
Diagnosis
Primary
Procedure
Secondary
Procedure
Horton NHS TC
Feb 15
2016
100%
98.1%
100%
98.0%
Quality Accounts 2014/15
Page 28 of 48
2.2.7 Stakeholders views on 2013/14 Quality Account
Statement from Oxfordshire Clinical Commissioning Group
(OCCG)
OCCG has reviewed the Horton Treatment Centre (HTC) Quality Account and believe that the
information it provides is accurate. OCCG commissions elective orthopaedic services from HTC
which provides the patients of Oxfordshire with greater choice.
OCCG is committed to commissioning high quality care for the population of Oxfordshire. OCCG
therefore recognises the importance of collaborative working between HTC with other NHS and
independent providers of orthopaedic services in Oxfordshire. In order to achieve the NHS
constitution standard for 18 week waits and 6 week diagnostic tests, HTC play an important role.
OCCG approve of the priorities selected by HTC and is pleased to see that they have included a
priority around safety culture as it is important for all organisations to self-reflect and continually
strive to improve.
There have been three serious incidents that occurred during 2014/15 and upon completing the
investigation, OCCG were satisfied that lessons had been learned and that these incidents can be
closed. HTC have been open in their Quality Account about these incidents and OCCG are
assured by the actions taken.
The Horton Treatment Centre Quality Account is laid out in a good format that allows the reader
to navigate through the document and the language avoids the use of jargon. OCCG look forward
to continue to work together with HTC to deliver high quality care for the patients of
Oxfordshire. Overall, OCCG believe that this Quality Account should give readers confidence that
HTC is committed to driving continuous quality improvement.
Quality Accounts 2014/15
Page 29 of 48
Part 3: Review of Quality Performance 2014/2015
Statements of quality delivery
Matron, Gina Taylor
Review of quality performance 1st April 2014 - 31st March 2015
Director of Clinical Services Statement
This publication marks the sixth successive year since the first edition of Ramsay
Quality Accounts. Through each year, month on month, we analyse our
performance on many levels, we reflect on the valuable feedback we receive from
our patients about the outcomes of their treatment and also reflect on
professional opinion received from our doctors, our clinical staff, regulators and
commissioners. We listen where concerns or suggestions have been raised and,
in this account, we have set out our track record as well as our plan for more
improvements in the coming year. This is a discipline we vigorously support,
always driving this cycle of continuous improvement in our hospitals and
addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient
privacy and dignity, hospital safety and good outcomes of treatment. We believe
in being open and honest where outcomes and experience fail to meet patient
expectation so we take action, learn, improve and implement the change and
deliver great care and optimum experience for our patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
Quality Accounts 2014/15
Page 30 of 48
Ramsay Clinical Governance Framework 2014
The aim of clinical governance is to ensure that Ramsay develop ways of working
which assure that the quality of patient care is central to the business of the
organisation.
The emphasis is on providing an environment and culture to support continuous
clinical quality improvement so that patients receive safe and effective care,
clinicians are enabled to provide that care and the organisation can satisfy itself
that we are doing the right things in the right way.
It is important that Clinical Governance is integrated into other governance
systems in the organisation and should not be seen as a “stand-alone” activity. All
management systems, clinical, financial, estates etc. are inter-dependent with
actions in one area impacting on others.
Several models have been devised to include all the elements of Clinical
Governance to provide a framework for ensuring that it is embedded,
implemented and can be monitored in an organisation. In developing this
framework for Ramsay Health Care UK we have gone back to the original Scally
and Donaldson paper (1998) as we believe that it is a model that allows coverage
and inclusion of all the necessary strategies, policies, systems and processes for
effective Clinical Governance. The domains of this model are:
•
•
•
•
•
•
Infrastructure
Culture
Quality methods
Poor performance
Risk avoidance
Coherence
Quality Accounts 2014/15
Page 31 of 48
Ramsay Health Care Clinical Governance Framework
National Guidance
Ramsay also complies with the recommendations contained in technology
appraisals issued by the National Institute for Health and Clinical Excellence
(NICE) and Safety Alerts as issued by the NHS Commissioning Board Special
Health Authority.
Ramsay has systems in place for scrutinising all national clinical guidance and
selecting those that are applicable to our business and thereafter monitoring their
implementation.
Quality Accounts 2014/15
Page 32 of 48
3.1 The Core Quality Account indicators
Mortality:
Period
Jan13-Dec13
Apr13-Mar14
Best
RKE
RKE
0.62
0.54
Worst
RXL
1.18
RBT
1.20
Average
Eng
1
Eng
1
Period
2013/14
2014/15
Horton
NVC25
0
NVC25
0
Horton NHS Treatment Centre mortality data is better than average, this is in part
a reflection of the nature of surgery performed, which is planned elective surgery
rather than urgent care. Nevertheless an extremely robust pre-assessment
process is in place where we assess and involve patients individually to identify
the most appropriate anaesthetic to minimise risks.
PROMS:
Period
Hips Apr13 - Mar14
Apr14 - Sep14
Best
NT441
24.444
RCB
25.418
Worst
RQX
17.634
RJD
18.357
Average
Eng
21.34
Eng
21.922
Period
Apr13 - Mar14
Apr14 - Sep 14
Horton
NVC25
21.114
NVC25
*
PROMS:
Period
Knees Apr13 - Mar14
Apr14 - Sep14
Best
NT404
19.762
RWP
20.44
Worst
NV323
12.049
RXF
14.416
Average
Eng
16.248
Eng
16.702
Period
Apr13 - Mar14
Apr14 - Sep14
Horton
NVC25
15.95
NVC25
*
Horton NHS Treatment Centre participates fully in the PROMs hip and knee
questionnaire. Patients are asked to complete the questionnaire before surgery
and 6 months after surgery in order to measure health gain. Low volumes of
returns of the post-operative survey have prevented us from being able to
measure heath gain. .
Readmissions:
Period
2010/11
2011/12
Best
Multiple
0.0
Multiple
0.0
Worst
5P5
22.76
5NL
41.65
Average
Eng
11.43
Eng
11.45
Period
2010/11
2011/12
Horton
NVC25
4
NVC25
4.28
Horton NHS Treatment Centre data demonstrates an exceptionally low
readmission rate which reflects the excellent care delivered by the team...
Responsiveness:
to personal
needs
Period
2012/13
2013/14
Best
RPC
RPY
88.2
87.0
Worst
RJ6
68.0
RJ6
67.1
Average
Eng
76.5
Eng
76.9
Period
2013/14
2014/15
Horton
NVC25
92.9
NVC25
92.3
Horton NHS Treatment Centre achieved a significantly higher than average rating
from patients when they were asked if we were responsive to their needs. This is
achieved by engaging patients in their care plan at all stages, having adequate
staffing levels across all departments and delivering excellent care throughout.
VTE Assessment:
Period
14/15 Q2
14/15 Q3
Best
Several
100%
Several
100%
Worst
RNL
86.4%
NT322
85.1%
Average
Eng
96.2%
Eng
96.0%
Period
14/15 Q2
14/15 Q3
Horton
NVC25
99.5%
NVC25
99.4%
Horton NHS Treatment Centre has a robust patient assessment process with full
support from all clinicians thereby minimising the risk of VTE for patients.
Quality Accounts 2014/15
Page 33 of 48
C. Diff rate:
per 100,000
bed days
Period
2012/13
2013/14
Best
Several
Several
0
0
Worst
RVW
30.8
RMP
32.5
Average
Eng
17.4
Eng
14.7
Period
2013/14
2014/2015
Horton
NVC25
0.0
NVC25
0.0
Horton NHS Treatment Centre has a robust patient screening process prior to
admission and excellent infection control process. We are very proud to have
reported zero cases of C Difficile across this period..
Incident Rate:
Patient Safety
Period
2011/12
2012/13
Best
RP6
2.6
RRF
2.0
Worst
TAJ
84.4
RAT
85.6
Average
Eng
13.5
Eng
14.8
Period
2012/13
2013/14
Horton
NVC25
5.65
NVC25
4.67
Horton NHS Treatment Centre senior management team investigate all incidents.
When lessons are learned from these events they are shared with staff across the
Centre so that we can prevent the same type of incidents happening again.
SUIs:
Period
Best
(Severity 1 only) Oct 13 - Mar 14
RBD
Apr - Sep 14 Several
0
0
Worst
R1F
3.72
RBZ
1.09
Average
Eng
0.43
Eng
0.17
Period
Oct13-Mar14
Apr-Sep14
Horton
NVC25
1.75
NVC25
0.00
Horton NHS Treatment Centre data shows a reduction in SUI (serious untoward
incident) for the period as a result of improving systems and processes within the
Treatment Centre.
F&F Test:
Period
Jan-15
Feb-15
Best
Several
100%
Several
100%
Worst
RPA02
51.2%
RHU10
75%
Average
Eng
94.0%
Eng
94.7%
Period
Jan-15
Feb-15
Horton
NVC25
100.0%
NVC25
99.1%
Horton NHS Treatment Centre is extremely proud to have achieved a consistently high
response rate and recommend rate on the Friends and Family Test. This reflects the
excellent quality of care provided by the staff.
3.2 Patient safety
We are a progressive hospital and focused 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.
Quality Accounts 2014/15
Page 34 of 48
Significant Clinical Events per 1000 Admissions
The Horton NHS Treatment Centre has seen a rise in the number of incidents in
this reporting period. We believe that this increase has been influenced by the
implementation of a more robust process or reporting. Staff members have been
trained to report not only incidents but also near misses. For example, a change
to administration processes was implemented in 2014. To allow us to monitor and
review the success or failure of the implemented changes the staff were
requested to ensure any administrative issues were recorded on our risk
management system (Riskman); this has contributed to the overall increase of
incidents recorded.
We have had three serious incidents across this reporting period.
The first incident concerned a patient who underwent a hand procedure which
unfortunately resulted in harm to the patient’s finger. The patient underwent an
operation to correct a contracture of a finger and developed a recognised but rare
complication which resulted in further surgery and the removal of part of the
finger. Following a full and thorough investigation it was deemed that the effects
of the complication may have been reduced if the patient was transferred to a
plastic surgeon earlier in their pathway.
This error in judgement was shared across the company and with our
commissioners Oxfordshire Clinical Commissioning Group. We implemented an
action plan and are confident that lessons have been learned from this incident
and that our transfer processes are more robust as a result.
Quality Accounts 2014/15
Page 35 of 48
Two patients had incidents similar in nature to each other in that during the
procedures a wire used to guide the placement of screws into the joints broke off.
On each occasion the Surgeons were aware of the broken wire and attempted to
remove it however it was judged that more damage would be caused by further
attempts and the decision was made to leave the wires in place.
The first patient later had the wire removed as it was accessible and following a
short procedure the wire was retrieved. The second patient remains stable with
no adverse effects from the wire. Both patients are now fully recovered.
Patients and Commissioners can have confidence in the management of our
safety systems within Treatment Centre.
Readmission per 1000 Admissions
The Horton NHS Treatment Centre recorded an overall increase in readmissions
within the reporting period. Monitoring rates of readmission to the Treatment
Centre is another valuable measure of clinical effectiveness. We have further
analysed all the readmissions to unearth any trends that may need addressing.
Quality Accounts 2014/15
Page 36 of 48
The summary below shows the trend and reasons for 2014.
Record summary;
14 readmissions for the following reasons:
Pain management
Infection
Dislocation
Bleeding/pain
Urine retention
=4
= 6 ( 2 of which were cellulitis)
=2
=1
=1
The 14 incidents were spread across 7 different Consultant Surgeons.
(8 surgeons perform 95% of the orthopaedic procedures).
Record actions taken to remedy any trends identified;
In early 2014 we changed the process for pain advice on discharge from the
Registered Medical Officer (RMO) to the discharging Registered Nurse. This
initially had an improved effect; however the Ward Manager is further reviewing
the discharge process with each individual Registered Nurse and the advice
given with regard to post discharge analgesia. We have also made improvements
to our medicines advice leaflet to support patients in the correct administration
after they have been discharged home.
The Physiotherapist team are also providing additional training to the Registered
Nurses and all Health Care Assistants (HCAs) about managing patient’s mobility
and rehabilitation at ward level.
There was no apparent trend for the infections; one patient had an existing history
of cellulitis and this was infected from scratching. The other was acquired after
surgery so this is considered a ‘hospital acquired infection’ even though the
patient had gone home.
Two of the infections appeared to be caused by a stitch issue, one an internal
stitch which protruded through the skin which the nurse/RMO dealt with at ward
level.
The other was a coiled and knotted stitch causing a sinus to form. Both of these
patients had different surgeons.
The remaining infections were of different bacteria so no trend identified.
Quality Accounts 2014/15
Page 37 of 48
3.2.1 Infection prevention and control
Horton NHS Treatment Centre has a very low rate of hospital acquired infection
and has had no reported MRSA Bacteraemia in the past 4 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 the Treatment
Centre with regular audits taking place. 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



Local bi-monthly infection control meetings with links to Oxford University
Hospitals NHS Trust
Lead Consultant involved in infection control providing link with Consultant
colleagues
Monthly report on all aspects of infection control to Heads of Departments.
Quality Accounts 2014/15
Page 38 of 48
Horton NHS Treatment Centre rate of infection
The graph shows a decrease in the number of patient infections. Within the
Treatment Centre a local committee meet bi-monthly to review the quality of the
infection prevention and control. This is a proactive group with representation
from all departments to ensure that each part of the patient’s pathway is
safeguarded against the risks of infections. Hand washing is high on the agenda
for example; we have increased the visibility in hand washing so that patients are
aware that this is an important aspect of care and infection prevention.
3.2.2 Cleanliness and hospital hygiene
Assessments of safe healthcare environments also include Patient-Led
Assessments of the Care Environment (PLACE)
PLACE assessments occur annually at Horton NHS Treatment Centre,
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 improvements can be made.
The main purpose of a PLACE assessment is to improve standards from a
patient perspective. The audit team is made up of 50% of people who have
used our services as patients and 50% staff members.
This year’s assessment was carried out in May 2015 the results of which will not
be published until August 2015.
Last year’s audit results are included here.
Quality Accounts 2014/15
Page 39 of 48
3.2.3 Safety in the workplace.
Safety hazards in hospitals are diverse ranging from the risk of slip, trip or fall to
incidents around sharps and needles. As a result, ensuring our staff have high
awareness of safety has been the basis for our overall risk management
programme and this awareness then naturally extends to safeguarding patient
safety. Effective and ongoing communication of key safety messages is important
in healthcare an example of which appears in the grid below.
The MHRA (Medicines & Healthcare Products Regulatory Agency) website
provides hospitals with multiple updates relating to drugs and equipment every
month and these are sent 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.
Corporate colleagues review all safety issues that occur within the Treatment
Centre
Each department maintains a register of risks which are reviewed yearly or more
often if incidents occur, for example, as a result of an alert we have risk-assessed
the likelihood of a child coming to harm by the window blinds pull cords. Although
it was of low risk within the Treatment Centre as we do not have under 16 year
old patients, we have ensured that each cord is secured to the wall to prevent
mishaps.
Quality Accounts 2014/15
Page 40 of 48
3.3 Clinical effectiveness
Horton NHS Treatment Centre has a Clinical Governance team and committee
that meet regularly throughout the year to monitor quality and effectiveness of
care. Clinical incidents, patients and staff feedback are systematically reviewed to
determine any trend that requires further analysis or investigation. More
importantly, recommendations for action and improvement are presented to
hospital management and medical advisory committees to ensure results are
visible and tied into actions required by the organisation as a whole.
3.3.1 Returns to theatre.
Ramsay is treating significantly higher volumes of patients every year as our
reputation and services grow. The majority of our patients undergo planned
surgical procedures and so monitoring numbers of patients that require a return to
theatre for supplementary treatment is an important measure. Every surgical
intervention carries a risk of complications which may warrant a return to theatre.
The value of the measurement is to detect trends that emerge in relation to a
specific operation or specific surgical team. The Horton Treatment Centre has
had 4 incidents in the last 12 months; however the rate of return remains low and
consistent with our track record of successful clinical outcomes.
Quality Accounts 2014/15
Page 41 of 48
3.4 Patient experience
Formal Complaints per 1000 HPD's
In 2014/15 The Horton NHS Treatment Centre was pleased to see a significant
drop in the number of complaints in this period. The aim last year was to reduce
the number of complaints and it is encouraging to see this decline. We have
managed to address all complaints at unit level and have had no complaints
escalate to the next level. Whilst encouraged by this improvement, we are not
complacent and staff are fully committed to reducing this still further.
We are guided by the following regulations:
Regulation 19, Health and Social Care Act 2008:
“The registered person must have an effective system in place for
identifying, receiving, handling and responding to complaints and
comments made by service users or persons acting on their behalf in
relation to the carrying on of the regulated activity”
“Information from complaints is used to identify non-compliance or any
risk of non-compliance with the regulations and to decide what will be
Quality Accounts 2014/15
Page 42 of 48
done to return to compliance”
• The Independent Healthcare Advisory Service (IHAS) Code of Practice on
Handling Patients’ Complaints (2009)
•
The NHS complaints procedure (2009).
3.4 .1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently
of the hospital so we receive a true reflection of our patient’s views. Please see
the graph below.
Every patient is asked their consent to receive an electronic survey or phone call
following their discharge from the hospital. The results from the questions asked
are used to influence the way the hospital seeks to improve its services. Any text
comments made by patients on their survey are sent as ‘hot alerts’ to the Hospital
Manager within 48hrs of receiving them so that a response can be made to the
patient as soon as possible.
A large part of our feedback comes from the Friends and Family Test. This
measure was introduced by the Government to ask patients whether or not they
would recommend the hospital they had attended for treatment.
This has been a tremendous success not only in terms of the exceptionally high
recommendation (please see Table) but also in the consistently high response
rate 80% and above. We share the wonderful comments that patients post on
their anonymous forms with the staff and intend in the future to also share these
with the public. It is such excellent patient recommendation scores that allow the
team at Horton NHS Treatment Centre to be confident in the delivery of services
to the public.
F&F Test:
Period
Jan-15
Feb-15
Best
Several
100%
Several
100%
Worst
RPA02
51.2%
RHU10
75%
Average
Eng
94.0%
Eng
94.7%
Period
Jan-15
Feb-15
Horton
NVC25
100.0%
NVC25
99.1%
Quality Accounts 2014/15
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Patient Satisfaction Score
Although we have experienced a very small decrease in this year’s patient
satisfaction score, the high level of satisfaction remains extremely high and is a
reflection of the excellent care provided. It remains heartening to be able to
evidence that the hard work and commitment shown by the team at Horton NHS
Treatment Centre results in the vast majority of patients being satisfied with the
care and attention they receive.
This survey covers all elements of the patient experience, for example the food
service, waiting times and admission procedures, of which we are very proud. In
addition to parking arrangements which unfortunately does not fall within our
remit.
Patient experiences are fed back in a variety of ways and are a regular agenda
item on Clinical Governance Committtees for discussion, trend analysis and
further action where necessary. Escalation and further reporting to Ramsay
Corporate, Commissioners and Department of Health bodies occurs as required
and according to Ramsay and DOH policy.
Feedback regarding patient experience is encouraged via:






Patient satisfaction surveys
‘We value your opinion’ leaflet
Patient complaints leaflet
Verbal feedback to Ramsay staff – (including Consultants, Matrons/General
Managers whilst visiting patients)
Provider/CQC visit feedback
Written feedback via letters/emails
Quality Accounts 2014/15
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GPs also have the mechanism to feed back to the Treatment Centre either
directly or via the Quality Team at the CCG.
All feedback from patients regarding their experiences with Horton NHS
Treatment Centre is welcomed and informs service development in various ways,
dependent on the type of experience (both positive and negative) and action
required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – anomymised letters and cards are displayed for staff to see in staff
rooms and notice boards.
The risk management system Riskman has the capacity to record feedback so
that individual Surgeons have access to a report relevant to their practice.
Managers ensure that positive feedback from patients is recognised and any
individuals mentioned are praised accordingly.
All negative feedback or suggestions for improvement are investigated to see if
there are lessons learned so that we can prevent a similar experience to any
other patient. All staff are aware of our complaints procedures should our patients
be unhappy with any aspect of their care and complaints advice leaflets are
available throughout the hospital.
Respect and Dignity scores from the patient satisfaction survey
This aspect of care is very important to the vast majority of patients. This graph
provides an indication that the majority of patients feel that the staff ensure their
dignity is respected. We place a great emphasis on this aspect of care as it sets
the foundation for many of the other aspects of care delivery.
Quality Accounts 2014/15
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Appendix 1
Services covered by this quality account
injury
Cosmetics
Services Provided
Cosmetics, Physiotherapy, Trauma clinics, Orthopaedic,
General surgery, Spinal surgery and Maxillofacial
Peoples Needs Met for:
Young persons 16 to 18yrs
All adults 18 yrs and over
surgery. Audiology, Allergy testing , Dermatology
Clinical Psychology , Pain management ,Choose
and Book ‘Outreach’ Orthopaedic Outpatient
Service
Surgical
Procedures
Orthopaedic, Cosmetic, General surgery, Spinal
surgery and Maxillofacial surgery, Urology,
Upper and Lower Gastrointestinal surgery.
Ambulatory, Day and Inpatient Surgery
Diagnostic
and
screening
MRI, Imaging services, Ultra sound Phlebotomy, Urinary
Screening and Specimen collection.
Young persons 16 to 18yrs and all adults
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

BMI > 40
Young persons 16 to 18yrs
All adults 18 yrs and over
Quality Accounts 2014/15
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Appendix 2 – Clinical Audit Programmee 2014/15. Each arrow links to the audit to be completed in each month.
Quality Accounts 2014/15
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Horton NHS Treatment Centre
Ramsay Health Care UK
We would welcome any comments on the format, content or
purpose of this Quality Account.
If you would like to comment or make any suggestions for the
content of future reports, please telephone or write to the
General Manager using the contact details below.
For further information please contact:
Treatment Centre phone number
01295 755000
Hospital website
WWW.hortontreatmentcentre.co.uk
www.ramsayhealth.co.uk
Quality Accounts 2014/15
Page 48 of 48