Mount Stuart Hospital
Quality Account
2014/2015
Contents
Introduction Page
Welcome to Ramsay Health Care UK
Introduction to our Quality Account
PART 1 – STATEMENT ON QUALITY
1.1
Statement from the General Manager
1.2
Hospital accountability statement
PART 2
2.1
Priorities for Improvement
2.1.1 Review of clinical priorities 2014/15 (looking back)
2.1.2 Clinical Priorities for 2015/16 (looking forward)
Mandatory statements relating to the quality of NHS services
provided
2.2.1 Review of Services
2.2
2.2.2 Participation in Clinical Audit
2.2.3 Participation in Research
2.2.4 Goals agreed with Commissioners
2.2.5 Statement from the Care Quality Commission
2.2.6 Statement on Data Quality
2.2.7 Stakeholders views on 2014/15 Quality Accounts
PART 3 – REVIEW OF QUALITY PERFORMANCE
3.1
The Core Quality Account indicators
3.2
Patient Safety
3.3
Clinical Effectiveness
3.4
Patient Experience
3.5
Case Study
Appendices
Appendix 1 – Services Covered by this Quality Account
Appendix 2 – Consultants and staff data
Appendix 3 – Clinical Audits
Welcome to Ramsay Health Care UK
Mount Stuart Hospital is part of the Ramsay Health Care Group
The Ramsay Health Care Group was established in 1964 and has grown to become a
global hospital group operating over 100 hospitals and day surgery facilities across
Australia, the United Kingdom, Indonesia and France. Within the UK, Ramsay Health
Care is one of the leading providers of independent hospital services in England, with a
network of 31 acute hospitals
We are also the largest private provider of surgical and diagnostics services to the NHS
in the UK. Through a variety of national and local contracts we deliver 1,000s of NHS
patient episodes of care each month working seamlessly with other healthcare providers
in the locality including GPs, Clinical Commissioning groups
The provision of high quality patient care is and will always be the highest priority of
Ramsay Health Care UK. Of course our team of clinical staff and consultants are very
much at the forefront of achieving this but there is also very much an organisation wide
commitment to ensure that we continue to improve out outcomes every day, week, month
and year.
Delivering clinical excellence depends on everyone in the organisation. Clinical
excellence cannot be the responsibility of just a few, it takes all of us to be responsible
and accountable for our performance in the various roles we all play. Having an
organisational culture that puts the patient at the centre of everything we do is key to
ensuring we enable everyone to perform at their peak to attain great outcomes.
Whilst I firmly I believe that across Ramsay we nurture the teamwork and professionalism
on which excellence in clinical practice depends, we will continue to strive to get ever
better.
I am very proud of our long standing and major provider of healthcare services across the
world and of our Ramsay very strong track record as a safe and responsible healthcare
provider. It gives us pleasure to share our results with you.
Mark Page
Chief Executive officer
Ramsay Health Care UK
Quality Account 2014/15
Page 3 of 36
Introduction to our Quality Account
This Quality Account is Mount Stuart Hospital’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 patient’s treatment outcomes are the best they can be. It will give a balanced
view of what we are good at and what we need to improve on.
Our first Quality Account in 2010 was developed by our Corporate Office and
summarised and reviewed quality activities across every hospital and treatment centre
within the Ramsay Health Care UK. It was recognised that this didn’t provide enough in
depth information for the public and commissioners about the quality of services within
each individual hospital and how this relates to the local community it serves. Therefore,
each site within the Ramsay Group now develops its own Quality Account, which
includes some Group wide initiatives, but also describes the many excellent local
achievements and quality plans that we would like to share.
Quality Account 2014/15
Page 4 of 36
Part 1
1.1 Statement on quality from the General Manager
Ramsay Health Care UK is committed to establishing an organisational culture that puts
the patient at the centre of everything we do. As the General Manager, I am passionate
about ensuring that high quality patient care is at the centre of what we do and how we
operate our hospital. This relies not only on excellent medical and clinical leadership but
also on our overall continuing commitment to drive year on year improvement in clinical
outcomes.
Mount Stuart Hospital has a tradition of working closely with Consultants and patients to
ensure the best quality healthcare is consistently being delivered. Hospital staff are fully
trained in the latest procedures and thus maintain all areas to the highest standards.
Working within the Department of Health guidelines we focus on patient safety and
cleanliness to minimise infection. Any patient who wants to satisfy themselves on the
quality of the hospital and its’ Consultants can be reassured by the Care Quality
Commission (CQC) Audits undertaken by the Department of Health which support the
hospital’s excellent reputation. As General Manager of Mount Stuart Hospital, I take great
pride in the service we offer our patients and relatives; this is only achieved through a
cohesive team effort and approach.
We at Mount Stuart Hospital have five key values which underpin everything we do as an
organisation. They are:
• Put the patient first;
• Work as one team;
• Respect each other;
• Strive for continual improvement;
• Respect environmental sustainability.
The experience that patients have in our hospital continues to be of the utmost
importance. As well as being treated quickly and safely, they continue to receive a
personalised service, enhanced by good communication and a commitment to ensuring
their privacy and dignity are respected at all times.
We have continued the progress made during 2013/14 driven by strong performance
across all areas of our business. Our results reflect the benefit of increased activity
through our facility, an ongoing focus on delivering a high quality service and effective
cost management. During the year our staff continued to successfully focus on
improving patient satisfaction and performance across a broad range of key performance
and clinical indicators.
Quality Account 2014/15
Page 5 of 36
The success of relationships built with the local NHS and Commissioners has proved
dividend as Choose & Book continues to grow. Mount Stuart Hospital aims to lead the
way in holistic day case care through innovation; evidence based clinical practice and
exemplary customer service. By continually updating skills and developing knowledge
we believe that staff develop a committed focus in building relationships to achieve
positive outcomes for all customers. We aim to grow our business by attaining and
maintaining excellent clinical outcomes, minimising risks, sustaining high levels of
profitability and by providing a basis for stakeholder’s loyalty. Quality indicators and
customer satisfaction levels have been maintained at consistently high levels.
Consultant engagement meetings have stimulated opportunities to grow the business by
increasing the range of services and explore new innovating methods of practice.
A continued focus will be on further improving operating efficiencies by monitoring KPI’s,
introducing further energy saving devices, multi-skilling, designing new processes to
capture revenue at the time of activity and pathways that screen and identify risk at an
earlier stage.
In addition, it shows how our values, combined with our priorities, are improving the way
in which we treat our patients. For example, we continue to have a very low infection rate
within our unit and submissions to Surgical Site Surveillance Service continues. Our
surgical site infection rates continue to be significantly lower than the national average.
The aim of our Quality Account is to provide current information to our patients and
commissioners to assure them we are committed in sharing our progressive
achievements year on year. As a long standing, major provider for healthcare services
across the world, Ramsay continues to have a very strong record in providing safe and
responsible healthcare of which we are proud to share our results. Our continued
emphasis is to ensure patients receive safe and effective care, that they feel valued and
respected in decisions about their care ensuring they are fully informed about their
treatment at each step of their pathway. We especially value patient’s feedback about
their stay, treatment and clinical outcome.
We believe it is vital that we live by The Ramsay Way values, having it guide the
decisions we make, through the services we deliver and through our interactions with all
our stakeholders. We remain positive about opportunities to capture further growth.
All professional and management teams at local level have been represented in
producing this account.
Quality Account 2014/15
Page 6 of 36
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.
Jeanette Mercer
General Manager
Mount Stuart Hospital
Ramsay Health Care UK
This report has been reviewed and approved by:
Mr Raj Ranjit, Consultant Gynaecologist,
Chair of the Medical Advisory Committee & Clinical Governance Committee
Mr Stefan Andrejczuk,
Regional Director South, Ramsay Healthcare UK
Comments invited from:
NHS South Devon and Torbay Clinical Commissioning Group
Gill Gant - Director of Quality Assurance and Improvement
Healthwatch Devon
Healthwatch Torbay
Quality Account 2014/15
Page 7 of 36
Welcome to Mount Stuart Hospital
Mount Stuart Hospital is one of the South Devon’s leading independent hospitals. The
facility has 31 individual rooms each with ensuite facilities and by investing in advanced
medical technology offers a wide range of treatments and services. Where clinical need
requires it, our team of well trained, competent and experienced staff provide 1:1 care.
All consultants undergo rigorous vetting procedures, ensuring only those who are
appropriately qualified and experienced are granted practicing privileges which are
reviewed on a regular basis. The hospital is strictly regulated and audited by the Care
Quality Commission, the governing body responsible for maintaining standards in
healthcare.
Onsite there are two fully equipped laminar flow theatres and a Minor Surgery/Endoscopy
Unit. We also have a Cosmetics Suite, a Radiology Department and a physiotherapy
department for both inpatient and outpatient services.
We pride ourselves on the delivery of high quality, safe, effective care in a manner and
environment that respects and protects the privacy and dignity of our patients be they
medically insured, self-funding or referred by the NHS. Our facilities and clinical and
support services are continually monitored to ensure that we are offering the very best
service to our patients. The hospital is strictly regulated and audited by the Care Quality
Commission, the governing body responsible for maintaining standards in healthcare.
The specialties for which services are provided at Mount Stuart Hospital include:
Bariatric, Dermatology, ENT, Gastroenterology, General Medicine, General Surgery,
Gynaecology, Haematology, Nephrology, Neurology, Ophthalmology, Oral and Maxillofacial, Orthopaedics, Pain Management, Physiotherapy, Plastic Surgery, Radiology
(including MRI Dexa and CT), Rheumatology, Urology, Health Screening, Step-Down
Convalescence and Respite Care. We are also able to offer our patients outreach clinics
in Totnes and Newton Abbot.
Direct referral services available include:
Mole Clinic
Laser Eye Surgery
Nurse Led Aesthetics
Cosmetic Surgery
Well-women (cervical smear)
Well-man
Allergy Clinic
Physiotherapy
Bariatric
Quality Account 2014/15
Page 8 of 36
Community Involvement
Mount Stuart Hospital holds regular open events which offer the general public an
opportunity to come to the Hospital meet the Consultants and privately discuss their
specific area of interest.
Mrs Carla Forbes is our GP Liaison Manager. Carla has close contact with both Practice
Managers and GPs at our priority (local) practices and ongoing contact with surgeries
located in the surrounding areas. Carla organises regular ‘Lunch & Learns’, taking
consultants into GP Surgeries to offer training and latest development awareness as well
as running evening GP training seminars on a regular basis. We also have a GP
representative, Dr Dylan Watkins, on the hospital’s MAC. We value our contact with GP’s
as “Customers” and strive to ensure we actively work in partnership to enhance patient
care.
Event examples:
24th September 2014 - Diabetes Overload: 24 attendees
26th November 2014 - Orthopaedics/Joint Injection: 32 attendees
28th January 2015
- Winter Educational: 27 attendees
4th March 2015
- Women's Health: 63 attendees
Quality Account 2014/15
Page 9 of 36
Part 2
2.1 Quality priorities for 2015/16
On an annual cycle, Mount Stuart Hospital develops an operational plan to set objectives
for the year ahead.
We have a clear commitment to our private patients as well as working in partnership
with the NHS ensuring that those services commissioned to us, result in safe, quality
treatment for all NHS patients whilst they are in our care. We constantly strive to improve
clinical safety and standards by a systematic process of governance including audit and
feedback from all those experiencing our services.
To meet these aims, we have various initiatives on going at any one time. The priorities
are determined by the hospitals Senior Management Team taking into account patient
feedback, audit results, national guidance, and the recommendations from various
hospital committees which represent all professional and management levels.
Most importantly, we believe our priorities must drive patient safety, clinical effectiveness
and improve the experience of all people visiting our hospital.
2.1.1 A review of clinical priorities 2014/2015 (looking back)
In last year’s Quality Account we set out our priorities for the coming year. This section
reviews our achievement against those priorities.
Patient Safety
JAG Accreditation – We successfully implemented a robust action plan to meet
the requirements of JAG accreditation and to maintain accreditation.
We maintained our accreditation, assuring patients that the endoscopy services
they receive at Mount Stuart meet exacting National standards.
Falls –The causes of falls are complex and older people in hospital are particularly
likely to be vulnerable to falling due to medical conditions including delirium,
cardiac, neurological or muscular-skeletal conditions, side effects from medication,
or problems with their balance, strength or mobility. Problems like poor eyesight or
poor memory can create a greater risk of falls when someone is out of their normal
environment on a hospital ward, as they are less able to spot and avoid any
hazards; whilst continence problems can mean patients are vulnerable to falling
whilst making urgent journeys to the toilet. However, patient safety has to be
balanced with independence, rehabilitation, privacy, and dignity – a patient who is
Quality Account 2014/15
Page 10 of 36
not allowed to walk alone will very quickly become a patient who is unable to walk
alone. Addressing inpatient falls and fall-related injuries is therefore a challenge for
all health care organisations. We have reviewed the Patient Safety First guide
and national advice on ‘shattered lives’ to reduce falls and put actions in place to
ensure that falls are have been managed in line with best practice. Falls audits
are in place and results are reviewed through our Clinical Effectiveness Committee
and Risk Management Meetings. Whilst the number of falls remains at around the
same level as in the previous year, we have treated significantly more patients so
falls as a percentage of admitted patients is less than 0.12% and no patient
sustained harm as a result of falling.
WHO Surgical Safety Checklist – Compliance with the WHO Surgical Safety
Checklist was a key priority during this year. Results of our audits were reported to
our Clinical Commissioning Groups (CCGs) throughout 2014/2015 and in every
audit we achieved >95%
National Safety Thermometer – we submitted data on the prevalence of the four
required harms: pressure ulcers, falls, urinary tract infection in patients with
indwelling catheters and VTE basis centrally to the NHS Information Centre. The
number of ‘harms’ reported by us is very, very low.
NJR – We continued to submit to this national register of people who have had
joint replacement surgery which is invaluable when there are nationally identified
concerns requiring patients to be contacted. This year we submitted data for 99%
of appropriate patients. A key performance benchmark in relation to NJR is 95% of
forms to have signed patient consent, this year Mount Stuart Hospital achieved
100%.
Never events - In line with Ramsay Reporting Policy, all Never Events are
reported through RISKMAN and to relevant third parties. Sadly this year there
were a number of Never events according to the Ramsay definition. They all
pertained to one cataract list where there was an error in the drug calculation. A
comprehensive investigation was carried out and shared with our commissioners
and the Care Quality Commission. Actions have been put in place to ensure no
such event should happen again. The learning has also been shared across
Ramsay Health Care UK to protect patients in all of the company’s UK hospitals
Real Time Incident Reporting – We have worked extremely hard to improve
incident reporting through RiskMan by ensuring that this is used as a real time
indicator for incident reporting. This system is the central point for the recording of
all incidents and risks for the business. RiskMan has improved the quality of our
reporting for internal and external use. This system has ensured that we can
analyse the data in more depth, in real time so remedial action can be taken more
quickly; also trends are identified earlier. Both these have improved patient safety
and quality of the service provided.
We continue to use RiskMan and the time lapse between incident, reporting and
investigation continues to reduce. The analysis of incident data both locally and
Quality Account 2014/15
Page 11 of 36
corporately has led to changes in practice within not only Mount Stuart but other
Ramsay units too.
Safeguarding / PREVENT – We take very seriously our responsibility for the
safeguarding of vulnerable members in our society. We will continue to ensure
that all staff working within the hospital have the level of DBS check appropriate to
their role. We will continue to provide training; reviewing the content of such
training, and, ensure staff have the necessary resources available to manage any
concerns appropriately and in a timely manner. Matron is the designated
Safeguarding Lead for Mount Stuart Hospital and regularly attends Adult/Children
Safeguarding CCG meetings/forums.
Corporate e-learning packages have been reviewed during this year to ensure
they are compliant with the intercollegiate recommendations. Locally staff have
annual refresher training in local reporting processes and PREVENT. Matron has
been an active member of the Safeguarding Forum.
Clinical Training - Mount Stuart Hospital has continued to ensure that patients at
our hospital are cared for by safe and competent staff. This has been achieved by
our clinical staff being supported through training by internal/external training
providers and Ramsay Academy.
Appropriate staffing levels: We strove to ensure that appropriate numbers of
staff were available for the care of our patients. Rotas are prepared in advance
and dependency tools are used daily on the ward to ensure adequate staffing
levels are maintained with appropriate skill mix. We have the ability to flex our
staffing levels up when required by using our own trained bank staff. In 2013
Ramsay invested in a new electronic Rostering tool called Allocate – this will
reduce the time spent on producing numerous rotas throughout the hospital and
will be accessible to all staff. The tool can be set to correlate rotas which reflect
the skill mix requirements and staffing levels specific to patient numbers.
Clinical Effectiveness
We take our responsibilities as a healthcare provider very seriously, putting staff wellbeing, patient safety and patient care at the forefront of all we do. Our business is about
optimising the outcomes for patients, which involves creating a framework for excellence
and systems that deliver the best possible clinical results. We are continually striving for,
and achieving, improvements in our clinical performance.
Our ability to deliver high-quality clinical care is due to the willingness of clinical teams to
work collaboratively with consultants and the Medical Advisory Committee to enable
modern and safe practice to flourish. We set great store on the availability of relevant,
accurate and timely management information to help us monitor, analyse and, most
importantly, act upon insights that drive up our standards of care.
Mount Stuart Hospital’s frontline staff provide hands-on care with dignity and
compassion, as well as being clinically effective. Our established and strong systems for
clinical governance support our teams with the information they need to help keep
patients safe, to make them better again and to provide great care.
Quality Account 2014/15
Page 12 of 36
Our results demonstrate that not only has Mount Stuart Hospital has achieved
considerable gains on last year, but it has also been able to sustain the hard-won
improvements from previous years. This marks Mount Stuart Hospital as a sophisticated
organisation with the maturity to learn when things do not go to plan, and to take prompt
action to effect lasting change for the better.
Patient experience
Patient reported outcome studies (PROMS) – we continued to participate in the
national PROMS data collection for Hips, Knees, Varicose Veins and Hernia
surgery. The results, which are encouraging for Mount Stuart Hospital, were
shared with the medical and clinical staff through the Medical Advisory
Committee, Clinical Governance Committee, and Head of Department and
Departmental meetings. Reviewing this data also provides the opportunity to
identify poor outcomes and examine practice if and when it exists. Data appears
later in this Account.
Patient satisfaction survey – Mount Stuart Hospital has always achieved a high
level of patient satisfaction even during recent building work. We will strive to
maintain this during the major capital development now underway.
2.1.2 Clinical Priorities for 2015/16 (looking forward)
For 2015/16 Mount Stuart will strive to continue delivering a safe, high quality experience
for all patients building on the priorities we achieved this year. In particular we will focus
on:
Service and facility development – we have just embarked on a major capital
programme to increase our clinical space by the addition of a third theatre, additional
patient rooms and a purpose built Ambulatory Care Unit for people having clinical
procedures that are beyond the scope of the outpatient department but do not require
overnight stay. Our priority will be that they are appropriately staffed and equipped to
provide safe, high quality services that meet the needs of our population.
Patient Safety
Surgical safety through use of the WHO checklist and other safe surgery processes
JAG Accreditation – We will maintain our accreditation, assuring patients that the
endoscopy services they receive at Mount Stuart meet exacting National standards.
Reduction of falls – We will maintain the low numbers of falls and seek to reduce
them even further during 2015/2016.
Nutrition and hydration – an important aspect of recovery is appropriate and
adequate nutrition and hydration but often patients don’t feel like eating and drinking
after surgery or if they are poorly. We will further improve our methods of
assessment/monitoring and our response where there are difficulties.
Quality Account 2014/15
Page 13 of 36
Safe staffing – our e-rostering system, Allocate, is now fully implemented across the
unit giving transparency of rostering to ensure safe staffing levels; we work in
accordance with the Royal College of Nursing and NICE Guidance of Safe Staffing,
as well as fairness whilst reducing time spent creating the rotas.
During the coming year we will seek to recruit staff of all grades and disciplines to
maintain safe staffing levels in our expanded facilities, whilst also exploring new roles
and ways of working to allow staff to maximise time spent on patient care.
Patient Experience
We will continue to work hard to ensure that all those who use our services have a
positive experience. This forms part of our quality targets (CQUINs) with the Clinical
Commissioning Group, and will be more challenging this year as we undertake our
capital development which is bound to bring with it some disruption.
Clinical Effectiveness
Begin implementation of a 3-day stay pathway for patients undergoing total hip
replacement and implement a 3-day pathway for patients undergoing total hip
replacement where this is appropriate.
Improve access to a wider range of weight loss procedures for private patients.
Continue our focus on reducing avoidable re-admissions within 30 days of surgery
Progress against all of these priorities will be monitored by the Senior Management
Team and reported to our local Clinical Governance Committee. Those that are
targets agreed with Clinical Commissioning Group will also be reported in our
regular quality reports to them.
2.2 Mandatory Statements
The following section contains the mandatory statements common to all Quality Accounts
as required by the regulations set out by the Department of Health.
2.2.1 Review of Services
During 2014/15 Mount Stuart Hospital provided and/or subcontracted 23 NHS services.
Mount Stuart Hospital has reviewed all the data available to them on the quality of care in
23 of these NHS services.
Total Number of patient admissions in the past year was 5059 (previous year 4613) of
which 4189 (3783) were NHS patients, just over 82% which is consistent with 2013/14.
The income generated by the NHS services between 1 April 2014 to 31st March 15
represents 64.2% per cent of the total income generated from the provision of services
by Mount Stuart Hospital in the same year.
Quality Account 2014/15
Page 14 of 36
Ramsay uses a balanced scorecard approach to give an overview of audit results across
the critical areas of patient care. The indicators on the Ramsay scorecard are reviewed
each year. The scorecard is reviewed each quarter by the hospitals senior managers
together with Regional and Corporate Senior Managers and Directors. The balanced
scorecard approach has been an extremely successful tool in helping us benchmark
against other hospitals and identifying key areas for improvement.
In the period for 2014/15, the indicators on the scorecard which affect patient safety and
quality were:
Human Resources
Staff Cost as % Net Revenue
HCA Hours as % of Total Nursing
Agency Cost as % of Total Clinical Staff Cost
Ward Hours PPD
% Staff Voluntary Turnover rolling 12 months
% Sickness rolling 12 months
% Lost Time
Appraisal %
Staff likely to recommend hospital if family or friends
needed treatment
Number of Significant Staff Injuries
Patient
Formal Complaints per 1000 HPD's
Patient Satisfaction Score
Clinical Events per 1000 Admissions
Readmission per 1000 Admissions
Quality
Workplace Health & Safety Score
Infection Control Audit Score
27%
35%
0%
4.3
13.4%
3.47%
16%
88%
93%
0
0.28
95.7%
65
9
98%
96%
2.2.2 Participation in clinical audit
During 1 April 2014 to 31st March 2015 Mount Stuart Hospital participated in 100%
national clinical audits in which it was eligible to participate in.
The national clinical audits that Mount Stuart Hospital participated in, and for which data
collection was completed during 1 April 2013 to 31st March 2014, are listed below
alongside the number of cases submitted to each audit as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
Name of audit / Clinical Outcome
Review Programme
National Joint Registry (NJR)
% cases
submitted
99
Quality Account 2014/15
Page 15 of 36
The reports of two national clinical audits from 1 April 2014 to 31st March 11 2015 were
reviewed by the Clinical Governance Committee and Mount Stuart Hospital intends to
take the following actions to improve the quality of healthcare provided.
Improve our systems for submitting data to the NJR
Strengthen our systems to ensure all pre-operative PROMS forms are collected /
submitted, and that patients understand the importance of submitting their postoperative PROMS questionnaire.
Local Audits
The reports of 70 local clinical audits from 1 April 2014 to 31st March 2015 were reviewed
by the Clinical Governance Committee and Mount Stuart Hospital intends to take the
following actions to improve the quality of healthcare provided.
Further improve our standards of documentation which will have a positive impact
on other audits
Review stock holdings and storage to assist with keeping the environment clean
and safe
Undertake monthly audits of WHO checklist compliance which is a major
contributor to patients surgical safety
The clinical audit schedule can be found in Appendix 2.
2.2.3 Participation in Research
There were no patients recruited during 2014/15 to participate in research approved by a
research ethics committee.
2.2.4 Goals agreed with our Commissioners using the CQUIN
(Commissioning for Quality and Innovation) Framework
A proportion of Mount Stuart Hospital’s income in from 1 April 2014 to 31st March 2015
was conditional on achieving quality improvement and innovation goals agreed Mount
Stuart Hospital 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. We are pleased to report that we achieved
100% in all CQUIN goals set for the year.
2.2.5 Statements from the Care Quality Commission (CQC)
Mount Stuart Hospital is required to register with the Care Quality Commission and its
current registration status on 31st March2015 is registered without conditions
Mount Stuart Hospital has not participated in any special reviews by the CQC
during the reporting period. However, following the reporting of the serious
Quality Account 2014/15
Page 16 of 36
incidents on the cataract list, the CQC conducted an independent investigation.
This took place on the 24th September; all standards inspected were met and the
CQC did not require any additional actions to be taken.
2.2.6 Data Quality
We regularly use statistical data to monitor clinical services – we are constantly
striving to improve this data by regular quality control initiatives.
Data contained in medical records are audited on a monthly basis and actions are
taken to improve quality as required. This applies to both private and NHS patient
streams.
The hospital has a data quality super user who manages the SUS pathway
processes and continually reviews administration functions to ensure data quality.
NHS Number and General Medical Practice Code Validity
Mount Stuart Hospital submitted records during 2013/14 to the Secondary Uses Service
(SUS) for inclusion in the Hospital Episode Statistics (HES) which are included in the
latest published data. The percentage of records in the published data which included:
The patient’s valid NHS number:
99.97% for admitted patient care;
99.96% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
The General Medical Practice Code:
100% for admitted patient care;
100% for outpatient care; and
0% for accident and emergency care (not undertaken at our hospital).
Information Governance Toolkit attainment levels
Ramsay Group Information Governance Assessment Report overall score for 2014/15
was 83% and was graded ‘green’ (satisfactory).
Clinical coding error rate
Mount Stuart Hospital was not subject to the Payment by Results clinical coding audit
during 2014/15 by the Audit Commission.
Quality Account 2014/15
Page 17 of 36
2.2.7 Stakeholders views on 2013/14 Quality Account
Comments on Mount Stuart Hospital’s Quality Account were sought from the South
Devon and Torbay Clinical Commissioning Group (SDT CCG). Health Watch Devon,
Health Watch Torbay and Devon Wellbeing and Health Scrutiny committee
South Devon and Torbay Clinical Commissioning Group
NHS South Devon and Torbay CCG (SDT CCG) commissions services from Mount
Stuart Hospital and welcomes the opportunity to provide a commentary on this Quality
Account. We can confirm that we have no reason to believe that this Quality Account is
not an accurate representation of the achievements of the organisation during 2014/15.
General comments
Quality Accounts are intended to help the general public understand how their local
health services are performing and should be written in plain English. Mount Stuart
Hospital have produced a comprehensive, attractive and well written Quality Account
which is easy to read and clearly set out. The aims and objectives of this account are in
line with national standards and drivers. There are routine processes in place with Mount
Stuart to agree, monitor and review the quality of services throughout the year covering
the key quality domains of safety, effectiveness and experience of care. We have
reviewed and can confirm that the information presented in the Quality Account appears
to be accurate and fairly interpreted, from the data collected. The Quality Account
demonstrates a high level of commitment to quality in the broadest sense and is
commended.
Key Values
We support and commend the five key values outlined in the Quality Account. In
particular we congratulate Mount Stuart Hospital for their work building relationships with
local NHS services via the Choose and Book system and contributing to strong patientcentred pathways of care.
Quality Improvement priorities for 2015/16
We note and commend Mount Stuart Hospital for working in collaboration with its
partners and key stakeholders to inform the planning of priorities for the year ahead. We
are pleased to see that the Mount Stuart Hospital’s priorities are centred around patient
safety, patient experience and clinical effectiveness. In particular we are keen to see the
progress of the service and facility development which will produce additional patient
rooms and an ambulatory care unit. This will allow for safe, high quality care to be
undertaken without unnecessary overnight stays, broadening the scope of activity at
Mount Stuart Hospital and ensuring the needs of the population are further met.
Four local incentive schemes under Commissioning for Quality and Innovations
(CQUINs) have been agreed with Mount Stuart Hospital this year. These CQUINs will
Quality Account 2014/15
Page 18 of 36
differ from those agreed in previous years. They are multi-agency, co designed CQUINs.
They are patient, and staff focused, intended to improve experience, improve
collaborative working across all of our providers, share expertise and knowledge and
underpin the essence of joined up care. We are delighted that Mount Stuart have agreed
to take part in this innovative way of working, and that they have been instrumental in
developing and agreeing these quality improvements.
Achievements in 2014/15
Last year Mount Stuart Hospital set out its aims for improving quality and we are pleased
to note the progress the organisation has made. Mount Stuart Hospital has achieved JAG
accreditation which demonstrates continuous improvement in patient processes and
outcomes whilst exacting national standards. Mount Stuart Hospital fall rate has
remained the same as previous year despite an increase in activity and patients, the
percentage of admitted patients who fall is 0.12% with no harm caused by any fall last
year. A further success relates to data collection for the National Joint Replacement
register where Mount Stuart Hospital submitted 100% compliance in patient consent
recording.
Overall we are happy to commend this Quality Account and Mount Stuart Hospital for its
continuing focus on quality of care, patient safety and an improved patient experience.
Healthwatch Torbay
Healthwatch Torbay's role is to give local people a stronger voice to influence and
challenge how their health and social care services are provided. Our various ways of
encouraging the public to share their experience is building up a body of knowledge
which forms the basis of our comment on this Quality Account.
It was a pleasure to read a Quality Account that was clearly written to be understood by
the lay public. The themes of openness and transparency mirrored the comments made
by the Care Quality Commission. It was reassuring to see that any incidents where
patient safety might be compromised are quickly followed through with increased staff
training.
100% response for the Friends and Family Test is something to be proud of as is the
involvement of patients in the assessment of the environment (PLACE). The account
could have been more informative on how privacy, dignity and wellbeing scores will be
improved, as 8 out of 10 for this score is the national average and as rightly stated, the
other scores are above average. We would also like to have read examples of how
patients and the public are directly involved in service design.
Healthwatch Torbay has received no comments from the public about Mount Stuart
Hospital which indicates that the Quality Account is a fair reflection of the services and
care provided.
No comments was received from Healthwatch Devon
Quality Account 2014/15
Page 19 of 36
Part 3: Review of quality performance 2014/2015
Statements of quality delivery
Review of quality performance 1st April 2014 – 31st March 2015
Introduction
“This publication marks the sixth successive year since the first edition of Ramsay Quality
Accounts. Through each year, month on month, we analyse our performance on many
levels, we reflect on the valuable feedback we receive from our patients about the
outcomes of their treatment and also reflect on professional opinion received from our
doctors, our clinical staff, regulators and commissioners. We listen where concerns or
suggestions have been raised and, in this account, we have set out our track record as
well as our plan for more improvements in the coming year. This is a discipline we
vigorously support, always driving this cycle of continuous improvement in our hospitals
and addressing public concern about standards in healthcare, be these about our
commitments to providing compassionate patient care, assurance about patient privacy
and dignity, hospital safety and good outcomes of treatment. We believe in being open
and honest where outcomes and experience fail to meet patient expectation so we take
action, learn, improve and implement the change and deliver great care and optimum
experience for our patients.”
Vivienne Heckford
Director of Clinical Services
Ramsay Health Care UK
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
Quality Account 2014/15
Page 20 of 36
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
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 Account 2014/15
Page 21 of 36
3.1 The Core Quality Account Indicators
Mortality
Period
Jan13-Dec13
Apr13Mar14
Best
Worst
Average
Period
Mount Stuart
RKE
0.62
RXL
1.18
Eng
1
2013/14
NVC08
0
RKE
0.54
RBT
1.20
Eng
1
2014/15
NVC08
0
Mount Stuart Hospital considers that this data is as described for the following reasons
there are very few patient deaths at, or following treatment, at this hospital.
Mount Stuart Hospital intends to take the following actions to maintain this rate and so
the quality of its services
maintain the strong focus on pre-admission assessment, and appropriate and
effective staff education and competence assessment
Hernia
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
Average
NT415
0.139
NVC11
0.008
Eng
0.085
RXR
0.125
Several
0.009
Eng
0.081
Period
Apr13 Mar14
Apr14 Sep14
Mount Stuart
NVC08
0.106
NVC08
0.098
Mount Stuart Hospital considers that this data is as described for the following reasons:
patients report good outcomes
we have good systems for ensuring pre-op questionnaires are returned but
patients do not always understand the importance of returning their post-op
questionnaire
Mount Stuart Hospital intends to take the following actions
to endeavour to make patients understand the importance of returning their postop questionnaire and thus further improve return rates
Veins
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
RTH
11.292
NT350
RYJ
-4.567
RWA
16.849
16.762
Average
Eng
-8.698
Eng
-9.479
Period
Apr13 Mar14
Apr14 Sep14
Mount Stuart
NVC08
NVC08
Mount Stuart Hospital considers that this data is as described for the following reasons
the number of veins procedures is too small for Mount Stuart to participate
Mount Stuart Hospital intends to take the following actions to improve this
it will monitor the amount of veins procedures and subscribe if the numbers
become sufficient
Quality Account 2014/15
Page 22 of 36
Hips
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
Average
NT441
24.444
RQX
17.634
Eng
21.34
RCB
25.418
RJD
18.357
Eng
21.922
Period
Apr13 Mar14
Apr14 - Sep
14
Mount Stuart
NVC08
22.027
NVC08
*
Mount Stuart Hospital considers that this data is as described for the following reasons
Care is planned on an individual basis.
We have good systems for ensuring pre-op questionnaires are returned and
patients understand the importance of returning their post-op questionnaire
Patients report good outcomes when returning for follow-up
Mount Stuart Hospital intends to take the following actions to improve this
to continue and further improve return rates
to ensure patients have realistic expectations and appropriate rehab
Knees
Period
Apr13 Mar14
Apr14 Sep14
Best
Worst
Average
NT404
19.762
NV323
12.049
Eng
16.248
RWP
20.44
RXF
14.416
Eng
16.702
Period
Apr13 Mar14
Apr14 - Sep14
Mount Stuart
NVC08
15.907
NVC08
*
Mount Stuart Hospital considers that this data is as described for the following reasons
Care is planned on an individual basis.
We have good systems for ensuring pre-op questionnaires are returned and
patients understand the importance of returning their post-op questionnaire
Patients report good outcomes when returning for follow-up
Mount Stuart Hospital intends to take the following actions to improve this
to continue and further improve return rates
to ensure patients have realistic expectations and appropriate rehab
Readmission
Period
Best
Worst
Average
Period
Mount Stuart
2010/11
Multiple
0.0
5P5
22.76
Eng
11.43
2010/11
NVC08
5.83
2011/12
Multiple
0.0
5NL
41.65
Eng
11.45
2011/12
NVC08
7.42
Mount Stuart Hospital considers that this data is as described for the following reasons
we have robust clinical pathways which include discharge criteria
discharge planning and the decision to discharge are based on individual needs
and condition
Mount Stuart Hospital intends to take the following actions
to continue to ensure patients are only discharged when it is safe and with the
proper advice/back-up
Quality Account 2014/15
Page 23 of 36
Responsiveness to Personal Needs
Period
Best
Worst
Average
Period
Mount Stuart
2012/13
RPC
88.2
RJ6
68.0
Eng
76.5
2012/13
NVC08
92.8
2013/14
RPY
87.0
RJ6
67.1
Eng
76.9
2013/14
NVC08
92.4
Mount Stuart Hospital considers that this data is as described for the following reasons
we provide excellent customer service as demonstrated by patient surveys
care is planned on an individual basis
Mount Stuart Hospital intends to take the following actions to improve this
to continue to ensure patients remain the focus of all we do
VTE Assessment
Period
Best
Worst
Average
Period
Mount Stuart
14/15 Q2
Several
100%
RNL
86.4%
Eng
96.2%
14/15 Q2
NVC08
99.9%
14/15 Q3
Several
100%
NT322
85.1%
Eng
96.0%
14/15 Q3
NVC08
99.9%
Mount Stuart Hospital considers that this data is as described for the following reasons
our clinical pathway documents direct staff to undertake VTE Risk assessment
staff understand the importance of VTE Risk Assessment
Mount Stuart Hospital intends to take the following actions to improve this
continue to undertake local audit and ensure risk assessment is completed where
indicated, and patients receive appropriate prophylaxis
C. Diff rate per 100,000 bed days
Period
Best
Worst
Average
Period
Mount Stuart
2012/13
Several
0
RVW
30.8
Eng
17.4
2012/13
NVC08
0.0
2013/14
Several
0
RMP
32.5
Eng
14.7
2013/14
NVC08
0.0
Mount Stuart Hospital considers that this data is as described for the following reasons
the hospital has an excellent record in infection prevention and control
assessment
there is low use of anti-microbials and any prescribing is in line with national best
practice and the CCG Formulary
Mount Stuart Hospital intends to take the following actions to maintain this
to continue to provide staff, patients and visitors with education and information
about good infection prevention and control practice
continue as an active participant in local and national infection control forum
Quality Account 2014/15
Page 24 of 36
SUI’S (severity 1 only)
Period
Oct 13 - Mar
14
Apr - Sep 14
Best
Worst
Average
Period
Mount Stuart
RBD
0
R1F
3.72
Eng
0.43
Oct13-Mar14
NVC08
0.00
Several
0
RBZ
1.09
Eng
0.17
Apr-Sep14
NVC08
8.46
Mount Stuart Hospital considers that this data is as described for the following reasons
we provide elective care only and are therefore able to risk assess and provide
patients with an appropriate environment
the procedures and processes in place to ensure safe practice and care, failed on
one operating list in early 2014 leading to a number of serious incidents
Mount Stuart Hospital took swift and decisive action following the operating list during
which the incidents occurred.
a full and thorough investigation was undertaken
it has been honest and transparent with the Clinical Commissioning Group and the
patients affected
staff have been sanctioned and have undergone further training and assessment
there has been organisational learning at Mount Stuart and across the wider
Ramsay Health Care UK organisation
Mount Stuart Hospital intends to take the following actions to maintain this
to continue to analyse patient safety incidents to identify areas where the
environment or practice can be further improved
ensure that our environment is well maintained and risk assessments are in place
where there is cause for concern
Friends and Family Test
Period
Best
Worst
Jan-15
Several
100%
RPA02
Feb-15
Several
100% RHU10
Average
Period
Mount Stuart
51.2%
Eng
94.0%
Jan-15
NVC08
100.0%
75%
Eng
94.7%
Feb-15
NVC08
100.0%
Mount Stuart Hospital considers that this data is as described for the following reasons
it actively encourage patients to complete the F&F test, and have systems in place
to facilitate them doing so
the hospital has an established reputation for high quality care and customer
service
Mount Stuart Hospital intends to take the following actions to maintain this
to continue to and facilitate patients in the completion of the test be they
inpatients, outpatients and those who attend for day case procedures
3.2 Patient safety
We are a progressive hospital and focussed on stretching our performance every year
and in all performance respects, and certainly in regards to our track record for patient
safety.
Quality Account 2014/15
Page 25 of 36
Risks to patient safety come to light through a number of routes including routine audit,
complaints, litigation, adverse incident reporting and raising concerns but more routinely
from tracking trends in performance indicators.
3.2.1 Infection prevention and control
Mount Stuart hospital 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 our hospital. An
annual strategy is developed by a Corporate level Infection Prevention and Control (IPC)
Committee and group policy is revised and re-deployed every two years. Our IPC
programmes are designed to bring about improvements in performance and in practice
year on year.
A network of specialist nurses and infection control link nurses operate across the
Ramsay organisation to support good networking and clinical practice.
Programmes and activities within our hospital include:
All staff receive education and training in IPC and Hand-washing. In addition clinical
nurses undertake further training and assessment of competence assessment in Aseptic
No Touch Techniques (ANTT)
The cleanliness of the hospital is audited regularly as part of the Ramsay corporate
clinical audit programme as well as regular monitoring by Matron, the Operations
Manager and other members of the local senior management team
There is a real focus on wearing uniform and protective clothing properly and
appropriately
We have introduced hand gel dispensers on every patient bed and at the entrance to
clinical departments
The Hospital Infection Control Committee meets regularly and reports to the Clinical
Governance Committee as well as the corporate IPC Committee.
All staff take their responsibility for preventing infection seriously
Quality Account 2014/15
Page 26 of 36
The graph below demonstrates the effectiveness of these systems with less than a
0.01% increase in the incidence of infection compared to last year despite increased
range of and complexity of surgical procedures
Infection Rates
(percentage of Admissiosns)
Infection Rates
0.07
0.06
0.05
0.04
0.03
0.02
0.01
0
2012/13
2013/14
2014/15
Mount Stuart Hospital
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 Mount Stuart
Hospital, providing us with a patient’s eye view of the buildings, facilities and food we
offer, giving us a clear picture of how the people who use our hospital see it and how it
can be improved.
The main purpose of a PLACE assessment is to get the patient view.
2015
Cleanliness
96.37%
Food and Hydration
96.79%
Privacy, dignity and wellbeing
84.00%
Condition, Appearance and Maintenance
89.67%
Mount Stuart is very proud that we were above average in all domains but continue to
strive to improve.
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
Quality Account 2014/15
Page 27 of 36
has been a foundation for our overall risk management programme and this awareness
then naturally extends to safeguarding patient safety. Our record in workplace safety as
illustrated by 6 Health and safety incidents per 1000 Admissions demonstrates the
results of safety training and local safety initiatives. It should be noted that none of these
incidents led to harm and this is an indicator of a good reporting culture.
Effective and ongoing communication of key safety messages is important in healthcare.
Multiple updates relating to drugs and equipment are received every month and these
are sent in a timely way via an electronic system called the Ramsay Central Alert System
(CAS). Safety alerts, medicine / device recalls and new and revised policies are
cascaded in this way to our General Manager which ensures we keep up to date with all
safety issues.
Activities during 2014/15;
Incidents are recorded on our electronic reporting system ‘RiskMan’ and analysed
by our Clinical Governance and Risk and Safety committees to identify areas for
action.
We have replaced all of hydraulic patient beds with electric ones. This provides
greater control for patients and reduces moving and handling for staff
Additional moving and handling equipment has been purchased including patient
slide sheets and straps
Internal floor coverings have been replaced and external paths and car parking
areas have been resurfaced to further reduce Slip, Trip Falls.
Staff continue to receive training in Risk Assessment, moving and handling and
fire and security.
3.3 Clinical effectiveness
Mount Stuart hospital has a Clinical Governance committee that meets regularly through
the year to monitor quality and effectiveness of care. Clinical incidents, patient and staff
feedback are systematically reviewed to determine any trend that requires further
analysis or investigation. More importantly, recommendations for action and improvement
are presented to hospital management and medical advisory committees to ensure
results are visible and tied into actions required by the organisation as a whole.
We remain alert to any sense of complacency and we will continue to challenge
ourselves to improve the services which we provide for the benefit of our patients and
those who care for them.
3.3.1 Returns to theatre
Ramsay is treating significantly higher numbers of patients every year as our services
grow. The majority of our patients undergo planned surgical procedures and so
monitoring numbers of patients that require a return to theatre for supplementary
treatment is an important measure. Every surgical intervention carries a risk of
Quality Account 2014/15
Page 28 of 36
complication so some incidence of returns to theatre is normal. The value of the
measurement is to detect trends that emerge in relation to a specific operation or specific
surgical team. Mount Stuart’s rate of return is very low consistent with our track record of
successful clinical outcomes; the chart below shows the rates over the last three years.
Return to Theatre Score
Retrnn to Theatre
(Percentage of Admissiosns)
0.3
0.25
0.2
0.15
0.1
0.05
0
2012/13
2013/14
2014/15
Mount Stuart Hospital
As can be seen in the above graph our return to theatre rate has reduced over the
last year despite increasing complexity of the procedures. We believe the decrease is
due in part to better pre-operative assessment and, where necessary, preoptimisation. Each return to theatre has been reviewed to see if there are trends or
commonalties, and we have not found any; the returns are attributable to a number of
specialties, and various times of day/day of week but most are accepted risks of the
various procedures. In all cases the patient made a full recovery.
We will continue to monitor all returns to theatre and take any action indicated as
necessary
3.4 Patient experience
All feedback from patients regarding their experiences with Mount Stuart are welcomed
and inform service development in various ways dependent on the type of experience
(both positive and negative) and action required to address them.
All positive feedback is relayed to the relevant staff to reinforce good practice and
behaviour – letters and cards are displayed for staff to see in staff rooms and notice
boards. Managers ensure that positive feedback from patients about individual staff is
recognised and praise given accordingly. There is also a Ramsay-wide Customer
Excellence Scheme which rewards staff frequently named by patients, or colleagues, for
‘going the extra mile’.
All negative feedback or suggestions for improvement are also fed back to the relevant
Quality Account 2014/15
Page 29 of 36
staff using direct feedback. All staff are aware of our complaints procedures should our
patients be unhappy with any aspect of their care.
Patient experiences are fed back via the various methods below, and are regular agenda
items on Local Governance Committees for discussion, trend analysis and further action
where necessary. Escalation and further reporting to Ramsay Corporate and
Department of Health (DH) bodies occurs as required and according to Ramsay and DH
policy.
Feedback regarding the patient’s experience is encouraged in various ways via:
Post-discharge patient satisfaction feedback via a web based invitation
Hot alerts received within 48hrs of a patient making a comment on their web survey
Annual CQC patient surveys
‘Friends and family test’ questions asked on patient discharge
‘We value your opinion’ leaflet
Verbal feedback to Ramsay staff
Written feedback via letters/emails
PROMs surveys
Care pathways – patient are encouraged to read and participate in their plan of care
3.1 Patient Satisfaction Surveys
Our patient satisfaction surveys are managed by a third party company called ‘Qa
Research’. This is to ensure our results are managed completely independently of the
hospital so we receive a true reflection of our patient’s views.
Every patient is asked to give 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.
As can be seen from the graph below our Patient Satisfaction Rate has slightly increased
over the last year. In comparison to the national average it remains above the 90%
expectation required by Ramsay Healthcare UK and in the ‘excellent’ percentile.
Quality Account 2014/15
Page 30 of 36
Satisfaction Scores
NHS/Private Patients
Satisfaction Scores
120
100
80
60
40
95.7
94.0
20
0
2013/14
2014/15
Mount Stuart Hospital
3.4 Mount Stuart Hospital Case Study
We regularly invite small groups of patients to conduct a Patient Led Assessment of the
Care Environment (PLACE). We spent time with these patients who then carry out their
assessment and gave us comprehensive feedback. As a result of the feedback we are
then able to make some changes to our external and internal facilities. The present
development and expansion plan will allow Mount Stuart to deliver on its commitment to
be the provider of choice for the residents of South Devon.
We are committed to continuing to engage with patients, consultants and other
stakeholders to continually improve our facilities, services and patient experience.
Quality Account 2014/15
Page 31 of 36
Appendix 1
Services at Mount Stuart Hospital covered by this quality account
The hospital delivers services to adults (people over the age of 18 years) and has 31
private inpatient beds with en-suite, 2 fully equipped theatres, Theatre Sterile Supplies
and decontamination unit, Endoscopy Suite with JAG accreditation.
Other on-site facilities include; outpatients, 7 consulting rooms, cosmetic suite, 24 hour
on-site Resident Medical Officer as well as a fully-equipped physiotherapy gymnasium.
The hospital has a radiology departments as well as regular mobile MRI/ CT access.
Specialties available at Mount Stuart Hospital
-
Breast Care
-
Cosmetic Surgery
-
Dermatology
-
Ear, nose and throat
-
Endocrinology
-
Gastroenterology
-
General medicine
-
General surgery
-
Gynaecology
-
Neurology (Consultation / Imaging)
-
Ophthalmology
-
Oral and maxillofacial surgery
-
Orthopaedic surgery
-
Pain management
-
Physiotherapy
-
Radiology
-
Urology
-
Vascular surgery
-
Weight loss surgery (Obesity)
Quality Account 2014/15
Page 32 of 36
Appendix 2 - Consultants and employed staff.
108 Consultants were approved to work from Mount Stuart Hospital as at 31 March 2015
Title
Dr
Initial
J
Surname
Ackers
Specialty
Anaesthetics
Title
Dr
Initial
P
Surname
Kember
Specialty
Radiology
Dr
Mr
Dr
Mr
Dr
Mr
Mr
Mr
Dr
Dr
Dr
Miss
Mr
Mr
Mr
Mr
Mr
Mr
J
S
L
M
A
J
P
S
J
D
I
V
D
L
H
J
D
A
Adams
Andrews
Archer
Ashworth
Baker
Barrington
Birdsall
Blake
Bridger
Buckley
Buley
Conboy
Cunliffe
Currie
David
Davis
DeFriend
Desmond
Dermatology
General Surgery
Radiology
Orthopaedics
Anaesthetics
Gynaecology
Orthopaedics
Orthopaedics
Pathology
Radiology
Histopathology
Orthopaedics
Maxillo-Facial
Plastics
Orthopaedics
Orthopaedics
Orthopaedics
Gastroenterology
Mr
Dr
Mr
Mr
Mr
Miss
Mr
Mr
Mr
Dr
Dr
Mr
Mr
Mr
Dr
Dr
Mr
Mr
N
W
M
S
C
M
R
S
A
A
I
R
R
J
A
M
S
B
General Surgery
Anaesthetics
Urology
Ophthalmology
Maxillo-Facial
Gynaecology
Orthopaedics
Urology
Orthopaedics (Medical Legal)
Pathology
Cardiology
Urology
General Surgery
Plastics
Anaesthetist
Anaesthetist
General Surgery
Ophthalmology
Dr
Mr
Dr
Mr
Dr
Dr
L
P
A
E
R
J
Dobson
Donnelly
Downs
Doyle
Dyer
Evans
Physician
Breast Surgeon
Dermatology
Ophthalmology
General Medicine
Plastics
Dr
Mr
Mr
Mr
Mrs
Mr
A
Frost
Ophthalmology
R
Perriss
Radiology
Miss
L
Fryer
Maxillo-Facial
Dr
Dr
Dr
E
R
S
D
O
D
Kenefick
Key
Kirollos
Kumaravel
Lansley
Leggott
Lofthouse
MacDermott
MacEachern
Maggs
Mahy
Mason
McCarthy
McDiarmid
McEwen
Mercer
Mitchell
MompeanMorales
Morris
Morris
Narayanan
Oliver
Osoba
Pappin
D
Portch
Anaesthetics
Dr
Dr
Dr
Dr
Mr
Dr
Dr
Dr
Dr
Mr
Dr
Dr
Mr
Mr
Mr
Mr
Dr
Mr
Dr
Dr
M
K
J
A
M
G
T
A
M
R
R
M
S
A
J
M
S
P
R
M
Garrido
George
Goldman
Goodman
Green
Gribbin
Guest
Gunatilleke
Halkes
Hawken
Heafield
Hearn
Hickey
Higgins
Hindley
Hockings
Hoque
Houghton
Hughes
HumenczykZybala
Histopathology
General Medicine
General Medicine
Oncology
Breast Surgeon
Cardiology
Anaesthetics
Anaesthetics
Anaesthetics
Orthopaedics
Radiology
Anaesthetics
ENT
Orthopaedics
Gynaecology
Orthopaedics
Pathology
General Surgery
Anaesthetics
Anaesthetics
Mr
Dr
Mr
Mr
Mr
Mr
Mr
Dr
Dr
Dr
Dr
Mr
Dr
Dr
Miss
Dr
Dr
Mr
Dr
Dr
J
M
R
R
J
R
P
P
N
N
S
P
r
D
T
S
D
G
M
D
Powles
Puckett
Pullan
Ramesh
Ramtahal
Ranjit
Reece
Roberts
Ryley
Rymes
Saad
Saxby
Seymour
Sinclair
Sleep
Smith
Snow
Srinivas
Tapp
Turner
ENT
Radiology
General Surgery
Orthopaedics
Urology
Gynaecology
ENT
Pathology
Pathology
Haematology
Anaesthetist
Plastics
Radiology
Physician (Medical Legal)
Ophthalmology
Haematology
Anaesthetics
General Surgery
Radiology
Haematology
Radiology
Plastics
Gynaecology
Plastics
Ophthalmology
Anaesthetics
Title
Dr
Mr
Dr
Mr
Dr
Dr
Initial
J
D
J
N
P
P
Surname
Ingham
Isaac
Isaacs
Johnson
Keeling
Kell
Specialty
Anaesthetics
Orthopaedics
Radiology
General Surgery
General Medicine
Gynaecology
Title
Dr
Dr
Mr
Mr
Dr
Dr
Initial
P
A
G
M
P
T
Surname
Turner
Varvinskiy
Wansbrough
Waterson
White
Wright
Specialty
Pathology
Anaesthetics
Orthopaedics
Bio-chemistry
Radiology
Histopathology
Our total full time equivalent employed staff complement as of 31 March 2015 was 87.08 made up of:
Physiotherapists
3.52
Porters
2.4
Nurses/ ODP’s
21.1
Admin Staff
HCA’s
13.62
Hotel Services
Radiographers
1.06
TSSU
Catering
6.44
Maintenance
1.8
Supplies
2
Plus Bank Support Staff
54
26.74
4.4
4
Quality Account 2014/15
Page 34 of 36
Appendix 3 Clinical Audit Programme 2014/2015.
Quality Account 2014/15
Page 35 of 36
Mount Stuart Hospital
Ramsay Health Care UK
We would welcome any comments on the format,
content or purpose of this Quality Account.
If you would like to comment or make any suggestions for
the content of future reports, please telephone or write to
the General Manager using the contact details below.
For further information please contact us:
Hospital phone number 01803313881
Hospital website
http://www.mountstuarthospital.co.uk
Quality Account 2014/15
Page 36 of 36