BRAINTREE COMMUNITY HOSPITAL
QUALITY ACCOUNTS 2010/11
Contents
1:
Statement from the Chief Executive
4
2:
Priorities for improvement
5
2.
2.1
2.2
2.3
2.4
5
5
6
6
2.5
2.6
2.7
2.8
2.9
2.10
3:
4:
Our Quality Priorities for 2011/12
Priority One
Priority Two
Priority Three
Statements relating to the quality of NHS Services
provided by Braintree Community Hospital
Statement 1 – Review of services
Statement 2 – Participation in Clinical Audit
Statement 3 – Participation in research
Statement 4 – Goals agreed with our commissioners
Statement 5 – Care Quality Commission
Statement 6 – Data Quality
7
7
10
10
10
11
12
Review of Quality Performance during 2010/11
13
3.
3.1
3.1.1
3.1.2
3.2
3.2.1
3.2.2
3.2.3
3.2.4
3.3
3.3.1
3.3.2
3.3.3
3.4
3.5
13
13
13
15
16
16
16
17
17
19
21
22
23
23
24
Review of performance during 2010/11
Patient safety
Learning from incidents
Safeguarding of children and vulnerable adults
Clinical effectiveness and reduction of risk
Audit
Pathways of care
Policies and procedures - following NICE/guidelines
Infection protection and control
Patient experience
Surveys
Internal Quality Improvement Group
Suggestion Box
Complaints
Delivering same sex accommodation
Views of stakeholders
Braintree Community Hospital
26
Quality Accounts 2010/11
2
Introduction
The establishment of Braintree Community Hospital follows years of campaigning from local
GPs and families who wanted health services closer to where they live. The £16.5m Hospital
has been designed with the patient in mind. It is a light and airy setting for our users, and this
is created through the use of „sun pipes‟ and roof lights. It has been built using contemporary
and traditional materials to create a unity with the existing listed buildings on site, whilst
complementing the rural setting of Braintree.
The unique aspect of this NHS hospital is that it brings together the best in public and private
healthcare; the caring clinical expertise of the NHS partnered with private enterprise
efficiencies. Clinical, surgical, nursing, diagnostic and catering specialists work together as
one team with integrated care pathways to give patients an unprecedented level of personal
care and attention. Our new building offers a state of the art, fresh environment in which we
provide a seamless service of care that is highly valued and improves the health of the local
community.
Braintree Community Hospital
Quality Accounts 2010/11
3
1. Statement from the
Chief Executive
I am very pleased to introduce the first set of Quality Accounts for Braintree Community
Hospital (BCH), demonstrating that we are committed to delivering exemplary patient
centered care. BCH is one of the first community hospitals to provide a wide range of day
case surgery, outpatients and diagnostic tests alongside the services traditionally available in
a community hospital such as rehabilitation, community beds and community nursing.
Braintree Community Hospital opened its doors as scheduled on 19th April 2010 welcoming
its first patients directly onto the ward. Patients from Braintree, Chelmsford and Maldon now
have access to a full range of health services under one roof saving them time and extra
journeys.
Braintree Clinical Services Ltd (BCSL) was appointed by NHS Mid Essex PCT to manage the
operation of the new Braintree Community Hospital, and was acquired by Serco Health in
March 2011. A new management team is now in place to oversee the quality of services
provided to patients.
The new BCSL management team is now working with all staff with the aim of ensuring a
thriving, high quality hospital that will:




Offer the shortest possible waiting times for outpatient and day surgery
Make the best use of the state of the art facilities
Be an active partner in the local health community
Become a centre of excellence for hospital based community services
We encourage our staff, patients, public and healthcare partners to look at these Quality
Accounts to understand what we are doing well and where improvements in services are
required. These Accounts outline our priorities for improvement in the coming year (2010/11)
and we welcome comment on and involvement in determining future priorities for
improvement.
To the best of my knowledge, the information contained within these Quality Accounts is
accurate.
I am looking forward to working to create a bright new future for healthcare in Essex and
pioneer a new type of community hospital in the UK.
Paul Forden
CEO
Braintree Community Hospital
Braintree Community Hospital
Quality Accounts 2010/11
4
2.
Our Quality Priorities
for 2011/12
Part 2: Priorities for improvement and statement from the Senior Management Team
(Board)
This section contains information on the key quality priorities for 2011/12 and provides the
nationally mandated information as required under Regulation 4 of the National Health
Service (Quality Accounts) Regulations 2010, as a series of quality statements.
2.0
Our Quality Priorities for 2011/12
For 2010/11 we have agreed three key quality objectives aimed at improving our services.
We developed these priorities through discussion with our staff and commissioner and will
monitor them regularly through our internal governance arrangements at both board and subcommittee level. In particular these include our Joint Integrated Governance Board, our
Clinical Risk and Information Governance Group and through our clinical performance
reporting systems in liaison with our commissioner, Mid Essex PCT.
2.1
Priority One
Improve patient experience and increase service user involvement
Quality priority
Patient
Improve patient
experience
experience through
increased listening to
and involvement of
service users
Rationale
Care should be organized
around the individual,
meeting their needs both
clinically and in terms of their
dignity and respect. We
intend to actively seek
patient‟s and service users
views, to listen to their
feedback and act on what we
hear.
Objective for 2011/12
 Develop patient user
group.
 Develop Internal CQC
Patient Involvement
Group.
 Recruit Patient Liaison
role.
 Install plasma screen in
Reception for public
display of indicator
achievements.
Completely eliminate
risk of breaches –
single sex
accommodation
BCH submitted their
„Declaration of Compliance‟
to Mid Essex PCT as
required by the 31 March
2011. This declaration has
now been placed on the BCH
website.
www.braintreecommunity
hospital.com
Following a compliance audit
a number of actions have
been identified that will
further reduce the risk of
breaches occurring
 Undertake all capital
works planned to further
improve
accommodation
provided for patients
within all services.
Braintree Community Hospital
Quality Accounts 2010/11
5
2.2
Priority Two
Reduce the number of preventable falls that occur within our services
Quality
priority
Patient falls
Rationale
Objective for 2011/12
Monitoring throughout
2010/11 has identified that
the level of falls occurring
within our inpatient ward
could be reduced.





2.3
Set as CQUIN target for 2011/12.
Work with our Community Services
provider to reduce the number of falls
occurring in the in-patient ward.
To monitor and report these incidents on
a monthly basis through internal
governance processes.
To ensure that each fall is recorded as an
incident and that a root cause analysis is
undertaken to assess the reasons for
each falls.
To act on lessons learnt in order to
prevent reoccurrence.
Priority Three
Improve the dissemination of lessons learnt identified through our comprehensive quality
monitoring programme.
Quality priority
Dissemination of
learning to
improve services
for patients
Incident reporting
Complaints
Braintree Community Hospital
Rationale
A computerized incident
monitoring system will
standardize reporting
practices across all subcontractors and assist in
identification of trends and
lessons to be learnt.
Although the level of
complaints received during
2010/11 has been relatively
low, improved systems to
monitor and report on
trends will assist in
effectively disseminating
any learning and thereby
facilitate improved services
for all users.
Objective for 2011/12
 To install the Datix
system within the
hospital, so that
comprehensive
analysis of trends
can be undertaken
and lesson easily
identified.
 To ensure that these
lessons are
disseminated to all
sub-contractors
through internal
governance
reporting systems.
 To ensure that all
complaints received
are thoroughly
investigated and
responded to in a
timely manner.
 To install the Datix
system within the
hospital, so that
comprehensive
analysis of trends
can be undertaken
and lesson easily
identified.
 To ensure that these
lessons are
disseminated to all
Quality Accounts 2010/11
6
Internal clinical
audit programme
All sub-contractors
providing clinical services
within BCH have in place a
comprehensive clinical
audit programme.
Combining and
standardizing practice
across all service providers
will provide the opportunity
of enhanced reporting and
sharing of lessons learnt
across all services.
sub-contractors
through internal
governance
reporting systems
and service
improvements are
implemented where
necessary.
 To implement a
hospital wide clinical
audit programme
that combines all
sub-contractor audit
programmes.
2.4
Statements relating to the quality of NHS Services provided by Braintree
Community Hospital
2.5
Statement 1 – Review of services
During the reporting period from 1 April 2010 until 31 March 2011, Braintree Community
Hospital provided 4 1 types of NHS Services.
Braintree Community Hospital is one of the first community hospitals to provide a wide range
of day case surgery, outpatients and diagnostic tests alongside the services traditionally
available in a community hospital such as rehabilitation, community beds and community
nursing. Our full range of services & facilities include:
Outpatient departments
New fully equipped treatment and consultation rooms enabling our medical specialists to
meet all the treatment needs of the patient.
Diagnostic services
A full range of diagnostic services
are available on-site including
digital x-ray, ultrasound and
endoscopy. MRI and CT scans can
be booked and performed off-site.
1
The Health and Social Care Act 2008 lays down a number of „activities‟ (types o f services provided) which are regulated by
the CQC. The CQC will register providers, like Braintree Community Hospital, to carry out registered activities if providers show
that they are meeting essential standards of quality and safety. The 4 types of activities that BCH have been registered by the
CQC to provide are:




Treatment of disease, disorder or injury
Surgical procedures
Diagnostic and screening procedures
Transport services, triage and medical advice provided remotely
Braintree Community Hospital
Quality Accounts 2010/11
7
Rapid Assessment Unit
A community based rapid access assessment service for elderly patients providing a
multidisciplinary team assessment and diagnostics to avoid inappropriate acute hospital
admission. The management of a care pathway to optimise recovery and promote
independence closer to home.
Day case surgery
The hospital has two modern
operating theatres in which a
wide range of procedures can
be performed; from minor
skin lesions to laparoscopic
cholecystectomys
and
orthopaedic
procedures.
Individual
postoperative
recovery bays are designed
for maximum privacy and
comfort.
In-patient services
There are twenty community in-patient beds, in mainly single rooms, available for patients
who need nursing and rehabilitation. Single sex washing facilities are available.
Therapies
A full range of clinical assessment and treatments for patients within the community hospital
and outreach clinics. This service focuses on a range of specific interventions, and is
provided by specialist therapists. The team works co-operatively with all the service
providers to provide an integrated pathway of care.
Café
The hospital Café offers a range of delicious dishes and sandwiches prepared using local
and organic produce for in-patients, visitors and the whole hospital community.
A seating area is available for dining and takeaway services are also on offer.
A sample menu can be viewed on the website.
During this reporting period, Braintree Clinical Services has reviewed all the data made
available to them on the quality of care in the subcontracted services.
The income generated by the NHS services reviewed in the 2010/11 reporting period
represents 100 per cent of the total income generated from provision of the NHS services by
Braintree Community Hospital during 2010/11.
Braintree Community Hospital
Quality Accounts 2010/11
8
BCSL has joined together a unique partnership of provision of public and private sector
organizations to deliver quality services to the local community. Subcontractors include:




2.6
Central Essex Community Services (CECS) – local NHS specialists in community
healthcare such as in-patient beds, physiotherapy, speech therapy, occupational
therapy and rehabilitation
Prime Diagnostics Limited (PDL) – a nationally accredited leader in community
endoscopy services who have been delivering services within Braintree for the
last 10 years
Specialist Medical Imaging Ltd (SMI) – a nationally accredited diagnostic
company offering expertise in x-ray and ultrasound
Ashlyns Organics Ltd– a local catering company that specialises in using locallysourced and organic produce. The hospital Café complements patient services by
providing food freshly prepared on site using local and organic produce for both
patients and the whole hospital community
Statement 2 – Participation in Clinical Audit
During 2010/11 there was a national clinical audit and no confidential enquiries that covered
the NHS services that Braintree Community Hospital provide.
During 2010/11, as Braintree Community Hospital was still within its first year of opening, it
elected not to participate in the national clinical audits or national confidential enquiries which
it was eligible to participate in.
BCH has confirmed with NCEPOD that of the national confidential enquiries undertaken in
2010/11, none were relevant to the services currently provided by the hospital. BCH has now
registered with NCEPOD.
Braintree Community Hospital
Quality Accounts 2010/11
9
The national clinical audits and national confidential enquiries that Braintree Community
Hospital was eligible to participate in during 2010/11 are as follows:
Confidential
enquiries/national
audit
BCH participation
Reporting period
Number of cases
submitted as a
percentage of the
number of cases
required
National confidential enquiry into patient outcome and death (NCEPOD)
No relevant enquiries
National audits as advised by the National Clinical Audit Advisory Group (NCAAG)
Elective procedures
Not
required
by 2010/11
(national
PROMS Commissioner
for
programme)
2010/11
2.7
Statement 3 – Participation in research
The number of patients receiving NHS services provided or sub-contracted by Braintree
Community Hospital in 2010/11 that were recruited during this period to participate in
research approved by a research ethics committee, numbered nil.
Braintree Community Hospital has not participated in or undertaken any clinical research
projects during 2010/11, however should this type of research activity be planned, a local
Ethics Committee will be appointed to approve any research proposals put forward.
2.8
Statement 4 – Goals agreed with our commissioners
One percent of the annual contractual value of Braintree Community Hospital‟s income in
2010/11 was conditional on achieving quality improvement and innovation goals agreed with
Mid Essex PCT through the Commissioning for Quality and Innovation (CQUIN) payment
framework.
Braintree Clinical Services Limited is currently in discussion with its Commissioner, Mid
Essex PCT to agree the new CQUIN targets for 2011/12.
Further details of the agreed goals for 2010/11 and for the following 12 month period are
available on request from Paul Forden, Chief Executive, Braintree Community Hospital.
Braintree Community Hospital
Quality Accounts 2010/11
10
CQUIN Indicator
To provide evidence of a clinical
audit programme supported by
action plans for changes to be
made to services as a result of
findings
Health Promotion – staff are
trained to deliver opportunistic
health promotion advice and refer
patients to relevant health
promoting services
Patient Satisfaction – the number
of patient responses of „Excellent‟
or „Very Good‟ evidenced from
patient feedback



Learning Disabilities – Routine
systems are in place to collect
data and information necessary
to allow people with Learning
Disabilities to be identified and
their pathways of care tracked
Audit Tool – Implement the use
of a patient specific decision
support tool that will enable staff
to systematically determine the
clinical appropriateness for
admission, continued stay and
discharge.
2.9
Target 2010/11
Assessment of
achievement of
target
>10 audits per contract year
100%
Corporate induction plans to include
staff training with evidence that staff
competencies in health promotion
which leads to increased referrals to
these services
Provider to conduct a minimum of 2
patient satisfaction projects with 90%
achievement of „Excellent‟ or „Very
Good‟ for :
Privacy and dignity
Customer service
Cleanliness
Provider to identify 5 case studies to
be presented
30%
Intentions for 2011/12
include increased
levels of staff training
and onward referrals
100%
Clinical staff to routinely use
appropriate review criteria for all
patients. To implement an internal
weekly reporting system
30%
Intentions for 2011/12
include an improved
system of monitoring
and reporting
outcomes of routine
audits undertaken.
100%
Statement 5 – Care Quality Commission
Braintree Clinical Services Limited is required to register with the Care Quality Commission
and its current registration status, awarded in April 2010, is unconditional.
Braintree Community Hospital is subject to the periodic reviews by the Care Quality
Commission.
Braintree Community Hospital has not participated in any special reviews or investigations by
the CQC during the reporting period 1 April 2010 to 31 March 2011. The CQC has not taken
any enforcement action against BCSL during 2010/11.
2.10
Statement 6 – Data Quality
Braintree Community Hospital has not submitted records during 2010/11 to the Secondary
Uses Service for inclusion in the Hospital Episode Statistics, however will be submitting
records to SUS from May 2011 onwards.
Braintree Community Hospital
Quality Accounts 2010/11
11
The Braintree Community Hospital‟s scores for 2010/2011, assessed using the information
governance toolkit, are documented below:
Information Governance Management
Assessment
Stage
Level
0
Version 8
Published
(2010-2011)
Target
Level
1
Level
2
Level Not
Total
Key
Key
Total
Overall
Grade
3
Relevant Req'ts Req'ts Req'ts Key
Score
Not
Met
Req'ts
Met
0
0
1
4
0
5
0
4
4
93%
Satisfactory
0
0
1
4
0
5
0
4
4
93%
Satisfactory
Confidentiality and Data Protection Assurance
Assessment
Stage
Level Level Level Level Not
Total Key
Key
Total Overall
Grade
0
1
2
3
Relevant Req'ts Req'ts Req'ts Key
Score
Not
Met
Req'ts
Met
Version 8
(2010-2011)
Published 0
0
3
4
1
8
0
6
6
85%
Satisfactory
Target
0
2
5
1
8
0
6
6
90%
Satisfactory
0
Information Security Assurance
Assessment
Version 8
(2010-2011)
Stage
Total Key
Key
Total
Level Level Level Level Not
0
1
2
3
Relevant Req'ts Req'ts Req'ts Key
Not
Met
Met
Req'ts
Overall
Grade
Score
Published 0
0
0
13
0
13
0
11
11
100%
Satisfactory
Target
0
0
13
0
13
0
11
11
100%
Satisfactory
0
Clinical Information Assurance
Assessment
Stage
Level Level Level Level Not
Total Key
Key
Total Overall
Grade
0
1
2
3
Relevant Req'ts Req'ts Req'ts Key
Score
Not
Met
Req'ts
Met
Version 8
(2010-2011)
Published
0
0
0
3
0
3
0
1
1
100%
Satisfactory
Target
0
0
0
3
0
3
0
1
1
100%
Satisfactory
Overall
Level Level Level Level Not
Total Key
Key
Total Overall
Grade
0
1
2
3
Relevant Req'ts Req'ts Req'ts Key
Score
Not
Met
Req'ts
Met
Assessment
Stage
Version 8
(2010-2011)
Published 0
0
4
24
1
29
0
22
22
95%
Satisfactory
0
0
3
25
1
29
0
22
22
96%
Satisfactory
Target
The Braintree Community Hospital was not subject to the Payment by Results clinical coding
audit, by the Audit Commission, during 2010/11.
Braintree Community Hospital
Quality Accounts 2010/11
12
3. Our Quality Review
for 2010/11
3.
Review of performance during 2010/11
3.1
Patient safety
3.1.1 Learning from incidents
Braintree Community Hospital recognises the importance of reporting all types of incidents
and accidents as an integral part of how we identify and manage risk. This is one of the key
measures we monitor closely. We are committed to improving the quality of care to patients,
and the safety of staff and members of the public, through the consistent monitoring and
review of all incidents.
In all, there were a total of 191 incidents reported during 2010. There were a further 89
incidents logged, from January to March 2011. The increase in incident reports in 2011 is
seen as improved reporting rather than the Hospital having increasing issues. The hospital is
also becoming busier, with more patients and visitors attending the site as it becomes part of
the local Health Community.
Incidents are reviewed via the internal governance reporting systems. This includes a review
by the management team through the Health and Safety Committee and the Clinical Risk
and Information Governance Group. Summary reports are then reviewed at the Joint
Integrated Governance Board and Medical Advisory Committee (MAC).
No RIDDOR (Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
which place a legal duty on employers, self-employed people and people in control of
premises to report serious incidents and accidents to the HSE) were reported in 2010/11.
Braintree Community Hospital
Quality Accounts 2010/11
13
The table below provides a breakdown of incidents by type, and reports this data by quarter.
Incidents By Type
90
14
80
3
70
Security
60
9
50
40
30
5
2
24
20
10
0
3
3
5
1st Quarter
37
Health and Safety
8
9
1
12
19
11
10
9
11
2nd Quarter
Medication
Communication + Clinical
22
3rd Quarter
Communication
Clinical
13
4th Quarter
Graph 1: Number of incidents recorded by type during 2010/11
As detailed above, the highest number of incidents reported during 2010/11 fell into the
category of Health and Safety. This category includes falls, which account for a number of
the incidents reported.
From research papers written, it is known that a higher patient fall rate is expected where
there are old, infirm, confused patients as in the Community ward. The NHS National Patient
Safety Agency report “Slips, Trips and Falls data 2010” indicates a mean rate of 8.6 falls per
1000 beds in Community Hospitals with higher rates in those wards where there are elderly
patients or dementia sufferers, namely 82.2% of falls in those 65-100 years; 67.6% of falls
75 -100 years; 34% 85-100 years.
The Community Inpatient ward caters for patients with high acuities (including E.O.L). The
table below documents the number of falls occurring throughout the hospital, from May 2010
through until March 2011.
Braintree Community Hospital
Quality Accounts 2010/11
14
No of Falls per Month
10
10
9
9
8
Total No of Falls
8
7
7
6
5
6
5
4
4
3
3
Total no
3
2
1
1
0
0
Month
Graph 2: Total number of falls, by month, as reported for 2010/11
Risk assessments are undertaken by staff on all patients alongside Falls Care Planning and
cot-side risk assessments. Each incident is investigated by the senior nursing staff using root
cause analysis to identify trends and risk factors. No fractures, head injuries or deaths
occurred as a result of these falls and all were classified as no or moderate harm.
However, Braintree Community Hospital is committed to reducing the number of preventable
falls that are occurring on the inpatient ward. Actions plans for 2011/12 include a review of
equipment used on the ward that assists in controlling the number of patient falls. The
Central Essex Community Service‟s Matron has also joined the Mid Essex Hospital Trust‟s
Falls Steering Group so that joint learning can occur. BCH has identified this key indicator as
a CQUIN target for 2011/12, as additional focus on monitoring and prevention is a top priority
for the hospital.
3.1.2
Safeguarding of children and vulnerable adults
Braintree Community Hospital is required to comply with the local Essex wide guidelines for
Safeguarding Adults. The Safeguarding Adults Board for Southend, Essex and Thurrock
have developed guidelines to set out clearly how concerns about vulnerable adults at risk of
abuse will be managed. Braintree Community Hospital have adopted these guidelines and
ensures compliance through both aligning internal policies and undertaking safeguarding
awareness training for staff, using external specialist trainers. Safeguarding leads for both
vulnerable adults and children have been identified. During 2011/12 the hospital will be
delivering an enhanced training programme for staff in the area of safeguarding. On-line
training modules have also been selected for inductees to complete over a 6 week period
during their induction programme, to enhance awareness and understanding by staff.
Braintree Community Hospital
Quality Accounts 2010/11
15
3.2
Clinical effectiveness and reduction of risk
Braintree Community Hospital has undertaken a range of quality improvement activities and
initiatives to ensure the care we provide is clinically effective including:
3.2.1
Audit
A comprehensive audit programme is in place within the hospital. All subcontractors have
their own individual annual audit plans and undertake regular monthly audits of both the care
delivered and the environment in which this takes place. Each of the sub-contracted service
providers have reviewed the outcomes of these audits within year and reported findings
through their internal governance arrangements. It is intended that an overarching BCSL
audit programme will be developed for 2011/12. The aim of this programme is to monitor that
the individual subcontractor‟s audits have been carried out according to their annual plans
and to ensure follow up action is undertaken. Shared learning will also enhance the
opportunity to improve the quality of care across all services delivered within the hospital.
3.2.2
Pathways of care
Pathway development
The Day Surgery Unit provides a surgical day care service which includes a patient pathway
which commences at first outpatient appointment, continues through the surgical procedure
and concludes with the required procedure specific follow-up. To support the documentation
of patient care within the medical notes, BCH makes use of an Integrated Care Pathway
(ICP) for Day case procedures. A project is now underway to further develop this ICP and to
create 17 procedure specific surgical ICPs that cover the majority of surgical procedures
being undertaken within the service. The second phase of this project will include the review
and development of medical patient pathways.
This is a six month project with the implementation of new ICPs being undertaken on a
phased basis, to ensure that all new paperwork is trialled and adjusted where needed to
facilitate accurate documentation of care. All clinical staff, including medical staff will be
consulted with regard to these changes to ensure clear understanding and support is in
place. Benefits to be realized through implementing procedure specific ICPs include the
standardization of clinical care around best practice and the monitoring of variances from
predicted pathways of care.
Community ward inpatient pathway
Central Essex Community Services (CECS), the service provider for the inpatient ward has
developed a decision support tool to assist staff to determine the appropriate pathway for
patients who access this service. Staff are now able to systematically determine the clinical
appropriateness for admission, continued stay and final discharge. The Multidisciplinary team
(MDT) then validates the assessment undertaken within the Rapid Assessment Unit (RAU)
and reviews which pathway the patient has been placed on. This is further reviewed through
regular audits. Audit findings from November 2010 through to March 2011, demonstrated
that 93% of decisions made regarding assignment to inpatient pathways (rehabilitation,
admission avoidance or end of life) were appropriate and accurate.
3.2.3
Policies and procedures - following NICE/guidelines
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Quality Accounts 2010/11
16
A comprehensive library of hospital policies has been developed, based on current best
practice and implementing the latest guidelines, including those published by the National
Institute for Health and Clinical Excellence (NICE). Policy is targeted at both hospital wide
level and at operational departmental level. Regular policy reviews are undertaken to ensure
that staff have access to current guidance, and staff training ensures that practice remains
current.
3.2.4
Infection protection and control
The main focus of infection prevention activity in our first year has been around setting up an
accountability and responsibility structure within the hospital. This has included the
implementation of an infection prevention and control committee, appointment/identification
of an infection control doctor, infection prevention and control nurse specialist and named
infection prevention link practitioners within every department.
The hospital has successfully introduced the „Saving Lives‟ (DH) High Impact Interventions
and hand hygiene rates to monitor good infection prevention practice. These results are
presented monthly to the Clinical Quality Review Group (the clinical performance review
mechanism in liaison with commissioners) and reported internally through the clinical risk
committee, and at the quarterly infection prevention and control committee.
The hospital has effectively implemented preadmission MRSA screening for all eligible
elective admissions to the day surgery unit and MRSA admission screening within 2hrs for all
intermediate care patients.
The hospital has had no reported infection control outbreak during 2010/11 and within the
same period has achieved excellent statutory reporting compliance by reporting a „zero‟
return to the Health Protection Agency against Healthcare Associated Infections (HCAI)
statistics. This includes reporting against MRSA and clostridium difficile bacteraemias.
The infection prevention nurse specialist and the infection prevention link practitioners have
audited hand hygiene compliance, environmental cleanliness, and infection prevention audits
and carried out risk assessments in all departments during the year.
Infection control audits
The annual infection prevention and control audit programme for 2010/11 included
environmental audits. All audits were completed during the audit year using adapted versions
of the Infection Prevention Society audit tools for monitoring infection control guidelines.
Action Plans were incorporated into the audit. Infection prevention and control audits carried
out in 2010-11 included the following:






Hand hygiene and compliance with ‟bare below the elbows‟
Matron‟s environment audit for wards
Theatre audit, theatre manager audit
Endoscopy department audit
Minor operations matrons audit
Soft facility management environmental audits
Braintree Community Hospital
Quality Accounts 2010/11
17
PEAT
PEAT is an annual assessment, established in 2000 by the National Patient Safety Agency,
for inpatient healthcare sites in England with more than ten beds. The PEAT assessments
were undertaken in February this year working jointly with our Commissioners, NHS mid
Essex. The results are excellent, as shown below and the aim is to continue to maintain
these standards.
BCH
ENVIRONMENT
excellent
FOOD
Excellent
DIGNITY
excellent
Hand Hygiene Protocols
Hand hygiene procedures and the supporting policy was reviewed in 2010. The policy follows
the World Health Organisation (WHO) and National Patient Safety Organisation‟s (NPSA),
‟five moments of hand hygiene‟. A drive to improve compliance with support from the link
practitioners within each department has seen sustained monthly compliance throughout the
year. The monthly hand hygiene observational audits have supported this compliance
throughout the year, with breaches below 100% reported to the line manager.
2010/11 Hand
hygiene audit:
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Jan
Feb
Mar
Outpatients
department
Endoscopy
No
data
No data
93.2%
No data
100%
100%
100%
100%
100%
100%
100%
100%
Day surgery
Wards
Minor
ops/endoscopy
Overall %
score
100%
No
data
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
No data
No data
100%
91%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
95%
94%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
100%
96.6%
-
97%
100%
100%
100%
100%
100%
100%
100%
Braintree Community Hospital
Quality Accounts 2010/11
18
On-going work for 2011/12
Braintree Community Hospital can celebrate a successful year, with very low infection rates
and high levels of environmental cleanliness. However, Infection Prevention and Control
remains a key focus and ongoing work for 2011/12 will include:
 To continue with excellent Healthcare associated infection (HCAI) figures
 To introduce the practice of Aseptic None Touch Technique (ANTT) supported by a
robust policy and comprehensive staff training
 To maintain infection prevention as a key priority within the integrated governance
framework operating within the hospital
 To enhance the infection prevention training programme for all staff at induction
 To have all key infection prevention policies available for all staff on a central BCH
site via a shared drive
 To improve signage for hand hygiene awareness and cleaning schedules
 To enhance the inter-department working and shared knowledge and learning across
the hospital
3.3
Patient experience
Braintree Community Hospital places a great deal of emphasis on the views and feedback of
patients; it is only with this feedback that we can identify areas for improvement, recognise
where things are going well and share this good practice across the hospital, and truly
understand more about what is important to our patients.
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Quality Accounts 2010/11
19
Here are some of the views expressed by our patients and their relatives:
“Everyone involved with the Hospital is doing a marvellous job.”
“Beautiful building, lovely decor, modern, bright, good ambiance,
interesting artwork.”
“I don‟t believe I would have a mother without the skill and care of many
people in your Hospital. It is my belief that the services currently provided
by BCSL are far ahead of the standards we have come to expect of our
NHS.”
“I was very impressed that there was plenty of parking and more
importantly it was free.”
“The Rapid Assessment Unit was unbelievably thorough and for
something like four hours every conceivable test was carried out.” As
someone who has regularly eaten at the Hospital cafeteria I have to say
the quality is really high at very reasonable prices.”
“Congratulations on making a trip to your Hospital as pleasurable an
experience as a Hospital visit can be”
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20
3.3.1 Surveys
In the drive for continual service improvement BCSL actively seeks the views of the service
users on a regular basis. All outcomes are reviewed through the Quality & Audit Committee.
Some sample summaries of surveys are shown below:
Endoscopy
During September 2010 the Annual Survey for endoscopy was carried out aiming to assess
the effectiveness of the service and to measure the views of the patients and GPs. The
sample size was 62 respondents from a total of 100 surveys distributed.
There was a very positive response from patients regarding the service they received at the
hospital. However, it was disappointing to note that 21% of patients still felt they were ill
informed by GPs despite action followed up from the previous year in which patient
information to GPs had increased.
The action plan for the year focused on continuing to circulate information to GPs and to
improve patient experience.
Food on the Ward
During October 2010 the first food survey was carried out within the inpatient ward. Over 400
patients were sampled with a view to determining whether the menu devised was appropriate
for both age/type of patients and appropriateness of content and required textures.
Overall the quality of the food received very positive feedback. Suggestions from patients
included requests for additional menu options/items and further information to be provided in
order that all patients have a good understanding of the menu. An action plan was devised to
implement these recommendations, and with discussion, changes have been made to the
menu, with some of the more modern dishes being removed and replaced with more
traditional fare.
Ashlyns Caterers have always responded directly to individual requests made for particular
types of food and have therefore been able to cope with individual patient needs. Nurses
simply make additional requests at ordering time and these are always accommodated. An
ad hoc assessment of the patient‟s view of food is taken on a daily basis. This determines
which dishes have been particularly popular and why. Feedback to the Chef then influences
the menu selection for the following week.
Daycare Services
Surveys have been carried out on a regular basis for daycare and outpatient services,
however response have been limited. For the survey samples that were carried out in
January, 18 patients responded in daycare and 26 in Outpatients. These surveys aim to
measure the levels of patient satisfaction and to seek ways in which the service could be
improved.
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Outpatients
The majority of the respondents scored the department in the top two categories measured
(excellent/good) and 21 of the 26 respondents stated that they would recommend the service
to a friend.
Day Surgery Unit
The day surgery unit (DSU) scored much higher than Outpatients with all the patients
unanimously stating that they would be happy to recommend the service to a friend.
After reviewing the survey results it was found that the structure and form of the
questionnaire needed enhancing to provide more in-depth information. An action plan has
been devised that addressed the issues raised and includes a review of the questionnaire
content. It was agreed to continue the circulation of the survey on a monthly basis in its
present form until review was completed and signed off.
As BCH has been in its first year of opening, the National Patient Survey has not been
carried out this year, but will be undertaken in November 2011.
3.3.2
Internal Quality Improvement Group
An internal quality group was convened specifically with the aim to integrate and coordinate
the feedback from patients and relatives attending the Hospital. In supporting compliance
with the new Care Quality Commission (CQC) Essential Standards of Quality and Safety
BCH supports increased patient involvement in all aspects of the patient pathway.
The group agreed to provide a programme of surveys for the year with a view to determining
whether they could be merged. Individual service specific reviews continue until an
integrated programme is implemented.
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Quality Accounts 2010/11
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3.3.3. Suggestion Box
A suggestion box has been installed in Main Reception, aimed at patients and staff who are
able to offer ideas and comments to facilitate future improvement. Suggestions during the
year have tended to be predominantly related to environmental issues. Subsequent changes
that have been made include the following:
Chairs with arms for cafe – new chairs have now been supplied
Clock requested in reception – new clock installed on Reception wall
Hooks requested in toilets – Hooks have been added to the backs of the toilet doors
More directional signage requested – Internal and external signage has been ordered
and some new internal signage has been installed
 New seating in the atrium – seating altered to accommodate request for lower seating
with arms




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Quality Accounts 2010/11
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3.4
Complaints
BCH has in place a robust complaints management process that is compliant with the NHS
Complaints process. Complaints are routinely monitored and logged. Analysis and reporting
of this data occurs through the internal governance processes and has been discussed at
Quality and Audit Committee meetings, and at a more senior level during the Joint Integrated
Governance Board and finally at Medical Advisory Committee (MAC).
During 2010/11 46 complaints were received at Braintree Community Hospital from a total of
40,091 patients attending within that period. This equates to only 0.11% which reflects the
aim and ethos of BCH which is to provide exemplary patient care. Of these complaints, 35
were upheld and 4 were partially upheld, the remaining 7 were not upheld.
Closed Complaints
9
1
8
7
3
6
1
5
1
1
Not upheld
1
4
3
2
1
1
1
5
4
1
2
4
2
5
5
5
Partially
upheld
2
Upheld
1
0
2010 2010 2010 2010 2010 2010 2010 2010 2011 2011 2011
May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
Complaints have been categorised using the nationally recommended coding system as
described within the NHS Data Model and Dictionary service provided by Connecting for
Health. The chart below provides a breakdown of the complaints by type.
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Quality Accounts 2010/11
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Upheld Complaints by Type
Admission, discharge and
transfer arrangements
Aids and appliances, equipment,
premises (including access)
1
All aspects of clinical treatment
4
5
6
Appointments,
delay/cancellation (out-patients)
15
8
2
Attitude of staff
Communication/information to
PATIENTS (written and verbal)
11
Failure to follow agreed
procedures
Other
The highest number of complaints received during the year fell into the categories of
delays/cancellations and communication issues. However, on investigation each complaint
has highlighted different areas of concern, thus making trend analysis challenging. Each
complaint has therefore been dealt with on an individual basis, and where lessons were
learnt, these have been disseminated to staff and service improvements implemented.
3.5
Delivering same sex accommodation
Every patient has the right to receive high quality care that is safe, effective and respects
their privacy and dignity. The Braintree Community Hospital is committed to providing every
patient with same sex accommodation, because it helps to safeguard their privacy and
dignity when they are often at their most vulnerable.
We are proud to confirm that mixed sex accommodation has been virtually eliminated in our
hospital. Patients who are admitted to our hospital will only share the room where they sleep
with members of the same sex, and same sex toilets and bathrooms will be close to their bed
area.
As part of our mission and value statement we promise:
„To deal with Patients as valued clients, responding to their needs and providing
comprehensive treatment during the time they spend with us.‟
What does this mean for patients?
Patients admitted to Braintree Community Hospital can expect to find the following:
The inpatient area has been designed to provide a large number of individual rooms to
accommodate personal needs with en-suite facilities. There are two 4 bedded bays where for
only members of the same sex will be accommodated.
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Quality Accounts 2010/11
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There are also some communal areas such as the dining room and cafe which are used by
both male & female patients and visitors.
In day-care, individual cubicles are provided to ensure privacy and great care is taken on
route to theatre to restrict any unnecessary encounters.
All other areas of the hospital operate to strict protocols and guidelines to maintain
compliance with single sex requirements.
What are our plans for the future?
Compliance with single sex accommodation forms only one part of the Hospital Development
Plan. There are some physical environmental changes underway to further enhance patient
privacy.
Staff will continue to be proactive in the protection of patient privacy and will be routinely
monitoring compliance against the standards.
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Quality Accounts 2010/11
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4 The views of
Our Stakeholders
Braintree Community Hospital Statement from Commissioning PCT
NHS Mid Essex can confirm that the quality data contained within the Quality Account for
Braintree Community Hospitals is in line with the information recorded by the PCT between
April 2010 and end of March 2011. The PCT can also confirm that all statutory requirements
have been included within the Quality Account.
NHS Mid Essex recognises Braintree Community Hospital‟s commitment to patient safety
and quality and has worked closely with Braintree Community Hospital to implement a series
of programmes to facilitate the quality and patient safety agenda.
NHS Mid Essex acknowledges the performance in relation to Health Care Acquired
Infections (HCAI) such as MRSA and Clostridium Difficile and commends BCH in
implementing a strong structure to support infection prevention activity.
Braintree
Community Hospital has achieved significant success in implementing the High Impact
Interventions and has consistently achieved cleanliness and other infection prevention
targets.
In the forthcoming year, Braintree Community Hospital has chosen to focus on areas for
improvement which offer the maximum opportunity to improve on patient safety, experience
and outcomes. The PCT remains committed to assist Braintree Community Hospital in
driving up quality and patient safety.
Braintree Community Hospital acknowledges and appreciates the written statement from
NHS Mid Essex and has made no further changes as a result of this statement.
This year the Quality Accounts have been submitted to both the Essex County Council
Health Overview and Scrutiny Committee and the Essex and Southend LINk. Both
organizations will be reviewing the Accounts however subsequent comments will not be
received in time for consideration prior to publication of these Accounts.
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