Kirklees Community Healthcare Services
Quality Account
2010 - 2011
Contents
Section One: 1.1
Foreword from the Chief Executive
4
1.2
Statement of Quality Assurance from the
Chief Executive and Chair
5
Section Two:
2.1
2
Kirklees Community Healthcare Services
4
Priorities for improvement
6
6
2.11How will we monitor, measure and
report these priorities?
7
2.2
Statements relating to the quality of services provided
9
2.2.1
Review of services
9
2.2.2
Participation in clinical audits
10
2.2.3
Participation in clinical research
11
2.2.4
Use of the CQUIN payment framework
12
2.2.5
Statements from Care Quality Commission
12
2.2.6
Data quality
12
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Quality Account 2010/11
Section Three: 14
3.1
Complaints
14
3.2
Claims and litigation
16
3.3
Local patient surveys
16
3.4
Patient opinion
16
3.5
Incident reporting and monitoring
17
3.6
Serious untoward incidents
17
3.7
Serious case reviews
17
3.8
Contract quality areas
18
3.9
Reducing mixed sex accommodation
19
3.10 Compliance with NICE guidance
20
3.11 NICE quality standards
20
3.12 Healthcare Associated Infections
20
3.13 Hand hygiene
20
3.14 Methicillin-resistant Staphylococcus Aureus (MRSA)
21
3.15 Screening patients for MRSA
21
3.16 Clostridium Difficile
21
3.17 Norovirus
21
3.18 PEAT (Patient Environment Action Team)
22
3.19 Compliance with national target for 18 weeks
from referral to treatment
22
Section Four: 24
4.1
Appendix 1
24
4.1.1
24
CQUIN compliance information
Section Five: 28
5.1
Statements from our Stakeholders
5.1.1
Kirklees Local Involvement Network
28
5.1.2
Kirklees Overview and Scrutiny Committee
28
5.1.3
Kirklees Primary Care Trust
28
5.1.4
Greater Huddersfield GP Commissioning Consortium
28
5.1.5
North Kirklees GP Commissioning Alliance
28
5.2
How to provide feedback on this account
Quality Account 2010/11
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Kirklees Community Healthcare Services
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3
Section one
1.1 Foreword
Welcome to our first annual quality account. This document will demonstrate that
the quality of our service is the lifeblood of this organisation. We are passionate
about the care and support we provide and equally passionate about helping our
staff to continually develop.
We are an organisation providing a diverse range of services – from nursing in
the home to specialised dentistry. All our colleagues in each of our services know
that safety comes first every time. Our Board has ensured that we have robust and
thorough procedures in place so that we learn quickly from mistakes and that we
continually review our clinical practice to make sure we are performing to our best.
I am particularly pleased that we have:
• Successfully complied with the rigorous requirements of the Care Quality
Commission (CQC) inspection at Holme Valley Memorial Hospital
• Developed new systems to track quality improvement in areas such as nutrition,
pressure sores and the healthy child programme
• Worked to minimise any community acquired infections, including MRSA and C
Difficile
The next year brings us a new and exciting challenge. Kirklees Community
Healthcare Services is becoming a community interest company (CIC), owned by
the staff with membership from the community. It will operate under a new name
– Locala Community Partnerships – and aims to continue to transform care within
the community.
My pledge is that Locala will continue to ensure safety comes first and that quality
is the key driver to all the care and support we give.
I look forward to reporting on quality improvement in future years.
Robert Flack
Managing Director, Kirklees Community Healthcare Services
Chief Executive designate of Locala Community Partnerships
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Quality Account 2010/11
1.2 Statement of Quality Assurance from Chief Executive and Chair
The Board of Kirklees Community Healthcare Services
endorses the first quality account which puts improving
quality and safety at the forefront of our work. We
know our colleagues are committed to providing care
which makes a genuine difference to people’s lives
and that they are driven by the desire to improve
their services.
The Board is excited that the community interest
company (CIC) that comes into being from October
2011 will have active involvement and direction
from both staff and members of the community. The
Board will listen to their experiences and respond by
helping the organisation develop around the needs
of the individual and the community they serve.
This account has been reviewed by the Board, and to
the best of our knowledge, accurately reflects both
an overview of the quality of the services provided
by Kirklees Community Healthcare Services during
2010-11 and our priorities for quality improvements
during the next year.
The information provided in this
report is, to the best of our knowledge
accurate and a reasonable reflection of
our commitment to quality in 2010-11
Robert Flack
Managing Director
Suzy Brain England, OBE
Chair
Quality Account 2010/11
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Kirklees Community Healthcare Services
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Section two
2.1 Priorities for improvement
In this section of our report, we intend to focus on the future and 201112 in particular. It should be noted that this section of the report has not
been planned in isolation but that the priorities discussed below have been
agreed through discussion with our staff and commissioners.
We believe that it is important that our priorities complement the Commissioning
for Quality and Innovation (CQUIN) scheme, our compliance with the 16 essential
standards for registration with the Care Quality Commission, and demonstrate our
development over time. We have agreed that we will focus on a small number of
important priorities during the next year and aim for significant improvement.
Table 1 – 2011/12 priorities
Lead Responsibility
Category
Aim
Objective
Priority 1:
Clinical effectiveness
To support patients to
remain at home following
discharge from hospital
To increase the number
of patients supported to
remain at home for at
least 90 days to 85% of all
patients discharged from
intermediate care units
following a stay in hospital
Patient safety
To reduce the number
of patients developing a
pressure ulcer whilst in the
care of KCHS
To reduce the incidence of
pressure ulcers by 50%
Patient safety
To reduce the number
of falls experienced
by patients within
intermediate care inpatient rehabilitation units
To reduce the number of
patient falls by 50%
Patient experience
To ensure patients within
the community nursing
service receive a response
appropriate to their
needs within a specified
timeframe
To ensure that 80%
of patients within the
community nursing service
receive a response from a
health care professional
within a specified time
frame
Patient experience
To improve outcomes
relating to child
development and
behaviour through the
targeted intervention of
community nursery nurses
To ensure that a minimum
of 50% of targeted
interventions by a
community nursery nurse
result in positive outcomes
for parents and children
Sponsor: Clinical and
Operations Lead
Responsible manager:
Head of Therapies
Priority 2:
Sponsor: Clinical and
Operations Lead
Responsible manager:
Head of Localities
Priority 3:
Sponsor: Clinical and
Operations Lead
Responsible Manager:
Head of Therapies
Priority 4:
Sponsor: Clinical and
Operations Lead
Responsible manager:
Head of Localities
Priority 5:
Sponsor: Clinical and
Operations Lead
Responsible manager:
Head of Localities
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Quality Account 2010/11
2.1.1 How will we monitor, measure and report these priorities?
Each priority is being sponsored by an Executive Director. The Governance Committee will monitor each priority and
report to the Kirklees Community Healthcare Services Board on progress.
The reports to the Board from the Governance Committee will be made by the Non-Executive Director chairing the Governance
Committee and will form part of the public agenda. The reports will be available to the public through the KCHS website:
www.kirkleeschs.nhs.uk.
Priority 1:
Priority 3:
Situation
The percentage of clients going home after a stay on a
bedded unit is variable, fluctuating from 70 – 100%
Situation
We have a relatively high number of falls within the IMC bed
bases compared to other non rehabilitation units
Why is there a problem?
The clients entering intermediate care bedded units are
getting older and have multiple medical conditions. The final
outcome for these individuals is less obvious than it would
have been in the past and as such there is a greater risk of
clients not ultimately going home.
Why is there a problem?
Rehabilitation by its very nature will involve the risk of falls. If
we reduce all risks we will increase the length of stay on the
unit and potentially increase the number of clients admitted
to 24 hour care. Increased numbers of clients would not
regain their previous level of mobility and independence.
Initiatives to be implemented in 2011-12
Initiatives to be implemented in 2011-12
• Home assessments for all clients that are at risk of not
going to their original home.
• Implementation of Falls Risk Bands to identify high risk clients
• Involvement of the social worker from day one to consider
alternative home situations i.e. sheltered housing.
• Mapping of falls on the unit to help identify any hot spots
• Full assessment of equipment requirements to manage
with independent living.
• Increased ongoing assessment
To support patients to remain at home following
discharge from hospital
To reduce the number of falls experienced by patients
within intermediate care in-patient rehabilitation units
• Increased signage around the ward
• New call bell system
• The purchase of pressure mats for high risk clients.
Priority 2:
To reduce the incidence of pressure ulcers caused whilst
in the care of KCHS by 50%
Situation
KCHS treats the development of pressure ulcers very seriously
as this delays mobilisation for patients and can result in
deteriorating health and quality of life - often necessitating a
hospital admission. KCHS is working with partners to ensure
that patients receive the highest quality care in a timely
manner and the appropriate equipment to support that care.
KCHS community nurses understand what actions they can
take that will have the most impact on patients in terms of
quality of care given and value for money.
Why is there a problem?
KCHS is monitoring the prevalence of pressure ulcer
development whilst patients are in its care and whilst system
failure is not an excuse, recognises that more can be done
particularly in work undertaken in residential homes.
Initiatives to be implemented in 2011-12
• Robust systems for assessing a patient’s skin on admission
to KCHS care in order to have a baseline when the skin
deteriorates
• Work with Kirklees Integrated Community Equipment Service
and local acute partners to develop a whole system approach.
Priority 4:
To ensure that 80% of patients within the community
nursing service receive a response from a health care
professional within a specified time frame
Situation
KCHS has developed a Single Point of Access for community
nursing which specifies the response time required within a
time frame, according to priority.
Why is there a problem?
KCHS has had challenges in developing the systems to ensure
that patients’ priorities are identified when care is ongoing
and their needs change
Initiatives to be implemented in 2011-12
• To develop a robust method of ensuring that each patient
is given the right priority level at the point of referral (or
referral for a new problem)
• To collect information to assure KCHS that the patient’s
need has been met according to the grade of priority
• To monitor the number of calls waiting to be answered
at the Single Point of Access as this is an indication of the
quality of response provided
Quality Account 2010/11
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Kirklees Community Healthcare Services
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Priority 5:
To ensure that a minimum of 50% of targeted interventions by a community
nursery nurse result in positive outcomes for parents and children
Situation
KCHS has a vibrant health visiting service of which nursery nurses play an
important part in providing parenting skills coaching for parents as part of the
Every Child Matters outcomes for children. KCHS is striving to maximise the use of
skills within the health visiting resource and to be the most productive and efficient
that it can with a limited resource.
Why is there a problem?
We know that nursery nurses in different teams across Kirklees undertake different
work and have not always had their work evaluated in terms of outcomes for
children.
Initiatives to be implemented in 2011-12
• To review the content and results of nursery nurse activity
• To develop detailed information on what the nursery nurses are able to offer parents
• To establish methods of evaluating the outcomes of nursery nurse interventions
with parents and children as detailed in Every Child Matters
The organisation has identified the areas for improvement and will review the
quality of performance as described above. The framework will enable the
organisation to be accountable for the quality of services it provides.
Each of these initiatives will be supported through strong executive leadership
and work with our main education providers to ensure that our staff are able to
develop additional skills and competences. Training and education is an important
part of quality and culture within the organisation.
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Quality Account 2010/11
2.2 Statements relating to the
quality of services provided
2.2.1 Review of Services
During 2010–11 Kirklees Community Healthcare Services
provided a range of services across Kirklees. On 31 March
2011, we were providing care for over 259,000 people
across Kirklees.
The organisation is led by a Managing Director and currently
has four operational service areas:
• Localities
• Therapies
Our clinical services are supported by a number of central
functions including Finance, Human Resources, Business
support, Integrated Governance and Training.
Kirklees Community Healthcare Services has reviewed all the data
available to them on the quality of care in 100% of these services.
The income generated by the NHS services reviewed in 201011 represents 100% per cent of the total income generated
from the provision of NHS services by Kirklees Community
Healthcare Services for 2010-11.
• Long term conditions
• Dental
Localities
Senior managers regularly spend time with clinical services to
review issues with staff and consider governance concerns.
Therapies
Long term conditions
District Nursing
Occupational Therapy (acute,
learning disabilities, children)
Community Matrons
Health Visiting
Speech and Language
Therapy (adults, children)
Children’s Community Nursing
(including Dermatology,
Respiratory and Diabetes)
School Nursing
Primary care Gynaecological
Service
Children’s Immunisation
team
Family Nurse Partnership
Community Rehabilitation
Service
MacMillan Nurse Specialists
for care homes
Looked After Children
Accessible Homes team
Continence Service
Chlamydia Screening
Jubilee Rehabilitation Service
Community Diabetes Service
Smoking Cessation Service
Musculoskeletal Service
Coronary Heart Disease
Service
Community Child Health
Day Surgery
Whitehouse GP practice
Pupil Referral Service
Maple Ward
Broughton House GP practice
Youth Offending Team
Moorfields Primary Care
Centre
Nurse Advisors for
Safeguarding Children and
Adults
Walk in Centre, Dewsbury
District Hospital
Breastfeeding initiative
counsellor
Podiatry
Vasectomy Service
Contraception and Sexual
Health
Dental
Community Dental Service
(Calderdale and Kirklees)
Falls Assessment
Intermediate Care Services
Kirklees Integrated
Community Equipment service
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Kirklees Community Healthcare Services
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2.2.2 Participation in clinical audits
During 2010-11, two national clinical audits covered NHS services that Kirklees Community Healthcare Services provides.
During this period, Kirklees Community Healthcare Services participated in 100% of the national clinical audits in which it was
eligible to participate.
The national clinical audits and national confidential enquiries that Kirklees Community Healthcare Services was
eligible to participate in during 2010–11 are as follows:
• National Sentinel Audit for Stroke
• National Paediatric Diabetes Audit
The national clinical audits and national confidential enquiries that Kirklees Community Healthcare Services
participated in during 2010–11 are as follows:
• National Sentinel Audit for Stroke
• National Paediatric Diabetes Audit
The national clinical audits and national confidential enquiries that Kirklees Community Healthcare Services 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.
Percentage of registered
cases required
Number of cases submitted
National Sentinel Audit for Stroke
28
100%
National Paediatric Diabetes Audit
67
100%
The reports of two national clinical audits were reviewed by the provider in 2010-11 and Kirklees Community Healthcare
Services intends to take the following actions to improve the quality of healthcare provided
National clinical audit
National Sentinel Audit for Stroke
Actions
• To increase FAST awareness of Community and Intermediate care staff
• To contribute to therapy review being undertaken by NHS Kirklees
• To develop care planning templates on SystmOne so that patient goals can be
monitored
• To improve data collection systems within SystmOne
National Paediatric Diabetes Audit
• To Identify and target population with HbA1c above 9.5%
• To give intensive education and support to those identified
• To ensure child or young person is initially followed up by telephone and
subsequently in a nurse led clinic or home visit
• To repeat HbA1c on a four monthly basis
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Quality Account 2010/11
Clinical audit is supported by the Integrated Governance team. All local clinical audits
are agreed through the Audit and Effectiveness Committee. Reports are considered
and action plans for quality improvement reviewed through this committee.
The reports of 20 local clinical audits were reviewed by the provider in 2010-11
and Kirklees Community Healthcare Services intends to take the following actions
to improve the quality of healthcare provided:
Safeguarding
Safeguarding policy requires that when information about vulnerable children is
shared between health visitors and school nurses with general practice teams,
work should be structured with reference to a ‘Best Practice Framework’. The
Best Practice Framework is detailed in NHS Kirklees Safeguarding Children Policy.
This policy further outlines the standard of record keeping of the information
sharing that should take place, and requires that health professionals utilise a
‘communication child protection template’, that is available on the SystmOne
electronic health record, to record this area of safeguarding work.
The use of this template prompts a high standard of record keeping that focuses
on improving the safety and wellbeing of children, and also enables reports of this
area of safeguarding work to be generated, which provides information about
trends and incidence of this aspect of safeguarding children work. Use of the
template was therefore audited.
The audit results indicate that the communication child protection template is being
used with increasing frequency by health visitors and school nurses working in locality
teams, when they discuss vulnerable children with colleagues in general practice.
The increasing frequency that the template is being used suggests that increasingly
discussions between health visitors, school nurses and general practitioners in
respect of vulnerable children is structured and focused, and agreement to a specific
action plan that will be influential on a child’s safety is being made.
Chlamydia
In November 2010 the National Chlamydia Screening Programme carried out
a quality assurance audit of turnaround times from the time of the test to
results being received, and to positives being treated. The audit covered a two
week period from 1-12 November. The audit showed that Kirklees Community
Healthcare Services has met all the standards required.
Kirklees Community Healthcare Services is aware of the importance of clinical audit
in improving the quality of the services it provides and as such aims to undertake
even more clinical audit during the next year.
2.2.3 Participation in clinical
research
During the past year, we have
concentrated on developing the
framework within which we can
examine our compliance with
evidence based practice through
clinical audit and benchmarking
against NICE guidance. The number
of patients receiving NHS services
provided or subcontracted by
Kirklees Community Healthcare
Services in 2010-11 that were
recruited during that period to
participate in research approved by a
research ethics committee was 178.
Participation in clinical research
demonstrates Kirklees Community
Healthcare Services commitment
to improving the quality of care we
offer and to making our contribution
to wider health improvement. Our
clinical staff stay abreast of the latest
possible treatment possibilities and
active participation in research leads to
successful patient outcomes.
Kirklees Community Healthcare
Services was involved in conducting
nine clinical research studies in eight
specialities during 2010-11. There
were seven clinical staff participating in
research approved by a research ethics
committee at Kirklees Community
Healthcare Services during 2010-11.
External reviews
Our systems are subject to periodic review by the West Yorkshire Audit
Consortium. During 2010-11, reviews were undertaken in four areas: records
management, incident reporting, clinical governance and risk. All were awarded
a ‘Significant Assurance’ grading which shows that we had established sound
systems of internal organisational control but that there is still more that we can
do. As a result, action plans have been developed and are being monitored. Our
progress in these areas will be reviewed.
2.2.4 Use of the CQUIN
payment framework
A proportion of Kirklees Community
Healthcare Services’ income in 2010-11
was conditional on achieving quality
improvement and innovation goals
agreed between Kirklees Community
Healthcare Services and NHS Kirklees
through the Commissioning for
Quality and Innovation (CQUIN)
payment framework.
Further details of the agreed goals
for 2010-11 and for the following 12
month period are available electronically
at the link below Our achievement
against both the regional and local
CQUIN targets is shown in Appendix 1.
www.institute.nhs.uk/world_class_commissioning/pct_portal/cquin.html
Quality Account 2010/11
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Kirklees Community Healthcare Services
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2.2.5 Statements from CQC
2.2.6 Data Quality
Kirklees Community Healthcare Services is required to register with the
Care Quality Commission and its current registration status is registered and
licensed to provide services. This means that it has been agreed that our
services meet the essential standards of quality and safety. These standards
are available electronically at www.cqc.org.uk.
We accept responsibility for providing
good quality information to support
effective patient care. We participate
in NHS Kirklees information
governance processes and are
supported by the Director of Patient
Care and Professions who is currently
our designated Caldicott Guardian.
The Care Quality Commission has not taken enforcement action against Kirklees
Community Healthcare Services during 2010-11.
The Care Quality Commission undertook an unannounced inspection to Holme
Valley Memorial Hospital on 16 June 2010 to assess that we were adequately
protecting patients, staff and others from healthcare associated infection. On
the inspection, it was found that there was no cause for concern regarding our
compliance with the regulation on cleanliness and infection control.
The organisation meets with the Care Quality Commission’s link manager on a
quarterly basis to maintain a regular dialogue.
Participation in Special Reviews
Kirklees Community Healthcare Services has participated in special reviews by
the Care Quality Commission relating to the following areas during 2010-11:
Supporting life after stroke
Kirklees Community Healthcare Services intends to take the following
action to address the conclusions or requirements reported by the Care
Quality Commission:
• A group with members from Kirklees Community Healthcare Services, Mid Yorkshire
Hospitals Trust and NHS Kirklees has been established to look at how patient
pathways could be improved within existing resources and what could have the
most impact with limited investment.
• The group agreed actions which included mapping the existing pathways for each
element of the pathway; identifying blockages in the pathway; looking at separating
costs between organisations , reducing waiting times for rehabilitation services
Kirklees Community Healthcare Services has made the following progress by
31 March 2011 in taking such action:
• P athways have been mapped and greater clarity has been given for each service in
the pathway. As a result of this work referral forms/information is being standardised
for referrals into Intermediate Care services.
• W
aiting times for rehabilitation services have reduced and this work will continue to
reduce waiting times further.
• C
onsideration has been given to separating costs for stroke between organisations
so as to strengthen community based rehabilitation and support services. Outreach
Occupational Therapy and Physiotherapy from acute hospital services has been
established as resources allow to bridge the gap between secondary and community
services whilst further work is done by NHS Kirklees
Support for families with disabled children
[the data collection period was January – February 2011; the results are expected
to be available in Spring 2011 when we will review the findings and develop action
plans in response]
“Thank you for the loving care you gave
Mum over the last few months. You all
do a fantastic job, sometimes in very
difficult circumstances.”
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Quality Account 2010/11
Most of our services now use electronic
records through SystmOne which
provides a single clinical information
system and reduces the number of
times a patient is required to provide
personal data. We have adopted
mobile technology which enables the
clinical professional to have access
to records whilst providing care,
whatever the location and saves the
clinician having to return to base. This
equipment also includes an alarm
system to enhance staff safety. The
project has been subject to strict
governance arrangements to ensure
that patient information is secure.
Kirklees Community Healthcare Services
will be taking the following actions to
improve data quality:
• Implement the mandatory data set for
Community Services in KCHS to ensure
consistency of data collection within all
clinical services.
• Achieve the Data Quality Priorities as
set out in the contract for community
services with NHS Kirklees.
• Ensure the appropriate use of
SystmOne functionality to support the
accurate recording of patient activities.
• Develop Data Quality measures
that will support the collection and
reporting of information to evidence
clinical / patient outcomes.
NHS Number
Clinical records audit
At the end of March 2011 we had 147,292 clinical records of which 99.4%
included the patient’s NHS number and 99.5% included the patient’s GP.
Record keeping is an essential, integral
and legally required part of the
patient care process. Patients/clients
benefit from records that demonstrate
effective assessment and planning
of care which supports high quality
clinical interventions. All health care
professionals are expected to provide
accurate, comprehensive and concise
information which justifies the rationale
regarding treatment, care and support
that is planned and provided for the
patient/client. They are also required to
comply with both locally agreed policies
and professional guidelines. The auditing
of records and acting on the results
allows for the assessment of the standard
of record keeping which in turn identifies
any areas where improvements might be
made (NMC 2009). A total of 610 clinical
records for KCHS were audited in 2010.
We plan to increase this number year on
year.
The following graph shows the age breakdown of our patients:
Kirklees Community Healthcare Services Age Bands
50%
45%
40%
35%
30%
25%
20%
15%
10%
5%
0%
Age
Band
0-5
Age
Band
6-10
Age
Band
11-15
Age
Band
16-20
Age
Band
21-25
Age
Band
26-30
Age
Band
31-35
Age
Band
36-40
Age
Band
41-45
Age
Band
46-50
Age
Band
51-55
Age
Band
56-60
Age
Band
61-65
Age
Band
66-70
Age
Band
71-75
Age
Band
76-80
Age
Band
81-85
Age
Band
86-90
Age
Age
Age
Age
Band Band Band Band
91-95 96-100 101-105 106-110
We have been working to increase the number of patient records that include the
ethnic background as stated by the patient. This has increased from 17.7% in April
2010 to 50.3% in March 2011. The breakdown is shown in the graph below:
Kirklees Community Healthcare Services Ethnic Coding
50%
45%
40%
35%
30%
The audit provided information
about specific issues regarding
electronic records which has proved
invaluable as services adopt electronic
record keeping. It identified areas
for improvement which have been
incorporated into mandatory training
and to a more specific audit on the
electronic record keeping of the
Supporting Families’ service.
25%
20%
Clinical coding error rate
15%
10%
Clinical coding is a process which
translates the medical language of
patients’ records into an internationally
recognised code describing the
diagnosis and treatment of a patient.
5%
0%
British
Irish
Other
White
White and White and
Other
Black
Black
Mixed
Caribbean
African Background
Indian
Pakistani Bangladeshi
Other
Caribbean
Background
African
Other
Black
Chinese
Any
Other
Not
Given
Information Governance Toolkit attainment levels
Information quality and records management are assessed using the Connecting
for Health Information Governance Toolkit which provides an overall assessment
of data systems, standards and processes. The toolkit is completed by specialists
advising the NHS Kirklees Information Governance Group and is validated by NHS
Kirklees directors before submission.
Kirklees Community Healthcare Services Information Governance Assessment
Report score is incorporated within the NHS Kirklees overall score for 2010-11,
which was 67% and was graded Red. NHS Kirklees has developed an action plan
to manage the issues identified and Kirklees Community Healthcare Services is also
working to develop its own systems and processes for separate assessment in 2012.
Quality Account 2010/11
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Kirklees Community Healthcare Services
was not subject to the Payment by
Results clinical coding audit during
2010-11 by the Audit Commission.
“Keep up the fantastic job
you’re doing – we need more
nurses like you.”
Kirklees Community Healthcare Services
13
Section Three
Review of Quality
Performance
3.1 Complaints
Community organisations have not
previously been required to develop
and publish a Quality Account.
As a result, this report focuses on
the information that is currently
available. In future years, we will be
including a review of progress on
our quality initiatives.
During the year, 22 letters of complaint were received relating to our services. In
that period there were over 750,000 patient contacts.
We encourage all clinicians and all services to respond immediately to issues raised
by patients and carers. The information below, therefore, refers solely to written
complaints that have been received.
We aim to acknowledge all letters within three days. A manager, independent
of the service concerned, is appointed to investigate the issues. This person
makes contact with the person complaining and works with them and the service
concerned to resolve the issues. At the end of the process a full written response
is provided and we aim to complete this process within 28 days. When this is
not possible, the complainant is kept fully informed of how the investigation is
progressing. The investigating manager also produces recommendations for service
improvement with are developed into an action plan. The implementation of this
plan is monitored through the Audit and Effectiveness Committee.
Learning from complaints
It is crucial that the organisation learns from all issues raised and ensures changes
in practice to further the provision of high quality services. The following describes
some of these changes that have occurred:
1.System implemented to ensure that telephone messages are collected and
responded to on day of receipt
2.Procedures established to improve the management of distraught children and
parents within clinic settings
3.Funding for additional therapy staff provided by commissioner to improve waiting times
4.Working with other providers to improve the patient’s journey from one provider
to another
Any complainant who remains unhappy after their complaint has been investigated is
provided with the opportunity to meet with a manager and the relevant clinical staff
in a further attempt to resolve the issues. All complainants are informed of their right
to refer the issue to the Health Service Ombudsman. During 2010-11 no complaints
were referred in this way
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The table below shows the number of complaints by service:
Service
Year 2010-11 complaints
Dermatology
1
Podiatry
1
Continence
3
District Nursing
5
Single Point of Access
1
Home Laundry
1
Dental
2
Multi-agency hospital discharge
1
Intermediate care
1
Contraception and Sexual Health (CaSH)
1
Community Rehabilitation team
1
Health Visiting
3
Musculo-skeletal service North
1
Total
22
Reasons for the complaint - Written complaints received from 1 April 2010 to 31 March 2011, by subject of
complaint (using Department of Health categories)
Reason for complaint
Number of complaints
Admissions, discharge and transfer arrangements
2
Appointments delay / cancellation (outpatient)
2
Attitude of staff
2
All aspects of clinical treatment
5
Communication / information to patients (written and oral)
4
PCT commissioning (including waiting lists)
5
Personal records (including medical and / or complaints)
1
Other
1
“A big thank you for all you did for my
Mum. I am so glad I finally met you,
such an understanding, kind, caring and
gentle person.
Thank you so much.”
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3.2 Claims and litigation
There are currently seven claims registered with the NHS Litigation Authority dating back
to 2007. Of these claims, four relate to clinical negligence and three to personal injury.
All cases are actively managed by our Governance team, lawyers and NHS
Litigation Authority.
3.3 Local patient surveys
During the year, we have used patient questionnaires across 42 of our services.
The number of questionnaires sent out varied across the services as some had a set
target within their service specification and others randomly handed them out at
clinics over the period of a week or a month.
Following return and collation, the results were considered by each service and
improvement plans implemented, of which examples are shown below.
In the Day Surgery Unit at Holme Valley Memorial Hospital, patients commented
on the lack of reading material in the waiting area. As a result, magazines and
newspapers are now provided.
In the CaSH service at Princess Royal Health Centre, concerns were expressed
about privacy in the reception area which has resulted in a risk assessment being
undertaken and the glass partition being reviewed.
The Community Matron survey showed that 91% of respondents knew how to
contact a Community Matron and 92% of respondents rated the personal manner
of staff as very good or excellent.
The questionnaire allowed the matrons to identify areas for improvement
which were:
To aim to provide care plans to all patients on the caseload and endeavour
to review these as appropriate at least six monthly
To discuss future goals/goal setting with all patients where possible once
their condition is stabilised and allows this to be feasible/practical.
A Reception services survey suggested that staff have a friendly professional
approach on Reception and on the phone and that the public feel the staff provide
good customer services.
It was identified that better quality of patient information could be displayed in the
reception areas. Reception Supervisors now promote campaigns each month which
may involve displaying promotional materials for weekly/national campaign days
e.g. National No Smoking Day.
The reception supervisors recognised the importance of monitoring confidentiality
when attending the reception area so therefore asked patients for their
perceptions. This highlighted a potential for improvement so the supervisors
have organised clear notices advising patients that should they wish to discuss
their personal details in confidence, this option is offered to them. Staff are also
encouraged to be sensitive towards the needs of the client when attending
reception and offer the option to speak in private with the member of staff.
Clients using the Jubilee Rehabilitation Service gave positive feedback regarding
all aspects of the service from the surroundings, to staff knowledge as well as
how well the clients feel that their needs were attended to. This client satisfaction
questionnaire is scored out of a possible 72. The clients that were surveyed gave
the service an average score of 66.
One area for improvement was identified. Several patients commented that they
waited a while for the ambulance to collect them from home. The key aspect was
to set realistic expectations for patients. For example the appointment cards now
state that the pick-up time is estimated as the ambulance has to collect other
service users and the route changes constantly. Waiting times continue to be
monitored and patients provided with a comfortable area in which to wait.
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3.4 Patient Opinion
Patient Opinion is a social enterprise
organisation that offers the
opportunity for patients to share
their experiences with others and to
gain support from each other.
People can submit stories via the
internet, postal system or telephone
calls with the opportunity for
organisations to respond. We have
encouraged patients attending
Moorfields Primary Care Centre to share
their experiences through these systems
and are delighted that 16 patients
have done so during the past year. Of
these, 15 were overwhelmingly positive
about the care they had received from
the services at Moorfields whilst one
was concerned about the waiting time
for an appointment. As a result of this
feedback, we have reviewed our clinic
appointments to reduce waiting times.
We are now considering how we can
extend this system to other services
provided by Kirklees Community
Healthcare Services.
3.5 Incident reporting and monitoring
The National Patient Safety Agency (NPSA) suggests that high levels of incident reporting should be viewed as
positive. Those organisations that report incidents are more likely to have systems and processes in place to learn
from incidents.
During 2010-11 we have further enhanced the safety culture within Kirklees Community Healthcare Services. This has included
Incident Monitoring training which was delivered to the senior and middle managers, individual training to teams and primary
research undertaken by one of our managers, the recommendations of which will be shared and implemented within the
organisation.
Over this year, incident reports from staff have increased by 100% which shows that work to increase the profile of incident
reporting has been successful. However, reporting is only part of the challenge and learning from incidents is of paramount
importance. The organisation’s Incident Monitoring Group meets monthly and works to ensure that learning is shared not only
within the organisation but with other agencies such as the acute trusts and social care. We continue to review and adjust
membership, thus ensuring that the most appropriate professionals are involved in the incident monitoring process. Trends and
themes are identified and where necessary, concerns are elevated to the Risk Committee.
The distribution of a monthly newsletter ensures that feedback and learning on the most pertinent incidents is received by all
staff within the organisation. Quarterly reports are submitted to the Governance Committee.
We are aware that the increasingly diverse nature of care being delivered in the community by a variety of health professionals
means that patient safety is even more important. We will continue to ensure that patient safety is paramount and that our
incident reporting and monitoring systems and processes are constantly reviewed to meet the ever changing demands in
community healthcare provision.
3.6 Serious Untoward Incidents
We have had two serious untoward incidents this year, both related to the
security of patient identifiable information.
Formal investigations were undertaken into both incidents, including a root
cause analysis. Action plans were subsequently developed and these have been
implemented. Key learning for us as an organisation related to colleagues adhering
to the requirements of our policies regarding email management and the storing
and transfer of patient identifiable information. This learning has been cascaded
throughout our organization and compliance has been monitored for assurance.
3.7 Serious Case Reviews
There have been three serious case reviews related to children and one
related to an adult this year.
Our Named Nurses have produced Independent Management Reviews for each of
these reviews regarding our involvement in the cases. These are then submitted to
the appropriate Safeguarding Board. We are represented at both the Children’s and
Adult’s Local Safeguarding Boards and actively participate in the management and
review of these serious case reviews.
Each of the serious case reviews has resulted in actions for us an organisation. This
learning has been cascaded throughout the organisation and is incorporated into
ongoing training and supervision.
“My District Nurse was extremely
punctual and caring. Her motivation
and encouragement led to a quick and
positive recovery.”
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3.8 Contract quality areas
Our contract to provide care includes a number of quality requirements. These are shown in the table below,
and include our achievements in 2009-10, the targets that were set for 2010-11 and our actual performance as
measured on 31 March 2011.
2009-10
Actual
2010
-11
Target
2010-11
Actual
0
2
0
Delayed transfers of care to be maintained at a minimal level
21%
Not below
2009-10
performance
26%
Failure to have a Delivering Same Sex Accommodation Plan or
missing a milestone in the Plan
0
Requirements
continue
to be met
0
Proportion of children who complete recommended
immunisations by 12 Months
97%
95%
95.8%
Proportion of children who complete recommended
immunisations by 24 Months
93.8%
95%
95%
Proportion of children who complete recommended
immunisations by 5 Years
91.9%
95%
92.1%
Four week smoking quitters (Specialist Service) Actual
607
453
520
Childhood Obesity Measurement Coverage - Reception Year
91%
No target
92%
Childhood Obesity Measurement Coverage- Year 6
87%
No target
92%
Quality Requirement
Community acquired MRSA bacteraemia
Improvement
In addition, there are a number of nationally specified targets with which we are required to comply and a number of Never
Events which are serious, largely preventable patient safety incidents that should not occur if the available preventative
measures have been implemented. Our compliance is shown right:
“I can’t express how grateful I am that
these professional women, who must
see hundreds of patients a week, took
the time and energy to make me feel
completely safe and comfortable with a
procedure I had been dreading.”
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Nationally Specified Event
Percentage of Service Users seen within 18 weeks across all
speciality groups for admitted and non-admitted pathways
Rates of Clostridium Difficile acquired in the community
4 hour maximum wait in A&E from arrival to admission, transfer
or discharge
Breach of the Same Sex Accommodation Requirements
2009-10 2010 -11 2010-11
Actual
Target
Actual
100%
95%
99.5%
0
< 11
3
100%
98%
100%
0
0
0
Improvement
2009-10 2010 -11 2010-11
Improvement
Actual
Target
Actual
Never Event
Wrong site surgery
0
0
0
Retained instrument post-operation
0
0
0
Misplaced naso-or orogastric tube not detected prior to use
0
0
0
3.9 Reducing mixed sex accommodation
Kirklees Community Healthcare Services has declared full compliance with the
national target for single sex accommodation. Within the 20 bedded ward at
Holme Valley Memorial Hospital, 15 beds are provided in five three-bedded wards,
and there are five single rooms. The accommodation can be used by either men or
women as all these rooms have en-suite toilet and shower facilities.
The ward moved into its present accommodation in August 2009. The ward area
was specifically designed for the client group. As part of the rehabilitation process,
all patients are fully dressed through the day.
Because all admissions are planned, there is no situation in which single sex
accommodation requirements would be breached. The layout of the ward allows
patients to move rooms as their condition improves which enables both male
and female admissions to be managed. Maple Ward would be able to accept a
husband and wife admission but they would be either within two single rooms or
in two separate bed bays. However, the admission of two sisters or brothers could
be facilitated within one bed bay.
The combination of environment and care processes fully supports the patients’
dignity and privacy. This is also monitored through a discharge questionnaire.
Analysis of returns consistently demonstrates that patients and their carers are
appreciative of the environment and care provided.
“I want them (the staff) to know that the
work they do, the time they take to make
people feel secure and their unfailing
good grace is so very much appreciated.”
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3.10 Compliance with
NICE guidance
3.11 NICE Quality Standards
The National Institute for Health
and Clinical Excellence (NICE)
provides guidance, sets quality
standards and manages a national
database to improve people’s
health and prevent and treat ill
health. Implementing NICE guidance
benefits everyone – patients, carers,
the public and the NHS.
It helps ensure consistent standards
in care, equal access to care and
improvement in the quality of care
provided. During the period from 1
April 2010 and 31 March 2011, 121
pieces of guidance have been issued.
The standards are sets of specific statements that act as markers of high
quality, cost effective patient care, covering the treatment and prevention
of different diseases and conditions. They are developed from the best
available evidence in partnership with NHS and social care professionals
and service users, and address the three dimensions of quality: clinical
effectiveness, patient safety and patient experience.
Of the eight standards published during 2010-11, we have determined that four
of them have relevance to the services that we provide. We have completed the
assessment of our current compliance against three of the standards: stroke,
dementia and venous thromboembolism prevention and are actively considering
our compliance against the standard concerning Diabetes in Adults. During
2011-12, we will be working with our commissioners and colleagues from other
organisations to ensure that we are able to provide evidence that our patients are
receiving high quality care.
3.12 Health Care Associated Infections
The guidance falls into five
categories:
Effective infection prevention and control is essential to ensure the safety of
patients in our care, through avoiding Healthcare Associated Infections (HCAIs),
as well as providing excellent patient experience. We are proud of our infection
control achievements, some of which are set out below:
• Cancer service guidance
• Clinical guidelines
• Interventional procedures
• Public health guidance
3.13 Hand Hygiene
• Technology appraisals
Of the guidance issued during the
past 12 months, 27 documents have
been determined as having relevance
to the services we provide. All of
these documents have been closely
considered by the relevant services
using the baseline assessment tool
provided by NICE. In 11 cases, evidence
has been provided by services to
demonstrate that they are fully meeting
the standards; and, in a further seven
cases, services were able to declare
partial compliance. More recent
guidance (nine documents) continues to
be considered by the relevant services.
When services are unable to show that
they are fully meeting the standards,
an action plan is developed and
implemented. These action plans are
monitored through the organisation’s
Audit and Effectiveness committee until
full compliance is achieved.
Studies show that infection rates can be reduced by 10-50% when healthcare
staff regularly clean their hands. The introduction of alcohol hand rub has
been important in improving hand hygiene compliance in healthcare and is
recommended for routine use in the clinical environment when hands are not
visibly soiled. Alcohol hand gel at the point of care is critical in increasing the
likelihood that staff will clean their hands at the appropriate times. All staff
are provided with community hand hygiene packs for home visits.
The National Patient Safety Agency (NPSA) developed the ‘clean your hands’
campaign which was extended to community services in 2008. All staff are required
to provide clinical care ‘bare below the elbows’. This has been included in our
Clinical Dress Code policy. Audit tools which measure compliance with hand hygiene
requirements include the ‘bare below the elbows’ requirement. During the past year,
staff compliance across all our services with these standards has been 98%.
In addition, in 2009-2010 we introduced a monitoring tool for use by staff
undertaking catheter care. This has been further enhanced by the introduction of
electronic care plans for urinary catheter insertion and continuing catheter care and
catheter training for all clinical staff. Compliance with these standards for the last
year has been 96%. A simple guide for catheter hygiene has also been developed
for carers, home care and care home staff for patients in their own homes which
have to be signed and dated daily by the carer.
Where compliance against these standards has not been demonstrated, additional
training is provided with close monitoring until compliance has been consistently
achieved.
“Many thanks for all the care and kindness
from everyone during my stay at the Hospital.
Food and cleanliness all very good.”
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3.14 Methicillin-resistant Staphylococcus
Aureus (MRSA)
We were set a target by NHS Kirklees of no more than two cases of MRSA during
2010-11. During this year no patients receiving care from Kirklees Community
Healthcare Services staff have been diagnosed with an MRSA bacteraemia.
3.15 Screening patients for MRSA
Mandatory screening of all patients admitted to intermediate care beds and
patients undergoing podiatric surgery was introduced in 2009 in line with
Department of Health policy. During 2010-11, 471 patients were screened, all of
whom had a negative result. Performance against this policy is monitored on a
monthly basis and has consistently achieved 100%.
3.16 Clostridium Difficile
Incidence of Clostridium Difficile is also monitored closely. We were given a target
of no more than 10 cases. During the year, three patients have been diagnosed as
having Clostridium Difficile whilst in the care of our staff. In each case, an in-depth
review has been undertaken and recommendations for improvement implemented
3.17 Norovirus
“Thank you for your compassion
and your care.
My Mum could not have wished
for better during the last days of
her life and I will always be grateful
to you for this.”
There has been one outbreak of diarrhoea and vomiting in the ward at Holme
Valley Memorial Hospital during 2010-11 which has resulted in the closure of the
unit to admissions, transfers and discharges for 15 days. (An outbreak is defined
as two or more connected patients with the same symptoms ). The outbreaks
were caused by the Norovirus which is the most common cause of gastroenteritis
in healthcare settings. It is a highly contagious virus which causes short term but
severe diarrhoea and / or vomiting. The outbreaks affected 15 patients and 24
staff. All staff observed the outbreak policy and compliance was closely monitored
by our Senior Infection Prevention and Control Nurse.
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3.18 PEAT (Patient Environment Action Team)
PEAT is an annual assessment of inpatient healthcare sites in England with more than 10 beds. The assessment
was started in 2000 and has been managed by the National Patient Safety Agency (NPSA) since 2006. It is
a benchmarking tool to ensure improvements are made in the non-clinical aspects of a patient’s healthcare
experience. It highlights areas for improvement and shares best practice across the NHS.
The annual assessment took place at Holme Valley Memorial Hospital in March 2011. The team included a non-executive
director and a representative from the Hospital’s League of Friends. Scores from all organisations are submitted to the National
Patient Safety Agency and are available on the NPSA website: http://www.nrls.npsa.nhs.uk/patient-safety-data/peat/
Results
Year
Environment
Food
Privacy and dignity
2011 (provisional)
Good
Excellent
Excellent
2010
Good
Excellent
Good
2009
Good
Excellent
Excellent
3.19 Compliance with National Target for 18
weeks from referral to treatment
The 2004 NHS Improvement Plan set out the concept that no-one would have
to wait longer than 18 weeks from GP referral to treatment. This target applies
to services that provide assessment and treatment but which may need to refer
onwards to a consultant led service.
Over the year, 100% of the relevant services were compliant with this approach.
Across these services, the average waiting time was four weeks.
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Section four: Appendix 1
Quality
priority
Aim
Rationale
Objectives
Achievement
80% of people with a Long
Term Condition have a
single personalised care plan
90%
80% of people on an end
of life pathway have a single
personalised care plan
100%
100% of Patients
identified as being End of
Life are on the End of Life
Care Register
100%
80% of Patients identified
as being End of Life are
on the Liverpool Care
Pathway or equivalent
13%
90% of patients who
express their preferred
place of death, actually
died in that place
97%
80% of CAFs for 0-5 year
olds are initiated by health
professional
82%
65% of CAFs for 6-11
year olds are initiated by
health professional
42%
40% of CAFs for 12-18
year olds are initiated by
health professional
39%
60% of CAFs for 0-5 year
olds are led by health
professional
43%
65% of CAFs for 6-11
year olds are led by health
professional
38%
40% of CAFs for 12-18
year olds led by health
professional
39%
Regional Indicators
Long Term
Conditions
End of Life
Care
Vulnerable
children
24
Improving and
sharing personalised
care plans for
patients with long
term conditions
Improving the
quality of palliative
care
Increase the use
of the Common
Assessment
Framework (CAF)
for vulnerable
children
Patients will begin to
experience seamless
responsive care in accordance
with their wishes and
agencies will have a
single, common vehicle to
improve communication
and understanding. This
will reduce unnecessary
admissions into hospital and
increase health outcomes.
Patients and carers will be
able to expect the highest
possible standards of end of
life care
Improve safeguarding of
vulnerable children
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Quality
priority
Child
protection
supervision
Nutrition
Pressure ulcers
on community
wards
Pressure ulcers
in non-ward
areas
Aim
Rationale
Maintain high levels
of Child Protection
Supervision given
to staff that have
regular contact with
children, young
people and parents
“Effective communication
is important to promoting
good standards of practice
and to support individual staff
members” (Working Together
to Safeguard Children, DH
2006)
Achieving best
practice standards
as set out in Essence
of Care
Improvement in
pressure ulcer
prevention and
management in
line with Essence of
Care
Reduction in the
number of pressure
ulcers requiring
care within the
community
Objectives
Use of a validated nutritional
indicator screening tool will be
encouraged to reduce rates of
malnutrition and associated
adverse outcomes
Inpatients experience care
that maintains or improves
the condition of their skin and
underlying tissues for all ages
All Patients experience care
that maintains or improves
the condition of their skin and
underlying tissues for all ages
Quality Account 2010/11
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Achievement
85% of staff who
are eligible for child
protection supervision
have child protection
supervision within each
quarter
90%
100% of admitted
patients who underwent
nutritional screening
within 24 hours of
admission
100%
100% of High nutritional
risk patients with
appropriate referrals/
continuing care plans in
place
21%
100% of patients with
a grade III pressure
ulcer or above have had
a root cause analysis
investigation
100%
No patients acquire a
pressure ulcer within10
days of admission to the
ward
0
< 19 patients with one or
more pressure ulcers, with
the highest ulcer having
NICE Trigger Grading III in
quarter four.
26%
< 17 patients with one or
more pressure ulcers, with
the highest ulcer having
NICE Trigger Grading IV in
quarter four.
9
100% of root cause
analysis investigations
undertaken for patients
with NICE Grade III
pressure ulcers and above.
52%
Kirklees Community Healthcare Services
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Quality
priority
Aim
Rationale
Objectives
Achievement
Local Indicators
Incidence of
pressure ulcers
Discharge Care
Planning
26
Reduce the
incidence of all
grades of pressure
ulcers
Maintaining more
people at home
through movement
towards a multi
disciplinary approach
to discharge planning
with patients and
carers fully involved
and informed along
the process.
Pressure ulcer incidence
data provides good evidence
regarding quality of care
provided to patients and it
is important to note that
pressure ulcers are increasingly
being linked to elder abuse
and neglect (Clarkson 2007).
This indicator closely links with
the Regional indicator around
discharge planning for people
with Long Term Conditions.
The two combined indicators
support the efficiency saving
for non-elective admissions
where we can influence
through this incentive scheme
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100% of all patients to
have had a Waterlow
Pressure Ulcer Risk
Assessment
82%
50% reduction in the
incidence of all grades of
pressure ulcers by 31st
March 2011
293
100% reduction in
community acquired
pressure ulcers of grade 3
and 4
Insufficient data
10% reduction in length
of stay through effective
discharge/care planning
by Quarter 3 2010-11
45%
20% reduction in length
of stay through effective
discharge/care planning
by Quarter 4 2010-11
46%
10% reduction in readmissions Quarter 3
2010-11
21%
20% reduction in readmissions Quarter 4
2010-11
18%
Quality
priority
End of Life
Aim
Rationale
Objectives
Achievement
Increase in patients
who are on an End
of Life care pathway
dying in their place
of choice
50 - 60% of deaths occur in
acute hospitals with patients
experiencing an average of 18
days as an inpatient spread
over 2 - 3 admissions in the
last year of life.
50% of all patients on an
End of Life care plan dying
in their place of choice
97%
And a reduction in
hospital as place of
death
Approximately half of all
complaints made to acute
trusts relate to an aspect of
end of life care.
40% reduction in hospital
as place of death, where
hospital is not the place
of choice by Quarter 4
2010/11
Data not available
100% compliance with
the urinary catheter
Essential Steps Audits
98%
40% reduction in
community acquired
urinary tract infections
Data not available
The indicator incorporates
questions which are known
to be important to patients
and where past data
indicates significant room for
improvement across England
and is based upon the
national indicator for acute
trusts.
90% positive score
across five questions by
September 2011
100%
Required by the Care Quality
Commission
50% of all patients on
Community Services
caseload aged 65 yrs
or over have received a
dementia assessment by
Quarter 4 2010-11
59%
50% of patients in crisis
receive a response from a
trained health professional
within 1 hour - by Quarter
2 2010-11
68%
80% of patients in crisis
receive a response from a
trained health professional
within 1 hour in Quarter 4
2010-11
86%
A reduction in
urinary tract
infections through
compliance with the
Essentials of Care
audits as required
by the NHS Kirklees
Infection Control
Team to by NHS
Kirklees Infection
Control team.
60% of healthcare associated
infections are related to
catheter care.
Patient
Experience
Surveys
Improve the
responsiveness to
personal needs of
patients
Early
Assessment of
Dementia
Early assessment
and diagnosis
of dementia to
improve the quality
of care for patients
with dementia
Reduction in
Urinary Tract
Infections
Single Point of
Access/Rapid
Response
Trained health
professional
response within
one hour will
lead to improved
quality of care for
and outcomes for
patients in crisis
Required by the Care Quality
Commission
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Section five:
Statements
5.1 Statements from our Stakeholders
5.1.1 Kirklees Local Involvement Network
No comments received.
5.1.2 Kirklees Wellbeing and Communities Scrutiny Panel
The Well-Being & Communities Scrutiny Panel welcomes the opportunity to
comment on Kirklees Community Healthcare Service’s Quality Account for
2010/11.
The Panel has not had extensive involvement with KCHS during the last 12 months,
although they have maintained a watching brief on the development of the
community interest company (CIC). The Panel would like to see closer engagement
in the coming months with KCHS as the CIC comes into being, particularly in
respect of the implications for potential health service users. The Scrutiny Panel also
hope to work more closely with KCHS over the next 12 months to develop their
understanding of the actions being taken to address the priorities.
5.1.3 Kirklees Primary Care Trust
No comments received.
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5.1.4 Greater Huddersfield GP Commissioning Consortium
We welcome the chance to comment on this first quality report and we do
appreciate this is still early days for this new provider unit.
The areas we would like to see worked on are as follows:
We would like to see more work on clinical priorities. This would be best aimed
at areas such as Children CAF, % patients on the Liverpool care pathway and
nutrition plans. We feel the SPA needs to record outcomes rather than just times
of response. We would like to know what actions have come from the complaints
/ significant events. How is this learning being incorporated into new ways of
working. We look forward to working together in the future.
5.1.5 North Kirklees GP Commissioning Alliance
No comments received.
5.2 How to provide feedback on this Quality Account
If you would like to request a copy of this document in an alternative format
or other language or have any queries about its content, please contact the
Integrated Governance Team:
Tel: 01924 351440
Email: gwen.ruddlesdin@kirkleeschs.nhs.uk
This report is also available at www.kirkleeschs.nhs.uk
30
Kirklees Community Healthcare Services
|
Quality Account 2010/11
Quality Account 2010/11
|
Kirklees Community Healthcare Services
31
June 2011