Central London Community Healthcare
A Head
NHS Trust
Barnet
Our Vision… is to see every person for whom
we provide healthcare become as well and
healthy as they can be.
Our Mission… is to provide the best
healthcare for people in their homes and
community.
Hammersmith and Fulham
Kensington and Chelsea
A Head
Westminster
Quality
Account
2010/11
Copyright © 2011
Central London Community Healthcare NHS Trust
48
Quality Account 2010/11
Quality Account 2010/11
1
If you or someone you know needs help understanding this document, or would
like the information in another format such as large print, easy read, audio, Braille
or another language, please contact our communications team on 020 7798 1420
or by email to communications@clch.nhs.uk
Contents
About our Quality Account
4
About CLCH
6
Statement from our Chief Executive
9
Review of quality performance and improvement areas
11
Safety12
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communications@clch.nhs.uk
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nossa equipe de comunicações no número 020 7798 1420 ou por email para
communications@clch.nhs.uk
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niniejszego dokumentu lub dokument ten potrzebny jest w innym formacie
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naszym zespołem pod numerem telefonu 020 7798 1420 lub na adres mailowy:
communications@clch.nhs.uk
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ku email-kan communications@clch.nhs.uk
Clinical effectiveness
18
Patient experience
28
Formal statements required by the Department of Health
36
Statement from the Care Quality Commission (CQC)
36
Use of the CQUIN payment framework
36
Participation in clinical audit
37
Participation in research
39
Data quality
39
Statements from our stakeholders 40
Statements from our Local Involvement Networks (LINks)
40
Statements from our local Overview and Scrutiny Committees
41
Statement from our commissioners
43
Glossary45
Useful contact details and links
46
Feedback47
2
Quality Account 2010/11
Quality Account 2010/11
3
About our Quality Account
What is a Quality Account?
A Quality Account is an annual
report that providers of NHS
healthcare services must publish to
inform the public of the quality of
the services they provide.
This is so you know more about
our commitment as Central London
Community Healthcare NHS Trust
(CLCH) to provide you with the best
quality healthcare services. It also
encourages us to focus on service
quality and helps us find ways to
continually improve.
Why has CLCH produced
a Quality Account?
CLCH is a community healthcare
provider. We provide healthcare to
people in their homes and the local
community. Therefore we must
publish a Quality Account. This is
the first year, from April 2010 to
March 2011 that we have published
a Quality Account.
What does the CLCH Quality
Account include?
Over the last year we have
collected a lot of information on
the quality of all of our services
within the three areas of quality
defined by the Department of
Health: safety, clinical effectiveness
and patient experience.
We have used the information
to look at how well we have
performed over the past year and
to identify where we could improve
over the next year, and we have
defined five main priorities for
improvement which we set out
later in our Quality Account.
4
Quality Account 2010/11
This Quality Account covers the
three boroughs in which we
were working during 2010/11:
Hammersmith and Fulham (H&F),
Kensington and Chelsea (K&C) and
Westminster.
CLCH and Barnet Community
Services merged on 1 April 2011.
However, the merger on 1 April
2011 was after the end of the
2010/11 year, which is the period
covered for this report. Therefore
Barnet Community Services
produced a separate Quality
Account for 2010/11.
You can find the Barnet
Community Services report
in the About us / Publications
section of our website
www.clch.nhs.uk
About our Quality Account
How did we produce
this Quality Account?
How can I get involved
now and in future?
About LINks
To make sure that our priorities also
reflect the priorities of our patients,
the wider public and the people we
work with, we involved different
groups to help us put the report
together: patient and community
representatives, our commissioners
and our staff.
At the end of this document you
will find details of how to let
us know what you think of our
Quality Account, what we can
improve on and how you would
like to be involved in developing
the report for next year. See the
feedback section on page 47.
A Local Involvement Network (LINk) is a network of local people, made up
of individuals and groups, who work together to make health and social
care services better. Anyone can be part of a LINk and a LINk should be able
to represent everyone in the community – meaning that all different groups
and types of people from the community can join. The job of the LINk is
to: give everyone the chance to say what they think about their local care
services, give people the chance to see how care services are planned and
run, and feedback what local people have said to commissioners, providers
and other scrutinisers of care services so that services can be improved.
How do I request a hard copy
of the CLCH Quality Account?
To find out more or to get involved, contact your LINk in Hammersmith
and Fulham, Kensington and Chelsea, Westminster or Barnet. Their
contact details are on page 46 of this document, in the ‘Useful contact
details’ section.
We established a dedicated Quality
Accounts Stakeholder Reference
Group to provide comments and
feedback right from the start of the
drafting process in February this
year. The membership of this group
includes representatives from Local
Involvement Networks (LINks),
local council Overview and Scrutiny
Committees (OSCs), commissioners
(PCTs) and developing GP consortia,
as well as clinical and managerial
members of our own staff.
We hope that this group will
continue throughout the year to
provide assurance and feedback as
we implement the plans laid out
in this report. You will find more
about the involvement of different
groups in their own statements on
pages 40 – 44.
To request a hard copy of the CLCH
Quality Account, contact the CLCH
communications team by phone
on 020 7798 1420 or by email to
communications@clch.nhs.uk.
About OSCs
A health overview and scrutiny committee (OSC) is a committee made up
of local councillors that “may review and scrutinise any matter relating
to the planning, provision and operation of health services in the area of
its local authority.”1 This means that local OSCs look in detail at how local
providers of health services plan and provide those services and they can ask
questions, make suggestions and escalate issues if they feel something is not
in the interests of their local constituents.
What if I want to know
about the quality of a
specific service that I use
or am interested in?
This Quality Account covers
the quality of services as a
whole across CLCH. However,
we understand that you may
be interested in a specific
service or services that you
have used, for example
Podiatry or Health Visiting.
To find how a specific service
of interest to you performed
during 2010/11, please go to
the About us / Publications
section of our website,
www.clch.nhs.uk, where
information on individual
services and service areas can
be found in a series of servicelevel Quality Reports for 2010,
produced in January this year.
What if I want to talk to
someone about CLCH’s
services or my experiences?
If you would like to talk to
someone about your experiences
of CLCH services or need to know
how to find a service, you can
contact our patient advice and
liaison service (PALS) in confidence
on 0800 368 0412 or email to
clchpals@nhs.net. You will also find
these and other contact details in
our ‘Useful contact details’ section
on page 46.
1
NHS Statutory Instruments 2002 No. 3048 www.legislation.gov.uk/uksi/2002/3048/contents/made
Quality Account 2010/11
5
About CLCH
About CLCH
The full range of CLCH services
includes:
Our vision is to see every person for whom
we provide healthcare become as well and
healthy as they can be.
•Adult community nursing
services – including 24
hour district nursing, community
matrons and case management
Our mission is to provide the best healthcare
for people in their homes and community.
•Child and family services including health visiting,
school nursing, children’s
community nursing teams,
speech and language therapy,
haemoglobinopathy, nursing and
children’s occupational therapy
Central London Community Healthcare NHS Trust (CLCH) delivers
community healthcare across the London Borough of Hammersmith
and Fulham (H&F), the Royal Borough of Kensington and Chelsea
(K&C), the City of Westminster, and – as of April 2011 – the London
Borough of Barnet.
•Rehabilitation and therapies
– including physiotherapy,
occupational therapy, podiatry,
speech and language therapy,
osteopathy
By ‘community healthcare’ we mean that we deliver healthcare services
to people in their homes and in their local community. During 2010/11,
we provided 35 major services lines to a population of over 600,000
people. Whilst the core services, such as District Nursing and Health
Visiting, are largely the same in each borough, there are also some
differences – for example, some smaller services such as Heart Nursing
are provided only in one borough area.
CLCH and Barnet
Community Services
merged on 1 April 2011.
How have we have covered
this in our Quality Account?
The merger on 1 April 2011 was
after the end of the 2010/11 year,
which is the period covered for
this report. Therefore Barnet
Community Services produced
a separate Quality Account for
2010/11.
Although the two documents
are separate, we have worked
together to ensure that our
priorities for improvement are
aligned. From next year we will
produce a single Quality Account
covering the whole of CLCH
across four boroughs.
6
Quality Account 2010/11
•Specialist services – including
learning disabilities, prison
services (at HMP Wormwood
Scrubs) and psychological
therapies
•Nursing homes, continuing care
and palliative care services
Barnet
Westminster
Hammersmith
& Fulham
Kensington
& Chelsea
You can find the Barnet
Community Services report
in the About us / Publications
section of our website
www.clch.nhs.uk
•Long term condition
management (diabetes,
chronic obstructive pulmonary
disease (COPD), tissue viability,
continence), phlebotomy,
community dental services,
diabetic retinal screening, sexual
health and contraceptive services
•Walk-in and minor injury services
For further information about
our services in each area,
please visit our website
www.clch.nhs.uk
the NHS, we will also be more
Becoming a NHS Trust and
independent and more locally
our journey to becoming a
Community Foundation Trust focused. As a FT, CLCH would
CLCH was first created by merging
the community healthcare services
across H&F, K&C and Westminster
in 2009. Then on 1 November 2010
we were officially established as a
NHS Trust.
Becoming a Trust has meant that
we are formally one organisation,
providing health services to
people in their homes and local
community. We have a single
leadership structure and are now
working towards joining up our
services and the ways we work
across the boroughs. This is better
for patients as we have more staff
working together and supporting
each other to provide you the best
possible care. We are also able
to strengthen our partnerships
with, for example, acute Trusts
(hospitals) which again is good for
patients as we can provide more
seamless care between home or
community and hospital.
This was one step on our journey
to becoming a community
Foundation Trust (FT). As a FT,
although we will still be part of
have greater freedom to manage
itself and to reinvest money
in improvements to meet the
needs of local people. We will
have ‘members’ and a Board
of Governors from our local
community who will directly shape
the future of CLCH. We will have
greater control over what we do
and how we do it, focusing on
providing high quality services to
our patients.
We currently run an internal
transformation programme at
CLCH and this focuses on the
changes that are essential to
ensuring the Trust delivers fit for
purpose services for patients and
commissioners, enables the best
possible outcomes for patients and
the local population, and is able
to sustain its place in the market.
This work will also support us in
achieving our goal of becoming a
Foundation Trust. Projects in the
programme look at strengthening
the ways we work, becoming more
efficient and focusing on raising
the quality of our services – some
of which is discussed here in our
Quality Account.
Quality Account 2010/11
7
Statement from our
Chief Executive
About CLCH
We are also in discussions at the
moment around potentially taking
on the management of adult social
care in H&F, K&C and Westminster.
These discussions are still at an
early stage, but if this move did go
ahead then we hope it would give
us a further opportunity to provide
more coordinated services for many
of our patients.
CLCH works with partners, such as
GPs, acute and mental health Trusts
and other providers, local councils
and primary care trusts (PCTs),
across our local boroughs, aiming
to provide joined-up and seamless
care pathways for our patients.
The main hospital Trusts that
we work with are Chelsea and
Westminster Hospital NHS
Foundation Trust and Imperial
College Healthcare NHS Trust.
The communities across H&F,
K&C and Westminster share
some common characteristics. For
example, the people in all three
boroughs are on average younger
and more mobile than the Londonwide average. Communities tend
to be densely populated and
ethnically diverse, with a high
proportion of people born outside
the UK. Health inequalities are
evident between people living in
the most affluent and the most
deprived areas. Overall, the main
causes of morbidity and premature
mortality are circulatory diseases
and cancer, and there are also high
rates of mental ill-health. However,
there are also some differences
between boroughs:
Hammersmith and Fulham
has relatively poor health and
deprivation indicators. The
borough also includes Wormwood
Scrubs prison and the healthcare
8
Quality Account 2010/11
of offenders placed there is the
responsibility of the NHS.
In Kensington and Chelsea the
health divide appears to be
widening as people become
healthier in track with London as
a whole, but health in the more
affluent areas is improving more
rapidly and therefore widening
the divide.
Westminster has high numbers of
homeless people and those living
in temporary accommodation,
with the associated adverse impact
on health. There are high numbers
of older people living alone and
the daily influx of commuters
and tourists swell the population
considerably.
Our Board is committed to providing quality
healthcare for our patients and their families.
Central London Community
Healthcare NHS Trust has made
a firm commitment through our
vision and mission to see every
person for whom we provide
healthcare become as well and
healthy as they can be.
staff can work together to manage
quality, and each of our service
areas produced a cross-borough
quality report summarising their
performance and identifying next
steps for future improvement in
their area.
We are there to respond promptly
and to help people get back on
their feet as quickly as possible.
We also provide support for the
long term - to help people to live
with any conditions as actively as
possible with our help.
Safety: We made good progress
towards building a culture of
openness and learning from
experience – although there is still
further work to do next year. The
most significant safety concern is
associated with poor discharge
processes of patients from hospitals
into CLCH to continue their care in
their homes and other locations in
their local communities.
In this Quality Account, we reaffirm
the importance CLCH places on
the three pillars of quality: safety,
clinical effectiveness and patient
experience. We have analysed our
performance last year in relation
to those three pillars and from
that we have committed to quality
improvement areas for the
coming year.
The CLCH Board’s view of the
quality of services provided
during 2010/11
By ‘community healthcare’ we mean that we
deliver healthcare services to people in their
homes and in their local community. During
2010/11, we provided 35 major services lines
to a population of over 600,000 people.
We are a new organisation –
established in 2009, and recognised
as an independent NHS Trust in
November 2010. So in 2010/11, the
period covered by this report, much
of our work behind the scenes was
to bring together our staff into a
single, coherent organisation. We
started to collect detailed data on
quality across the whole Trust, we
created a number of groups where
Clinical effectiveness: In line with
the Government’s principle of
“no decision about me without
me”, we worked hard last year to
develop and implement ways of
measuring effectiveness from the
patient’s point of view. Specifically,
we conducted Patient Reported
Outcome Measures (PROMs –
see page 19) surveys in 16 of
our services areas, all of which
produced positive initial results.
This year we are very eager to
build on this work to collect better
evidence of the effectiveness of
our care, and to use that evidence
to improve the outcomes that our
patients achieve. We will do this
in a variety of ways, including:
improving the quality of our clinical
audit programme, conducting
more PROMs surveys in more
areas, and developing new ways to
Quality Account 2010/11
9
Statement from our Chief Executive
Review of quality performance
and improvement areas
organise our services so that they
take greater account of the overall
needs of each patient.
This section is about the quality
of our services over the last year,
2010/11, and where we think we
need to improve over the coming
year, 2011/12. We look at the
quality of our services in three
areas: safety, clinical effectiveness
and patient experience.
Patient experience: We focused
a great deal on developing
our understanding of patient
experience through the systematic
collection of patient feedback
surveys known as Patient Recorded
Experience Measures (PREMs –
see page 29). Overall, indicative
results from these surveys were
positive - 89 percent of the 9,000
patients surveyed rated overall
experience of their care as “good”
or “excellent”. Next year we want
to build an even richer, more robust
understanding of what matters
most to patients and how we
can improve.
Summary of our five main
improvement areas for
2011/12
During 2010/11 we established
basic systems to collect and
interpret information on the
quality of our services looking
across the whole Trust. Over the
coming year we will concentrate
on refining and improving our
approach, gathering even better
information but also using that
information to understand how
we can further improve.
Central London Community Healthcare NHS
Trust has made a firm commitment through
our vision and mission to see every person for
whom we provide healthcare become as well
and healthy as they can be.
Looking across the whole Trust, we
have identified five main areas for
improvement for 2011/12. We will
monitor and report on progress
against each of these areas over
the course of the year:
1Improve discharge processes
from hospitals to the community
2Strengthen results of clinical and
patient reported outcomes
3Involve patients more in
designing and managing their
own care – “No decision about
me without me”
This Quality Account has been
developed in consultation with our
patients, staff, Local Involvement
Networks (LINks), commissioners
and Board members, based on
evidence of how we performed
in 2010/11 and what our patients
have told us. We would like to
express our sincere thanks to all
involved in supporting us with the
production of this account.
To the best of my knowledge,
the information contained in this
document is an accurate reflection
of our performance for the period
covered by the report.
The information here
is a summary of all the
information we have collected
about our individual services.
If you are interested in a
particular service, such as
School Nursing or Speech
and Language Therapy,
you can find service-specific
information, and specific
improvement actions in our
2010 Quality Reports that
can be found in the About us
/ Publications section of our
website www.clch.nhs.uk
Summary of our five quality improvement areas for 2011/12
1
2
3
4Improve service models and
develop ‘integrated pathways’
of care
4
5Develop a more detailed
understanding of patient
experience in order to
improve quality
Improvement
area
What we will do in 2011/12 to tackle
this area
Improve discharge
processes from
hospitals to the
community
•Carry out a pilot project to test ways of
improving discharge processes
•Based on the results of this pilot, we
will produce recommendations and a
framework for further improvement
Strengthen results
of clinical and
patient reported
outcomes
•Provide central support to ensure that
each of our services can carry out the
improvement actions that they have
identified in their area
•Improve the quality of clinical audits
so that we can identify further ways to
improve clinical effectiveness
•Implement guidance from the national
High Impact Actions for Nursing
and Midwifery
Involve patients
•Improve support for patients with long
more in designing
term conditions (specifically respiratory)
and managing
to manage their own conditions where
their own care –
appropriate
“No decision about •Implement Patient Reported Outcome
me without me”
Measures (PROMs – see page 19) more
broadly across the Trust so that more
patients are involved in joint goal setting
and measurement
Improve
service models
and develop
‘integrated
pathways’ of care
•Develop and test patient pathways where
care is structured around the patient
(this work will take place through our
Transforming adult services and Getting
it right for children and young people
programmes)
•Implement the Liverpool Care Pathway to
improve end of life care across relevant
adult services
Develop a
more detailed
understanding of
patient experience
in order to
improve quality
•Refine our patient survey questions and
methodology (PREMs – see page 29)
•Pilot ways to collect experience data
from harder to reach groups – including
through patient stories and using
technology to capture patient feedback
James A. Reilly
Chief Executive
Central London Community
Healthcare NHS Trust
5
10
Quality Account 2010/11
Quality Account 2010/11
11
Review of quality performance and improvement areas
Safety
What do we mean when we talk
about safety?
“Treating and caring
for people in a safe
environment and
protecting them from
avoidable harm”– for
example, ensuring
that medicines are
managed safely.2
We treat safety as an absolute
priority at all times. We ensure
safety is on the agenda of every
CLCH Board meeting. Our approach
is to learn from our experiences
and to improve patient safety
and the safety of our staff
wherever possible.
For further information
related to the safety of our
individual services, please
see the service-level Quality
Reports for 2010, in the About
us / Publications section of our
website www.clch.nhs.uk
2
3
Looking back: What have we
done over the past year to
improve safety?
Developing a robust approach
across the organisation
Over the past year we have
focused on bringing together
ways of working in the three
boroughs (Hammersmith and
Fulham, Kensington and Chelsea,
and Westminster) so we have a
common approach to managing
safety across the whole of CLCH.
We want to make sure that staff
across the organisation feel
supported to be open about
reporting specific safety incidents,
and that there is a free and honest
approach to learning from every
experience.
The main steps that we have taken
to build this culture over the past
year are as follows:
1
Gathered more accurate data on
safety incidents: We have been
working hard to reach the point
where all ‘incidents’ and ‘near
misses’ are reported in every
case. The more incidents and
near misses that are reported,
the more we can learn about
how to improve.
In order to do this, we have
been providing training and
support to staff to build levels
of trust and to make it easier
to report safety incidents. As
a result, the level of formal
Review of quality performance and improvement areas
incident reporting has increased
significantly (over 80 percent
since October 2009), and we are
now reaching a point where
incidents are routinely reported
across the organisation.
In 2011/12 we will provide
further support and training
to our staff, including our new
colleagues from Barnet, in order
to develop a culture where
incidents are systematically
reported in every case.
2
Established a CLCH-wide
‘Learning from Experience
Group’: The Learning from
Experience Group is a group
of clinical and non-clinical staff
from across the organisation
that meets monthly, chaired by
the Director of Operations, Jane
Clegg. The group has a formal
role in reviewing safety data
and identifying specific areas for
action or further investigation.
A ‘safety incident’ is any
unintended or unexpected
incident which could have or
did lead to harm for one or
more patients receiving
NHS care.
In September 2010 we established
a single Learning from Experience
Group across all of CLCH. Before
then, there were three separate
groups – one working in each of
the three boroughs. By creating a
single group, we are now able to
identify trends and share lessons
learned much more effectively
across the whole organisation.
One example of how this group
has helped us to coordinate
more effectively across the three
boroughs is the work that it did
on misplaced records. At the end
of 2010 the group noticed that a
number of incidents were reported
in relation to health records being
misplaced or being left incomplete.
It therefore recommended an
organisation-wide approach to
tackling this issue. The Learning
from Experience Group Coordinator worked with other
teams across the organisation to
hold a records amnesty where
misplaced records across the entire
organisation were collected,
reviewed, and returned to the
appropriate place. This action will
now be followed up by regular
quarterly health records audits.
The Learning from Experience
Group now plays a central role in
the regular monitoring of safety at
CLCH. The data routinely reviewed
by the Learning from Experience
Group includes:
Root Cause Analysis is
a standard way of investigating
incidents to make sure that
lessons are learned and to
prevent the same thing
happening again.
•Incidents – any unexpected
incident that could have or
did harm a patient (see full
definition on page 12)
All CLCH managers are
expected to use Root Cause
Analysis to investigate incidents
within their services, although
more serious incidents are
investigated via the Learning
from Experience Group.
•Any contacts received through
the Patient Advice and Liaison
Service (PALS), including formal
complaints
•‘Root Cause Analysis’ reports in
relation to specific issues (see
box text)
We use the Best Practice
template for Root Cause
Analysis from the National
Patient Safety Agency for
all investigations.
•Serious untoward incidents
(SUIs) – very serious incidents
such as unexpected or
avoidable death.
Where a particularly high risk
is identified, it will be escalated
to the Board for more detailed
scrutiny and review, and an
action plan will then be
developed accordingly.
‘Near miss’ is the term used to
describe any incident that had
the potential to cause harm
but was prevented, resulting
in no harm.3
HS Outcomes Framework, December 2010, definition of the safety domain
N
Definitions from the National Patient Safety Agency www.npsa.nhs.uk
12
Quality Account 2010/11
Quality Account 2010/11
13
Review of quality performance and improvement areas
Review of quality performance and improvement areas
Tackling specific issues
Looking across the whole Trust, the most common types of incidents
reported in 2010/11 were in relation to ’communications’ and ’slips, trips
and falls’. The graph below shows how many incidents of each type were
reported across the whole Trust last year.
were unable to visit the newborn
child within the target time of
10-14 days after birth. To tackle
this, our child health teams and
the business managers worked
together to monitor late new
birth notifications over a four
month period. Our teams then
met with the hospitals that were
presenting the highest numbers
of late notifications to CLCH to
discuss what could be done jointly
to improve the system. Discharge
letters are now being provided by
the hospitals to our Health Visiting
service for every baby, and this
allows our child health teams to
double check the new births in
their areas. As a result, the number
of communications incidents
reported by the Health Visiting
service dropped by 50 percent in
the final quarter of the year.
Total incidents (including near misses) reported
Apr 2010-Mar 2011, by type of incident
Communications
Slips, Trips & Falls
Health & Safety
Medicines Management
Violence & Abuse
Records
Clinical Treatment
Pressure Sore Level Two & Above
Security
Equipment & Medical Devices
Staffing Levels
Potential Safeguarding Issue
Moving & Handling
Infection Prevention
IT System
0
200
400
600
800
The total number of reported patient contacts over this period was just
over 1 million and the total number of incidents reported was 3,346.
We therefore recorded incidents at a rate of 0.003 incidents per patient
contact. Note that some incidents are recorded under more than one
category in the above chart.
Communications incidents
The communications category relates to a range of issues in different areas
across CLCH. We have carried out a number of actions over the past year in
order to tackle issues within this category, but it still remains a significant
area of safety concern.
One particular concern in many areas is the poor communications between
CLCH and hospitals when a patient is discharged. In the worst case, this can
result in situations where a patient is discharged into a CLCH community
service but the community staff do not have the papers to tell them what
medication they need to provide to the patient. This issue has been chosen
as our main Trust-wide safety improvement priority area for 2011/12. It is
covered in more detail later in this section.
Another communications issue we faced was specific to the Health Visiting
service, relating to delays in notifying the service when a new birth took
place. If a health visitor had not received notification of a new birth, they
14
Quality Account 2010/11
Slips, trips and falls incidents
Slips, trips and falls were the
second most common type of
incident reported during 2010/11
across the whole Trust. Many of
these incidents were reported
by the Inpatient Rehabilitation
service and Palliative Care service,
and to some extent are due to the
nature of the clinical conditions
and the activities within these
services. It is not always possible to
mitigate against all such incidents
in these circumstances. However,
the Continuing Care service has
reported a relatively high number
of slips, trips and falls, and this
is not necessarily related to the
clinical conditions of the patients
treated by that service. Our Falls
Prevention service and clinical
governance facilitators are now
looking into the details of these
incidents to understand the root
causes, and what can be done
to improve.
CASE STUDY
Tackling specific issues within individual service areas:
Managing challenging behaviours at the Learning Disability
Emergency/Crisis and Short Break Service
Challenging behaviour from certain individuals is a relatively frequent
issue for the Learning Disability Emergency/Crisis and Short Break
service. This issue is closely linked to the specific group that the service
works with, and we continuously try to minimise the risk of challenging
behaviour and to manage it as safely and effectively as possible. Some of
the main steps that we have taken include:
Bringing specialist support into the team: The service has a challenging
behaviour specialist and works very closely with the Learning Disability
teams in K&C and Westminster, in particular clinical psychologists,
psychiatrists and challenging behaviour nurses.
Providing appropriate training to all staff: All staff are trained in
a specific approach for working with individuals who show severe
challenging behaviour. The focus of this approach is on consistency, early
intervention and enabling learning for the individual.
Developing tailored care plans for patients: All service users have
specific care plans tailored to their individual needs and multidisciplinary
involvement from learning disability community services.
Getting the right structures in place to support our staff: Staff never
work in isolation without support and are offered a debrief after
any incident.
Brooke Morris, Operational Manager, Services for People with
Learning Disabilities
Quality Account 2010/11
15
Review of quality performance and improvement areas
Review of quality performance and improvement areas
Looking forwards: How do
we plan to further improve
safety in the coming year?
1
Tackling specific issues within individual service areas:
Managing medication as safely as possible in our District Nursing service
2
011/12 Improvement area number one:
improve discharge processes from hospitals
to the community
The issue
As mentioned above, one of the
most common quality issues across
many CLCH services is that of poor
referrals and discharge processes
between CLCH and the local
hospitals. Poor communications
between CLCH and local hospitals
can result in potentially serious
safety incidents – for example,
where patients have been
discharged from hospital requiring
care from our community teams,
but the necessary information
relating to the patient has not been
transferred from the hospital to the
relevant community service. In this
case, the community teams, such as
the district nurses, may not know
what medications an individual
patient needs to be taking.
In this case, discharge refers to
when a patient leaves hospital
and starts to be cared for by
one of our community teams.
At this point the responsibility
for their care will often
pass over to the staff of a
community healthcare service,
such as district nurses, who
will visit the patient in their
own home.
16
CASE STUDY
Quality Account 2010/11
This issue can also impact on the
patient’s experience of their care.
For example, the patient may feel
frustrated or confused if they are
not properly informed about where
they are moving to and who is now
responsible for their care.
What we plan to do
In order to tackle this issue, we
will be testing out ways of placing
our own staff within hospitals so
that they can communicate more
effectively with the hospital staff
and GPs and ensure a smoother
handover of responsibility for the
patient. This approach – known as
‘in-reach’ – is something that we
have already piloted in a few areas
over the past year, and we think it
has a lot of potential to help with
this communications issue.
We have agreed with our
commissioners to focus a CQUIN
goal for 2011/12 on a pilot project
that builds on our existing in-reach
work and tests out further ways to
use this approach to improve the
safety and patient experience in
relation to discharge.
The pilot will develop
recommendations and a
framework to support future
planning in partnership with the
relevant acute hospital Trusts,
including Chelsea and Westminster
and Imperial.
How we will measure and monitor
our progress
We will monitor the percentage of
all safety incidents that relate to
poor discharge processes and we
will especially look for where our
in-reach activity is having a positive
impact in reducing the frequency
of this sort of incident. We expect
the baseline data across all four
boroughs to become available in
summer 2011 and will identify a
specific target for improvement
at that point. We expect to
continue to consult closely with
our patient and public Stakeholder
Reference Group throughout this
monitoring process.
We will also produce a report and
recommendations at the end of the
pilot project. This will be complete
around January 2012.
What are CQUIN goals?
CQUIN stands for
‘commissioning for quality
and innovation’ and CQUIN
goals are agreed with
commissioners (currently PCTs)
to reward excellence by linking
a proportion of providers’
income (what PCTs pay us)
to the achievement of local
quality improvement goals
(Department of Health guidance on
CQUINs, 2010)
One of the main safety concerns
faced by our District Nursing
service is in relation to medication
errors. The service has been
working closely with our partner
organisations looking at ways to
minimise the risk of medication
errors occurring. The areas we
have been working on include:
Pre-packaged medication: There
has been a risk of error where
the nurse dispenses the patient’s
medication into a weekly pill
box. Over the past year we
have tried to reduce this risk by
working with local community
pharmacists to use pre-packaged
‘blister packs’. Patient prescribed
medication is dispensed by a
professional pharmacist into
blister packs containing a
daily supply of the required
medication. This then means
there is no longer a need for the
nurse to dispense the medication.
Standardised templates: We
have looked at the way we
record information and how
we ask our partners to record
Safety priorities for Barnet
Barnet Community Services (BCS)
did not identify the same major
challenge in relation to discharge
processes. In reviewing their own
approach to safety over 2010/11,
BCS found that a general theme
that they faced in their area is
around needing to improve risk
assessment of patients.
information about patients’
medications. From this analysis,
we’ve found that we can improve
the accuracy of medication recording
by standardising the content and
the format of the District Nursing
service referral template. This is the
template that we use when a patient
is referred from another provider
(for example, a hospital) into our
service. If our partners always have
to provide standard information in
the same format it means that the
process becomes more consistent,
therefore leading to less chance
of errors being made. This work is
being undertaken in 2011/12, led by
the service leads in partnership with
local acute care providers.
Innovative new approaches:
We are working with Imperial
College Healthcare NHS Trust on a
research project around improving
prescribing for elderly patients.
During this project we will be
testing a new medication review
system known as STOPP (Screening
Tool of Older Persons potentially
inappropriate Prescriptions). The
STOPP system is a series of questions
Now that BCS has merged with
CLCH, this is an issue that we
will focus on in Barnet as part
of our overall monitoring of
safety performance. We will track
progress on this issue and include
updates on progress when we
meet with our Stakeholder
Reference Group during the
course of 2011/12.
and criteria that a clinician uses to
assess a patient’s medication and
needs, and this helps flag where
a patient might be at risk of an
adverse reaction by taking multiple
medicines at the same time.
Working with general practice
in the identification of patients
requiring a medication review:
Through working with GPs we can
identify when patients may need a
medication review – meaning that
we look at what medications and
in what doses they are prescribed
and if this is meeting their needs,
if changes are required or if things
could be done differently with their
nursing support. Often medication
reviews can lead to a reduction in
the number of medications that
a person may need to take. This
reduction in polypharmacy (where
multiple medications are prescribed)
not only ensures that people take
their medication correctly but also
reduces the likelihood of medication
errors occurring.
Darren Jones,
Adult Service Manager
We plan to improve this issue by
implementing falls, nutrition and skin
risk assessment into our Inpatient
and District Nursing services in
Barnet. An action plan for this has
been developed and started as of
April 2011, and this will incorporate
learning from a similar exercise
carried out for nutrition screening
within K&C District Nursing and
Rehabilitation services last year.
Quality Account 2010/11
17
Review of quality performance and improvement areas
Clinical effectiveness
The main ways that we monitor
and measure effectiveness are:
What do we mean when we talk
about clinical effectiveness?
Clinical effectiveness is about whether or not a patient’s
care or treatment was successful. In other words, did it
have the impact that it was supposed to have? And did
it achieve the best possible result for the patient?
This may include improvement in specific medical or
health conditions, but in the community we also have
a strong focus on improving quality of life, for example:
independence, mobility, activities of daily living and
social participation.4
Providing effective healthcare is at
the heart of our vision and mission;
it is the guiding principle behind
everything that we do. Our aim
is to make sure that the care we
provide to our patients and their
families achieves the best possible
impact on their health, wellbeing
and quality of life.
This section summarises the main
themes and next steps that we
have identified across the whole
of CLCH in relation to clinical
effectiveness. Because the ways
of measuring effectiveness are
often so specific to a particular
service, we have given a number
of examples and summarised the
general picture.
4
How do we know if we are
achieving the best possible results
for our patients?
Each of our services regularly
monitors its own effectiveness in
order to identify areas for possible
improvement. Effectiveness can be
monitored in different ways and
the approach is often very specific
to the particular service that is
being provided.
For further information
related to the clinical
effectiveness of our individual
services, please see the servicelevel Quality Reports for 2010,
in the About us / Publications
section of our website
www.clch.nhs.uk
F or further information on clinical effectiveness, see the following useful overview from
NHS Scotland: www.clinicalgovernance.scot.nhs.uk/section2/clinicaleffectiveness.asp
18
Quality Account 2010/11
Review of quality performance and improvement areas
Body Mass Index (BMI) is a
measure of whether you are a
healthy weight for your height
and it applies to men and
women. For more information,
and to calculate your BMI and
look at the healthy ranges for
your height, visit the BMI pages
of NHS choices www.nhs.uk
•
Clinical Outcome Measures –
measuring a patient’s progress
or improvement in terms of
basic clinical goals. For example,
an improvement in body
mass index (BMI – see box text)
as a result of a successful obesity
management programme.
•
Patient Reported Outcome
Measures (PROMs) – in this case,
patients set their own goals
for how they would like the
treatment to affect their health
and quality of life. The clinician
then works with the patient to
review progress against these
goals. For example, rather
than aiming for a scientific
improvement in their body
mass index, the patient on the
obesity programme may be
more interested in achieving
an overall improvement in the
quality of their life. PROMs are
a relatively new approach to
measuring effectiveness within
community healthcare and so
the measurement tools are not
yet fully developed for all of
our services.
•
Measuring compliance of our
services with best practice
guidance – for example,
guidance from the National
Institute for Health & Clinical
Excellence (NICE). NICE is an
independent organisation
that issues guidance based on
evidence from medical research.
NICE guidance provides a very
robust standard for us to use
when we are deciding how to
provide the most effective care
to our patients.
•
Clinical audit – a formal
way of analysing a service
against specific standards,
and then identifying areas for
improvement where necessary.
The ‘specific standards’ that are
used could include any of the
above three measures.
Looking back: What have
we done over the past
year to improve clinical
effectiveness?
Developing and implementing
Patient Reported Outcome
Measures (PROMs)
Using PROMs to measure
effectiveness is a helpful way to
make sure that the individual
patient is at the very centre of
the care and treatment that they
are receiving. This is because
PROMs measure improvements by
the patient’s own assessment of
themselves, not only through the
eyes of the clinician.
What does a PROM look like?
A Patient Reported Outcome
Measure (PROM) is essentially
a questionnaire that the
patient will fill in once at the
start of their treatment, and
then once more at the end of
their treatment.
The questions can be general
– about basic aspects of quality
of life, such as how anxious the
patient is feeling. They can also
be more specific to the patient’s
particular condition – such as
“how much does difficulty with
your vision affect your personal
safety?”5 which is taken from
a PROM for patients having
cataract surgery on their eyes.
By measuring the difference
between the patient’s answers
at the start and at the end
of their treatment, we can
see whether the treatment
was effective.
As a tool for measuring
effectiveness, PROMs are still at a
fairly early stage of development.
However, we strongly support this
approach and we have focused
our efforts over the past year to
test it out and implement it
where possible.
5
E xample question from the daily living PROM used in the New Zealand points system for cataract
surgery, quoted by the King’s Fund, 2010, “Getting the most out of PROMs”
Quality Account 2010/11
19
Review of quality performance and improvement areas
Example PROM results from
our services last year:
The Podiatric Surgery service
used the PASCOM (Podiatric
Audit of Surgical and Clinical
Outcome Measures) tool which
measures positive overall
outcomes. Using this tool, 88
percent of patients reported
that they were better or much
better after their surgery.
Respiratory service PROM
for patients with Chronic
Obstructive Pulmonary Disease
(COPD) found that 77 percent
of patients in the sample
showed an improvement in
quality of life scores following
treatment by the service.
During 2010/11 we started to use
PROMs, or similar approaches,
to measure effectiveness in 16 of
our services. In some cases this
meant using measurement tools
that have already been developed
and validated by research
institutions – for example, the
heart nursing service is using The
Minnesota Living with Heart Failure
Questionnaire, which assesses the
impact of chronic heart failure on
quality of life. Meanwhile, in other
cases the validated tools do not yet
exist – for example there was no
validated PROM tool for District
Nursing, so the service worked
together last year to develop and
trial their own approach.
Overall, there were positive initial
results from the areas that used
PROMs in 2010/11. In each case,
the measurements helped us to see
evidence of positive results from
the patient’s point of view.
In 2011/12 we want to expand the
use of PROMs within our services
so that more services are using
this approach on an increasingly
routine basis. Ultimately our vision
is to use this patient-centred
method of measuring success
as part of standard day-to-day
practice in all of our services. This
has been identified as a priority
area for improvement for 2011/12
and further detail of our plans
is included later in the ‘Looking
forwards’ part of this section.
An improved approach for making
sure we are up to date with the
latest NICE guidelines
We made a number of
improvements over the past year
in order to make sure that we
Review of quality performance and improvement areas
are keeping track of the latest
guidance from NICE and that
we are updating our services
accordingly. In particular, our
Quality Assurance and Safety team
strengthened the way in which we
monitor and communicate NICE
guidance across the whole of our
organisation. A new process was
started as follows:
•All NICE guidance published
each month is reviewed by a
specialist group of clinicians in
our Clinical Reference Group
•The group identifies where new
guidance might be relevant to a
specific CLCH service
•Our Quality Assurance and
Safety team contacts the services
that have been identified and
asks them to complete a form to
indicate the level of relevance
to the service and the extent to
which the service is compliant
with the guidance
•Newly published NICE
guidance is also highlighted
to all of our staff within our
quarterly Clinical Audit and
Quality Bulletin.
What is the Clinical
Reference Group?
This is a group of senior clinicians
from across CLCH, Chaired by
Keith Stone, our Director of
Quality, Clinical Leadership and
IM&T (Information Management
and Technology).
The group scrutinises the
strategies and standards that
we use to guide our operations
and provides advice on the
clinical implications.
20
Quality Account 2010/11
CASE STUDY
Embedding patient reported outcome measurement into
standard clinical practice within the Rehabilitation service
Last year the Rehabilitation (rehab)
service introduced Goal Attainment
Scaling (GAS) as the main way
of measuring patient reported
outcomes within the service. GAS
is a method for scoring how much
progress is made in achieving a
patient’s individual goals during
the course of the treatment and
care provided. Essentially, each
patient has their own tailored
outcome measure, but this is scored
in a standardised way to allow for
statistical analysis.
how he was going to carry things
back from the shop with crutches.
The physiotherapist worked with him
on his exercise tolerance and balance,
and he progressed from walking with
a frame to walking with crutches
independently. The speech and
language therapist (SLT) helped him
develop the strategies he needed
to overcome his communication
difficulties to convey his message to
the shop keeper on what he required
when he arrived in the shop. The
team of therapists working with Mr
Smith used their clinical reasoning
For example, Mr Smith had a
to score the likelihood of Mr Smith
goal of: being able to walk to
accomplishing the goal based on the
the shop at the end of his road
level of difficulty attached to it. The
independently and buy a daily
probability was scored at 2 (range
paper within six weeks of returning 1-3, with 3 being probable).
home from hospital. He had set
this goal with the therapists at the After six weeks, Mr Smith had
first appointment and this was the achieved a better than expected
most important thing he wanted to level, and was now going to the
achieve. At the start of therapy, Mr local supermarket rather than just
Smith’s baseline level in relation to the shop and so scored higher on his
his goal was scored at -1 (range -2
outcome (+2). The Goal Attainment
to +2, with -1 being much less than Scale was able to capture what
expected). Mr Smith also reflected specific outcome was important
the importance he gave to
to Mr Smith in a standardised,
achieving his goal, by scoring it as 3 evidence-based format. The Goal
on a weighted scale of importance Attainment Scale has helped bring
1-3 (3 being most important).
into focus what is important to our
patients, ensuring our treatment
Mr Smith had been in hospital with plans meet the many different
expectations, cultures and choices of
a relapse of his Multiple Sclerosis
(MS). To achieve this goal, Mr Smith our populations while providing a
needed Occupational Therapy (OT) statistically significant benchmark for
input to help him plan his journey, our services.
plan his day to manage his levels of
fatigue, to provide rails at the front In the last year, the service developed
of his house to enable him to leave and implemented an action plan in
his property, and to help him plan
order to embed this approach across
day-to-day practice. Some of the
main steps that we took were:
•Training packages were
developed locally
•Staff have been trained in the
use of GAS goals including the
setting, scoring and recording
of outcomes
•A database was developed to
record GAS data
•A range of audits have been
carried out using the GAS
data looking at overall goal
achievement, effect on rereferral rates, the quality of
the goals set by therapists and
a significant piece of work
towards a common language
for goal setting across
professional groups.
Over 600 patients have now set GAS
goals, including around 70 clients
with a diagnosis of stroke.
Our initial analysis of the data we
have gathered is showing that there
has been significant achievement of
the goals that patients have set.
In 2011/12, we plan to further
develop and embed this approach
by refining the ‘basket’ of clinical
outcome measures that we use
alongside the GAS tool, and by
improving the IT systems for
recording and processing this data.
Leigh Forsyth, Head of
Rehabilitation Services, Community
Assessment Rehabilitation
Quality Account 2010/11
21
Review of quality performance and improvement areas
Monitoring and implementing
NICE guidance – examples from
some of our services
In some areas, the guidance
is very new:
NICE guidance in regard to
Looked after Children and
Young People was only recently
published in October 2010.
We are now reviewing this
guidance and will audit the
service against it in 2011/2012.
Nursing service for Looked
after Children
Other areas have a large
number of guidelines that they
already follow:
The following NICE guidance is
relevant to the Stop Smoking
service and implemented fully.
•PH16: Brief interventions
and referral for smoking
cessation in primary care
and other settings
•PH5: Workplace health
promotion: how to help
employees to stop smoking
•PH10: Smoking
cessation services
•PH26: Quitting smoking
in pregnancy and
following childbirth
•TA397: Guidance on the use
of nicotine replacement
therapy and bupropion for
smoking cessation
•TA123: Varenicline for
smoking cessation
Continuous improvement
using clinical audit
Clinical audit is a way of improving
the quality of patient care; it
means analysing a service to
see whether it meets particular
standards (for example, NICE
guidance), and identifying ways in
which the service could improve.
We see it as a very important way
of understanding how we can
continuously improve the quality
of our services.
In 2010/11 we conducted 137
clinical audits and service
evaluations and this helped us
to identify many specific areas
for improvement. Further detail
around these audits and the
improvement actions that we
identified is provided in the
‘Participation in clinical audit’
section on pages 37-38.
In 2011/12 we plan to expand
and improve our programme of
clinical audit. We see this as one
of the main ways in which we
can continue to improve clinical
outcomes overall. For this reason,
clinical audit has been highlighted
as one of the priority improvement
areas below.
Stop Smoking service
6
7
P H – Public Health guidance www.nice.org.uk/Guidance/Type PH
TA – Technology Appraisals www.nice.org.uk/Guidance/Type TA
22
Quality Account 2010/11
Review of quality performance and improvement areas
A clinical audit within
our diabetes service in
Hammersmith and Fulham
In 2010/11 this service
participated in a national
clinical outcomes audit of
nurse-led diabetes services.
The audit team looked at a
number of measures, such as
blood pressure and cholesterol
levels. They looked at how
these measures improved
for individual patients over
the course of their care with
the service.
The results were very positive
– showing that patients being
cared for by the service showed
significant reductions in blood
pressure, cholesterol and
other areas.
Looking forwards: What
do we plan to do over
the coming year to
further improve clinical
effectiveness?
Three out of our five priority
quality improvement areas for
2011/12 are in relation to the
area of clinical effectiveness. This
emphasis on effectiveness is partly
because delivering effective services
is such an essential part of what
we aim to do for our patients.
However, it also reflects the many
changes that we are experiencing
within our own organisation and
across the healthcare sector more
broadly. The fact that so much
change is taking place presents us
with an opportunity to reorganise
and redesign some of the ways in
which we deliver our services to
enable even better outcomes for
our patients.
CASE STUDY
Nutrition and dietetics: constantly checking that we are
getting the best outcomes for our patients
Quality and continuous quality improvement are at the heart of
everything that we do – to make sure that we are getting the best
outcomes for our patients at every opportunity. Last year we reviewed
a large number of activities that we deliver to make sure that they were
working and to identify any further improvements that we could make.
One of the areas we identified for improvement was in relation to
meeting the needs of community meal users in Kensington and
Chelsea (K&C).
An independent review of community meal users in K&C found that
these service users are likely to be at nutritional risk, with weight
loss and poor appetite frequently noted. A malnutrition screening
review found that 21.6 percent of meal users screened were at risk
of malnutrition, almost double the national average of 13.8 percent
of older people living in the community in the UK. This shows that
community meal users are a particularly at risk group compared to
their peers. It highlights the need for regular weight monitoring and
screening of all community meal service users in order to achieve early
identification of malnutrition risk. Referral to the Nutrition and Dietetic
service for malnutrition screening is now mandatory for all commencing
community meal users, a significant quality improvement action.
Joanne Jones, Community Diabetes and Specialist Weight Management
Services Manager, Nutrition and Dietetics service
Jessica Taylor, Public Health Dietitian, Older People, Nutrition and
Dietetics service
Quality Account 2010/11
23
Review of quality performance and improvement areas
2
Review of quality performance and improvement areas
2
011/12 Improvement area number two:
Strengthen results of clinical and patient
reported outcomes
The issue
This priority area is very simply
about taking practical steps to
improve outcomes for our patients.
It is about the fundamental task
of making sure that our patients
achieve the best possible result in
every single case.
We chose this as a priority area
in consultation with patient and
public representatives from LINks
groups. Together, we all agreed
that although we already have
mechanisms in place to review and
improve outcomes on a routine
basis, this area is so important that
we should make it one of our
top priorities.
What we plan to do
We have identified three main
actions that will help us further
improve patient reported
and clinical outcomes within
our services:
1
Make the changes necessary
to improve outcomes at each
service level
From the clinical audit and
outcome measurement that
took place in 2010/11, many
of our services have identified
specific ways in which they may
be able to improve outcomes
for their patients. For example,
providing extra information or
advice to patients or improving
the skills of staff to manage
particular situations.
For further details of the
improvement areas that each
service has identified, please
see the individual service-level
Quality Reports for 2010,
available in the About us /
Publications section of our
website www.clch.nhs.uk
During 2011/12 we will
make sure that all services
are supported to make these
improvements wherever
possible. This support
will include:
• Providing appropriate
training to staff
• Providing a forum for
sharing lessons learned
and best practice between
different services
• Improving IT and data
management systems
• Creating new roles for senior
staff who will take a specific
responsibility for overseeing
quality improvement across a
group of services.
2
Carry out more detailed clinical
audits to identify further ways
to improve outcomes
In 2011/12 we plan to improve
the quality of our clinical audits
by providing further training to
staff in this area. We will also
introduce a basic expectation
that each service should
undertake at least two audits
3
during the year. In turn, this
will help us to understand more
detail around what we can do
within each service to improve
outcomes. Specific actions
will then be implemented
and monitored as part of the
ongoing audit process. This
work is being led by our Clinical
Governance team which has
already established audit plans
with each service area.
Barnet has identified a
particular priority in relation to
the District Nursing service, so
part of this audit programme
will include a specific analysis of
clinical practice in that area.
3
Implement the national
guidance in relation to High
Impact Actions for Nursing
and Midwifery
The High Impact Actions for
Nursing and Midwifery: The
Essential Collection is a set of
improvement actions that was
developed by the NHS Chief
Nursing Officer in 2010. These
improvement actions provide a
framework for services to use in
order to achieve good nursing
outcomes. For example, some of
the areas that they target are:
Across H&F, K&C, Westminster
and Barnet we have already
started to implement these
actions in 2010/11. In 2011/12
we will embed these further
across the Trust so that they
can be used to help us improve
patient outcomes.
How we will measure
and monitor our progress
Working through our Patient
Safety and Quality Committee and
Quality Metrics Group, we will
monitor the results of all PROMs
and clinical outcome measures
carried out across CLCH on a
quarterly basis, and then we will
summarise the full results in our
Quality Account at the end of the
year. For some of these measures,
we will be able to compare the
results to those collected during
2010/11 and identify whether there
has been any improvement over
time. For other measures, especially
those that were not collected last
year, we will look for evidence
of how our service has been
performing in comparison to other
healthcare providers or to a wellknown ‘gold standard’.
The issue
This priority area is about putting
the patient at the centre of their
own care and treatment. This
means making sure, wherever
possible, that patients and their
carers are involved in planning
their care. It also means involving
patients in identifying what goals
they aim to achieve and, where
appropriate, that they are given
all the support and tools that they
need in order to take charge of
their own condition. Improvements
in this area will not only have
a positive impact on clinical
effectiveness, but we also expect
that they will lead to improved
patient experience as well.
We have chosen this as an
improvement priority for a number
of reasons:
Quality Account 2010/11
•We have agreed with our
commissioners that in 2011/12
we will put a particular focus on
improving support for patients
with long term conditions (such
as respiratory disease) to be able
to manage their own conditions
more effectively. This is in line
with a regional and national
agenda to improve support for
putting patients more firmly in
control in this way.
•The Government’s 2010 White
Paper, Equity and excellence:
Liberating the NHS 8 placed a
strong emphasis on the idea of
“no decision about me without
me” and putting patients at the
centre of their own care and
treatment in this way.
•Many of our services have
expressed a strong desire
to develop and implement
PROMs on a routine basis, so
that patients are more closely
involved in setting their own
goals, and so that care can be
more effectively designed in
order to achieve the results that
patients really value.
• Preventing avoidable
pressure ulcers
• Preventing falls
• Keeping nourished
• Prevention of infection in
urinary catheter care.
8
24
011/12 Improvement area number three:
2
Involve patients more in designing and managing
their own care – “No decision about me without me”
www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
Quality Account 2010/11
25
Review of quality performance and improvement areas
What we plan to do
We have identified two main
actions that will help us to move
closer towards the Government’s
key principle, “no decision about
me without me”:
1
Improve the way in which we
support patients with long term
conditions to manage their own
conditions where appropriate
We have agreed with our
commissioners that we will
focus on this area for one of our
CQUIN targets this year. Our aim
is to increase the proportion
of patients that are supported
to develop a joint plan to
help them manage their own
condition. We will also look at
the information and advice that
our clinicians are providing to
patients. We will identify ways
to improve by asking patients
what information they found
particularly useful and whether
they felt that the clinician
helped them to focus on what
was most important for them.
We will start this year by
improving our approach within
the respiratory service in
particular. We will then expand
to look at other services that we
provide to patients with long
term conditions, such as heart
nursing and diabetes.
2
Embed PROMs further into
standard clinical practice
We will increase both the
number of services that are
conducting PROMs (or similar
approaches that involve joint
goal setting and measurement)
and the number of actual
patients who are involved in
PROMs (or similar approaches).
26
Quality Account 2010/11
How we will measure
and monitor progress
We will monitor progress
separately for each of the two
actions listed above.
For action (1) – around
improving self-management
– we have agreed a specific
set of measures with our
commissioners, initially focusing
on respiratory services, and we
will report these around July
2011 and then again around
January 2012 to identify any
improvements. The measures
that we have agreed are:
•The percentage of relevant
patients with a self
management plan in place
Review of quality performance and improvement areas
•The percentage of patients
reporting that they had a chance to
discuss what was most important for
them in managing their own health
•The percentage of patients saying
that they think that the information
they were given will help them to
manage their own health better in
the future.
For action (2) – around implementing
more PROMs – we will track the
following data on a quarterly basis:
•The number of service areas
conducting a PROM
•The total number of patients
involved in a PROM during the
previous three months.
4
011/12 Improvement area number four:
2
Improve service models and develop ‘integrated
pathways’ of care
The issue
This priority area is about the
structure underpinning our
organisation and the services that
we deliver. Our aim is to improve
the way in which our services
are organised around the
individual patient.
Last year, CLCH delivered 35
different service lines across three
London boroughs. Historically,
these services have tended to be
organised according to the specific
expertise of the clinical staff – for
instance Podiatry or a Specialist
Nursing service. However, in reality
many of our patients are in contact
with several different services at the
same time, or might pass from one
service to the next many times.
Because the services are all
managed separately, this means
that the patient may feel that
they are constantly dealing with
different people. It also makes it
difficult for any of the clinicians
involved to take an informed view
about the needs of the patient
overall, and how the treatment
or care offered within one service
should match up with other services
that the patient may also require.
We have already taken a number
of steps to address this issue. For
example, several of our services
already work closely in multidisciplinary teams; that is with a
range of different clinical specialists
working together around an
individual patient. We have also
started work to map out ‘pathways’
of care that follow a typical
patient’s journey through a number
of different services.
However, we believe that there is
still a lot more that we can do in
order to reorganise our services
around the patient themselves. This
has been chosen as a priority area
because it is a major element of our
Board’s own Clinical Strategy, and
we believe that if we get it right, it
will really improve the effectiveness
of the care that we provide, as
well as the patient’s experience.
What we plan to do
We have identified two main
actions in this area:
1
Developing and implementing
integrated ‘pathways’ and
‘patient journeys’ as a way of
organising our services more
closely around the patient
themselves.
We have already established
two work programmes in this
area called Transforming adult
services and Getting it right for
children and young people.
Through these two programmes,
we will work closely with our
commissioners, local partners
including hospitals and GPs,
and patients and the public, to
develop and start testing patient
‘pathways’ and ‘journeys’
where care is structured
around the patient.
2
Managing End of Life Care
according to the Liverpool
Care Pathway
The Liverpool Care Pathway
for the dying patient (LCP)
is a well recognised way of
bringing together all of the
different teams in relation to
a dying patient – including
physical treatment, psychological
support, support for carers and
spiritual care. It aims to make
sure that no matter where the
patient has chosen to die, they
and their family will receive the
same level of quality, joined-up
support as they might expect in
a hospice.
We have agreed with our
commissioners that we will
implement the Liverpool Care
Pathway for our relevant adults’
services as one of our CQUIN
targets for 2011/12.
How we will measure
and monitor progress
We will produce a quarterly update
on progress with developing new
pathways through the Transforming
adult services and Getting it right
for children and young people
programmes. We hope to be
able to discuss these and other
progress updates with our external
Stakeholder Reference Group
as a way of measuring and
monitoring progress.
We have agreed with our
commissioners that for the relevant
adult services, we will track the
percentage of patients who die that
are on the Liverpool Care Pathway.
We will report this number around
July 2011 and then once more
around January 2012 to identify if
there has been an improvement.
Quality Account 2010/11
27
Review of quality performance and improvement areas
Review of quality performance and improvement areas
Patient experience
Average percentage of patients rating their experience as
“good” or “excellent” (01 September – 15 November 2010)
Patient involved in planning
own treatment
What do we mean when we talk
about patient experience?
Easy to understand explanation
from clinician
Would you recommend the service
to others
Patient experience is about ensuring patients, relatives
and carers have as positive experience as possible
at every stage of the care or treatment that is being
provided. Patient experience refers to the overall
experience throughout the course of treatment, and
not just the results that were achieved at the end.
Suitable timing of appointment
Rating for overall experience
Listened to patient carefully
Patient treated with politeness
/ dignity / respect
For example, a patient’s experience could be strongly
influenced by whether they felt treated with dignity
and respect, or whether they found it easy to access
the service.9
Looking back: What have we
done over the past year to
improve patient experience?
Improving the way that we gather
feedback from patients
Last year we put a lot of work
into surveying our patients about
their experiences. In the previous
year (2009/10) we conducted one
simple survey across the whole of
CLCH which only gave us a very
limited view of how patients felt
about our services. So last year we
improved on this and carried out
over fifty individual surveys, known
as Patient Reported Experience
Measures (PREMs), covering every
service area. The questions that
were asked in each area were
designed for the specific patient
9
group using that service – which
allowed us to get a more detailed
understanding of what patients
were telling us.
From September to November
2010, around 9,000 patients
(approximately 40 percent of the
new patients that we saw during
the survey period) responded to
PREM surveys across all of our
service areas.
The results of these surveys
indicate a very positive level of
overall feedback from patients.
Across CLCH an average of 89
percent of patients rated their
overall experience as “good” or
“excellent”. The chart overleaf
shows the average results for all
0%
20%
40%
60%
80%
100%
Note: For the question around whether you would recommend the service to others, the
figure reported is for those who answered “yes” to this yes/no question.
and so when we combined the results we had to compromise some of
the statistical robustness in the data. In other words, we have combined
information that was not collected in exactly the same way.
of our services in relation to seven
basic questions that were asked
across most areas last year.
Please note that the data in this
graph provides only a general
indication of how patients
responded across all of our service
areas. In each area, the questions
were asked slightly differently
For further information
related to patient experience
of our individual services,
please see the service-level
Quality Reports for 2010, in
the About us / Publications
section of our website
www.clch.nhs.uk
In 2011/12 we will strengthen the reliability of this data by updating our
PREM surveys again. Each service will continue to select specific questions
that relate to the patients in that particular context, but all services will
also include a core set of standard questions in their surveys. This core set
of questions will be the same right across CLCH and will therefore give us
much more robust data to report on overall patient experience next year.
It will also help us to compare service areas with each other to identify
where there might be need for improvement in a certain area.
Patient Reported Experience Measures (PREMs)
A PREM is a relatively simple questionnaire that is given to a patient,
relative or carer to ask them about their experience of the care or
treatment they received.
The results of these questionnaires can help an organisation to
understand what matters most to their patients and how they can
update their services in order to meet those needs more effectively.
Research into patient experience has shown that one of the most
important things for many patients is whether they felt that staff
treated them with dignity and respect.
F or further information on patient experience, see the following helpful website from NHS surveys:
www.nhssurveys.org/improvinghealthcare
28
Quality Account 2010/11
Quality Account 2010/11
29
Review of quality performance and improvement areas
What our patients told us
and how we responded
In addition to the quantitative data
that we collected, for example the
results shown in the above graph,
we also received a large number of
free text comments from patients
last year. These came both through
the PREMs and through other
compliments and complaints that
patients sent to us.
We collected and analysed these
comments in each area, and
together with the quantitative data
this helped us to identify a number
of ways in which we could improve
the experience that patients are
having with our services.
The most common area for
improvement that we identified is
around access to services. This was
not a problem in every single service
area, but it was something that was
raised by patients in various ways
across quite a few of our services.
Some of the particular issues that
were raised by patients were:
•Difficulties with booking
appointments: for example, the
Musculoskeletal service (MSK)
noted that “The most common
negative comment made about
the service is in relation to the
appointment booking process.”
(MSK 2010 Quality Report,
January 2011)
Review of quality performance and improvement areas
•Difficulties contacting our
services: there were also a
number of issues raised around
patients or schools/carers not
having the correct contact
details for our services
•Waiting times: in several cases
patients suggested that we
could potentially do more
to reduce our waiting times,
although there was also an
appreciation of the fact that this
need must be balanced with
financial and other constraints.
Each of our services that has
identified a problem in this area
has now developed a plan for how
they will improve patients’ access
to services where possible. For
example, some of the steps that
individual services are planning to
take are:
•Double check that patients and
others are provided with the
right contact numbers
•Improve the communications
between reception staff and
clinicians so that patients can
be better informed about any
delays whilst they are waiting
•Explore the possibility of opening
clinics for extended hours.
CASE STUDY
Ensuring a positive experience for children, parents and
carers with the Children’s Community Nursing teams
The Children’s Community Nurses are a team of specialist children’s
nurses, offering families the choice of caring for their child in the
familiar environment of their own home, school or nursery. The
service conducted a patient experience survey (PREM – see page 29)
with patients and carers last year which indicated positive results – for
example, in general parents and carers said that they felt listened to,
included and respected by the health professionals from the teams.
The following quote is from one of the parents of a child treated by our
Kaleidoscope team, which provides palliative care for very sick children:
“The Kaleidoscope team provided amazing care and security for us. They
were always available on the phone and were incredibly supportive in
those early weeks so my confidence quickly built up. Community nursing
continues to provide advice and training when we need it and efficiently
organises our equipment. It did transpire that it was an inappropriate
referral though as the baby is thriving and therefore not in need of the
service. So sad to lose Kaleidoscope input but understandable. Thank
you so much for everything you have done for us. You are an incredible
service and have helped us be the confident parents we are.”
The PREM feedback also helped us identify a number of areas
for improvement and further investigation over the coming year,
for example:
•We will develop written leaflets for all aspects of the service in order
to highlight the differences between the services
•We will gather further detailed feedback about punctuality for
appointments and the timing of introduction of families to the
Kaleidoscope team.
Elizabeth Welch, Children’s Community Nursing Manager
These plans are being implemented
during 2011/12 and the services will
be monitoring patient experience
in this area over the course of the
year. Although this area has not
been selected as one of the top five
priorities for improvement listed in
this Quality Account, we will review
it on a quarterly basis throughout
the year and will provide an update
on progress in next year’s
Quality Account.
30
Quality Account 2010/11
Quality Account 2010/11
31
Review of quality performance and improvement areas
Review of quality performance and improvement areas
5
Looking forwards: What
do we plan to do over the
coming year to further
improve patient experience?
Specific improvement actions have
been identified by each of our
services on the basis of what our
patients told us last year.
These action plans are laid out
in the individual service-level
Quality Reports for 2010 that
were produced in January
2011 and can be found in the
About us / Publications section
of our website
www.clch.nhs.uk
32
Quality Account 2010/11
011/12 Improvement area number five:
2
Develop a more detailed understanding of
patient experience in order to improve quality
The issue
Although we gathered a lot of
useful feedback from patients over
the past year, we did not necessarily
collect enough to give us a really
full picture of how different people
experience our services. So our
main focus for the coming year is
to improve the way in which we
gather feedback from patients.
Ultimately, the more we are
able to understand our patients’
experience, the more we will
be able to improve our
services accordingly.
We will also place particular focus
on making sure that we treat
patients with dignity and respect
at all times. The results from our
own patient surveys indicated
that this is something that matters
a great deal to many patients
and it is also something that is
frequently emphasised by research
conducted at a national level. In
2011/12 we will develop further
training modules for all of our
staff, including those who have
recently joined us from Barnet,
around ‘customer care’ and how to
treat our patients with compassion,
dignity and respect. This is an
improvement area that relates
to the whole of CLCH. However,
Barnet has specifically identified
this as one of its main priorities
for improvement.
We have also identified one
overarching priority improvement
area for patient experience for
2011/12 that will benefit all of
our service areas across CLCH: to
develop a better understanding of
which factors are most important
to different groups of patients
when it comes to how they
experience our services.
One of the main challenges is
to make sure that the surveys
capture feedback from a truly
representative sample of our
patients. Last year we collected
most of the feedback through
handwritten paper surveys, but
there were many people who may
not have been able to access the
questionnaires presented in that
way if they were not able to read
and write in English. Particular
groups that may have had
difficulties include: older people,
people with Learning Disabilities,
children, or people who do not
speak English as a first language.
We did try a number of ways to
make the surveys more accessible,
including translating some of the
surveys into other languages that
were common in the community
or talking through the questions
with the patient and asking them
to respond by circling pictures of
happy or unhappy faces. However,
many of our services feel that
there is still a lot more that could
be done to collect feedback in a
more accessible way from a more
representative group of patients.
Another challenge is to make
sure that we are asking the right
questions. In order to help us
really understand our patients’
experience, the feedback that
we collect needs to be collected
in a consistent way, and it needs
to cover the areas that are
most important for the patients
themselves. Last year we developed
over 50 different PREM surveys
across our services and there
was a fairly wide variation in the
questions that we were asking. We
are now in a position to update the
surveys from last year, building on
the lessons that we have learned
from that exercise. We will update
the surveys to include both a core
set of questions that will provide
consistency across the Trust, as
well as tailored questions in each
service to give us a detailed level of
specific feedback.
How do we plan to improve?
We have identified a series
of actions to improve our
understanding of patient
experience, focusing on both
breadth (ensuring representative
data from all groups) and depth
(rich, meaningful data). The main
actions that we will take are:
•Refine our PREM questionnaires
so that we are asking questions
that are simple to understand
and focus on the issues that are
most important for patients
•Introduce a standard set of core
questions that will be asked in
every service area - by collecting
consistent data in this way, we
will be able to understand how
patient experience varies across
our services, and spot potential
areas for improvement
•Continue to include some
specific questions that relate to
a particular service
•Pilot ways to collect data from
harder to reach groups – for
example using technology to
make an audio recording of a
patient’s comments
•Conduct further detailed
research and analysis to improve
our understanding of what is
important to patients
•Start to collect patient stories
– this means providing training
to our staff to be able to listen
to an individual patient’s story
and record it in a way that
helps to really communicate
that patient’s experience of our
services. This is an approach
that Barnet Community
Services (BCS) already started to
implement during 2010/11 and
following the merger of CLCH
with BCS in April 2011,
we will now be able to expand
this approach across the
other boroughs.
Quality Account 2010/11
33
Review of quality performance and improvement areas
Responding to patient
feedback in Barnet
Similar to the rest of CLCH,
services in Barnet also carried
out a patient survey in 2010/11
and identified a number of
ways in which they could
improve patient experience
based on what the patients
said. For example, some district
nursing patients in Barnet
said that they do not feel well
informed about the district
nursing team that is visiting
them in their homes. The
service is therefore developing
a detailed patient information
leaflet of how the District
Nursing service operates, and
will ensure that staff talk
through the leaflet with
every patient.
Review of quality performance and improvement areas
CASE STUDY
Homeless health: looking at developing a better
understanding of how this group of patients experience
our healthcare services
How we will measure and
monitor progress
We will produce quarterly updates
to show how we are progressing
in this area. We hope to discuss
these updates with our Stakeholder
Reference Group so that our
patients and public will be able to
be involved in what we are doing
in this area.
We will also present the results to
the six new standard questions that
will be asked across all PREMs in
CLCH. These questions will cover
the following themes:
The main elements of the progress
updates will cover:
3Being treated with dignity and
respect
•Progress on updating the
PREM surveys
4Being able to understand the
explanation that was given by
the clinician
•How many patients have
responded to a PREM in the past
three months
•What we have done to test
out new ways of gathering
feedback from harder to
reach groups
1Overall experience
2How involved the patient was in
planning their care or treatment
Our Homeless Health team works
very closely with our community
partners and we provide nurseled primary care services in
fully equipped clinics onsite at
homeless day centres.
Last year we conducted a patient
experience survey (PREM – see
page 29). The initial results from
this were generally very positive.
98 percent of patients surveyed
said they would use the service
again and that they would
recommend it to others. Here
are some of the comments
we received:
“It’s great that there is a service
for homeless people to use.
Thank you for your help.”
“I found everyone very kind and
easy to talk to.”
It is acknowledged however that
there were some limitations to the
questionnaire approach that was
used to collect this information.
There are many things that can
contribute to users of our service
not being able to give us feedback
on their experiences via a paper
survey format at the time that we
see them. Some of our patients
attend the clinics in crisis with
unstable mental health conditions,
whilst others may present under
the influence of alcohol or drugs.
All of these things will impact on
what and how they are able to tell
us about their experience.
Next year we are aiming to
strengthen our approach and
collect more meaningful and
representative data. In particular,
we plan to hold a focus group
with the daycentre staff who have
regular contact with our patients.
The three daycentres where our
clinics are held five days a week,
provide a broad range of support
for homeless people. This support
includes not only food, laundry,
showers, housing and benefit
advice, but also activities such as
art and writing groups. The staff
at these centres are therefore able
to speak informally to some of the
‘harder to reach’ patients whom we
have been unable to target through
our paper based survey. By holding
a focus group with these staff, it is
hoped that a greater understanding
of the needs of our patients can
be achieved and inform any future
service developments to meet
those needs.
Pat Baugh, Team Leader,
Homeless Health Team
5Appointment and waiting times
6An open question around “what
could we do better?”
•What we have learned from our
ongoing research and analysis in
relation to patient experience.
34
Quality Account 2010/11
Quality Account 2010/11
35
Formal statements required
by the Department of Health
Statement from the
Care Quality Commission (CQC)
Central London Community Healthcare NHS Trust is
required to register with the Care Quality Commission
and its current registration status is registered.
Central London Community Healthcare NHS Trust has
the following conditions on registration, all related to
the standard two regulatory conditions that the CQC
imposes on every registered bedded unit.
The first condition states “The Registered Provider must
ensure that the regulated activity accommodation for
persons who require nursing or personal care is managed
by an individual who is registered as a manager in
respect of that activity at or from the location.” Central
London Community Healthcare NHS Trust has registered
managers for each of our bedded units.
The second regulatory condition relates to the agreed
maximum capacity of each unit. The agreed limits for
the CLCH bedded areas are as follows:
The Care Quality Commission has not taken
enforcement action against Central London
Community Healthcare NHS Trust during 2010/11.
Central London Community Healthcare NHS Trust has
not participated in any special reviews or investigations
by the CQC during the reporting period.
Use of the CQUIN
payment framework
2010/11 framework:
A proportion of CLCH’s budget 2010/11 was conditional
on achieving quality improvement and innovation
goals agreed between CLCH and any person or
body they entered into a contract, agreement or
arrangement with for the provision of NHS services,
through the Commissioning for Quality and Innovation
payment framework. Further details of the agreed
goals for 2010/11 and for the following 12 month
period are available in the About us / Publications
section of our website www.clch.nhs.uk. Our CQUIN
goals for 2010/11 were as follows:
Formal statements required by the Department of Health
achieved a 16 percent improvement against a target
of 20 percent). Therefore we only received partial
payment for that goal. This is an area that we will
continue to focus on in 2011/12.
Participation in clinical audit
Number of national clinical audits
During 2010/11, five national clinical audits and no
national confidential enquiries covered the NHS
services that CLCH provides. During that period CLCH
participated in 100 percent of the national clinical
audits and none of the national confidential enquiries
of the national clinical audits and national confidential
enquiries which it was eligible to participate in.
The national clinical audits and national confidential
enquiries that CLCH was eligible to participate in
during April 2010 to March 2011 are as follows:
•National Audit of Falls and Bone Health Care in
Patients over 65
Training:
•Continue with the established ongoing training of
the nurses who are involved in the management of
people with continence problems within CLCH
•Applicants to identify mentor when applying for
the training course
•Audit of continence assessments within CLCH
Clinic Assessment:
•All patients with bowel dysfunction who attend the
continence clinic to have a quality of life assessment
using a validated quality of life assessment tool
•Include digital rectal exam (DRE) in urinary
continence assessment
Challenges: Staff capacity within the continence service
to carry out the audit in CLCH. How can these be met:
•Identify a staff member to take the lead with
assistance from the continence team
•National Audit of Multiple Sclerosis
•
Alison House Short Breaks Service
The Registered Provider must only accommodate a
maximum of five service users at Alison House Short
Breaks Service.
1To increase the amount of patients referred to the
Smoking Cessation Service
•
Athlone House Nursing Home
The Registered Provider must only accommodate
a maximum of 24 service users at Athlone House
Nursing Home.
3To increase time spent on patient focused care in
Health Visiting and District Nursing
•
Garside House Nursing Home
The Registered Provider must only accommodate
a maximum of 38 service users at Garside House
Nursing Home.
•
Learning Disability Flats
The Registered Provider must only accommodate
a maximum of 11 service users at Learning
Disability Flats.
•
Princess Louise Nursing Home
The Registered Provider must only accommodate
a maximum of 60 service users at Princess Louise
Nursing Home.
36
Quality Account 2010/11
2To develop innovation in reporting
4To measure the effectiveness of clinical
interventions through the development of
quality accounts
5To increase staff awareness of vulnerable patients/
clients with dementia
6To improve the quality and effectiveness of
information shared between care providers
(Westminster only)
All of the goals from 2010/11 were achieved in full,
with the one exception of goal three – to increase time
spent on patient focused care in Health Visiting and
District Nursing. For that target we were only partially
successful for the Health Visiting service in K&C (we
•National Audit of Psychological Therapies
•Work in collaboration with Clinical
Governance Facilitator
•National organisational audit of the
implementation of NICE public health guidance for
the workplace
•Continence promotion team to decide which
quality of life assessment tool would be most
suitable for use
The national clinical audits and national confidential
enquiries that CLCH participated in, and for which data
collection was completed during 2010/11 are listed
overleaf 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.
•Contact the various clinical and professional leads
for support
The reports of two national clinical audits were
reviewed by CLCH in April 2010 to March 2011 and
CLCH intends to take the following actions to improve
the quality of healthcare provided:
National Audit of Continence Care (data collection
finished previous year but National report released and
local actions implemented 2010/11). Actions arising:
National organisational audit of the implementation
of NICE public health guidance for the workplace
- Report just made available (end April 2011) and
currently under review – therefore actions are not
yet confirmed.
The reports of 137 local clinical audits were reviewed
by the provider in 2010/11 and as a result CLCH intends
to take a wide range of actions to improve the quality
of healthcare provided. A full list of the actions that
we have taken, or intend to take as a result of 2010/11
clinical audits is available in the About us / Publications
section of our website www.clch.nhs.uk.
Quality Account 2010/11
37
Formal statements required by the Department of Health
Formal statements required by the Department of Health
Eligible Audits
Involved
Cases
Submitted
Cases eligible
%
Actions
National Audit
of Falls and
Bone Health
Care
Yes
39
60
65%
Eligible audits determined by
acute Trusts submission of cases
to Community Falls Services.
Royal College of Physician’s
(RCP) report due imminently.
Local actions to be formulated
and ratified by the Patient
Safety and Quality Committee
once report is published. All
agreed actions for national
audits in minutes to the Board
National Audit
of Multiple
Sclerosis
National Audit
of Psychological
Therapies
Yes
Yes
N/A
organisational
audit
(ie no cases)
N/A
Servicer users
questionnaire
sent n=200
Service user
questionnaires
responses
n=65
33 staff
questionnaires
National
organisational
audit of the
implementation
of NICE
public health
guidance for
the workplace
Yes
National Audit
of Continence
Care
Yes
N/A
organisational
audit
(ie no cases)
42
N/A
33%
100%
33 staff
questionnaires
N/A
80
N/A
52%
Recently started. Data
submitted to RCP
Questionnaires only used in
the current audit. Report from
RCP due imminently and local
actions to be formulated and
ratified by Patient Safety and
Quality Committee
National report recently
received from RCP. Paper
currently submitted to Nonexecutive Directors for review
in the first instance. Actions
to follow
Data collection finished
previous year and National
report released 2010. Local
actions formulated and to be
ratified by Patient Safety and
Quality Committee 2011.
Participation in research
The number of patients receiving NHS services
provided or sub-contracted by CLCH in 2010/11 that
were recruited during that period to participate in
research approved by a research ethics committee
was: 209.
Data quality
Our actions to improve data quality
CLCH will be taking the following actions to improve
data quality:
•CLCH is committed to obtaining, holding and
making use of high quality data in its clinical and
corporate record-keeping systems.
•As a newly established Community Trust, we are
not able to demonstrate year on year metrics.
In-year monitoring of data quality however
demonstrates significant improvement in collection
of data around ethnicity, NHS Number, GP details
and activity recording. As a result, CLCH can
demonstrate that it now consistently meets the
national targets for collection of ethnicity data and
validated NHS Number.
•We understand the significance of supporting and
training staff to prioritise the collection of high
quality data: CLCH has made good progress towards
meeting the NHS London KPI around patient facing
time within the Health Visiting and District Nursing
services by working with staff to teach them the
importance of full recording, and providing them
with specific training and reference documents to
help them record on the system correctly.
•We undertake an audit of paper-based record
keeping standards twice a year, and will expand this
audit to cover electronic records in 2011/12.
•CLCH has agreed and implemented a Data Quality
Policy, with a defined minimum dataset.
38
Quality Account 2010/11
•The Information team routinely monitors data
quality. A range of standard reports are available
to staff and team managers to identify missing
data items.
•Business managers and the Head of Performance
monitor data month on month to identify trends.
•The information team ensures outlying values are
investigated and confirmed prior to the issuing
of reports.
•The Trust Board has commissioned the Improving
Management Information and Single Performance
Framework projects to ensure that we collect
meaningful data that will improve services received
by our patients, and which can be used by CLCH to
manage its services, plan for the future and develop
CLCH into the leading community service provider
in London.
•We are working to define accurate service line
financial reporting to ensure our services offer best
value for money.
NHS Number and General Medical Practice
Code Validity
CLCH did not submit records during 2010/11 to the
Secondary Uses service for inclusion in the Hospital
Episode Statistics which are included in the latest
published data.
Information Governance Toolkit (IGT)
attainment levels
CLCH Information Governance Assessment Report
score overall score for 2010/11 was 68 percent and was
graded red. Please note that the scoring on the IGT
was changed this year from Red/Amber/Green to Red/
Green, based on achievement of level two in every
standard; we did not meet the level required for a
green grading (like most of the cohort of community
trusts), although we were very close to achieving
that grade.
Clinical coding error rate
CLCH was not subject to the Payment by Results clinical
coding audit during 2010/11 by the Audit Commission.
Quality Account 2010/11
39
Statements from
our stakeholders
Please note that the following statements have been
reproduced exactly as they were provided by these
groups and have not been amended for consistency in
form or style in line with the CLCH style guide.
Statements from our Local
Involvement Networks (LINks)
Statements from our stakeholders
The LINk is delighted to note that CLCH has recently
amended the draft QA to reflect our concerns on:
•Language, Style & Structure
•Background to the Trust
•Action planning and
•Case studies
Hammersmith and Fulham LINk statement
Hammersmith and Fulham Local Involvement Network
(H&F LINk) welcomes the opportunity to comment on
the Central London Community Healthcare NHS Trust
Quality Accounts (QAs) 2010/11.
We have welcomed the opportunity to have a H&F
LINk participant, Donovan Philips and the late George
Ross, H&F LINk Steering Group, present to make
comments at the Trust’s Quality Accounts Stakeholder
Reference Group meetings over the past few months.
We trust their input on presentation style and
language used was of value and has been used to
make this document more accessible to the public.
The K&C LINk would suggest that further information
is needed to clarify:
1The overall quality assurance structure for the Trust
for 2011/2 that will be used to follow through on
the priorities for the coming year
2The major organisational and service changes faced
by CLCH in 2011/12
– to complete the integration of its internal
staff structure as well as service delivery across
4 boroughs and 60 services, while maintaining
attention to quality improvement throughout
these structural changes
3The incident rate per patient
In respect of the content of the accounts we at H&F
LINk plan to use the information contained within
the report to assess whether feedback from the local
community matches the statements provided.
4How nutrition is monitored across the tri-borough?
For example, was nutrition screening also
implemented in H&F and Westminster?
Harry Audley and Malika Hamiddou
Chairs – H&F LINk
5How priority 1, Improve discharge processes from
hospital to community, will be measured – baseline
and target required
Kensington and Chelsea LINk statement
6What is the target % for patients on the Liverpool
Care Pathway?
Kensington and Chelsea Local Involvement Network
(K&C LINk) welcomes the opportunity to comment on
the Central London Community Healthcare NHS Trust
Quality Accounts (QAs) 2010/11.
We appreciate that this is the first year of Quality
Accounts for the Trust and that the process was a steep
learning curve for us all. The LINk would like to thank
Trust staff for their engagement with K&C LINk in 2011
and we look forward to more strategic partnership
working in the coming year.
40
Quality Account 2010/11
Regarding priority 5, Develop a more detailed
understanding of patient experience in order to
improve quality, CLCH will also need to dedicate
time and resources to achieving the correct balance
between asking consistent patient experience
questions and tailoring for service specific dimensions.
The LINk representatives on the Stakeholder Reference
Group feel this is a key area to which they can
contribute going forward.
We are pleased that the Trust has identified ‘improving
discharge’ as a priority for 2011/12. This is a key
concern for K&C LINk. We welcome the opportunity
to work with the Trust on reviewing baseline data
and setting targets for 2011/2. To help with this, we
would suggest that the Trust might want to consider
categorising “discharge related incidents” separately
from other incidents during this year at a minimum.
For our information, the LINk would also find CLCH
case studies on ‘improving discharge’ most helpful as
we are conducting a comparative study of discharge
practices at local hospitals in the coming months.
Overall, the Trust has developed a constructive working
relationship with the LINk in Kensington and Chelsea
in developing the Quality Account this year. We look
forward to further involvement on quality and patient
experience in 2011/12 including the active continuing
engagement of the Stakeholder Reference Group
and will take a keen interest in your progress to
Foundation Trust status.
K&C LINk Representatives: Ms Tera Younger & Mrs
Angeleca Silversides
Westminster LINk statement
Westminster LINk is grateful to CLCH for involving it
in the preparation of 2010/11 Quality Accounts. We
approve the selection of improvement areas and in
particular the decision to refine surveys of patient
experience, even though existing surveys indicated a
high level of satisfaction.
Statements from our local Overview
and Scrutiny Committees (OSCs)
Royal Borough of Kensington and Chelsea
Overview and Scrutiny Committee statement
Central London Community Healthcare NHS Trust
Consultation on the Trust’s Quality Account 2010/2011
Introduction
As Chairman of this Council’s Health, Environmental
Health and Adult Social Care Scrutiny Committee
(HEHASC SC), I welcome the opportunity to comment
on Central London Community Healthcare NHS Trust’s
Quality Account 2010/2011.
The Scrutiny Committee and the Council both have
a good working relationship with Central London
Community Healthcare NHS Trust (CLCH).
Comments
There is concern about the financial outlook for NHS
provider trusts in North West London. The NHS in
North West London need to close a projected £1,014m
funding gap between available resources and “doing
nothing” by 2014/15.10 “£0.7bn of the funding gap
should be realised from real terms cuts in prices paid
to providers (e.g. national tariff), leaving £0.3bn to be
found through Commissioners managing demand and
commissioning different care pathways.”11 For 201112, “CLCH will need to deliver a minimum of 5% cashreleasing efficiency savings in order to fund general
price increases, pay costs and incremental drift and
10
T his scenario, that uses assumptions reflecting local circumstances, is on page 37 of “North West London Strategic Commissioning
and QIPP Plan 2014/15 (15 December 2010)”
http://hillingdonlink.org.uk/wp-content/uploads/2010/12/NWL-Approved-Strategic-Commissioning-and-QIPP-Plan-2011_14Main-Document-20101215-FINAL.pdf
11
HS Kensington and Chelsea’s Draft QIPP plan 2011/12
N
www.kensingtonandchelsea.nhs.uk/media/78327/2.1-qipp-plan2011-12.pdf
Quality Account 2010/11
41
Statements from our stakeholders
Statements from our stakeholders
the estimated cost of local cost pressures. In addition,
commissioners will be expecting CLCH to deliver up to
2% additional activity without any additional funding.
Each directorate will therefore be expected to identify
cash-releasing savings equivalent to 5% of their initial
budget control total. Managers should note that the
5% efficiency requirement is likely to be an annual
requirement for the next three to five years and
managers should therefore be considering now how
savings of this magnitude can be delivered across the
next three to five years.”12 The cash pressure could lead
to cuts to patient care. The Trust is to be supported in
its efforts to make efficiency savings without loss
of service.
At present, PCTs commission a block of community NHS
services from a single organisation on a geographic
basis. CLCH provides community NHS services in
Kensington and Chelsea, Hammersmith and Fulham,
Westminster and Barnet. In the future, it is likely
that there will be a move towards commissioning
a number of different organisations to provide the
best value for a particular stream of work (e.g. district
nursing, health visiting, podiatry and dietetics). CLCH
will face competition for the provision of community
NHS services from other NHS trusts and “any
qualified provider”. It is a concern that the impact of
competition on the Trust’s finances is uncertain.
The CLCH’s full involvement in the relevant boroughwide health promoting strategies (e.g. the Community
Strategies or public health strategies [such as
“Choosing Good Health – Together” in Kensington and
Chelsea]) is to be encouraged. More could be said in
the Quality Account on how the proposed actions of
the Trust align with major public health campaigns.
CLCH’s Information Governance Assessment Report
was graded level 2 in every standard in 2010-11 (page
34). The trust will have to improve if it is to achieve
foundation trust status.
12
It has been somewhat of a challenge to make a
meaningful response to the Trust draft Quality
Account. The Trust needs to pay due attention to
how readable and accessible its Quality Account is.
For example, it is difficult to analyse these Quality
Accounts as much information is not included (e.g.
data comparisons over a long timeframe to show the
ups and downs of performance).
Input from local involvement networks (LINks) and
Health overview and scrutiny committees should be
sought as early as possible, further engagement with
the Trust on its Quality Account over the course of the
year would be welcomed, so that the process does not
become only an annual consultation response, but an
ongoing dialogue.
consultation that had been undertaken in order to
inform its content. In summary the document gives
much confidence in terms of the Trust’s forward
direction in seeking Foundation Trust status.
The Committee were informed of the Quality
Account’s priorities on improving discharge procedures
with the acute sector, better involving patients in
their care, and developing understanding of how to
improve the patient experience. Members were also
encouraged to see that the Trust is seeking to further
improve its information gathering processes with more
representative surveys, the use of qualitative data and
approaches, and potentially touch pad technology and
audio/visual methods.
Overall, the progress that the Trust has made over the
last year is to be welcomed, and the HEHASC SC will
look forward to being informed of how the priorities
outlined in the Quality Account are implemented over
the course of 2011/12.
The Committee did issue a concern that efforts be
taken to ensure that the health inequalities across
the three boroughs of Westminster, Hammersmith
& Fulham and Kensington & Chelsea be adequately
respected in order to enable councils and partners to
address health issues in their respective boroughs.
Councillor Mary Weale
Chairman of the Health, Environmental Health and
Adult Social Care Scrutiny Committee, Royal Borough
of Kensington and Chelsea
As chairman of the committee I would like to thank
CLCH for engaging with the scrutiny committee and
wish them the best of luck in improving the outcomes
and experiences of patients.
Westminster Overview and
Scrutiny Committee
Sarah Richardson
Chairman of the Society, Families and Adult Services
Policy and Scrutiny Committee
On 11th May 2011 the Society, Families and Adult
Services Policy and Scrutiny Committee considered
CLCH’s Quality Account and fed back comments to
the Trust. This represents the written response to the
Quality Account.
The Committee was impressed by the level of work
that had obviously gone into preparing the Trust’s
Quality Account and applauded the extensive
Statement from
our commissioners
Statement from Inner North West London
PCTs re: Central London Community
Healthcare Quality Accounts 2010-11
Inner North West London (INWL) PCTs have reviewed
Central London Community Healthcare NHS Trust’s
(“the Trust”) Quality Account (QA) report for 2010-11.
The Trust presented its QA proposal and improvement
areas for 2011-12 to representatives of INWL subcluster PCTs in May 2011, with earlier drafting
involvement in February 2011. The Trust’s QA was
reviewed by the INWL Executive Management Team,
which included GP Consortia representation.
INWL PCTs can confirm that, in their view, the QA
complies with the guidelines where applicable for the
Trust’s first QA report.
The PCTs monitor the performance and the quality of
services routinely each month with the Trust. The PCTs
can confirm that, to the best of our knowledge, the
Trust’s QA 2010-11 contains accurate information in
relation to the services provided.
The Trust has set their priorities by exploring multiple
sources ranging from patient feedback to local
intelligence collected via incident reporting and
complaints, as well as by consulting staff, LINks, OSCs
and commissioners. This approach to setting priorities
is commended by the INWL PCTs and we are happy to
endorse the targets that have been set.
The monitoring of each of the priorities is deemed to
be set at appropriately timed intervals for each specific
priority, allowing a timely response to address issues
that may cause the target to be missed. However, it
is suggested that there is a consistent committee to
oversee the progress of all of the priorities to ensure,
where necessary, timely corrective activity is
taking place.
P age 9 of the paper “Budget Setting and Cost Improvement Plans 2011/12” that was taken to the CLCH Board of Directors on
3 February 2011:
www.clch.nhs.uk/about/board/Documents/CLCH%20NHS%20Trust%20Board%20Papers%203%20Feb%202011.pdf
42
Quality Account 2010/11
Quality Account 2010/11
43
Glossary of terms not explained
elsewhere in our Quality Account
Statements from our stakeholders
INWL PCTs are glad to see the inclusion of the priority
for improving discharge processes. The results from
the pilot in-reach project are eagerly anticipated.
INWL PCTs understand that CLCH play a pivotal
role in providing continuity of care between acute,
community and social care settings. Hence, we would
like to see future developments for this priority to
incorporate social care too; thus encouraging CLCH to
emphasise their role in terms of ‘practical’ integration
between secondary and social care.
INWL PCTs would also encourage the further
integration of community services across INWL
boroughs as a driver for the provision of quality
services. We believe this will help to resolve cross
borough boundary issues that currently remain.
The involvement of patient and public representatives
in setting the priority for strengthening results of
clinical and patient reported outcomes is good. This
coupled with supporting activity to establish gaps,
learning and standard practice is encouraging. It is
hoped that this priority could be more targeted and
focused in the next QA report to areas requiring the
most attention.
It is good to see the patient centred approach to
setting the priority for improving self management
and patient involvement in measuring outcomes.
This two pronged approach should help validate the
outcome of the priority. INWL PCTs would have liked
to have seen some consideration on how the uptake
of the complete PROMs cycle will be encouraged /
ensured over a specified timescale.
Although again quite broad, the priority to develop a
more detailed understanding of patient experience in
order to improve quality is an important first step.
The priority does, however, have targeted activities
to allow for the development of more focused
future priorities.
The actions to improve data quality appear to be
a good mix of training, monitoring and policy.
Compliance to the Information Governance Toolkit
is expected to be achieved soon.
It was thought that the opening section of the report
clearly sets out why QA reports are produced, how
service users and the public can get involved with its
development, as well as providing a good overview of
what services are provided by the Trust. It was
also noted that there was good use of case studies
and explanations of NHS terminology throughout
the report.
Overall, the Trust has good plans to improve quality
during 2011-12, and with this starting point, it has
room for the development of more focused priorities
and quality improvement activities for the future.
Clinical coding
The use of nationally and internationally understood
codes to describe a patient’s complaint, diagnosis and
treatment. Clinical coding assists in the recording of
patient data.
Payment by Results (PbR)
A system used to reimburse hospitals in England
for their activity. It means that payment is directly
related to the number of operations and other activity
undertaken.
Clinical coding errors
When medical complaints, diagnoses or treatments
are coded incorrectly which leads to incorrect data
collection.
Qualitative data
Information that cannot be measured or counted
numerically, such as a patient’s story about their
experience or their description of the quality of a
service.
Commissioners
Commissioners are the people responsible for buying
services from us for the patients and staff in a
particular area or organisation. Commissioners include
primary care trusts (PCTs), other health organisations,
local councils or private enterprise.
Quantitative data
The type of information that can be measured or
collected numerically, such as numbers of patients or
someone’s height and weight.
Deprivation indicators
These are the factors that are looked at to help
determine the needs of a community. Indicators
include income, employment, health, education,
housing and crime. Find out more from the Office for
National Statistics: www.statistics.gov.uk
Hospital Episode Statistics (HES)
HES is a data warehouse that contains information
about hospital admissions and outpatient attendances
in England. The data in HES comes from the Secondary
Uses Service (SUS), which collects data that’s passed
between healthcare providers and commissioners. The
data is published monthly for the last year. (Source:
NHS - The Information Centre www.ic.nhs.uk) You can
also find out more at www.hesonline.nhs.uk
The priority to improve service models and develop
pathways of care to improve effectiveness and
patient experience, although quite broad, is integral
to delivering quality services. It is encouraging to see
that safeguarding vulnerable adults and children as
well as end of life care are specifically highlighted for
incorporation. It is also encouraging to see stated the
involvement of other healthcare agencies and the
public. INWL PCTs would also like to see social care
integrated into community service pathways.
44
Quality Account 2010/11
Quality Account 2010/11
45
Useful contact details and links
Feedback
CLCH NHS Trust
Now that you have read our first Quality Account, we would really like to
know what you think, how we can improve and how you would like to be
involved in developing our Quality Accounts in future.
CLCH Communications
e:communications@clch.nhs.uk
t: 0207 798 1420
w:www.clch.nhs.uk
CLCH Patient Advice and Liaison
Service (PALS)
e:pals@clch.nhs.uk
t: 0800 368 0412
Switchboard for service contacts
t: 020 7798 1300
Partners mentioned in our
Quality Account
Local Involvement Networks
(LINKs)
Hammersmith and Fulham LINk
e:hflink@hestia.org
t: 020 8969 4852
w:www.lbhflink.org.uk
Kensington and Chelsea LINk
e:rbkclink@hestia.org
t: 020 8968 7049/ 6771
w:www.rbkclink.org.uk
Westminster LINk
e:general@vawcvs.org
t: 020 7723 1216
w:www.vawcvs.org
Chelsea and Westminster Hospital
NHS Foundation Trust
w:www.chelwest.nhs.uk
Barnet LINk
e:link@communitybarnet.org.uk
t: Tel: 020 8364 8400
w:www.barnetlink.org
Imperial College Healthcare NHS
Trust
w:www.imperial.nhs.uk
Local councils (for Overview
and Scrutiny Committees)
Primary Care Trusts (PCTs)
Inner North West London Cluster
(Currently based at NHS
Westminster – details below)
NHS Hammersmith and Fulham
w:www.hf.nhs.uk
NHS Kensington and Chelsea
w:www.kensingtonandchelsea.nhs.uk
NHS Westminster
w:www.westminster.nhs.uk
NHS Barnet
w:www.barnet.nhs.uk
46
Quality Account 2010/11
Healthcare organisations
Care Quality Commission
w:www.cqc.org.uk
Department of Health
w:www.dh.gov.uk
Please use the following links or contact details to take our short
feedback survey. The survey should only take five minutes to complete.
We appreciate your time.
King’s Fund
w:www.kingsfund.org.uk
Go to www.clch.nhs.uk/feedback/qualityaccountfeedback.html to fill out
the survey online.
National Institute for Health and
Clinical Excellence (NICE)
w:www.nice.org.uk
Go to www.clch.nhs.uk/feedback/CLCH_Quality_Account_Feedback_Survey.pdf
to print out a paper copy and post to:
National Patient Safety Agency
w:www.npsa.nhs.uk
NHS Choices
w:www.nhs.uk
Communications
Central London Community Healthcare NHS Trust
7th Floor
64 Victoria Street
London SW1E 6QP
Write to us if you would like us to send you a paper copy using the address
above or via email to communications@clch.nhs.uk
Alternatively, if you or someone you know would like to provide feedback
in a different format or request a copy of the survey by phone, call our
communications team on 020 7798 1420.
Hammersmith and Fulham
e: 020 8748 3020
w:www.lbhf.gov.uk
Kensington and Chelsea
e:information@rbkc.gov.uk
t: 020 7361 3000
w:www.rbkc.gov.uk
Westminster
e:info@westminster.gov.uk
t: 020 7641 6000
w:www.westminster.gov.uk
Barnet
e:first.contact@barnet.gov.uk
t: 020 8359 2000
w:www.barnet.gov.uk
This report has been printed throughout on Cocoon Preprint
Offset, made from 100% genuine de-inked post consumer waste.
Cocoon Preprint Offset is FSC certified.
Quality Account 2010/11
47