City Health Care Partnership
Quality Accounts
2010/11
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Contents
Part 1
Statement from the Chief Executive..................5
Part 2
Priorities for Improvement..................................7
Patient Experience...................................................8
Clinical Effectiveness...............................................8
Patient Safety..........................................................9
Quality of Our Services......................................11
Part 3
Review of Quality..............................................20
How did we do in 2010/11................................21
Supporting Statements.....................................33
3
Part 1
4
Statement from the
Chief Executive
Welcome to City Health Care
Partnership CIC’s first Quality
Accounts.
The 1st June 2010 was a landmark date for City
Health Care Partnership CIC as this was the date
that we formally separated from Hull Teaching
PCT and became our own company. Building on
the excellent reputation for delivery of healthcare
services in Hull and East Riding of Yorkshire our aim
is to be the community provider of choice in the
area. In short, we’re here to improve the lives of
local people.
These accounts area record of our achievements in
2010/11 and the quality of our services underpins
our values as an organisation which are;
l Service and Excellence
l Equality and Diversity
l Creativity and Innovation
l Cooperation and Partnership
To the best of my knowledge the information
contained within these Quality Accounts is
accurate.
Andrew Burnell
Chief Executive
City Health Care Partnership CIC
5
Part 2
6
Priorities for
Improvement
Consultation Process
City Health Care Partnership CIC has
undertaken consultation with the following
groups in the production of the Priorities for
Improvement for 2010/11:
To ensure that our priorities for improvement
are reflective of our stakeholder’s wishes, we
have undertaken an extensive consultation
exercise to identify our three priorities. The
consultation took place in three key phases:
l NHS Hull
Phase 1 - we contacted all our stakeholders
via letter, email and our website, asking for key
themes they would wish us to consider under
the headings of:
l NHS East Riding of Yorkshire
l Patient Experience
l Hull City Council Overview & Scrutiny Committee
l Clinical Effectiveness
l East Riding of Yorkshire Council Overview & Scrutiny Committee
We collated all of the responses to develop our
‘long-list’ of potential priorities.
l City Health Care Partnership CIC patients (through our website)
Phase 2 – we issued our ‘long-list’ to all our
stakeholders and asked them to vote for
their top priority in each category. Patients
and staff were given the opportunity to vote
via our internet site. All the responses were
collated and from this we determined our
three Priorities for Improvement.
l Hull LINks
l East Riding of Yorkshire LINkS
l City Health Care Partnership CIC staff
l Patient Safety
Phase 3 – the final Quality Accounts were sent
to the stakeholders and the key statements
are published in the final chapter of this
document.
City Health Care Partnership CIC would like to
thank all stakeholders for their involvement
in the production of the Priorities for
Improvement and production of
supporting statements.
7
Patient
Experience
Telephone Access
Definition
Increase ease of patient’s ability to get through
on the telephone.
How will we measure?
Annual patient questionnaire – comparing
last year’s response rate to this year’s response
rate.
How will we Report?
l Report of annual patient questionnaire and
next year’s Quality Accounts.
l Monitoring of PAL’s / compliments /
complaints data and reporting updates on
our website.
8
Clinical
Effectiveness
Clinical Audit
Definition
How will we Report?
Establishment of Clinical Audit processes
within CHCP to record and disseminate best
clinical practice.
l Quarterly updates will be reported on our
website.
How will we measure?
l Final year end update in next year’s Quality
Accounts.
Progress against an implementation plan.
9
Patient Safety
Root Cause Analysis
(RCA)
Definition
Roll out of root cause analysis (RCA) training
within the organisation to provide the platform
for incident investigation.
How will we measure?
Progress against an implementation plan.
How will we Report?
l Quarterly updates will be reported on our
website.
l Final year end update in next year’s Quality
Accounts;
These will include:
l Number of Root Cause Analysis training
sessions held.
l Number of CHCP staff who have
undertaken Root Cause Analysis Training.
l Number of Root Cause Analysis’s
undertaken within CHCP.
10
Review of
Services
Community Services
During 2010/11 City Health Care Partnership
CIC provided 40 NHS services under the
following business units:
l Adults Services
l Children & Young People
l Specialist Services
l Primary Care
l Corporate
Primary Care Services
During 2010/11 City Health Care Partnership
CIC provided NHS General Practitioner services (5
practices) and NHS Dental Services (general dental
and community dental). Details of these services
are included within these Quality Accounts.
City Health Care Partnership CIC has reviewed all
the data available to them on the quality of care in
40 of these NHS Services.
The income generated by the NHS services
reviewed in 2010/11 represents 100% of the
total income generated from the provision of NHS
services by City Health Care Partnership CIC for
2010/11.
11
Participation in
Clinical Audits
National Clinical Audits and National
Confidential Enquiries
During 2010/11 4 national clinical audits and
no national confidential enquiries covered NHS
Services that City Health Care Partnership CIC
provides.
During that period City Health Care Partnership
CIC participated in no national clinical audits
and no 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 City Health Care
Partnership CIC was eligible to participate in
during 2010/11 are as follows:
National Clinical Audits
Diabetes (RCPH National Paediatric Diabetes
Audit)
Diabetes (National Adult Diabetes Audit)
Heavy menstrual bleeding (RCOG National
Audit of HMB)
Depression & anxiety (National Audit of
Psychological Therapies)
National Confidential Enquiries
None
12
The national clinical audits and national
confidential enquires that City Health Care
Partnership CIC participated in during 2010/11
are as follows:
No audits or Confidential Enquires
participated in.
The national clinical audits and national
confidential enquires that City Health Care
Partnership CIC participated in, and for which
data collection was completed during 2010/11
are listed below alongside the number of
cases submitted to each audit or enquiry as a
percentage of the number of registered cases
required by the terms of that audit or enquiry
NATIONAL CLINICAL AUDITS
Participation
%
Perinatal mortality (CEMACH)
N/A
N/A
Neonatal intensive and special care (NNAP)
N/A
N/A
Paediatric pneumonia (British Thoracic Society)
N/A
N/A
Paediatric asthma (British Thoracic Society)
N/A
N/A
Paediatric fever (College of Emergency Medicine)
N/A
N/A
Childhood epilepsy (RCPH National Childhood Epilepsy
Audit)
N/A
N/A
Paediatric intensive care (PICANet)
N/A
N/A
Paediatric cardiac surgery (NICOR Congenital Heart Disease
Audit)
N/A
N/A
0
0
N/A
N/A
Emergency use of oxygen (British Thoracic Society)
N/A
N/A
Adult community acquired pneumonia (British Thoracic
Society)
N/A
N/A
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
N/A
N/A
Pleural procedures (British Thoracic Society)
N/A
N/A
Cardiac arrest (National Cardiac Arrest Audit)
N/A
N/A
Vital signs in majors (College of Emergency Medicine)
N/A
N/A
Adult critical care (Case Mix Programme)
N/A
N/A
Potential donor audit (NHS Blood & Transplant)
N/A
N/A
Emergency use of oxygen (British Thoracic Society)
N/A
N/A
Adult community acquired pneumonia (British Thoracic
Society)
N/A
N/A
Non invasive ventilation (NIV) - adults (British Thoracic
Society)
N/A
N/A
Peri- and Neonatal
Children
Diabetes (RCPH National Paediatric Diabetes Audit)
Paediatric pneumonia (British Thoracic Society)
Acute care
13
Participation in
Clinical Audits (cont)
NATIONAL CLINICAL AUDITS
Participation
%
Diabetes (National Adult Diabetes Audit)
0
0
Heavy menstrual bleeding (RCOG National Audit of HMB)
0
0
Chronic pain (National Pain Audit)
N/A
N/A
Ulcerative colitis & Crohn’s disease (National IBD Audit)
N/A
N/A
Parkinson’s disease (National Parkinson’s Audit)
N/A
N/A
COPD (British Thoracic Society/European Audit)
N/A
N/A
Adult asthma (British Thoracic Society)
N/A
N/A
Bronchiectasis (British Thoracic Society)
N/A
N/A
0
0
Elective surgery (National PROMs Programme)
N/A
N/A
Cardiothoracic transplantation (NHSBT UK Transplant
Registry)
N/A
N/A
Liver transplantation (NHSBT UK Transplant Registry)
N/A
N/A
Coronary angioplasty (NICOR Adult cardiac interventions audit)
N/A
N/A
Peripheral vascular surgery (VSGBI Vascular Surgery
Database)
N/A
N/A
Carotid interventions (Carotid Intervention Audit)
N/A
N/A
Familial hypercholesterolaemia (National Clinical Audit of
Mgt of FH)
N/A
N/A
Acute Myocardial Infarction & other ACS (MINAP)
N/A
N/A
Heart failure (Heart Failure Audit)
N/A
N/A
Pulmonary hypertension (Pulmonary Hypertension Audit)
N/A
N/A
Acute stroke (SINAP)
N/A
N/A
Stroke care (National Sentinel Stroke Audit)
N/A
N/A
Familial hypercholesterolaemia (National Clinical Audit of
Mgt of FH)
N/A
N/A
Acute Myocardial Infarction & other ACS (MINAP)
N/A
N/A
Long term conditions
Elective procedures
Hip, knee and ankle replacements (National Joint Registry)
Cardiovascular disease
14
NATIONAL CLINICAL AUDITS
Participation
%
Renal replacement therapy (Renal Registry)
N/A
N/A
Renal transplantation (NHSBT UK Transplant Registry)
N/A
N/A
Patient transport (National Kidney Care Audit)
N/A
N/A
Renal colic (College of Emergency Medicine)
N/A
N/A
Renal replacement therapy (Renal Registry)
N/A
N/A
Lung cancer (National Lung Cancer Audit)
N/A
N/A
Bowel cancer (National Bowel Cancer Audit Programme)
N/A
N/A
Head & neck cancer (DAHNO)
N/A
N/A
Hip fracture (National Hip Fracture Database)
N/A
N/A
Severe trauma (Trauma Audit & Research Network)
N/A
N/A
Falls and non-hip fractures (National Falls & Bone Health Audit)
N/A
N/A
Hip fracture (National Hip Fracture Database)
N/A
N/A
0
0
Prescribing in mental health services (POMH)
N/A
N/A
National Audit of Schizophrenia (NAS)
N/A
N/A
O Neg blood use (National Comparative Audit of Blood
Transfusion)
N/A
N/A
Platelet use (National Comparative Audit of Blood Transfusion)
N/A
N/A
Participation
%
Renal disease
Cancer
Trauma
Psychological conditions
Depression & anxiety (National Audit of Psychological Therapies)
Blood transfusion
NATIONAL CONFIDENTIAL ENQUIRIES
None applicable to City Health Care Partnership CIC
The reports of no national clinical audits were reviewed by the provider in 2010/11 and City
Health Care partnership (CIC) intends to take the following actions to improve the quality of
healthcare provided - no actions as no reviews undertaken
15
Participation in
Clinical Audits (cont)
Local Clinical Audits
The reports of 10 local clinical audits were
reviewed by the provider in 2010/11 and City
Health Care Partnership CIC intends to take
the following actions to improve the quality of
healthcare provided.
l Revise documentation to improve patient
experience, clinical management and
patient pathway through the service.
l Streamline the provision of services to
match patients needs in geographic areas
and provide additional treatment room
sessions for patients.
l Provide additional training for clinicians in
the Palliative End of Life Care.
l Provide confidential feedback cards on the
services provided for younger people.
l Introduce drop in session clinics to increase
the access and availability of services.
l Utilise text messaging technology to
advertise services to specific groups.
Participation in Clinical
Research
The number of patients receiving NHS services
provided or sub-contracted by
City Health Care Partnership CIC in 2010/11
that were recruited during that period to
participate in research approved by a research
ethics committee was zero.
16
What others say about City
Health Care Partnership CIC
Goals agreed with
Commissioners
Commissioning for Innovation and
Quality Improvement (CQUIN)
A proportion of City Health Care Partnership
CIC income in 2010/11 was conditional on
achieving quality improvement and innovation
goals agreed between City Health Care
Partnership CIC 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 on request from
qualityaccounts@chcphull.nhs.uk
Care Quality Commission
(CQC)
City Health Care Partnership CIC is required to
register with the Care Quality Commission and
its current registration status is ‘Registered.’
City Health Care Partnership CIC has no
current conditions on registration.
The Care Quality Commission has taken no
enforcement action against City Health Care
Partnership CIC during 2010/11.
City Health Care Partnership CIC is subject
to periodic reviews by the Care Quality
Commission. To date City Health Care
Partnership CIC has not been reviewed.
17
Data Quality
Statement on Relevance
of Data Quality and
actions to improve
City Health Care Partnership CIC will be taking
the following actions to improve its data quality:
• The organisations Data Quality Policy shall
be refreshed, revised and briefed to the
organisation
• Staff new to the organisation shall be given
specific I.T. Systems training appropriate for
their role upon induction to ensure patient
safety is maintained
• Refresher training for I.T. Systems shall be
incorporated into staff development reviews
• Raise awareness of the importance of data
quality throughout the organisation and
this contributes to patient care and safety
18
Secondary User Service
City Health Care Partnership CIC 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
City Health Care Partnership CIC Information Governance Assessment Report score
overall score for 2010/11 was 48% and
was graded red
Clinical Coding
City Health Care Partnership CIC was not
subject to the Payment by Results clinical
coding audit during 2010/11 by the Audit
Commission.
Part 3
19
Introduction
1st June 2010 was a landmark date for City
Health Care Partnership CIC as this was that
date that we formally separated from Hull
Teaching PCT and became our own company.
Building on the excellent reputation for
delivery of healthcare services in Hull and
East Riding of Yorkshire our aim is to be the
community provider of choice in the area. In
short, we’re here to improve the lives of local
people. We can minimise the need for acute
care in hospital through early interventions,
community based treatment and promotion of
healthy lifestyles.
Our organisation consists of business units
providing clinical services to the population of
Hull and the East Riding and in 2010/11 our
contact activity was:
20
Business Unit
Contacts
Adults
308,470
Children & Young People
66,434
Primary Care
207,224
Specialist Services
42,435
Total
624,563
How did we do in
2010/11?
My worries put to rest by the
health visitor
Story from question804 as
a relative - 28/03/2011
What our Patients Say
Patient Opinion
Listening to our local population is fundamental
for City Health Care Partnership CIC both as a
healthcare provider and a community interest
company. For us, the local community, our
patients and their carers have a role to play in
shaping the services we provide.
The philosophy behind this approach is that
in order to provide a high quality service that
meets our local communities’ needs, it is vital
that the views of our service users are taken
account.
As well as having a legal duty, we understand
the importance of creating a culture of
partnership, participative decision making and
collaboration.
Patient Opinion is an independent organisation
where members of the public can share their
comments, complaints and compliments about
City Health Care Partnership CIC and the
services we provide.
Feedback Type
Concern: 17%
Story: 21%
Review 4%
:2%
Thank you 55%
21
How did we do in
2010/11? (cont)
Wonderful care of my elderly
mother
Story from lazyboy as a
relative - 02/04/2011
Feedback posted by
a carer: 2%
a relative: 21%
a staff member: 3%
other: 5%
the patient: 69%
Patient Survey 2010/11
There is an aspiration, opportunity and need
both reflect in our values and contractual
relationships to engage with local people
to improve the health and wellbeing of the
local population. This will ensure we are able
to deliver a comprehensive and equitable
range of high quality, responsive and efficient
22
services within allocated resources, where this
gives “best value”.
City Health Care Partnership CIC views patient
and service user experience as a key priority in
the delivery of their services. Not only is this
part of our contractual obligations but also an
integral method by which we can gather and
benchmark important patient feedback for the
services we provide to the communities of Hull
and the East Riding of Yorkshire.
Our Patient Survey report is reviewed and used
to monitor and track customer experience and
feedback measures. The data provided by the
annual survey also feeds into our performance
management and CQUINs targets.
Recipients
The 2010 survey included 15 service areas
covered by the East Riding of Yorkshire
Community Contract, Hull Community
Contract, Primary Care Medical Services
(GP’s), Dental and Addictions Services. 3,000
questionnaires were distributed across the
service areas.
PALS
PALS gives patients and their carers the
opportunity to discuss a concern or complaint
with a member of our customer service team.
We deal with concerns and complaints in a
confidential manner, providing on the spot
information, practical advice and support with
the aim of resolving any patient problems or
difficulties.
In 2010/11 we received 637 PALS contacts and
the chart opposite shows the nature of the
contacts:
23
How did we do in
2010/11? (cont)
PALS contacts
Request for Assistance
Expression of Concern
General Advice
Request for Information
Suggestion for Improvement
Complaints & Compliments
As an organisation we review all feedback on
our services. Our complaints procedure has been
established to enable people to complain about
services or the treatment they receive from our
organisation. Our aim is to deal with complaints
quickly and thoroughly and to involve those who
know most about your care. In 2010/11 we
received 28 complaints in connection with services
provided by City Health Care Partnership CIC.
As an organisation we also log when patients
feedback positively on our services and in 2010/11
we received 583 compliments in connection
with the services provided by City Health Care
Partnership CIC.
24
120
100
80
60
40
20
0
ne
Ju
st
ly
Ju
gu
Au
Complaints
pt
Se
ct
O
v
No
c
De
Compliments
n
Ja
b
Fe
ch
ar
M
What have we learnt?
The key to our complaints procedure is to listen to our patients and their families and learn from
their experiences. Below are some examples of how feedback has enabled us to shape our
services to meet the needs of our population:
Feedback
We Did
Lack of communication between patient
and family leading to confusion at patient
meetings
Re-organised visits and care planning
meetings to ensure that patients and their
families received timely information.
Essential supplies being delivered to a patient
when out at work.
Re-organised the delivery schedule to ensure
that the supplies arrived at a time when the
patient was at home.
Not all healthcare information used when
giving a statement to a third party.
The organisation ensures that all records are
used when preparing any statements for third
parties.
NHS Ombudsman
If patients are not happy with the manner in which City Health Care Partnership CIC deal with a
complaint, they can refer to the NHS Ombudsman. In 2010/11 three complaints were referred to
the ombudsman with the following outcomes:
Compliant
Ombudsman decision
Complaint 1
Complaint undergoing further investigation by CHCP CIC and the results
of the investigation will be fed back to the patient and the Ombudsman.
Complaint 2
No further recommendations or actions suggested by the Ombudsman.
Complaint 3
The ombudsman requested clarification on 3 separate points. Upon
supplying the information the Ombudsman closed the case with no
further recommendations or actions.
25
Key Performance
Smoking Cessation –
4 Week Quits
NHS Hull
NHS East Riding of
Yorkshire
5000
4500
4000
Target
Actual
3000
3133
3500
3000
2500
2000
1682
2057
1500
1000
500
0
NHS Hull
NHS ER
Combined
Target
Smoking Cessation –
4 Week Quits, targeted
NHS Hull – Young People
NHS Hull – Pregnant
Women
Target
Actual
32
53
Actual
180
160
140
120
100
80
60
40
150
169
20
0
Pregnant
Young People
Target
Chlamydia Screening
NHS Hull
NHS East Riding of
Yorkshire
Actual
40%
35%
Target
Actual
35%
37%
30%
25%
20%
15%
10%
23%
10%
5%
0%
NHS Hull
NHS ER
Target
26
Actual
18 Weeks Wait –
Non Admitted Care
Target
100%
90%
80%
Actual
70%
60%
City Health Care
Partnership CIC
95%
99.4%
40%
Paediatric Dentistry
95%
68.2%
30%
Community Gynaecology
95%
99.1%
Other (Family Planning,
Erectile Dysfunction &
Genito-Urinary Medicine)
50%
20%
10%
0%
CHCP
95%
Paediatric
Dentistry
99.99%
Genito-Urinary Medicine
(GUM)
Community
Gynaecology
Target
Other
Actual
96
95
94
93
Target
Access to a genito-urinary
medicine (GUM) clinic
within 48 hours of
contacting a service
Actual
91
90
89
88
90%
95.3%
Minor injuries Unit (MIU)
Waits
Percentage of patients
who are seen and start
treatment within 4
hours of arriving
92
Target
Actual
87
Target
Actual
Bransholme
Freedom Centre
100.0%
99.5%
99.0%
98.5%
98.0%
97.5%
97.0%
96.5%
Bransholme Health
Centre
97.9%
100%
Freedom Centre
97.9%
100%
Target
Actual
27
Key Performance (cont)
Quality & Outcomes
Framework (GP Surgeries)
– Clinical Domain
The surgeries are rated in the clinical domain
against a maximum of 697 points.
Max
Kingston Medical
Centre
28
Actual
%
700
600
500
400
300
200
100
697
676.46
97.1
Mizzen Road (closed
31/03/11)
697
516.56
74.1
Calvert Medical
Centre
697
696.54
99.9
Riverside Medical
Centre
697
692.01
99.3
The Quays
697
663.04
95.1
0
Kingston
Medical
Centre
Mizzen
Road
(closed
31/03/11)
Calvert
Medical
Centre
Riverside
Medical
Centre
Maximum
The Quays
Actual
Governance
Incidents
Degree of Harm
At City Health Care Partnership CIC we are
committed to the safety of our patients, their
families and our staff. At times accidents and
incidents happen and our philosophy is to record,
action and learn from these events. In 2010/11
we recorded 2,250 incidents and the graph below
outlines the types of incident that were recorded.
Every incident is profiled to ascertain the
degree of harm. The harm can be classed in
terms of effect on patients, staff or services.
The table below gives a simplified definition
for the way that we categorise the degree of
harm.
1000
900
800
700
600
500
400
The organisation records, investigates and
learns from a range of incidents including
those which have impacted on the delivery
of services, issues with buildings and
infrastructure and Information Technology.
These incidents maybe categorised as major or
catastrophic although they have not harmed
an individual.
In 2010/11 City Health Care Partnership CIC
reported the following degree of harm for the
incidents reported.
300
200
100
900
in
e
G
800
700
600
ic
io
n
500
400
300
200
100
ic
Ca
ta
st
ro
M
aj
ph
or
te
M
od
e
ra
in
or
M
ig
eg
l
N
o
ha
rm
ab
le
0
N
at
fo
rm
In
M
ed
fe
In
na
nc
M
e
an
ag
em
en
Sa
t
fe
gu
ar
di
ng
Se
cu
rit
y
ov
er
Co
nt
r
ct
io
th
n
&
ol
ty
n
Sa
fe
tio
ca
H
ea
l
un
i
m
G
Co
m
ov
er
na
nc
e
0
29
Governance (cont)
Serious Untoward
Incidents
Serious incidents in healthcare are uncommon
but when they occur health providers have a
responsibility to ensure there are systematic
measures in place for safeguarding people,
property, NHS funded resources and reputation.
This includes responsibility to learn from these
incidents to minimise the risk of them happening
again.
In 2010/11 City Health Care Partnership CIC
launched three Serious Untoward Incident (SUI)
investigations two of which are currently being
investigated, the following learning points were
determined from the completed investigation.
• The use of the Liverpool Care Pathway has
been implemented within a patient area and
assists the staff in providing specialist palliative
care services
• To complement the single assessment process
for a particular patient group “community
care plans” are being introduced
Infection Control 2010/11
Good infection prevention and control are
essential to ensure that people who use health
services receive safe and effective care. City
Health Care Partnership CIC has an established
Infection Prevention & Control Team to assist
the organisation in achieving this. Key activities
over the past year have been:
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• The infection Prevention & Control Team
have investigated eleven cases of MRSA
Bacteraemia in the Community during 2010
/ 2011 with no causes directly attributable
to services provided by City Health Care
Partnership CIC
• A professional group of link nurses has
been established to ensure good practice is
shared across the organisation, the group
meets on a quarterly basis
• An Infection Control Care Package
was developed to help a patients with
particular needs to be treated in their home
environment
• Within our dental services we are
implementing the new HTM0105 infection
control standards and during 2010/11 60%
of our practices achieved compliance, the
remaining practices will become compliant
within the timeframe of the guidance.
Staff Survey 2010/11
City Health Care Partnership CIC under took
a staff survey in 2010/11. Staff comments are
important to us to help improve our employees’
working lives with the aim of City Health Care
Partnership CIC becoming an employer of choice.
Key comments for this year’s staff survey are:
• 88% agreed that as an employer CHCP
is committed to learning, training and
development.
• 79% agree that CHCP takes a positive
interest in the health and well-being of
employees.
Making Every Contact
Count (MECC)
• 73% would recommend City Health Care
Partnership as a place to work.
2010/11 saw City Health Care Partnership CIC
begin its drive to enhance the public health
capabilities of its workforce as part of the Making
Every Contact Count (MECC) strategy.
• 76% understand the changes the
organisation has gone through to become a
social enterprise.
• 85% agree the people they work with treat
them with respect.
Our decision to embrace the prevention and
lifestyle behavior change framework, which
underpins the region’s key public health strategy
‘Making Every Contact Count’, will:
• 88% agree that they are trusted to do their
job.
• offer a common/universal approach across all
areas of the organisation.
• 100% agree that they try to help colleagues
whenever they can.
• create opportunities to introduce or bring about
lifestyle behaviour change for its patients.
Equality & Diversity
City Health Care Partnership CIC is committed
to promote equality of opportunity following
the launch of the Equality Bill in April 2010.
During 2010/11 we published our Equality
and Diversity Policy which sets out our
commitment to maintaining a pro-diverse
and anti-discriminatory workforce and our
aim to deliver equality and fairness to all our
employees and patients.
• add value to good practice.
2010/11 saw the building blocks of MECC and
we will continue this throughout the next year and
report our progress in next year’s accounts.
In 2010/11 City Health Care Partnership CIC
launched its Equality Impact Assessment
tool and has begun a programme of impact
assessing all policies, procedures and services.
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Social Audit
Social Audit 2010/11
Social Accounts are seen as an integral part of
the organisation’s development as a not-forprofit organisation and part of its obligations as
a Community Interest Company. Undertaking
Social Accounts early in the organisations life
demonstrates City Health Care Partnership’s
CIC desire to be held accountable to its
Social Objectives and Values. In addition, we
recognise the value of the Social Accounting
process as a tool in our development as a
socially responsible organisation.
The Social Accounts cover the period from
1st June to 31st December 2010. The
organisation obtained feedback from a range of
stakeholders.
City Health Care Partnership CIC Social
Objectives are split into 5 broad areas:
1. To grow a socially responsible business
2. To contribute to the wider well being of
communities
3. To deliver high quality services
4. To be responsive, caring and inclusive to all
5. To be a place where people love to work
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Key Performance Indicators (KPIs) were
developed based upon our values.
The KPIs therefore:
• are relevant to City Health Care Partnership
CIC as a healthcare organisation (not just
any not for profit organisation / Social
Enterprise);
• look at the added value of us as an
organisation rather than just the
effectiveness of the services that it delivers;
• make extensive use of existing data and
information but is not completely driven by
it.
Reflect this is an ongoing process and that this
is just the start of the process.
Statements
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Statements
NHS Hull
The Quality Account represents a
comprehensive and balanced description
of the quality of services provided by CHCP
during 2010-11. The Quality Account
confirms CHCP’s commitment to work with
stakeholders to improve the experience of
service users and carers, and the quality of
the services provided. The Quality Account
identifies that CHCP has focused this year on
key issues including safeguarding patients
through the establishment of new systems
for capturing learning from patient safety
incidents; improving the care environment;
promoting good infection prevention control,
and the drive to enhance the public health
capabilities of its workforce as part of the
Making Every Contact Count (MECC) strategy.
The Quality Account may benefit from
further elaboration on the achievements and
challenges faced by the organisation in the
following areas:
• An Information Governance Toolkit
Action Plan to identify the actions being
undertaken to achieve compliance with the
key requirements of the assessment tool;
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• Demonstration of how ‘root cause analysis’
methodologies would enhance the learning
from incidents, investigations and improve
the safety of services for patients, and
• Demonstration of how NICE guidance has
improved clinical practice, clinical outcomes
and service delivery across the organisation.
NHS Hull can hereby confirm that the content
of the Quality Accounts appears to be accurate
and consistent with the data and information
available to NHS Hull and we will continue to
work in partnership with CHCP CIC to seek
assurance of quality improvements through
the existing governance arrangements. For
2011–12, NHS Hull supports the areas that
CHCP has identified as key priorities for
further quality improvements to ensure that
these areas remain a central focus for the
organisation.
NHS East Riding Of
Yorkshire
over and above the expected target will
have a positive impact on the health of our
population.
NHS East Riding of Yorkshire is pleased to
receive and be asked to comment on the
City Healthcare Partnership Quality Account.
We have paid particular consideration to
the services we commission which are in
relation to Chlamydia, Sexual Health, Smoking
Cessation and Tuberculosis Services.
It is encouraging to see an improvement with
regard to the uptake of Chlamydia screening
across the East Riding of Yorkshire.
It is important that there is obvious stakeholder
involvement in the development of the
account and a clear consultation process has
been followed identifying the 3 domains of
quality. The report is clearly set out with a
public focused layout.
We are pleased to see that City Healthcare
Partnership has had a positive response with
regard to the 4 Week Quits for Smoking
Cessation. The achievements of results
There is acknowledgement of a low
percentage score in relation to the IG toolkit
however the account does not describe the
plans for 2012 to improve this.
We are pleased to see that there is a
commitment to the safety of patients and that
the majority of incidents reported are profiled
in the categories of none to minor harm.
NHS East Riding of Yorkshire looks forward
to continued working with City Healthcare
Partnership to bring about further
improvements in quality during 2011/12 in the
services we commission.
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Statements (cont)
East Riding of Yorkshire
LINks
East Riding of Yorkshire Local Involvement
Network (ERYLINk) has been identified as a
group included in the consultation process,
identifying priorities for improvement.
Unfortunately due to communication issues
it has only been possible to contribute to
the process at Phase 3 and we are therefore
grateful to City Health Care Partnership CIC
for working with ERYLINk to resolve the
technical difficulties which has enabled this to
happen.
CHCP have obviously consulted widely
with the community in order to establish
the priorities, it may have been useful to
provide an explanation as to why these areas
of concern have been put forward. There
appears to be little connection between Part
3, the Review of Quality and the 3 areas for
improvement identified.
36
repetitive with very little applicable content.
However the Local Clinical Audits are briefly
summarised but would have benefited from
much more background detail and content.
The Commissioning for Innovation and Quality
Improvement (CQUIN) goals would have been
better represented here rather than having
to access on line. Accessing the internet for
documents can be a problem for residents of
the East Riding who have limited connectivity.
The Quality Account could act as an overall
quality document if the CQUIN information
was included, perhaps in a table summary.
‘What Our Patients Say’ is written much more
clearly and demonstrates some excellent
feedback from patients and relatives. A
summary of the types or categories of
complaint would have been helpful.
‘Telephone access’ is simple and easy to
understand, however ‘Clinical Audit’ and
‘Root Cause Analysis’ would have benefited
from further detail, for example in both cases,
content of the ‘implementation plan’. With
regard to Root Cause Analysis, the reporting
measures are quantitative and perhaps a
qualitative measure should be considered.
The ‘Key Performance’ section needs
explanation and context although CHCP
should be congratulated on exceeding set
targets in many areas. In the same way that
an explanation has been given as to how
complaints have been followed up, the section
on ‘Incidents’, ‘Degree of Harm’ and ‘Serious
Untoward Incidents’ also require follow up
statements particularly where the degree of
harm is identified as ‘catastrophic’, without
this it could cause real concern to current and
future patients.
It is recognised that the content of Quality
Accounts is prescriptive, however the section
‘Participation in Clinical Audits’ is very
We recognise that this is the first set of
Quality Accounts produced by CHCP and
the presentation and content needs to be
reviewed in order to make it accessible to
everyone. There are several areas where
providing background information or further
explanations would have helped the reader to
understand not only the document but also
the services provided by the organisation. The
illustrated version of the document certainly
improves the readability.
A simple diagram providing an explanation
of the services provided, the geographical
areas covered and the commissioners involved
would have been beneficial particularly as only
a small number of services are provided within
the East Riding of Yorkshire.
Hull LINks
The opportunity for people involved in the
LINk to contribute to the decision making
process was welcome. The commitment to
actions to secure improvements in the areas
of patient safety, clinical effectiveness and
patient experience is to be applauded, and
people involved in the LINk look forward to
developing the constructive relationship with
City Health Care Partnership in the coming
year.
Hull Overview & Scrutiny
Committee
Due to pressures of elections, Hull City Council
Overview and Scrutiny Committee have been
unable to provide a statement for these
accounts. Plans are in place to ensure that the
committee can review the accounts in future
years.
East Riding of Yorkshire
Overview & Scrutiny
Committee.
Due to pressures of elections, East Riding
Council Overview and Scrutiny Committee
have been unable to provide a statement for
these accounts
37
Statements (cont)
City Health Care
Partnership Response to
Statements
We would like to thank all partners for their
statements on our first set of Quality Accounts.
We are pleased that all partners recognise the
consultation process that has been undertaken
in development of the priorities for the coming
year and that the data reported is an accurate
reflection of our achievements. It has not been
possible this year to include statements from
the Overview and Scrutiny Committees and
due to other priorities the Committees have
been unable to review our accounts within the
time schedule. We have plans to ensure that
next year’s accounts are pre-planned into the
committee’s timetable.
We are aware that there are areas in Part
2 that seem to show a lack of activity with
regard to clinical audit, this is however due to
the regulations stating which audits are to be
included within the accounts. The majority of
38
the audits are not applicable to a Community
Services Provider. We will be feeding this
comment back to the Department of Health,
as this is the first year that community
providers have been required to publish
Quality Accounts.
With regard to the comments made regarding
the Information Governance Toolkit and
further explanations of the priorities for
improvement, we will publish quarterly
updates on our website (www.chcphull.nhs.
uk) to inform all stakeholders of our progress
and will welcome feedback in-year on our
updates.
As this is our first set of accounts we have
learnt much about the process and will ensure
that for future years we are able to consult
and involve stakeholders at an early time
within the year.
How to
Feedback
Should you wish to provide and comment and
feedback on this report or give suggestions for
future reports please email
qualityaccounts@chcphull.nhs.uk
or write to:
Quality Accounts
City Health Care Partnership (CIC)
Unit 2 Earls Court
Priory Park East
Henry Boot Way
Hull
HU4 7DY
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Logos to be included:
Supporting Logos:
Investors in People
If you would like this document in an alternative language or format, such
as audio tape, large print or Braille, please call 01482 347649.
City Health Care Partnership CIC is a not for profit Community Interest Company
responsible for providing NHS services in Hull and the East Riding.
Registered in England No: 0627 3905
www.chcphull.nhs.uk
CS22068