Quality
Account
2010/11
Putting you first is at the heart of everything we do
Contact
Trust Headquarters
Bridge House
Unit 16, The Point
Lions Way
Sleaford
Lincolnshire
NG34 8GG
(
8
Tel: 01529 220300
Website: http://www.lincolnshirecommunityhealthservices.nhs.uk
Communications
For more information about communication activities happening across the
Trust please contact Sue Barnston, Senior Communications Manager
(
8
Tel: 01522 515343
E-mail: Communications@lpct.nhs.uk
Trust Board Information
For more information on our Trust Board please contact Bev Wormald, Trust
Board Secretary
(
8
Tel: 01529 220482
E-mail: bev.wormald@lpct.nhs.uk
This leaflet can also be made available upon request in Braille, audio cassette,
large print or in other languages.
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em português.
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2 Quality Report 2010/11
Patient Advice and
Liaison Service (PALS)
PALS is a confidential service that helps patients, their families and carers to find answers to
questions or concerns regarding the care or treatment received from NHS Trusts in Lincolnshire.
As a patient, relative or carer you may sometimes need to turn to someone for on-the-spot help,
advice and support. This is what the Patient Advice and Liaison Service does on a daily basis.
The service provides confidential advice and support, helping to sort out any concerns people
may have about the care provided by the NHS by guiding them through the different services
available.
PALS can:
• Provide information about local health services
• Listen to any problems in relation to health care or the health care of a loved one or friend
• Help ask questions about health care
• Tell people about relevant help and support groups
(
Tel: 0845 602 4384
Calls via typetalk are welcome
8
Email: info@lincspals.nhs.uk
+ Write to us at:
Lincolnshire PALS
Greetwell Place
Lime Kiln Way
Greetwell Road
Lincoln
LN2 4US
¿
A member of the team will be available Monday to Friday, 9am - 5pm
(Except Bank Holidays)
This service is confidential
3 Quality Report 2010/11
Contents
Glossary............................................................................................................................... 4
Part 1........................................................................................................................................ 5
Welcome............................................................................................................................. 5
Statement by the Chief Executive..................................................................................... 6
Statement from the Board................................................................................................. 6
Part 2........................................................................................................................................ 7
Our priorities for quality improvement in 2011/12.......................................................... 7
Clinical Effectiveness....................................................................................................... 8
Patient Safety.................................................................................................................. 9
Patient Experience........................................................................................................ 10
Statements relating to quality of NHS services provided........................................... 12
Part 3...................................................................................................................................... 15
Review of Quality Performance 2010/11......................................................................... 15
Patient Safety................................................................................................................ 15
Clinical Effectiveness..................................................................................................... 17
Patient Experience........................................................................................................ 18
Quality Achievements in 2010/11................................................................................. 19
Involvement and engagement..................................................................................... 21
Statement of changes to content post consultation.................................................. 22
Statements from other bodies..................................................................................... 23
Glossary
CAPAAS Children and Parents Asperger Autistic Support
CQC
Care Quality Commission
CQUINCommissioning for Quality and Innovation – a scheme to encourage improvement
FRAT
Falls Risk Assessment Tool
HPV
Human Papillomavirus
HSCL
Health Scrutiny Committee for Lincolnshire
IV
Intravenous Therapy
LCHS
Lincolnshire Community Health Services NHS Trust
LINk
Local Involvement Network
MRSA Meticillin-resistant Staphylococcus Aureus
NHS
National Health Service
NHSLA National Health Service Litigation Authority
OOH
Out of Hours
PALS
Patient Advice and Liaison Service
PEAT
Patient Environment Action Team
ULHT
United Lincolnshire Hospitals NHS Trust
4 Quality Report 2010/11
Part 1 Welcome
This has been an important year for Lincolnshire
Community Health Services NHS Trust (LCHS). From
the 1st April 2011 LCHS became an independent
NHS Trust and during the production of the Quality
Account the new Board has been established. A
big thank you to everyone who was involved in and
supported the organisational transition and to all the
staff who continue to provide high quality services.
Through our diverse range of community services
we aim to deliver excellent services, recognised as
such by those we serve, whilst achieving a sound
financial position. Improving quality is the primary
focus for the organisation and LCHS has a growing
portfolio of quality improvement initiatives that
enhance the safety, experience and outcomes for
all our patients.
Lincolnshire Community Health Services
NHS Trust Services Chart
Family & Healthy
Lifestyles
Community
Hospitals
Health Visiting and
School Nursing
Services provided at 4
Community Hospitals,
Louth, Johnson, John
Coupland, Skegness
Safeguarding
Vulnerable Children
and Young People
Children’s Therapy
Services
Smoking Cessation,
Weight Management
and Sexual Health
Dental Service
Primary Care
Services
GP Practices
Walk in Centre
Out of Hours
LCHS is embedding a culture of continuous quality
improvement and will work in partnership with
our staff, patients and other stakeholders to
ensure that addressing all aspects of quality is a
priority for us in the coming year.
We have learnt from our experiences gained from
the East Midlands pilot of Quality Accounts for
community services last year. This year our process to
consult and engage all of our stakeholders has been
much more robust. We have engaged patients, the
public, organisations representing patients and the
public, our staff, our commissioners, GPs, the Health
Scrutiny Committee for Lincolnshire (HSCL) and the
Local Involvement Network (LINk), in giving initial
feedback about our chosen priorities to improve
service quality and patient experience as well as
giving us feedback about the presentation and
content of our report.
Integrated
Community
Based Services
Adult integrated
teams (including
Community Nursing,
Specialist Nursing
and Community
Response and
Rehabilitation
services)
Adult Therapy
Services,
(physiotherapy,
Occupational
Therapy, Speech and
Language Therapy
and Podiatry)
Infrastructure
Corporate Services
Human Resources
Estate and Facilities
Management
Informatics and
Performance Services
Finance
Lincolnshire Learning
Academy
Communications
Assisted Discharge
Stroke Service
Clinical Governance
& Risk
Anti Coagulation
Service
PALS
Adults Electronic
Assistive Technology
Service (EATS)
Patient & Public
Involvement &
Engagement
Care Quality
Commission
Assurance
5 Quality Report 2010/11
Statement by the
Chief Executive
LCHS has put considerable effort into developing a clear vision,
mission statement and branding that communicates the fundamental
principles of the organisation. The vision, values and strategic aims
have been developed with patients, staff and partners and are
embedded across the organisation becoming the cornerstone of LCHS
interaction with patients and the public.
As LCHS continues as an independent NHS Trust it is essential that the
organisation re-affirms its vision, values and strategic aim. Leaders and
managers across the organisation will be engaged to achieve this.
Ellen Smith
Chief Executive, LCHS
LCHS Vision: To be the first choice for community services provision.
LCHS Values: P utting you FIRST is at the heart of everything we do
Strategic Aims:
• Listen to users, value their views to
improve their experiences
• Ensure clinical services perform to best
practice standards
• Deliver a quality driven financial strategy
• Engage clinical leaders to take responsibility
for identifying opportunities to improve services
and reduce costs
• Develop transformational leadership
• Manage the reputation of the organisation
Statement from the Board
Dr Don White, Chair, LCHS
Insightful leadership and clinical experience will be key to
securing the success of LCHS as an aspiring Community
Foundation Trust. The successes achieved by everyone as they
worked to establish LCHS as an independent provider are as
a direct result of the dedicated staff who genuinely live the
values of the organisation every day in putting people and
patients first.
6 Quality Report 2010/11
Part 2
Dianne Judge received care from the Assisted
Discharge Stroke Service and told the service that:
“It’s made a phenomenal difference
to my life”.
Dianne Judge
Our Priorities
for Quality
Improvement
in 2011/12
LCHS has sought the views of stakeholders
throughout the process by conducting a
comprehensive and robust consultation to set the
priorities, content and format of this report. This
has been achieved with:
• staff through regular staff conferences
•the Trust Board through regular updates at board
meetings
•a selection of local patient groups through
consultation questionnaires including Children
and Parents Asperger Autistic Support (CAPAAS),
Diabetes 4 All, Lincolnshire Parent Carer Council,
the Healthy Hub Community Interest Company,
MIND, Positive Health, Cancer Forum, Stroke
Communication support groups and Carers
Partnership Forum
•the local GP community via consultation
questionnaires
•NHS Lincolnshire, the commissioners through
meetings to support the process and
engagement with their board
•the HSCL and the LINk, through established
forums and processes to review the Quality
Accounts of all local health care providers
Appendix A is the preliminary consultation
conducted with stakeholders about the priorities
for 2011/12.
7 Quality Report 2010/11
Staff Engagement
LCHS holds staff conferences twice a year to
ensure that the workforce is kept up to date
with organisational developments. At the spring
quadrant conferences staff were involved in the
development of the Quality Account and were
given the opportunity to ask questions regarding
the priority setting consultation and respond to
the consultation. 54 employees directly responded
to the consultation at the spring quadrant
conferences out of a possible 400.
General Practitioners
General Practitioners were approached by NHS
Lincolnshire (NHSL), the commissioners for
Lincolnshire, to seek their involvement in setting
the priorities for the LCHS Quality Account, as
part of the Community Services Contract sign
off process.
LINk and the HSCL
Prior to conducting the consultation the Health
Scrutiny Committee for Lincolnshire (HSCL)
and Local Involvement Network (LINk) were
approached to determine the most appropriate
method of engagement during the consultation
process. Their response informed LCHS that they
wished to take part in the 30 day consultation
process once the document had been produced.
Patient and Public Engagement
A vital aspect of setting the priorities for the
account was to directly seek the views of patients
and carers. This was carried out by contacting
various patient forums/support groups. The
consultation paper was circulated to these groups
and their feedback requested to ensure that the
priorities set by LCHS for 2011/12 represented
issues of real interest for patients.
Based on the feedback from this consultation
process the key priorities for 2011/12 were
identified within the areas of Clinical Effectiveness,
Patient Safety and Patient Experience.
The Quality Improvements for LCHS in 2011/12 are:
Clinical Effectiveness
Transforming Community Services – Introduction of Business Units in the new
NHS Trust and the development of integrated services
Aim/Goal
To introduce Business Units into LCHS to ensure the development of integrated services.
Current Status
The formation of LCHS NHS Trust on 1st April 2011 has been followed by the development of
the Business Units. 5 Business Units will be created – 4 Adult Service Business Units (North West,
North East, South West, South East) and 1 Family and Healthy Lifestyle Business Unit to support
delivery of services across the county.
Identified Areas for Improvement
The Business Units will be held accountable for their performance across various domains:
• Performance – achieving specific key performance indicators to underpin positive and good
quality patient experiences
• Quality – ensuring achievement of Care Quality Commission (CQC) standards
• Finance – achieving financial balance and ensuring efficient use of resources
Current Initiatives in 2010/11
The organisation has been working towards the formation of Business Units. This work has
already resulted in the ability to allow:
• Greater flexibility of service provision
• Responsive services to meet local needs
• Improved Patient and Public Involvement at a local level
• Improved local relationships with other providers of health and social care services
New Initiatives to be Implemented in 2011/12
• Continued development of Business Unit function to ensure integration of services enabling
efficient use of resources
• Ensure close working relationships with clinical commissioning groups and other stakeholders
• Ensure continuous service improvement
Board Sponsor
Sue Cousland, Chief Nurse/Director of Operations
Implementation and Programme Lead
Business Unit General Managers
8 Quality Report 2010/11
The Quality Improvements for LCHS in 2011/12 are:
Patient Safety
Medicines Management – Monitoring of medicines administration for
all disciplines
Aim/Goal
To develop LCHS specific systems and processes in relation to Medicines Management.
Current Status
• Service Level Agreement being developed with NHS Lincolnshire to provide support and
advice regarding medicines management
• Devolve Non-Medical Prescribing (qualified professionals other than medical staff prescribing
medication within their competence) responsibilities to Business Units
• LCHS to develop own medicine management policies
Identified Areas for Improvement
• Ensuring consistency in medication administration
• Process for monitoring non-medical prescribing
• Rigorous analysis and investigation of errors
• Standardisation of syringe drivers (Medical equipment used to deliver measured doses of
medication over a prescribed time period) and Blood Glucose Monitoring equipment
Current Initiatives in 2010/11
The development within LCHS of specific systems and processes are:
• Ensuring consistency in medication administration
• Enabling standardisation of current syringe drivers and Blood Glucose Monitors
• Allowing improved monitoring of systems
New Initiatives to be Implemented in 2011/12
• Replacement of syringe drivers countywide
• Further develop monitoring and analysis of medicines management
• Re-launch Non-Medical prescribers network
Board Sponsor
Dr Phil Mitchell, Clinical Director
Implementation Lead
Sue Cousland, Chief Nurse/Director of Operations
Programme Lead
Business Unit General Managers
9 Quality Report 2010/11
The Quality Improvements for LCHS in 2011/12 are:
Patient Experience
Project to evaluate patient and carer experience of End of Life Care
Aim/Goal
Evaluation of patient experience of End of Life Care
Current Status
The involvement of patients in the development and refinement of service provision is a key element
of NHS strategy. LCHS engages with patients and carers across a range of services using a range
of methods.
NHS Lincolnshire has set a Commissioning for Quality and Innovation (CQUIN) indicator for LCHS
which will place greater focus on overall experience and will help a culture shift in patient reported
quality and experience.
This builds on the requirements of the organisation to collect evidence of achievement of the CQC
outcome 1 – Respecting and involving people who use services.
Identified Areas for Improvement
To ascertain patient and carer’s perspectives on End of Life Care. The organisation is putting in place
measures to gain further insight into the experiences of patients and carers.
Current Initiatives in 2010/11
Development within End of Life Care services has enabled the:
• Introduction of patient diaries to record feedback and ensure service improvement
• Review the End of Life Care pathway to include a review of patient and carer information
New Initiatives to be Implemented in 2011/12
• Development of patient diaries
• Use of semi structured interviews with carers who have lost a friend or relative in the previous
6 months
• An annual audit via the cancer focus group and the Long Term Conditions focus group
will be conducted
• Development of patient and carer information in respect of the end of life care pathway
Board Sponsor
Sue Cousland, Chief Nurse/Director of Operations
Implementation Lead
Liz Ball, Business Unit General Manager
Programme Lead
Di Rigby, Operational Lead
10 Quality Report 2010/11
The Quality Improvements for LCHS in 2011/12 are:
Patient Experience
Improved patient feedback by use of patient diaries and ‘real time’ patient feedback
Aim/Goal
Improve patient feedback by the use of patient diaries and ‘real time’ (immediate) patient feedback.
‘Real time’ feedback is particularly useful as evidence of service user experience as it gives an
immediate observation as to the quality of services being received. Methods used to capture
‘real time’ feedback vary but can range from an electronic screen which asks a number of
straightforward questions through to the more detailed method of asking patients to keep
diaries of their experiences when receiving care over a longer period of time.
Current Status
Patient and carer feedback is currently captured by a range of methods including thank you letters,
patient surveys, PALS enquiries, complaints and via service user representatives.
Where further insight is required into the experiences of service users additional methods will be
used including focus groups, deliberative/consultation events and other means of consultation.
Identified Areas for Improvement
• Greater opportunity for patients to give feedback about the care they have received using a range
of approaches
• More timely feedback to ensure patient concerns/compliments are followed up
• On the spot quality checking by a team of both health professionals and service user representatives
Current Initiatives in 2010/11
LCHS has introduced patient diaries to record feedback and ensure service improvements can be
made as required.
New Initiatives to be Implemented in 2011/12
• Continued use of patient diaries in both community and hospital settings
• Introduction of ‘real time’ patients feedback
• Patient forum to be established within the Johnson Community Hospital
• Introduction of mystery shopping by service users and carers
Board Sponsor
Sue Cousland, Chief Nurse/Director of Operations
Implementation and Programme Lead
Sarah Gec, Patient and Public Involvement Manager
11 Quality Report 2010/11
Statements Relating to
Quality of NHS Services
Provided
Review of Services
Participation in Clinical Research
LCHS became an independent NHS Trust on April
1st 2011. The services that the Trust provides
were reviewed as part of Department of Health
assurance processes supported locally by both NHS
Lincolnshire and East Midlands Strategic Health
Authority. The assurance process included looking
at service quality as well as cost effectiveness and
‘best fit’ with local health provider organisations.
A range of LCHS services were reviewed as part of
existing contract processes and, following the NHS
Trust assurance process, new contracts have been
developed between NHS Lincolnshire and LCHS
which further strengthen quality monitoring.
588 patients receiving NHS services, provided or
sub-contracted by LCHS in 2010/11, were recruited
by a research ethics committee to participate in
approved research.
Participation in Clinical Audit
During 2010/11, 3 national clinical audits and no
national confidential enquiries covered NHS services
that LCHS provides.
During that period LCHS participated in 10% of
national clinical audits.
The national clinical audits and national
confidential enquiries that LCHS were eligible
for and participated in during 2010/11 are
as follows:
• Continence
• Falls
• Diabetes
• Stroke
12 Quality Report 2010/11
Goals Agreed with Commissioners
A proportion of Lincolnshire Community Health
Services NHS Trust’s income in 2010/11 was
conditional on achieving quality improvement and
innovation goals agreed between Lincolnshire
Community Health Services NHS Trust and
NHS Lincolnshire, 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 from NHS Lincolnshire at:
http://www.lincolnshire.nhs.uk/en/
Commissioning/CQUIN---Commissioning-forQuality-and-Innovation/
Douglas Gabriel received services from
LCHS including Tele-health which has
“been a great support to me”.
Douglas Gabriel
Care Quality
Commission
Statement
Paul Robinson, Deputy Chief Executive LCHS,
Board nominated individual for CQC
LCHS was required to register with the Care Quality
Commission (CQC) as a new organisation. LCHS has
full and unconditional registration status.
LCHS intend to take the following action to address
the conclusions of the Children with Disabilities
review:
LCHS is registered to carry out the following
regulated activities:
• Review referral forms to ensure that ethnicity
information is recorded and collated to support
service planning purposes
• Treatment of Disease, Disorder or Injury
• Surgical Procedures
• Diagnostic and Screening Procedures
• Information will be available in an accessible
format to service users/carers
• Nursing Care
• Develop a protocol to ensure that assessments
identify and record cultural and
religious needs
LCHS has participated in special reviews or
investigations by the Care Quality Commission
relating to the following areas during 2010/11:
LCHS was not subject to the Payment by Results
clinical coding audit during 2010/11 by the Audit
Commission.
• Family Planning
• Care Home Review
• Stroke Services
• Children with Disabilities
• Children who are subject to safeguarding and
children looked after
• Inspections of John Coupland and Johnson
Community Hospitals with regard to compliance
with the hygiene code
13 Quality Report 2010/11
Unannounced Quality Visits
Statement on Data Quality
As part of the continual quality review process
Senior Managers within LCHS conduct
unannounced spot checks to services. These are
conducted in a similar style to that of the CQC
unannounced checks, to ensure that service quality
is monitored.
LCHS became responsible for Clinical Coding
(the process of recording a patients illness in a
nationally and internationally recognised format)
at Louth County Hospital from 5th September
2010. For 2010/11 LCHS was part of the return
that was completed by NHSL, as such the data is
not able to be reported for LCHS this year.
During 2010/11 LCHS carried out at total of 14
internal spot checks at:
• Community hospitals – Johnson Community
Hospital, Louth County Hospital, John Coupland
Hospital and Skegness Hospital
• Adult Integrated Services – covering the North
East, North West, South East and South West
• Children’s Services – covering the North East,
North West and South West
• Prison Healthcare Services – HMP Lincoln, HMP
Morton Hall and HMP North Sea Camp (services
no longer part of LCHS)
The Senior Management Team identified the
focus for the spot checks to assure compliance
with the CQC outcomes. Information gathered
from these spot checks was reported to the
Senior Management Team and an action plan
was put in place to address issues raised. Spot
checks will also be carried out in 2011/12 with
the outcomes for review being selected by the
Senior Management Team.
LCHS has been subject to unannounced visits
from the CQC with regards to Cleanliness and
Infection Control at John Coupland and Johnson
Community Hospitals. The visits resulted in the
sites being rated as compliant in respect of this
outcome.
14 Quality Report 2010/11
The process has commenced for 2011/12 and a
local agreement to randomly audit Clinical Coding
has been agreed with United Lincolnshire Hospitals
Trust (ULHT). It is anticipated that LCHS will
participate in the national audit in the future.
Part 3 Review of Quality
Performance 2010/11
Patient Safety
Implementation of Quality Standards for the
Out of Hours service
Sue Cousland,
Chief Nurse/Director of Operations, LCHS
A Quality Improvement Strategy is being
developed by LCHS with a vision to provide
excellent levels of quality care to our patients.
The Quality Improvement Strategy will ensure
a continual assurance process focused on
Patient Safety, Patient Experience and Clinical
Effectiveness. During 2010/11 LCHS will strive
to improve quality through the implementation
of this strategy and this will be demonstrated in
the 2011/12 Quality Account.
This section is a review of the Trust’s quality
performance over the past year based on
the priorities set within the 2009/10 quality
account. The areas that were selected to be
reported against were identified as the most
important by patients, staff, Board members
and people who purchase our services on
behalf of the local population.
15 Quality Report 2010/11
In order to ensure the patient safety quality
standards for the Lincolnshire Out of Hours (OOH)
service in 2009/10 were delivered, LCHS has
worked towards the full implementation of and full
compliance with the quality standards. The quality
standards are detailed in the table on page 16.
During 2010 Out of Hours Care was receiving
national negative coverage. To ensure an effective
response, LCHS took a proactive approach and was
able to report service improvements and compliance
with the standards.
In August 2010 quality standard 9 was achieved,
this was the last standard that needed to be
achieved by the Out of Hours service. This standard
measures the time taken to speak to a primary care
clinician and is defined, for urgent calls, as a limit
of 20 minutes. This standard has been recognised
nationally as a target that is difficult to attain and
as such it was a big achievement for the service.
This achievement resulted in the service being fully
compliant with all of the 13 elements of the Quality
Requirements Summary.
This coincided with the award of the Customer
First accreditation which is a nationally recognised
customer focused kite mark. This award is
applied for directly by services and acknowledges
achievement of a high standard of customer care.
The Out of Hours service is the second NHS service
to have achieved this accreditation nationally.
National Quality Standards
1
Providers must report regularly to PCTs on their compliance with the Quality Requirements
2
Providers must send details of all OOH consultants to the practice where the patient is
registered by 08:00 the next working day
3
Providers must have systems in place to support the regular exchange of up-to-date and
comprehensive information
4
Reporting on clinical audit
5
Reporting on audits of patient’s experience of the service
6
Reporting on complaints
7
Providers must demonstrate their ability to match their capacity to meet predictable
fluctuations in demand for their contracted service
8
Initial telephone call. No more than 1.0% engaged and 5% abandoned. Calls must be
answered within 60 seconds of the end of introductory message
9
Telephone clinical assessment. Definitive clinical assessment must start within 20 minutes of
the call being answered by the person
10
Face to face clinical assessment. Definitive clinical assessment must start within 20 minutes
of the patient arriving at the centre
11
Providers must ensure that patients are treated by the clinician best equipped to their needs
12
Face to face consultations must be started within 1 hour for emergencies, 2 hours for
urgent and 6 hours for less urgent
13
Patients unable to speak effectively in English will be provided with an interpretation service
within 15 minutes. Must have provision for sight and hearing impaired patients
16 Quality Report 2010/11
(L-R: Representative from Customer First and Andi Bennett,
Out of Hours Manager receiving the Customer First Award)
In order to gain this prestigious award the Out of Hours service was
assessed against 32 standards. The standards were to demonstrate
that we:
• Listened to our customers needs
• Delivered an effective and efficient service
• Acted upon evaluations provided by staff, patients and carers
A self assessment enabled the service to evaluate its current position
in relation to the standards given and to further identify any
improvements or areas for development.
The Out of Hours service continues to ensure it monitors the quality
of service it provides against the patient safety quality standards.
Clinical Effectiveness
Meeting the Next Stage Target for Human
Papillomavirus
LCHS delivers the Human Papillomavirus (HPV)
immunisation programme within a national
framework and works closely with parents and
schools to obtain vaccination consent. The catch
up programme has been completed and almost
all schools in Lincolnshire have received the
programme.
There are several areas where further improvement
can be achieved and recently the HPV team has
been integrated into the generic School Nursing
Service. This change is to improve quality and
safety of the service, increase vaccination take up
and ensure eligible females receive the full course
of vaccines in the programme time frame.
Current and Future Initiatives 2010/11 –
2011/12
HPV is the cause of most cervical cancers in women
under 35 years of age, the immunisation given at
age12-13 should show a significant decrease in
the incidence of the disease over time in young
women.
The aim is to continue to immunise a significant
number of 12-13 year old girls to protect them
against developing cervical cancer caused by HPV.
Of the young women who consented to receive
the HPV immunisation over 95% will receive
the vaccine.
Although progress has been made in increasing
the number of girls consenting for immunisation,
continued efforts need to be made to raise the
profile and increase awareness in schools.
The current initiatives taking place in 2010/11
are to encourage the young women who have
not consented to immunisation to seek access
if they have changed their decision. Access to
immunisation for those students who have been
absent from school and missed immunisation
needs to continue.
Initiatives to be implemented in 2011/12 include
the School Nursing Teams to take on the delivery of
the HPV programme and work closely with pupils,
parents and schools to increase awareness. Support
needs to be given to ensure increased uptake and
ensure all consented pupils receive the full course
of immunisations.
17 Quality Report 2010/11
Patient Experience
Responding to the GP Patient Survey and Improving Waiting Times
The GP is excellent.
The GP is understanding and patient.
An asset to this surgery.
Comments posted by a patient on NHS Choices in
respect of the Burton Road Surgery February 2011
LCHS continues to directly manage five General
Practices:
• Pottergate Surgery, Gainsborough
• Metheringham Surgery, Metheringham
• Burton Road Surgery, Lincoln
• Arboretum Surgery, Lincoln
• University Surgery, Lincoln
The National Patient Survey undertaken from
January 2010 – December 2010 demonstrates that:
•99% of patients are satisfied with the opening
hours of the surgeries
• 2% of patients had to wait more than 30 minutes
Reference National Patient Survey January 2010 –December 2010
The identified areas for improvements for 2010/11
include:
•A recent privacy and dignity survey of over 65
patients scored 100%
•Extended services are offered at each site for
patients who work 9am – 5pm
A survey carried out in April 2010 identified a need
for drop-in sessions with a Nurse at the University
Health Centre. A pilot was put in place to identify
if this was a real need for patients. The pilot for
the drop-in sessions was so successful that this has
been extended and the service is now available
during normal working hours at the University
Health Centre.
“I saw the practice nurse and they
were fantastic, understanding, caring
and knowledgeable. They listened to
me and involved me in the decisions
about my treatment options. The
nurse was also keen to follow me up.
What a fantastic nurse.”
Comments posted by a patient on NHS Choices in
respect of the Burton Road Surgery March 2011
• Improving waiting times for clinicians
•Patients have difficulty identifying staff and GPs
as NHS badges are not always visible
• Have a suggestion box
• Keep the notice board up to date
•Ensure that there are GPs who work in the
practices on a more regular basis to ensure
consistency of care and better knowledge of the
local patients
The improvements that have been made to services
as a result of patient feedback are:
•Patients can identify staff as they all wear name
and ID badges
• Notice boards are kept up to date
•Suggestions boxes are available in each of the
surgeries
• Regular patient participation groups take place
18 Quality Report 2010/11
Current and Future Initiatives 2010/11 –
2011/12
The current and future initiatives for the LCHS GP
practices:
• Address feedback from local and national surveys
•Continue to listen and respond accordingly to
patients
•Proactively manage patients who live in nursing
and residential homes to improve their health
outcomes
•Continue to strive towards improved waiting
times
•Operate an enhanced SMS texting service to
enable patients to book appointments and receive
test results via texting service
Quality Achievements in 2010/11
LCHS continues to make progress with regards to
quality improvements and achievements in areas
such as the Patient Environment Action Team (PEAT)
inspections (a national tool to ensure improvements
are made in non-clinical aspects of care including
environment, food, privacy and dignity), health
acquired infection reporting, feedback from staff
surveys and compliments and complaints.
Dr Phil Mitchell,
Clinical Director,
Lead for Infection
Control, LCHS
PEAT Scores
The PEAT inspections are carried out in the four Community Hospitals in Gainsborough,
Louth, Skegness and Spalding. We pride ourselves on the high level of cleanliness
achieved in our services, below the PEAT results demonstrate the continual improvement
across the four community hospitals.
Environment
Site
John Coupland
Hospital
Privacy and Dignity
2009
2010
2009
2010
2009
2010
Excellent
Excellent
Excellent
Excellent
Excellent
Excellent
Good
Excellent
Excellent
Excellent
Acceptable
Excellent
Excellent
Excellent
Good
Good
Excellent
Excellent
Good
Excellent
Johnson Hospital
Louth County
Hospital
Food
Acceptable Acceptable
Skegness Hospital
Good
Excellent
Our community hospitals are audited for environmental cleanliness audits on a monthly
basis and consistently achieve a greater than 95% cleanliness score.
Health Acquired Infection
Controlling the risk of avoidable infection is a key role for LCHS and we aim to ensure
that all service users who access healthcare and the staff who provide the care do so
in a safe and clean environment. This can be demonstrated through the low Meticillinresistant Staphylococcus aureus (MRSA) results for both 2009/10 and 2010/11.
MRSA Blood Stream Infection comparison 2009/10 - 2010/11 for LCHS
Number of MRSA Infections
1.2
1
0.8
0.6
2009/10
2010/11
0.4
0.2
0
Quarter 1
19 Quality Report 2010/11
Quarter 2 Quarter 3 Quarter 4
Staff Survey
By responding to feedback received through the National
Staff Survey LCHS works to improve quality outcomes not
only for patients but also for its staff. The 2010 staff survey
results demonstrate that 61% of staff completed and
returned the survey, more than the average for England.
The 2010 survey demonstrates that staff experiences have
improved most in the following areas:
• Increase in the number of staff appraised
Ian Warren, Director of Human
Resources and Organisational
Development, LCHS
•Increase in number of staff reporting that they have a
Personal Development Plan in place
•Reported improvement in the structure of appraisals
received by staff
•Communication between senior management and staff has
improved and is above the national average
Reporting of appraisals, improvement in the structure of
appraisals and staff with Personal Development Plans are
comparative with the national averages reported in the Staff
Survey results.
East Midlands Leadership Academy
A team of health professionals from LCHS won first
place in a regional leadership challenge beating
ten other teams to secure £50,000 of funding to
further develop their project to deliver Intravenous
Therapy (IV) in a range of community settings
including patients’ homes and community hospitals.
The aim of the Transforming Community Services
Multi Professional Leadership Challenge, hosted
by the East Midlands Leadership Academy, was to
develop health and social care professionals to lead
innovative change through service improvement.
Professor Rachel Munton from East Midlands
Leadership Academy, who was on the deciding
panel said: “We are delighted to have awarded
the winning prize to the team at Lincolnshire
Community Health Services. The East Midlands
Leadership Academy looks forward to
supporting this exciting project over the next
12 months to develop, implement and deliver
their idea of delivering an Intravenous Therapy
service to patients in Lincolnshire and the
positive effects this will have on enhancing
individual patient experiences.”
20 Quality Report 2010/11
Michelle Johnstone, Senior Manager said: “This
is a well deserved achievement for everyone
who took part from the Community IV Project
Team. The day was very fast paced and
challenged our ability to work under pressure.
The event helped us to identify potential
challenges when developing new services and
allowed us to focus on how to improve the
Community IV project plan even further.”
(L-R: Liz Allen-Wright, Fran Taylor, Jo WrightLakin, Michelle Johnstone, Gemma Marshall,
Sara Jayne Moore, Donna Procter)
Complaints and Compliments
LCHS responds to all complaints received from
patients or carers and ensure that lessons are
learnt from these to ensure that good quality
services are delivered to the population of
Lincolnshire.
During 2010/11 LCHS received 182 complaints,
none of which have been reviewed by
the Ombudsman. LCHS ensures that all
complaints are acknowledged within the set
National Standard of 3 working days. When
acknowledgment of the complaint is made
a time frame for the response is agreed with
the complainant. This is usually agreed as 25
working days. If, the complaint is complex, an
extension on the timeframe can be negotiated
with the complainant.
Fewer complaints were received by LCHS in
2010/11 than in 2009/10. LCHS is taking a
proactive approach to addressing issues raised
through the Patient Advice and Liaison Service
(PALS) by addressing concerns prior to a formal
complaint being made. This measure is helping
to ensure that number of formal complaints
received is reduced.
Compliments are received directly by LCHS
services from patients and carers. These
compliments are recorded by the services and
influence the monitoring of service quality.
National Health Service Litigation Authority
(NHSLA)
The NHSLA regularly assess healthcare
organisations against a range of standards and
assessments. The standards that healthcare
organisations are assessed against are available
at: http://www.nhsla.com/RiskManagement/.
In November 2010 LCHS was reviewed by
the NHSLA in respect of level 1 standards. It is
expected that LCHS will be reviewed against the
level 2 standards within the next 2 years.
These reviews ensure that the services provided
by LCHS are of an appropriate safety standard.
In order to achieve the level 1 assessment
organisations are required to achieve 7 out
of 10 in each of the 5 standards. LCHS was
successful in achieving 8 out of 10 for three
standards and 10 out of 10 in the other 2.
Involvement and Engagement
The three key priorities identified within the
quality account have been chosen as a result
of the feedback received from the consultation
carried out with our staff, patient and carer
groups and GPs.
Without this feedback the quality account
would not include those priorities which mean
the most to our stakeholders. Thank you to all
who participated in the consultation process.
We will learn from the feedback our
stakeholders have given us and continue
to strive to improve our priority setting
consultation process.
21 Quality Report 2010/11
Statement of changes to
content post consultation
What you told us you didn’t like
What we changed
Presentation
Presentation
• Charts and tables were too small
• Chart sizes increased to ensure legible
• Colours used on charts and tables
• Lighter colours used
• 2011/12 priorities unclear due to column
layout of text
• Each priority placed on to a single page,
not in column format
• Photos unclear
• Photo sizes and quality improved
What you told us you didn’t like
Language
• Use of abbreviations
• Use of business speak
What we changed
Language
• Glossary included at the beginning of the
document to detail what abbreviations have
been used
• Explanations have been given to explain terms
used and language was altered to plain English
where possible
Barbara Keeley received care from staff at John
Coupland Community Hospital her comments
about the care received included:
“The staff made an awful lot of
difference to my recovery.”
Phoenix Weight Management Service helps obese
adults look carefully at their lifestyle and identify
what they can change in order to become healthier
and lose weight.
“Phoenix changed my life nearly 100%,
I can do more, I’m not so breathless
and I can do much more than I could
12 months ago.”
Feedback from Kev who attended the service.
22 Quality Report 2010/11
Statements from
other bodies
As part of the process for developing the
Quality Account we were required to
share a draft version with a range of other
organisations and publish their comments.
Below are the responses received.
Commissioning high quality, safe patient services
is our highest priority and the areas identified
will enhance the patient experience and improve
patient safety and clinical outcomes. NHS
Lincolnshire therefore welcomes the focus that
the Trust still places on reducing medication
administration errors across all services.
In terms of performance against the 2010/11
CQUIN indicators, the following indicators were
achieved:
•Percentage of community drug delivery
devices that have been safety checked in the
appropriate time period
•Percentage of patients readmitted within 28
days following discharge from community
hospital
•Percentage of grade 2 or higher pressure sores
in older people treated in a community setting
•Waiting times for treatment and therapy
services. This indicator will ensure people can
access high quality care from Allied Health
Professionals and access services as quickly as
possible
•The percentage of people discharged from
hospital and benefiting from acute inpatient
care who have not been readmitted within 90
days
•Children’s Safeguarding - Concentrate on
appropriate skills and training to strengthen
capacity
•Out of Hours - telephone triage compliance - To
implement and roll out across the county in a
phased approach the quality audit tool in Out
Of Hours triage
23 Quality Report 2010/11
•Out of Hours – Induction programme - Roll
out county wide induction programme for all
OOHs practitioners and ongoing Continuing
Professional Development
•Staff treat patients with dignity and respect in
Community Hospitals - To measure in-patient
experience of dignity and respect in community
hospitals
•Complex case manager avoidable admission
and subsequent effectiveness of reducing
admissions
The following CQUIN indicators were partially
achieved:
•Percentage of Long Term Condition (LTC)
patients with a personal health/ care plan
•Out of Hours - To reduce the percentage of
inappropriate referrals to A&E in the Out of
Hours period that could have been avoided.
Evidence of better patient management,
education and services offered within the Out
of Hours period should result in a reduction of
the number of patients whose admissions could
have been avoided.
•Effectiveness of weight management
programme– (Phoenix programme)
•Primary care access – reducing inappropriate
admissions to A&E
•Percentage of mothers breastfeeding at primary
birth visit (10-14 days) will still be doing so at
6/8 weeks
•Offender Health – To increase in the number of
offenders known and being managed in Long
Term Conditions management clinic
•Tele-health Increase in number of deployments
& Improvement in tele-health response
•Completion of the Falls Risk Assessment Tool
(FRAT) for over 65 years)Where indicated via
the FRAT tool a full falls assessment will be
completed
NHS Lincolnshire supports the examples of the
quality improvement schemes that have been
worked on during 2010/11 and areas that have
been identified for development within 2011/12.
Statements from
other bodies
In particular the implementation of and
compliance with the quality standards for the
Out of Hours service. It is acknowledged that the
HPV immunisation programme has progressed
well, however further work is required in order to
ensure full delivery. The positive patient feedback
in respect of the 5 directly managed General
Practices is also noted.
NHS Lincolnshire notes that the Trust’s current
registration status with the Care Quality
Commission is full and unconditional. Further,
it is noted that Lincolnshire Community Health
Services has participated in several reviews or
investigations by the Care Quality Commission
during 2010/11 and supports the actions that the
Trust intends to take in respect of the conclusions
of the Children with Disabilities review.
NHS Lincolnshire notes the considerable hard
work undertaken by the Trust to maintain low
MRSA results during 2010/11. Specifically we
note the Trust’s achievements with regard to the
PEAT inspections across the four Community
hospitals and the high level of cleanliness
achieved in these services. NHS Lincolnshire
recognises that the Trust has made progress on
eliminating mixed sex accommodation generally
and that further action will be taken at Louth to
improve the patients experience and comply with
the Department of Health requirements.
NHS Lincolnshire endorses the areas identified
for improvement for 2011/12 and the associated
initiatives
as detailed within the Quality Account as:
•To introduce Business Units in to LCHS NHS
Trust to ensure the development of integrated
services.
•To develop LCHS specific systems and processes
in relation to Medicines Management.
•To evaluate the patient experience of End of
Life Care.
•To improve patient feedback by use of patient
diaries and ‘real time’ patient feedback.
Additionally, the priorities identified by NHS
Lincolnshire as CQUIN indicators for 2011/12
include:
24 Quality Report 2010/11
•Breastfeeding – To measure the number of
mothers who are breastfeeding at their primary
visit are still breastfeeding at 6-8 weeks
•Stroke - Improving treatment planning and
reviews for those patients who have had a
stroke.
•Ensuring that the patients are nursed and
treated in accordance with NICE Quality
Standards
•High Impact Actions - Composite Indicator
Falls, Pressure Sores and Urinary Tract Infections
•Median waiting time for treatment and therapy
services
•Percentage of Personalised Care Plans with a
defined content
•The percentage of people discharged from
hospital and benefiting from intermediate care/
rehabilitation enablement who have not been
readmitted to hospital by day 90
•End of Life - An increased percentage of
people who die in their place of choice
•PPI - Increasing qualitative awareness and
understanding of carers’ experiences of services
relating to End of Life services delivered by
LCHS
•Long Term Conditions - A reduction in
inappropriate admissions and re-admissions
from a Complex Case Manager caseload
•Out of Hours - A reduction the number of
avoidable admissions within the Out Of Hours
service
•Children - Improvement in triage and serviced
involved in the management of children from
A&E, Minor Injuries and Illness Unit
NHS Lincolnshire supports the work underway to
capture real time feedback from patients and to
be more responsive to patients needs.
NHS Lincolnshire endorses the accuracy of the
information presented within the LCHS Quality
Account and the overall quality programme
performance will be reviewed through the formal
contract quality review process.
Statements from
other bodies
HEALTH SCRUTINY COMMITTEE FOR LINCOLNSHIRE
This statement has been prepared jointly by
the Lincolnshire Local Involvement Network
(LINk) and the Health Scrutiny Committee
for Lincolnshire.
Priorities for 2011-12
The Lincolnshire LINk and the Health Scrutiny
Committee for Lincolnshire recognise the diverse
range of services provided by Lincolnshire
Community Health Services, as a newly created
NHS Trust. The LINk and the Health Scrutiny
Committee are supportive of the new Trust
as a means of keeping these services in a
single organisation, rather than the services
being provided in several separate entities.
This approach will strengthen the relationship
between the Trust, as a provider, and the local
commissioners; and should in turn improve the
delivery of services in the community.
The LINk and the Health Scrutiny Committee
note that the Quality Account includes four aims
or goals, covering the three areas of Clinical
Effectiveness, Patient Safety and the Patient
Experience. The LINk and the Committee would
like to see a little more detail on the rationale
for each of these four priorities. The LINk and
the Health Scrutiny Committee note that one of
the priorities relates to a project evaluating the
patient experience of End of Life Care, which we
would like to support, as a specific service priority.
We suggest that in future years the Trust might
wish to focus on more priorities, which relate to
specific services or activities.
25 Quality Report 2010/11
Achievements
We congratulate the Trust on several notable
achievements, which have rightly been included
in this Quality Account. We emphasise the
importance of highlighting these achievements in
the Quality Account in a more meaningful way.
Patient and Public Involvement
The Health Scrutiny Committee has developed
a strong working relationship with the Trust.
This has included a detailed presentation to the
Committee on 20th October 2010, by the Trust’s
Chief Executive and her senior management
colleagues. Members of the Committee attended
the launch of the new Trust on 4th April 2011.
The Committee look forward to this working
relationship continuing.
The LINk and Health Scrutiny Committee are
grateful for the Trust for sharing its priorities in
advance of the draft Quality Account and look
forward to working with the Trust in this regard
during 2011-12.
Conclusion
We are grateful for the opportunity to provide
comments on the Trust’s draft Quality Account
and believe that the Quality Account is a true
reflection of the services provided by the Trust.
Appendix A
Quality Account 2010 – 2011
Please tick those priorities that you consider should be included in respect of Lincolnshire Community Health Services NHS
Trust Quality Account for the period June 2011 to May 2012.
Whilst the aim is to identify one clear priority within each priority area there is no limit to how many priorities you tick if
you consider there should be more than one per area. Comments in respect of any of the priorities are welcomed.
Local Priorities for consultation
Preferred
priority
Comments
Clinical Effectiveness
Development of information to enable the patient
and their carer to make choices about their End of
Life care plan.
Introduction of Business Units into the new NHS Trust
to ensure local delivery of integrated community
health care services.
Patient Safety
Improved treatment planning for Stroke patients
To implement Datix (electronic information system) to
ensure the assessment of patient safety is of a high
standard.
To update all medication delivery equipment (syringe
drivers) across the NHS Trust.
Medicines Management – Monitoring and improved
medicines administration for all disciplines
Patient Experience
End of Life Care – project to evaluate patient and
carer experience of End of Life Care services
Developing the range of methods used to capture
feedback from patients about their experience
of using community health services; for example
introducing patient diaries and asking patients for
their comments at the point of using services.
Collection and monitoring of equality and diversity
information when undertaking patient surveys to
ensure that Lincolnshire Community Health Services
NHS Trust is treating all people fairly and to help
identify any barriers that need to be addressed.
Introduction of Business Units into the new NHS Trust
to enable services to be delivered according to local
needs and preferences.
Thank you for completing this questionnaire.
If you require this questionnaire in a different format or language please contact:
Sarah Gec; Patient Public Involvement Manager
Telephone: 01522 582923
Email: sarah.gec@lpct.nhs.uk
FREEPOST RSKS-YSUX-BYYS
FAO Patient Public Involvement
Lincolnshire Community Health Services
FREEPOST RSKS-YSUX-BYYS
Bridge House
FAO Patient Public Involvement
Freepost SPG000000/AA
Unit Trust
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Lincolnshire Community Health Services NHS
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Email: info@lincspals.nhs.uk
info@lincspals.nhs.uk
Email:
Telephone: 0845
0845 602
602 4384
4384
Telephone:
Patient Advice
Advice and
and Liaison
Liaison Service
Service (PALS)
(PALS)
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Hosted by Lincolnshire Teaching Primary Care Trust
Become a service user representative within
Become a service user representative within
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Lincolnshire Community Health Services NHS Trust
y
a
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e
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offer you reliable services
respect your decisions
n
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n
ask public representatives to work with us
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ask the public representatives for their views
on the services they have received or would
wish to receive.
provide the public representatives with
information about the services we provide.
Lincolnshire Community Health Services NHS
Trust also aims to work with the community
by involving members of the public in the
work we do. Involvement can include a
number of different activities including:
listen to your needs as an individual
n
Lincolnshire Community Health Services
NHS Trust is committed to working with
service users, patients, families and carers
to improve your health. To achieve this we
try our hardest at all times to:
4 Act as a service user representative
pro actively working in partnership in time
limited projects.
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