Clinical Audit Plan: 2010-2011
Domain
Quality and
Management
Essential standards of quality and safety
Outcome
Comments
Outcome 16: Assessing and monitoring the quality of The Cornwall & Isles of Scilly Community Health Services
service provision
(CHS) Clinical Audit Plan will be determined by the Integrated
Governance Committee based upon the four categories
outlined on page 2. It should be understood however that all
clinical audits undertaken by CHS staff should provide
evidence for one or more of the outcomes contained in
Essential standards of quality and safety (CQC 2010).
Introduction
The reinvigoration of clinical audit has been set as a priority by the Department of Health. In 2006 the Chief Medical Officers report ‘Good Doctors,
Safer Patients’ called for the reinvigoration of clinical audit to enable it to reach its potential as a rich source of information to support service
improvement, better information for patients and other activities such as the revalidation if clinicians. In February 2007 the White Paper ‘Trust
Assurance and Safety and in 2008 the Next Stage Review, ‘High Quality Care For All’ also recognised the crucial value of clinical audit in
assessing the quality of clinical care and maintaining high quality professional performance. In December 2009 (updated March 2010), the Care
Quality Commission (CQC) published Essential Standards of Quality and Safety to support the new registration regulations; Health and Social
Care Act 2008 (regulated activities) regulations 2009. These standards describe the essential standards of quality and safety the people who use
health and adult social care services have a right to expect.
Clinical Audit is defined as “A quality improvement process that seeks to improve patient care and outcomes through the systematic review of
care against explicit criteria and the implementation of change. Aspects of the structure, processes and outcomes of care are selected and
systematically evaluated against specific criteria. Where indicated, changes are implemented at an individual, team or service level and further
monitoring is used to confirm improvement in health care delivery”. (Principles of Best Practice in Clinical Audit – NICE 2002)
This plan is designed to be a working document and as such will be subject to amendments and additions throughout the year to reflect changes
to the organisation as well as changes to local and national priorities
Page 1 of 17
Clinical Audit Plan 10/11:
Development of the Clinical Audit Plan
Effective Clinical Audit is not a simple task and the pressure of incorporating complex requirements into an ever increasing workload presents yet
another demand on clinical time. It is therefore important for Community Health Services to demonstrate a systematic approach to audit topic
selection, taking into account any organisational priorities and new government initiatives together with any local needs. This will ensure time is
spent efficiently by concentrating on well-structured audit projects that produce effective results and highlights areas of practice requiring change.
The aim is to increase audit activity across Community Health Services and to reduce the number of poorly conducted audits that are often
unsupported, carried out under pressure, and on occasions never completed.
The Clinical Audit Plan will be determined by the Integrated Governance Committee based upon the four categories below:
1: External ‘must do’ audits: Failure to participate or deliver on these externally driven audits may carry a penalty for CHS (either financial or in
the form of a failed target or non-compliance). These are externally monitored and assessed by the CQC and in some areas by the local PCT
commissioner.
 National Clinical Audit & Patient Outcome Programme (NCAPOP)
 Audits demonstrating compliance with regulation requirements e.g. NICE guidance, NSFs, NPSA alerts
 CQUINS and other commissioner priorities
 DH statutory requirements, e.g infection control monitoring
 External accreditation schemes, e.g., NHS Litigation Authority (NHSLA), Information Governance Toolkit (IGT)
2: Internal ‘must do’ audits: Priorities reflective of organisational objectives for clinical audit as outlined in the local clinical audit strategy or
strategic objectives
 Clinical risk issues
 Serious untoward incidents/adverse incidents
 Organisational clinical priorities
 Priorities identified via Patient and Public Involvement initiatives
 Complaints
 Access
 Patient Safety First Campaign
3: Business Unit / Service priorities
 Local clinical interest audit agreed by business units/services as a priority
 National audits not part of NCAPOP, e.g. some Royal College initiated projects that lie outside of NCAPOP
 Locally adopted clinical standards benchmarking e.g., Essence of Care
4. Clinician interest
Page 2 of 17
Clinical Audit Plan 10/11:
INDEX
Business Unit
KEY
Page Number
Numbering system
Community Hospitals
4
MIU
6
District Nursing
7
Community Matrons
8
Intermediate Care
8
G
Completed Projects
Caradon
8
A
Projects underway but not completed
North Cornwall
9
R
Restormal
10
Projects over due / No information
received
Carrick
10
Kerrier / Penwith
11
Therapies
11
Children’s Services
13
Dental
15
Safeguarding Team
15
Governance
16
Commissioning
16
Year / Priority / Audit number
Position key
Page 3 of 17
Clinical Audit Plan 10/11:
Business Unit: All
Service: Community Hospitals
No.
10/1/1.
10/1/2.
10//3.
10/1/4.
10/1/5
10/1/6.
10/1/7.
10/1/8.
10/1/12.
10/1/13.
Title
Audit to demonstrate compliance with
28 days dispensing for discharge,
including medicines management and
planning
Audit to provide evidence that all
prescribing adheres to the locally
agreed joint formulary
Audit to demonstrate the prudent and
appropriate use of antibiotics in line
with the joint formulary
Audit to demonstrate compliance with
and adherence to standard operating
procedures for controlled drugs
Clinical Record Keeping Audit
Audit to determine the number and
proportion malnutrition on admission
for patients over the age of 65 years
Audit to check for recorded
Healthcare Associated Infections on
death certificates where appropriate
Audit of antipsychotic drug prescribing
for patients in Community Hospitals
To reduce avoidable death, disability
and chronic ill health from Venousthromboembolism (VTE) through risk
assessment
To reduce avoidable death, disability
and chronic ill health from Venousthromboembolism (VTE) through
Rationale
Contract
Lead(s)
Ros Palmer /
Matrons
Contract
Ros Palmer /
Matrons
Contract
Ros Palmer /
Matrons
Contract
Ros Palmer /
Matrons
Contract, NHSLA , IGT
Matrons
Contract
Matrons
Contract
Matrons
Contract
CQUINS
Ros Palmer /
Matrons
Matrons
CQUINS
Matrons
Page 4 of 17
Clinical Audit Plan 10/11:
10/1/29
appropriate prophylaxis
To implement the nursing metric
system across community hospitals to
include patient survey
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 multidisciplinary 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.
40% decrease in community hospital
acquired pressure ulcers (grade 2 or
above)
Hand Hygiene -local
10/1/30
Hand Hygiene -IPC nurses
DoH - IPC
10/1/31
Central Lines
DoH - IPC
10/2/9
Kitchen audit
CHS priority - IPC
10/2/10
PPE audit
CHS priority - IPC
10/2/11
Mattress audit
CHS priority - IPC
10/2/14
Sharps audit
CHS priority - IPC
10/1/14.
10/1/16
10/1/17.
10/1/18
10/1/19.
CQUINS
Trish Cooper /
Matrons
CQUINS
Sue Wright /
Sharon
Eustice /
Matrons
CQUINS
Matrons
CQUINS
Matrons
CQUINS
Nicci Kimpton
DoH - IPC
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Sue Wright /
Matrons
Page 5 of 17
Clinical Audit Plan 10/11:
10/2/15
Urinary catheters audit
CHS priority - IPC
Sue Wright /
Matrons
Sue Wright /
Matrons
Karen Phillips
/ matrons
Matrons
10/2/17
Linen audit
CHS priority - IPC
10/2/1.
Cardiac arrest
CHS priority
10/2/2.
Patient satisfaction survey
CHS priority
10/2/3.
Prescription charts
CHS priority
10/3/1
.Essence of Care Benchmarking
Ros Palmer /
Matrons
Matrons
10/4/2
Depression Screening for inpatients
at SACH
Junior doctor audit
Matt
Tremaine /
Rod Bland
Service: Community Hospitals, MIU units
No.
10/1/20
Title
National falls and bone health care
audit
Rationale
NCAPOP
Lead(s)
Dee Hore /
Jax Dobell
1/1/11a
NICE CG56 Head injuries
Contract / NICE
Dee Hore
1/1/11b
Contract / NICE
Dee Hore
10/1/5
NICE CG89 When to suspect child
maltreatment
Clinical Record Keeping Audit
Contract, NHSLA , IGT
Dee Hore
0/3/5
Paediatric Analgesia
Service priority
Dee Hore
Page 6 of 17
Clinical Audit Plan 10/11:
Service: District Nursing
No.
1/1/10
Rationale
Contract
Lead(s)
Sue Wright /
Sharon
Eustice / Val
Derks
10/1/5
Title
Audit to determine the proportion of
people under the care of community
services at home (including those who
live in a residential care home without
nursing) who have a catheter in situ
and length of time that this has been
the case
Clinical Record Keeping Audit
NHSLA , IGT
Val Derks
10/1/32
Hand Hygiene inspection
DoH - IPC
10/133
Hand Hygiene observation
DoH - IPC
10/134
Hand Hygiene glow box
DoH - IPC
10/1/35
Central Lines
DoH - IPC
10/2/18
PPE audit
CHS priority - IPC
10/2/12
Mattress audit
CHS priority - IPC
10/2/13
Sharps audit
CHS priority - IPC
10/2/16
Urinary catheters audit
CHS priority - IPC
10/2/4
Pressure ulcers prevalence
CHS priority
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Sue Wright /
Val Derks
Nicci Kimpton
/ Val Derks
Page 7 of 17
Clinical Audit Plan 10/11:
Service: Community Matrons
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Helen Lyndon
10/1/39
Personalised care planning
contract
Helen Lyndon
Business Unit: Intermediate Care
Service: CATS/RATS
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Nicky Harvey
/ Sue Rogers
Business Unit: Caradon
Service: Cardiac Rehabilitation and Heart Failure Nurses
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Gill Payne /
Debbie Welsh
Page 8 of 17
Clinical Audit Plan 10/11:
Business Unit: North
Service: Primary Care Liaison Nurses
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Chris Would
Service: Tissue Viability
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Nicci Kimpton
10/1/19
40% decrease in community hospital
acquired pressure ulcers (grade 2 or
above)
Pressure ulcers prevalence
CQUINS
Nicci Kimpton
/ Hospital
Matrons
Nicci Kimpton
/ Val Derks
10/2/4
CHS priority
Service: Continence Specialist Nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Sharon
Eustice
Page 9 of 17
Clinical Audit Plan 10/11:
Business Unit: Restormal
Service: Respiratory Nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Deirdre Denn
10/1/9
Audit of reviews by the Specialist
Respiratory Nursing Service of
patients who have been prescribed to
emergency O2 determine timeliness
and outcomes
Contract
Deirdre Denn
Business Unit: Carrick
Service: Diabetic Liaison Nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Caroline
Dunstan
Service: Macmillan Nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Joy Mulliner
10/1/40
10/3/8
Preferred Place of Care
Liverpool care pathway
Contract
Service priority
Ally Hardman
Ally Hardman
Rationale
NHSLA , IGT
Lead(s)
Catherine
Aitkenhead
Service: Health for the Homeless
No.
10/1/5
Title
Clinical Record Keeping Audits
Page 10 of 17
Clinical Audit Plan 10/11:
Service: Acute Care at Home
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Matt
Englefield
Rationale
NHSLA , IGT
Lead(s)
Maggie Scott
Lead(s)
Lynne
Osborne
Lynne
Osborne /
Katharine
Stone
Business Unit: Kerrier / Penwith
Service: Stroke Care Co-ordinators
No.
10/1/5
Title
Clinical Record Keeping Audits
Service: Parkinsons Disease Specialist Nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
10/3/9
Parkinsons referrals to therapy
services
Service priority
Business Unit: Therapies - Rehabilitation
Service: Falls co-ordinators
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Jax Dobell
10/1/20
National Falls and Bone Health Audit
NCAPOP
Dee Hore /
Jax Dobell
Page 11 of 17
Clinical Audit Plan 10/11:
Service: Occupational Therapy
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Julie Smith
10/3/2
Audit of Therapies Clinical
Supervision Policy
Recommendation from
RKS audit
Julie Smith
Service: Physiotherapy
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Roz Collins
Service: Speech and Language (Adults)
No.
10/1/5
Title
Clinical Record Keeping Audit
Rationale
NHSLA , IGT
Lead(s)
Margaret Ray
Business Unit: Therapies - Outpatient
Service: Podiatry
Page 12 of 17
Clinical Audit Plan 10/11:
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Tracey
Willshee /
Steve Enoch
10/1/36
Hand hygiene – inspection; all clinics
DoH - IPC
10/1/37
Hand hygiene – observation; RCHT
clinics
Hand hygiene – observation; all other
clinics
PPE; all clinics
DoH - IPC
Audit of nail re growths post nail
surgery with chemical ablation.
Referrals to podiatry specialist
musculoskeletal clinics
Clinical interest
Sue Wright /
Steve Enoch
Sue Wright /
Steve Enoch
Sue Wright /
Steve Enoch
Sue Wright /
Steve Enoch
Edwina
Bottone
Beverly
Bowring
10/1/38
10/2/20
10/4/1
10/3/4
DoH - IPC
CHS priority - IPC
Service priority
Service: Musculoskeletal physiotherapy
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
10/1/41
NICE CG88 Management of nonspecific back pain, Falmouth
outpatients
Staff Rapid Access to Physio Scheme
NICE
The appropriateness of XR Ordering
in an Outpatient Physiotherapy
Department
Service priority
10/2/19
10/3/7
Evaluation of QUINs
pilot
Lead(s)
Maria
Stickland /
Roz Collins
Andy Graham
/ Maria
Stickland
Maria
Stickland /
Lesley Pallett
Simon Adams
Page 13 of 17
Clinical Audit Plan 10/11:
Service: Orthopaedic Clinical Assessment Service
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Lucy Thomas
Rationale
NHSLA , IGT
Lead(s)
Caroline
Davey
Rationale
NSF
Lead(s)
Alison Cook
Service: Elective Orthopaedics
No.
10/1/5
Title
Clinical Record Keeping Audits
Business Unit: Childrens Services
Service: All
No.
10/1/21
Title
Childrens NSF
Service: Community Paediatrics (community childrens nurses, home care service, Diana nurses)
No.
10/1/5
10/3/4
Title
Clinical Record Keeping Audits
Standard of service provision: manual
handling. Lone worker
Rationale
NHSLA , IGT
Service Priority
Lead(s)
Joan Gowans
Joan Gowans
Rationale
NHSLA , IGT
Lead(s)
Joan Gowans
/ Lucy Brewer
Service: Epilepsy specialist nurse
No.
10/1/5
Title
Clinical Record Keeping Audits
Page 14 of 17
Clinical Audit Plan 10/11:
10/1/25
Paediatric epilepsy – NICE guideline
NICE
Lucy Brewer
Service: Health Visitors and School Nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Lead(s)
Anne Hall
10/1/15
Record asking of NICE CG45‘Wooley questions’ at new birth visit.
CQUINS
Anne Hall
Rationale
NHSLA , IGT
Lead(s)
Sue Newman
Rationale
NHSLA , IGT
Lead(s)
Jo Staves
Rationale
NHSLA , IGT
Lead(s)
Alison Cooke
/ Alison Blake
Title
Clinical Record Keeping Audits
Rationale
NHSLA , IGT
Infection Control Audits
Essential Steps
Lead(s)
Iona Loh /
Peter Knibbs
Sue Wright /
Iona Loh /
Neil
Service: Speech and Language Therapy (Children)
No.
10/1/5
Title
Clinical Record Keeping Audits
Service: Youth Offending Team (Healthcare)
No.
10/1/5
Title
Clinical Record Keeping Audits
Service: TB nurses
No.
10/1/5
Title
Clinical Record Keeping Audits
Business Unit: Dental
No.
10/1/5
Page 15 of 17
Clinical Audit Plan 10/11:
McDonald
Business Unit: Safeguarding Team
No.
10/2/5
Title
Audit of adult safeguarding alerts
Rationale
CHS priority
10/2/7
Audit of communication between
referrer and DASC
Audit of safeguarding policy: alerts
made by CHS staff visiting nursing
and residential homes
CHS priority
10/2/6
CHS priority
Lead(s)
Charmain
Nicholas
Charmain
Nicholas
Chris Nash
Business Unit: Governance, affecting all clinical services
No.
10/1/27
Title
Consent
Rationale
NHSLA / Contract
Lead(s)
Debby Blease
10/1/28
Injectable medicines (alert 20)
NPSA alert
Ros Palmer
10/1/29
CAS alerts
NPSA alerts
Trish Cooper
10/130
Safe & secure handling of medicines
NPSA alerts,
Ros Palmer
10/1/31
10/1/32
10/2/8
10/3/6
Right patient right blood
Gastrostomy
Deprivation of liberty
Blood transfusion, patients
observation and documentation
Syringe drivers
NPSA alerts,
NPSA alerts,
CHS priority
Audit recommendation
Trish Cooper
Trish Cooper
Debby Blease
Alison Rundle
Trust Priority
Ally Hardman
/ Andrea
Rotchell
10/2/
Page 16 of 17
Clinical Audit Plan 10/11:
NHS Cornwall & Isles of Scilly – commissioning led audits affecting CHS services
No.
C1
C2
Title
Stroke Improvement National Audit
Programme (SINAP)
Parkinson’s Pathway – Map of
medicine
Rationale
Lead(s)
Maggie Scott
Lynne
Osborne
Page 17 of 17
Clinical Audit Plan 10/11: