Anglian Community Enterprise
(Community Interest Company)
previously NHS North East Essex PCT Provider Services (NEEPS)
Quality Account
2010 - 2011
From 1st January 2011 North East Essex Provider Services (NEEPS) became Anglian
Community Enterprise (ACE) Community Interest Company hereafter referred to as ACE.
This change occurred as a result of the requirement for North East Essex PCT to divest
itself of its Provider arm.
ACE is a provider of NHS community services and also provides Learning Disabilities
Therapy and some Specialist Nursing. At present our services are mainly provided to the
population of North East Essex, with some Learning Disability services provided across
North Essex.
In the same way as a private company, ACE is controlled by the appointed Board
Members and its shareholders. However, in addition, the Directors and Shareholders are
responsible for ensuring that the company is run in such a way that it will continue to
satisfy the Community Interest Test. The Management team runs the organisation on a
day-to-day basis, and the board ensures that through systems of oversight, constructive
challenge and stewardship that management delivers on its strategy and complies with
proper standards of conduct
Contact details for ACE:
Anglian Community Enterprise (ACE) Community Interest Company
Kennedy House
Kennedy Way
Clacton on Sea
Essex CO15 4AB
Tel: 01255 206060
-1-
Contents
Page
Part 1
Statement from Anglian Community Enterprise
Managing Director
4
Statement from Anglian Community Enterprise
Chairman
6
Review of Services
7
Part 2
Priorities for Quality Improvement 2011-12
National Mandatory Audits
Participation in Clinical Audit
Participation in Clinical Research
Goals Agreed with Commissioners
Care Quality Commission
Data Quality
7
10
10
11
11
12
15
Part 3
Feedback on the 2009/10 Quality Account
16
Priorities for Quality Improvement for 2010-11
How we performed?
19
Patient Safety – Priority 1
Patient Safety – Priority 2
Clinical Effectiveness – Priority 3
Clinical Effectiveness – Priority 4
Patient Experience – Priority 5
Patient Experience – Priority 6
Capturing Quality – Priority 7
Review of Quality Performance
Annual Patient Experience Survey
Compliments and Complaints
Clinical Audits
Hand Hygiene and Essential Steps
Incidents
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19
20
22
24
25
25
26
26
27
27
30
30
31
Recognising and Rewarding Quality
35
Stakeholder Engagement
35
Supporting Statements
36
NHS NEE Commissioning PCT
Essex & Southend Local Involvement Network
Essex Health Overview & Scrutiny Committee
36
37
37
Appendices
38
Appendix 1. Participation in Local Clinical Audit
Appendix 2. Essential Standards Monitoring
Appendix 3. Action Plan for CQC Report
Appendix 4. Strategic Objectives 2010-15
Appendix 5. MUST Assessment Tool
Appendix 6. EQ5D Health Questionnaire
Appendix 7. Monitoring Clinical Outcomes
38
77
84
94
95
97
99
Glossary of Terms
102
Acknowledgements
108
Notes
109
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Part 1
Statement from Anglian Community Enterprise (ACE)
Community Interest Company Managing Director.
I am pleased to present Anglian Community Enterprise’s (ACE) Quality
Account for the period 2010-11 which gives us the opportunity to look back
and reflect on the quality of our services during 2010-11 and to set out our
priorities for quality improvements for 2011-12.
First and foremost this Quality Account is written and provided to the
population we serve and has been influenced by the outcomes of our 201011 Annual Patient Experience Survey, discussions with staff, and a review of
the many indicators of quality we measure as a matter of routine.
We have continued to build on communication and engagement with Health
Overview and Scrutiny Committee and Local Involvement Network
colleagues so that we can better understand the communities we serve and
to form lasting partnerships to improve patient and carer experience.
During 2010-11, we have been through transition from North East Essex
Provider Services to the launch of Anglian Community Enterprise on 1
January 2011. During this transition period we have continued to focus on
Transforming Community Services in partnership with staff to design
improved ways of working and service delivery that will enable us to have a
greater impact on the health and wellbeing of the patients and local
communities.
As a Social Enterprise we have greater freedom to innovate, identify
efficiencies and improve productivity. Members of staff are shareholders in
the organisation and have an increased community focus.
These key areas are supported by our vision:
To be the leader in the communities that we serve, providing
innovation, quality, and value for money as we deliver community
healthcare services that are accessible to all.
I write on behalf of ACE’s Senior Executive Team to pledge our continued
commitment to strive for high quality, safe and effective care and to confirm
that the content of this report is an accurate account.
-4-
Lynne Woodcock
Managing Director
Anglian Community Enterprise (Community Interest Company) previously
North East Essex Provider Services (NEEPS)
May 2011
-5-
Statement from Anglian Community Enterprise (ACE)
Community Interest Company Chairman.
Our 2010/11 Quality Account reflects the results and ambitions of our past
year’s achievement as reflected by both our stakeholders and internal
measurements. We continue to consult and engage with staff, patients and
community groups to ensure we strive for our right first time and continuous
improvement ethos which remains at the heart of our responsibility to deliver
a quality service.
The board continues to take every opportunity to engage via staff and patient
forums as well as safety and quality walkabouts to meet with front line
clinicians and users of our services to augment and improve upon our
patient experience.
The past year has seen the conclusion of our journey towards separation
from the Primary Healthcare Trust as a standalone Social Enterprise. Our
new found status as Anglian Community Enterprise CIC and the
opportunities presented by the freedoms to expand our influence and service
to commissioners are reflected in our approach and transformational plans
for the coming year.
Quality continues to be our benchmark for success within our overall
responsibilities. The past achievements of the organisation combined with
the opportunity to transform community services provide confidence that our
enterprise is well able to deliver its vision for the future.
Richard Kearton,
Chairman
Anglian Community Enterprise (CIC)
May 2011
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Review of Services
During 2010/11 ACE (previously NEEPS) provided 50 + 5 Learning Disability NHS
services.
ACE (previously NEEPS) has reviewed all the data available to them on the quality of
care in all of these NHS services.
In addition to reports on quality received, the Executive and Non-Executive Team are
committed to ensuring the delivery of high quality and safe care. We have participated in
patient safety walkabouts in accordance with National Patient Safety Agency guidance
and have taken other opportunities to meet with front line clinicians and users of our
services.
The income generated by the NHS services reviewed in 2010/11 represents 95% of the
total income generated from the provision of NHS services by ACE/NEEPS for 2010/11.
Part 2
Priorities for Quality Improvement 2011-12
During 2011-12 ACE has identified the following priorities for quality improvement. The
ACE Clinical Audit Programme will link to the Quality Account priorities (Clinical
Effectiveness, Patient Experience and Patient Safety Darzi 2008 & 2009) and to the
ACE Strategic Objectives (Appendix 4) to ensure full monitoring and management of
these key areas. They have been determined in a number of ways: as the top 3 reported
patient safety incident types; through the annual patient survey and other local indicators
and through national imperatives. The sub priorities e.g. 'How to raise a concern’ are also
related to issues identified within Department of Health guidance and requirements. Each
of the 3 domains of safety will have a minimum of 3 priorities; where appropriate we will
carry out at least one audit against each of these 3 priorities. ACE will also continue
to advise and promote that all services aspire to undertake at an audit of their choice on
an annual basis.
Progress on these priorities will be reported in a number of ways utilising the ACE
website, through publishing reports, both internally to staff and the ACE board; externally
to our patients and other stakeholders and to the commissioners of our services.
1. Patient Safety
Priority 1 - Slips, trips and falls
ƒ
Audit 1 – Falls Audit (Ward based)
ƒ
Audit 2 – NICE Audit Assessment and Prevention of Falls in Older people
(CG21)
Priority 2 - Pressure ulcers
ƒ
Audit 3 – NICE Pressure Ulcer Management and Prevention (CG29)
-7-
Priority 3 – Patient Information and Governance
ƒ
Audit 4 – Record Keeping
ƒ
Audit 5 - Administration of Insulin (NEE13)
ƒ
Audit 6 – Medicines Policy (NEE23)
In addition during 2011/12 ACE will also be implementing the DATIX software for
Patient Safety system. This will allow us to disseminate communications form the
Department of Health’s Central Alerting system (CAS), the Medicines and
Healthcare Products Regulatory Agency (MHRA) and the National Patient Safety
Agency (NPSA). It will allow us to broadcast information about medical devices
and other healthcare safety issues, automatically recording responses and
formulating action plans.
We shall also be auditing 2 Patient Safety Alerts in 2011/12. These have yet to be
decided.
2. Patient Experience
Priority 4 - How to raise a concern
The Annual Patient Survey acts as a useful audit tool to measure the effectiveness
of our complaints handling service and identify if we need to do more to assist
patients, families and the public to raise concerns they may have about the
services we deliver.
This years survey has identified that more emphasis may be required to ensure our
patients, families and the public are aware of where and who they should approach
to discuss their concerns with.
Data is collected throughout the year and this is used to identify trends. Quarterly
reports are produced and action plans are put in place and monitored to address
those key trends. Outcomes from the action plans are shared across the
organisation with the aim of ‘learning from patient experience’.
Assistance to members of the public is offered by:
ƒ
ƒ
ƒ
ACE literature (posters and leaflets) is available within all ACE service areas
and highlights how to raise a concern.
Spring 2011 – We have added additional resources to the existing Complaints
team to receive and act on comments and concerns received from patients,
carers and their families.
We will be raising awareness of the outcome of the survey with front line staff
and provide additional training and education to encourage them to handle
concerns locally wherever possible.
Priority 5 - Cleanliness
ƒ
Audit 7– Hand Hygiene Audits for Community Hospitals (monthly)
-8-
ƒ
Audit 8 – Essential Steps – Preventing the Spread of infection
(monthly all areas except Community Hospitals)
ƒ
Audit 9 - Environmental Infection Control Audit (yearly for all service areas)
Priority 6 – Improving Communications
ƒ
Audit 10 – Annual Patient Experience Survey
ƒ
Audit 11 - Patient Opportunistic Surveys
ƒ
Audit 12 - LD Annual Survey
3. Clinical Effectiveness
Priority 7 – Discharge from Hospital
ƒ
Audit 13 – Policy Audit – Audit of Discharge Policy (Community Hospitals)
NE266
Priority 8 – Improving Participation in Clinical Audit
It is acknowledged that it is not only important to improve participation, but also to
ensure that any recommendations made following an audit are carried out and
follow-up audits can demonstrate how effective the changes were. This would then
complete the audit cycle.
ACE will aspire to complete 100% of audits, where appropriate, within 3 months of
the stated end date. It will have sub-objectives.
ƒ
Audit 14 – Audit of the Clinical Audit Policy (see below)
Once a clinical audit is complete and the action plan is implemented the lead of the
clinical audit project completes an outcomes form (appendix 7). This enables the
team to report how the audit report/results are disseminated to patients, staff and
others. The Clinical Audit Strategy is currently under review and will evolve into a
new Clinical Audit Policy. The policy will provide further clarity around feedback to
patients/public.
Priority 9 – Patient Reported Outcome Measures (PROMS)
ƒ Audit 15 – PROMS pilot to include Continence, Prolotherapy & Podiatry
ƒ
Audit 16 - End of life audits – Palliative Care Quality Toolkit
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National Mandatory Audits
These are ‘must do’ audits mandatory to each organisation.
HQIP to confirm audit programme for 2011/12 although it is likely to include:
ƒ
National Diabetes Audit
ƒ
National Audit of Falls and Bone Health
Participation in clinical audit 2010-11
During April 2010 to March 2011, 4 national clinical audits covered NHS services
that Anglian Community Enterprise provides.
There were no applicable national confidential enquiries.
During that period Anglian Community Enterprise participated in 100% of national clinical
audits and they are as follows:
ƒ
ƒ
ƒ
ƒ
National Audit of Continence Care
National Audit of Falls & Bone Health
National Diabetes Audit (NDA)
Diabetes E Questionnaire
The national clinical audits and national confidential enquiries that ACE participated in,
and for which data collection was completed during 2010-2011, are listed below alongside
the number of cases submitted to each audit or enquiry as a percentage of the number of
registered cases required by the terms of that audit or enquiry.
Title of National Clinical Audit
No of cases
required for
audit
National Audit of Continence CareRoyal College of Physicians (RCP).
Patients with
urinary
incontinence50
No of
cases
submitted
for audit
100% (50)
0% (0)
Patients with
bowel
incontinence50
Reasons for
non
submission of
cases
Not submitted
as the
organisation did
not have
patients which
fulfil the sample
requirements,
RCP notified.
National Audit of Falls and Bone
Health (RCP)
The report of 1 national clinical audit was reviewed by the provider in 2010-2011 and
Anglian Community Enterprise (ACE) intends to take the following actions to improve the
quality of healthcare provided:
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National Audit of Continence Care- Royal College of Physicians (RCP).
Recommendations
Men with bladder (and/or bowel)
incontinence should have a Digital Rectal
Examination (DRE) (with their consent) as
a basic part of assessment.
Healthcare professionals should ensure
that they are competent to perform Digital
Rectal Examination.
Those responsible for services should
ensure that there are practitioners who are
appropriately skilled to perform the
examination and that training is provided to
all non-specialist clinicians engaged in
assessment of patients with urinary (and
faecal incontinence.)
Use of scoring for functional ability/
cognitive ability
Use National Occupational standards to
guide training and competency for
continenence team members
User Group to advise, comment etc on
service
Actions
Discussions with team.
Plan to offer Digital Rectal Examination
(DRE) as part of assessment for men
over 50 years old.
Release of half day per week Whole
Time Equivalent band 6 Digital Rectal
Examination trained and experienced
staff to provide this and also offer flow
test at home when thought appropriate.
Discussions with team as to usefulness
of scores and which system would be
appropriate
Discussions with team and look at
training and competency documents to
see how standards can be incorporated
Discussions with users, staff.
Possibly arrange meeting for
stakeholders
The reports of 66 local clinical audits were reviewed in 2010-2011 and ACE intends to
take a number of actions to improve the quality of healthcare provided. These are detailed
at Appendix 1.
Participation in clinical research
Whilst ACE does not have dedicated research resources it is supportive of clinical
research and will participate and assist with any proposals as far as possible.
Goals agreed with commissioners
A proportion of North East Essex Provider Services income in 20010/11 was conditional
on achieving quality improvement and innovation goals agreed between North East Essex
Provider Services (ACE) and NHS North East Essex Commissioners through the
Commissioning for Quality and Innovation (CQUIN) payment framework.
Greater detail on the CQUIN’s can be found online on the following link:
http://www.institute.nhs.uk/images/documents/wcc/PCT%20portal/CQUIN%20schemes/N
orth%20East%20Essex%20Provider%20Services%20Scheme.doc
- 11 -
Further details of the agreed goals for 2010/11 and for the following 12 month period are
available on request from:
Tanya Matilainen, Director of Governance
Anglian Community Enterprise (Community Interest Company)
Kennedy House
Kennedy Way
Clacton on Sea
CO15 4AB
Care Quality Commission (CQC)
ACE is required to register with the Care Quality Commission (CQC) and its current
registration status is full registration without conditions. Last year upon registration because of information gathered via the Quality Risk Profile - NEEPS had conditions
imposed against its registration. Action plans were drawn up to show full monitoring of
these conditions and ACE has made progress by 31st March 2011 in taking such action.
Details on this progress can be found in the action plan at appendix 3.
ACE has not participated in any special reviews or investigations by the CQC during the
reporting period.
The Quality Risk Profile (QRP) is an essential tool that the Care Quality Commission
(CQC) compile on an annual basis for gathering together key information about
healthcare providers to support how they monitor our compliance with the Essential
Standards of Quality and Safety. The QRP enables CQC compliance inspectors to
assess where risks lie and could prompt front line regulatory activity, such as further
enquiries. QRPs are also an important tool to support continuous monitoring of
compliance, by ensuring that everyone is working from the same information, and to
improve how care is provided and commissioned. Our QRP should be used to support
how we quality internally, by identifying areas of lower than average performance and
taking action to address them where necessary.
The QRP combines both quantitative (numerical) and qualitative (textual) information.
Most quantitative data comes from existing nationally-held data sets from:• The Information Centre for Health & Social Care.
• The Department of Health.
• Medical royal colleges.
• Other organisations with an interest in healthcare.
• National assessments carried out by CQC (e.g. patient surveys, reviews and studies).
Qualitative information can come from a variety of sources including:• Engagement activities by local CQC staff with providers and stakeholders.
• Information from providers.
• Information from people who use the services.
• Our inspection reports, for example, findings from monitoring compliance with regulation
on cleanliness and infection control.
The QRP is produced using information from people who use services. Sources include:• Information from user representative bodies such as. Local Involvement Networks
(LINks)
- 12 -
• Information from statutory bodies, such as foundation trust boards of governors and
overview and scrutiny committees.
• Information from people’s feedback on NHS Choices and Patient Opinion.
• Findings from the national NHS patient survey programme, for example, inpatient
survey, outpatient survey.
QRPs focus on the 16 essential standards that most closely relate to quality and safety
being Respecting and involving people who use the services; Consent to care and
treatment; Care and welfare of people who services; Meeting nutritional needs; Cooperating with other service providers; Safeguarding people who use the services from
abuse; Cleanliness and infection control; Management of medicines; Safety and suitability
of premises; Safety, availability and suitability of equipment; Requirements relating to
workers; Staffing; Supporting workers; Assessing and monitoring the quality of service
provision; Complaints; Records.
It should be noted that the information contained within the QRP is for guidance for
organisations only as the data may relate to their pre-merger organisations. Plus there
may be more than one instance of the same measure (item), as it was measured in all
predecessor organisations.
Within North East Essex Provider Services our QRP is mainly 'similar to expected' - 66%.
23% falls within the 'better than expected' margin and 11% falls within the 'worse than
expected' margin.
Action plans have been developed against all items within the QRP that were recorded as
being 'worse than expected' and these will be monitored at our IGC.
QRP Score
%
Numbers
Much better than expected
Positive comment
Tending towards better than expected
Similar to expected
No information
Tending towards worse than expected
Much worse than expected
Negative comment
Grand Total
13.83%
1.06%
9.22%
65.60%
0.35%
4.61%
3.55%
1.77%
100%
39
3
26
185
1
13
10
5
282
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NEEPS Quality Risk Profile - Scoring by Percentage
(against a total of 282 items of information)
100.00%
90.00%
80.00%
65.60%
60.00%
50.00%
40.00%
9.22%
1.06%
No information
Similar to expected
Tending towards
better than
expected
0.00%
0.35%
Score
14
4.61%
3.55%
1.77%
Negative comment
10.00%
Much worse than
expected
13.83%
Postive comment
20.00%
Tending towards
worse than
expceted
30.00%
Much better than
expected
Percentage
70.00%
Data Quality
The Integrated Governance (IG) Toolkit is an online system which allows NHS
organisations and partners to assess themselves against Department of Health
Information Governance policies and standards. It also allows members of the public
to view participating organisations' IG Toolkit assessments. It is a requirement of
Clinical Information Assurance that procedures are in place to ensure the accuracy
of service user information on all systems and/or records that support the provision
of care.
Given that ACE (CIC) is a new organisation we have received special dispensation
from Connecting for Health as it has been recognised that we would not have been
in a realistic position to meet all level two requirements of the toolkit in such a short
space of time. ACE is therefore now expected to attain this level by July 2011 and is
working to this deadline.
Many of the changes in version 8 of the toolkit have meant a number of Trusts have
failed this year’s submission primarily because they have been unable to provide the
evidence to support compliance; this has also been an issue for ACE (CIC).
ACE will be taking the following actions to improve data quality. Error reports are to
be produced and made available to Heads of Service and Assistant Directors to
review. Training is linked in with the reporting to ensure where errors are identified
training is given accordingly. ACE holds a Data Quality Policy which is available to
all staff on the intranet. Currently the IG department are working with Heads of
Service and the Essex Shared Service Agency to review the informatics
requirements to ensure that quality at all levels is addressed.
Monitoring of compliance of the use of the NHS Number as the prime default patient
identifier is carried out in the annual Record Keeping Audit. This is a requirement of
the Patient Identification Policy (NEE83)
Results
(based on requirements version 8 )
Overall Results
50% (RED)
Results
(based on requirements version 7 )
Initiative
Clinical Information Assurance
55% (RED)
Confidentiality and Data
Protection Assurance
50% (RED)
Corporate Information
Assurance
Not Categorised for 2011/12
Information Governance
Management
60% (RED)
Information Security Assurance
46% (RED)
15
Overall ACE’s Information Governance Assurance Report score for 2010/11 was
50% and was graded Red with the caveats previously mentioned.
ACE (previously NEEPS) did not submit records during 2010/11 to the Secondary
Uses Service for the inclusion in the Hospital Episode Statistics which are included
in the latest published data.
ACE (previously NEEPS) were not subject to the Payments by Results clinical
coding audit during 2010/11 by the Audit Commission.
Part 3
Feedback on the 2009/10 Quality Account
The following comments were provided by the Health Overview and Scrutiny
Committee with a view to improving future quality accounts. Their original comment
is made in black with the action ACE has taken/will take in blue.
General comments
•
An introduction and explanation of the services NEEPS provide is needed
Brief detail of services provided contained within introduction and expanded
within the glossary of terms
•
Clinical terms should also be included in the Glossary
This year we have included an enlarged glossary of terms.
•
The Quality Account should provide contact details on the front page We
have included this for 2010/11
•
Quality Account overall is long and complex – It could be written in a more
accessible way also a summary with appendices might be considered in order
to improve the usefulness of the report for the public in future
This year we have attempted to write the account in a more-simplified, easierto-read way, with limited use of jargon which we hope will improve its
readability and usefulness. The Glossary of Terms has also been expanded.
Specific comments, questions and/or suggestions for improvement
Part 1: Priorities for Quality Improvement 2010-11
Priority 1
• Information on the target, how the trust will measure, monitor and report on
progress needs to be made clearer and accessible to the community
Environmental audits are carried out annually by the Infection Prevention and
Control Team, this requires the area manager to complete an action plan to
address any issues that are identified in terms of cleaning; in addition our
cleaning contractors carry out weekly audits. Each of the clinical areas has
cleaning schedules in line with The National Standards of cleanliness for the
NHS.This is reported to the ACE Infection Prevention and Control Committee.
16
With regard to Methicillin Resistant Staphylococcus Aureus (MRSA) and
Clostridium Difficile (C Diff) our ceiling for 2009/10 is:
•
MRSA bacteraemia (bloodstream infection) 4 for the North East Essex
community, this target is not broken down specifically for North East Essex
Provider Services
• The ceiling for Clostridium Difficile is 55 for the North East Essex
community, a ceiling has not been set specifically for our 2 Community
Hospitals
How will we measure and monitor?
The data for MRSA bacteraemia and Clostridium Difficile is updated daily for
the whole of the North East Essex. The Anglian Community Enterprise
Infection Prevention & Control Team monitor the daily microbiology list.
How will we report on progress?
Monthly reports are provided to the service managers and to our Governance
and Risk Committee. In addition, we will report on a monthly basis to our
commissioners and also at the quarterly Infection Control Committee.
•
Need to be defined MRSA and C-Difficile, health economy, acute and nonacute settings
Definitions for each can be found within the Glossary of Terms
Priority 2
• A sample care plan to ensure in-patients from being malnourished could be
appended for the public to see.
A MUST assessment sheet is included at Appendix 4.
Priority 3
• A sample questionnaire could be appended to the Quality Account.
The EQ5d Questionnaire is included at Appendix 5
•
Clinical terms not defined enough
An updated and enlarged glossary of terms has been included this year to
include commonly used clinical terms
•
How often progress will be reported to the Integrated Governance
Committee?
The Integrated Governance Committee has now been reconstituted into the
Governance and Risk Committee and meets bi-monthly with progress being
reported at each meeting
•
What representation is there within the Integrated Governance Committee in
terms of race, disability, age, sex, faith etc?
Whilst ACE is an Equal Opportunities employer representation at each
meeting is focussed towards individuals undertaking specific professional
roles irrespective of race, disability, age, sex, faith etc. However should there
be the need to discuss elements likely to need particular expertise or input on
any of the above than this will be taken into account when looking for an
appropriate member of staff.
17
Priority 4
• The
term
‘Dementia
Diversion
tool’
needs
to
be
defined
The Tiptree Box is a toolkit originally designed for staff in acute hospital
wards, which was felt to be of use for patients residing on community hospital
wards. It has been developed to provide distraction therapy for patients with
dementia. It is named after the ward in Colchester Hospital University
Foundation Trust (CHUFT) where it was conceived.
•
How will ‘incidents relating to patients with dementia etc’ will be monitored?
An indicator has been established on DATIX to enable us to capture which
patient incidents relate to those who are suffering from ‘cognitive impairment
(CI)’. The first full quarter data will not be available until the end of May 2011
This will be used to highlight the trends showing the relationship between
those patients who have CI and those who do not in terms of %. This historic
information will be report on a quarterly basis to Ward Sisters.
•
A sample survey to capture the views of patients, carers and visitors would
have been useful.
These are the 5 core questions that are used across all service areas for all
service users for the opportunistic surveys - these questions have been
agreed with our commissioners:•
•
•
•
•
•
How satisfied are you with the service you have received?
What do you think of the information given to you?
How satisfied are you with the attitude of our staff?
Were you given enough privacy when discussing your condition or
treatment?
Were you involved in decisions about your treatment and care?
How often will progress be reported to the Integrated Governance
Committee?
Bi-monthly reports to the Governance and Risk Committee
Priority 5
• More information needed on how the Trust will capture patient experience
and monitor complaints and specific plans to increase user satisfaction
Patient experience survey results will be co-ordinated into statistical data
arising from complaints, concerns, compliments and feedback from other
sources. Action plans are put in place and monitored for all complaints and
most concerns. We have 18 months of data showing work undertaken to
improve service delivery on the wards and elsewhere in the organisation. This
coming year, we will focus on ‘auditing’ that the measures have resulted in
actual improvements. This work will be tied in with the other monitoring we
currently undertake in reviewing action plans in respect of Rapid
Response(RR) /Alerts, incidents/claims and Serious Incidents (SI’s).
Priority 6
• What is the objective of the carers’ assessment?
The objective of the carers’ assessments is to raise awareness of the
financial and practical support and advice that is can be made available to (in
this case) adult carers.
18
`The CQUIN relating to carers has been very successful – with over 600 (out
of 10000 letters sent for period up to 1 Dec 10) carers (not previously known)
being identified and offered carer assessments by Essex County Council. A
further 5000 letters have been sent since 1/12/10.
Priority 7
• Needs an indication of timescales and examples of measurable indicators
During 2010 the organisation developed a Quality Dashboard that displays
quality performance indicators. This dashboard is reported at Board level and
will evolve further during 2011 to fully capture all areas of the quality spectrum
within ACE.
Priorities for Quality Improvements 2010/11
How we performed?
The following section details progress made on the 7 priorities identified in 2009/10.
Future monitoring and assurance will be maintained through a range of tools such as
clinical audits either national or local; reports to standing committees or groups or as
part of the general admission/treatment process. In some cases they have been
identified as continuing priorities for 2011/12.
Patient Safety
We will ensure that when patients need our services they receive
the safest possible care
Priority 1
Standards of Cleanliness
Environmental audits were carried out annually by the infection prevention and
control team, this required the area manager to complete an action plan to address
any issue that were identified in terms of cleaning; in addition our cleaning
contractors carried out weekly audits. Each of the clinical areas had cleaning
schedules in line with The National Standards of cleanliness for the NHS. This was
reported to our infection prevention and control committee.
With regard to Methicillin Resistant Staphylococcus Aureus (MRSA) and Clostridium
Difficile (C Diff) our ceiling for 2009/10 was:
•
MRSA bacteraemia (bloodstream infection) 4 for the North East Essex
community, this target was not broken down specifically for North East Essex
Provider Services
• The ceiling for Clostridium Difficile was 55 for the North East Essex
community, a ceiling was not set specifically for our 2 community hospitals
19
How will we measure and monitor?
The data for MRSA bacteraemia and Clostridium Difficile is updated daily for the
whole of the North East Essex. ACE Infection Prevention & Control team monitor the
daily microbiology list.
How will we report on progress?
Monthly reports are provided to the service managers and to our Integrated
Governance Committee. In addition, we will report on a monthly basis to our
commissioners and also at the quarterly infection control committee.
Priority 2
Assessing the risk of malnutrition in the community hospital
setting
Outcomes
•
Clacton and Harwich Community Hospitals uphold the NICE Clinical
Guideline 32 ‘Nutrition support in adults’.
•
Nutritional screening using Malnutrition Universal Screening Tool (‘MUST’) is
undertaken on patient’s admission to a community hospital ward, at regular
intervals during their stay and on discharge
•
Nutrition support is considered in patients who are malnourished or at risk of
malnutrition. Nutritional care plans have been developed and are used.
•
The community hospital wards currently have access to registered dietician
who is skilled and trained in nutritional requirements and different methods of
nutrition support
•
Patients who require nutritional support are monitored
•
All healthcare professionals who are directly involved in patient care receive
education and training on the importance of providing adequate nutrition.
•
MUST scores and action taken is recorded on a spread sheet by ward clerks.
How we will measure and monitor?
•
By continuing to record that MUST is carried out on patient’s admission and
discharge and appropriate action is taken.
How we will report on progress?
Assessing the risk of malnutrition in the community hospital setting was identified as
a CQUIN for NEEPS for 2010/11 and we have been monitoring our progress on a
monthly basis as follows:•
•
ALL admissions to our community hospitals must have a MUST (malnutrition
universal screening tool) assessment
ALL patients with a MUST score equal to 1 must be monitored and all
patients with a MUST score over 1 must have a nutritional plan
20
•
ALL patients discharged from our community hospitals must have a MUST
assessment
We achieved compliance with these measures for 2010/11 as demonstrated below:-
We also used this information to monitor any change of MUST score during the
patient's stay in their community hospital so that we could demonstrate scores that
had remained stable and scores that had improved:-
21
As the year progressed we saw a gradual increase in MUST score improvements
compared to MUST scores declining.
Finally, we ensured that when patients were discharged they were either informed
about nutrition if their MUST score was still 1 or above or they were referred to a
dietician if their MUST score was 3 or above:-
For 2011/12 this monitoring will continue but it will become a standard KPI as
opposed to a CQUIN.
Clinical Effectiveness
We will ensure that the care and treatment that we give is based on
evidence in order to provide the most effective care possible.
Priority 3
Patient Reported Outcome Measures (PROMs)
PROMs are measures of a patient’s health status or health-related quality of life.
They are typically short, self-completed patient questionnaires which measure the
patients’ health status or health related quality of life at a single point in time. This is
measured at the beginning of their episode of care and at an agreed time following
their end of care.
PROMs remains important to ACE in ensuring that we measure quality as assessed
by patients themselves, allowing us to measure effectiveness of care from the
patient’s perspective.
22
Throughout 2011/12 we will continue to introduce PROMs across our services in
order to ensure that patients views of how they feel about the effectiveness of
treatment are gathered along side what the clinician measures.
Our aim is to align PROMs with patient experience questionnaires gaining a greater
consolidated view of the patient’s perspective which will enable us to respond more
effectively.
How we will measure and monitor
PROMs will be measured using agreed service specific patient questionnaires as
part of a pilot programme. These results will be accessible to clinicians on a daily
basis and will provide ACE with valuable information on the efficacy of treatment.
Once combined with the patient experience questionnaires PROMs will be
measured and monitored more routinely across service areas.
How we will report on progress
PROMs information is reported bi-monthly to the Clinical Effectiveness Group at an
operational level and the Governance and Risk Committee for assurance against the
project delivery. In addition, a quarterly report to the commissioners will be produced
as part of our contract monitoring arrangements.
Outcomes
A PROMs Pilot was undertaken at Clacton and Harwich Community Hospitals in
May 2010. A report was completed in August 2010 and the following outcomes were
achieved:
•
•
•
85% of patients felt an improvement in their health status following their
episode of care within the Community Hospitals.
The EQ5d (sample at appendix 5) was a suitable questionnaire to be used in
the Community Hospital setting.
A greater understanding was required by staff of the processes involved in
obtaining the PROMs data. This outcome would be on hold until the PROMs
Project across other service areas had been completed.
An overall positive outcome was achieved by the pilot but a clear benchmark of best
practice will be established for follow up PROMs to support more effective
measurement of these outcomes.
The PROMs Project due to be underway in December 2010 has been delayed due
to unforeseen IT constraints. These have been addressed and the project will
commence in March 2011. The outcomes from the project will be reported in July
2011.
The PROMs Pilot will be conducted over a 3 month timeframe using agreed service
specific questionnaires; these will be monitored by an IT model which will support
analysis of the results. These results will be accessible to clinicians on a daily basis
and will provide ACE with a patient mandate for the development of services.
NICE Quality Standards
NICE Quality Standards are independent standards that clarify what high quality
care looks like in relation to the 3 dimensions of quality:
23
•
•
•
Clinical Effectiveness
Patient Safety
Patient experience
ACE will use the NICE Quality Standards to support benchmarking of current
performance against evidence based measures of best practice and to identify
priorities for improvement.
How we will measure and monitor
ACE undertake baseline reviews of all published NICE Quality Standards, assessing
the results and establishing action plans where appropriate. ACE will work with
partners and providers to ensure best practice and continuity of service provision in
line with care pathways.
As further NICE Quality Standards are developed and published ACE will agree on
how the quality measures outlined within the standards will be used as potential
quality indicators for measuring quality in line with the NHS Outcomes Framework
2011/12.
How we will report on progress
NICE guidance and NICE Quality Standards are reported bi-monthly to the Clinical
Effectiveness Group at an operational level and the Governance and Risk
Committee for assurance on compliance and any exceptions or areas to consider for
improvement. In addition a quarterly report to the commissioners is produced as part
of our contract monitoring arrangements.
Priority 4
Improved care for people with confusion and dementia
Progress during 2010/11
Bespoke training was commissioned and delivered by Essex University in
collaboration with NEEPT (Previously MHPT). This was made available to all ACE
staff and received good attendance from across community hospital and community
services. Plans are now in development to repeat training or cascade and to provide
further bespoke 'situational' training i.e. specific for service needs. The community
ward sisters are developing a project to review the methodology for dependency
scoring for patients with confusion and dementia which includes the development of
an integrated care pathway, risk assessments and procedures for effective and safe
in patient management.
How we will measure and monitor
ƒ
ƒ
ƒ
ƒ
Uptake of training - register of attendance
more detailed incident reporting regarding the identification of patients with
dementia and confusion experiencing incidents and complaints - use 2011 as
baseline for improvement thereafter
Implementation of ICP and procedural documents
Reviewed and updated discharge processes for patients with dementia and
confusion
24
How we will report on progress
ƒ
Monthly update on progress will be provided via the community hospitals
QIPP meetings.
Patient Experience
We aim to ensure everyone who needs our care and their relatives
and carers consistently have the best possible experience.
Priority 5
Improved Communications
During 2010/11 we successfully set up an 'Information and Involvement' working
group to help us demonstrate compliance with the Care Quality Commission, who
are one of our main regulatory bodies. This group meets bi-monthly and is
accountable to our Governance and Risk Committee. The aim of this group is to
ensure that we respect and involve people who use our services and make sure
that the information that is available to them will enable them to make informed
choices about their care, treatment and support. This group also aims to ensure that
people who use our services - or those acting on their behalf - are sufficiently
involved in making decisions about their care, treatment and support. This group
also has representatives from our local LINKs attending.
We also have a 'Suitability of Staffing' working group that meets on a bi-monthly
basis that is also accountable to our Governance and Risk Committee. The aim of
this group is to ensure that staff have the right skills, qualifications, experience and
knowledge to enable them to support all service users.
How we will measure and monitor
By feedback from LINKs representatives and through the introduction of hand-held
survey devices which allow for real-time reporting across a wide selection of
services. This will allow for a prompt response to the issues/observations/comments
which the public are identifying.
How we will report on progress
Reports on progress and status for both of these groups are part of our standard
Governance and Risk Committee agenda and will continue to be so for 2011/12.
Priority 6
Supporting carers and improving carer experience
Since April 2010, all patients have been asked if they have any caring
responsibilities or if they have someone caring for them on an informal basis.
We have adapted our methods of engaging with potential carers. Using both face to
face and postal methods to identify and offer support to those caring for others. A
leaflet, produced in partnership with Essex County Council detailing the support
available for carers is available to all patients.
25
Excellent progress has been made. To date, more than 10% of all the patients we
have contacted have identified themselves as 'informal' carers. Essex County
Council have advised us that; as a result of the activity we have undertaken, they
have been contacted by over 600 carers who had not been identified as carers
previously.
There is further potential to identify more carers over time. It is estimated that, up to
10% of the population are providing informal care - in North East Essex, this figure
could be as high as 35,000.
We are continuing to work with our partners in support of Carers. NHS North East
Essex has recently established a Joint Carers Task Team. The aim of the team is to
identify and resolve whole economy issues concerning carers and to improve
communication between organisations.
How we will measure and monitor
ACE is a partner in this initiative and the measurement and monitoring is the
responsibility of Essex County Council.
How we will report on progress
As ACE is a partner in this initiative it has still to be decided as to how progress will
be reported.
Priority 7
Capturing Quality
During 2010/11 we devised a quality dashboard that has a suite of quality indicators
from Infection Control, Patient Experience, Patient Harm and Safeguarding that is
reported to our Board (copy attached). During 2011/12 this information will be
enhanced further to incorporate trends and action plans.
Review of Quality Performance
Anglian Community Enterprise (CIC) is a community health service provider and
currently delivers services across 3 ‘divisions’ or departments:
1. Community Services i.e. District Nurses, Intermediate Care Teams,
Community Matrons, Community Rehabilitation and other health care
professionals working out in the community in patients homes or within
clinics.
2. Childrens and Health & Wellbeing Services i.e. Health Visitors, School
Nurses, Health Trainers and Health Promotion Services i.e. smoking
cessation and breast feeding.
3. Specialist Services i.e. Specialist clinical teams such as respiratory, diabetes
and heart failure services, dental services, retinal screening, 2 General
Practices and 2 community hospitals.
During 2010/11 we will be developing and implementing an enhanced set of core
quality indicators that are applicable to all service areas together with service
specific indicators for future quality monitoring.
26
Annual Patient Experience Survey
On an annual basis ACE runs a paper-based annual survey which targets 5% of the
population across all our service lines. This survey has 30 questions structured
around specific themes which are - the environment; the staff; communication and
information; and overall. Service users are given several months to respond to this
question enabling them to give a considered response to how well we are doing.
This annual survey is complemented throughout the year by discharge surveys and
opportunistic surveys which are carried out across various service lines as
appropriate. These surveys differ in their nature as they are 'short and snappy' and
are designed to capture more of an 'on the spot' reaction of our service users.
During 2010 the organisation undertook a project that targeted 35 service lines with
paper-based opportunistic surveys.
These surveys consisted of 5 core questions (as above) plus some additional
service-specific questions where relevant and did not total more than 10 questions in
total for any one service line. By carrying out this project we were able to drill down
into areas of potential concern within specific services.
For the main annual survey the results highlighted a very positive response in
relation to the care and/or treatment received; encouraging comments were also
documented by many patients. An overall satisfaction score of 90% was achieved,
while 81% of patients described the quality of care received as being either excellent
or very good.
Patients using the Community Matrons’ Service were surveyed separately. The
overall satisfaction score of 80% was achieved. Additionally 78% of patients
described the quality of care received as being excellent, very good or good
Compliments and Complaints
We value the feedback we receive about the services we provide. All complaints and
concerns raised are investigated fully.
Action plans are formulated to ensure that the risks of such events happening in the
future are minimised and patient care is improved. All action plans are monitored by
Managers until they are completed. Complaints are reported to and action plans are
reviewed by the Governance and Risk Committee and Patient Safety Working
Group.
27
Compliments
In the period 1 April 2010 to 31 March 2011, there have been a total of 430
compliments received by the organisation. A breakdown by directorate within ACE is
detailed below as well as some examples of the type of compliments staff receive.
Compliments by Directorate
185
202
Adult Community and
Specialist Services
Children's Health and
Improvement Services
Community Hospitals
43
An example of compliments received by each Directorate:
ƒ
“To all staff in Kate Grant Ward. Thank you for getting my husband home to me.”
Community Hospitals and Specialist Services
ƒ
“Thank you so much for all your care, kindness and gentleness. I could not have
been looked after better. You gave me back my confidence, I seem to have lost.”
Adult Community Services
ƒ
“I am writing this letter to express my gratitude for your breastfeeding service
and to one of your staff members. Her help and advice was second to none. She
gave me some hints and tips (and) made herself readily available either by
phone or text so if I needed her, she could offer advice. I was so much more
comfortable with the whole process (and) definitely gave my daughter the best
start in life! Thank you very much for this service”
Children’s and Health Improvement Services
28
Complaints
In the period 1 April 2010 to 31 March 2011, there have been a total of 150
complaints and concerns received by the organisation. Of that number there were 94
actual complaints received.
Outcome of Complaints Closed
Complaints
by
Directorate
and
Outcome following
Investigation
of
Complaint
Adult Community
Services
Children's
and
Health
Improvement
Services
Community
Hospitals
and
Specialist
Services
Totals:
Complaint
Withdrawn
*Not
Applicable
Complaint
Not
Upheld
Complaint
Partially
Upheld
Complaint
Upheld
Total
0
8
6
3
8
25
0
2
2
2
4
10
2
8
6
11
18
45
2
18
14
16
30
80
* Not applicable: Refers to MD letters for information only and are responded to in
writing by the Patient Experience Team in line with Policy.
The following table represents the number of complaints that have been closed
during the period 1 April 2010 to 31 March 2011.
Outcome of Complaints following Investigation
Complaint Withdrawn
2
Not Applicable
18
30
Complaint Not Upheld
14
16
Complaint Partially
Upheld
Complaint Upheld
29
The main aspects of complaints relate to the following subject types:
Breakdown of Complaints by Main Subject Type
Communications (All)
Failure to Access/Treat/Care Appropriately
Hygiene/Cleaning/Infection Control
Premises and Access to
Prescribing
Privacy/Dignity/Respect
59
41
1
7
3
5
We are very keen to ensure that we can identify and act on trends in respect of
complaints received. All complaints are held on our DATIX reporting system and
each aspect of the complaint is recorded individually and collectively. The system
provides us with the ability to easily identify where trends are appearing and allows
us the opportunity to act on these; by identifying key areas of concern and working
with teams to improve service delivery.
We have processes in place to ensure that action plans are developed and
monitored on a regular basis and the steps we have taken to improve services.
Clinical Audits
A detailed breakdown of the clinical audits carried out during 2010/11 is located at
appendix 1.
Hand Hygiene & Essential Steps
We measure compliance with Hand Hygiene in order to ensure staffs are following
best practice in terms of preventing the spread of infection and that they are
following Trust and National guidelines.
Essential Steps to Safe Clean Care is a Department of Health Initiative which is
designed to assure organisations and the public that staff are following best practice
in relation to specific procedures i.e. urinary catheter care.
There is a compliance and reporting framework in place to ensure that where
compliance is less than 100% actions are taken by the service to ensure immediate
feedback is provided to the person being observed. If necessary a change in actions
or practice is implemented. A feedback form is completed detailing actions
/recommendations and sent to the head of service. This informs subsequent onward
reporting to the infection prevention and control groups and committee.
With regard to MRSA and C-Difficile our ceiling for 20010/11 is:
•
MRSA bacteraemia x 4 for all non-acute settings, this is a target for the whole
health economy and is not broken down specifically for North East Essex
Provider Services
•
The ceiling for C Difficile for non acute services across the local health
economy is 55. A ceiling set specifically for our 2 community hospitals is 6.
30
How we will measure and monitor
The data for MRSA bacteraemia and C Difficile is updated daily for the whole of the
North East Essex health economy. The NEEPS Infection Prevention & Control team
monitor the ‘alert organisms’ list which is provided daily by microbiology.
How we will report on progress
Monthly reports are provided to the service managers and to our Integrated
Governance Committee.
Progress during 2010/11
Methicillin-resistant Staphylococcus Aureus (MRSA) and Clostridium Difficile (Cdiff)
figures continue to remain low and remain below trajectory. There has been 1 case
of Cdiff and 1 MRSA bacteraemia for the year 2010/11 to date in the community
hospitals.
Incidents
Risk Management is an essential feature of a modern, health and social care
organisation. Although a risk free environment is generally considered impossible,
much can be done to minimise risk by having all embracing adequate policies and
procedures in place.
The ultimate objective of Anglian Community Enterprise (CIC) is to protect the
public, patients, staff and the organisations’ assets and reputation.
Our primary concern is therefore, the provision of safer, risk controlled environments
together with working policies and practices which address identified risks. To
achieve this principle objective we have adopted a pro-active approach with its Risk
Management programme addressing all clinical, non-clinical, organisational,
financial and strategic and information governance risks.
The main categories of incidents reported are:
Key categories of Reported Incidents
400
365
350
300
270
250
200
150
100
50
28
15
0
Information Security &
Confidentiality
Medication
Slip, Trips & Falls
31
Tissue Viability
These 4 key categories of incidents make up almost 80% of all incidents reported in
the period 1 April 2010 -31 March 2011.
The largest numbers of reported incidents come from the in-patient and specialist
services areas:
Incidents by Directorate
Learning Disabilities 13
Community Services 306
Specialist Services 488
Children, Health & Wellbeing 54
Community Services
Children, Health & Well-being
Specialist Services
Learning Disabilities
It is essential that risk awareness and control becomes part of all employees’
everyday working life and those incidents, accidents, near misses and hazards are
reported using Anglian Community Enterprise's newly acquired DATIXWeb Incident
Reporting system.
Community Services Incidents
300
243
250
200
150
100
Examination of patient
ill Health
Healthcare Records
Inappropriate Behaviour
Information Security & Confidentiality
IT & Clinical Systems
Manual Handling
1
2
4
1
2
1
1
10
1
Violence and Agression
Equipment - Medical
32
12
Tissue Viability
2
Slip, Trips & Falls
1
Clinical Sharps and Splash Incidents
1
Self Harm
3
Safeguarding Issues
1
Referral Issues
5
Procedures
1
Patient Accident (Not Slip, Trips & Falls)
1
Other
3
0
Medication
5
Equipment - General
Communications
3
Diagnosis/Treatment
1
Discharge & Transfer
1
Burns/Scalds
50
There has been an increase in the reporting of tissue viability incidents due to the
new processes implemented following NICE guidance (CG29). NICE guidance
states that all pressure ulcers graded 2 and above should be reported as a local
clinical incident.
* There was a sharp rise in the numbers of Serious Incidents being declared in Q4
(Jan-Mar 2011). This was due to a national requirement applicable from January 1st
for all NHS healthcare providers to declare grade 3 and 4 pressure ulcers as serious
incidents. During this period, all pressure ulcers were being declared by ACE
regardless of whether or not the patient was receiving care from our nursing teams
at the time the ulcer was identified.
Specialist Services Incidents
1 April 2010 – 31 March 2011
400
349
350
300
250
200
150
27
2
2
3
1
2
2
Violence and Agression
1
Staffing
12
Tissue Viability
1
Security
1
Slip, Trips & Falls
1
Referral Issues
5
Safeguarding Issues
2
Property Loss/Damage
1
Patient Transport & 999 Ambulance
9
Other
Delay
Diagnosis/Treatment
3
Patient Accident (Not Slip, Trips & Falls)
Contract Issues
3
Medication
Contact with Object
3
Manual Handling
Burns/Scalds
Communications
13
1
Infection Related
Appointment Issues
17
Information Security & Confidentiality
2
Inappropriate Behaviour
1
ill Health
4
Healthcare Records
1
Equipment - Medical
6
Equipment - General
2
Discharge & Transfer
1
Environmental Concerns
2
Blood & Blood Products
4
Absconding
0
4
Administration Error
50
Non Incident
100
Children’s Health & Wellbeing Services Incidents
1 April 2010 – 31 March 2011
14
13
12
10
9
8
7
6
6
4
3
2
2
2
3
2
1
2
2
1
1
33
Violence and
Agression
Slip, Trips & Falls
Safeguarding Issues
Patient Accident (Not
Slip, Trips & Falls)
Other
Medication
Information Security &
Confidentiality
Inappropriate
Behaviour
Healthcare Records
ill Health
Equipment - Medical
Diagnosis/Treatment
Communications
Administration Error
0
Learning Disabilities Incidents
1 April 2010 – 31 March 2011
5
4
4
4
4
3
3
2
1
1
Equipment - Medical
1
Bullying and
Harrassment
2
1
1
1
1
Violence and
Agression
Slip, Trips & Falls
Patient Accident (Not
Slip, Trips & Falls)
Manual Handling
ill Health
0
Serious incidents
Serious Incidents by Type*
SOVA 1
Unexpected Death 1
Medication Errors 2
Information Governance 4
Pressure Ulcers 34
Pressure Ulcers
Information Governance
Medication Errors
SOVA
Unexpected Death
A Serious Incident (SI) requiring investigation is defined as an incident that:
•
•
•
•
•
occurred in relation to NHS funded services and care
resulted in unexpected or avoidable death
resulted in serious harm
threatens an organisations' ability to continue to deliver healthcare services
resulted in allegations of abuse
34
With the new direction of the organisation it is essential that effective risk
management is at the heart of the business, and that work begins in earnest to learn
lessons from incidents.
A positive indicator that lessons are being learned and the organisation supports a
reporting culture would be to see a further increase in the amount of incidents
reported, but a decrease in the severity of these incidents. The complexity and
breadth of risk management inevitably means some lessons still need to be learned
from incidents.
Recognising and Rewarding Quality
ACE recognises its staff as our greatest asset. We will recognise and reward staff in
terms of their commitment to innovation and striving to continually improve the
services we provide.
We are holding our annual ‘Sharing Best Practice’ event on September 7th 2011
which helps us to reward innovation and disseminate learning across the
organisation. In the future we will hold more of these events in order to stimulate
innovative ideas and quality improvements.
*See note on page 33 regarding the reporting of pressure ulcers
Stakeholder Engagement
Staff and stakeholder involvement in the governance of ACE is an important aspect
for both the organisation and to remain as a Community Interest Company (CIC).
Engagement and involvement of stakeholders is a key principle in the development
of ACE and the work that we have done with members of community during the right
to request process to become a social enterprise will be used as a firm foundation
for their continued involvement in the future. To achieve ACE’s Social Mission we
will utilise surpluses from our operations to prioritise and invest in local projects and
initiatives that improve health and well-being.
We are delivering training in clinical audit and best practice on a bi-monthly basis to
all ACE clinical staff.
ACE will continue to develop a meaningful partnership arrangement between Essex
Health Overview and Scrutiny Committee (HOSC) and the Essex & Southend Local
Involvement Network (LINk) so that they are fully informed about what we do and
what we are continually striving to achieve. Both organisations were represented at
our annual ‘Sharing Best Practice’ event in May 2010, which helped us to celebrate
some of the high quality care delivered during 2009 and to help form our quality
priorities for 20010/11.
This year the HOSC and LINk were both happy with our progress and had no
concerns which they wished to raise with us. LINk are in the process of transforming
their role into a new body, ‘Healthwatch’. We will of course be building on our good
relationship with LINk as and when it transfers its role to Healthwatch.
ACE will be holding another Sharing Best Practice event on 7th September 2011.
35
Supporting Statements:
NHS NEE PCT Commissioners
NHS North East Essex (Primary Care Trust - PCT) welcomes this Quality Account
as a commitment to an open and honest dialogue with the public regarding the
quality of care in Anglian Community Enterprise CIC (ACE). Assurance from the
PCT is required to ensure that the information in this Quality Account is accurate,
fairly interpreted, and representative of the range of services delivered.
Though the PCT are commenting on a draft version of this Quality Account, it is
pleased to be able to assure the accuracy of the content in general. The PCT is
however unable to assure all data reported, as some was yet to be reported and
therefore missing from the draft sent for assurance. A number of areas that could not
be fully assured are detailed below.
The information presented in this Quality Account gives an overall picture of the
quality of the services provided, and represents most of the required elements. The
information is presented in a range of appropriate formats, and highlights positive
achievements and improvements. ACE have responded to the comments from
stakeholders relating to last year’s Quality Account and clearly recognises areas for
improvement from 2010-11 performance. The PCT would like to confirm these, and
to add further areas to be considered for 2011-12.
The PCT wishes to comment on significant achievement in 2010-11 in contributing
to an excellent local result in reducing the incidence of healthcare associated
infections, with NHS North East Essex achieving the lowest rate in the East of
England in C-Difficile infections. Similarly, ACE have demonstrated good working
across the local health economy in their liaison with other health providers to
enhance outcomes of the Safety Express and High Impact Actions for Nursing
initiatives, and in hosting events to share good practice.
The PCT commends ACE’s commitment to improving clinical effectiveness through
participation in local and national clinical audits. The Quality Account demonstrates
how the outcomes of local audit activities are translated into quality improvement
actions. The data from national audits in which ACE have participated is not fully
reported. The PCT would like to see ACE clinicians also taking part in research.
There are some areas of data recording and reporting which the PCT would like to
see improved. There is a discrepancy in the numbers of pressure ulcers, for which
ACE are reporting a higher number than the PCT have on record. There is no data
reported on NHS Number compliance or General Medical Practice Code validity.
The PCT can confirm that this data is available and demonstrates good
performance. There is no information relating to clinical coding accuracy, and how
ACE are addressing any required improvements in this area, which the PCT would
like ACE to consider as a priority, in addition to confirming how information is used
for improvement.
The PCT considers the quality indicators chosen as priorities for 2011-12 to be
suitable and relevant to the services provided. The indicators have been agreed in
consultation with stakeholders and the PCT and cover all domains of quality, linking
coherently to the organisation’s strategic objectives. The PCT looks forward to
working with ACE to support the achievement of these objectives.
36
In summary, this Quality Account has given a positive overview of the quality of
services in ACE, and identified some areas for improvement, reflected in the
priorities chosen for 2011-12. The PCT encourages and will support ACE to continue
to implement the multiple and wide-ranging efforts and initiatives to improve the
quality of its services.
Sarah-Jane Relf
Director of Quality and Governance
NHS North East Essex
May 2011
Essex & Southend Local Involvement Network
The current contract for Essex and Southend LINk is finishing on 31st March 2011.
The organisation is in transition between E & S LINk and Healthwatch.
I can confirm that at this stage we have no comments at this time regarding the
quality account process.
Sharon Cohen
Project Coordinator (North East Locality)
Essex & Southend LINk
Room 431
4th Floor
Queensway House
Essex Street
Southend on Sea
Essex
SS1 2NY
Web: www.essexandsouthendlink.org.uk
Essex Health Overview & Scrutiny Committee
The HOSC works on the basis that if it has any issues/concerns, etc it will raise
these with the health body direct and at the time. As a result it will only comment on
the Accounts if there have been any concerns during the year. During 2010/11 there
have been no concerns with Anglian Community Enterprise, therefore the HOSC
has no comments to make.
Submitted on behalf of Essex Health Overview & Scrutiny Committee
Graham Redgwell
Policy, Community Planning and Regeneration
Essex County Council
37
APPENDICES
Appendix 1
Clinical Audit
Participation in local clinical audits
During 2010-2011, 4 national clinical audit and 66 local audits were undertaken
which covered the NHS services which ACE provides. During that period ACE
participated in 100% of national clinical audits which it was eligible to participate in.
These are detailed in part 2.
There were no national confidential enquiries applicable to ACE.
The national clinical audits that ACE participated in, and for which data collection
was completed during 2010-2011, are listed below alongside the number of cases
submitted to each audit or enquiry as a percentage of the number of registered
cases required by the terms of that audit or enquiry.
Title of National
Clinical Audit
No of cases
required for
audit
National Audit of
Continence CareRoyal College of
Physicians (RCP).
Patients with
urinary
incontinence50
Patients with
bowel
incontinence50
No of
cases
submitted
for audit
100% (50)
Reasons for non
submission of cases
0% (0)
Not submitted as the
organisation did not
have patients which fulfil
the sample
requirements, RCP
notified.
The report of 1 national clinical audit was reviewed by the provider in 2010-2011 and
ACE intends to take the following actions to improve the quality of healthcare
provided.
National Audit of Continence Care- Royal College of Physicians (RCP).
Recommendations
Men with bladder (and/or bowel)
incontinence should have a Digital
Rectal Examination (DRE) (with their
consent) as a basic part of
assessment.
Actions
Discussions with team.
Plan to offer Digital Rectal Examination
DRE as part of assessment for men over
50 years old.
Healthcare professionals should
ensure that they are competent to
perform Digital Rectal Examination.
Release of half day per week Whole Time
Equivalent band 6
38
Those responsible for services should
ensure that there are practitioners
who are appropriately skilled to
perform the examination and that
training is provided to all nonspecialist clinicians engaged in
assessment of patients with urinary
(and faecal incontinence.)
Cure rather than containment should
be the principle aim of treatment.
Healthcare professionals should fully
discuss treatment options with
patients.
Local audit cycles should be used to
push up standards and adherence to
national guidance.
Use of scoring for functional ability/
cognitive ability
Use National Occupational standards
to guide training and competency for
continenence team members
User Group to advise, comment etc
on service
Digital Rectal Examination trained and
experienced staff to provide this and also
offer flow test at home when thought
appropriate.
Plan to release a staff member half day
per week, whole time equivalent band 6
continence specialist nurse to oversee
review of continence assessments for
elderly residential home clients and some
housebound clients who have been
provided with containment products but
may be cognitively able and willing to
consider pelvic floor exercises, bladder
training and possibly medication such as
tolterodine, solifenacin etc
Discussions with team as to usefulness of
scores and which system would be
appropriate
Discussions with team and look at
training and competency documents to
see how standards can be incorporated
Discussions with users, staff.
Possibly arrange meeting for
stakeholders
The reports of 66 local clinical audits were reviewed by the provider in 2010-2011
and ACE intends to take the following actions to improve the quality of healthcare
provided
NICE Pressure Ulcer Audit
Recommendations
To agree how to measure monthly
patient activity for Pressure ulcers
To agree when a referral needs to be
made to the Tissue Viability Team.
To agree when regular assessments
and photographs and tracings need to
be undertaken
To view documentation and consider
European Pressure Ulcer Advisory
Panel and clinical incident reporting
as additions and streamline the
assessment paperwork
Look at training requirements.
Actions
Discuss with operational leads how this
could be measured.
An activity return could be completed
monthly.
Set clear criteria for referrals.
Set clear criteria for regular assessments,
photographs and tracings for community
nursing and the community hospitals.
Revise documentation.
Ensure all staff are appropriately trained
– look at training undertaken within
teams.
39
To agree repositioning regimes
To agree when a referral needs to be
made to the Tissue Viability Team
To agree when regular assessments
and photographs and tracings need to
be undertaken
To agree when it is appropriate to
order pressure relieving equipment
To consider whether the Health care
Quality Team need to support the
completion of the Record Keeping
Audit
To agree whether the National
Institute for Health and Clinical
Excellence (NICE) Pressure Ulcer
Audit becomes the annual audit for
the Tissue Viability Team.
Set clear criteria for repositioning
regimes.
Set clear criteria for referrals.
Set clear criteria for regular assessments,
photographs and tracings for community
nursing and the community hospitals.
Set clear criteria for appropriate ordering
of pressure relieving equipment.
Discuss at the Clinical Effectiveness
Group and Governance and Risk
Committee for agreement.
Look at the paperwork and findings and
revise where appropriate.
More questions may need to be added.
Partnership working may need to be
considered.
Annual Record Keeping Audit – DOMSEM
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure that the patient’s next of kin is Discussion with Dr Marfleet and
recorded for all patients where instructions from the System One team of
where to store the data on Systmone
appropriate
when next of kin is necessary.
Ensure that all entries are timed
Systemone now times all entries
Ensure that the patient’s gender is Systemone now has a record of all
genders from main spine
clearly recorded
Ensure that ethnicity is recorded
where applicable
Ethnicity is now being recorded on
Systemone
Document clearly all known allergies Allergies are already discussed with
patient and recorded when applicable.
or if there are no known allergies
We will now make a note on Systemone
when there are no known allergies
40
Annual Record Keeping Audit – Physiotherapy Clacton
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
All staff to be made aware by e-mail
and staff meeting on the need to
improve note keeping. Especially to
ensure all entries are timed, have the
NHS no on all pages.
Allergies should be documented
clearly.
Each Physiotherapist must make sure
they print name alongside signature.
Medication provides a general
background to the patient’s health
and so drugs are included when
taken however physiotherapists are
not trained in specific doses so this
information does not affect treatment.
Patients who are being treated away
from the hospital should have next of
kin if known in their notes. It is not
necessary for those being treated in
out patients as system one
information is readily accessed
Random checks will be made by
senior staff throughout the year to
check a high standard is maintained.
Annual Record Keeping Audit - Physiotherapy Harwich
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
41
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Staff have been informed by e-mail
and will be given feedback at the next
staff meeting to ensure that notes
include the following:
All pages are correctly numbered,
timed and contain the N.H.S number.
Student notes are counter signed.
Medication doses are included (if
known) - documentation of specific
dosages are outside our scope of
practise
If appropriate next of kin to be taken
off system one (this applies to those
being seen at home). For those
patients seen at hospital NOK can be
easily accessed if required.
Random checks to occur during the
year to check compliance.
Annual Record Keeping Audit – Podiatry Services
Recommendations
Repeat the audit in one year
Record all known allergies
Clearly identified patient care
planning
Avoid use of jargon
Document all relevant medication,
doses and frequency
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Quick launch button added to podiatry
template to assist staff in recording
allergies. This information can be shared
with other units. Staff to record all known
allergies
All staff to ensure that all new patients
have a clear care plan
Ensure all staff have attended record
keeping training
Encourage all staff to complete this within
Systmone
42
Annual Record Keeping Audit – Podiatric Surgery
Recommendations
Repeat the audit in one year
Clearly document that the patient has
either consented or de-consented to
their information being shared with
other non-NHS organisations
Ensure that ethnicity is recorded
where applicable
Ensure that all pages contain the
patients NHS number
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
This requires an alteration to the
Systmone template. Will need to discuss
with Lynda Simpson.
Administrative task. Questionnaire
collected at assessment contains patient
information on ethnicity.
This data is already collected as a
Systmone entry?
Ensure that all entries are timed
When the records contain any
alterations or additions, make sure
that these have been dated, timed
and signed in such a way that the
original entry can still be read clearly
Annual Record Keeping Audit – Occupational Therapy Clacton
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
43
Staff to be made aware by e-mail and at
the next staff meeting in September, that
Occupational Therapy notes should
include: correct gender, medication and
changes to medication, allergy status if
known, and to ensure that student notes
are countersigned.
Random checks will be carried out by
senior staff to monitor notes during the
coming year.
Annual Record Keeping Audit – Speech & Language Therapy –
Gainsborough Wing Colchester Hospital University Foundation Trust
Recommendations
Actions
Repeat the audit in one year
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Liaise with System One team to
Ensure that a next of kin is recorded
determine how this can be put into patient
for all patients where appropriate
template
Ensure that a complete register of
Dept to have an updated set of
signatures to be placed in the front of signatures that are kept in dept, not
every set of records
always relevant for paper lite records.
Annual Record Keeping Audit- Tier 2 aims
Recommendations
Repeat the audit in one year
Improve outcome
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Moving all records to Systmone
Annual Record Keeping Audit- Child Health
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
44
Share findings of audit with Child
Health admin staff and advise Head
of Children’s community Services to
do the same re School Nurse input.
Ensure all mandatory fields are
completed in the records e.g. NHS
numbers, date and times etc.
Clearly document if there are or have
been child protection concerns about
a child in order that these concerns
are able to be identified immediately
Clearly document that the patient (or
parent of) has either consented or deconsented to their information being
shared with other non-NHS
organisations
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Share with relevant staff at staff meeting
and 1 to 1 supervision sessions.
Ensure all staff are aware of the
appropriate documentation to use to
record child protection concerns.
Consent stamp to be ordered for use in
the notes as a reminder to ensure
consent or de consent to information
sharing has been recorded.
Annual Record Keeping Audit- Paediatric Speech and Language
Recommendations
Repeat the audit in one year
Staff Awareness of areas for
improvement targeted
Documentation amended to enable
compliance with standards
Maintain improvements over the year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Presentation of report recommendations
at Speech and Language Therapy team
meeting.
Copy of report and recommendations and
target list for team audit to team leaders
Common Assessment Framework
triangle form to be devised for use.
Standing item on team agendas
Quarterly review of progress through
team leader meetings
Gain clarifications from record keeping
working group with a view to re-audit
45
Annual Record Keeping Audit- Paediatric Speech and Language
(Learning Disabilities)
Recommendations
Actions
Repeat the audit in one year
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Staff Awareness of areas for
improvement targeted
Documentation amended to enable
compliance with standards
Maintain improvements over the year
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Presentation of report recommendations
at Speech and Language T team meeting
Copy of report and recommendations and
target list for team audit to team leaders
Common Assessment Framework
triangle form to be devised for use.
Standing item on team agendas
Quarterly review of progress through
team leader meetings
Gain clarifications from record keeping
working group with a view to re-audit
Annual Record Keeping Audit - Paediatric Rehabilitation
Recommendations
Repeat the audit in one year
Repeat smaller audit within service 6
months by December 2010 to ensure
action points are improving
Improve staff awareness of results of
survey to target areas for action. .by
adding complying with record keeping
policy as an objective for each staff
member in their yearly Personal
Development Plan and by presenting
this years report results at staff
meeting.
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Use existing data forms with agreement
from the Audit team for internal collation
by Head of Specialist & AHP services.
By adding complying with record keeping
policy as an objective for each staff
member in their yearly Personal
Development Plan and by presenting this
years report results at staff meeting.
Standing item on staff meeting agenda
46
Clearly document that parent or
patient has consented or de
consented to information being
shared with other non NHS
organisations.
New consent stamps ordered for paper
record files and stamp will be used to
mark the front history sheet of record to
reduce the risk of clinician not asking for
consent/de consent.
Clinicians to use consent option on
systmone.
Annual Record Keeping Audit- Specialist Health Visitor
Recommendations
Repeat the audit in one year
To ensure each child’s record has
their G.P practice recorded on front
sheet
To ensure each child’s Date of
birth/age is documented at every
contact
Where applicable ensure parent/carer
has consented to referral to other
organisation
Ensure every page contains the
child’s full name and NHS number
To ensure that every entry has been
documented with clinicians
job title
To document the place of contact
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
This information should be recorded and
checked as correct at each review
appointment
Most assessment contacts will be made
during a short time span so child would
be the same age. To ensure age
recorded at each review
To ensure parent/carers sign the 332
referral forms to education
Initially to complete with all new referrals
and then as children return for reviews to
gradually update the records
This is important if the record doesn’t
specify whose record it is
All contacts are in Children’s
Development Centre other than for 2
clinicians
Annual Record Keeping Audit- Children’s Service for Central and North
Colchester
Recommendations
Actions
Repeat the audit in one year
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
47
Ensure all entries are timed
The child’s age Date of Birth is
documented when applicable for
every entry.
Ensure that letters of
correspondence, reports and others
such as documents placed in
chronological order and treasury
tagged.
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
To be highlighted to practitioners
discussing the importance and legal
implications. Refer to policy
To be highlighted to practitioners and the
reasoning behind this action.
Refer to policy.
To be highlighted to practitioners
discussing the importance and legal
implications.
Refer to policy
Annual Record Keeping Audit- Children’s Service for South, East and West
Colchester
Recommendations
Actions
Repeat the audit in one year
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure that the record reflects the
To redistribute the Assessment triangle
use of the Assessment framework
as A5 laminated copy. To be highlighted
Triangle, inc observations an
to the practitioners discuss the
attachment patterns
importance and legal and safe guarding
implications.
Refer to policy
Annual Record Keeping Audit- Children’s Service North Tendring
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
48
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
When applicable document the child’s To be discussed with practitioners: To be
school / nursery
acknowledged that the majority of clients
seen by Health Visitors would not be of
an age to attend school or nursery. In
future this section of the audit to be
completed as N/A to prevent the
presentation of non completion.
Ensure that ethnicity is recorded
Highlighted to practitioners:
Acknowledgement shown that the
ethnicity was not recorded on the written
record until 2008:
Refer to policy.
To include a full sized centile chart if
To remind practitioners that this is
applicable.
applicable for children who are being
monitored for growth or a Child Protection
Plan.
Clearly document that the patient has This is recorded on Systmone
consented or de consented to their
information being shared with other
non NHS organisations.
Annual Record Keeping Audit- Children’s Service South Tendring
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure that ethnicity is recorded
The child’s age Date of Birth is
documented when applicable for
every entry.
Date time and sign all alterations
ensuring original remains clear to
read.
Highlighted to practitioners:
Acknowledgement shown that the
ethnicity was not recorded on the written
record until 2008:
Refer to policy.
To be highlighted to practitioners and the
reasoning behind this action.
Refer to policy.
To be highlighted to practitioners
discussing the importance and legal
implications.
Refer to policy.
49
Annual Record Keeping Audit- District Nursing, Tendring
Recommendations
Repeat the audit in one year
Ensure that ethnicity is recorded
where applicable
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Current paperwork reviewed new notes
implemented to allow ethnicity to be
documented. Inform all staff of record
keeping audit and outcomes for all
recommendation for whole of report.
Record keeping is on the agenda for all
community service meetings.
Ensure that all pages contain the
patients name in full and NHS
number
Current paperwork reviewed new notes
implemented to allow patients name in
full and NHS number
Ensure that all entries are made in
black ink
Informed staff of their reasonability to
ensure that all entries are made in black
ink.
Current paperwork reviewed new notes
implemented to allow recording of timed
entries
Current paperwork reviewed new notes
implemented to allow recording of all
entries listed in a chronological timed
order
Ensure that all entries are timed
Ensure that all entries listed in
chronological order
Ensure that all entries are free of
jargon
Ensure that letters of
correspondence, reports and other
such documents placed in
chronological order and treasury
tagged (e.g. held securely within the
file)
Document clearly that diagnostic
and/or screening tests have been
requested and when applicable that
the results been received and
explained to the patient and acted on
appropriately
Current paperwork reviewed new notes
implemented to ensure entries are free of
jargon.
Current paperwork reviewed new notes
implemented with dividers to ensure all
documents/correspondence are placed in
chronological order. Folders are provided
to ensure notes are held securely.
Current paperwork reviewed new notes
implemented to ensures diagnostic
screening and tests can be documented,
to enable explanation to the patient
where appropriately.
50
Documentation of all relevant
medication, doses and frequency
Documentation and clear identication
of all known allergies or if there are
no known allergies
On the first occasion that a health
professional makes an entry that they
print his/her name designation
alongside his/her signature
Clearly document any unexpected
outcomes, complications of treatment
or remedial actions and the
discussion of these with the patient
and/or his/her family
Current paperwork reviewed new notes
implemented with dividers to ensure all
relevant medication is documented and
known allergies highlighted.
Current paperwork reviewed new notes
implemented to ensure professionals
identify names, designation and
signature. Informed staff of their
reasonability
Current paperwork reviewed new notes
implemented to ensures any agreed
treatment, complication or remedial
action are documented. Informed staff of
their responability .
Annual Record Keeping Audit- District Nursing, Colchester
Recommendations
Repeat the audit in one year
Ensure that all pages contain the
patients NHS number
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Record keeping is on the agenda for all
community service meetings.
Current paperwork reviewed new notes
implemented to allow patients name in
full and NHS number
On the first occasion that a healthcare Current paperwork reviewed new notes
professional makes an entry that they implemented to ensure professionals
print his/her name and designation
identify names, designation and
alongside his/her signature
signature. Informed staff of their
responsibility.
Ensure that all entries made by
Current paperwork reviewed new notes
unqualified personnel e.g. students
implemented to allow countersigning by
have been countersigned by a
qualified staff.
qualified member of the team
Ensure that a complete register of
A complete set of signature lists are held
signatures to be placed in the front of at office base. Current paperwork
every set of records
reviewed, new notes implemented with
interdisciplinary log enabling all discipline
to document involvement.
51
Clearly document if a patient has
refused treatment
Current paperwork reviewed, new notes
implemented to show clear
documentation of a refusal of treatment
by a patient.
Annual Record Keeping Audit- Community Matrons, Tendring
Recommendations
Repeat the audit in one year
Ensure that letters of
correspondence, reports and other
such documents placed in
chronological order and treasury
tagged (e.g. held securely within the
file)
Where appropriate, document clearly
the care that is planned for the
patient. Ensure that all entries are
timed
Ensure that all pages contain the
patients NHS number
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Current paperwork reviewed new notes
implemented with dividers to ensure all
documents/correspondence are placed in
chronological order. Folders are provided
to ensure notes are held securely.
Current paperwork reviewed new notes
implemented with dividers for clear
documentation.
Ongoing plan of care to be included in
care plan and documented.
Current paperwork reviewed new notes
implemented to allow recording of timed
entries
Current paperwork reviewed new notes
implemented to allow patients name in
full and NHS number
Annual Record Keeping Audit- Community Matrons, Colchester
Recommendations
Repeat the audit in one year
Ensure that all entries are timed
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Record keeping is on the agenda for all
community service meetings.
52
Current paperwork reviewed new notes
implemented to allow recording of timed
entries
Document clearly all known allergies
or if there are no known allergies
Ensure that letters of
correspondence, reports and other
such documents placed in
chronological order and treasury
tagged (e.g. held securely within the
file)
Recording all information on Systmone
Current paperwork reviewed new notes
implemented with dividers to ensure all
relevant medication is documented and
known allergies highlighted. Informed
staff of their responsibility
Current paperwork reviewed new notes
implemented with dividers to ensure all
documents/correspondence are placed in
chronological order. Folders are provided
to ensure notes are held securely.
Annual Record Keeping Audit- Falls Service
Recommendations
Repeat the audit in one year
The following areas have been
identified as benefiting from some
improvement –
Ensure that all pages contain the
patients name in full and NHS
number
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Action still waiting for clarification on the
issue above since the assessment form is
a single document with all demographic
details on the front page. There is
conflicting information with some advising
us that if it’s a single document with
several pages patients name is only
required on the front page
Annual Record Keeping Audit- Intermediate Care Services
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
53
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
All Pages contain the patients NHS
Current paperwork reviewed and altered
Number
to allow NHS Number to be recorded
Record GP and Ethnicity
Current paperwork reviewed and altered
to allow recording of Ethnicity and GP
Ensure that all entries are legible
Record Keeping and Documentation to
On the first occasion that a healthcare be added to rolling programme of
professional makes an entry that they education within Intermediate Care to be
print his/her name and designation
reinforced at monthly staff meetings and
alongside his/her signature
handovers
Ensure that all entries made by
unqualified personnel e.g. students
have been countersigned by a
qualified member of the team
Ensure that a complete register of
A complete set of signatures are kept in
signatures to be in place in the front
the office.
of every set of notes.
All staff who visit each client is logged
and timed on Systmone in the patient
journal
Where appropriate document clearly
On going plan of care to be included in
the arrangements for continuing care care plan.
Discharge plan and where clients are
referred onto to be included in notes and
recorded in Patient journal in Systemone.
Annual Record Keeping Audit- Kate Grant Ward, Clacton Hospital
Recommendations
Repeat the audit in one year
Gender to be recorded on admission
All entries to be timed in main record,
on Morse Falls Risk assessment &
Bedrails Decision Aid
Entries are made in black ink
Healthcare professional prints name,
designation alongside signature
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Staff to ensure that gender is
documented as part of admission process
Staff to ensure this is completed as part
of admission process and when updated
Staff to ensure all members of the team
including bank staff use black ink
Staff to ensure that printed name,
designation and signature is documented
54
Annual Record Keeping Audit- St Osyth Priory Ward, Clacton Hospital
Recommendations
Repeat the audit in one year
Feed back to all staff
Re Audit in 3 months
All staff as appropriate to attend/be
booked for the clinical record keeping
up dates.
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Staff to be made aware that they are only
to use black ink also to be fed back to
NHS Professional. Staff to be reminded
to record gender and ethnicity, time all
entries especially on risk assessments
and bed rails assessments. Staff must
remember to put patients name on each
page. On the admission page of booklet
1 the admitting Registered Nurse must
print and sign their name. All must
scores must be completed. Patients with
a high risk for falls must have an
Integrated Care Pathway. In the Multi
Disciplinary Team log staff must
remember to document medication
changes.
To be completed by ward managers
2 hour update must be completed every 3
years. Training records keep on the ward,
and the extranet
Annual Record Keeping Audit- Durban Ward, Clacton
Recommendations
Repeat the audit in one year
Feed back to ward staff
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Staff made aware that all patients’
records need to contain their NHS
number.
All staff must not use highlighter pens on
legal documents.
55
All contact referrals must be signed by
the patient to show consent of sharing of
information.
The first entry in booklet 1 by the
admitting Registered Nurse must be
printed and signed, ensure that
Integrated Care Pathway is used for all
patients that are of a high risk of falls.
Annual Record Keeping Audit- Jubilee Ward, Clacton Hospital
Recommendations
Repeat the audit in one year
Ensure patients gender is recorded
Ensure all entries are timed
First entry in patient notes to have
signature and printed details of staff
member
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Print first 3 pages of Patient
Administration System which include all
patient details clearly written and place in
nursing notes.
This has now been discussed with all
trained nurses who have also had access
to audit report to see what needs action.
Reminder to be added to unit meetings to
reinforce compliance
To be discussed with staff during week of
27th September 2010
Annual Record Keeping Audit- Minor Injuries Unit, Clacton Hospital
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure that ethnicity is recorded for Reiterate to reception staff the need for
100% compliance
all patients where appropriate
Introduce use of booking in form which
records this information
56
Ensure that a next of kin is recorded
for all patients where appropriate
Reiterate to reception staff the need for
Next of Kin recording
Encourage Nursing staff to complete
‘accompanied by’ section of template
Introduction of Minor Injuries Unit module
in Systmone will make this mandatory
field
Document clearly that consent (verbal Remind clinical staff of need to document
or written) for significant/invasive
consent
procedures or treatment e.g.
Introduce box in template to reflect this
catheterisation, diagnostic tests has
when Minor Injuries Unit module in place
been discussed with the patient
Annual Record Keeping Audit- Trinity Ward, Clacton Hospital
Recommendations
Repeat the audit in one year
Ensure that all entries are timed
Ensure that all entries are legible
Document that the results of any
diagnostic and/or screening results
have been explained to the patient
and acted upon appropriately
Ensure that all details on the Care
Pathway 11 and integrated care
pathway for falls are documented
appropriately
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Inform all staff at Ward meeting
Review at weekly record validation
Inform staff who are not meeting target
Inform all staff at Ward meeting
Review at weekly record validation
Inform staff who are not meeting target
Inform all staff at Ward meeting
Inform staff who are not meeting target
Inform all staff at Ward meeting
Review at weekly record validation
Inform staff who are not meeting target
Annual Record Keeping Audit- Dietetics
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
57
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Page contains NHS no
All entries are timed
Register of signatures
This should no longer be an issue. The
service has moved over to Systmone
where the NHS number will always be
recorded
This should no longer be an issue where
the time is recorded at each contact.
We have a register of signatures in the
office which is updated on a yearly basis.
Many of the notes are kept on computer
now so a signature is not necessary. The
register will continue to be kept anyway.
Where signature where not found on the
paper records these was actually print off
of the computer records when it could be
verified whose notes they were.
Annual Record Keeping Audit- Occupational Therapy, Learning Disabilities
Recommendations
Repeat the audit in one year
Ensure that all entries made by
unqualified personnel e.g. students
have been countersigned by a
qualified member of the team.
Ensure that a complete register of
Signatures to be placed in the front of
every set of records.
Clearly document that the patient has
either consented or de-consented to
their information being shared with
other non-NHS organisations
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
We have electronic notes on systm1.
Apparently no other services in ACE do
this on systmone
Again, we are keeping electronic notes so
no longer relevant.
To create a form to be completed with the
client/carer during the first visit.
Annual Record Keeping Audit- Physiotherapy Learning Disabilities
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
58
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure that ethnicity is recorded where
applicable
Ensure that all pages contain the patients
NHS number
Document all relevant medication, doses
and frequency
Document clearly any reason for the
discontinuation of medication - not sure
we would know this or it is relevant for
Physiotherapy.
Change from EPEX information system to
System1 – Sept 2010 :Meet with staff 2 weekly to ensure that
the above information can be inputted for
patients.
To monitor reports produced by the
Systmone team to ensure required data
is collected
Annual Record Keeping Audit- Speech and Language Therapy, Learning
Disabilities
Recommendations
Actions
Repeat the audit in one year
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure ethnicity is recorded for all
All clinicians to check records for their
patients registered for Speech and
caseloads on epex and transfer eligibility
Language Therapy input on
information to Systmone registration
Systmone
Ethnicity information to be recorded at
Speech and Language Therapy Triage
appointments
Consider adding ethnicity to the referral
form for Learning Disabilities Allied
Health Professionals.
59
Non-qualified staff and Speech and
Language Therapy student records to
be countersigned by a qualified
Speech and Language Therapy
Ensure that records do not contain
subjective statements
All patients seen by unqualified staff or
students to have an allocated responsible
clinician
Discuss with systmone team how
students can access patient records for
recording purposes.
Agree with team wording for patient
records that will make clear who is the
supervising clinician.
Where records are printed supervising
clinician to sign all entries by unqualified
staff. This to be requested by unqualified
staff member when appropriate or at
supervision.
Ensure that member of staff completing
audit fully understands what a ‘subjective
statement’ means.
Agree amongst team how to word
reported events or patient behaviour in an
objective manner.
Annual Record Keeping Audit- Safeguarding Colchester
Recommendations
Repeat the audit in one year
Cascade the results of audit out to all
of the teams.
Consider introducing quarterly peer
review into the audit cycle.
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Head of Safeguarding will put together a
short brief offering the highlights of the
results report.
Safeguarding Lead to share with
Children’s Health & Well-Being Division.;
most likely at a regular Heads of team
meeting.
Heads of service to then start the
cascade of audit
outcomes/recommendations to their team
leaders/coordinators at their regular team
meetings.
Team leaders/service leads/managers to
present at local team meetings
Discuss further with Heads of Service
60
Refresher training for staff
Will need further discussion as to the best
way to proceed with this.
Has resource implications and may
impact on business continuity.
Discussions to include Systmone trainers.
Further consideration to be given to the
audit of individual practitioner’s record
keeping. Consider using Systmone
reporting alongside peer review.
Annual Record Keeping Audit- Safeguarding Tendring
Recommendations
Repeat the audit in one year
Cascade the results of audit out to all
of the teams.
Consider introducing quarterly peer
review into the audit cycle.
Refresher training for staff
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Head of Safeguarding will put together a
short brief offering the highlights of the
results report.
Safeguarding Lead to share with
Children’s Health & Well-Being Division.;
most likely at a regular Heads of team
meeting.
Heads of service to then start the
cascade of audit
outcomes/recommendations to their team
leaders/coordinators at their regular team
meetings.
Team leaders/service leads/managers to
present at local team meetings
Discuss further with Heads of Service
Will need further discussion as to the best
way to proceed with this.
Has resource implications and may
impact on business continuity.
Discussions to include Systmone trainers.
Further consideration to be given to the
audit of individual practitioner’s record
keeping. Consider using Systmone
reporting alongside peer review.
61
Annual Record Keeping Audit - Cardiac Services
Recommendations
Repeat the audit in one year
Share audit results with team
Review paper records
Offer staff clinical record keeping
study day
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Review audit results at next team
meeting and engage staff with this
process, reminding them of there
professional obligations to record
keeping.
Remind staff of the Nursing and
Midwifery Council Guidance for record
keeping.
Provide copies of this if needed
Team to review paper work & make
amendments to paper record with
reference to recommendations from audit
to ensure all data is captured.
Managers to nominate staff or staff to
nominate themselves. Send Training,
Education and Development forms to
training dept
Annual Record Keeping Audit – Continence and Urology Services
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
On the first occasion that a healthcare Agree staff all to write name and
professional makes an entry that they designation at first entry.
print his/her name and designation
alongside his/her signature
62
Ensure that if a patient has refused
treatment that this is clearly
documented
Agree exactly what we will write – Health
Care Assistant, Associate Practitioner,
Clinical Nurse Specialist or in full? Or
Nurse or Registered Nurse Agreed at
team meeting ‘Nurse’ is only designation
needed. Discuss need for this.
Agree on documentation – exactly what
to put. Agreed this happened rarely and
that the event noted was really a choice
rather than a refusal to have treatment
Annual Record Keeping Audit - Respiratory Services
Recommendations
Repeat the audit in one year
Ensure that the patient’s gender is
clearly recorded
Clearly document that the patient has
either consented or de-consented to
their information being shared with
other non-NHS organisations
Document clearly all known allergies
or if there are no known allergies
Document all relevant medication,
doses and frequency
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Action 1: all to record on current
paperwork (front cover)
Action 2: to amend the front sheet to
include "GENDER"
Action 3: Kay/Janet/Yvonne: please
amend the front sheet to include
"Consent to Sharing Information"
Action 4: all to record where known on
the front cover
Action 5: Kay/Janet/Yvonne: please
amend the front sheet to include
"KNOWN ALLERGIES"
Action 11: All comply
63
Annual Record Keeping Audit – Dental Services
Recommendations
Repeat the audit in one year
Inform Team
Paperless records
Do not include Dental Services in
NHS Number count
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Report disseminated and discussed at
Team meeting
All staff to comply and have resources to
support this
Inform Audit Team
Annual Record Keeping Audit – Diabetes Services
Recommendations
Repeat the audit in one year
Ensure that the patient’s next of kin is
recorded for all patients where
appropriate
Ensure that all entries made by
unqualified personnel e.g. students
have been countersigned by a
qualified member of the team
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Discuss with team members and
document where appropriate
Student nurses are not to document
within our notes as they will not be
reviewing patients on their own.
Document clearly all known allergies To ensure staff are aware of the Allergy
key within system one and input data id
or if there are no known allergies
appropriate.
To document blood test request made
If any diagnostic and/or screening
tests have been requested to ensure
they are documented within the
healthcare record and results are
recorded
64
Annual Record Keeping Audit - DRSS
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Ensure that the patient’s next of kin is There isn’t a facility to record this on the
current software however, an updated
recorded for all patients where
version is being installed late Sept 2010
appropriate
where this will be investigated
Ensure that all entries are free from All information is recorded onto a clinical
database where only Optoms can record
jargon and subjective statements
data. This will be highlighted to them
Document all relevant medication,
doses and frequency
Medication is documented and necessary
however, does and frequency is not
required
Clearly document that the patient has An information leaflet is given to every
either consented or de-consented to patient to consent to treatment and
their information being shared with information sharing
other non-NHS organisations
Annual Record Keeping Audit – Epping Close GP Practice Services
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Discussed at staff meeting
Training carried out as required
Entries timed;
Following changes cannot be made;
1).All records electronic so no signatures
65
Countersignature of entries by
students
Documentation of consent /non
consent to sharing information with
non-NHS organisations
2). Records always show GP by name
and role but not possible to show role of
other staff on consultation header. All
shown on User Manager.
3). Reference to entries ‘on official
documentation’ N/A computerised
Computerised. Induction to include
instruction by training clinicians – trainee
should state name of clinician with whom
discussed entry
Read coding where available
Annual Record Keeping Audit – Frinton road Medical Practice Services
Recommendations
Repeat the audit in one year
Next of Kin Details
Lack of capacity, due to Mental
Capacity Act 2005
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
To incorporate Next of Kin Details on the
New Patient Questionnaire, and other
questionnaires given out by the practice,
so that details can be added to the
patient record.
Make all clinical team aware of the need
to record why consent was not agreed,
due to lack of capacity, under the Mental
Capacity Act 2005, including the basis
upon which treatment decisions were
made.
Annual Record Keeping Audit – Tissue Viability Services
Recommendations
Repeat the audit in one year
Actions
Update data collection form, in line with
any changes to the Policy.
Clinical Audit Specialist to send relevant
data collection forms to Service Lead,
ready for data collection to be undertaken
by service areas within the agreed
timeframe.
66
Document all relevant medication,
doses and frequency
Data analysis & collation of final report to
be carried out by the Clinical Audit
Specialist.
Nurses to be aware to document all
relevant medication, doses and frequency
Clearly document that the patient has
either consented or de-consented to
their information being shared with
other non NHS organisations
Nurses to clearly document that the
patient has either consented or deconsented to their information being
shared with other non NHS organisations
Service Users Feedback on Child Health (Childrens Health and Wellbeing
Services)
Recommendations
Actions
No Recommendations identified. to
No actions identified
be implemented at this time
Service Users Feedback on Immunisation Sessions (Childrens Health and
Wellbeing Services)
Recommendations
No Recommendations identified. to
be implemented at this time
Actions
No actions identified
Productive ward Audits for St Osyth Priory Ward
Recommendations
Patient Status at a Glance
The “white board”
Handover sheet
Re-audit handover sheet
Patient Observations
Staff to ensure that all areas of
chart are completed.
Well Organised Ward
Knowing How We Are Doing
Ward Rounds
Consultants will undertake ward
round on designated day.
Ward round will not interfere with
patient meals
Actions
Updated every day as changes occur
Updated every night, more frequently if
required
None at present
None Required
None Required
Consultants will ensure ward is aware if
day needs to change.
Consultants made aware that they cannot
undertake round during patient meal times
67
Productive ward Audits for Durban Ward
Recommendations
Patient Status at a Glance
The “white board”
Handover sheet
Re-audit handover sheet
Patient Observations
Staff to ensure that all areas of
chart are completed.
Well Organised Ward
Knowing How We Are Doing
Ward Rounds
Consultants will undertake ward
round on designated day.
Ward round will not interfere with
patient meals
Actions
Updated every day as changes occur
Updated every night, more frequently if
required
None at present
None Required
None Required
Consultants will ensure ward is aware if
day needs to change.
Consultants made aware that they cannot
undertake round during patient meal times
Blood transfusion Audit
Recommendations
Planned meeting with Doctors
within the first working week at
Clacton Hospital
Actions
Lead Nurse for Blood transfusions to be
advised by Dr Rasool / Dr Chan Personal
Assistant when New doctors are due to
start and book a 1 hour discussion slot
Clinical Training and development will
update the register held every time a
member of staff attends an update or
renews competency.
Clear accurate records to be held
by ACE of all staff who have
attended blood transfusion updates
and are competent in caring for
patients receiving a transfusion.
All bleep holders must be up to date Clinical Matron and line managers MUST
with transfusion training and have a ensure that if a member of staff is
valid competency.
requested to hold the bleep they meet the
transfusion requirements. Staff who are not
up to date must state this if asked to carry
the hospital bleep
Transfusions to only take place
Transfusions only to take place between
when ward doctors are on duty.
0800 and 2000hrs Monday to Friday.
To look at alternative ways of
e-learning and regular classroom updates.
supporting staff to maintain
competencies and up to date
training
68
Access Time for Rehabilitation referrals Medical Wards Clacton Re - Audit
Appropriateness of referrals to OT and Physio from Care of the Elderly
wards at Clacton Hospital Audit (combined )
Recommendations
Actions
Share the report
Circulate this audit report to Physiotherapy
and Occupational Therapy inpatient teams
and relevant professionals
Further discussion regarding
Discussion and arrangements to be
arrangements, competencies and
discussed with rehabilitation Services
work allocation for cover of staff
manager in the first instance
annual leave and ensuring this is
incorporated into department
planning and standards of care.
Repeat the audit to ensure
Re audit using same methodology.
improvements and quality of
Discuss with Clinical Services manager if
service. If a significant difference
systmone inputting needs adjustment to
continues, it may indicate that
assist with identifying cause of delays.
further investigation and changes
Verify with management if Occupational
might be needed.
Therapist and physiotherapist should be
covered in the same audit, or separate
audits and if they wish to use the same
standards.
Spinal Triage Outcomes (Community Services)
Recommendations
To develop/include a checklist of
required information to the MRI
magnetic resonance imaging Request
Form
To develop/include a checklist of
required information to the X-Ray (for
spine) Request Form
Reject referrals that are not on a fully
completed current spinal pathway
referral form or documented on a full
referral letter
To develop series of workshops
and/or paper based information for
GP's giving top-tips on the spinal
pathway and spinal problems.
Actions
Compilation of list
Complete
Letter to all GPs
Workshops need to be discussed with
Practice Based Commissioning team.
The top tips can be written separately
School Teachers Presenting with Voice Problems
Recommendations
To endeavour to see if there is a
viable business / health promotion
opportunity to give voice care
advice to schools
Actions
Audit results to be discussed at the
Integrated Governance Committee to
determine if suitable for development.
69
Podiatry Service Re-Profiling, New Patient Audit (Community Services)
Recommendations
Share audit results with the Podiatry
team, ensure those not attending
have access to results
Podiatry DNA (Did Not Attend) policy
brought in line with Provider services
Policy
Change in discharge system Administration team (previously
clinical staff) to undertake discharging
of patients off system one and ending
referral
Actions
Presentation of audit to Podiatry Staff –
Admin and Clinical staff. Results included
in minutes of meeting circulated to all
staff members
Ensure all clinical and admin staff are
aware of the Provider services DNA (Did
Not Attend) policy and ensure all new
patient letters reflect this policy.
Agreement of change of admin roles
regarding discharging patients required
from both clinical and admin staff. A
system of communicating which people
are for discharge needs to be
implemented.
X-ray Request Audit (Community Services)
Recommendations
Share results with podiatry team to
identify how improvements can be
made
Identify where information about x-ray
requests should be placed within
patient record
Encourage appropriate recording of
thought process in patient record
Assess whether recording of x-rays
has improved
Actions
Presentation of results at staff meeting,
ensure those not attending meeting have
access to the results.
Discussion with staff at staff meeting and
decide on location within patient record
for information regarding rationale and
follow-up of x-rays.
Ensure staff are aware of what level of
information is required in the patient
record and that staff are up to date on
their mandatory training on record
keeping.
Submit an audit proposal
Carry out re-audit
X-ray Request Re - Audit (Community Services)
Recommendations
Share results with podiatry team,
showing how our recording has
improved over the past year
Encourage continued recording of
thought process in patient record
Actions
Presentation of results at staff meeting,
ensure those not attending meeting have
access to the results.
Ensure staff are aware of what level of
information is required in the patient record
and that staff are up to date on their
mandatory training on record keeping
70
In accordance with IRMER
Submit an audit proposal
(requirements, assess whether
Carry out re-audit in a years
Ionizing Radiation (Medical
Exposure) Regulations) recording of
x-rays continues to improve
Review of use of Catheterisation Record Audit
Recommendations
Nurses should always be aware of
rationale for catheter – need to
make sure they do or they find out
Catheters need to be documented
in nursing notes - encourage and
monitor
Catheters need to be documented
in medical notes - encourage and
monitor
Should always be review of catheter
or reason why not - monitor
Improved liaison between
Colchester Hospital University
Foundation Trust and Anglian
Community Enterprise. Perhaps coordinate paperwork
Ensure enough supplies in patient
home, but not excessive amounts of
bags/valves/catheters etc
Actions
High Impact Actions catheter plan – active
High Impact Actions catheter plan – active
High Impact Actions catheter plan – active
High Impact Actions catheter plan – active
High Impact Actions catheter plan – active
High Impact Actions catheter plan – active
Bowel Care Audit
Recommendations
Repeat the audit in one year
Actions
Continence Team to complete audit of
Community Hospitals and Community
patients within the agreed timeframe. Data
analysis & collation of final report to be
carried out by Nurse Specialist –
Continence with guidance from Clinical
Audit department
Documentation from evidence based
To update the questionnaire as
practice, national guidelines and good
appropriate.
practice to be incorporated
All areas to be working to and
Action plans to be put in place for all
implementing action plans based on service areas to improve on information
individual results.
gathered in the documentation.
All staff to attend Bowel
Bowel Management course should be
Management training where
complete by all clinical staff. Details and
appropriate (all staff should be able relevant application forms can be found on
the Training & Education intranet site.
to evidence their competence and
knowledge in this area)
71
To update Bowel Management
Policy
Review Bowel Management Policy against
outcomes of Audit and National guidance
taking into consideration any comments
received.
Quality of Dental Radiographs Audit (Specialist Services)
Recommendations
To check operator issues
To check display functions.
Actions
To rectify over exposure and under
exposure issues with the equipment
To rectify over exposure and under
exposure issues with the equipment
Prescribing Audit (Specialist Services)
Recommendations
Improve patient safety by
standardising drugs and regimens
prescribed and share best practice.
Outliers will be identified
Actions
This second audit had reduced the
incidence of outliers.It was decided to
continue the audit and revisit annually.
Prescribing regimens had become more
consistent. It was agreed that guidelines
for this group would not be written as an
independent document but clinicians
should follow guidance in the British
National Formularly.
Diabetes Inequalities Project (Specialist Services)
Recommendations
The pilot is rolled out as a permanent
project across the Anglian Community
Enterpriseand becomes part of the
service delivered by the specialist
diabetes team.
All patients should be referred by their
GP practices according to need
All patients identified as having an
HbA1c (The most common test is the
HbA1c test, which indicates your
blood glucose levels for the previous
two to three months.) more than9% or
less than 6% including hard to reach
are referred to the service
PARR++ (Patients at Risk of
Readmission) is used across North
East Essex to identify patients who
have high admissions and require
support
Actions
The pilot is rolled out as a permanent
project across the Anglian Community
Enterprise and becomes part of the
service delivered by the specialist
diabetes team.
All patients should be referred by their
GP practices according to need
All patients identified as having an HbA1c
(The most common test is the HbA1c
test, which indicates your blood glucose
levels for the previous two to three
months.)more than 9% or less than 6%
including hard to reach are referred to the
service
PARR++(Patients at Risk of
Readmission) is used across North East
Essex to identify patients who have high
admissions and require support
72
To reduce sudden impact on service, Practices to be introduced onto the
the team to be allocated a group of
scheme in a stepped approach according
practices to provide continuity of care. to QoF (Quality Outcomes Framework)
results and which practices show greater
numbers of patients more than 9%.
Personalised Care Plan Audit
Recommendations
Report all results to all team
members within each speciality
Undertake Pilot of New PHP
(Personalised Health Plan)
documentation
Actions
Cascade at team meetings
Reinforce to all team members
Team Leaders to feedback full results to all
team members
In all areas pilot the new PHP
(Personalised Health Plan) documentation
Activity on referrals for Dysphasia Audit
Recommendations
Establish whether Royal College
Speech and Language Therapy
guidance re response times is
appropriate to a Community
Learning Disability service. Agree
response times for Adult Services
Actions
Discuss with the Adult Acquired Speech
and Language Therapy Team to develop a
consistent approach across Adult services.
Follow and contribute to the National
debate and with Royal College Speech and
Language Therapy as to National guidance
Be informed by Service Specification
currently being discussed with Learning
Disability Commissioners
Develop system to record factors
Identify & record the factors to be
influencing clinical judgement as to considered when making a decision
urgency of referrals in order to
regarding urgency
maintain consistency &
Develop appropriate paperwork to be used
transparency
in conjunction with the Case, caseload and
workload indicators for Speech and
Language Therapy
Investigate whether it is advisable to save
this onto the Community Information
System
Establish guidelines and
Follow National debate and get advice from
consistency within the Speech
National Dysphasia advisors.
Language Therapy team as to what Discuss within Learning Disability team and
is meant by the first ‘contact’ and
establish consistent approach and
when does the clock start ticking
recording.
Minimise delay in receipt of referrals Work with other Allied Health Professionals
by the Speech and Language
to establish the new system of referrals
Therapy team
after April 2010 when other Learning
Disabilities colleagues move to
Hertfordshire Foundation Trust.
73
Ensure succession planning within
the team for Dysphasia qualification
Ensure that all referring agents are aware
of the new procedures
Establish a system of quickly alerting senior
clinicians as to new Dysphasia referrals
Train another therapist to post graduate
Intermediate level in Dysphasia
Aseptic Non Touch Technique - Principles of Best Practice for Clinical
Procedures (Learning Disabilities- Allied Health Professionals)
Recommendations
Actions
Report all results to all team members Cascade at team meetings
within each speciality
Undertake Pilot of New Personal
In all areas pilot the new Personalised
Health Plan documentation
Health Plan documentation
Reinforce to all team members
Team Leaders to feedback full results to
all team members
Essential Steps – Compliance of Clinical Interventions (monthly audit for all
Community Hospitals)
Recommendations
Actions
Measure compliance with effective
Further audit requirements as identified
hand hygiene
from Aseptic Non-Touch Technique audit
undertaken July /August 10. To focus on:
Community hospitals – observing a range
of clinical skills (as opportunity allows)
clinical and non clinical staff.
Community – Health Care Assistant’s
undertaking wound care.
Community -Clinical skills other than
wound care i.e. catheterisation / enteral
feeds / venepuncture / central lines.
Development of Aseptic Non-Touch
Further development of the policy to
Technique policy /procedure
include Aseptic Non-Touch Technique
pictorial guides
To ensure all associated policies are All relevant policies to be updated with
Aseptic Non-Touch Technique
principles
compliant e.g. catheterisation
Intravenous therapy, central venous
access device
Assurance staff take part /attend
Bench mark practice - % of clinical staff
appropriate learning and practice
attending existing clinical skills training
activities to effectively maintain and
past 3 years/and or attained competency
develop competence and
against the number staff undertaking
performance relating to Aseptic Non- /expected to use this skill in their practice.
Touch Technique
74
Delivery of Aseptic Non-Touch
Technique principles to clinical staff
ensuring staff have up to date
knowledge and skills when
undertaking clinical skills.
Develop Aseptic Non-Touch
Technique Assessors
Aseptic Non-Touch Technique
Training & competency assessment
available to all staff (includes Clinical
staff new to the trust and newly
qualified staff – preceptorship –links
to above i.e. establishing the trust
standard for clinical staff attending
essential clinical skills training to be
arranged.
All existing clinical skills training to
incorporate Aseptic Non-Touch
Technique principles
Provision of wound care training and
competency assessment for clinical
staff. Aseptic Non-Touch Technique
(compliant)
Focus on 5 key areas – wound care TIME
(Tissue management; Inflammation and
infection control; Moisture balance;
Epithelial) Leg ulcer), catheterisation
(links to urinary catheter plan),
Intravenous therapy / central lines,
enteral feeds.
Declaration of competency’ work in
progress (Community nursing)
Raising awareness:
Development of Aseptic Non-Touch
Technique workshops. (Timetable of
workshop delivery (hospital and
community).
Stands/display lunch periods
Consider e-learning programme to
support clinical skills training.
Identify Aseptic Non-Touch Technique
assessors for hospital & community.
Consider TV link practitioners
Train the assessor programme in
Aseptic Non-Touch Technique
Development of Aseptic Non-Touch
Technique training session for clinical
staff.
Train the Aseptic Non-Touch Technique
assessors
Update preceptorship packs to ensure
Aseptic Non-Touch Technique compliant.
Incorporate Aseptic Non-Touch
Technique into existing learning
packages and clinical skills training
Professional Practice Portfolios,
catheterisation, Intravenous therapy, and
venepuncture. Standard statement in
introduction of learning packages and
adjust competency accordingly.
Develop general wound care training /
learning package / Professional Practice
Portfolios, /competency benchmark / for
(Aseptic Non-Touch Technique
compliant)? Incorporate into existing
TIME (Tissue management; Inflammation
and infection control; Moisture balance;
Epithelial) Leg ulcer) training or
workbook that includes general wound
care including dressings.
75
Medical Devices Audit
Recommendations
Overdue bed maintenance
Revise staff training records
Remove old Continuous Passive
Motion machine and arrange
Disposal
Add new armchair to asset register
Arrange repair of urine analyser
Actions
Discuss with EBME (Electro-Biomedical
Engineering- hospital equipment
technicians Manager the need to ensure
beds are checked as per the agreed
Service Level Agreement
Update competency statements
Contact Porters
Update the planet system
To order spare parts
76
Area
Community Hospitals
Community Nursing
Month
Preventing the
Spread of
Infection
Enteral
Feeding
Urinary
Catheter Care
- Insertion
Urinary
Catheter Care
- Continuing
Care
Central
Venous Ongoing Care
Peripheral
Intravenous
Cannula Insertion
Peripheral
Intravenous
Cannula Ongoing
Number of
Returns Teams
Submitted
Numbe
r of
Teams
April
(25/25)
100.0%
(20/20)
100.0%
(7/7)
100.0%
(20/20)
100.0%
(5/5)
100.0%
(13/14)
92.9%
(19/19)
100.0%
(28/28)
100.0%
5
May
(24/25)
96.0%
(15/15)
100.0%
(13/13)
100.0%
(20/20)
100.0%
(5/5)
100.0%
(15/15)
100.0%
(20/23)
87.0%
(28/28)
100.0%
5
June
(25/25)
100.0%
(7/7)
100.0%
(9/9)
100.0%
(20/20)
100.0%
(5/5)
100.0%
(16/17)
94.1%
(16/16)
100.0%
(28/28)
100.0%
5
July
(25/25)
100.0%
(15/15)
100.0%
(6/6)
100.0%
(20/20)
100.0%
(5/5)
100.0%
(14/15)
August
(25/25)
100.0%
(6/6)
100.0%
(7/7)
100.0%
(20/20)
100.0%
(5/5)
100.0%
(8/8)
September
(25/25)
100.0%
(4/4)
100.0%
(7/7)
100.0%
(20/20)
100.0%
(5/5)
100.0%
October
(25/25)
100.0%
(6/6)
100.0%
(8/8)
100.0%
(20/20)
100.0%
(5/5)
November
(22/22)
100.0%
(5/5)
100.0%
(11/11)
100.0%
(16/16)
100.0%
(5/5)
December
(25/25)
100.0%
(5/5)
100.0%
(14/14)
100.0%
(20/20)
100.0%
January
(25/25)
100.0%
(2/2)
100.0%
(10/10)
100.0%
(20/20)
April
(55/55)
100.0%
(3/3)
100.0%
(18/18)
100.0%
May
(56/56)
100.0%
(1/1)
100.0%
(17/17)
100.0%
June
(52/52)
100.0%
(5/5)
100.0%
(18/18)
July
(52/52)
100.0%
(5/5)
100.0%
(25/25)
August
(46/48)
95.8%
(5/5)
100.0%
September
(52/52)
100.0%
(5/5)
October
(52/52)
100.0%
(4/4)
November
(52/52)
100.0%
December
(46/46)
January
(47/47)
93.3%
(16/16)
100.0%
(28/28)
100.0%
5
100.0%
(13/13)
100.0%
(28/28)
100.0%
5
(12/13)
92.3%
(18/18)
100.0%
(28/28)
100.0%
5
100.0%
(14/14)
100.0%
(16/16)
100.0%
(28/28)
100.0%
5
100.0%
(15/15)
100.0%
(16/16)
100.0%
(28/28)
100.0%
5
(5/5)
100.0%
(17/17)
100.0%
(21/21)
100.0%
(28/28)
100.0%
5
100.0%
(5/5)
100.0%
(10/10)
100.0%
(13/13)
100.0%
(28/28)
100.0%
5
(19/19)
100.0%
(0/0)
No Op
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
(17/17)
100.0%
(2/2)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
100.0%
(12/12)
100.0%
(4/4)
100.0%
(0/0)
No Op
(2/2)
100.0%
(68/68)
100.0%
12
100.0%
(16/16)
100.0%
(1/1)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
(9/9)
100.0%
(12/12)
100.0%
(1/1)
100.0%
(0/0)
No Op
(0/0)
No Op
(75/75)
100.0%
13
100.0%
(15/15)
100.0%
(21/21)
100.0%
(2/2)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
100.0%
(17/17)
100.0%
(12/13)
92.3%
(7/7)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
(4/4)
100.0%
(18/18)
100.0%
(14/14)
100.0%
(5/5)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
100.0%
(0/0)
No Op
(14/14)
100.0%
(4/4)
100.0%
(3/3)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
100.0%
(2/2)
100.0%
(13/13)
100.0%
(13/13)
100.0%
(3/3)
100.0%
(0/0)
No Op
(0/0)
No Op
(68/68)
100.0%
12
Appendix 2
Essential
Standards
Monitoring
77
Area
Children's Services
Learning Disabilities
Month
Preventing the
Spread of
Infection
Enteral
Feeding
Urinary
Catheter Care
- Insertion
Urinary
Catheter Care
- Continuing
Care
Central
Venous Ongoing Care
Peripheral
Intravenous
Cannula Insertion
Peripheral
Intravenous
Cannula Ongoing
Number of
Returns Teams
Submitted
Numbe
r of
Teams
April
(42/42)
100.0%
(13/13)
100.0%
13
May
(40/40)
100.0%
(13/13)
100.0%
13
June
July
(42/42)
(37/37)
100.0%
100.0%
(13/13)
(13/13)
100.0%
100.0%
13
13
August
(40/40)
100.0%
(13/13)
100.0%
13
September
(44/44)
100.0%
(13/13)
100.0%
13
October
(41/41)
100.0%
(13/13)
100.0%
13
November
(39/39)
100.0%
(13/13)
100.0%
13
December
(46/46)
100.0%
(12/12)
100.0%
12
January
(45/45)
100.0%
(11/11)
100.0%
11
April
(6/6)
100.0%
(2/6)
33.3%
6
May
(20/20)
100.0%
(6/6)
100.0%
6
June
(20/20)
100.0%
(6/6)
100.0%
6
July
(16/16)
100.0%
(6/6)
100.0%
6
August
(16/16)
100.0%
(6/6)
100.0%
6
September
(17/17)
100.0%
(6/6)
100.0%
6
October
(15/15)
100.0%
(6/6)
100.0%
6
November
(15/15)
100.0%
(6/6)
100.0%
6
December
(16/16)
100.0%
(6/6)
100.0%
6
January
(20/20)
100.0%
(6/6)
100.0%
6
78
Area
Children's AHP Services
Specialist Services
Month
Preventing the
Spread of
Infection
Enteral
Feeding
Urinary
Catheter Care
- Insertion
Urinary
Catheter Care
- Continuing
Care
Central
Venous Ongoing Care
Peripheral
Intravenous
Cannula Insertion
Peripheral
Intravenous
Cannula Ongoing
Number of
Returns Teams
Submitted
Numbe
r of
Teams
April
(10/10)
100.0%
(3/3)
100.0%
3
May
(12/12)
100.0%
(3/3)
100.0%
3
June
(10/10)
100.0%
(3/3)
100.0%
3
July
(10/10)
100.0%
(3/3)
100.0%
3
August
(10/10)
100.0%
(3/3)
100.0%
3
September
(10/10)
100.0%
(3/3)
100.0%
3
October
(10/10)
100.0%
(3/3)
100.0%
3
November
(10/10)
100.0%
(3/3)
100.0%
3
December
(11/11)
100.0%
(3/3)
100.0%
3
January
(10/10)
100.0%
(3/3)
100.0%
3
April
(19/19)
100.0%
(6/6)
100.0%
6
May
(19/19)
100.0%
(6/6)
100.0%
6
June
(21/21)
100.0%
(6/6)
100.0%
6
July
(19/19)
100.0%
(6/6)
100.0%
6
August
(21/21)
100.0%
(6/6)
100.0%
6
September
(22/22)
100.0%
(6/6)
100.0%
6
October
(22/22)
100.0%
(6/6)
100.0%
6
November
(22/22)
100.0%
(6/6)
100.0%
6
December
(25/25)
100.0%
(6/6)
100.0%
6
January
(25/25)
100.0%
(6/6)
100.0%
6
79
Area
Rehabilitation (Adult)
Minor Injuries Unit Clacton
Month
Preventing the
Spread of
Infection
Enteral
Feeding
Urinary
Catheter Care
- Insertion
Urinary
Catheter Care
- Continuing
Care
Central
Venous Ongoing Care
Peripheral
Intravenous
Cannula Insertion
Peripheral
Intravenous
Cannula Ongoing
Number of
Returns Teams
Submitted
Numbe
r of
Teams
April
(14/15)
93.3%
(3/3)
100.0%
3
May
(14/15)
93.3%
(3/3)
100.0%
3
June
(15/15)
100.0%
(3/3)
100.0%
3
July
(11/15)
73.3%
(3/3)
100.0%
3
August
(15/15)
100.0%
(3/3)
100.0%
3
September
(15/15)
100.0%
(3/3)
100.0%
3
October
(15/15)
100.0%
(3/3)
100.0%
3
November
(15/15)
100.0%
(3/3)
100.0%
3
December
(15/15)
100.0%
(3/3)
100.0%
3
January
(15/15)
100.0%
(3/3)
100.0%
3
April
(5/5)
100.0%
(1/1)
100.0%
1
May
(3/5)
60.0%
(1/1)
100.0%
1
June
(5/5)
100.0%
(1/1)
100.0%
1
July
(5/5)
100.0%
(1/1)
100.0%
1
August
(5/5)
100.0%
(1/1)
100.0%
1
September
(5/5)
100.0%
(1/1)
100.0%
1
October
(4/4)
100.0%
(1/1)
100.0%
1
November
(5/5)
100.0%
(1/1)
100.0%
1
December
(5/5)
100.0%
(1/1)
100.0%
1
January
(5/5)
100.0%
(1/1)
100.0%
1
80
Area
PMS Practices
Green Elms
Month
Preventing the
Spread of
Infection
Enteral
Feeding
Urinary
Catheter Care
- Insertion
Urinary
Catheter Care
- Continuing
Care
Central
Venous Ongoing Care
Peripheral
Intravenous
Cannula Insertion
Peripheral
Intravenous
Cannula Ongoing
Number of
Returns Teams
Submitted
Numbe
r of
Teams
April
(8/8)
100.0%
(2/2)
100.0%
2
May
(6/6)
100.0%
(2/2)
100.0%
2
June
(6/6)
100.0%
(2/2)
100.0%
2
July
(6/6)
100.0%
(2/2)
100.0%
2
August
(6/6)
100.0%
(2/2)
100.0%
2
September
(10/10)
100.0%
(2/2)
100.0%
2
October
(8/8)
100.0%
(2/2)
100.0%
2
November
(8/8)
100.0%
(2/2)
100.0%
2
December
(6/6)
100.0%
(2/2)
100.0%
2
January
(6/6)
100.0%
(2/2)
100.0%
2
April
(0/0)
No Op
(1/1)
100.0%
1
May
(0/0)
No Op
(1/1)
100.0%
1
June
(0/0)
No Op
(1/1)
100.0%
1
July
(0/0)
No Op
(1/1)
100.0%
1
August
(0/0)
No Op
(1/1)
100.0%
1
September
(0/0)
No Op
(1/1)
100.0%
1
October
(0/0)
No Op
(1/1)
100.0%
1
November
(0/0)
No Op
(1/1)
100.0%
1
December
(2/3)
66.7%
(1/1)
100.0%
1
January
(5/5)
100.0%
(1/1)
100.0%
1
81
Area
OVERALL TOTAL
Month
Preventing the
Spread of
Infection
Enteral
Feeding
Urinary
Catheter Care
- Insertion
Urinary
Catheter Care
- Continuing
Care
Central
Venous Ongoing Care
Peripheral
Intravenous
Cannula Insertion
Peripheral
Intravenous
Cannula Ongoing
Number of
Returns Teams
Submitted
Numbe
r of
Teams
April
(184/185)
99.5%
(23/23)
100.0%
(25/25)
100.0%
(39/39)
100.0%
(5/5)
100.0%
(13/14)
92.9%
(19/19)
100.0%
(127/131)
96.9%
52
May
(194/198)
98.0%
(16/16)
100.0%
(30/30)
100.0%
(37/37)
100.0%
(7/7)
100.0%
(15/15)
100.0%
(20/23)
87.0%
(131/131)
100.0%
52
June
(196/196)
100.0%
(12/12)
100.0%
(27/27)
100.0%
(32/32)
100.0%
(9/9)
100.0%
(16/17)
94.1%
(18/18)
100.0%
(131/131)
100.0%
52
July
(181/185)
97.8%
(20/20)
100.0%
(31/31)
100.0%
(36/36)
100.0%
(6/6)
100.0%
(14/15)
93.3%
(16/16)
100.0%
(131/131)
100.0%
52
August
(184/186)
98.9%
(11/11)
100.0%
(16/16)
100.0%
(32/32)
100.0%
(6/6)
100.0%
(8/8)
100.0%
(13/13)
100.0%
(138/138)
100.0%
53
September
(200/200)
100.0%
(9/9)
100.0%
(22/22)
100.0%
(41/41)
100.0%
(7/7)
100.0%
(12/13)
92.3%
(18/18)
100.0%
(131/131)
100.0%
52
October
(192/192)
100.0%
(10/10)
100.0%
(25/25)
100.0%
(32/33)
97.0%
(12/12)
100.0%
(14/14)
100.0%
(16/16)
100.0%
(131/131)
100.0%
52
November
(188/188)
100.0%
(9/9)
100.0%
(29/29)
100.0%
(30/30)
100.0%
(10/10)
100.0%
(15/15)
100.0%
(16/16)
100.0%
(131/131)
100.0%
52
December
(197/198)
99.5%
(5/5)
100.0%
(28/28)
100.0%
(24/24)
100.0%
(8/8)
100.0%
(17/17)
100.0%
(21/21)
100.0%
(130/130)
100.0%
51
January
(203/203)
100.0%
(4/4)
100.0%
(23/23)
100.0%
(33/33)
100.0%
(8/8)
100.0%
(10/10)
100.0%
(13/13)
100.0%
(129/129)
100.0%
50
82
NOTES
Columns 1 - 7:
Figures in brackets e.g. (4/7) 57% There were 7 opportunities to undertake all the elements within the respective clinical intervention. Four were carried out correctly but
during three of the opportunities there were some elements either missed or carried out incorrectly.
No Op:
This is recorded where the team have not had any patients with an invasive device.
Column 8:
Number of returns teams
submitted
This indicates how many teams within the particular service have sent in returns. The figures in the brackets i.e. (63 / 73) indicate that 73 returns were expected but only
63 were returned (NB Within some services there are teams that only undertake the essential steps relevant to their practice).
Column 9:
Number of Teams
IMPORTANT
PLEASE NOTE
Green =
Amber Btw
This represents the number of teams in the service.
Precise detail of data indicating individual team’s performance in each essential step and the number of opportunities available is held electronically by the heads of
service and also sent to The Infection Prevention and Control team.
In August 2010 the Community Nursing teams were restructured. Brightlingsea team became Brightlingsea & Gt Bentley, Mistley & Gt Bentley became Mistley &
Harwich. Walton, Frinton & Harwich became Frinton & Walton. Data prior to August 2010 reflects the old teams, whereas data post August 2010 reflects the new teams.
100.0%
95.0%
99.9%
Red <
95.0%
83
Appendix 3
Action Plan for the CQC Improvement Report Reference Number FRR-9C20:5PW-1-3
CQC Review of Compliance Reference Number – 1-112824377
Update Date – 30th September 2010
Owner – Denise Hagel, Interim Director of Clinical Services
Regulation
Outcome
12
Why CQC have
concerns
The staff survey
results 2008/9
highlights that the
perception of the
availability of
hand washing
facilities was
worse for this
trust compared
with other similar
trusts.
8
The outcome for people
that should be achieved
The trust must demonstrate
that activities within the trust
staff survey action plan
address these concerns and
that the trust complies with
the requirements of the Code
of Practice for Health and
Adult Social Care on the
prevention and control of
infections and related
prevention and control of
infections related guidance
including provision of
sufficient hand washing
facilities.
Actions to achieve
compliance and
timescales
During 2009/10 hand
hygiene packs containing
hand wash, soap and
moisturising cream were
issued to all peripatetic staff
working in the community.
These packs were
purchased so that staff who
could not be guaranteed
hand washing facilities out
‘in the field’ i.e. in patients
homes were enabled to
follow high quality and safe
practice.
84
Lead
Jane Bazzali
Head of
Infection
Prevention
and Control
Progress
Compliant
Status
Completed
Packs are topped up by the
individual teams as
required. In all clinic bases
and hospital wards hand
hygiene facilities are
available together with hand
gel.
Weekly audits are
undertaken across all ward
areas for correct hand
hygiene procedures –
compliance with hand
hygiene best practice
observations is consistently
100%.
A further audit to assess
hand washing facilities in
non clinical bases is to be
carried out in June 2010.
In terms of Infection
Prevention and Control
training the 2009 staff
survey indicates an
increase of 12% from the
2008 survey in staff
accessing this training
within the last 12 months.
85
In terms of staff access to
hand hygiene materials; the
2009 staff survey indicates
an increase of 6% from
2008 in ‘always being able
to access facilities.’
The Hand Hygiene and
Infection Prevention and
Control Policies were highly
praised by the NSHLA
assessment which took
place in March 2010
following which NEEPS
obtained level 1 compliance
of the NHSLA Risk
Management Standards.
86
Regulation
Outcome
23
Why CQC have
concerns
In the staff survey
results 2008/09
show that the
trust was
consistently in the
worst 20% of
issues relating to
staffing such as
staff appraisals,
work-related
stress, staff
experiencing
verbal or physical
abuse, work
related injury,
harassment or
support from
immediate
managers.
14
The outcome for people
that should be achieved
The trust must demonstrate
that activities contained within
the trust staff survey action
plan address these concerns
and that the trust ensures that
staff are properly trained,
supervised and appraised to
provide high quality patient
care to people who use
services.
Actions to achieve
compliance and
timescales
Following the publication of
the 2008/09 staff survey a
small staff working group
lead by HR and the Joint
Staff Council was
established in order to take
forward the developments in
response to staff concerns.
A new ‘Managing Stress’
Policy was implemented,
together with ‘Dealing with
Stress’ workshops designed
to support staff and
managers in identifying and
dealing with stress. Each
year we also hold a number
of staff ‘Pamper Days’,
these include head
massages, manicures etc.
in order to help reduce staff
stress.
87
Lead
Carole
Hughes
Interim
Director of
Human
Resources
Progress
Status
The ‘Stress Management
All completed
Policy’ has been
- compliant
implemented within NEEPS
and has also been
assessed – and passed - at
NHSLA level 1. The
‘dealing with stress’
workshops have been rolled
out and information about
these can be found
internally within our Training
and Education Directory.
NEEPS held its latest
Health and Wellbeing day
on Friday, 24th September.
HR have also introduced a
‘Wellbeing at Work’
scheme, run in-house by
Occupational Health, to help
identify recurring staff
issues - such as headaches
– and offer advice and
guidance.
In addition, staff are
encouraged to access
NEEPS health trainers for
advice and support for
weight management,
smoking cessation and
health & well being
strategies.
The approach to appraisals
has been simplified and a
new process is being
implemented.
The completion of
appraisals for all those with
more than one year service
will take place between May
and July.
Performance is to be fed
back during Corporate
Management Team monthly
meetings.
88
The simplified appraisal
approach has meant that
the % of completed
appraisals this year has
increased significantly and
now stands at 81% for all
staff with more than on year
service.
Appraisal uptake and
completion is now
monitored at the monthly
Corporate Management
Team meetings.
The 2009 staff survey
shows a 10% increase in
staff having had an
appraisal in the past 12
months, with and increase
of 4% of staff reporting they
feel very satisfied with the
level of support their
manager gives.
No change from this
progress report as staff
surveys are annual.
The level of physical abuse
was high in earlier years
due to the learning
disabilities service which
has now been transferred to
another NHS provider as
part of a tender process.
The LD staff who remain
continue to have PI training
- the type and level of
training is being reviewed
during 2010.
The Physical Intervention
training for LD staff is
mandatory on an annual
basis for all relevant staff.
Information about these
courses, including the
training grid which advises
levels of training required, is
available in our in-house
training directory. Updates
of mandatory training are
monitored.
E-learning is being piloted
and will develop during
2010.
E-learning has been
implemented. The SHA has
asked NEEPS as an
exemplar to be represented
on the SHA e-learning
project group to offer
guidance.
89
The 2009 staff survey
shows a 6% decrease in
staff experience of violence
from patients/service users
in the past 12 months.
No change from this
progress report as staff
surveys are annual.
The health and wellbeing
agenda within NEEPS will
continue to look at stress
reduction and improving
mental health well being.
The introduction of the
‘Wellbeing at Work’ project,
which commenced in
August 2010 run by
Occupational Health, will
help support stress
reduction and improving
mental health wellbeing.
90
Regulation
Outcome
10
Why CQC have
concerns
The trust scored
worse in the staff
survey 2008/09
than similar
providers for
fairness and
effectiveness of
procedures for
reporting errors,
near misses or
incidents.
16
The outcome for people
that should be achieved
The trust must demonstrate
that activities contained within
the trust staff survey action
plan address these concerns
and that the trust ensures that
patients benefit from safe,
quality care treatment and
support, due to effective
decision making and the
management of risks to their
health, welfare and safety.
Actions to achieve
compliance and
timescales
Lead
NEEPS was granted the
Right to request to become
a social enterprise by the
PCT Board in March 2010.
As part of the transition
work programme for
NEEPS to become a social
enterprise by Jan 2011, we
are currently undertaking a
full review of our Incident
Reporting and Management
Policy and Serious
Untoward Incident Policy.
The processes will be more
transparent and easier to
follow (by August 2010)
Elaiyne
Jennings,
Interim Head
of Patient
Experience
and Risk
Management
91
Progress
Status
As part of the NEEPs
In progress transition to become a
AMBER
social enterprise in January
2011, NHS North East
Essex has approved the
move into shadow form
from 1st October 2010. As
part of the approval process
a Due Diligence Review
was undertaken by Price
Waterhouse Cooper, the
report rated the organisation
as Green on arrangements
for Clinical Governance and
Risk Management. Work
has been completed in
respect of the review of the
risk management strategy
and policy and the Serious
Incident handling Policy.
Both policies are due to be
presented for approval at
the IGC meeting on 4
October 2010 and will be
effective during the
‘shadow’ phase. During the
‘shadow’ phase all risk
management policies and
processes will undergo a
further review to ensure that
they are fit for purpose and
enable ownership at all
levels of the organisation
and this will include the
Incident Reporting/
Management Policy.
The Risk Management
Strategy will also be
reviewed in the next three
months.
Completed.
NEEPS is currently in the
process of purchasing its
own Datix system in
preparation for its
separation from the
commissioning PCT.
The purchase of a ‘stand
alone’ DATIX system has
been approved. The
intention is to take this
forward as part of the
overall review of Policies
and Processes within Risk
Management and will be
completed during the
‘Shadow phase’.
92
Once this is achieved, there
will be a further roll out of
Datix web to enable more
staff can access this easier
and more user friendly
reporting system.
Datix training will take place
during ‘Shadow’ phase.
DATIX training will be part
of the roll out programme
(NEEPS stand alone Datix
system to be in place by
end of September 2010)
Confirmed – in place.
NEEPS has a designated
risk management team who
will work to raise the profile
of incident reporting within
the organisation. They will
also be a driving force for
ensuring lessons are
learned through trend
analysis and dissemination
of those findings
(continuous).
93
Appendix 4
Strategic Objectives
2010-2015
1.
Survive and Thrive
To manage the business to ensure continual and ongoing viability
2.
With you, not to you
To deliver safe, high quality care
3.
Keep lean, keep keen
To continually develop efficient services that meet customer needs
4.
One enterprise, one purpose, one voice
To develop a culture where we are one team with a common purpose
5.
Make and measure social impact
To make a social investment
94
Appendix 5
95
Appendix 5 (contd)
96
Appendix 6
EQ5d Health Questionnaire
By placing a tick in one box in each group below, please indicate which
statements best describe your own health state today.
Mobility
I have no problems in walking about
I have some problems in walking about
I am confined to bed
‰
‰
‰
Self-Care
I have no problems with self-care
I have some problems washing or dressing myself
I am unable to wash or dress myself
‰
‰
‰
Usual Activities (e.g. work, study, housework, family or leisure activities)
I have no problem with performing my usual activities
I have some problems with performing my usual activities
I am unable to perform my usual activities
‰
‰
‰
Pain/Discomfort
I have no pain or discomfort
I have moderate pain or discomfort
I have extreme pain or discomfort
‰
‰
‰
Anxiety/Depression
I am not anxious or depressed
I am moderately anxious or depressed
I am extremely anxious or depressed
‰
‰
‰
© EuroQoL Group 1990
97
Best
Imaginable
health state
100
To help people say how good or bad a health state is, we
have drawn a scale (rather like a thermometer) on which
the best state you can imagine is marked 100 and the
worst state you can imagine is marked 0.
We would like you to indicate on this scale how good
or bad your own health is today, in your opinion.
Please do this by drawing a line from the box below to
whichever point on the scale indicates how good or
bad your health state is today
9 0
8 0
7 0
Your own
health state
today
6 0
5 0
4 0
3 0
2 0
1 0
0
Worst
Imaginable
health state
© EuroQoL Group 1990
98
Appendix 7
Monitoring Clinical Outcomes.
This form is to be used to notify the Quality
Improvement Team of the outcomes of Clinical
Audits, which have taken place. These will be entered on the
Trust’s Clinical Audit Database. The purpose of the database is
to:
•
•
•
•
•
Facilitate Clinicians to record their audit activity
Avoid duplication of Audit Projects within the organisation
Ensure service improvement is based upon the most recent government
guidelines.
Enable lessons learned from projects to sensitively inform other services
across the Trust.
Inform organisational reports and the Healthcare Commission.
Patient/client/service user and staff outcomes.
Q1. Has the audit led to improvements for patients/clients/service users?
Yes
No
Don’t know
Q2. Has the audit led to a re-audit?
Yes
No
Don’t know
Q3. Has the re-audit confirmed measurable improvements in practice following the
last audit?
Yes
No
Don’t know
Q4. Please provide details of improvements to patients/clients/service users care as
a result of this audit…
99
Q5. Please provide details of improvements to staff/organisation as a result of this
audit…
Protocols or Guidelines:
Q6. Have protocols or guidelines been written as a result of this audit?
Yes
No
Don’t know
Q7. If YES, please provide brief details:
Guideline
name
Government document
utilised to create the
guideline
Created Brief
by
details
Approval Review
date
date
Dissemination of Audit Results
Q8. Please provide details of which forum/people the results were presented to…
Q9. On what date/s did this dissemination/presentation take place
Q10. Have results been disseminated to patients?
Yes
No
Q10a. If yes, please give brief details of dissemination to patients (method and
date, and say whether done or planned):
Q10b. If NO, are there any plans to disseminate results to patients?
Q11a. Are you planning a re-audit?
Yes
No
100
Q11b. Reason, if no re-audit planned:
Potential for future work:
Q12a. Proposed re-audit date:
/
/
Q12b. Details of any potential future work:
Q13a. Research
Patient Involvement Project
Other
Q13b. Details of any lessons learned: (Things you would do differently next time /
any important or significant difficulties encountered at any stage of project)
Learning about Clinical Audit.
Q14a. What have you learned about the Clinical Audit Process from undertaking this
audit.
Name of person completing summary form:
Date: /
/
Signature:
101
Glossary of terms
Acute Care/Services
Services provided usually in large general hospitals with immediate access to
emergency care, theatres and intensive care facilities and specialist staff.
Care Quality Commission (CQC)
The Care Quality Commission (CQC) replaced the Healthcare Commission, Mental
Health Act Commission and the Commission for Social Care Inspection in April
2009. The CQC is the independent regulator of health and social care in England. It
regulates health and adult social care services, whether provided by the NHS, local
authorities, private companies or voluntary organisations. Visit: www.cqc.org.uk
Clostridium Difficile (Cdiff)
Clostridium Difficile (or Cdiff) is a type of bacterium, or extremely small organism
that can cause serious illness and that is very difficult to treat
Children's Services
Services provided for the Children and families of North East Essex including Health
Visiting, School Nursing, Children's Health Clinics, children who are 'Looked After'
and Safeguarding Children, Paediatric Rehabilitation and Paediatric Speech and
Language Therapy.
This service has been crucial within North East Essex for many generations, with
some well known and well respected team members.
Clinical audit
Clinical audit measures the quality of care and services against agreed standards
and suggests or makes improvements where necessary.
Commissioners
Commissioners are responsible for ensuring adequate services are available for
their local population by assessing needs and purchasing services. Primary care
trusts are the key organisations responsible for commissioning healthcare services
for their area. They commission services (including acute care, primary care and
mental healthcare) for the whole of their population, with a view to improving their
population’s health.
Commissioning for Quality and Innovation (CQUIN)
High Quality Care for All included a commitment to make a proportion of providers’
income conditional on quality and innovation, through the Commissioning for Quality
and Innovation (CQUIN) payment framework.
Visit:
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuid
ance/DH_091443
Community Services
This includes Community Nurses, Matrons, Hospital staff in both Harwich and
Clacton and many other services such as Physiotherapy, Minor Injury Units,
Intermediate Care, Occupational Therapy, Podiatry, Falls Prevention, Physio Direct
and Adult Speech and Language Therapy.
102
CQUIN
Commissioning for Quality and Innovation (CQUIN) is a nationally agreed framework
schemes linked to additional payments for successful achievement of locally agreed
quality improvement initiatives.
Clinical Dashboard
A ‘Clinical Dashboard ‘ is a toolset of visual display developed to provide clinicians’
with the relevant and timely information they need to inform daily decisions that
improve quality of patient care.
DATIX
DATIX is a commercial incident reporting tool system
Dementia Diversion Tool (also known as ‘Tiptree Box’)
An evidence based method of engaging and stimulating people with dementia, often
in the form of a ‘memory box’ full of recognisable memorabilia such as photographs
which has been show to reduce wandering further confusion of the patient This box
is also known as The Tiptree Box named after the hospital ward it was designed on
at Colchester Hospital University Foundation Trust (CHUFT).
Department of Health
The Department of Health is a department of the UK government but with
responsibility for government policy for England alone on health, social care and the
NHS.
Essential Standards of Quality and Safety
These standards detail what essential standards of quality and safety that people
who use health and adult social care services have a right to expect.
Health Economy
A discrete geographical area such as North East Essex for example, where a
number of health and social care providers operate.
The Healthcare Quality Improvement Partnership (HQIP)
Promotes clinical audit and healthcare quality improvement. HQIP is currently
contracted by the Department of Health to deliver a programme of activity to
reinvigorate clinical audit.
Health Overview and Scrutiny Committees
Since January 2003, every local authority with responsibilities for social services
(150 in all) have had the power to scrutinise local health services. Overview and
scrutiny committees take on the role of scrutiny of the NHS – not just major changes
but the ongoing operation and planning of services. They bring democratic
accountability into healthcare decisions and make the NHS more publicly
accountable and responsive to local communities.
Health and Wellbeing Services
A team that promotes a health and wellbeing philosophy across North East Essex
delivering a range of services to the population within their own community
locations.
103
This team provides clients with a range of options to improve their health and will
often be seen at many community locations, workplaces and public events such as
the Clacton Air Show.
Services provided include; Smoking Cessation, Sexual Health, Weight Management
classes for both adults and children, Healthy Walks, NHS Health Checks, Health
Trainers, Volunteer Health Champions, School Road shows and Cornerstone.
Cornerstone is a multi-agency centre where you can drop in free of charge and get
general health advice, sexual health advice and much more, including a FREE
health check.
Healthcare Quality Improvement Partnership, HQIP, promotes clinical audit and
healthcare quality improvement. HQIP is currently contracted by the Department of
Health to deliver a programme of activity to reinvigorate clinical audit.
High Impact Changes for Nursing
A national project lead by the Chief Nursing Officer of England to ensure that nurse
are contributing to innovative and evidence based practice to delivering high quality
care.
High Quality Care for All
High Quality Care for All, published in June 2008, was the final report of the NHS
Next Stage Review, a year-long process led by Lord Darzi, a respected and
renowned surgeon, and around 2000 frontline staff, which involved 60,000 NHS
staff, patients, stakeholders and members of the public.
Integrated Governance Committee (IGC)
The IGC is a sub-committee of the Provider Services Committee (PSC) and has
delegated authority on behalf of the PSC to monitor the quality and safety of our
services and risk management processes across NEEPS.
Learning Disability Services (LD)
This is a specialist service which provides holistic, person centred assessment and
care for a wide range of patients including those with profound and complex needs.
The service also trains other professionals and staff, including doctors and nurses,
in how to communicate with and manage patients who have learning disabilities.
The aim is to support all our patients to have improved health and well-being living
an ordinary life in the community. Highly trained staff work in multidisciplinary teams
and have a capacity for cross-boundary and cross-discipline working which is
unique to this service.
Patients are cared for mainly by community teams across North Essex. It also
provides an intensive inpatient assessment and treatment service in Colchester as
well as a Community Outreach Team based in Braintree. All referrals must be made
through one of the community teams, except for inpatient assessment and treatment
104
Local Involvement Networks (LINks)
Local Involvement Networks (LINks) are made up of individuals and community
groups which work together to improve local services. Their job is to find out what
the public like and dislike about local health and social care. They will then work with
the people who plan and run these services to improve them. This may involve
talking directly to healthcare professionals about a service that is not being offered
or suggesting ways in which an existing service could be made better. LINks also
have powers to help with the tasks and to make sure changes happen.
Malnutrition
Malnutrition is a nutrient deficiency state of protein, energy or micronutrients
(vitamins and minerals). This causes measurable harm to body composition,
function or clinical outcome.
Malnutrition is both a cause and consequence of ill health. We tend to visualise
malnutrition as solely affecting starving children in the developing world but it is
common at home, particularly in elderly and hospitalised populations and massively
increases a patient's vulnerability to disease.
Methicillin-Resistant Staphyloccocus Aureus (MRSA)
MRSA stands for methicillin-resistant Staphylococcus aureus, which is a type of
Staphylococcus aureus that is resistant to the antibacterial activity of methicillin and
other related antibiotics of the penicillin class.
The treatment of infections due to Staphylococcus aureus was revolutionised in the
1940s by the introduction of the antibiotic penicillin.
However,, most strains of Staphylococcus aureus are now resistant to penicillin.
This is because Staphylococcus aureus can make a substance called ß-lactamase
(pronounced beta-lactamase), that degrades penicillin, destroying its antibacterial
activity.
MRSA infections are a particular problem in hospitals. As with ordinary strains of
Staphylococcus aureus, some patients harbour MRSA on their skin or nose without
harm (such patients are said to be 'colonised').
However, these patients may develop infections if the MRSA spread to other parts
of the body (eg if MRSA spread from the colonised nose to a wound). When this
happens the resulting infection is described as 'endogenous'.
National Patient Safety Agency
The National Patient Safety Agency is an arm’s-length body of the Department of
Health, responsible for promoting patient safety wherever the NHS provides care.
Visit: www.npsa.nhs.uk
NHS East of England
NHS East of England is the strategic health authority for the east of England,
covering Bedfordshire, Cambridgeshire, Essex, Hertfordshire, Norfolk and Suffolk.
NHS East of England is the regional headquarters of the NHS, and provides
strategic leadership for all NHS organisations across the six counties.
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NHS Next Stage Review
A review led by Lord Darzi. This was primarily a locally led process, with clinical
visions published by each region of the NHS in May 2008 and a national enabling
report, High Quality Care for All, published in June 2008.
Non Acute Services
Services that are delivered often over longer periods of time usually within
community settings i.e. District Nursing or primary care i.e. GP practices.
Opportunistic Survey
Surveys undertaken at random to take advantage of a given situation
Primary Care trust
A primary care trust is an NHS organisation responsible for improving the health of
local people, developing services provided by local GPs and their teams (called
primary care) and making sure that other appropriate health services are in place to
meet local people’s needs.
Providers
Providers are the organisations that provide NHS services, for example NHS trusts
and their private or voluntary sector equivalents.
Provider Services
Anglian Community Enterprise (ACE) provides services that are aimed at, improving
health, promoting well being, preventing ill health, preventing admission to hospital
and providing either long term care or rehabilitation.
We aim to provide this as close to the home as is safe and practical. ACE services
are provided to residents of North East Essex and others, often in close
collaboration with other statutory and non-statutory agencies, and are and will
remain, for the most part, free at the point of use.
Registration
From April 2009, every NHS trust that provides healthcare directly to patients must
be registered with the Care Quality Commission (CQC). In 2009/10, the CQC is
registering trusts on the basis of their performance in infection control.
Research
Clinical research and clinical trials are an everyday part of the NHS. The people who
do research are mostly the same doctors and other health professionals who treat
people. A clinical trial is a particular type of research that tests one treatment against
another. It may involve either patients or people in good health, or both.
Secondary Uses Service
The Secondary Uses Service is designed to provide anonymous patient-based data
for purposes other than direct clinical care such as healthcare planning,
commissioning, public health, clinical audit and governance, benchmarking,
performance improvement, medical research and national policy development. Visit:
www.ic.nhs.uk/services/the-secondary-uses-service-sus/using-this-service/
dataquality-dashboards
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Serious Incidents
A serious incident requiring investigation is defined as an incident that occurred in
relation
to NHS-funded services and care resulting in one of the following:
• Unexpected or avoidable death of one or more patients, staff, visitors or
members of the public;
• Serious harm to one or more patients, staff, visitors or members of the
public or where the outcome requires life-saving intervention, major
surgical/medical intervention, permanent harm or will shorten life
expectancy or result in prolonged pain or psychological harm (this
includes incidents graded under the NPSA definition of severe harm);
• A scenario that prevents or threatens to prevent a provider organisation’s
ability to continue to deliver healthcare services, for example, actual or
potential loss of personal/organisational information, damage to property,
reputation or the environment, or IT failure;
• Allegations of abuse;
• Adverse media coverage or public concern about the organisation or the
wider NHS;
• One of a pre-determined list of ‘Never Events’: healthcare events which
should never happen for example, wrong site surgery
Social Enterprise
The government defines social enterprises as "businesses with primarily social
objectives whose surpluses are principally reinvested for that purpose in the
business or in the community, rather than being driven by the need to maximise
profit for shareholders and owners."
Specialist Services
A service that provides care for Patients that have certain medical conditions. The
areas of expertise include Cardiac Rehabilitation, Heart Failure, Cardiac Obstructive
Pulmonary Disease (COPD), Diabetes including Digital Retinal Screening, Dental,
Tissue Viability / Leg Ulcer and Continence and Urology.
In addition, 3 GP practices, the 2 community hospitals and the 2 MIU are managed
within Specialist Services.
These teams have many years experience and provides their services across all of
North East Essex.
Transforming Community Services
The Government is committed to helping the NHS work better by extending best
practice on improving discharge from acute hospital and increasing access to care
and treatment in the community.
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The Transforming Community Services (TCS) programme aimed to deliver this,
through supporting the NHS to empower clinicians to deliver the best outcomes and
results, and put patient's needs at the heart of community services.
Quality Account
A Quality Accounts is produced annually in order to demonstrate to purchasers of
healthcare services and the general public their quality improvement agenda. Each
Quality Account contains a section looking back at how the organization performed
against its stated objectives for the previous year as well as publishing its quality
intentions for the coming year. Each account has internal and external scrutiny.
Acknowledgements
I would like to thank all those staff, managers and directors who contributed to
the production of this year’s Quality Account.
David Baker
Patient Safety Manager
May 2011
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NHS North East Essex
Kennedy House
Kennedy Way
Clacton-On-Sea
Essex CO12 4AB
T : 01255 206060