Cornwall and Isles of Scilly
Community Health Services
Quality Account 2010/11
CHS QA v8 23rd June 2011
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Welcome
Welcome to the first Quality Account of NHS Cornwall and Isles of Scilly Community Health
Services. This account allows us to report on our commitment to and progress towards
assessing and improving quality and safety across all of our services.
This has been a challenging year with further change to come, and I extend my appreciation
to all staff within Cornwall & Isles of Scilly Community Health Services for their hard work and
continued focus on improving patient safety and experience throughout this time. Through
our diverse range of community services, we have delivered excellent quality recognised by
those we serve. Where people have received services that were below their expectations we
have investigated their concerns and worked to further improve the areas highlighted for
change.
The year has seen the introduction of dedicated Stroke care facilities, a significant reduction
in key infections including MRSA and Clostridium difficile, reduction in the number of
inpatients incurring pressure ulcers, and excellent work in the prevention of venous thromboembolism (DVT), as well as improvements to the physical environment in many of our
community hospitals. All of our staff are committed to improving quality and safety and
Community Health Services has a growing portfolio of quality improvement activities and is
an enthusiastic participant in the NHS Southwest Quality and Safety Improvement Initiative.
The provision of high quality, personalised care that enriches the lives of local people and
communities remains our key objective, and we will continue to promote the health and wellbeing of all, independence and opportunity wherever possible.
We have been registered with the Care Quality Commission (CQC) since April 2010, and our
registration is unconditional. Unannounced visits by the CQC in 2009/10 found good
standards in infection prevention and control and no recommendations for improvement were
issued. Although this is reassuring to both our patients, service users and staff, we
recognise that we need to be constantly improving and identifying new ways to providing
exemplary care.
Improving the experience of those who use our services is very important to us and in early
January 2011 we introduced a new way of gathering patient experience feedback to make
sure it is timely and meaningful.
During the coming year Community Health Services will continue its commitment to providing
the right care for our community, in the community. We will ensure quality remains at the
heart of what we do, keeping the trust of the community and never allowing our vision and
values to be compromised.
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This Quality Account is endorsed and approved by the Board of Community Health Services
which believes that the information contained within it is accurate. I hope you find it an
interesting and informative document.
Kevin Baber, Managing Director
NHS Cornwall & Isles of Scilly Community Health Services,
CHS QA v8 23rd June 2011
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1.
Priorities for Improvement 2011/12 .............................................................................. 6
2.
Review of Services provided ...................................................................................... 13
3.
2.1
Care Quality Commission ........................................................................................ 13
2.2
Research ................................................................................................................. 13
2.3
Audit participation .................................................................................................... 13
2.4
Goals agreed with commissioners........................................................................... 14
2.5
Data Quality............................................................................................................. 15
2.6
Information Governance .......................................................................................... 16
2.7
Clinical Coding Error Rate ....................................................................................... 16
Performance Review 2010/11...................................................................................... 17
3.1
Reducing avoidable healthcare associated infections ............................................. 17
3.2
Blood Transfusion.................................................................................................... 18
3.3
Medicines Management .......................................................................................... 20
3.4
Reducing the Incidence of Pressure Ulcers Grade 2 and above ............................. 22
3.5
Reducing harm from Patient Falls ........................................................................... 23
3.6
Maintaining Essential Standards : Care Quality Commission .................................. 24
3.7
NHSLA Assessment ................................................................................................ 24
3.8
Investing in Technology to improve patient safety and reliability of service............. 25
3.9
Venous Thromboembolism...................................................................................... 30
3.10 NHS Southwest Early Warning Trigger Tool............................................................ 31
3.11 Stroke and Transient Ischaemic Attack Services..................................................... 31
3.12 Older People and Long Term Conditions: Progress in 2010/11……………..............32
3.13 End of Life Care....................................................................................................... 34
3.14 Continence Promotion Service ................................................................................ 35
3.15 PEATS..................................................................................................................... 36
3.16 Nursing Metrics and Patient Experience Measurement 2010/11 ............................ 37
3.17 Privacy and Dignity Visits ........................................................................................ 41
3.18 Eliminating Mixed Sex Accommodation (ESMA) ..................................................... 41
3.19 Complaints and Compliments.................................................................................. 41
3.20 Staff Survey ............................................................................................................. 43
3.21 Key Performance Indicators .................................................................................... 45
4.
5.
Quality and Safety Improvement Programmes ......................................................... 47
4.1
NHS Southwest Quality and Safety Improvement Programme................................ 47
4.2
The QIPP Safe Care Workstream known as “Safety Express” ................................ 48
Response to this report from our stakeholders........................................................ 48
5.1
Overview and Scrutiny Committee .......................................................................... 48
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6.
5.2
Cornwall LINk .......................................................................................................... 48
5.3
NHS Cornwall and Isles of Scilly Commissioning .................................................... 50
Conclusion ................................................................................................................... 51
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1. Priorities for Improvement 2011/12
Community Health Services Senior Management team in collaboration with staff groups
have established six quality improvement priorities for 2011/12. We have organised them
into three domains, consistent with the core domains for quality patient care identified by
Lord Darzi in the ‘NHS Next stage Review: High Quality Care for All’. They reflect what
we believe are the priority areas for achieving the best possible outcomes for those we
serve:

Patient safety

Clinical effectiveness

Patient experience
These quality improvement priorities are detailed below and include the ongoing
development of some work that is already underway as well as new work that we
consider to be just as important. The priorities have been set following consultation with
our stakeholders including, LINk Cornwall, LINK4Scilly, Cornwall Council Overview and
Scrutiny Committee, NHS Cornwall and Isles of Scilly and the acute hospitals of Devon
and Cornwall.
It is probable that in future, the existing Community Health Services will be provided by
the Community Interest Company, known as Peninsula Community Health. The priorities
identified for 2011/12 will transfer to the new provider.
Domain
Patient Safety
Priority
1. Identification and Management of the
deteriorating Patient
Reason for Priority
 Learning from Complaints
 Coroners recommendation from
national and local inquests
 National Policy
 Feedback from Care Quality
Commission visits
 Serious untoward incident
learning
 Implementation of Nursing Metrics
– which is a tool to measure
nursing care
2. Prevention of Venous
Thromboembolism (VTE) – undertaking
risk assessment and appropriate
preventative treatment for all patients
admitted to a community hospital
CHS QA v8 23rd June 2011
 Learning from Complaints
 Coroners recommendation from
national and local inquests
 National Policy
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 Feedback from Care quality
Commission visits
 Serious untoward incident
learning
 Implementation of Nursing Metrics
– which is a tool to measure
nursing care
3. Prevention and Management of
Pressure Ulcers
 Learning from Complaints
 Coroners recommendation from
national and local inquests
 National Policy
 Feedback from Care Quality
Commission visits
 Serious untoward incident
learning
 Implementation of Nursing Metrics
– which is a tool to measure
nursing care
 Learning from Safeguarding
incidents
Clinical
Effectiveness
4. Ensure effective pathways of patient
care, particularly for patients with
cognitive impairment and dementia
 South West Dementia Strategy
 LINKs consultation
 Learning from complaints
 Implementation of Nursing
 Identified through the public
consultation for Health and Social
Care Hubs
 Feedback from Care Quality
Commission visits
5. Patient Information
 Dignity in Care visit feedback
 South West Dementia Strategy
 LINKs consultation
 Learning from complaints
 Implementation of Nursing
 Identified through the public
consultation for Health and Social
Care Hubs
 Feedback from Care Quality
Commission visits
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Patient
Experience
6. Improve the patient experience within
the Community Hospitals and in the
wider community services
 Dignity in Care visit feedback
 South West Dementia Strategy
 LINKs consultation
 Learning from complaints
 Implementation of Nursing
 Identified through the public
consultation for Health and Social
Care Hubs
 Patient Environment and Action
Team visits
 Feedback from Care Quality
Commission visits
Patient Safety
Priority 1
Identification and Management of the Deteriorating Patient
All patients to have observations undertaken by staff who are trained to identifiy
the early warning signs of deterioration
Early identification of a deterioration of a patients condition and ensuring that they receive
the correct treatment in a timely manner, not only reduces harm, but reduces the length of
time a patient will need to spend in hospital and improves the quality of their recovery.
We are implementing a new patient observation chart across all our community hospitals
which will include an early warning score calculated from the results of those
observations. The early warning score will identify the patients who are at risk of
deterioration and alert the staff to the required action to take; this may be to call a doctor,
alert the senior nurse, or to increase the frquency of observations further, depending on
the level of risk of deterioration identified.
A new observation policy will be published to guide staff, and all patients in all community
hospitals will have a full set of observations including the early warning score, recorded
twice per day as a minimum.
We will also be implementing a new communication tool for staff to use to communicate
deterioration in a patient to medical staff. This tool is called SBAR (Situation,
Background, Assessment and Recommendation). This tool provides a structured,
standardised method of communication and assists staff in ensuring messages are
delivered and received effectively.
Staff training in use of the tool has already begun, and through assessment and audit
throughout the year we will be making sure staff are using it properly. We will also be
checking to ensure that the action indicated by the tool has been implemented by the
staff.
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Priority 2
Prevention of Venous Thromboembolism (VTE) – undertaking risk assessment and
appropriate preventative treatment for all patients admitted to a community hospital.
We believe that 100% of our patients should receive assessment and
treatment and we are working towards that target.
VTE is recognised as a condition that causes a significant number of deaths per annum,
many of which could be avoided; it is estimated that 25,000 people die needlessly every
year. Fulfilling the NICE screening and treatment guidelines will save lives and prevent
avoidable stays in hospital.
During 2009/10 patient risk assessments and treatment policies were developed and
implemented across all community hospitals in Community Health Services, in line with
NICE Guidelines. This guidance states that 90% of all patients should have a VTE
assessment on admission.
We monitor compliance monthly and any drop below 90% requires immediate action.
This priority will form one of our CQUINs for 2011/12 as agreed with NHS Cornwall &
Isles of Scilly, which will also be monitoring monthly.
Priority 3
Prevention and Management of Pressure Ulcers
Zero tolerance of avoidable pressure ulcers
Understanding why pressure ulcers occur and working to prevent avoidable occurrences,
is an area of work that has been a priority for us in Community Health Services and will
continue to be so during 2011/12.
All pressure ulcers, either developed before, during or after admission to hospital are
reported by staff using a nationally recognised grading system, and all occurrences of
grade 3 and 4 pressure ulcers have a detailed investigation, called a root cause analysis,
undertaken from which any learning about how the ulcer may have been prevented is
shared across all our services.
A new form of risk assessment and ongoing monitoring of all patients’ skin, called the
Skin Bundle, has been implemented in our community hospitals. Many of our hospitals
have no reported pressure ulcers that have developed after a community hospital stay for
over a year and none of our hospitals have had a grade 3 or 4 pressure ulcer develop
after community hospital admission for over five months.
We recognise the existing good performance of our hospitals needs to be maintained and
we are working towards a zero tolerance of any preventable pressure ulcer across all our
services, not just hospitals.
As well as prioritising our work in relation to pressure ulcers, we will review our practice of
the management of leg ulcers. In particular, our community nursing teams manage
patients in their own home who have leg ulcers and correct and timely treatment is
paramount, to ensure maximum healing potential.
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Pressure ulcer monitoring is undertaken not only by our matrons and tissue viability
specialist teams, but also through our Professional Practice Forum, Integrated
Governance Committee and to our Board. Our Managing Director discusses prevention
of pressure ulcers with staff during the Patient Safety Executive Walkrounds, where staff
share their experiences and ideas for improving safety.
P
Clinical Effectiveness
Safety
Priority 4
Ensure effective pathways of patient care
As patients move from differing care providers and from inpatient to
community, we want to ensure appropriate follow-up, continuity of clinical
care, reducing length of stay and reducing delayed discharges
Embedded improving quality is ensuring we are providing not just the right services, but
also in a place where the patient feels most comfortable and promotes their
independence. As patients move from differing care providers and from inpatient to
community, we want to ensure appropriate follow-up, continuity of clinical care, reducing
length of stay and reducing delayed discharges. Community Health Services is a key
member of the implementation of the Health and Social Care Hubs, where services will be
provided seamlessly and in a manner that is timely for the needs of the patient. Planning
is presently underway for the first Hub in Cornwall, and both health and social care
partners are working to ensure that the services provide the best outcomes for patients.
It is proposed that the new hubs will be introduced at nine sites in the county, with expert
staff from a range of disciplines and providers offering a range of services from the heart
of the community. The hubs will be formed around current GP boundaries and referrals to
the hub will include referrals from GPs, voluntary groups, by family and carers and self
referral. Access to community hospitals will be managed through the hubs.
All patients with a long term condition will have a personalised care plan and be
supported if required by a key worker who will coordinate all aspects of their care. An
electronic vehicle for personalised care planning across community and acute services is
under development.
Frailty screening will be introduced to ensure that frail elderly are identified wherever they
enter the health and social care system and are offered a comprehensive multidisciplinary
assessment with a personalised care plan.
Community Matrons will be informed by the hospital using a new flagging system when
their patients are admitted to hospital. They will then be able to work with the OPAL team
to facilitate rapid discharge.
Tele-health will expand to have 1200 active users at any given point in time. We will build
the service working in the areas of Urinary Tract Infection, Falls prevention, Stroke, and
early discharge as well as the already established areas of Chronic Obstructive
Pulmonary Disease (COPD), Diabetes and Heart Failure
We will implement a Risk Stratification tool on a 12 month trial which will be used to
predict those at risk of going into hospital and offering interventions such as case
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management or Tele-health; the aim being to see whether we can manage these patients
more effectively in their own homes and avoid them being admitted to hospital.
CHS were involved in a Dementia Information Day LINk held in November 2010 and
Community Health Services will be participating in the implementation of the South West
Standards for Dementia Care. This is a key area of care provision within CHS and we will
work across all agencies to ensure patients with Dementia and their families receive the
right care. Staff training is paramount in this area and CHS is committed to ensuring that
all staff have the right skill at the right time to
Priority 5
Patient Information
To improve the quality of information provided to patients when they come
into a community hospital
We recognise that coming into hospital can be a very stressful time for patients, their
carers and family. From the information we have gathered this year from patients, visitors
and family we have identified that we need to improve the information we provide to
patients on their admission to hospital.
The Community Hospital matrons are presently updating existing information leaflets,
ensuring information such as ward telephone numbers, times for meals, advertising the
availability of food and drink 24 hours a day, who is the patient’s doctor and when do they
visit the ward, will be included in this leaflet.
We will also be reviewing the information available around the ward areas to ensure it
provides all the information that patients and the public require. We will be checking our
progress in this priority by undertaking Nursing Metrics. Discussed in Priority 6.
Patient Experience
Priority 6
Improve the patient experience within the Community Hospitals and in the wider
community services
We want to ensure that all patient feedback is utilised to improve future
experiences and we want to show the local community how important their
comments and concerns are to us.
In collaboration with Heart of England Foundation Trust, Community Health Services has
introduced ‘Nursing Metrics’, to allow effective measurement of the nursing care we
provide, including checking with patients the quality of the information that we provide.
Senior Nursing staff visit every ward area to check the environment and review the
nursing documentation. There is a list of metrics the senior nurses check and they input
their findings directly onto the web link. The results are immediately sent to Heart of
England Foundation Trust, for user friendly interpretation of the results to be available for
frontline staff. The subjects reviewed include:

Infection Control
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
Nutrition and Hydration

Pain management

Tissue Viability

Medicines Management

Clinical observations
Also, non clinical senior managers visit ward areas and ask patients to complete an online
questionnaire. The questions are on many occasions directly linked to the senior nurse
metrics. An example of this is:

The senior nursing review looks at the completion of nutrition and hydration
charts. It checks that this documentation is in place and the completeness of the
forms. Also, if a patient is high risk of poor hydration or nutrition, part of the
review is to check that the appropriate actions have been taken.

The patient questionnaire asks if patients require help with eating and drinking
and if they received this help. The questionnaire also asks if they use the call
bell for help, how quickly, if at all, it is answered.
The results of each area’s reviews are fed back to the ward staff and any required actions
identified. At the time of the next review, the previous results will be available to the
reviewer to enable checking that previous actions have been implemented. All ward
areas’ results and required actions will, in the future, be monitored by the Professional
Practice Forum which is a sub-group of the Integrated Governance Committee and
Community Health Services Board.
During the next year, we want to continue with this measurement of patient experience
and nursing processes and ensure that learning is shared and improvements can be
shown. We also plan to roll out the metrics within our community based services and
therapies.
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2. Review of Services provided
During 2010/11 Community Health Services provided and/or sub-contracted 36 NHS
services. The income generated by the NHS services reviewed in 2010/11 represents
100% of the total income generated from the provision of NHS services by Community
Health Services for 2010/11.
Community Health Services works from over 100 locations throughout Cornwall and the
Isles of Scilly including 14 community hospitals. Community Health Services reviews all
the data in regard to these services monthly
2.1
Care Quality Commission
Community Health Services is required to register with the Care Quality Commission and
its current registration status is without condition.
The Care Quality Commission has not taken any enforcement action against Community
Health Services during 2010/11.
Community Health Services is compliant with the regulations/outcomes as set out in the
Health and Social Care Act 2008.
Community Health Services has not participated in special reviews or investigations by
the Care Quality Commission as at 31st March 2011.
2.2
Research
In 2010/11 Community Health Services recruited two research nurses. These nurses
work with the Research team at Royal Cornwall Hospital and their roles are to improve
and enhance the research in relation to improving patient outcomes.
The number of patients receiving NHS services provided or sub-contracted by Community
Health Services in 2010/11 that were recruited during that period to participate in
research approved by a research ethics committee is presently being collated, due to the
recent appointment of the research nurses.
2.3
Audit participation
During 2010/11, the national clinical audits that Community Health Services were eligible
to participate in, are as follows:

National Falls and Bone Health Audit

National Parkinson’s Disease Audit

National Continence Audit
Audit is critical to the improvement of services and Community Health Services have staff
fully dedicated to supporting a fully comprehensive audit program to demonstrate
effectiveness and safety for patient care. During 2010/11 the Clinical Audit Programme
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(appendix 1) covered all the services we provide and the results were extremely helpful
and have formed the focus of local and organisational action plans. Participation in
national clinical audits allows us to benchmark the quality of the services that we provide
with other Trusts and also helps develop and highlight best practice and methods of
providing high quality patient care.
2.4
Goals agreed with commissioners
CQUIN – A proportion of Community Health Services income in 2010/11 was conditional
on achieving quality improvement and innovation goals agreed between Community
Health Services and our commissioners NHS Cornwall & Isles of Scilly. The 2010/11
eleven of the twelve CQUINs in the chart below have been achieved. The only CQUIN
not achieved was number ten relating to sickness absence.
CQUINs 2010/11
Goal no.
Description of goal
1
To reduce avoidable death, disability and chronic ill health from Venousthromboembolism (VTE) through risk assessment
2
To reduce avoidable death, disability and chronic ill health from Venousthromboembolism (VTE) through appropriate prophylaxis
3
To implement the nursing metric system across community hospitals to include
patient survey
4
To develop a dementia link worker per ward for each community hospital and each
locality
5
6
7
8
9
10
11
12
80% of staff who have patient contact in MIU, outpatients and all community staff will
undertake the basic training in brief intervention advice on smoking, alcohol, physical
activity and healthy weight that is provided by Health promotion Cornwall & IoS.
(Website link provided below). This training is provided free of charge and can be
delivered in the work place/local area. Sufficient capacity to offer the level of training
required has been commissioned from Health promotion
Record asking of NICE CG45- ‘Whooley questions’ at new birth visit.
Reduce the number of new catheterisations during inpatient stay in community
hospital to less than 10% of the total number of completed patient spells
Decrease the number of people who suffer harm from falls by 30% for patients in
community hospitals
Increase the number of patients who have a comprehensive multi-disciplinary plan
for their inpatient stay and discharge (including an estimated date of discharge)
developed within 3 days of admission to hospital to 80% of patients who had an
inpatient stay of 4 days or longer.
Reduce sickness absence in all nursing and allied health professional grade
workforce by 1%
40% decrease in community hospital acquired pressure ulcers (grade 2 or above)
Reduce the incidence of negative feedback via PALS and complaints regarding staff
attitude and/or communication by 2%
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The philosophy of the framework is to bring health gains for patients recognising quality
improvements and innovation and rewarding Community Health Services with a
percentage of income.
The CQUINs for 2011/12 have been agreed with NHS Cornwall & Isles of Scilly and they
are:
1
Venous-thromboembolism
To reduce avoidable death, disability
and chronic ill health from Venousthromboembolism (VTE)
2
Patient Experience
To implement the nursing metric system
across community services to include
patient survey showing an improvement
in patient experience
Increasing number of patients who have
expected deaths and are placed on the
Liverpool Care Pathway in community
Hospitals
3
4
2.5
End of Life Care
Long Term Conditions
5
Personalised Care Planning
6
Community MEWS
7
Stroke NICE Quality Standards
8
Prescribing
All patients over the age of 75 screened
for frailty on admission to community
hospitals
Improve personalisation of care
planning and self-management
100% of all in patients in community
hospitals should have CMEWS
completed according to CHS policy
Patients with stroke are offered a
minimum of 45 minutes of each active
therapy that is required for a minimum
of 5 days a week.
Full (Level 2) Medicines Reconciliation
completed for 95% of inpatients within
24 hours or admission to the
Community Hospital
Data Quality
Good data quality is an indicator that an organisation has robust systems and methods for
capturing accurate information about their patients. Community Health Services submitted
records during April 2010 – March 2011 to the Secondary User Service for inclusion in the
Hospital Episode Statistics which are included in the latest published data. These are
one of the measurements that the Care Quality Commission use within the monthly
Quality and Risk Profile, to monitor our ongoing compliance.
As per the SUS Data Quality Dashboard Apr10-Feb11, the percentage
NHS number compliance:
Inpatient =
99.7%
Outpatient =
99.8%
Minor Injury Units = 96.4%
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GP Practice compliance:
Inpatient = 100%
Outpatient = 100%
Minor Injury Unit = = 97.7%
2.6
Information Governance
Community Health Services Information Governance Assessment Report for 2010/11 has
recently been submitted and our results are Level 2.
2.7
Clinical Coding Error Rate
Community Health Services was not subject to the Payment by Results clinical coding
audit during 2010/11 by the Audit Commission.
Community Health Services has undertaken some work with the cooperation of Dr Foster
to improve the quality of the clinical coding in particular, community hospitals coding in
End of Life Care.
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3. Performance Review 2010/11
PATIENT SAFETY
3.1
Reducing avoidable healthcare associated infections
Priority to improve Patient Safety through reduction in Clostridium Difficile
infections
This was chosen as a priority area for all the local health community in Cornwall. The
decision was taken to introduce RCA for cases of Clostridium Difficile (C.Diff) to ensure all
mechanisms of reduction were utilised, to consolidate reductions and reduce variation in
incidence between different health settings.
Root cause analyses have been undertaken on all inpatient cases and a proportion of
cases diagnosed at home. Learning has been disseminated via the Community Health
Services Infection Prevention Committee & Cornwall County Prescribing group.
2010 –11 was the last year of the 3 year national target to reduce cases of C.Diff by 30%.
Community Health Services have achieved this target already.
In order to maintain the momentum of improvement a 5% reduction target was set locally
for Cornwall Community Health Services (CHS) based on the 2009-10 out turn.
Community Health Services did not meet the local target by 1 case.
A whole health community action plan for the reduction of C diff has been developed
based on the findings of root causes analysis investigation. This has been refreshed and
tightened for 2011-12 as the C diff ‘Objective’ reduction targets come into force.
pre and post 72 hour CDI Community Hospitals
16
14
12
10
Pre 72 hours Cumm Total
Post 72 Hours Cumm.Total
Post 72 Hours Cumm. Target
8
6
4
2
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3.2 Blood Transfusion
To be compliant with the National Patient Safety Agency Safer Practice Notice 14, all staff
involved in the transfusion process must be able to show documented evidence that they
are up to date with transfusion training and have been assessed in the appropriate
competencies. The deadline for 100% Compliance was November 2010.
93% of appropriate CHS nursing staff are compliant with Safer Practice Notice 14.
Credit should be given to the hard work of the ward based assessors as CHS staff have
achieved a very high percentage of compliance.
Those staff who have not been assessed will not take part in the transfusion process
unsupervised. If this did occur, it could lead to a non compliance for each location in
relation to registration with the CQC
In 2006 the National Patient Safety Agency (NPSA) issued a Safer Practice Notice
(SPN14) stating that:
“Formal assessment of the relevant competencies is required for nurses,
midwives, medical staff, phlebotomists, healthcare assistants, porters …….
And other staff involved in the blood transfusion process.”
The initial notice required 100% compliance by November 2009 but as no Trust was near
meeting this target the deadline was extended to November 2010. By end November
2010 CHS was required to be 100% compliant in the training and competency
assessment of all staff involved in the transfusion process.
Those staff who have not been assessed will not take part in the transfusion process
unsupervised until their assessment has been completed.
The training and competency requirements have been set down in CHS Transfusion
Training and Competency Policy.
There are Transfusion Assessors in place in each of the community hospital sites. The
Transfusion Practitioner (TP) is assessing the community teams and the medical staff.
The Medicines and Healthcare Regulatory Agency is now including training and
competency figures in it’s inspection of blood centres.
The GP’s that cover the community hospitals have been informed by both CHS and the
PCT of the necessity to complete the training and competency.
All areas should have achieved 100% compliance. Of the 22 Community Hospital areas,
15 areas have achieved the 100% target for completion of the training and 16 areas have
achieved 100% compliance for assessment. Another 2 have achieved over 90 %. In both
of these cases this is just one member of staff non compliant. Three areas are below 80%
compliance.
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New staff who have joined since October 2010 have been excluded from the competency
numbers as they are not expected to have achieved compliance unless they are working
in area with a large number of transfusions. They are expected to be working through an
induction with the ward based assessors. Preceptor nurses are expected to have
completed the training but may not have yet completed the competency assessment.
The table below illustrates Training Compliance from March to 6th December 2010. The
figures have been adjusted to take account of maternity or long term sick leave and new
staff.
hospital team training
120
100
Feb % trained
percentage
80
March % trained
April % trained
July % trained
60
august % trained
Sept % trained
Oct % trained
40
Nov % trained
20
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The next table illustrates the Hospital teams Assessment compliance which has been
adjusted to take account of maternity or sick leave.
Hospital team assessed
120
100
Feb
80
percentage
Mar
April % assessed
July % assessed
60
Aug % assessed
Sept % assessed
Oct % assessed
40
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20
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CHS QA v8 23rd June 2011
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3.3 Medicines Management
For Community Health Services to fulfill the contract with NHS Cornwall and Isles of Scilly
a series of clinical audits need to be undertaken. 6 of these are medicine management
related.
The Medicines management audit programme for all community hospitals has now been
completed, with all 14 Community hospitals visited.
Four medicine management audits were completed at each site.

Prescription Chart audit – to include missed and delayed dose audit.

Prescribing in accordance with the Joint Formulary

Review of antipsychotic prescribing

Antibiotic audit
Ten prescription charts on each ward were reviewed for the Prescription chart, formulary
compliance and antipsychotic prescribing audits. All prescription charts were checked for
the antibiotic audit. On units which have fewer than 10 beds, all prescription charts were
reviewed.
3.3.1 Clinical Quality Prescribing audit – prescription chart audit
The purpose of this audit was to monitor the quality of the documentation on the
prescription chart against the ‘Policy for the Safe Ordering, Prescribing and Administration
of Drugs in Community Hospitals and Minor Injury Units’, 2010.
The audit reviewed both the prescribing and administration sections on the prescription
chart. Areas audited included
0B

Inclusion of NHS number/ Hospital number

Allergy status completed

Quality of prescribing information

Legibility

Documentation of administration of medicines

Documentation of reasons for missed doses

Use of approved forms to support correct administration of non-oral preparations
e.g patch forms
The introduction of the Standard Operating Procedure for missed doses and the dose
code ledger happened during the audit period. It is therefore unlikely that these support
materials were being used on all units at the time.
This audit provides evidence of the importance of continuing staff education on the
correct documentation of medicines. Updates on medicines management have been
provided this year to nursing staff.
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3.3.2 Formulary Compliance Audit.
This audit confirmed the impression that prescribing within our community hospitals and
the wider health community in Cornwall does reflect the recommendations in the joint
formulary.
5 different groups of medicines were reviewed in the audit- ACE Inhibitors/Angiotensin II
receptor antagonists, bisphosphonates, non-steroidal anti- inflammatory agents
(NSAIDs), proton pump inhibitors (PPIs) and statins. Compliance arranged from 90 to
100% for the above groups.
3.3.3 Antipsychotic Prescribing audit
The purpose of this audit was to review all antipsychotic prescribing in community
hospitals to ensure that prescribing of these agents was appropriate.
Only 6 patients out of 188 audited were identified as being prescribed an antipsychotic
agent on the day the audit was completed. 4 of these patients were prescribed an
antipsychotic agent as an appropriate part of their end of life care.
1B
3.3.4 Antibiotic Audit
This antibiotic audit reviewed the same parameters as the previous one carried out in
March this year. Formulary compliance, indication for use and course lengths
documented on the prescription chart were audited.
As in March the percentage of inpatients prescribed an antibiotic on the day of the audit
was 12%, a fall from the previous year.
The action plan following completion of this audit recommends:

Share results of audit with the individual community hospitals, prescribers,
antimicrobial lead pharmacist RCHT, Tissue Viability Lead and Infection Control
Lead.

Ensure laminated antibiotic poster and stock lists are available on wards to
prescribers. Monitor antibiotic stock-lists and adjust to reflect any updates to
guidelines. Provide EROS codes for formulary dressings

Feedback to prescribers where documentation of indication and course
length/review date are omitted.

Train nursing staff to access microbiology results and request antibiotic review

Provide ‘refresher’ training for nursing staff to update skills to administer IV
antibiotics
Provide training on antibiotic prescribing guidelines for all prescribers working in
Community Health Services
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3.4 Reducing the Incidence of Pressure Ulcers Grade 2 and above
The Tissue Viability team is managed by a Lead Practitioner who provides strategic lead
and clinical leadership to two Tissue Viability Nurse Specialists (TVNS) who provide
assessment, education and support across CHS. The TVNS’ work closely with Tissue
Viability Link nurses across the NHS and independent sector. The Tissue Viability
Services works closely with all members of the multidisciplinary team, secondary care,
social services, the independent sector and voluntary groups in order to ensure seamless
care for the patient and carers.
Aims of the Tissue Viability Service:
The Tissue Viability Service aims to provide a skilled peripatetic countywide service to
support a reduction in prescribing costs, reduction in pressure ulcers in line with
Department of health NICE guidance, an integrated seamless and efficient service across
all inter-professional teams. Providing education and support to ensure CHS is able to
deliver a high standard of care in all aspects of Tissue Viability management.
Objectives of the Tissue Viability Service:
 To provide a triage service in order to prevent hospital admissions and the reduction
of secondary care out patient referrals.

To work collaboratively with secondary care consultants as required, reducing waiting
times and providing a follow up service to reduce the need for further secondary care
involvement.

To develop and implement local and national guidelines and protocols in relation to
tissue viability services required by the population of CHS.
Outcomes Achieved during 2011:





Provision of care closer to home in the form of joint Tissue viability/Vascular Surgery
clinics in order to reduce the 18 week wait for varicose vein surgery.
The reduction of waiting times between primary and secondary care referral through
joint working. Thus reducing the wait for diagnostic tests speeding up the time
between referral and treatment for the patient, increasing patient satisfaction and
reducing costs as the contact period for the patient is reduced.
The reduction in the incidence of pressure ulcers in Community Hospitals by 50%
(CQUIN target of 40%) with the introduction of SKIN Bundles in Community Hospitals,
increasing awareness of the issues by providing education, support and equipment to
care givers.
Development and introduction of Pressure Ulcer Root Cause Analysis (PURCA) on all
grade 3 and 4 pressure ulcers to understand the reasons behind their development
and learning outcomes in order to improve practice and clinical outcomes.
Reduction of secondary care admissions relating to Tissue Viability needs and the
facilitation of earlier discharge (reducing number of bed days) of patients with the use
of advanced technologies, providing education, support and equipment to
practitioners. Tissue Viability Referrals have doubled compared with 2010.
CHS QA v8 23rd June 2011
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




The completion of a wound care audit, which has identified a total of 2357 wounds.
The results of this audit will identify trends leading to service improvement,
educational needs and efficiencies.
Appointment and development of two Assistant Practitioners in Tissue Viability in
order to raise standards in residential and nursing homes and reduce the provision of
equipment and therefore costs. This has realised a saving of £6000/mth since
November 2010. This is set to increase.
Continued review of Joint Wound Care formulary and analysis of prescribing practices
in the community and community hospitals in order to realise continued changes.
Savings of £20,000 have been saved during January 2011 to March 2011 in the direct
purchasing of dressings, with additional savings expected of £50,000 over the coming
financial year.
In addition the TV lead nurse has been a member of the Peninsula wide alliance
purchasing and supplies group. This group aims to reduce the overall costs of
provision of dressings. The county has to date saved £45,000 with a further potential
saving of £277,000.
A leg ulcer audit undertaken in 2007 highlighted that there were 1500 patients with leg
ulceration in Cornwall community and 500 patients suffering from pressure ulceration.
A wound care audit carried out in February 2011 shows significant changes to this
profile, with 800 leg ulcers patients demonstrating a 50% reduction during the Leg
Ulcer Training and Management project more in line with the National average of
0.1%, with an additional 440 patients suffering from pressure ulceration.
3.5 Reducing harm from Patient Falls
Community Health Services have a team dedicated to the reduction in falls but there are also
many other services which contribute to the shared aim of reducing falls and reducing harm
caused by falls.
In 2010, a Falls Link Group was set up to support the work required to reduce harm caused
by falls. The group consisted of nurse representatives from the wards in the community
hospitals and therapists. It is important to differentiate between patients who were admitted
to a community hospital for any number of reasons, eg urine infection, stroke, COPD, post
fracture etc and those who were admitted as a result of a fall at home. The issues of
assessment and management of risk of falls are similar but this group was specifically set up
to aid the reduction and management of the risk of falls during admission.
The group has reviewed the current policy and incorporated the Safe Use of Bedrails Policy.
There has been a significant amount of new research and guidance to review and a number
of new issues have been included in the policy.
Areas the group has initiated and considered in reduction harm by falls include:
Intentional rounding
This is a method of ensuring regular, documented observation and assessment of inpatients
identified at risk of falls. It is similar but not the same as something called ‘specialing’, where
a patient is in need of one to one care. The Group agreed that the policy would include
guidance on intentional rounding and a specific care plan for documentation on intentional
CHS QA v8 23rd June 2011
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rounding but the that decision to use intentional rounding as part of a person centred care
plan would be a local ward based decision taking into account the appropriate risk
assessment.
Assistive Technology
The use of specialist equipment and assistive technology can be very useful in falls and
injury prevention in a ward environment. The Group reviewed varying types of bed and chair
occupancy sensors, which are in use throughout the community hospitals.
Immediate assessment after a fall on the ward
The policy has considered NICE guidance on head injury to support best practice around the
immediate assessment after a fall to ensure that no further harm is caused by inappropriate
interventions.
Hip protectors
The evidence to support the use of hip protectors has been inconclusive but is more positive
in terms of the use of hip protectors in inpatient settings. This is due mainly to the issues
around compliance with the product, as they can be uncomfortable to wear. In terms of
reducing harm to patients, the use of hip protectors for patients at risk of fracture as well as
at risk of falls assessed.
Safe footwear and footcare
There is a significant issue around safe footwear for patients identified at risk of falls. Often
patients are admitted without safe footwear to wear around the ward. Staff regularly discuss
with carers the issues around this and advise on purchase of new footwear. We have
identified that we need to undertake more training with staff regarding education and
identification of correct footwear and we are changing the admission documentation to
ensure this is included.
3.6
Maintaining Essential Standards for Registration with the Care Quality Commission
Community Health Services is required to register with the Care Quality Commission
and its current registration status is without condition. The Care Quality Commission
has not taken any enforcement action against Community Health Services during
2010/11. Community Health Services is compliant the regulations/outcomes as set out
in the Health and Social Care Act 2008. Community Health Services has not
participated in special reviews or investigations by the Care Quality Commission as at
31st March 2011.
3.7 NHSLA Assessment
There was no formal assessment for general NHSLA standards during 2010/11.
CHS QA v8 23rd June 2011
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3.8 Investing in Technology to improve patient safety and reliability of service
T34 Syringe Driver
The complexities associated with the prescription, preparation and administration of
injectable medications means that there are potentially greater risks for patients other
than routes of administration. Weak operating systems increases the potential risk of
harm, safe systems of work are required to minimise the risk.
There were several clinical governance issues with the use of Graseby MS16.
Following a robust review in the safety of the use of Graseby syringe drivers a clinical
decision was made that to ensure safe practice an alternative model would be used and
since November 2009, CHS has ceased in using Graseby drivers and now has only one
driver in use for subcutaneous infusions – McKinley T34. Since the implementation of the
McKinley T34 there have been no reported incidents of patient suffering any discrepancy
in administration of medications through a T34 syringe driver.
The T34 is a small, lightweight, robust, battery powered, ambulatory syringe pump
designed to deliver the contents of most commonly 2 to 50ml syringes over a specified
duration at a given rate in milliliters per hour (ml/hr). T34 offers 3 point syringe
detection enabling the pump to identify all commonly used syringe brands and size.
This feature ensures that the pump can make volume and rate calculations thereby
minimising the risk of user programming error; the mode of the T34 has been set to
calculate and deliver the contents of a syringe over a 24 hour duration. T34 allows
users to lock the operation of the keypad if concerned about untrained personnel
tampering with the pump, it is also to be kept in a locked box within the patients home
or hospital setting, the key is held by the healthcare professional.
McKinley have provided Royal College of Nursing accredited ‘train the trainer’ workshops
to ensure that teams in each locality are resourced with a key health professional familiar
with the new device to be able to deliver training and support locally, therefore, increasing
the accessibility and compliance of the mandatory 12 monthly training. 180 CHS
employees received the ‘train the trainer’ training in September 2009. In 2010 McKinley
updated the training programme for the McKinley T34, making it much more robust,
creating a system of ‘super users’. CHS staff identified as a key health professionals in
the original training have received this ’super user’ training in 2010. A programme has
now been set up by the Macmillan team in partnership with McKinley to provide yearly
updates for the T34 ‘super users’.
Whole System Demonstrator/Telehealth
Cornwall and the Isles of Scilly health and social care community is one of three
national Whole System Demonstrator (WSD) sites participating in the largest clinical
trial in the world of Telehealth and Telecare. The trial focuses on taking those most at
risk of going into hospital or needing social care and installs equipment into their
homes to help them. Through taking their own medical readings each day or having
passive care monitors installed in their homes, the programme aims to reduce hospital
admissions and to provide targeted care interventions.
Telehealth allows patients to record vital signs such as blood pressure using simpleto-use biometric equipment installed in their homes. Telehealth Nurses, community
CHS QA v8 23rd June 2011
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matrons and specialist nurses, who can intervene early if they are needed, monitor the
data remotely. The trial is focused on those with Diabetes, COPD and Heart Failure.
Telecare packages are also being provided to help people with dementia or at risk of
falling to stay at home more safely, using devices that track movements and prevent
incidents such as the bath overflowing. Patients are more able to understand and take
control of their care and remain where they want - in their own homes. For telecare
users there is reassurance to the clients and carers.
The programme is scheduled to be completed in Spring 2011 which will include the
publication of the national evaluation by the Department of Health.
Cornwall have been leading the way as part of the WSD national trial and achieved all
targets set by the Department of Health for patient participation and installation. We
have over 2000 patients as part of the trial, split between Telehealth & Telecare and
have been monitoring them since February 2009. Over 1000 had equipment installed
in 2009. The remaining participants acted as a control group for the first 12 months of
the trial. Control participant installations commenced in February 2010 and are due for
completion before the end of the year.
As of the 1st March 2011 the number of installations for WSD were as follows:
Telehealth – 1020
Telecare – 725
There are 45 GP practices that are participating in WSD and Telehealth in Cornwall
and Isles of Scilly.
In total we are actively monitoring over 700 patients in Cornwall both from both the
WSD and mainstream operations.
The national evaluation of the WSD programme is being carried out by a number of
Universities and Research bodies, co-ordinated by the University of Central London.
Data has been collected during the past two years from each WSD site for the various
evaluation themes which include looking at the cost effectiveness of the assistive
technology and what it delivers to participants
The Department of Health schedule for the production of the evaluation reports
remains Spring 2011.
Whilst we can look at evaluating the service locally we are unable to publish any
results as this would be seen as prematurely reporting the WSD evaluation results.
Despite this, our own local analysis and research is overwhelmingly positive and an
early indication from the WSD results suggest it looks very promising.
The Telehealth service is run centrally through a team of 15 people (13 WTE). This
comprises a Telehealth Lead / Manager, clinical team of Telehealth Nurses, Field Staff
and administrators. Eighty percent of the clinical monitoring is carried out through the
central service and twenty percent is carried out through the community matron and
specialist nurse teams.
In April 2010, Cornwall and Isles of Scilly PCT made the decision to mainstream its
Telehealth service. Whilst this meant being able to continue with the WSD trial, it also
CHS QA v8 23rd June 2011
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meant being able to widen the scope of potential participants. Telehealth forms part of
the QIPP Long Term Conditions workstream.
As such the service is being developed into other areas, some of which have are
pioneering, to assess and develop how the equipment can be used in the future.
These areas are:
i. Falls Prevention
One area that has already been trialled on a small scale is using Telehealth to prevent
people from falling through the diagnosis of postural hypertension. This historically has
been very difficult to diagnose but through working with the Falls Clinic at Royal
Cornwall Hospital, patients have been referred to the Telehealth Service where
postural hypertension has been suspected as a reason for them falling on a regular
basis.
The system has been used with 14 patients, monitoring their Blood Pressure, assisting
diagnosis and then monitoring medication administered following diagnosis. Patients
are monitored daily over a defined period. Reports are provided to consultants
showing graphs of the patient’s readings over time so trends can be identified.
Results have to date been very positive in terms of both assisting diagnosis and
tracking the reaction to medication. Whilst it is too early to say whether this
intervention has positively impacted upon admissions, there has certainly been a
positive response from patients as they know that someone is monitoring them on a
daily basis.
This part of the service is being developed further through additional funding received
from Cornwall Council, where a £70k grant has been received to develop Telehealth
specifically in the area of falls. Further communication and meetings have taken place
in Feb 2011 with the geriatricians at RCHT and we continue to receive referrals.
ii. Stroke
In May 2010, the Telehealth service started working with our Stroke team to identify
whether Telehealth could be used for patients who have had a TIA. The aim being to
monitor them for the onset of signals which might indicate a potential Stroke. This was
further extended to look at high risk Stroke patients. Patients measure their Blood
Pressure on a daily basis and are monitored by Stroke Care Co-ordinators who track
their readings.
To date 32 patients have / are being monitored as part of the Stroke trial. Evaluation
will be taking place during March looking at diagnosis, medication changes, lifestyle
change and better management of risk factors.
We now receive referrals from the Stroke Consultants at RCHT.
iii. Urinary Tract Infections (UTI’s)
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The number of patients developing UTI’s and being admitted as an unplanned
admission to hospital in Cornwall is significant. As such consideration was given as to
whether Telehealth could be used for those at high risk of developing at UTI and had
historically been admitted as a result.
A trial is commencing in March 2011 with 5 patients to see whether using Telehealth
to predict the onset of a UTI is feasible. To the best of our knowledge, this is the first
trial of its kind globally looking at Telehealth technology.
The process will mean that a patient will be asked to answer a series of questions on
a daily basis over a 3mth period. The answers to the questions will dictate whether the
patient is asked to test their urine. To do this a urine analyser will be installed in the
patient’s home to allow them to test and to then report back the response to a
clinician. If the test comes back positive for the onset of a UTI then the patient will be
asked to get an emergency prescription from their GP to address the infection.
Evaluation will take place over the 3mth period and benefits determined by the
number of UTI’s diagnosed and prevented.
This trial is funded through a successful bid the NHS Innovations fund and will allow
us to expand to up to 50 patients who are at high risk of UTI.
iv. Referrals through GP / Community Matron Service
In addition to referrals for WSD for COPD, Heart Failure and Diabetes, referrals are
also received in these condition areas direct from Community Matrons and GP’s. To
date we have had 65 referrals to the service, all of whom are being monitored by the
community matron service or specialist nurse teams.
v. Service Commissioned by Torbay Care Trust
In June 2010, Torbay Care Trust approached NHS Cornwall and Isles of Scilly to
understand whether we could work together by providing Telehealth services to
Torbay. As a result, the service was commissioned by Torbay using telehealth
resources from Cornwall including the leasing and installation of equipment,
administration and clinical coverage in times of absence.
As such 75 patients with COPD have been installed in Torbay and are being
monitored by Torbay Care Trust through their community matron and specialist nurse
teams. This resulted in income being received into the Telehealth service of £75k, the
majority of which has been re-invested back into the service.
The commissioning of services across NHS trusts, in this case, enabled a trial to take
place which would not have been financially possible without collaborative working.
The Torbay contract has not been renewed for 2011/12 due to lack of funding and
their service evaluation not yet being completed.
Although we do not yet have any results back from the evaluation of the WSD
programme, we have been focused on understanding our patient’s experiences. As
a result we have opened up communication channels with patients, including setting
up user groups to provide an ongoing forum for support and information. User
CHS QA v8 23rd June 2011
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groups run once a quarter in the west, east and central Cornwall and are attending
regularly by up to 15 patients at each group.
The majority of feedback has been on the patient’s experience of using the
equipment, the monitoring process involving the clinicians and what it has meant to
the patient themselves.
Patient feedback can be categorised under the following:
 Being able to manage their condition better as they can see their own readings
and relate it to how they are feeling.
 Promoting independence and peace of mind as they their health is being
monitored
 Feeling empowered to help themselves with their condition e.g. by losing weight
due to them having weight scales and their weight being monitored
 A belief that it has contributed to earlier diagnosis and treatment of condition e.g.
a pace maker being fitted due to the fact that daily readings from the telehealth
equipment pointed to this being a requirement
 A ‘belief’ that for some it is stopping them from going into hospital
An example of this is detailed below from an interview completed with a participant
with COPD:
“Mr. B has COPD which had placed severe restrictions on his life. “At one point I
was unable to venture out of the house for 112 days – I counted them!” he recalled.
His condition had made him feel both anxious and lacking in confidence.
In 2008 he was in and out of hospital many times and was visiting his GP on a
regular basis. This culminated in a lengthy stay in hospital at the beginning of 2009.
Then in February 2009 he agreed to take part in the Whole System Demonstrator
programme. He had equipment installed in his home to monitor his oxygen levels
and his blood pressure which were then reviewed each day by his Community
Matron. In addition, his Community Matron was able to provide a ‘flutter’ device and
oxygen. In a matter of weeks he started to notice a difference.
Mr B explains:” Being on this programme has allowed me to control my condition,
rather than it controlling me. By looking at my oxygen levels I can see when I am
likely to have a potentially bad or good day. I know when I should be using my
oxygen or when I need to start taking medication. It has given me confidence
knowing that I can go outside – I am now able to walk up and down the hill to my
house, something previously that I had been unable to do (it is really steep as well!).
I am able to visit family and this has a really positive impact on my life. It is the best I
have felt in the last two years.”
Mr B has received tremendous support from his Community Matron, and his
practice. Since being on the Programme he has not had to visit his GP or go into
hospital. He has gone from seeing his Matron every week to only seeing her once a
month. Marie explains: “Eddie is a totally different person to when we first met. The
combination of the Programme and the approach we have taken with him has made
a real difference”
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Some of the clinical feedback also shows benefits to the patient experience:
 Reduction in Community Matron visits to those being monitored by WSD
 Stopping serious complications from a persons condition i.e. stopping a potential
diabetic coma due to trend analysis of daily blood glucose readings
 Providing assurance to someone that they should visit their GP as their readings
indicate the need for treatment
 Early diagnosis of potential problems resulting in early treatment e.g. blood
pressure readings leading to treatment through medication which might otherwise
have not happened until much later
 Hospitals and consultants using the readings to support diagnosis
 Potential alternative uses for the readings captured e.g. falls prevention
Telehealth will continue to develop as part of QIPP and Community Health Services.
This will include exploring new ways of using the technology with fully evaluated
outcomes. Included as part of this will be the use of Risk Stratification, which
predicts the risk of someone going into hospital. It is anticipated that risk stratification
will be an enabler to Telehealth in the future, identifying potential patients. Further
uses of the technology could extend to:
 Facilitation of early discharge from via the OPAL team / early discharge teams at
RCHT
 Step-down service from acute care at home
 Step-down service from the community matrons caseload
 Early discharge from Community Hospitals
 Looking at how the change to NICE guidelines around home blood pressure
monitoring will enable us to carry out short term monitoring with Primary Care for
those with suspected Hypertension
The national trial results in Spring 2011 will help shape and determine the future
growth and direction of the service.
3.9 Venous Thromboembolism
Two of the Commissioning for Quality and Innovation (CQUINs) targets set in
2010/11 were linked with the management of Venous Thromboembolism (VTE).
 By the end of March 2011 90% of all patients admitted to a community hospital
bed must receive a documented VTE risk assessment on admission and
repeated within 24 hours.
 90% of patients are prescribed appropriate VTE prophylaxis.
Monthly VTE audits have been completed at each community Hospital showing a
steady improvement in results, quarter 3 target of 75% for each CQUINs has been
easily achieved. Quarter 4 target of 90% has been achieved.
CHS QA v8 23rd June 2011
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Sept
10
Oct
10
Nov
10
Dec
10
Jan
11
Feb
11
Mar
11
% of patients admitted
with completed VTE 73
risk assessment
86
88
94
92
95
91
%
of
patients
prescribed appropriate 70
VTE prophylaxis
89
91
89
92
92.5
96
Following consultation with medical and nursing staff involved in the VTE process the
paperwork and audit process have been reviewed.

The VTE Risk Assessment tool has been revised to include questions about the
mobility of the patient and has an improved layout to prompt practitioners to complete
the second assessment.

The VTE flowchart has been updated to reflect these changes.

The policy now includes a section on the ongoing biochemical monitoring required as
well as clear guidance for the audit process

The audit tool has been simplified.
The new assessment form and audit tool were trialled at Bodmin Community Hospital
during February before being rolled out to all sites.
4 half-day road-shows for hospital and community staff were delivered in October and
November 2010. Meetings have also taken place with GP Practices providing medical
cover at 3 of the community hospitals to discuss the VTE assessment process.
3.10 NHS Southwest Early Warning Trigger Tool
This tool identifies the potential for deteriorating standards in the quality of care delivered
by a team in a ward area. It provides a set of organisational indicators which when taken
together, give an indication of how well an individual team is functioning. It has been
developed in the NHS South West area largely for Acute Units and is now being piloted in
Community Hospitals.
CLINICAL EFFECTIVENESS
3.11 Stroke and Transient Ischaemic Attack Services
Within the comprehensive Strategic Health Authority (SHA) report in regard to the Clinical
Review of Stroke Services Visit in June 2010, a number of actions related to the acute
services and so are not shown in this report. This report was overall very positive
regarding the services being delivered.
However some areas of improvement were identified and each provider agency reports
against the action plan on a monthly basis to the Stroke Programme Board. CHS has
progressed on a number of items;
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1. Staffing levels at CRCH have been reviewed. For Speech and Language on the
Lanyon Stroke unit levels are at baseline with qualified staffing supplemented by
dedicated Support worker
2. A trial of a system to monitor and showing evidence of the ‘45 minutes therapy’ target
is underway
3. Self referral system to therapy has been introduced
4. Competency training for Nursing and Healthcare assistant staff is underway.
5. Community therapy is developing a version of the competency framework for its
Stroke Specialists
A number of issues are under discussion with NHS Cornwall & Isles of Scilly including
exploration of a model to deliver annual follow up for all stroke patients. As indicated in
Section 3.21 Key Performance Indicators the TIA Service continues to perform well.
The Consultant Nurse Stroke is working at regional levels investigating models of
practice.
Early Supported Discharge (ESD) is a care and rehabilitation model recommended in the
SHA review and promulgated in the National Stroke strategy. Cornwall’s agencies
including Department of Adult Social Care are discussing how provision of rehabilitation
and care can be enhanced given the dispersed rural setting. This discussion will bring
together the objectives in the audit about review of the pathway and exploration of ESD.
In October 2010 Community Health Services were awarded the contract for 9 Stroke beds
at Bodmin Hospital following a feasibility study. Work is underway with the Private
Finance Initiative contractors on the environmental changes required. Staffing
enhancements for therapy have been agreed and recruitment planned.
3.12 Older people and long term conditions: progress in 2010/11
There has been a complete review of case management services to establish a baseline
picture and develop plans to move the service forward into the future
An action plan is being drawn up to as part of the Long term conditions Quality Innovation
Prevention Productivity (QIPP) Group
Tele-health has now been deployed to over 1000 patients with over 700 being actively
monitored
In June last year NHS Cornwall & Isles of Scilly launched the ‘Self Care in Cornwall’
website to provide a one stop shop of information to those with Long Term Conditions.
Posters and leaflets have been distributed to every GP practice and to date there have
been over 20,000 hits.
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Frail older people’ are defined as patients who are usually over 75 years of age - and often
over 85 years - with multiple diseases (which may include dementia). They tend to present at
hospital with symptoms such as falls, immobility and confusion. The main characteristic of
‘frailty’ is reduced functional reserve, and hence frail older people are more susceptible to
developing complications in hospital. England has an ageing population, and it is recognized
that older people are high users of healthcare. By 2025, the number of people of 80 years of
age will have increased by 50%, and the number aged over 90 years will have doubled since
1995. In 2005/06 in England, 55,568 patients aged over 75 years were admitted as an
emergency, diagnosed with a UTI, this cost the NHS at least £146 million.
Community Health Services is presently ensuring that frailty screening is a priority during a
patient’s admission as well as ongoing care, the chart below is a draft pathway for frailty
assessment and this will be further developed in the coming months.
Frailty Pathway
Older person comes to the
attention of primary care
services
Frailty screening is carried out
Person identified
as frail
Person referred for
Comprehensive
multi-disciplinary
geriatric assessment
Intervention and
personalised care
plan put in place
in collaboration with
the person
Outcomes are
Regularly monitored
and care plan
amended
CHS QA v8 23rd June 2011
Person not
identified as frail
Leaves pathway
Signposted to other
services
Acute care
•Rapid specialist assessment and diagnostics
•Timely turnaround to intermediate care
•Inpatient ‘pull’ to specialist frailty
service
Intermediate care:
•Step up/down facilities
•Multi-disciplinary and medical input
•Rapid Assessment Teams
•Acute Care at Home
Primary Care:
•Community health and social care
services
•Community matrons
•Case finding and case management of
frail elderly people
•Falls prevention
Page 33 of 51
3.13 End of Life Care
The End of Life Strategy and ambitions are based on a “whole systems” and a “care
pathway” approach. The vision of the strategy:
To care and support individuals to live as well as possible until they die – adding life to
years
That everyone has access to the best possible care in the place of their choice.
Everyone is cared for with respect and dignity
Family and friends are supported during their illness and bereavement as required
In order to achieve this, our aims are to:

Reduce the number of people who die in hospital

Reduce inappropriate admissions from nursing homes to acute trusts in the last
week of life

Reduce inappropriate admissions from home into acute hospitals

Increase the number of people dying in their preferred place of care

Implement the preferred priorities of care tool, demonstrating best practice
alongside the Gold Standards framework and the Liverpool Care Pathway

Deliver an efficient, timely and cost effective service.
In 2010 the foundations for achieving the aims have been pulled together in a
coordinated, whole systems approach across providers to ensure that positive change
and an excellent quality of care is sustainable and measurable.
Where possible CHS has worked closely with all local providers, and the national end
of life care team, beginning to implement and improve upon known, proven
programmes of end of life care.
CHS has a team of specialist palliative care nurses (Macmillan) who are dedicated to
providing specialist advice and care in the community as well as providing guidance,
education and training for all involved in end of life care. CHS also has a dedicated
team of end of life care facilitators, which in 2011, will add another two staff members
to further support the embedding of the principles of high quality of end of life care for
all.
2010’s achievements are:

Further development of the National End of Life Care Strategy, 2008 locally.
Prioritising all initatives in line with information collected from Patient and carer
interviews, and views sought from a wide range of staff. A House of Quality for
End of Life care has been created from this information.

Creation and adoption of end of life competencies for all staff, including
dedicated specialist competencies.

Verification of death policy and setting up of appropriate training, inclusive of
online and practical assessment

Training programmes for Advanced care planning and communication skills at
various levels have been extremely well attended.
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
Preferred Place of Care (PPC) achieved for 54-65% of patients, 45% dying at
home (national average 21%), 86% had their PPC documented (audit of 850
patients)

Agreement with the national end of life care team that Cornwall should be the
pilot site for Gold Standards Framework in community hospitals, due to start in
June 2011.

A dedicated End of Life care service embedded into District nursing teams in
the central area of Cornwall, providing and coordinating all high quality care for
those reaching the end of their lives. Agreement with Continuing Healthcare
commissioning to roll this service out to the remainder of the District Nursing
teams in 2011. This service enabled 85-90% of the patients cared for by the
team to die in their own homes.

National version 12 of the Liverpool Care Pathway (LCP) has been adapted to
version 1 for Cornwall, with all providers agreement to use the same document
(from originally 4 different documents). To be rolled out across Cornwall in
2011.

Development of a T34 syringe driver library to support Care homes with
Nursing, due to be fully implemented in 2011.

Regular Mortality review is undertaken using Dr Foster information and locally
collected statistics, to monitor deaths of patients cared for by CHS in the
community hospitals. This system is currently being developed further to aid
the monitoring of quality of care.
3.14 Continence Promotion Service
This is a county wide, specialist service for adults, young people and children, providing
direct care to patients and leadership to health and social care professionals.
A problem such as incontinence (urinary or faecal) is an ageless symptom that is often
overlooked, under treated and misunderstood. Incontinence is a symptom of an
underlying condition, not a disease in itself. Daily incontinence can occur in 4 -7 % of
women under 65 and 4-17% for those older than 65. Also, for middle-aged and older
women, prevalence of incontinence has been reported to reach 30-60% (increasing with
age) and is possibly twice as much compared to men.
During 2010/11, the service has:

Contributed to the ‘National Audit for Continence Care’ supported by the Royal
College of Physicians. Four clinical areas across the county performed an indepth audit of care to enable us to better understand areas for improvement.

Reduced the use of indwelling urinary catheters through weekly data collection
and targeted patient reviews in collaboration with the Infection Control Nurse and
Community Hospital Matrons.
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
Developed and implementing clinical care pathways for women with lower urinary
tract dysfunction through Map of Medicine.

Commenced redesigning of the management of urinary tract infection (UTI)
through innovation using tele-heath technology with people at risk of UTI so they
can assist with early identification of symptoms in their own home

Commenced a survey of patient experience of diagnostic services for bladder
conditions and using the findings to further improve delivery of care.
PATIENT EXPERIENCE
3.15
PEATS
Final scores for 2010/11 have not yet been publicly released by the National Patient
Safety agency.
2010 Results were:
Year
Sites
Results
ENVIRONMENT
BODMIN
COMMUNITY GOOD
HOSPITAL
CAMBORNE
REDRUTH
ACCEPTABLE
COMMUNITY
HOSPITAL
EDWARD
HAIN
ACCEPTABLE
COMMUNITY
HOSPITAL
FALMOUTH
GOOD
HOSPITAL
FOWEY
GOOD
HOSPITAL
HELSTON
COMMUNITY ACCEPTABLE
HOSPITAL
LAUNCESTON
GENERAL
ACCEPTABLE
HOSPITAL
LISKEARD
COMMUNITY GOOD
HOSPITAL
NEWQUAY
GOOD
HOSPITAL
POLTAIR
ACCEPTABLE
HOSPITAL
ST AUSTELL GOOD
FOOD
PRIVACY
DIGNITY
EXCELLENT
GOOD
GOOD
GOOD
GOOD
GOOD
EXCELLENT
GOOD
EXCELLENT
GOOD
GOOD
GOOD
GOOD
GOOD
EXCELLENT
GOOD
EXCELLENT
ACCEPTABLE
EXCELLENT
GOOD
EXCELLENT
GOOD
AND
H
H
H
H
2010
H
H
H
H
H
H
H
CHS QA v8 23rd June 2011
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Year
Sites
COMMUNITY
HOSPITAL
ST
MARY'S
GOOD
HOSPITAL
STRATTON
ACCEPTABLE
HOSPITAL
H
H
Results
EXCELLENT
GOOD
GOOD
GOOD
During 2010/11 Community Health Services have continued to invest in the
ward/hospital and health centre environments, to enhance the patient experience. A
number of wards have been redecorated and a major refurbishment of Stratton Hospital
is underway, which will greatly improve the inpatient areas.
The theatres at Liskeard and St Barnabas Hospitals have been upgraded to allow an
increased diversity in the types of daycase surgery to be performed locally.
3.16 Nursing Metrics and Patient Experience Measurement during 2010/11
A key objective of reporting patients’ and carers’ experiences is to assure the
organisation that those experiences have been listened to, acted upon and have
influenced change in services and patient care. Crucial to being able to report the
patient and carer experience is the effective collection and recording of their
experiences, making it as easy as possible for patients, their families and carers to
share their experiences with us. To improve the patient and carer experience it is
important that there are the systems and processes by which those reported
experiences are translated into action for improvement.
There is no single or simple route to understanding patients’ experiences and it is
necessary to draw on a wide range of sources and types of information – formal and
informal, real time and periodic, quantitative and qualitative, ad hoc and systematic.
Triangulating these various sources of intelligence to assess the reality of the situation
is key.
The Operating Framework for the NHS for 2010/2011 outlined the need to significantly
expand the measurement of patients’ satisfaction with individual services so that staff
can understand and improve the service they provide. It required providers to combine
both nationally coordinated snapshot surveys and ongoing feedback, including real-time
models – along with other sources of intelligence such as complaints and further
development of patient experience measures – to build up a comprehensive and
continuous picture of the views, experiences and priorities of patients and users to
inform service improvement
One strategy put in place during 2010/2011 was the commencement of mandatory
‘Enhancing the Patient Experience’ training for all staff. The intention of this training is to
raise awareness of staff as to the elements that serve to deliver a first class patient
experience, and the interpersonal skills that make patients feel ‘cared for’.
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Community Hospital Inpatient Survey
This continued until December 2010, as Nursing Metrics commenced in January 2011.
The main findings combined from all hospitals during Q3 are:
U
Welcome to ward – 100% satisfaction (73% ‘very’ satisfied)
Participation in decisions – 98% satisfaction (60% ‘very’ satisfied)
Sufficient information – 97% satisfaction (62% ‘very’ satisfied)
Standard of cleanliness – 100% satisfaction (75% ‘very’ satisfied)
Environment – 99% satisfaction (67% ‘very’ satisfied)
2 of the 8 questions scores increased from Q2 and returning to Q1 level:
Treated with respect/dignity – 99% satisfaction (71% ‘very’ satisfied)
Privacy maintained by staff – 99% satisfaction (72% ‘very’ satisfied)
1 of the 8 questions continues to represent the area of least satisfaction:
Choice/presentation of food – 93% satisfaction with only 53% ‘very’ satisfied. Those
‘dissatisfied’ now at a high of 7% (Q1 5%; Q2 6%)
The results clearly indicate that patients admitted to our community hospitals (who
completed the questionnaire) were largely satisfied with their care.
Actions taken in response to the Community Hospital Surveys:
The main cause of dissatisfaction, and therefore the main indicator for action is the
quality and service of the food.
In an effort to increase patients’ calorie intake and stimulate their appetite and desire for
food, small fresh cakes are served in all hospitals for afternoon tea. A variety of small
cakes are served from a plate using serving tongs to enable patients to choose. For
patients on a soft diet, pureed puddings such as blancmange are available.
Feedback that the creamed potato tasted like reconstituted potato resulted in the
development of an improved recipe by the suppliers. Creamed potato is made with the
addition of butter and milk powders to increase its calorie content and nutritional value.
Reconstituted soup used to be on the evening meal menu but this has been replaced
with a more nutritious soup made by fresh ingredients.
Porridge or Readybrek made with whole milk is available for breakfast.
Providing hot breakfasts is currently under consideration. A breakfast of scrambled egg,
sausage and beans in individual microwaveable packets are available; an advantage
with these is that they would enable an ‘all day breakfast’ to be on offer.
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Patient dissatisfaction with the menu at Bodmin Community Hospital has been
addressed by revamping the menu. As it is a PFI partner, the food at Bodmin is not
sourced from the same suppliers as the other hospitals, but is conventionally cooked on
site.
In-depth Patient Experience Studies
This years contract with the Commissioner required a series of in-depth patient
experience studies across the following care groups:
1. Adults receiving regular, frequent care at home (District Nursing Service)
2. Adults with chronic respiratory disease
3. Adults with diabetes
4. Children receiving regular, frequent care at home (Children’s Home Care Service)
5. Children receiving speech and language therapy
6. Young people in transition from child to adult services (Diana Nursing Service)
Four studies have been completed. They were all quite different in terms of scope and
methodologies used.
Community Health Services is committed to constantly improve and enhance the nursing
care we provide. Audits and evaluation already takes place to monitor ongoing
performance and compliance, but up until this year, it has been difficult to triangulate
these findings with the actual experience the patients have whilst receiving care from us.
In collaboration with Heart of England Foundation Trust, CHS is presently implementing a
programme of nursing and patient quality metrics to allow effective regular measurement
of the care we are providing. This has commenced throughout the community hospitals,
but it is planned for this to be rolled out to our community services within the next 12
months.
NHS Cornwall and Isles of Scilly has also set the implementation of Nursing Metrics as a
CQUINN.
Senior Nursing staff have commenced visits to every ward area to check the environment
and review the nursing documentation. There is a list of metrics the senior nurses are
checking and they input their findings directly onto the web link. The results are
immediately available for frontline staff.
The subjects reviewed include:

Infection Control

Nutrition and Hydration

Pain management
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
Tissue Viability

Medicines Management

Clinical observations
In addition, non clinical senior managers also visit ward areas and ask patients to
complete an online questionnaire. The questions are on many occasions directly linked to
the nursing metrics. An example of this is:

The senior nursing review looks at the completion of nutrition and hydration charts.
It checks that this documentation is in place and the completeness of the forms.
Also, if a patient is high risk of poor hydration or nutrition, part of the review is to
check that the appropriate actions have been taken.

The patient questionnaire asks if patients require help with eating and drinking and
if they received this help. The questionnaire also asks if they use the call bell for
help, how quickly, if at all, it is answered.
The results of each area’s reviews are fed back to the ward staff and any required actions
identified. At the time of the next review, the previous results will be available to the
reviewer to enable checking that previous actions have been implemented. All ward
areas’ results and required actions will in the future, be monitored by the Professional
Practice Forum, which is a sub group of the Integrated Governance Committee. Presently
the Nursing Metrics Implementation Board review this data, until the pilots and full
implementation is complete.
Summary Results for Nursing and Patient Quality Metrics
At the commencement of the Nursing Metrics in January 2011, the highest score across
all units was that of 97% on Infection Control, and Privacy and Dignity. Whilst the lowest
score of 20% relates to pain management and indicates that CHS currently does not have
a single pain management measure and care plan which is used consistently across all
site. This situation is being rectified with a new process being introduced with education
and training programme throughout March 2011 so therefore this should result in overall
improvements in this area.
It is disappointing that six areas out of eight possible indicators scored below 80% in
January/February 2011, however these findings mirror the experience of other units when
introducing this tool.
It is the intention that this tool is very much used as an improvement tool with feedback
being given at the time of review and the ward team being able to work immediately on
the areas which have been highlighted.
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3.17 Privacy and Dignity Visits
Dignity in Care Assessors assist NHS Cornwall & Isles of Scilly in achieving their key priority
‘ensuring patients and service users are treated with dignity and respect’ by monitoring the
privacy and dignity standards set out in service level agreements with providers. They do this
through unannounced visits to observe care environments, talk to patients and staff and
complete a Dignity In Care Audit Tool which covers the safety, cleanliness and maintenance
of the patient environment; privacy, dignity and modesty; communication with patients; and
equality and diversity issues.
The Dignity in Care Assessors have submitted five reports to Community Health Services in
2010/11 following visits to:
 Launceston Community Hospital
 Camborne & Redruth Community Hospital (Lanyon Ward)
 St Barnabas Community Hospital
 Liskeard Community Hospital (a report each for Willow and Oak Ward)
The reports are on the whole very positive and note:
 high levels of cleanliness and well maintained facilities
 consideration given to patient privacy and confidentiality
 facilities provided for patients to make personal phone calls
 involvement of patients and families in care and treatment
 good communication with staff
 good menu choices and food of high quality
 protected mealtimes and patients who needed it being assisted to eat.
Some less positive observations were recorded with a request that they be addressed and
these include:
 Storage of equipment
 Patient modesty when transferring between locations within the hospital
 Use of open backed gowns
 Signage for bed curtains
 Some toilets only accessible from one side
The Matrons of each hospital have worked with their Ward Managers to develop action plans
where needed or have addressed issues with instant remedial action.
3.18 Eliminating Mixed Sex Accommodation (ESMA)
Community Health Services is fully compliant with ESMA and submits a monthly report.
No breeches reported since reporting commenced in December 2010.
3.19 Complaints and Compliments
Cornwall and Isles of Scilly Community Health Services welcomes complaints, comments
and suggestions about any aspect of our services. During the year 2010-2011 we received a
total of 120 complaints. Of these, 10 were passed to another NHS organisation to
investigate, 6 were withdrawn and 2 were passed to the Claims Department. The remaining
102 complaints were about community health services. Of these, 87 were made in writing
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and 23 were made verbally to staff. 14 of these verbal complaints were resolved without
escalation.
402 PALS contacts were received during this year. 100 of these were referred to other
organisations for action and response
The table below details the complaints and PALS contacts recorded during this period, in
relation to the services concerned:
SERVICE
Complaints
7
61
10
8
2
1
0
5
3
3
0
8
0
10
2
Community Dental Services
Community Hospital Services
Community Nursing Services
Physiotherapy Services
Podiatry Services
Occupational Therapy
Adult SALT
Children’s Services (incl. child SALT)
Macmillan Services
RATS & CATS Services
Continence Services
Other Community Services
Interpretation/Translation
Services provided by other orgs
Passed to Claims Dept.
Pals
6
74
20
16
11
6
1
6
2
0
1
18
141
100
0
Totals:
120
402
Top Five Issues arising from Complaints and PALS
ISSUE/Category
All aspects of clinical treatment
Access to services (incl. admission, discharge,
transfers, outpatient appointments, delays,
cancellations, transport and waiting times)
Attitude of staff
Comps
57
18
PALS
34
53
TOTAL
91
71
22
13
35
Communication/information to patients
34
20
54
Aids, appliances, equipment, premises
6
13
19
We place an emphasis on resolving complaints and PALS concerns as quickly and
effectively as possible, and in a way that is both proportionate and agreed with the
complainant. The investigation of individual complaints identifies actions to be taken to
reduce the risk of the complaint recurring. Work is ongoing across Community Health
Services to ensure that learning from individual complaints is spread across the organisation.
Where any part of a complaint is upheld, the complainant always receives an apology, an
explanation and information about the actions identified and taken to address the issue.
Some PALS issues require a level of investigation and the same principle applies where the
findings agree with any aspect of an issue. There are also occasions when suggestions are
made, for example to improve an environment or a service procedure and, where
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appropriate, these ideas are acted upon. Listed below are some examples of the actions
identified during this year following investigation of complaints and concerns.
 Changes to the transport booking system in community hospitals in line with Patient
Transport Service guidelines
 Reinforcement of good communication with patients and relatives, including ensuring
a flexible approach to visiting times where necessary, and a recognition of the need
for sensitivity, support and understanding to address concerns about a patient’s health
and progress.
 Training programme to address customer care, staff attitude, communication and
aspects of basic nursing care (to commence in June 2011).
 Specific programmes of clinical training for individuals, and formal procedures carried
out where appropriate.
3.20 Staff Survey 2010
The staff survey is carried out annually by all NHS organisations in England.
NHS Cornwall and Isles of Scilly commissioned Quality Health (QH) to undertake the 2010
staff survey. In accordance with DH guidance all employees of the PCT were sent a
questionnaire and a sample of 800 employees from Community Health Services were
selected randomly and invited to take part in the survey.
The survey is crucial in assessing objectively what staff are thinking about their employment
and how they feel they are being treated. We receive feedback from many sources, but the
survey gives us extremely useful data about our ongoing development and how we compare
to other organisations.
This year’s response rate was 68% a small increase on the figure returned in 2009. This puts
the organisation in the top 20% of PCTs surveyed by QH for response rates. Considering
the enormous amount of change taking place within the organisation the increase, although
small, should be seen as significant.
Summary of 2010 Combined key findings for Cornwall and Isles of Scilly Primary Care
Trust
U
Top Four Ranking Scores:
The following results highlights four key findings of which the PCT compares most favourably
with other PCTs in England.
 Equality and Diversity Training
The percentage of staff having Equality and Diversity Training in the last 12 months is 77%
above the national average of 48% for PCTs.
 Staff Intention to Leave Jobs
The PCT score for this outcome (2.49) has risen slightly from 2009 (2.38) but remains below
the national average (2.71).

Staff Job Satisfaction
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The PCT’s score for this outcome was high (3.70) when compared with the National average
(3.60)
Bottom Four Ranking Scores
Percentage of staff experiencing physical violence from patients, relatives or the public in the
last 12 months was 2% above the national average at 4% as was the percentage of staff
experiencing harassment, bullying or abuse from staff (14%)
30% of staff reported good communication between senior management and staff this fell
below the national average of 34%
21% of staff felt pressured to attend work when feeling unwell this is above the national
average of 19%.
Top Four Areas Where Staff Experience Has Improved
Percentage of staff feeling valued by their work colleagues (2009 = 77%; 2010 = 82%)
Percentage of staff appraised in the last 12 months rising from 72% in 2009 to 84% in 2010.
Percentage of staff feeling satisfied with the quality of work they are able to deliver rising
from 70% in 2009 to 78% in 2010.
Trust commitment to work life balance
Our score for this has risen from 3.56 in 2009 to 3.68 in 2010 this is a significant rise and
demonstrates a higher commitment from the trust in relation to work life balance.
Areas where staff experience has deteriorated
Apart from the outcome mentioned above in relation to staff intention to leave jobs the only
other outcome that deteriorated was the percentage of staff saying hand washing materials
are always available. Our score for this in 2009 was 72% the score for 2010 has dropped to
66% having said this, the PCT is still in the top 20% of all PCTs in 2010.
An action plan has now been developed setting out what we will do to improve in key areas,
and consolidate areas of strength.
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3.21 Key Performance Indicators
Area
National
Requirements
Service
Indicator
Choose and Book system
Target
96%
Delayed transfers of care to
be maintained at a minimal
level
Infection
Control
Year End
March 2011
97.6%
45
38
25
35
MIU 4 Hour waits
98%
99.7%
Rates of Clostridium difficile
13
14
MRSA Bacteraemia
0
MIU
MIU 2 Hour waits
65%
96.6%
Stroke and
TIA
Stroke TIA
60%
80.0%
60%
80.0%
60%
79.0%
95%
99.0%
2%
-15.4%
Service
Specific
Indicators
Falls Prevention
Podiatry
Urgent cases seen within 2 working days of referral
100%
Respiratory Nursing
New home oxygen service users contacted within 4
weeks of HOOF referral
New home oxygen service assessed within 8 weeks of
HOOF referral
New long term oxygen therapy service users assessed
at home within 4 weeks of a HOOF referral indicating
the initiation of LTOT treatment
DNA’s and cancellations rate
95%
100.0%
95%
100.0%
95%
100.0%
5%
0.0%
90%
100.0%
Wheelchairs
Musculo Skeletal
Physiotherapy
Mcmillan Nursing
Orthopaedic Clinical
Assessment
Stroke Rehabilitation
District Nursing
TB Nursing
Referral to
Treatment
Times
RTT 18 weeks
CHS QA v8 23rd June 2011
Time for receipt of referral (to RMC) to issue of
prescription is no more than 28 working days
Urgent cases seen within 4 working days
100%
Non-urgent cases seen within 4 weeks
85%
81.0%
Telephone contact made within 2 days of referral.
December’s position
Patients are screened and signposted with 1-2 days of
receipt of referral
When an appointment is required it is within 4 weeks of
a receipt of referral
Referrals to the unit will be scheduled for admission on
th
the 7 the day after the stroke occurred and will take
place on that day unless there is a clinical reason for
delayed transfer from acute setting (February 11
position)
Routine patients seen within 3-5 working days
TBA
91.0%
100%
100.0%
95%
92.0%
90%
71.0%
90%
88.4%
97%
100.0%
The proportion of patient for whom the 12 month posttreatment outcome is recorded. Improvement from
95.5% to Q1 - 97%, Q2 - 99%, Q3 - 100%
The proportion of people with active TB completing the
prescribed course of treatment as expected during the
period measured. Improvement from 57.1% to Q1 60%, Q2 - 65%, Q3 - 70% and Q4 - 70%
Adult SLT
70%
100.0%
95%
96.2%
Continence
95%
98.6%
Dermatology
95%
100.0%
Musculo-skeletal Physio
95%
100.0%
Page 45 of 51
RTT 13 weeks
RTT 8 weeks
CHS QA v8 23rd June 2011
OT
95%
99.5%
Physio Ass Service
95%
100.0%
Physio Other
95%
98.7%
Podiatry
95%
93.2%
Tissue Viability Nurses
95%
98.2%
Specialist Respiratory Nurses
95%
97.5%
Parkinsons Nurses
95%
100.0%
Diabetes
95%
100.0%
Heart Failure Service
95%
100.0%
Specialist Falls
95%
97.0%
Adult SLT
95%
94.2%
Continence
95%
84.9%
Dermatology
95%
100.0%
Musculo-skeletal Physio
95%
96.9%
OT
95%
97.8%
Physio Ass Service
95%
100.0%
Physio Other
95%
95.8%
Podiatry
95%
86.2%
Tissue Viability Nurses
95%
98.2%
Specialist Respiratory Nurses
95%
84.0%
Parkinsons Nurses
95%
100.0%
Diabetes
95%
100.0%
Heart Failure Service
95%
97.0%
Specialist Falls
95%
91.3%
Adult SLT
85%
91.3%
Continence
76%
67.1%
Dermatology
85%
91.5%
Musculo-skeletal Physio
85%
89.6%
OT
85%
94.1%
Physio Ass Service
85%
100.0%
Physio Other
85%
89.2%
Podiatry
76%
67.2%
Tissue Viability Nurses
85%
94.5%
Specialist Respiratory Nurses
76%
74.1%
Parkinsons Nurses
95%
86.7%
Diabetes
69%
100.0%
Heart Failure Service
TBA
100.0%
Specialist Falls
TBA
75.8%
Number of patients seen over 18 weeks in the time
period
0
4
Page 46 of 51
4. Quality and Safety Improvement Programmes
4.1 NHS Southwest Quality and Safety Improvement Programme
In line with the national QIPP Safe Care Work-stream known as “Safety Express”, NHS
South West have developed a programme called The Quality and Patient Safety
Programme.
In November CHS sent a team of 11 staff to a 2 day course with NHS South West, as
CHS is participating in the South West programme. The objectives of the programme are
to:

Reduce Mortality 15%

Reduce Adverse events 30%

Develop and build a culture of patient safety and quality improvement

Build long term sustainability through increased capacity and capability for
improvement at all levels

Build on existing work and integrate other national and local initiatives into a
coherent whole

Achieve 95% reliability on all care processes identified in the programme

To have the ability to share learning on a regional basis
CHS is committed to achieving the aims of this programme and reducing harm. The
specific aims of the programme participant organisations are:

Pressure ulcers (III &1V) reduced 80% in hospital

Pressure ulcers (III &1V)reduced 30% in community

CAUTI (catheter acquired urinary tract infection) reduced by 50%

Serious injury from falls reduced by 50%

VTE events reduced

Reduction in unplanned transfers to secondary care

Standardised care of the deteriorating patient.
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4.2 The QIPP Safe Care Workstream known as “Safety Express”
In December 2010, CHS received a letter from NHS South West (Appendix 1) updating
organisations regarding South West Quality and Patient Safety Improvement Programme
and the QIPP Safe Care Work-stream known as “Safety Express”. The South West
programme is the localisation of the national ‘Safety Express’
In order to demonstrate successful improvement in four areas of harm (falls, VTE, catheter
prevalence pressure ulcers), the Department of Health QIPP Safe Care Team has developed
a tool for measurement called the “Safety Thermometer”. This is a prevalence survey tool
designed to be undertaken initially on a quarterly basis but increasing to monthly in 2011
On 15th December CHS participated in the Safety Thermometer.
5. Response to this report from our stakeholders
A number of stakeholders have been consulted or previous feedback has been utilised to
ensure that the report addresses areas and priorities of importance to them. These are:
5.1 Overview and Scrutiny Committee
Cornwall Council's Health and Adults Overview and Scrutiny Committee (HAOSC) agreed to
comment on the Quality Account 2011-2012 of Cornwall and Isles of Scilly Community
Health Services. All references in this commentary relate to the period 1 April 2010 to the
date of this statement. (10/06/11)
The Committee had hoped to see further information on the patient participation and patient
public involvement, in decision making. It is felt that this is vital going forward to the new
Community Health organisation.
The HAOSC believes that the Quality Account is a good reflection of the services provided by
the Trust, and gives a comprehensive coverage of the provider's services.
Community Health Services Response: We thank the Overview and Scrutiny
Committee for their comments regarding the Quality Account. Patient Participation
and improving public involvement are embedded within all of our identified priorities.
We will ensure that as we develop and improve, we will communicate with our patients
and the wider public and ensure we are providing what is needed at a place and time
that is convenient to the care receiver, not care giver. One of our identified priorities is
to improve the quality of patient information we provide. We will be linking closely
with our stakeholder groups to ensure we get this right.
5.2 Cornwall LINk
Do the priorities of the provider reflect the priorities of the local population?
U
LINk in Cornwall is pleased that patient pathways is a priority for CHS for 2011-12. LINk has
been working on specifically discharge from hospital during 2010-11 and is reassured that
CHS is looking at the partnership working that is necessary to deliver a smooth patient
pathway at the beginning and particularly at the end. Particularly important is the flagging of
CHS QA v8 23rd June 2011
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patients to make Community Matrons aware of admission as, through our work around
hospital discharge, LINk has heard how much this support can help when discharged. LINk is
part of a Cornwall Wide Hospital Discharge Forum, chaired by CHS and the Department of
Adult Care and Support, monitoring and improving the experience and support provided for
patients. LINk is also part of the Health and Social Care Hubs Development Group looking at
how the Health and Social Care Hubs will work.
LINk is also reassured that another priority for CHS is information for patients. LINk regularly
hears that this is one of the main concerns for people using health and social care services.
The sixth priority of improving patient experience is very positive to see, especially with the
focus on showing where learning has taken place and where improvements have occurred.
LINk is also pleased that this will roll out across community based services and therapies.
This work should be complimented by the work of the research nurses looking at patient
outcomes.
Are there any important issues missed in the Quality Account?
U
LINk feel that Community Health Services transition to a community interest company should
have been addressed in the Quality Accounts 2010-11 to demonstrate how quality will not be
affected by the work leading to these changes, that staff moral and performance will not be
affected and to show how quality of care will be ensured in the transition in 2011-12.
A priority for LINk in 2010-11 was the training of staff in hospital to support patients with
dementia. LINk wrote to CHS about this and CHS were involved in a Dementia Information
Day LINk held in November 2010. LINk feel that this could have been documented in the
Quality Account to show how CHS are committed to continue training of staff.
Has the provider demonstrated they have involved patients and the public in the
production of the Quality Accounts?
CHS involved LINk in the selecting the priorities for the Quality Account 2010-11 but this is
not reflected in the document, nor is any other patient and public involvement in the
production of the Quality Account.
U
Is the Quality Account clearly presented for patients and the public?
LINk feels that a better explanation of Commissioning for Quality and Innovation (CQUIN)
should be given. However, overall, the document is clear and well presented with a good
level of detail without overwhelming the reader. Where abbreviations are included they are
explained.
U
Community Health Services Response: We thank LINk Cornwall for their response to
to the Quality Account. We take all feedback very seriously and have updated the
Quality Account in regard to stakeholder engagement in the development of the
Account and the attendance of CHS at the LINk arranged Dementia event in November
2010. CHS are committed to ensuring our staff are appropriately trained to undertake
the care that they provide and our commitment to this is evidenced by managers and
staff continuously reviewing what training has taken place, critiquing the training to
make sure it is relevant and provides what is required and ensuring that staff attend
training. The Board of the organisation receive monthly reports on training levels to
ensure any area not performing is prioritised quickly.
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5.3 NHS Cornwall & Isles of Scilly Commissioning
NHS Cornwall and Isles of Scilly (NHS CIOS) is pleased to have the opportunity to comment
on the Quality Accounts 2010/11 for Cornwall Community Health Services (CHS), and
welcomes the open approach the Trust has embraced in developing and setting out its
current approach to quality improvement. There are robust arrangements in place with CHS
to agree, monitor and review the quality of services covering the key quality domains of
safety, effectiveness and experience of care.
The Quality Account presents a broad overview of a wide range of quality improvement work
being undertaken with an emphasis on inpatient care, we would wish to see the same focus
on outpatient care. We particularly commend the continued progress that has been made in
fostering patient safety through the implementation of the NHS Southwest Quality and Safety
Improvement Programme, and the ‘safe care’ work stream, above all in promoting incident
reporting although there are still some concerns regarding the timeliness of investigating
Serious Incidents to improve learning. In addition we acknowledge the achievement of
compliance with the Department of Health Same Sex Accommodation standards, with no
reported beaches for the year.
The report presents a fair reflection of progress in 2010/11, and we congratulate the
Community Health Services for its TIA service, however it would be helpful for the Trust to
develop action plans and provide progress reports for the areas that are deemed to be below
the national average. It would also be useful to know how the outcomes of taking part in the
national audits will shape service delivery in 2011/12.
We have reviewed and can confirm the information presented in the Quality Account as
accurate and fairly interpreted, from the data routinely collected throughout the year.
However we feel in order to further improve this that the information presented should include
complaints and incidents now included in the Account following discussions at the
Professional Executive Committee.
In terms of the performance against the 10/11 CQUIN goals the following indicator was not
achieved:
Reduction in sickness absence in nursing and allied health professional workforce
The PCT looks forward to working with the Community Health Services throughout the year
to achieve more efficient pathways delivering high quality services to patients close to home,
reducing unplanned admission, and particularly with the development of the Health and
Social Care Hubs and a further stroke rehabilitation unit.
NHS CIOS notes the organisation’s registration with the Care Quality Commission with no
conditions for all its regulated activities, and the subsequent planned review, for which
outcomes are awaited.
We are pleased to see that the priorities chosen for 2011/12 have been identified with key
stakeholder involvement and agree the priorities selected. In addition to those highlighted in
the Account we would expect the Trust to focus on the following that have not been selected
as a priority:
Internal organisational improvements that have a wider impact on quality such as
dignity and respect, personalised care and communication
Leg Ulcer Management
Improving the reporting rate for incidents.
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Community Health Service Response: We thank NHS Cornwall and Isles of Scilly for
their comments regarding the Account. In each of our identified priorities we will be
working across all our services, including community and therapy to ensure the
quality of patient care and outcome continues to improve. Unless something is
specific to inpatient care, all our priorities are to be translated to all the services we
provide. We acknowledge that NHS Cornwall & Isles of Scilly would also like us to
focus on:
 Internal organisational improvements that have a wider impact on quality such
as dignity and respect, personalised care and communication
 Leg Ulcer Management
 Improving the reporting rate for incidents.
We have already added a leg ulcer management review/clinical audit to our priority in
regard to the wider pressure ulcer management and we feel that internal
organisational improvements that have a wider impact on quality such as dignity and
respect, personalised care and communication are intrinsic to all our priorities.
Reporting rates for incidents forms part of our bi-monthly reporting and monitoring
and we take incidents reporting numbers and learning from incidents very seriously.
We have just introduced a new incident reporting system and there has been a great
deal of awareness training for staff over the last few months. This should result in
improvement rates of incident reporting and will continue to be robustly monitored at
all levels of the organisation.
6. Conclusion
It is hoped that you have found our first Quality Account an interesting and helpful document,
and that it has re-assured you that CIOS Community Health Services is committed to
improving the quality and safety of services it delivers as well as engaging with and involving
its local community and service users.
If you have any comments, or questions about any of the information it contains or any of
CHS services please do not hesitate to contact our Patient Advice and Liaison Team (PALS)
on 01326 435885.
CHS QA v8 23rd June 2011
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