NHS Heywood, Middleton and
Rochdale
Community Health Care
Quality Account 2010-2011
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Contents
Page
Part 1
1.0
Statement from the Managing Director
3
2.0
Priorities for Improvement and Statements of Assurance
from the Board
4
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
Priorities for Improvement
Statements of Assurance from the Board
Participation in Clinical Audits
Participation in Clinical Research
Use of the CQUIN Framework
Statements from the Care Quality Commission (CQC)
Data Quality
NHS Number and General Medical Practice Code Validity
Information Governance Toolkit Attainment Level
Clinical Coding Error Rate
4
4
4
5
5
6
6
7
7
7
3.0
Review of Quality Performance in 2010-11
8
3.1
3.2
3.3
3.4
3.5
Patient Safety
Incident Reporting to Support Patient Safety
Records Audit
Clinical Effectiveness
Care Quality Commission Regulated Outcomes to Improve
Clinical Effectiveness
Mandatory Training
Patient Experience Survey
8
8
8
9
9
4.0
Comments on the Quality Account 2010-11
11
4.1
Statement from NHS Heywood, Middleton
& Rochdale (commissioner) regarding the HMR CHC
Quality Account 2010-11
11
Part 2
Part 3
3.6
3.7
9
10
Part 4
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Part 1
1.0
Statement from the Managing Director
NHS Heywood, Middleton and Rochdale Community Healthcare (HMR CHC)
provides community health care services for the population of the Rochdale
borough. We made good progress in 2010-11 towards providing high quality care
to the people of Heywood, Middleton and Rochdale, thanks to the continued hard
work and enthusiasm from our workforce.
Quality is fundamental to everything we do and we have strived hard to achieve
quality improvements in patient safety, patient experience and clinical
effectiveness through a range of initiatives. We have also developed and
implemented a robust governance infrastructure to give us the level of scrutiny
required to make continuous year on year improvements.
We are pleased to report that we successfully registered with the Care Quality
Commission (CQC) during 2010-11 and have implemented robust systems to
ensure ongoing compliance with the CQC’s full range of essential quality
standards that are fundamental to the registration system and to the services that
we deliver.
From 1st April 2011, HMR CHC transferred from the local PCT to Pennine Care
Foundation Trust.
During the transition, clinical and non clinical staff
encountered and overcame significant challenges brought about by new ways of
working within new organizational structures. Despite these difficulties, staff
have continued to deliver high quality services throughout the year.
This is the first Quality Account for HMR CHC and it aims to offer assurance to
the public on our approach to a continuous programme of quality improvement to
ensure positive health outcomes for patients.
To the best of my knowledge, the information in this document is accurate.
Signed:
John Boyington
Managing Director
29 June 2011
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Part 2
2.0
Priorities for Improvement and Statements of Assurance from the
Board
2.1
Priorities for Improvement
NHS Heywood, Middleton and Rochdale Community Health Care (HMR CHC)
transferred to Pennine Care Foundation Trust (PCFT) on 1st April 2011. As such,
priorities for 2011-12 are included in the PCFT Quality Account. The priorities for
2011-12 that relate to community services are:
• Engagement and participation in the Safety Express programme to reduce
harm
• An increase in the reporting of incidents
• An increase in the take-up of child safeguarding training
Further detail about each priority can be found in the PCFT Quality Account.
2.2
Statements of Assurance from the Board
During 2010-11, HMR CHC provided one NHS service.
HMR CHC has reviewed all the data available to it on the quality of care in this
NHS service.
The income generated by the NHS services reviewed in 2010-11 represents 100
per cent of the total income generated from the provision of NHS services by
HMR CHC for 2010-11.
2.3
Participation in Clinical Audits
During 2010-11, there were 18 national clinical audits and no national
confidential enquiries that covered NHS services that HMR CHC provides.
During that period HMR CHC participated in two national clinical audits which it
was eligible to participate in. The national clinical audits and national confidential
enquiries that HMR CHC was eligible to participate in during 2010-11 are as
follows:
•
•
•
•
Anxiety and depression national audit
Cancer standards gold framework
National falls and bone health audit
Continence audit
HMR CHC undertook a programme of local clinical audit and evaluations which
were reported to the Clinical Audit and Scrutiny Group and the Provider
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Governance Group. Reports of local clinical audits that were reviewed by HMR
CHC in 2010-11 included, for example:
•
•
•
•
•
•
Adult musculoskeletal physiotherapy service patient outcome measures
evaluation
UNICEF Baby Friendly Breastfeeding audit (of Standard 1 – first re-audit)
Baseline audit of Active Case Management medication reviews
Hand hygiene
Pressure ulcer incidents
Indwelling devices
Actions identified by clinical audits to improve the quality of healthcare were
taken forward by and monitored by HMR CHC. Further detail of the clinical audit
programme and outcome monitoring are available from PCFT, as the recipient of
HMR CHC from 1st April 2011.
2.4
Participation in Clinical Research
The number of patients receiving NHS services provided or subcontracted by the
HMR CHC in 2010-11 that were recruited during that period to participate in
research approved by a research ethics committee was 6 for portfolio studies
and at least a further 40 patients recruited to other studies (non-portfolio).
Participation in clinical research demonstrates HMR CHC’s commitment to
improving quality of the care offered and to making HMR CHC’s contribution to
wider health improvement. Clinical staff stay abreast of the latest possible
treatment possibilities and active participation in research leads to successful
patient outcomes
During 2010-11 there were a total of 68 active research studies being undertaken
in NHS HMR and involving HMR CHC clinical staff, that had been approved by a
research ethics committee. Three of these studies were completed during the
year. Research studies covered a range of clinical specialties including
management of long term conditions, end of life care, psychology, non medical
prescribing, dentistry, smoking cessation, community children’s nursing, and
physiotherapy.
2.5
Use of the CQUIN Framework
A proportion of HMR CHC income in 2010-11 was conditional on achieving
quality improvement and innovation goals agreed between HMR CHC and any
person or body they entered into a contract, agreement or arrangement with for
the provision of NHS services, through the Commissioning for Quality and
Innovation (CQUIN) payment framework.
Achievement of these quality
improvement and innovation goals attracts financial awards of up to 1.5% of the
total contractual value. This was the first year CQUIN had been applied to
community services. The agreed schemes for 2010-11 were:
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•
•
•
•
To improve data collection and quality of patient information in order to
optimise service delivery (regional scheme)
To enhance clinical supervision in clinical practice in order to maximise
patient safety (local scheme)
To provide baseline information on the experience of patients using services
that will enable the identification of areas for improvement (local scheme)
To improve baseline information on the quality of records in HMR CHC
services (local scheme)
All of the agreed goals for 2010-11 were fully achieved. Further details are
available electronically at http://www.institute.nhs.uk/
Information about agreed CQUIN schemes for 2011-12 is available from PCFT.
2.6
Statements from the Care Quality Commission (CQC)
HMR CHC was required to register with the CQC and its registration status in
2010-11 was, “registered”. HMR CHC had no conditions on its registration.
Though HMR CHC declared only partial compliance with Regulation 23,
Supporting Workers and Regulation 20, Corporate Records, the Care Quality
Commission (CQC) accepted the registration with no conditions. As a
consequence of partial compliance, action plans were submitted to NHS North
West to ensure that HMR CHC would work towards full compliance in all areas.
During 2010-11 HMR CHC has delivered against this action plan and now has a
robust process and pathway for managing corporate records in order to be fully
compliant with Regulation 20.
To declare compliance with Supporting Workers (Regulation 23) HMR CHC has
developed a clinical supervision framework which enables all clinical and therapy
staff who have face to face contact to access supervision.
The CQC has not taken enforcement action against HMR CHC during 2010-11.
HMR CHC has not participated in any special reviews or investigations by the
CQC during the reporting period.
2.7
Data Quality
PCFT as the recipient of HMR CHC from 1st April 2011 will be identifying and
taking action during 2011-12 to improve community provider data quality.
HMR CHC in 2010-11 has seen an increase in iPM usage from a baseline of
20% in 2008/09 where most people just turned the machine on, to 100%
compliance recorded in most services.
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2.8
NHS Number and General Medical Practice Code Validity
HMR CHC did not submit records during 2010-11 to the Secondary Uses Service
for inclusion in the Hospital Episode Statistics as NHS HMR does not provide
these services.
2.9
Information Governance Toolkit Attainment Level
HMR CHC information governance assessment overall score for 2010-11 was
63% and was graded as red. This percentage score represented both the
commissioning and provider arm of the PCT.
2.10 Clinical Coding Error Rate
HMR CHC was not subject to the Payment by Results clinical coding audit by the
Audit Commission during 2010-11.
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Part 3
3.0
Review of Quality Performance in 2010-11
HMR CHC has continued to make good progress in 2010-11 towards providing
high quality care to the people of Heywood, Middleton and Rochdale.
The following provides a brief summary of some of the excellent work that has
been undertaken during 2010-11
3.1
Patient Safety
Patient Safety is paramount and in 2010 we signed up to the Patient Safety
Campaign. The aim of the campaign is to make the safety of patients everyone’s
highest priority, thereby supporting the vision “no avoidable death” and “no
avoidable harm”. For HMR CHC as an organisation this means continuing to
carry out risk assessments; the identification and management of patient related
risks; the reporting and analysis of incidents; and the capacity to learn from and
follow-up on incidents and implement solutions to minimise the risk of them
recurring.
Of particular note are the improvements with the prevention, identification and
management of pressure ulcers.
In 2011-12 work to improve patient safety is being developed further through the
‘Safety Express’ programme which is a national initiative to reduce patient harm.
3.2
Incident Reporting to Support Patient Safety
HMR CHC now uses an on-line system for reporting and this has resulted in an
increase in both the number of incidents and the quality of the information. It is
difficult to identify therefore, whether the increase in incidents is actual, or as a
result of the introduction of the new system.
All incidents and action plans to support lessons learnt have been discussed at
the Clinical Audit & Scrutiny Group. This group was tasked with providing
assurance to the Provider Board that lessons learnt were being addressed. In
order to develop and build upon the process for sharing information of lessons
learnt across all services, a process of reporting incidents to each service on a
monthly basis has been developed. This will be further developed following the
move of HMR CHC into PCFT.
3.3
Records Audit
To further support patient safety in 2010-11 all our clinical services engaged with
the monthly records audit. This audit was carried out to improve and standardise
baseline information on the quality of records across HMR CHC services. Five
records were randomly selected from each service per month for audit to cover
50% of services. 63% of HMR CHC services have completed the audit and
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produced internal action plans which are audited against and monitored through
the Clinical Audit and Scrutiny Group.
3.4
Clinical Effectiveness
HMR CHC is committed to providing a clinical non-management supervision
programme, which enhances the clinical support and professional development
for all healthcare staff who engage in face to face patient/client activity.
Clinical Supervision is recognised as a key element to supporting Clinical
Governance that enables practitioners to examine their practice, their skills,
knowledge, attitudes and values in a safe structured environment. Effective
participation in clinical supervision is seen as individuals demonstrating their
accountability and taking responsibility for the continuous improvement of their
practice, contributing to more effective clinical risk management and
improvements in patient care (Butterworth and Woods 1998).
In 2010-11 HMR CHC launched the principles of clinical supervision supported
by a framework and clinical supervision training delivered by a local university.
During 2010-11 HMR CHC also embarked on the Productive Community
Services programme, which provides a systematic approach to reviewing ways in
which services operate in order to optimise time clinical staff spend with patients
and service users, so improving clinical effectiveness and patient experience.
3.5
Care Quality Commission Regulated Outcomes to Improve Clinical
Effectiveness
Following registration with CQC an internal CQC Task and Finish Group was
established to ensure that services were informed of their responsibility in
relation to delivering against the outcomes for CQC. This resulted in the launch
of a CQC governance tool which services were asked to complete by self
assessing themselves against the patient focused outcomes. On completion of
their assessment, with the use of a judgement framework ratified by external
auditors, the project team reviewed service evidence and provided guidance as
to where some patient evidence outcomes could be improved. Following the
internal CQC visits, services produced an action plan, identifying potential areas
of improvement which were monitored through the Clinical Audit and Scrutiny
Group.
3.6
Mandatory Training
HMR CHC targeted mandatory training to improve attendance and compliance to
support and enhanced clinical effectiveness. Baseline data (Nov 2010) on
infection control training was reported as 26.49% improving to 69.92% in March
2011.
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3.7
Patient Experience Survey
During 2010-11 all 34 services engaged with a comprehensive patient
experience survey. This generic survey aimed to capture patients’ experiences in
relation to care received, involvement in decision making, being treated with
dignity and privacy and confidentiality. Overall the results of the survey identified
that patients/clients believed that their experience of HMR CHC was very
good/good. All services completed action plans to address any areas of
improvement which were monitored through the Clinical Audit and Scrutiny
Group.
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Part 4
4.0
Comments on the Quality Account 2010-11
The Quality Account was shared with members of the Overview and Scrutiny
Committee and the Local Involvement Network (LINKs) prior to publication to
offer the opportunity to comment.
4.1
Statement
from
NHS
Heywood,
Middleton
&
Rochdale
(commissioner) regarding the HMR CHC Quality Account 2010-11
Whilst HMR CHC was part of NHS HMR during 2010-11, it operated as a
separate organisation within NHS HMR, with its own governance structures,
Provider Board and reporting arrangements to NHS HMR as a service provider to
a service commissioner.
As such NHS HMR has reviewed the HMR CHC Quality Account 2010/11 as it
would review such accounts from other service providers. The review has
compared the accuracy of the qualitative information and data contained in the
Quality Account with the qualitative information and data provided by HMR CHC,
as part of its contractual requirements during the year. The presentation and
scrutiny of this information and data in year has been facilitated through the
Integrated Governance Committee (subsequently the Quality Committee) which
in turn reports to the PCT Board.
HMR CHC has worked with the commissioners to devise and implement its
quality programme which has provided a firm foundation on which to progress
the quality agenda. This has helped to embed a culture of ongoing quality
monitoring in readiness for the introduction of the new contractual monitoring
arrangements as HMR CHC becomes part of PCFT from April 2011. The
commissioners look forward to developing further comprehensive measures of
quality and safety for community services in 2011-12.
Having considered the contents of this Quality Account, NHS Heywood,
Middleton and Rochdale confirms that it considers that this Quality Account
contains accurate information in relation to the services provided to it by HMR
CHC during 2010-11.
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